Dr Rambanapasi Gynaecologist

08/10/2024

Vaginal Birth After Ceasarean Section.
A patient who once had a ceasarean section asked me if she could deliver normally. This is my response:

Once the womb is cut,as in a cesarean section, it will no longer be as strong as it was before a ceasar. The incision we make on the womb becomes a 'fault line' which is susceptible to tearing during a subsequent delivery
As such in recommending a mode of delivery we are actually very very careful and we consider a number of factors explained below:
1. How many ceasarean sections has she had before.? A trial of va**nal birth is only considered if one has had only one C/section before. Beyond that the risk of uterine rupture is unacceptably high.
2. What was the reason for the first C/section?
Some reasons for a ceasar are permanent. For example a woman with a small pelvic bone passage will remain like that for life. If she failed to deliver a normal size baby in a previous pregnancy there is no reason to think that will change in future pregnancies. However if the reason for the ceasar was say Breech and the current baby is head down then there is a chance of a normal delivery
3. What is the size of the current baby? Obviously if the current baby is big we are likely to have challenges. Some countries use 4kg as the cut off but we seem to have challenges once the baby is above 3.5kg
4. Is there any other problem in that pregnancy?
We generally are not comfortable having to deal with more that one risk in any labour process. So if there is one previous ceasar plus any other complication we usually recommend a ceasar... complications like high BP, post date, breech, twins, baby not growing well, etc
5. Are we in a hospital that is capable of providing the required close monitoring? Books recommend 1 to 1 midwife to patient ratio and availability of that machine called a CTG that should be attached to the patient throughout to monitor the heart of the baby. The hospital should also be able to do a very quick ceasar should ther be signs that the womb is about to rupture. If the wombs rupture usually we lose the baby and we may also end up removing the womb.
6. What are the patient's wishes.? If the patient satisfies the above criteria and is willing to accept the risk of uterine rupture and possibility of resorting to an urgent unscheduled ceasar then we can try va**nal birth after ceasar.
7. Let me hasten to say most of our hospitals are not able to meet the above criteria and that's why you see that most gynaecologists are adopting a 'once a ceasar, always a ceasar policy.

So as always we encourage you to have an in depth conversation with your gynae if you are faced with this situation.

Thank you

21/09/2024

Lets talk about fetal movements (kicks)..

A healthy baby in their mother's womb moves. The movements may be whole body movements or flexion and extension of the the limbs. These movements are considered proof of normal nervous and muscular development of the baby.

The first time a woman feels fetal movements is reffered to as quickening. Historically, before the advent of pregnancy tests and ultrasound scans this, along with other signs and symptoms, would also help to alert the woman that she is pregnant.

When does the pregnant woman start feeling fetal movements?

It really depends on whether its the first pregnancy or not.
In their first pregnancy(primigravida), women first experience fetal movements from 20 to 22 weeks

Those who have been pregnant before normally experience fetal movements much earlier between 16 and 18 weeks of pregnancy.

I generally ask my patients to pay particular attention to the fetal movements. From the time you first feel the movements they tend to increase until the last 6 weeks of pregnancy at which point they plateau. They never reduce.
The kicks are a simple method of monitoring the baby and help in the establishment of the bond between the baby and their mom. The mother will have a sense of what is normal for their baby

WHAT IF FETAL MOVEMENTS ARE ARE REDUCED OR ABSENT?

There are a number of reasons why a mother can experience reduced fetal movements (RFM):
1. Mother is just too busy and is not paying attention
2. Smoking, alcohol intake,
3. Use of sedative drugs such as diazepam
4. Reduced amniotic liquid around the baby
5. Fetal compromise.... the baby is "sick"
6. Baby not growing well
7. Dead baby
8. Mother lying on their back(not advisable) also affects perception of fetal movements

If you think your baby has not been kicking well, the Cardiff count to 10 is helpful. This basically means if a woman counts 10 kicks in a 12 hour period while going about her normal duties then the baby is fine.
If the woman is not happy with the kicks then they should quickly contact their midwife or gynaecologist who will help ascertain whats going on and advise on way forward.

08/09/2024

Post menopausal bleeding!

In the absence of a hysterectomy (removal of the womb) a woman typically stops having periods around the age of 52 years. This is called menopause
We wait for 12 months of no periods to diagnose menopause.

If a woman then starts bleeding va**nally after that we call it post menopausal bleeding.

CAUSES.

1. Atrophic vaginitis. Because of lack of female hormones (estrogen) the tissues down there become "thin" and "brittle" and they bleed easily either spontaneously or after sexual intercouse.

2. Cancer in the inside lining of the womb. (Endometrial cancer) or its precursor, Endometrial hyperplasia

3. Cervical cancer.

4. Some cancers of the ovaries which produce female hormones.

5. Sometimes the blood is not coming from the va**na per se, but rather from the urinary system through the urethra or even from the back through the a**s and the woman erroneously ascribes it to va**nal bleeding.

Please take note. Only a small proportion, about 10% of post menopausal bleeding is due to cancer. The vast majority is due to non cancerous causes.
It is however important to have it thoroughly evaluated to rule out cancers.

Contact your trusted gynaecologist, doctor or nurse if you encounter someone with post menopausal bleeding

04/09/2024

We did that for the national broadcaster some time ago. I hope you find it useful.

Contraception is a form of birth control, targeted toward the female reproductive system to prevent pregnancy.

31/08/2024

Cervical weakness- a cause of recurrent miscarriages

Definition: this is a scenario whereby the mouth of the womb (cervix) in a pregnant woman is unable to remain closed and "hold" the pregnancy until 9 months.

Typically the distraught patient comes to us with a story like this
1. Doc, I have had more than 3 pregnancies but they all ended with miscarriages at or after 11 weeks.
2. I have heard 4 pregancies but I deliver prematurely all the time and my babies stay in an incubator for a long time and in 3 of the cases my babies died because they were very small
3. I was 15 weeks pregnant. I lifted a heavy bucket while doing laundry and my pregnancy "popped out" just like that
4. Every time I fall pregnant my "waters" break early before the baby is mature
5. I had a miscarriage in my first pregnancy. Now I am in 2nd pregnancy and the scan is saying my cervix is short.
In all cases there is a disturbing theme of: as the baby becomes heavy, the cervix opens up and the pregnancy is lost.

So what causes this?

1. In the vast majority of the cases we simply don't know. We say its idiopathic
2. Sometimes after a normal delivery a patient may sustain a huge tear on the cervix which may not heal well
3. Sometimes in illegal abortions performed in the backyards, sticks, wires etc are shoved down there which may cause damage to the cervix
4. As part of treatment of early cervical cancer we sometimes remove significant chunks of the cervix.

Are there any remedies?

Yes.
One very useful intervention is a stitch we insert on the cervix after 12 weeks of pregnancy. The stitch is popularly known as Shirodkar stitch but its real name is Mcdonald stitch.
We remove it when the patient gets to 37 weeks if the plan is to deliver normally or in theatre soon after a cesarean section.
If you get into labour with the stich in place quickly inform your nurse or gynaecologist so that it can be promptly removed.
We have also found over the years that support from the partner and family along with close follow up by your nurse or doctor is crucial in such cases

Contact your trusted health care provider if you encounter someone in this situation.

25/08/2024

19/08/2024

Pliz find that very important video pertaining to the dangers of giving cooking oil to your babies. All credit goes to the colleagues featured there in. Thank you

18/08/2024

I was asked to do this article by the Sundaynews during the World breastfeeding week.

I hope you find it useful. Here is the link

Bringing you the best

18/08/2024

What would have happened if one remains with a big tummy after giving birth and are there any remedies.?......

In response to our previous post there was that question.....

As a matter of necessity a pregnant woman has to gain weight.... in fact we get concerned if a pregnant woman's weight remains constant as the pregnancy progresses. Also the skin and muscles of the abdomen have to stretch to accommodate the growing womb and baby. So after delivery the abdomen remains lax for sometime. So its the laxicity of the abdomen and, in first few weeks of delivery, the womb itself that accounts for the big tummy after giving birth.

What you need are exercises that increases the tone of the abdominal muscles(exercises that tense up the abdominal muscles. Examples are the sit ups and planks.
Also ensure that you eat well and maintain a healthy weight.

17/08/2024

So while you are breastfeeding in the first few days to a few weeks you feel these cramps that are like period pain.... Do not worry.
Breastfeeding stimulates the release of a hormone called oxytocin.
Oxytocin, among other things, causes the womb the contract resulting in the cramps.
The contraction of the womb is important in reducing blood loss after delivery and also helps the womb to revert to its original small size. Usually a simple pain killer like paracet is all you need for the cramps.

Enjoy whats left of the weekend

15/08/2024

13/08/2024

Lets talk about one of the most popular methods of family planning in Zimbabwe.