Pelvic Organ Prolapse

Have no idea what it is called in Malay. I wished i had a dictionary specialised in medical terms in Malay. It would help a lot of  medical students and young doctors in Malaysia. What a horror for me to describe inflammation to malay and arguing wether its correct or not. I wished we could just teach laymen the proper medical terms instead of laymens term.

Ha, mungkin namanya rahim jatuh atau peranakan jatuh. Erm, betul kot...

Classification of prolapse

Anterior vaginal wall-upper one third :cyctocoele

Posterior vaginal wall-Lower one third :Urethrocele

Posterior vaginal wall

Upper one third - Enterocele

Lower one third -Rectocele

Uterine descent

-Descent of cervix into vagina

-Descent of the cervix upto the introitus

-Descent of the cervix outside the introitus

-Procedentia:All Uterus outside the introitus

Management

It is divided into  >Preventive>conservative>surgery

Preventive care

• Adequate antenatal anda intranatal care
• Adequate postnatal care
• General measures -avoid strenuous activities,chronic cough,constipation and heavy weight lifting,avoid too many and too soon pregnancies

Conservative

• Improve general measures above
• Oestrogen therapy replacement
• Pelvic floor exercise : Kegel exercise

Pessary treatment

Pessary treatment does not cure uterine prolapse. It relieves the symptoms by steching the hiatus urogenitalis thus preventing vaginal and uterine descent.

It is used in patients with

• Early pregnancy:placed upto 18 weeks when the uterus is sufficiently enlarge to sit on the brim of pelvis.
• Puerperium: to facilitate involution.
• Unfit for surgery
• Unwillingness for surgery
• While waiting for operation

Surgical Management of prolapse

-It is indicated when the conservative treatment has failed or not indicated.

-There is no single procedure for all types of prolapse.It depends on anatomical alteration of structures and the degree of prolapse.

-Age,reproductive abiliity and sexual functions should be considered before any specific surgery.

Types of operation

Anterior colporhaphy

•    To correct cycstocele and urethrocele.
• Sim's speculum is introduced, posterior lip of cervix is held by by multiple vulsellum and firmly brought down by assistant.
• Metal catheter is introduced to know the lower limit of bladder.
• Inverted T incision made to anterior vaginal wall.Horizontal incision is made below the bladder and the vertical incision is made starting from midpoint of the transverse incision upto a point abount 1.5cm below the external urethral meatus.
• The triangular vaginal flaps including fascia on either sides are separated from the endopelvic fascia covering the bladder by knife and gauze dissection.
• The bladder with the covering endopelvic fascia (pubocervical) is exposed as the edges of the vaginal wall are retracted  laterally.
• The vesico cervical ligament is held up with Allis tissue forceps and divided. The bladder is then pushed up by gauze covered finger till the peritoneum of the uterovesical pouch is visible. The vesico-cervical space is now exposed.
• The pubocervical fascia is plicated by interupted sutures with No "O" chromic catgut using round body needle.The lower one or two stiches include a bite on the cervix thus closing the hiatus through which the bladder herniates. The redudndant portion of the vaginal mucosa is cut on either side.
• The cut margins of the vagina are apposed by interrupted sutures with No 'O' chromic catgut using cutting needle.
• The catheter is reintroduced once more to be sure that the bladder is not injured.
• Toileting of the vagina is done.
• Vagina is tight packed with  roller gauze smeared with antiseptic cream.
• A self retaining catheter is introduced.

Paravaginal defect repair

Cyctocele is repaired by anterior colporrhaphy and plicating the endopelvic fascia in the midline under the bladder neck. but anterior vaginal prolapse may be due to the detachment of the endopelvic fascia from the lateral pelvic side wall.In the case repair should be done by reattaching the endopelvic fascia to the arcus tendineus fascia(white line) of the pelvis. This may be done retropubically through the space of Retziusor vaginally. This is indicated in cases with recurrent cyctocele following repair.

Perineorrhaphy/Colpoperineorrhaphy

Posterior vaginal wall prolapse is fixed by repairing

• Relaxed perineum - The operation is extended to repair the torn perineal body.
• Rectocele - The repair is extended to correct rectocele by tightening the pararectal fascia.
• Enterocele - High perineorrhaphy is to be done right upto the cervicovaginal junction along with correction of enterocele.

*restoration of perineal body is essential with any form  of pelvic floor  repair. This maintains the normal vaginal  axis.

Step of operation

• A pair of Allis tissue forceps is placed on each side at the lower end of labium minus and a third pair of  Allis is placed on the  posterior vaginal  wall in the midline  well above the rectocele bulge.
• A horizontal incision is made on the mucocutaneous junction joining the two allis tissue  forceps.
• Through the incision , with the help of perineorrhaphy scissors, the posterior vaginal wall is dissected off from the perineal body and rectum  upto third Allis forceps placed on the posterior vaginal wall.
• A vertical incision is made from the apex to the  middle of the horizontal incision (inverted T shaped incision)
• The two triangular flaps are now  dissected laterally to expose the rectum and musculofascial structures levators ani muscle.
• Lax vaginal flaps are excised.
• The rectocele is corrected by suturing the pararectal fascia with interupted sutures.
• Two or three interrupted sutures are placed through  the levator ani  and fibro muscular  tissues  of the  perineal body  using No I catgut. The rectum should be  pressed back by finger while the sutures are placed.
• The knots to be placed  at later stage.
• The cut margins of the posterior vaginal wall are approximated ,starting  from the apex using  No 'O' catgut untill it reaches upto the perineal body.
• The knots are now placed to the sutures passed through the perineal body.
• The rest of the posterior vaginal wall and the skin margins are apposed by interrupted catgut sutures.
• Toiletetting of the vagina is done.
• tight vaginal pack is optional.

Repair of enterocele and vault prolapse

Enterocele is corrected transvaginally. The principles of correction are to obliterate the neck of the enterocele sac as high as possible by purse string suture, to  excise the excess peritoneal sac and approximation of the uterosacral ligaments.

step by step procedure.

• An inverted T shaped incision is made with the vertical arm of the T extending up to the apex of the vaginal vault and the horizontal arm, along the mucocutaneous border.
• Dissection is carried out to expose the enterocele sac.
• The sac is opened the contents (bowel and omentum ) is pushed away.
• The peritoneum of the posterior cul-de-sac is dissected off the anterior surface of the rectum and lower sigmoid and excised.
• A purse string suture (2-0 vicryl)is placed high at the neck of the sac and tied. The excess peritoneum is resected off.
• The cervix is pulled upwards. Two interupted sutures are now placed around the uterosacral ligaments. These sutures also pass through the posterior aspect of the cervix.These sutures are tied. rest of the steps are the same as that perineorrhaphy.

*AAbdominal repair of enterocele is done by obliterating the pouch of Douglas to prevent herniation of bowel. This is known as Moschowitz procedure. Generally three or four concentric sutures are placed incorporating the uterosacral ligaments and peritoneum over the rectosigmoid.

Pelvic Floor Repair (PFR)

PFR includes anterior colporrhaphy and colpoperineorrhaphy. It should be emphasized that the pelvic floor repair is not the operation for uterine descent. but as the uterine descent is most frequently associated with prolapse of the vaginal wall, pelvic floor repair has to be done along with operation for uterine descent.

Fothergill's or Manchester Operation

The operation is designed to correct uterine descent associated with cyctocele and rectocele where preservation of the uterus  is desireble.

The indications are :

• Preservation of reproductive  functin
• when the symptoms are due to vaginal prolapse associated with elongation of the (supravaginal) cervix.

Principles steps of the operation are:

1. Preliminary dilatation and curretage
2. Amputation of the cervix
3. Plication of the mackenrodt's ligaments in front of the cervix.
4. Anterior colporrhaphy
5. Colpoperineorrhaphy

If family is completed vaginal sterilisation is to be done.

Steps of operation

• D & C
• Anterior colporrhaphy upto pushing the bladder
• The posterior lip of the cervix is to be held with vulsellum and the cervix is drawn upwards.
• A pair Allis forceps is placed in midpoint of the posterior cervicovaginal junction.
• The anterior transverse incision is now extended posteriorly across the posterior cervicovaginal junction. The lateral and posterior vaginal wall is dissected off from the cervixby scissors and finger dissection.
• The Mackenrodt's ligament with descending cervical artery of either side is clamped at higher level of amputation , cut and replaced by ligature(chromic catgut No 1)
• The presence of enterocele should be searched for and if detected, to be repaired.
• The cervix is now amputated at the calculated level.
• Anterior lip of the amputated cervix is now held with single-toothed vulsellum.
• The posterior lip of amputated cervix is covered by the vaginal flap using a Sturmdoff sutur or by Bonney's method.
• The cut ends of Mackenrodt's ligament are sutured to the anterior surface of the cervix. alternatively, the ligaments are fixed using Fothergill's stitch. Fothergill's stitch is used to make the uterus anteverted. The stitch passes through the following tissues in sequence. Vaginal skin at the level of Fothergill's lateral point->Mackenrodt's ligament->through the cervical tissue from outside inwards->cervical tissue from inside outwards->Mackenrodt's ligament of the other side -> vaginal skin(Fothergill's lateral point) of the other side.
• Pubocervical fascia is approximated as in anterior colporrhaphy.
• Redundant portion of the vaginal mucosa is excised.
• The cut margins of the vagina are apposed by interuppted sutures.
• Posterior colpoperineorrhaphy is performed.
• Toiletting the vagina is done.
• Vaginal pack is given.
• Self retaining catheter is introduced.

Vaginal Hysterectomy with Pelvic Floor Repair

-Also called as Ward Mayo's operation.

-Indications:

• Uterovaginal prolapse in postmenopausal women.
• Genital prolapse in perimenopausal age group along with the diseased uterus like DUB, unhealthy cervix or small submucuous fibroid requiring hysterectomy.
• As alternative to Fothergill's operation where family is completed.
• As an alternative to abdominal hysterectomyin undescended uterus either as a routine or in selected cases where abdominal approach is unsafe.PFR is not done in such cases.
• As an alternative to laparoscopic assisted vaginal hysterectomy (LAVH)in selected cases of undescended uterus. Compared to LAVH vaginal hysterectomy is less expensive and the perioperative morbidity is no different.

Principles of the operation in prolapse

• Removal of the uterus through vaginal route.
• Correction of the enterocele, if any.
• Approximation of the pedicles in the midline to have a good buttress.
• Fixation of the uterosacral ligaments to the vault to prevent vault prolapse.
• Bladder support is reconstituted utilising the broad ligaments and round ligaments as buttress.
• Repair of cyctocele.
• Reconstuction of the perineum.

Steps of operation for vaginal hysterectomy (indication -genital prolapse)

• Anterior colporrhaphy procedure same, up till pushing the bladder.
• The uterovesical peritoneum is  cut open.Landon's retractor is introduced and to be held by an assistant.
• The posterior vaginal wall along the cervico vaginal  juncton is cut  as  in Fothergills operation.The vaginal wall is dissected down till the pouch of Douglas is reached. The peritoneum is cut open.
• First clamp is placed which includes uterosacral ligament,Mackendrodt's ligament and descending cervical artery. The tissue are cut as close to the cervix and replaced by vicryl No 1 .Simmilar procedures the followed on the other side.
• Second clamp includes uterine artery and base of the broad ligment. The structures are cut as close to the uterus and and replaced by ligature (vicryl No 1) .Same procedures are done other side.
• The fundus is now brought out through the anterior pouch by a pair of Allis tissue forceps.
• The third clamp includes round ligament , fallopian tube, mesosalphinx and ligament of the ovary.The structures are cut and replaced by transfixing suture (Vicryl No 1). Same done the other side.The uterus is removed.
• Correction of enterocele is to be done at this stage.
• Peritoneum is closed by purse string suture.
• The sutures of the uppermost pedicles on either side are tied. The excess suturesof the uterien artery pedicle on each side are cut.The sutures of the pedicle containing the uterosacral and Mackenrodt's ligaments are passed throughthe vault crosswise and are to be held temporarily.
• As in anterior colporrhaphy , the pubocervical fascia is approximated and fixed to thhe uppermost tied broad ligament pedicles to close the hiatus.
• Redundant portions of the vaginal flaps are excised and the margins approximated by interupted sutures(Vicryl No 0)
• Crosswise passed sutures of the lowermost pedicles are tied, thus fixing the ligaments with the vaults.
• Perineorrhaphy is done.
• Vaginal packing is optional.
• Self retaining catheter is introduced.

Vault prolapse . Post hysterectomy (vaginal or abdominal )vault prolapse is usually accompanied by an enterocele ( 70%). However, cyctocele and or rectocele may be present. The vault prolapse in such cases may be effectively repaired transvaginally mantaining the same  principle of repair of enterocelealong with anterior colporrhaphy and colpoperineorrhaphy.

Conservative Rx: Pessary generally not recommended.

Surgical Rx: 

Transvaginal approach : 

• Repair of enterocele along with pelvic floor repair.
• Le fort operation
• Colpocleisis (cases following hysterectoy)
• Sacrospinious colpopexy.

Abdominal approach

• Vault suspension (sacral colpopexy)

Le Fort operation

The procedur is almost obsolete. It may be done in old agevwith procidentioa he the patient is unfit for longer duration of surgery as vaginal hysterectomy with PFR. There should not be any uterine or pelvic pathology.Cervical cytology (pap smear) should be normal.The operation can be done under local anaesthesia.

Step b ystep

• Denudation of rectangular vaginal flap from the anterior and posterior vaginal walls.
• Apposition of the denuded anterior and posterior vaginal walls by chromic catgut. Two small channels are left in the vagina one on either side or drainage.
• The comlications include -pyometra and urinary stress incontinence.

Colpocleisis (after hysterectomy)

Denudation of vaginal mucosa is done all around. Successive purse string absorbable sutures are placed from above downwards to appose the vagina walls.It is simple , safe and effective opertion for a woman who is no longer interested in coital function.

*sacrospinous colpopexy is done by fixing the vaginal vault to the sacrospinous ligamenton the right side. This procedure may cause damage to the bowel ,ureter or the pudendal vessels.It has higher failure rates.

Abdominal approach

Vault suspension (sacralcolpopexy):principle of the operation is to suspense the vaginal vault to be anterior longitudinal ligament in front of the 3rd sacral vertebra. Non absorbable suture material (Mersilene or Gore-tex mesh) is used.

Step by step

• Abdomen is opened by vertical or transverse incision.
• A verticle incision is made on the posterior peritoneum over the sacral hollow while the rectosigmoid is pulled up laterally.
• Lateral angles of the vagina are identified and grasped with Allis tissue forceps.
• Two strips or Mersilene or Gore-Tex mesh(1.5cm wide ) are fixed to the vaginal angles and are pulled up in the midline.The other ends are fixed to the anterior longitudinal ligament in front of 3rd sacral vertebra with proper tension.
• Posterior peritoneum is sewn over the strips to make them retroperitoneal .
• Complications: Stress urinary incontinene is important one.

*Laparoscopic sacrocolpopexy is found to be effective with similar result to open sacrocolpopexy.

Cervicopexy or Sling operation (Purandare's operation)

The operation is indicated in congenital or nulliparous prolapse without cyctocele where the cervix is pulled mechanically through abdominal route.Strips of rectus sheath of either side passed extraperitoneally are stiched to the anterior surface of the cervix by silk.

Step by step

• A transverse abdominal incision is made through the skin and fat.
• Two facial strips (retus sheath) of 1.5c wide are dissected off,keeping its lateral attachment at the lateral border of the rectus muscle intact.
• The peritoneal cavity is opened in midline. Bladder peritoneum is dissected off and the uterine isthmus is exposed mobilising the bladder.
• The medial ends of the facial strips are now brought down between the leaves of the broad ligament to this site of uterine isthmus.
• The free edges of the facial strips are now fixed at the uterine isthmus  with a sturdy bite using silk. This is done after adjusting the correct position of the uterus.
• Bladder peritoneum is repaired and abdomen is closed in layers. This operation may be combined with Moschowitz procedure.Instead of facial strips , currently non-absorbable(Marlex or Gore Tex) tape is used for this purpose.

Dysfunctional Uterine Bleeding

Im rewriting the answers for my sessional exams. Urgh, i know it was a disaster.

Definition of DUB : It is a state of abnormal uterine bleeding w/o clinically detectable organic,systemic pathology and iatrogenic causes.

It a diagnosis done by ruling  out :

• pregnancy  related complications
• tumours of uterus -Benign (Cervical polyp, endometrial polyp, fibroids)
• Infections
• foreign body- IUD
• Systemic -Hepatic,Renal,
• Blood disorders
• idiopathic
• endocrinal disorders

Types of DUB

• Anovulatory (80%) -Threshold bleeding of puberty menorhagia,Metropathia Hemorhagica,Premenopausal DUB
• Ovulatory(20%) - Irregular ripening,Irregular shedding, IUCD insertion,following sterilization operation.

Signs and symptoms

.Abnormal bleeding are associated with  or without ovulation and are grouped into:

• Ovuular bleeding (polymenorrhea/polymenorhagia/oligomenorrhea/menorhagia of irregular shedding and ripening)
• Anovular bleeding (usually excessive bleeding due to anovulation causing endometrium growth is under unopposed action of oestrogen in absence of progesterone).

Investigations of anovulatory DUB

• Detailed history of menstruation ( no of pads used, passage of clots size & nomober, and duration of bleeding)
• History of IUCD or  steroidal contraception
• History of abnormal bleeding from gums, injury site, epistaxis.
• Bimanual (per vagina, per rectal) examination done to exclude pelvic pathology.(  PV done  for all except virgins)
• Blood haemoglobin estimation,platelet,PT,prothrombin time,
• TSH,T3,T4 estimation done is suspected thyroid cases.
• D&C ( Diagnostic uterine curretage)
• USG and colour Doppler (endometrial hyperplasia : ET> 12mm,hyperechoic,and regular outline)
• Hysteroscopy
• Laparoscopy
• Hysterography

Plan of investigations : Blood values->USG->D&C->Hysteroscopy/hysterography->laparoscopy

Management of anovulatory DUB

DUB treatment includes a general,medical and surgical treatment.

General treatment - Rest, correct anemia,

Medical treatment - Hormones,Prostaglandins synthethase inhibitors,Antifibrinolytics

Surgical treatment - Uterine curettage,endometrial ablation/resection,hysterectomy

Gynaecology terms

Menorrhagia : It is a cyclical bleeding occuring with excessive amount(80ml) or duration or both.

Polymenorrhea : It is  a cyclical menstrual bleeding that occurs less than 21 days .

Oligomenorrhea : It is a cyclical bleeding that occurs for more than 35 days.

Hypomenorrhea: It a scanty menstrual bleeding that occurs less than 2 days.

Metrorhagia:It is irregular and acyclical  uterine bleeding.

Menometrorhagia: It is irregular and excessive bleeding in which menstruation is difficult to be identified.

OBG Posting: Aduh..peritnya si Ibu...

They giggled..., while the mother gritted her teeth trying so hard to push her first baby into this world.

It took four to five people to assist with the normal vaginal delivery of Mrs A.

One trying to poke her into the vagina, streching it as far as possible for the head.

One person to support the perineal muscles from tearing.

One person sitting kneeling over the patientt, giving a big push using her fist onto the abdomen.

One person waiting anxiously with the tray for baby on her hands.

One person waiting for the baby nearby the radiator.

20 of us students, watching with horrified-wondrous face.

It happen in a blink of an eye.

One moment the baby was out, and less than 5 minutes the placenta went out too.

and yeah.


She had a cut 'down' there. And of course without local anesthesia.

The mother can only endure the pain with a tear-less cry each time the doctor poke the hook needle into her flesh, approximating it together as soon as possible if so the vagina can be healed into its former glory.


I suddenly imagined how in the world can  one soul endure such pain?
That is only for the first child.

Y'all know my grand mothers both had like 12 t0 14 children!!!


All hail to Mothers!!!

Thank you for enduring such pain so we can see the world!

Love you Ibu.!!!!

OBG : Final day with ease

Saturday, final day unit 2 OBG.

Ho yeah~! *\(*u*)/*

No more hospital melodrama. No more kena leter dan kena marah.

Last day in unit 2 was magnificent! Although i was a bit nauseated and a bit uneasy during normal vaginal delivery at  labour theater, i finally realized that how much strength Allah gave to women to endure the pain during labour. At first , that female was yelling and screaming "amma appa..ayyooo" in so much pain and accompanied by the yelling of the PGs who tried to calm her down, my ear and my head began to be in pain. "Amma, chill madi!", said the male PG in charge while he was holding a episiotomy scissor  getting ready to cut her 'down' there. I can see everyone's forehead fill with wrinkles and sneering faces. Cut her some slack please! She was in pain! I can't help my self but to frown too. But, i had different reason. I just want the staff to treat her better. No wonder lah, many people said that during labour, the staffs always yells at the pitiful mothers who doesn't even have their husbands to accompany them. I wonder if my-husband-to-be will be able to hold my hand and be with me along the way in labour. Maybe, one day i can have my own hospital exclusive for women in labour where all the staff are nice and caring and most importantly, i want to hire only FEMALE staffs to work with me. At least, i can provide a choice to mothers who are unwilling to have a male doctor putting his hands in side her vagina, slicing them and watching them in pain.

I knew that all medical students have to master in every subject reagardless of the gender monopoly (im trying to say that male doctors have to learn and see female anatomy, and vice versa), but as a Muslim, i have responsibility to provide healthcare that emphasizes not only to medical care and supervision but also supervision and care from aurh( areas where non marriable people can't see) invasion.

After watching the delivery in a cloudy-state-of-mind, we dashed off to wards to finish writing our history presentation case.This time my teammates pleaded me to present the case as i have the non-jackable-non-anger inducing-face regardless of my mistakes i do during presentation. Like what they have predicted, Dr S who was known to be very aggresive  in taking viva and presentation didn't even bother to get angry as i was caught bluffing with a smiling face. I can clearly remember her saying " if you want  to bluff the vitals score or the examintion, at least put it at a normal level..." with a sinister face. Hihih, gomenne mera dhosti! I was in a hurry to copy the case sheet and present it without noticing the abnormal levels! Haha, i told you i can't lie with a straight face! Cikgu, sorilah. We didnt mean to cheat you by not taking the measurement and examined her ourselves,its just that we don't have adequate time to finish taking the case.Plus, the patient went to USG examination. So, we had to make up the history ourselves! Teehee! Sorry! (--_--)''



Baru teringat nak update pasal pesakit cancer ovari. Yup, haritu, sempatlah jugak palpate patient ni. Abdomen dia penuh ngan air(ascites). So, bila masuk OT cegu sedutlah segala air dalam abdomen tu. Teringat jugaklah yang dia panggil cekgu surgery untuk buat stage laparoscopy. Puihhh, buakan main banyak lah ketul-ketul air(cyst) yang dah merebak kat usus kecil dia. Impression diagnosis : Sero-mucinous ovarian cyst.

p/s: Argh...sakit hati pulak bila tak sempat nak tengok macam mana PG tu suture episiotomy incision tu. 

OBG : Its a BOY

Day three,week three in unit 2.


Tak lama lagi masuk unit 1 yang cool and sporting.
Sila sabar untuk tiga hari lagi.



Today we got to see a baby. Finally after two weeks posted in unit 2 i can finally see a baby being born into this world. It was an elective caesarean section. The babt was healthy and cried immediately after cord was clamped. Seronok betol bila dengar baby nangis.

Heheh, BYu memang suke menyakat budak. Suka sangat buat diorang nangis. Dah maen,pukkk huaawaaawaaa. ...lepas tu lari jauh-jauh. Jahat tol kak awe ni.

Ok. Viva di OT hari ni.

- caeserian section
- adnexal tu sebenarnya ovary n tube.
-management of pre, during n post c section patients
-Absolute indication n relative indication of c sec.
-steps of c sec.
-suturing the layers of incised uterine layers.ar lower part,how long,which material,which method of suturing.
-advice to patients after discharge.

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OBG : Week Three 9th term

Day 13.

Its OT day again. Every alternate days in unit 2 OBG, we have OT. On wednesdays at 11am we have theory class with Dr. DKS in OPD.

Case we've seen in fibroid uterus. Its a 34 yr old female,unmarried,had h/o bleeding pv, abdominal mass... It was BIG! Maybe around 3-4kg. Lots of bleeding during myomectomy. She was conscious all the way due to epidural anaesthisia.

The HUGE BUT!

Before we were allowed to enter the room,i could see the VULGARITY of surgical procedure. She is unmarried and we could assume that she had not been sexually active,hence had never been exposed physically in front of anyone in her life.
However,like what my mom uses to tell ;

"Once in the OT, everything will be EXPOSED and you are no longer subjected to privacy."

It felt horrible towards the lady,who is conscious and aware that a lot of people are staring at her lower private part including the OT male assistant(the one who angkat her onto the bed since she is quite obese),male OT assistant,the male interns, the male medical students, the doctors and the anaestheticians.

Yeah. I knew that in a teaching hospital, this kind of situation is common.Nevertheless,if we put ourselves in her place,imagine the trauma and horrifying experience of being exposed in front of so many people that she had never seen in her life. I can just geleng kepala aje.

Well,what to do kan? If you want a cheaper cost of treatment at the expense of infiltration of your body privacy, teaching hospitals in the usual way out of financial insufficiency.

It is unbelievable that the ones that offer complete care of women physical privacy makes their patients pay for what supposed to become their human rights. Yeap,it is the 'special service,special price policy' nowadays.

*sighs*

Sempat jugak borak about my very first experience of warching normal vaginal delivery and reminincing the joy of endorphins running through my veins all day. It was an AWESOME feeling i had ever had. I just couldnt stop smiling! Hekk, it is even better from getting all A1's in SPM or getting having had to receive thr scholarships etc... It is a complete PURE OF JOY and HAPPINESS that i felt that day. It is a miracle of the birth of a life to this world and that feeling of ecstacy is what i am searching for in this path i have chosen.

Come on dear ME!

Wake up and remember that feeling!
Yosh!

Gosh! Tomorow we will have MCQs on caesarean section in class. Wish me luck! ^_^

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OBG :Lesson learned

Dr D.K.S. Graduated in Europe,did his internship there andcame to his homeland to serve his people.

Today,i've bewn reminded again how difficult to vain knowledge in medicine.

"You people are all USELESS peole! "

"You people dont even know the basic!"

"You are all BLOODY LAZY! "

"You don't even have any initiatives to read and find the basics in clinicals. Theory is important but during end of posting, your understanding in assessing the case is much more superior than your theory knowledge. "

Shame on me.

Shame.

Than goes on and on asking the basic questions. Nk one dared to answer. All of us are quiet as people at the funeral. He kept saying that we have to speak up and do mistakes now and nog during exams in which good examiners will never let IGNORANT medic students to PASS.

Passing is all i need. Distinction or first class won't even matter anymore. To pass is almost a miracle to me.

Dear me,please dont be disheartened by what they say. They are just doing their job as a teacher. Without them,you wont be here.

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OBG - Ot day

Yup,it is the second week of OBG postings. Today,the weather is super awesome!

Imagine yourself sitting in a nearly empty bus,the chilled breeze blew softly to your cold face,when you outside through the window, the only thing your eyes could see thick-magical-like mist surrounding the bridge. The bus ride seems more like a cloud ride to Alice's Wonderland.

What a good feeling to start your day.


Today, we were posted in OT. Again,got scolded by Dr N.

"You people never take the case before coming to OT! "

"Always shaking heads when asked!"

"You people dont know anything at all. Already ninth term but donno anything!"

"You people should come and see the case first before coming to OT."

Scoldings,nagging,smirking,jagging. All become our daily breakfast in OBG.

Ahah. I shall stop here. No more complaints ok. This was all things they should do. At least they nag and say something to wake us up. It would be worse to have staffs who doesnt even care to nag when we dont know the answers... Let them do their job dear.



Now..coming to the viva in OT.

-Differrence between thr pseudo and true broad ligament in fibroid uterus?

- Indications of hysterectomy and myomectomy. Age wise,family completion,recurrence,

-History findings in ovarian mass and uterus mass.

-Clinical features in mass per abdomen in ovarian mass and uterus mass.

-Complications of ureter injuri during operation.

-Post menopausal bleeding causes.

-Dysfunctional uterine bleeding.

-What can you feel when palpating mass per abdomen? Give differential diagnosis.

-Cystic feeling,firm consistency,Grooves sign.Bimanual feeling,continouity of mass in uterus through cervical examination.

-DNC,Currete instrument,Abortion.

-Menstrual irregularities in mass per abdomen.

-Why there is menorhagia in post menopausal women?
=Increase surface area,hyperplasia of the endometrium due to oestrogen level increase.

- DX of Surgical causes of mass per abdomen.TB,retroperitoneal carcinoma,...

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OBG : OT Day

Day 2.



Its OT day.

Today, we had seen the common.
A known case of ovarian cancer, its seromucinous type which produces ascitic-like fluid in the peritoneum. From tip-toeing behind Dr N and Dr L, i could see grain-like thingy scattered all over the bowel. They decided to do colonoscopy and sent us all out. Instead Dr L asked one of the unfortunate PG to take a class on ovarian tumour. As expected,she taught us whatever she knew,and let us go early.

Pheww,

Today,it is so much like a pasar malam or a kindergarten. There are people screaming,some runs,some frowns,some giggling at the corner and so on.

It is going to be alternate days of pure boredomeness in OT in which much better than having class in OPD.Why? Coz it is so boring and most importantly NO AIRCOND!





Bring flip flops!

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OBG: The womenhood and maternity world

DAY-1 9th term

Instead of watching educational videos..try this!

Heheh..that one is a korean drama. Do watch the drama. I haven't seen it yet.I found it in Youtube asi was trying to search for antenatal examination.

Hihih...

OBG

I don't like that you do abortions, but if you didn’t...

I don't like that you do abortions, but if you didn’t, I would probably be dead

I was paged by labor and delivery three times during the 10 minute drive from my house. I headed straight from the parking lot to the labor ward expecting a patient of mine to be close to delivery. I was wrong.

The chief resident and attending obstetrician were waiting. They looked tired and worried.

A woman had arrived on Friday with ruptured membranes. She was 21 weeks along in her pregnancy and now there was no amniotic fluid left at all. She and her husband wanted everything done. Despite the dismal prognosis for her baby, in respect for the patient’s autonomy, antibiotics were started. Within 24 hours it was clear she had an infection.

Delivery was recommended as these infections are potentially deadly. The parents refused. “The antibiotics might work,” they said. And no amount of discussion about the overwhelming medical evidence that supported delivery could sway their decision. Inducing labor at 21 weeks while their baby was still alive was abortion.

The infection worsened despite the antibiotics. The patient, who was rapidly deteriorating, and her husband reluctantly consented to an induction of labor.

And now it was clear why I was needed. Infected uteruses don’t contract very well. Prostaglandins and oxytocin both failed to produce even a cramp.

“They are very pro-life,” the resident warned. “It took several hours of convincing just to get them to agree to talk with you.” Considering I practiced in the bible belt this was not an unfamiliar scenario. I shrugged and walked into the room.

My patient was clearly very ill. Flushed, sweating, and drifting in and out of consciousness. The smell of anaerobes unmistakeable.

I reviewed what had transpired to date. The infection. The prognosis. And what I could offer. A dilation and evacuation.

They had two concerns. The first, their baby was still alive in spite of the infection. The second problem was that I was an abortionist. Couldn’t a doctor who didn’t perform abortions do the procedure?

“I understand your baby is still alive, but he or she cannot live. It is sad and it is unfair, but the pregnancy is now killing you. It is not a matter of if you die, but when.” I paused. “You have other children at home and they will be without a mother. If it is any consolation, at 21 weeks babies do not feel pain.”

The husband’s body language said it all. “How did you learn to do these procedures,” he asked.

“By doing abortions. Lots of them. I have done more late term abortions than most doctors of my generation. That makes me very skilled. But the privilege of helping women end their pregnancies safely also gave me the skill to help women like your wife. There is no other way. You have to do a lot of these procedures to become proficient. Even more to do them safely for a women at 21 weeks who has an infection.”

There was no response, so I continued. “This is a very precarious situation. An infected uterus is easy to damage. I could make a hole and injure other organs. Even if the procedure goes well, the bleeding might not stop. A hysterectomy could still be needed. The infection in the blood stream might still get worse. But without the procedure, your wife will die.”

My patient spoke. “I don’t want to die.”

Within the hour we were in the operating room. The procedure went well. The bleeding, though profuse, was controlled without a blood transfusion. Within 24 hours she looked like a completely different woman.

Several months later I was surprised to find her name on my schedule. Especially given the reason was a first prenatal visit. After the appointment was over, I expressed my pleasure to have her in my practice, but also my surprise.

She looked at me and said, “I don’t like that you do abortions, but if you didn’t, I would probably be dead and not celebrating this new life. My husband isn’t thrilled that I am seeing you. He just can’t wrap his head around the fact that women sometimes really need someone who can do what you do. But I don’t see how I could go to anyone else. You saved my life.”

I think of the many times I have been in this exact situation over the years and it makes me wonder what happens now to the women who rupture their membranes at 21 weeks in Idaho, Nebraska, North Carolina, and Ohio. These women can’t choose to have a dilation and evacuation or even an induction of labor. They must wait until their baby succumbs in utero or for a spontaneous delivery, almost always a grim prognosis for their baby. Unless of course an infection develops and her life and health are in danger. Only then, when it is more dangerous, can a woman terminate her pregnancy at 21 weeks with ruptured membranes.

And if the induction of labor fails, as they often do, will these women be able to find a provider in one of those states skilled enough to safely perform a dilation and evacuation at 21 weeks in the presence of an infection?