Reply to Sean Coles

Dear Dr,

my wife and I lost our daughter this week at 40 weeks. My wife had at least five ultrasound scans due to her age 40 years . We were informed that everthing was fine with the baby and it was developing as normal. Her last scan was at 37-38 weeks and again nothing was mentioned of conern. She visited the midwife on Tuesday 20th October, when she was informed that everything was alright. This appointment involved a blood pressure and urine test as well as the midwife listing to the baby's heart. My wife questioned the midwife about the heart beat not being very loud, but was assurred that it was ok. The midwife referred my wife to the hospital for a carbohydrate blood test the following day. We received the result as being normal on Thursday 22 October. On Sunday morning at 8.30 am my wife noticed a small jelly like discharge. We rushed to the hospital where the doctor conducted a scan and heartbeat monitor. Sadly no heartbeat could be detected a second doctor conducted a scan but this confirmed the same.Obviously devistated my wife then had to endure a 48 hour natural birth, knowing what the outcome would be. When the baby was finally delivered, it was found to have the umbilical cord wrapped around the neck tightly, no less than 4 times. There was obvious sore markes and damaged sknin on the baby's neck, presumably where the cord had been. Please can you help. Should the hospital have noticed this during the numerous scans that had taken place during my wife's pregnacy, or as one of the doctors told me , it would not have been possible to detect this.

The baby was difficult to birth as it's neck was pulled back
We have decided to have an autopsy and our daughter has been sent to a hospital in London. Her body is due to return this week.

Thank you for your time .

Regards

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Hi, Mr Sean Coles,

It is very regrettable for this terrible incidence happened to your family. You have my full sympathy. I hope your family could gain the strength and determination to overcome it.

Cord-round-neck is a common incidence to happen during antepartum period. However, this condition rarely lead to fetal in-utero demise. It is because the cord entanglement to the neck is usually very loose and rarely resulting in neck strangulation.

It is important to perform an autopsy to investigate for the cause of death before we can make any conclusion that the demise is related to the cord round neck.

The autopsy should include:

1) Fetal chromosomal constitute to exclude chromosomal abnormality.

2) Fetal blood for bacterial culture to look for possibility of in-utero fetal infection

3) Internal organs examination for any internal organ malformation

4) Placenta for any infarction/ infection/ blood clots.

After exclude all the possibilities above, then only we could possible link the death to the cord round neck.

Unfortunately, the clinical management guideline is not available in the Royal College of Obstetricians and Gynaecologists (RCOG) of London. Most of the doctors will consider cord round neck as a benign condition as far as the fetal heartbeat and the fetal growth rate are not compromised.

This condition could be detected by using umbilical Doppler scan to locate the position of the umbilical cord.

In my own practice in Malaysia, I usually perform cord round neck screening at 36 weeks of pregnancy.

If the cord tightly entangles the neck, I may advise the patient for early delivery.

i hope my opinion is useful for your reference.

Warm regards.

Dr. Jason Ong.

Epidural Pain Relief (硬膜外麻醉)

What is epidural anesthesia?

Epidural anesthesia is an effective pain relief approach to control labour pain during normal delivery.
Epidural blocks the nerve impulses from the lower spinal segments resulting in decreased sensation in the lower half of the body.
If it is given correctly, epidural could reduce the labour pain up to 90% to 100%.

Area of numb after the epidural

How is an epidural given?

A doctor who specializes in anesthesia will administer your epidural.
You will be asked to arch your back and remain still while lying on your left side or sitting up. This position is vital for preventing problems and increasing the epidural effectiveness.

After the cleaning process with antiseptic, a needle will be inserted into the area that surrounds the spinal cord in the lower back. A plastic small tube is inserted through the needle into the epidural space. The needle is carefully removed leaving the plastic tube in place so medication can be given through periodic injections or by continuous infusion.
The plastic tube will be taped to your back to prevent it from slipping out.

A needle is used to guide the plastic tube into epidural space

Needle is removed and the plastic tube will remain in the epidural space for medication infusion

The plastic tube is plastered to the skin until the labour process is completed.


What are the benefits of epidural anesthesia?

1) Effective in labour pain control

2) Allows you to rest if your labor is prolonged

3) Relieving the discomfort of childbirth can help some woman have a more positive birth experience

4) Most of the time an epidural will allow you to remain alert and be an active participant in your birth

5) If you deliver by cesarean, an epidural anesthesia will allow you to stay awake and also provide effective pain relief during recovery.

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What are the Disadvantages of epidural anesthesia?

1) Epidurals may cause your blood pressure to suddenly drop. As a result, you may feel dizzy and vomit.

2) You may experience a severe headache caused by leakage of spinal fluid. Luckily, it is not a common problem to happen (less than 1%)

3) You may experience the following side effects: shivering, ringing of the ears, backache, soreness where the needle is inserted, nausea, or difficulty urinating

4) You may find that your epidural makes pushing more difficult when the baby is about to deliver. As a result, sometimes forceps or vacuum extraction may become necessary

5) For a few hours after birth the lower half of your body may feel numb which will require you to walk with assistance

Possibility of Vacuum / forceps delivery is increased with epidural.

The Overweight Baby

A baby is considered overweight if the birth weight after 9th months of pregnancy is more than 4.0kg.

About 5 to 10 percent of babies are overweight by term.




What are the common reasons for the baby to be overweight?

The birth weight of the baby is genetically determined. If both parents are big size, most probably the baby is big size as well.

The mother who has delivered a big baby before has higher tendency to pregnant another big baby.

Other reasons that may cause the baby to be overweight:

1) The mother has diabetes mellitus during pregnancy
2) The mother has excessive weight gain during pregnancy
3) Pregnancy is overdue.
4) A baby boy is generally bigger than a baby girl.





What are the problems associated with the overweight baby?

For those mothers who keen to try normal delivery, the labour process maybe more complicated and prolonged.
It may lead to slow dilatation of the cervix, excessive perineal tear, excessive bleeding after the delivery and the chance for emergency caesarean delivery is higher.
Sometimes, the baby’s shoulder maybe impacted behind the pelvic bone. As a result, the baby shoulder was stuck and unable to deliver normally. Excessive use of force to dislodge the baby shoulder will lead to fracture collarbone and sometimes even the nerve injury.

The baby's left shoulder is stuck behind the pelvic bone

Excessive use of force to deliver the shoulder may lead to baby's bone fracture and nerve injury.

Left hand is paralysed due to birth injury.

How to prevent my baby from overweight?

You need to avoid excessive weight gain during pregnancy.
The doctor will monitor your urine and blood to make sure that you are not diabetic.
Ultrasound scan is useful to estimate the baby’s weight and detect early sign of big baby.
Sometimes, you are advised by the doctor to undergo caesarean delivery to prevent the complication of normal delivery if the baby is suspected to be overweight.

A Preventable Tragedy!

I believe many of you have read about the tragic news above. A woman who just delivered a baby committed suicide because of depression due to the baby in-born problem.

Post partum depression (產後抑鬱症)is a common problem during confinement period. It is estimated 25% of women suffer from depression during the confinement period.

Among the reasons that cause depression during confinement period:

1) Unexpected result from the pregnancy. All of the pregnant women expect to deliver a healthy and beautiful baby.

Unfortunately, sometimes baby is born with some degree of in-born defects, for example, hole in the heart, cleft lip.

2)Bad experience from the labour process. The duration of labour maybe too long and they suffer from long duration of labour pain.

3) Poor husband/family support. The women from a broken family have a higher chance of developing post partum depression.

4) Lack of sleep during confinement and uncomfortable living environment, especially if the newborn is frequently crying for milk.

5) The women with depressed personality and mental illness before the pregnancy have higher chance to face with this problem. A cheerful and open minded personality has less chance of developing this problem.

What are the symptoms of post partum depression?

The symptoms usually appear after 1 week of delivery. The woman who suffer from this problem usually feels hopeless, sleepless, moody and sometimes crying for no reason. Her appetite for food is poor.
Sometimes, in the severe cases, the patients may have the intention to commit suicide.

What should I do to prevent post partum depression?

1) You need to work closely with your doctor. Find a doctor who you can trust and comfortable with. The doctor concerned will take care of you throughout the pregnancy period.

2) Your husband must understand this situation and provide you with the support to assist you to go through this difficult period.

3) If possible, spend your confinement period at home to stay close to your family members. Generally, those stay in confinement home are more common to suffer from this problem.

4) You need to have at least 8 hours of quality sleep during confinement period. The duty to take care of your baby should pass to a confinement lady.

5) Drink plenty of water.

6) You can pursuit your hobby during confinement. If you like reading, surfing internet, watching TV or chit-chatting, just do it.

7) See your doctor early if you have symptoms of depression. Some medications may help to prevent the problem from worsening.

Reply To Anonymous

Hello Dr Jason.

I am thalassemia carrier. I just went to see my doc and my doc now wants to check my husband's full blood count. However my husband works in Shanghai and won't be back until mid Dec. Is it ok to wait till then? I am 4 1/2 months pregnant.

Thanks.

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Hi, Anonymous,

Your problem needs urgent action!!

Since you have already known that you are a Thalassemia carrier(地中海貧血), your husband should be checked for his status before the pregnancy. That is the reason the doctors usually encourage the couples to perform pre-marital medical checkup to identify this problem early.

Currently you are 18 weeks into your pregnancy. You can't wait until mid of December because at that time you are 22 weeks already. It is too late to do anything if your husband is a carrier as well.

Since Full blood count is a simple and widely available test, I advise your husband to do the test in Shanghai now and fax the result to your doctor as soon as possible.

If your husband is a carier as well, 25% of the chance that your baby will develop severe Thalassemia Major. This type of disease requires life-long blood transfusion and it will bring severe emotional distress to your family.

With the modern medical service, the doctor can diagnose your baby whether have Thalassemia before the delivery and this should be done before 22 weeks. Amniocentesis (羊膜穿刺术) is a procedure to obtain small amount of amniotic fluid (羊水) to check for the Thalassemia gene.

Amniocentesis

If your husband is not a carrier, your baby is safe.If your husbnd is a carrier, you need to undergo amniocentesis to determine your baby status.


Anyway, I wish you luck in your subsequent follow up with your doctor.

Sleepless Night…..(失眠)

Good quality of sleep is important for the pregnant mother to achieve emotional wellbeing and normal baby development.
Every pregnant mothers should have at least 8 hours of sleep everyday.
Unfortunately, nearly 30% to 40% of the pregnant ladies unable to sleep well, particularly toward later stage of pregnancy.

Among the reasons that cause you to be sleepless:

1) Constant baby’s movement during night time. The baby usually starts its gymnastic lesson during night time : )
2) Heavy compression from the womb to the back muscle.
3) Frequent urination. Most of you need to wake up 3 to 4 times every night to pass urine.
4) Leg cramping which is commnoly occurred during half way of sleep.



Tips to achieve good quality of sleep:

1) Make sure you are really tired and sleepy before going to bed.

2) Avoid from taking supper and drinking too much of water before sleep.

3) Avoid from taking excessive coffee and tea during day time. You are advised to drink not more than one cup of coffee/tea perday.

4) Avoid engaging in any excessive physical exercise before sleep.

5) Learn some relaxation techniques to induce sleep, such as muscle relaxation and breathing exercise.

6) Establish a regular and routine sleeping time. Try to regulate your sleep / wake schedule by going to bed and getting up at the same time every day.

7) Use your bed only for sleep. If you're in the habit of paying bills or watching TV in bed, stop. Reserve your bed for enjoyable activities, like sleep, sex, and maybe a little light reading.

8) Always sleep on your left side to avoid back muscle compression by the womb.

Always turn to the left side to avoid back muscle compression

9) If you still could not sleep…..get out from bed and leave the bedroom. You can watch TV or listen to music first before you try again.

10) Taking a nap in the afternoon is helpful to regain alertness if you are sleepless the night before.