11. II मातृ देवो भव II
Tight rope walk
• Poor paramedical supportPoor paramedical support
• No health insuranceNo health insurance
• Shoestring budgets and packagesShoestring budgets and packages
• Monsoon economyMonsoon economy
– Farmer suicidesFarmer suicides18, 2015गुरवार जून 1.11
27. II मातृ देवो भव II
IDEAL METHOD….
• BANGLES CAN BECOME A CAUSE OF
DEATH
• BREAKING CAN BE UNSAFE AND
TRAUMATIC FOR THE PATIENT AND
THE HEALTH CARE PROVIDER.
18, 2015गुरवार जून 1.27
28. II मातृ देवो भव II
ALL THAT IT NEEDS IS…
RINGS USED FOR HAND
EMBROIDERY
THICK SEE THROUGH
PLASTIC BAG
SIX INCH METAL SCALE
WOODEN ROD (ROLLING
PIN!!)
18, 2015गुरवार जून 1.28
29. II मातृ देवो भव II
DO IT YOURSELF…
18, 2015गुरवार जून 1.29
30. II मातृ देवो भव II
THIS IS THE WAY TO USE IT
18, 2015गुरवार जून 1.30
59. ESPECIALY AT THE PHC
LEVEL…
II मातृ देवो भव II18, 2015गुरवार जून 1.59
60. COMPLICATIONS…
• ACCIDENTAL OPENING OF THE BLADDER
• AVULSION OF THE TUBE
• RARELY
– INFECTION
– BOWEL INJURY
II मातृ देवो भव II18, 2015गुरवार जून 1.60
64. THE LARYNGOSCOPE
PROVIDES RETRACTION,
ILLUMINATION AND GOOD
PNEUMOPERITONIUM.
TUBES NEED NOT BE
HOOKED OUT OF THE
ABDOMEN. NO FEAR OF
AVULSION.
LESS PAINFUL. QUICK.
MORE REVERSIBLE.
BAND APPLICATION AT
THE ISTHMUS IS EASIER
THAN WITH MPM.
IT KEEPS THE
LARYNGOSCOPE IN GOOD
WORKING CONDITION. II मातृ देवो भव II18, 2015गुरवार जून 1.64
65. II मातृ देवो भव II
India is a land of festivals…
• Menarch
• Engagement
• Marriage
• Honeymoon
• Pregnancy
• Childbirth
• Naming ceremony
18, 2015गुरवार जून 1.65
66. II मातृ देवो भव II
But…..
• Termination of fertility…..
18, 2015गुरवार जून 1.66
67. USE OF VAGINAL BALL
BEARING:
AN EFFECTIVE AND
COST-EFFECTIVE METHOD TO
TREAT POST PARTUM SUI AND
EVEN THAT EMBARRASING
PASSAGE OF GAS PER VAGINUM.
18, 2015गुरवार जून 1.67II मातृ देवो भव II
68. SUI, A COMMON CLINICAL
PROBLEM.
AN EPIDEMIC WAITING TO
HAPPEN.
DOCTORS ARE
RELLUCTANT TO OFFER
TREATMENT
PATIENTS HARDLY SEEK
TREATMENT..
II मातृ देवो भव II
GRANDGRAND
18, 2015गुरवार जून 1.68
70. NECESSITY IS THE
MOTHER OF
INVENTION
SO BALL BEARINGS
THOSE USED FOR TRUCKS AND TRACTORS.
CHEAP
20 gm TO 100 gm WEIGHT.
READILY STERILISED.
THEY DISCOURAGE ‘VALSALVA’ &
ENCOURAGE ‘KEGEL’
BUT
TOO SMALL AND TOO LARGE
II मातृ देवो भव II18, 2015गुरवार जून 1.70
71. HOW TO GO ABOUT
IT…
CONFIRM SUI,
ETC:
BE SURE THAT
VAGINAL
WEIGHTS WILL
HELP.
GIVE DETAILED
EXPLANATION.
START WITH THE
‘PASSIVE
WEIGHT’.
ENDOWS
CONFIDENCE.
II मातृ देवो भव II18, 2015गुरवार जून 1.71
72. 20 gm INCREMENT / DAY.
15 TO 20 min OF WALKING
WITH WEIGHTS IN SITU
.
NO SQUATTING OR SITTING
TO BEGIN WITH.
LATER PERMIT SITTING
AND EVEN SQUATTING.
THERAPY AT HOME GOOD
ENOUGH.
II मातृ देवो भव II18, 2015गुरवार जून 1.72
76. RCOG GUIDELINES
NT, sos biochemical markers
Consider maternal age
(30%)
Do an NT scan at 11 to 13+6
weeks ( 75%)
If >3 offer invasive testing.
If grey zone consider
Nasal bone (90%)
Biochemical markers if
grey zone results
(95%)
18, 2015गुरवार जून II मातृ देवो भव II 1.76
77. II मातृ देवो भव II
Fundal pressure
• Ventouse and Forceps… only after you
have tried Biceps and Triceps
• WHO says…
– Level C recommendation
– Proper pressure, direction and timing
18, 2015गुरवार जून 1.77
78. II मातृ देवो भव II
THINK OF AUTOLOUGUS
DONATION / TRANSFUSION
• ANY WOMEN WITH NOANY WOMEN WITH NO
OTHER CONTRAINDICATIONOTHER CONTRAINDICATION
FOR DONATION & Hb OF 10+FOR DONATION & Hb OF 10+
& PCV 35%+ MAY DONATE& PCV 35%+ MAY DONATE
BLOODBLOOD
18, 2015गुरवार जून 1.78
79. RCOG GUIDELINES
• USE STARCH SOLUTIONS TO PRE-LOAD
THE PATIENT PRIOR TO SPINAL
ANAESTHESIA.
II मातृ देवो भव II18, 2015गुरवार जून 1.79
80. • ADMINISTER O2 ON MASK
THROUGHOUT THE SURGERY, SINCE
THE SpO2INVARIABLY DROPS WITH
SEDATION (PENTAZOCINE).
18, 2015गुरवार जून 1.80II मातृ देवो भव II
81. II मातृ देवो भव II
INSIST ON A BT, CT, PC, AND PT
(IF POSSIBLE EVEN APTT).
OBSERVE THE CLOT
VERY KEENLY AND FREQUENTLY.
IF IT FORMS AND DISSOLVES,
WARN OF MORTALITY,
EVACUATE FIRST THE UTERUS
AND
THEN THE PATIENT.
RCOG GUIDELINES
IN HIGH RISK PATIENTS…
18, 2015गुरवार जून 1.81
82. INTRACATH CAN READILY BE PLACED IN
THE FEMORAL VEIN, SUTURE IT THERE.
II मातृ देवो भव II18, 2015गुरवार जून 1.82
83. JUGULAR ACCESS IS EASY;
NEVER HESITATE
II मातृ देवो भव II18, 2015गुरवार जून 1.83
84. HAVE ANATOMY CHARTS, PROTOCOLS, NO16
INTRACATH AND CENTRAL CATHETERISATION KIT
TAPED ON THE WALL
II मातृ देवो भव II18, 2015गुरवार जून 1.84
85.
86. A place for everything and
everything in its place
88. जरर करावं असं काही...
II मातृ देवो भव II18, 2015गुरवार जून 1.88
89. GIVE AN ANTENATAL DOSE…
300 mcg @ 28 weeks
Or
100 mcg @ 28 & then
again @ 34 weeks
18, 2015गुरवार जून 1.89II मातृ देवो भव II
90. TESTS FOR QUANTIFYING
FMH
• ERYTHROCYTE ROSETTE TEST
– HIGHLY SENSITIVE (100%).
– POOR SPECIFICITY.
– THUS RESULTS NEED CONFIRMATION BY ONE
OF THE TESTS BELOW.
• FLOW CYTOMETRY
– HIGHLY SENSITIVE (100%), COSTLY,
TECHNICALLY DIFFICULT.
• KLEIHAUER-BETKE TEST
– LAB & TECH ERRORS
18, 2015गुरवार जून 1.90II मातृ देवो भव II
91. D immunoglobulin cross
matching
• D immunoglobulin cross-matched with
maternal blood
• + ve if 20 ml or more feto-maternal bleed
• K-B still the test of choice to assess exact
volume.
II मातृ देवो भव II18, 2015गुरवार जून 1.91
92. जरर करावं असं काही...
• सवयंचिलत रक चाचणी अहवाल काळजीपूवरक
वाचावा.
II मातृ देवो भव II18, 2015गुरवार जून 1.92
93. RCOG guidelines for Thal screening
• High RBC count
– RBC > 4.5
• Low indices
• MCV < 72
• MCH < 22
MCV2
* RDW
Hb*100
<65 ….THALASSEMIA
18, 2015गुरवार जून II मातृ देवो भव II 1.93
94. THE PREVELENCE OF BETA THAL IN
INDIA IS 3.3%
6.5% in Punjab
8.4% in Tamilnadu
4.3% in south India
3.5% in Bengal
MY CLINIC 2.8%
High prevalence in some communities Sindhi, Luvana, Tribes,
and Rajputs (10% to 15% in these communities)
18, 2015गुरवार जून II मातृ देवो भव II 1.94
99. जरर करावं असं काही...
II मातृ देवो भव II18, 2015गुरवार जून 1.99
100. MgSO4 FOR IMMINANT PT
BIRTH
Recommendations
For women with imminent
preterm birth (≤ 31+6
weeks), antenatal
magnesium sulphate
administration should be
considered for fetal
neuroprotection. (I-A)
II मातृ देवो भव II18, 2015गुरवार जून 1.100
113. • Congenital hypothyroidism incidence of 2.1
per 1000
• Incidence of 1 in 4000 reported in Western
literature and
• 1 in 1700 from other regions of India
• Urvi Sanghvi and KK Diwakar,
Department of Neonatology,
Malankara Orthodox Syrian Church
Medical College,
Kolenchery PO, Kochi 682311, Kerala,
II मातृ देवो भव II18, 2015गुरवार जून 1.113
148. मनःपूवरक धनयवाद
• DR.VIDYADHAR GHOTAWDEKAR
• DR. MANISH MACHAWE
• DR. ANURADHA RIDHORKAR
• DR. MILIND SHAH
• DR VILAS PARAMANE
• AND MANY MORE WHO HAVE DARED TO
SERVE THE RURAL MASSES RISKING SO
MUCH FOR SO LITTLE…
II मातृ देवो भव II18, 2015गुरवार जून 1.148
Notas del editor
Rural obstetrics has its unique set of problems, which unfortunately do not find a separate mention in textbooks. Even those penned by indian authors.
I am here to present a pot pourri of tips and tricks which one may take up. I must humbly state that they are not al of my own imagination. I am indebted to many of friends and colleagues who have contributed… and of course this list of tips and tricks is not complete. I look forward to cull many more ideas from you all.
Rural obstetric practice is high risk practice. Rational medicine is challenged at every step and one has to work through a maze of avenues. Challenges come in the form of illiteracy, poverty, traditional practices, low social status of women; why even political affiliations of the doctor or the patient, even the caste one belongs to! Add to this lack of medical infrastructure such as blood-banks & pathology & compromised equipment & erratic power supply & awareness of CPA, or at least its nuisance value and you have a very very deadly concoction.Thus a rural obstetrician is taking surgical, medical, legal & social risks all the time.
Rural obstetric practice is high risk practice. Rational medicine is challenged at every step and one has to work through a maze of avenues. Challenges come in the form of illiteracy, poverty, traditional practices, low social status of women; why even political affiliations of the doctor or the patient, even the caste one belongs to! Add to this lack of medical infrastructure such as blood-banks & pathology & compromised equipment & erratic power supply & awareness of CPA, or at least its nuisance value and you have a very very deadly concoction.Thus a rural obstetrician is taking surgical, medical, legal & social risks all the time.
Rural obstetric practice is high risk practice. Rational medicine is challenged at every step and one has to work through a maze of avenues. Challenges come in the form of illiteracy, poverty, traditional practices, low social status of women; why even political affiliations of the doctor or the patient, even the caste one belongs to! Add to this lack of medical infrastructure such as blood-banks & pathology & compromised equipment & erratic power supply & awareness of CPA, or at least its nuisance value and you have a very very deadly concoction.Thus a rural obstetrician is taking surgical, medical, legal & social risks all the time.
Rural obstetric practice is high risk practice. Rational medicine is challenged at every step and one has to work through a maze of avenues. Challenges come in the form of illiteracy, poverty, traditional practices, low social status of women; why even political affiliations of the doctor or the patient, even the caste one belongs to! Add to this lack of medical infrastructure such as blood-banks & pathology & compromised equipment & erratic power supply & awareness of CPA, or at least its nuisance value and you have a very very deadly concoction.Thus a rural obstetrician is taking surgical, medical, legal & social risks all the time.
Rural obstetric practice is high risk practice. Rational medicine is challenged at every step and one has to work through a maze of avenues. Challenges come in the form of illiteracy, poverty, traditional practices, low social status of women; why even political affiliations of the doctor or the patient, even the caste one belongs to! Add to this lack of medical infrastructure such as blood-banks & pathology & compromised equipment & erratic power supply & awareness of CPA, or at least its nuisance value and you have a very very deadly concoction.Thus a rural obstetrician is taking surgical, medical, legal & social risks all the time.
Rural obstetric practice is high risk practice. Rational medicine is challenged at every step and one has to work through a maze of avenues. Challenges come in the form of illiteracy, poverty, traditional practices, low social status of women; why even political affiliations of the doctor or the patient, even the caste one belongs to! Add to this lack of medical infrastructure such as blood-banks & pathology & compromised equipment & erratic power supply & awareness of CPA, or at least its nuisance value and you have a very very deadly concoction.Thus a rural obstetrician is taking surgical, medical, legal & social risks all the time.
Rural obstetric practice is high risk practice. Rational medicine is challenged at every step and one has to work through a maze of avenues. Challenges come in the form of illiteracy, poverty, traditional practices, low social status of women; why even political affiliations of the doctor or the patient, even the caste one belongs to! Add to this lack of medical infrastructure such as blood-banks & pathology & compromised equipment & erratic power supply & awareness of CPA, or at least its nuisance value and you have a very very deadly concoction.Thus a rural obstetrician is taking surgical, medical, legal & social risks all the time.
Rural obstetric practice is high risk practice. Rational medicine is challenged at every step and one has to work through a maze of avenues. Challenges come in the form of illiteracy, poverty, traditional practices, low social status of women; why even political affiliations of the doctor or the patient, even the caste one belongs to! Add to this lack of medical infrastructure such as blood-banks & pathology & compromised equipment & erratic power supply & awareness of CPA, or at least its nuisance value and you have a very very deadly concoction.Thus a rural obstetrician is taking surgical, medical, legal & social risks all the time.
A good way to face all these challenges is to hold regular ante-natal classes for all your patients. I can assure you that it is no western fad; but very much a social need. Our clinic holds regular sessions for the past 5 years. It builds confidence,
improves compliance
and works as excellent, clean publicity (marketing) strategy too.
The place is all spruced up for the occasion,
A good collection of models, charts, slides and videos accumulates.
Patients too are at ease, can sit back, listen, see, think & come up with questions which they are loath too ask in a busy OPD.
A good way to face all these challenges is to hold regular ante-natal classes for all your patients. I can assure you that it is no western fad; but very much a social need. Our clinic holds regular sessions for the past 5 years. It builds confidence,
improves compliance
and works as excellent, clean publicity (marketing) strategy too.
The place is all spruced up for the occasion,
A good collection of models, charts, slides and videos accumulates.
Patients too are at ease, can sit back, listen, see, think & come up with questions which they are loath too ask in a busy OPD.
A good way to face all these challenges is to hold regular ante-natal classes for all your patients. I can assure you that it is no western fad; but very much a social need. Our clinic holds regular sessions for the past 5 years. It builds confidence,
improves compliance
and works as excellent, clean publicity (marketing) strategy too.
The place is all spruced up for the occasion,
A good collection of models, charts, slides and videos accumulates.
Patients too are at ease, can sit back, listen, see, think & come up with questions which they are loath too ask in a busy OPD.
The course content is anybodies guess. What has proved more rewarding is the fact that apart from purely medical aspects the rest of the talking is done by the paramedics.
This helps in many ways. The paramedics often present the material in more informal way
and in a more native tongue.
Having spoken in the programme patients now identify them as the doctors trusted aids and don’t mind them monitoring or even conducting labor.
The paramedics on their part are always on their toes, trying to acquire precise information & skills trying to update themselves since they are no longer servants but teachers too.
Not just that but by talking about the ideal way in which labor is conducted or a baby is wrapped, they are promising a certain standard of care and in practice are bound to adhere by it.
The course content is anybodies guess. What has proved more rewarding is the fact that apart from purely medical aspects the rest of the talking is done by the paramedics.
This helps in many ways. The paramedics often present the material in more informal way
and in a more native tongue.
Having spoken in the programme patients now identify them as the doctors trusted aids and don’t mind them monitoring or even conducting labor.
The paramedics on their part are always on their toes, trying to acquire precise information & skills trying to update themselves since they are no longer servants but teachers too.
Not just that but by talking about the ideal way in which labor is conducted or a baby is wrapped, they are promising a certain standard of care and in practice are bound to adhere by it.
The doctor benefits the most. All the routine, boring, repetitive, time consuming, soporific advise and counseling sessions in the OPD are done away in one stroke.
One has more time to concentrate on clinical aspects and the OPD speeds up.
Everybody lands up in a tight corner sometime or the other. The obstetricians are especially prone to this. The ANC classes make explanation of untoward incident a very tame affair.
More over in the hurry and flurry of activity that precedes an emergency LSCS or an operative vaginal delivery; getting a ‘truly’ informed consent of the patient is very easy.
As has been through the ages one word counts, it is rapport. It is this the classes seek to establish and do it with exemplary ease.
Bangles are the sign of ‘Saubhagya’. The pregnant women is gifted bangles as a goodwill gesture, at times covering the forearm from wrist to elbow.
g off bangles and securing an I/V access is a routine problem in rural practice. This may take unduly long , may cause injury to the patient or the health care provider. We have devised an ingeneous way to thackle this problem.
All it needs is…
You fix the bag in the ring and stick in the metal scale so that it juts out inside the bag.
You have to thread the bangles in the scale and break them against it.
Obstetrics they say is bloody buisiness. Soiling of table and floor is very common, so is spills and spurts of biohazardous body fluids. Also in peripheral private practice universal precautions are unknown. The only universal precaution followed is not admitting HIV positive patients.
Obstetrics they say is bloody buisiness. Soiling of table and floor is very common, so is spills and spurts of biohazardous body fluids. Also in peripheral private practice universal precautions are unknown. The only universal precaution followed is not admitting HIV positive patients.
…read…
While working under local anaesthesia catching the isthumic region is very difficult. It is simpler to hook out the fimbrial end, tie it and finish of the procedure.
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Yes sex, that gives me a talking point. And I request you to…..
And here are a few tips for those in such a predicament.
…read..
The anaesthetist may not be keen on spending time on this time consuming prerequisite for spinal anasthesia.
…read….
Many places do not have a pulse ox.
…read…
Never disregard the trickle.passage of clots mean that the coagulation syatem is intact but a trickle is ominious. It heralds DIC.
..read…