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MATRUDEVOBHAV
A
Ethical, Moral and Philosophical Aspects of
OBSTETRICS & GYNAECOLOGY
An Indian Perspective
By
Foreword by
Dr. K. Bhasker Rao, M.D., F.R.C.O.G., F.M.S.
Emeritus Professor of Obstetrics and Gynaecology
Madras Medical College
(Formerly Director, Institute of Obstetrics and
Gynaecology,
Govt. Hospital for Women and Children, Egmore,
Madras)
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MATRUDEVOBHAVA
Mother
The Universal Mother is in the form of
Bhoomata who bears all of us ! She is the Prakriti or
Shakti or energy without whom the world cannot
exist. She is the same Shakti in the form of
Goddess of Learning; Saraswati who helps Lord
Brahma to create this world; in the form of Goddess
Lakshmi; Goddess of wealth who helps Bhagwan
Vishnu to protect the world bestowing health,
happiness, prosperity and well-being of the people;
in Goddess Parvati; she gave Shakti or energy to
Lord Shiva to destroy the world.
She is the same Mother to whom we also pray
as Durga during Navaratri, to destroy the evil forces
and cut the knot of ignorance in our heart and also
the quality of Ahamkara in us and bestows upon us
knowledge and wisdom!
`The Universal Mother has many other
manifestations – in the form of Gayatri – she protects
us; as Ganga Bhavani – she gives us water for
survival; as Gomata (cow) – she gives us milk for
health the nourishment and as Mother
Geeta (Bhagavadgeeta)whose door is open to any
one who knocks and seeks refuge in distress in her
bosom. Stree or Ammai is the incarnation of
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(K. Bhasker
Rao)
9 th August
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1994
Madras
PREFACE
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Chapters
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2. Pregnancy – Essentially a 32
Physiological Process
4. Anaemia in Pregnancy 49
5. Abortion Problem 59
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23 Dysmenorrhea 182
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Immunological Tolerance
Trophoblast is of foetal origin and has antigens
of paternal type. In the blood flowing through the
chorio-decidual space there are both foetal cells
from the trophoblast and the maternal cells. Yet the
antigens on the trophoblast are either masked, shed,
or modified at the cell surface and do not express
their antigenicity. On the part of the mother (as
described above) the maternal cells in decidua do
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PREGNANCY
ESSENTIALLY A PHYSIOLOGICAL PROCESS
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finally the after birth (or) the placenta mops up all the
organisms as it comes out.
While this is so with nature – the obstetrician (if
proper care and antiseptic and aseptic precautions
are not taken), can cause pelvic infection. Any
examination during delivery or any operative
procedure causing trauma to the genital tract
predisposes to pelvic infection as all these carry
infection from septic tract through antiseptic and
ultimately to the aseptic cavity.
Mother nature has also seen that the baby is
surrounded all the time in the uterine cavity by
amniotic fluid. This fluid, during pregnancy, serves
several important functions. It provides a medium in
which the foetus can freely move, cushions the
foetus against any possible injury, helps to maintain
an even temperature and not the least, it provides
useful information to the doctor regarding health and
matuity of the foetus.
The Maternal Internal Environment is Altered to
Create Conditions favourable to the Foetus and the
Changes are in Apparent Excess of the Needs of the
Foetus.
(a) The blood volume is increased during
pregnancy. Plasma volume increases by 45%
upto 1250 ml in primigravida and 1500 ml in
multigravida. Increase of red cell mass occurs upto
400 ml (18%) in women given iron supplements
and 250 ml when not given iron supplements.
The blood volume increase is essential to
maintain uteroplacental circulation and the
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diagnosis of anaemia.
“Anaemia may antedate conception, it is often
aggravated by pregnancy and accidents of labour
may precipitate it. It is one of the prime concerns of
ante natal care to forestall it for the safety of labour
may precipitate it. It is one of the prime concerns of
ante natal care to forestall it for the safety of labour
and puerperal state, let alone the future health which
in a large measure depend upon the state of
patients’ health”.
As I write about the subject of anaemia in
pregnancy my thoughts go back to all the cases
seen and treated during all these years. Most of
these patients belonged to the low socio-economic
group, never attended ante natal clinics – usually
multiparrae with rapid succession of pregnancies
without spacing and also had some other obstetric
problem. Some had twin pregnancy, others admitted
for antepartum bleeding. In many of them
haemoglobin was less than 5 gms% and in a few it
was just 2-3 gms%. They were admitted with
dyspnoea, breathlessness tand palpitation. Some
had gastro-intestinal upset like diarrhoea and others
with severe oedema and had severe hypoprotinemia
in addition. They looked very pale and were
cyanosed and on examination presented incipient
signs of heart failure due to dilated heart. Some
could not stand labour and developed acute heart
failure and died during the end of second stage or
mostly after delivery of the placenta or thereafter due
to collapse or obstetric shock.
Some of the patients belonged to the working
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pray for the day when the homes for the aged are
scrapped and the old parents are looked after by
their children.
ABORTION PROBLEM
(LOVE’S LABOUR LOST
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cases.
The other important cause of spontaneous
abortion is faulty maternal environment. It may be
that the corpus luteum and the developing placenta
do no produce enough progesterone and oestrogen
for proper nidation and the decidua is poorly
developed not giving enough nutrition for the
developing embryo. There is a correlation between
maternal diet and foetal development. Vitamin C, P
and Folic acid are essential for nucleic acid
production and deficiency of these can cause
defects in the developing embryo.
Anatomical uterine defects like double uterus,
septate uterus or bicornuate uterus – in all these the
fertilized ovum may not only not get proper nutrition
but the growth is also affected by the abnormality.
Even if the pregnancy continues for some time – all
these also have an incompetent cervix and
pregnancy gets terminated later in second trimester.
Implantation over a submucus myoma or over a scar
again leads to nutritional deficiency and failure of
growth. Hypertension in pregnancy causes changes
in the decidual vessels and results in less blood
supply ad nutrition.
In both the above two causes of abortion, most
often the embryo or ovum dies first and the abortion
is only the end process. Mother nature does not
want defective children with various abnormalities to
be borne and live in the world. Abortion in such
cases is a protective phenomenon on the part of
nature to get rid of such foetuses. However it is not
known why some chromosomal anomalies like
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LABOUR
HARD WORK ON PART OF THE MOTHER
“If I put one flower at the feet of Goddess I shall
put two flowers at the feet of mother in labour.”
These were the remarks of Dr Sudhir Kumar when
as a resident (in my unit), was posted in the labour
ward.
Labour is the process by which the products of
conception – foetus, placenta, membranes and
liquor are all expelled entire from the uterine cavity at
term. There are three factors involved in the
physiology of labour:
1. Forces of uterine contractions
2. Passages – the uterus and pelvic passages
3. Passenger or the foetus.
During labour because of forces of contractions
the uterus divides itself into two segments – upper
and lower segments and the cervix of the uterus
opens up and dilates and the passenger or foetus
descends from the upper segment to the lower part
of the uterus and then traverses through the pelvic
cavity and it ultimately delivered.
True labour is usually heralded by the
contractions of the uterus. These contractions during
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any eventuality!
VAGARIES OF UTERINE CONTACTIONS DURING
LABOUR
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weeks of gestation.
To utilize testosterone effectively the external
genital organs must convert testosterone into
dihydrotestosterone through the action of an enzyme
5- α-reductase it is necessary for these substances
to be bound to receptors in the cytoplas of the cells.
Hence, deficiency of 5- α-reductase and ineffective
binding of testosterone lead to abnormal sex
differentiation known as androgen insensitivity and
this can lead to intersex problems.
It is a traditional belief among our people that
they must have at least one son in the family – not
only to keep up the family name but also to save
hem from a particular kind of Hell called in Sanskrit
punnaamanarakam. It is also ingrained that the son
only should lit the funeral pyre of the parents when
they die. It is for the above reasons that those who
do not have any children do lot of pujas and prayers
and observe austerities so as to evoke the
prasanna of the Lord to bless them with a son.
However, sex of the baby in the womb is
determined by which of the sex spermatozoon meets
the ovum and fertilizes it. If one containing Y
fertilizes the ovum the resulting child will be a male.
If the one containing the X fertilizes, the child will be
a female. Nobody can predict except perhaps those
with super-natural powers what will be the sex of the
future baby. It does not depend upon the wife; nor
does it depend upon the obstetrician, nor upon the
nursing home where the patient is going to deliver
and there is little that the husband can do about it as
he has no control over the spermatozoon that
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Emotional Support
Unwanted pregnancy can be a cause of acute
emotional stress. Many of those who seek abortion
are young and unmarried. They very often do not
know that when they miss a period it could be
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infertility cases).
(l) Patient should be advised not to abandon
treatment especially if clomiphene is given for
induction of ovulation. If conception does not
occur after three months it should not be taken
as a failure. Treatment should be extended for
some more time with or without other drugs.
Surprisingly in some cases conception occurs
after stoppage of treatment.
(m) In the end, optimism should be the keynote
even when investigations suggest that the
prospects for pregnancy are poor.
(n) Even if both husband and the wife after
investigations were found normal in every
respect and there is no absolute cause, yet in
some, conception does not occur – such are
called cases of “unexplained infertility” and are
a monument to medical ignorance and a cause
for concern. In the absence of a determined
cause, there is a logical sequence i.e no
treatment. In spite of IVF and embryo transfer,
some do not conceive, which only shows that
unless Lord Almighty blesses whatever one
may do, success will not occur.
End Results of Treatment
(a) Whatever treatment or advice is given to an
infertile couple – conception will not occur in
certain cases – this is inevitable by the laws of
chance that govern conception.
(b) It is all too easy to claim a coincidence as a
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ADOPTION
Individual outlooks differ regarding adoption of
a child. Some couple find the idea attractive and
others cannot tolerate it. Only the former make good
foster parents, even though the venture may not
always bring the happiness expected. Hence
adoption as a solution to the sterility problem
deserves cautious approach and initiative should
come from the infertile couples and not from the
gynaecologist. Pros and cons should be discussed
regarding for or against the procedure and the
couple must also be made to realize that they may
later on have a child of their own especially in a
cases of unexplained infertility or even in cases of
idiopathic oligospermia. It is surprising, while wanting
to adopt many a couple prefer a female child
instated of male. This is exactly opposite to their
expectation after a normal delivery. Is it because
they feel that the female babies look after their
parents well in their old age? There is an old saying,
`son is a son till he gets married and a daughter is a
daughter forever’.
Insemination with mixed semen (AIHD)
`In order to quieten conscience of the couple
and to provide hope, mixing of the husband semen
with that of donors semen is suggested. If the
woman conceives the origin of the fertilizing
spermatozoa then remain in doubt. If the husband is
not sterile this procedure is not justified and if he is,
the method has all the objections of AID.’
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the public and the child that is born and lastly upto
what age can a surrogate mother be treated with IVF
(lot of controversies being discussed nowadays
when a 59year old lady surrogate mother gave birth
to twins and a 63 year old woman became pregnant
after being inserted with the egg taken from a young
woman). Can the surrogate mother refuse to hand
over the child and make it a ward of court. Problem
of consent may arise if the surrogate mother requires
an abortion: whose consent is necessary? To the
gynaecologist the patient must come first. But should
he take the consent of the biological parents for the
destruction of the child.
These are thorny, difficult and controversial
problems. All these point out that a gynaecologist
who recommends surrogacy has a tremendously
difficult decision to make and he/she has moral
responsibility for four persons – infertile couple,
surrogate and the resulting child.
Fortunately in our country it will be quite some
years hence that the ethical problems of surrogacy
will arise.
IVF Was Known and Practised in Ancient Times
IN the Mahabharata, Gandhari, wife of King
Dhritarashtra, conceived but the pregnancy
prolonged for nearly two years; then she delivered a
mass (?Mole). Bhagwan Vyasa found that there
were 101 cells which were normal in the mass.
These cells were put in a nutrient medium and were
grown in vitro to full term. Of these, 100 developed
into male children (Duryodhana, Duhshasana and
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ENDOMETRIOSIS
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endocardium
Of all the sites in the pelvic, ovarian
endometriosis is the commonest and next in order is
in the pouch of Douglas. These are the sites on
which endometrium can fall and get implanted, when
there is retrograde menstruation through the
fallopian tubes into the pelvic cavity (Implantation
theory). When once it gets implanted and survives –
endometrium has a unique property; i.e in the
prliferative phase of menstrual cycle (first half) the
endometrium proliferates and in the secretory phase,
it un dergoes secretory change and during
menstruation it bleeds. In that process it produces an
inductor substance and spreads to the surrounding
areas. In the ovary it invades the cortex of the ovary
and burrows into it and forms a cyst and as a result
of repeated menstruation this cyst becomes
enlarged and is known as chocolate cyst of the
ovary.
In the pelvic cavity in extreme cases the whole
pelvic peritoneum is affected with areas of
haemorrhage followed by puckering and scarring
and the whole pelvis and become a frozen pelvis as
a result of endometriosis. As a result of these
changes the patient suffers from severe pain during
periods i.e. dysmenorrhoea, profuse bleeding i.e.
menorrhagia and dyspareunia (pain during
intercourse). Even in remote areas like umbilicus it
forms a nodule which becomes gradually bigger with
each menstruation and the same occurs in other
areas. If it affects the bladder there will be
haematuria during menstruation. It can produce
symptoms of intestinal obstruction if it affects small
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OVARIAN TUMOURS
These can either be solid or cystic and
some are both cystic and solid. They can be
benign or malignant. So long as the tumour is
within the pelvis it may not produce any
symptoms. But when the tumour grows-becomes
moderate in size-then it develops a pedicle and
raises above the level of the pelvic brim. Then the
tumour acquires a much greater degree of
mobility and is therefore more prone to undergo
torsion or axial rotation. It is not uncommon for
the tumour to be rotated through three or more
complete circles. Tumour becomes congested,
internal hemorrhages occur, adhesions form to
intenstines or ormentum and the cyst may
become infected. These adhesions can contribute
to a new blood supply to the tumor, which when
severed from its original connection – then
becomes a “parasite”.
As I teach the subject to the students I am
always reminded of what is happening and what
we see in everyday life. Whatever may be the
type of tumour-so long as it is in the protection of
the pelvis it does not undergo torsion; only when it
develops a tail or pedicle and when it comes out
of pelvis and acquires mobility then only this
complication occurs. So long as the children are
under the protective influence of the parents –
(usually upto 10-12 class) students do well. But
once they go to the college, they get a pedicle or
a tail – usually a moped or a motor cycle. The
atmosphere in the college is also such that they
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urinary bladder.
PREMENSTRUAL TENSION
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MENOPAUSE
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physical love.
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SEX EDUCATION
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acceptance.
Regarding sterilization upon which the entire
programme is depending, there is no doubt that post
partum tubectomy is ideal and simple. It is easy to
approach the tubes with a small incision as the
fundus of the uterus is high up in the abdomen. It is
good in those women having three or more children.
Many young couple are requesting today for the
sterilization operation even after only one child,
basing their argument that to have one more child is
a luxury that they cannot afford in these days of
escalating cost of living. In these one has to think
twice before doing tubectomy, in the immediate post
partum period as it is not a reversible method. It is
better to advice the couple to use either barrier
method or pill or loop till the children grow and
develop resistance and do an interval sterilization by
doing tubal ligation by the laparoscopic method. It is
not uncommon to hear that the only child of a couple
either died as a result of accident or disease.
None is against the target oriented and mass
sterilization operations done in camps. It looks as
though to tell the public that so many operations are
being done by various agencies organizing them
(Governmental or voluntary) and for the operating
surgeons (each one of them) to say and claim to
have done so many per day and one vying with the
other for the shortest time taken for each case.
Every one would like to compliment them. But in the
bargain, overconfidence and the quick turnover led
to the round ligament being cauterized or clipped
and thus resulting in many failures. Also in these
camps the patients are not being screened properly
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