What are Obstetric Ultrasound Scans?

(From: www.ob-ultrasound.net)

The information obtained from different reflections is recomposed back into a picture on the monitor screen (a sonogram, or ultrasonogram). Movements such as fetal heart beat and malformations in the fetus can be assessed and measurements can be made accurately on the images displayed on the screen. Such measurements form the cornerstone in the assessment of gestational age, size and growth in the fetus. A full bladder is often required for the procedure when abdominal scanning is done in early pregnency. There may be some discomfort from pressure on the full bladder. The conducting gel is non-staining but may feel slightly cold and wet. There is no sensation at all from the ultrasound waves.

Why and when is Ultrasound used in Pregnancy?

Ultrasound scan is currently considered to be a safe, non-invasive, accurate and cost-effective investigation in the fetus. It has progressively become an indispensible obstetric tool and plays an important role in the care of every pregnant woman.

The main uses of ultrasonography are in the following areas:

1. Diagnosis and confirmation of early pregnancy. The gestational sac can be visualized as early as four and a half weeks of gestation and the yolk sac at about five weeks. The embryo can be observed and measured by about five and a half weeks. Ultrasound can also very importantly confirm the site of the pregnancy is within the cavity of the uterus. 2. Vaginal bleeding in early pregnancy. The viability of the fetus can be documented in the presence of vaginal bleeding in early pregnancy. A visible heartbeat could be seen and detectable by pulsed Doppler ultrasound by about 6 weeks and is usually clearly depictable by 7 weeks. If this is observed, the probability of a continued pregnancy is better than 95 percent. Missed abortions and blighted ovum will usually give typical pictures of a deformed gestational sac and absence of fetal poles or heart beat.

Fetal heart rate tends to vary with gestational age in the very early parts of pregnancy. Normal heart rate at 6 weeks is around 90-110 beats per minute (bpm) and at 9 weeks is 140-170 bpm. At 5-8 weeks a bradycardia (less than 90 bpm) is associated with a high risk of miscarriage. Many women do not ovulate at around day 14, so findings after a single scan should always be interpreted with caution. The diagnosis of missed abortion is usually made by serial ultrasound scans demonstrating lack of gestational development. For example, if ultrasound scan demonstrates a 7mm embryo but cannot demonstrable a clear-cut heartbeat, a missed abortion may be diagnosed. In such cases, it is reasonable to repeat the ultrasound scan in 7-10 days to avoid any error. The timing of a positive pregnancy test may also be helpful in this regard to assess the possible dates of conception. A positive pregnancy test 3 weeks previously for example, would indicate a gestational age of at least 7 weeks. Such information would be useful against the interpretation of the scans.  In the presence of first trimester bleeding, ultrasonography is also indispensible in the early diagnosis of ectopic pregnancies and molar pregnancies.

3. Determination of gestational age and assessment of fetal size.

Fetal body measurements reflect the gestational age of the fetus. This is particularly true in early gestation. In patients with uncertain last menstrual periods, such measurements must be made as early as possible in pregnancy to arrive at a correct dating for the patient. In the latter part of pregnancy measuring body parameters will allow assessment of the size and growth of the fetus and will greatly assist in the diagnosis and management of intrauterine growth retardation (IUGR).

The following measurements are usually made:

a) The Crown-rump length (CRL) This measurement can be made between 7 to 13 weeks and gives very accurate estimation of the gestational age. Dating with the CRL can be within 3-4 days of the last menstrual period. An important point to note is that when the due date has been set by an accurately measured CRL, it should not be changed by a subsequent scan. For example, if another scan done 6 or 8 weeks later says that one should have a new due date which is further away, one should not normally change the date but should rather interpret the finding as that the baby is not growing at the expected rate. b) The Biparietal diameter (BPD) The diameter between the 2 sides of the head: This is measured after 13 weeks. It increases from about 2.4 cm at 13 weeks to about 9.5 cm at term. Different babies of the same weight can have different head size, therefore dating in the later part of pregnancy is generally considered unreliable. Dating using the BPD should be done as early as is feasible.

c) The Femur length (FL)

Measures the longest bone in the body and reflects the longitudinal growth of the fetus. Its usefulness is similar to the BPD. It increases from about 1.5 cm at 14 weeks to about 7.8 cm at term. Similar to the BPD, dating using the FL should be done as early as is feasible.

d) The Abdominal circumference (AC)

The single most important measurement to make in late pregnancy is AC. It reflects more of fetal size and weight rather than age. Serial measurements are useful in monitoring growth of the fetus. AC measurements should not be used for dating a fetus.

The weight of the fetus at any gestation can also be estimated with great accuracy using polynomial equations containing the BPD, FL, and AC. computer softwares and lookup charts are readily available. For example, a BPD of 9.0 cm and an AC of 30.0 cm will give a weight estimate of 2.85 kg. 4. Diagnosis of fetal malformation. Many structural abnormalities in the fetus can be reliably diagnosed by an ultrasound scan, and these can usually be made before 20 weeks. Common examples include hydrocephalus, anencephaly, myelomeningocoele, achondroplasia and other dwarfism, spina bifida, exomphalos, Gastroschisis, duodenal atresia and fetal hydrops. With more recent equipment, conditions such as cleft lips/ palate and congenital cardiac abnormalities are more readily diagnosed and at an earlier gestational age. First trimester ultrasonic 'soft' markers for chromosomal abnormalities such as the absence of fetal nasal bone, an increased fetal nuchal translucency (the area at the back of the neck) are now in common use to enable detection of Down syndrome fetuses.

Ultrasound can also assist in other diagnostic procedures in prenatal diagnosis such as amniocentesis, chorionic villous sampling, cordocentesis (Percutaneous umbilical blood sampling) and in fetal therapy.

5. Placental localization. Ultrasonography has become indispensible in the localization of the site of the placenta and determining its lower edges, thus making a diagnosis or an exclusion of placenta previa. Other placental abnormalities in conditions such as diabetes, fetal hydrops, Rh isoimmunization and severe intrauterine growth retardation can also be assessed. 6. Multiple pregnancies. In this situation, ultrasonography is invaluable in determining the number of fetuses, the chorionicity, fetal presentations, evidence of growth retardation and fetal anomaly, the presence of placenta previa, and any suggestion of twin-to-twin transfusion.

7. Hydramnios and Oligohydramnios.

Excessive or decreased amount of liquor (amniotic fluid) can be clearly depicted by ultrasound. Both of these conditions can have adverse effects on the fetus. In both these situations, careful ultrasound examination should be made to exclude intrauterine growth retardation and congenital malformation in the fetus such as intestinal atresia, hydrops fetalis or renal dysplasia.

8. Other areas.

Ultrasonography is of great value in other obstetric conditions such as:

a) Confirmation of intrauterine death.
b) Confirmation of fetal presentation in uncertain cases.
c) Evaluating fetal movements, tone and breathing in the Biophysical Profile.
d) Diagnosis of uterine and pelvic abnormalities during pregnancy e.g. fibromyomata and ovarian cyst.

Transvaginal Scans

With specially designed probes, ultrasound scanning can be done with the probe placed in the vagina of the patient. This method usually provides better images (and therefore more information) in patients who are obese and/ or in the early stages of pregnancy. The better images are the result of the scan-head's closer proximity to the uterus and the higher frequency used in the transducer array resulting in higher resolving power. Fetal cardiac pulsation can be clearly observed as early as 6 weeks of gestation. Vaginal scans are also becoming indispensible in the early diagnosis of ectopic pregnancies. An increasing number of fetal abnormalities are also being diagnosed in the first trimester using the vaginal scan. Transvaginal scans are also useful in the second trimester in the diagnosis of congenital anomalies.

Doppler Ultrasound The Doppler shift principle has been used for a long time in fetal heart rate detectors. Further developments in Doppler ultrasound technology in recent years have enabled a great expansion in its application in Obstetrics, particularly in the area of assessing and monitoring the well-being of the fetus, its progression in the face of intrauterine growth restriction, and the diagnosis of cardiac malformations. Doppler ultrasound is presently most widely employed in the detection of fetal cardiac pulsations and pulsations in the various fetal blood vessels. The "Doptone" fetal pulse detector is a commonly used handheld device to detect fetal heartbeat using the same Doppler principle.

Blood flow characteristics in the fetal blood vessels can be assessed with Doppler 'flow velocity waveforms'. Diminished flow, particularly in the diastolic phase of a pulse cycle is associated with compromise in the fetus. Various ratios of the systolic to diastolic flow are used as a measure of this compromise. The blood vessels commonly interrogated include the umbilical artery, the aorta, the middle cerebral arteries, the uterine arcuate arteries, and the inferior vena cava. The use of color flow mapping can clearly depict the flow of blood in fetal blood vessels in a real-time scan, the direction of the flow being represented by different colors. Color doppler is particularly indispensible in the diagnosis of fetal cardiac and blood vessel defects, and in the assessment of the hemodynamic responses to fetal hypoxia and anemia. A more recent development is the Power Doppler (Doppler angiography). It uses amplitude information from Doppler signals rather than flow velocity information to visualize slow flow in smaller blood vessels. A color perfusion-like display of a particular organ such as the placenta overlapping on the 2-D image can be very nicely depicted. Doppler examinations can be performed abdominally and via the transvaginal route. The power emitted by a Doppler device is greater than that used in a conventional 2-D scan. Its use in early pregnancy is therefore cautioned. Doppler facilities are generally an integral part of modern ultrasound scanners. They merely would need to be switched on to function. One does not need to 'go' to another machine for the Doppler investigations.

3-D and 4-D Ultrasound

3-D ultrasound can furnish us with a 3 dimensional image of what we are scanning. The transducer takes a series of images, thin slices, of the subject, and the computer processes these images and presents them as a 3 dimensional image. Using computer controls, the operator can obtain views that might not be available using ordinary 2-D ultrasound scan. 3-dimensional ultrasound is quickly moving out of the research and development stages and is now widely employed in a clinical setting. It too, is very much in the News. Faster and more advanced commercial models are coming into the market. The scans require special probes and software to accumulate and render the images, and the rendering time has been reduced from minutes to fractions of a seconds. A good 3-D image is often very impressive to the parents. Further 2-D scans may be extracted from 3-D blocks of scanned information. Volumetric measurements are more accurate and both doctors and parents can better appreciate a certain abnormality or the absence of a certain abnormality in a 3-D scan than a 2-D one and there is the possibility of increasing psychological bonding between the parents and the baby.

An increasing volume of literature is accumulating on the usefulness of 3-D scans and the diagnosis of congenital anomalies could receive revived attention. Present evidence has already suggested that smaller defects such as spina bifida, cleft lips/palate, and polydactyl may be more lucidly demonstrated. Other more subtle features such as low-set ears, facial dysmorphia or clubbing of feet can be better assessed, leading to more effective diagnosis of chromosomal abnormalities. The study of fetal cardiac malformations is also receiving attention. The ability to obtain a good 3-D picture is nevertheless still very much dependent on operator skill, the amount of liquor (amniotic fluid) around the fetus, its position and the degree of maternal obesity, so that a good image is not always readily obtainable. More recently, 4-D or dynamic 3-D scanners are in the market and the attraction of being able to look at the face and movements of your baby before birth was also enthusiastically reported in parenting and health magazines. This is thought to have an important catalytic effect for mothers to bond to their babies before birth. What are known as 're-assurance scans' and the rather misnamed 'entertainment scans' have quickly become popular. Most experts do not consider that 3-D and 4-D ultrasound will be a mandatory evolution of our conventional 2-D scans, rather it is an additional piece of tool like doppler ultrasound. Most diagnosis will still be made with the 2-D scans. 3-D ultrasound appears to have great potential in research and in the study of fetal embryology. Whether 3-D ultrasound will provide unique information or merely supplemental information to the conventional 2-D scans will remain to be seen.

The Schedule

There is no hard and fast rule as to the number of scans a woman should have during her pregnancy. A scan is ordered when an abnormality is suspected on clinical grounds. Otherwise a scan is generally booked at about 7 weeks to confirm pregnancy, exclude ectopic or molar pregnancies, confirm cardiac pulsation and measure the crown-rump length for dating.

A second scan is performed at 18 to 20 weeks mainly to look for congenital malformations, when the fetus is large enough for an accurate survey of the fetal anatomy. multiple pregnancies can be firmly diagnosed and dates and growth can also be assessed. Placental position is also determined. Further scans may be necessary if abnormalities are suspected.

Many centers are now performing an earlier screening scan at around 11-14 weeks to measure the fetal nuchal translucency and to evaluate the fetal nasal bone (and more recently, to detect tricuspid regurgitation) to aid in the diagnosis of Down Syndrome. Some centers will do blood test biochemical screening at the same visit.

Further scans may sometimes be done at around 32 weeks or later to evaluate fetal size (to estimate the fetal weight) and assess fetal growth. Or to follow up on possible abnormalities seen at an earlier scan. Placental position is further verified. The most common reason for having more scans in the later part of pregnancy is fetal growth retardation. Doppler scans may also be necessary in that situation.

The total number of scans will vary depending on whether a previous scan has detected certain abnormalities that require follow-up assessment. What is often referred to as a Level II scan merely indicates a "targeted" examination where it is done when an indication is present or when an abnormality is suspected in a previous examination. In fact professional bodies such as the American Institute of Ultrasound in Medicine does not endorse or encourage the use of these terms. A more "thorough" examination is usually done at an a perinatal center or specialized clinic where more expertise and better equipments may be present. One should not dwell too much on the definitions or guidelines for a level II ultrasound scan. The prenatal sonologists should always try very hard to look for and assess any abnormality that may be present in the fetus. It is not very meaningful to be talking about level III or even level IV scans. That a pregnancy should be scanned at 18 to 20 weeks as a rule is gradually becoming a matter of routine practice.

What about Safety?

It has been over 40 years since ultrasound was first used on pregnant women. Unlike X-rays, ionizing irradiation is not present and embryotoxic effects associated with such irradiation should not be relevant. The use of high intensity ultrasound is associated with the effects of "cavitation" and "heating" which can be present with prolonged insonation in laboratory situations.

Although certain harmful effects in cells are observed in a laboratory setting, abnormalities in embryos and offsprings of animals and humans have not been unequivocally demonstrated in the large amount of studies that have so far appeared in the medical literature purporting to the use of diagnostic ultrasound in the clinical setting. Apparent ill-effects such as low birth weight, speech and hearing problems, brain damage and non-right-handedness reported in small studies have not been confirmed or substantiated in larger studies from Europe. The complexity of some of the studies have made the observations difficult to interpret. Every now and then ill effects of ultrasound on the fetus appears as a news item in papers and magazines. Continuous vigilance is necessary particularly in areas of concern such as the use of pulsed Doppler in the first trimester.

The greatest risks arising from the use of ultrasound are the possible over- and under- diagnosis brought about by inadequately trained staff, often working in relative isolation and using poor equipment.

Ultrasound scans should best be performed when there is a clear indication to do so. When there is, safety considerations should not be an issue to prevent its prudent use.

It should be borne in mind that prenatal ultrasound cannot diagnose all malformations and problems of an unborn baby (reported figures range from 40 to 98 percent), so one should never interpret a normal scan report as a guarantee that the baby will be completely normal. Some abnormalities are very difficult to find or to be absolutely certain about.

Some conditions, like for example hydrocephalus, may not have been obvious at the time of the earlier scan. The position of the baby in the uterus has a great deal to do with how well one sees certain organs such as the heart, face and spine. Sometimes a repeat examination has to be scheduled the following day, in the hopes the baby has moved.

Images tend also to be strikingly clear in skinny patients with lots of amniotic fluid, and frustratingly fuzzy in obese women, particularly if there is not much amniotic fluid as in cases of growth restriction. As in almost every endeavor, there is also a wide difference in the skill, training, talent, and interest of the sonographer or sonologists. The improvements in equipment has also lead to the earlier detection of abnormal structures in the fetus bringing along with it "false positives" and "difficult-to-be-sure-what-will-happen" diagnosis that could generate huge amount of undue anxiety in patients.

What is intrauterine growth restriction (IUGR)

Intrauterine growth restriction (IUGR) is a term used to describe a condition in which the fetus is smaller than expected for the number of weeks of pregnancy. Another term for IUGR is fetal growth restriction. Newborn babies with IUGR are often described as small for gestational age (SGA).

A fetus with IUGR often has an estimated fetal weight less than the 10th percentile. This means that the fetus weighs less than 90 percent of all other fetuses of the same gestational age. A fetus with IUGR also may be born at term (after 37 weeks of pregnancy) or prematurely (before 37 weeks).

Newborn babies with IUGR often appear thin, pale, and have loose, dry skin. The umbilical cord is often thin and dull-looking rather than shiny and fat. Babies with IUGR sometimes have a wide-eyed look. Some babies do not have this malnourished appearance but are small all-over.

What causes intrauterine growth restriction (IUGR)?

Intrauterine growth restriction results when a problem or abnormality prevents cells and tissues from growing or causes cells to decrease in size. This may occur when the fetus does not receive the necessary nutrients and oxygen needed for growth and development of organs and tissues, or because of infection. Although some babies are small because of genetics (their parents are small), most IUGR is due to other causes.

Some factors that may contribute to IUGR include the following:
• Maternal factors:
o High Blood Pressure
o Chronic Kidney Disease
o Advanced Diabetes
o Heart Or Respiratory Disease
o Malnutrition, Anemia
o Infection
o Substance Abuse (Alcohol, Drugs)
o Cigarette Smoking
• Factors involving the uterus and placenta:
o Decreased Blood Flow In The Uterus And Placenta
o Placental Abruption (Placenta Detaches From The Uterus)
o Placenta Previa (Placenta Attaches Low In The Uterus)
o Infection In The Tissues Around The Fetus
• Factors related to the developing baby (fetus):
o Multiple gestation (twins, triplets, etc.)
o Infection
o Birth defects
o Chromosomal abnormality

Why is intrauterine growth restriction (IUGR) a concern?

IUGR can begin at any time in pregnancy. Early-onset IUGR is often due to chromosomal abnormalities, maternal disease, or severe problems with the placenta. Late-onset growth restriction (after 32 weeks) is usually related to other problems.
With IUGR, the growth of the baby's overall body and organs are limited, and tissue and organ cells may not grow as large or as numerous. When there is not enough blood flow through the placenta, the fetus may only receive low amounts of oxygen. This can cause the fetal heart rate to decrease placing the baby at great risk.

Babies with IUGR may have problems at birth including:
• Decreased oxygen levels
• Low Apgar scores (an assessment that helps identify babies with difficulty adapting after delivery)
• Meconium aspiration (inhalation of the first stools passed in utero), which can lead to difficulty breathing
• Hypoglycemia (low blood sugar)
• Difficulty maintaining normal body temperature
• Polycythemia (too many red blood cells)

Severe IUGR may result in stillbirth. It may also lead to long-term growth problems in babies and children.

How is intrauterine growth restriction (IUGR) diagnosed?

During pregnancy, fetal size can be estimated in different ways. The height of the fundus (the top of a mother's uterus) can be measured from the pubic bone. This measurement in centimeters usually corresponds with the number of weeks of pregnancy after the 20th week. If the measurement is low for the number of weeks, the baby may be smaller than expected.

Other diagnostic procedures may include the following:
• Ultrasound
Ultrasound (a test using sound waves to create a picture of internal structures) is a more accurate method of estimating fetal size. Measurements can be taken of the fetus' head and abdomen and compared with a growth chart to estimate fetal weight. The fetal abdominal circumference is a helpful indicator of fetal nutrition.
• Doppler flow
Another way to interpret and diagnose IUGR during pregnancy is Doppler flow, which use sound waves to measure blood flow. The sound of moving blood produces wave-forms that reflect the speed and amount of the blood as it moves through a blood vessel. Blood vessels in the fetal brain and the umbilical cord blood flow can be checked with Doppler flow studies.
• Mother’s weight gain
Mother’s weight gain can also indicate a baby's size. Small maternal weight gains in pregnancy may correspond with a small baby.

How is intrauterine growth restriction (IUGR) managed?

Management of IUGR depends on the severity of growth restriction, and how early the problem began in the pregnancy. Generally, the earlier and more severe the growth restriction, the greater the risks to the fetus. Careful monitoring of a fetus with IUGR and ongoing testing may be needed.

Some of the ways to watch for potential problems include the following:
• Fetal movement counting - keeping track of fetal kicks and movements. A change in the number or frequency may mean the fetus is under stress.
• Nonstress testing - a test that watches the fetal heart rate for increases with fetal movements, a sign of fetal well-being.
• Biophysical profile - a test that combines the nonstress test with an ultrasound to evaluate fetal well-being.
• Ultrasound - a diagnostic imaging technique which uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to assess blood flow through various vessels. Ultrasounds are used to follow fetal growth.
• Doppler flow studies - a type of ultrasound which uses sound waves to measure blood flow.

Treatment for IUGR:
Although it is not possible to reverse IUGR, some treatments may help slow or minimize the effects. Specific treatments for IUGR will be determined by your physician based on:
• your pregnancy, overall health, and medical history
• the extent of the disease
• your tolerance for specific medications, procedures, or therapies
• expectations for the course of the disease
• your opinion or preference

Treatments may include:
• Nutrition
Some studies have shown that increasing maternal nutrition may increase gestational weight gain and fetal growth.
• Bed rest
Bed rest in the hospital or at home may help improve circulation to the fetus.
• Delivery
If IUGR endangers the health of the fetus then an early delivery may be necessary.

Prevention of intrauterine growth restriction:
Intrauterine growth restriction may occur, even when the mother is in good health. However, some factors may increase the risks of IUGR, such as cigarette smoking and poor maternal nutrition. Avoiding harmful lifestyles, eating a healthy diet, and getting prenatal care may help decrease the risks for IUGR. Early detection may also help with IUGR treatment and outcome.

FAQs for Caesarean section

(Contributed by Dr. Sarbani Ghosh – Kolkata

Consultant Obgyn specialist

Bhagirathi Neotia Hospital

Kolkata

033-22815000)

What is a caesarean section?

A caesarean section involves having a surgical incision made through your abdomen and uterus to deliver your baby in cases where a vaginal delivery is not possible or advisable.

Why might it be necessary for my baby to be delivered by caesarean?

Caesarean sections are advised if your doctor feels that a normal vaginal delivery could threaten the health of you and/or your baby or that it would be impossible to achieve.

What are elective and emergency Caesareans?

There are two kinds of Caesareans.  An elective Caesarean (sometimes called a ‘cold section’ in medical jargon) means a Caesarean that is carried out before labour begins. An emergency Caesarean is one that is carried out as a result of some complication arising during labour. It may not necessarily be an emergency situation.

What are some reasons that would mean I would need a Caesarean?

Your obstetrician might advise you to have an elective Caesarean if:

• Your baby is lying across your tummy and cannot be turned to a head down position.

• Your baby is too big to be able to get through your pelvis

• Your baby is in the breech position.( Bottom bit of the baby is facing down)

• The placenta is positioned across the neck of your womb, making it impossible for your baby to be born vaginally.

• Your baby is not growing adequately and is mature (37 weeks), or your doctor feels the baby has a better chance of survival outside the womb than inside it, even if he is premature.

• You have serious pre-eclampsia which is threatening your own health and the well-being of your baby.

• You have a serious medical condition which means that you should avoid the stress of labour.

• You are expecting triplets, quadruplets or more.

An emergency Caesarean might become necessary after labour has started because:

• Your baby’s heartbeat shows that he is not coping well with contractions (in medical terms, the baby is described as being ‘distressed’)

• The cervix stops dilating or dilates very slowly so that both mother and baby become exhausted

• The placenta starts to come away from the wall of the uterus and there is a risk of haemorrhage (bleeding)

• The baby does not move down into the pelvis, indicating that the pelvis is too small for the baby to get through

Prolapsed cord (where the cord comes down before the baby), is an emergency situation where you will need a caesarean section as soon as possible.

Whether you are offered an elective or an emergency Caesarean, make sure that you understand the reasons why. Even in an emergency situation, there’s nearly always time to give a brief explanation of why a Caesarean is considered necessary.

What happens during a Caesarean?

If you are having an emergency Caesarean, a lot of things will happen very quickly. If you are having an elective Caesarean, the atmosphere will be calmer!

The preliminary procedures are as follows:

• You need to sign a consent form for the operation (if you are too ill, your husband or guardian will be asked to sign for you)

• You will have a drip put into your arm or the back of your hand

• The top few centimetres of your pubic hair will be shaved off.

• You will be asked to remove all your jewelry. If you have a special ring you want to keep on, the nurse will tape over it. Your nail polish will also need to be removed.

• An anaesthetist will give you an epidural or spinal anaesthetic, or a general anaesthetic.

• A catheter will be put into your bladder to empty it. Some surgeons can ask you to pass urine just before the operation to avoid putting in the catheter.

How long will it be until my baby is born?

It is generally 3-5 minutes from the time that they make the initial incision until the baby is born. The rest of the surgery will take about 30 -40 minutes, including repair.

What kind of anaesthetic will they give me?

Nowadays, most hospitals do Caesarean sections under local rather than general anaesthetic. This means that you will be awake when your baby is born. You will probably lose less blood if you have a local anaesthetic and your recovery will be quicker because you will be able to get up and about much sooner. Talk to the Anesthetist before your date of surgery.

Local anaesthetic

A local anaesthetic means an epidural or a spinal. If you are in labour when the decision is made to deliver your baby by Caesarean, you might already have an epidural in place for pain relief. In this case, it is often possible simply to top up the epidural for the operation.

Or you could have a spinal anaesthetic which is a single injection into your back. Spinals take effect quickly, give excellent anaesthesia for the Caesarean and wear off over a period of five to six hours, offering you some pain relief after the operation.

General anaesthetic

You may feel that you would be absolutely terrified if you had to be awake during a Caesarean and that you would definitely prefer a general anaesthetic. In this case, you will be asked to breathe some oxygen through a mask for a few minutes before the anaesthetic is given into the back of your hand.

As you drop off to sleep, the anaesthetist will press on your neck. This is to prevent the contents of your stomach being regurgitated into your lungs. Then you will be aware of nothing until you start to come round about an hour later, after the surgery is over.

You will probably feel groggy for quite a while and perhaps not very interested in your baby.

Will it hurt to have a spinal anesthetic?

You will be given an injection of local anesthetic directly over the spot where the spinal or epidural anesthetic will be given, to decrease pain from the needle used to administer the spinal or epidural anesthetic.

 After spinal anesthesia, you’ll be kept in bed with your head flat for several hours. This is to prevent you from developing a headache.

Will I have back pain after a spinal anesthetic?

No, spinal anesthesia is unlikely to cause back pain. During pregnancy, certain physiological changes occur in the pelvis and in the vertebral region. There is stretching of the ligaments at the joints. After child birth it takes sometime to normalize. You should take proper rest and should not exert too much like lifting heavy weights. If you put on too much weight after the operation that too can lead to  backache.

What should I expect during the operation?

If you are awake during the operation, you will see a large number of people filling the operating theatre (perhaps as many as 10): 

• Anaesthetist

• Surgeon

• Assistant surgeon

• Theatre nurse

• Nurse for holding the baby

• Paediatrician (one per baby, so if you are expecting triplets, there will be three paediatricians)

• Operating department assistant (ODA)

• Your birth partner ( Depends on hospital policy)

These people will be wearing masks and gowns.

You will hear:

• The clinking of surgical instruments

• The beeping of the monitor which records your heartbeat

• The sound of suction as your waters break

• Slightly muffled voices talking about the surgery

You will feel:

• When the baby is being delivered you will feel the assistant surgeon leaning over your chest to help push out the baby. This is only for a short while and not really painful.

• A sensation as if someone is rummaging around in your tummy! This isn’t painful, but it’s an odd feeling and might be frightening if you were expecting to feel nothing at all.

When do I get to see my baby?

When your baby is born, you will get a quick glimpse of him as he is held above the screen which has been placed between you and the surgeons. Then he will be taken to another part of the operating theatre where a paediatrician will check him over to make sure that he is breathing properly and is healthy. So long as your baby is well, he will be brought straight back to you so that you cuddle him during the rest of the operation.

How will they close the cut on my abdomen?

The skin layer may be closed with staples, a long running stitch or individual stitches. You can ask your doctor for dissolvable sutures which can be kept in and don’t need to be cut.

What will the scar be like?

Generally, a bikini cut is made horizontally just below the level of your pubic hair. When the hair grows back and the scar has turned silver it will be barely noticeable. Occasionally, a vertical cut is made down the middle of your tummy. This is very rare.

Will I feel much pain after the operation?

It is important for you to have excellent pain relief for the first few days after your operation. This may mean:

• Topping up the epidural that was used for the Caesarean

• Injections of strong drugs such as pethidine, or diamorphine

•  Suppositories which are absorbed through the back passage to give very good pain relief

Don’t suffer in silence. If your tummy is hurting, tell the nurse. It’s better to keep the pain under control and to ask for pain medication before you become very distressed.

Do I need to use a belt after the operation?

Abdominal binders or belts can be helpful in providing support to the lax abdomen in the initial days. It might make moving and walking more comfortable but please don’t think they have a miraculous power of getting your tummy back in shape. For that you have to do it the hard way by doing exercises after about 6-8 weeks to regain the tone of the abdominal muscles.

 How long will I need to remain in hospital?

Most women are advised to remain in hospital for five days following a caesarean section.

 

Some practical hints for coping after a Caesarean include:

• Drink peppermint water to help with the wind that always troubles people after abdominal surgery!

• Wear very large knickers that don’t put any pressure on your scar.

• Get a pair of slippers without backs so that you can put them on without having to bend down

There are a lot of things you can do to help yourself recover:

• Don’t expect too much of yourself. You’ve had major surgery and you should be convalescing for several weeks

• Rest as much as you can. Try to take everything easy, although walking as soon as possible is very helpful in your recovery. The rule of thumb is to not lift anything heavier than your baby.  

• Have plenty of drinks of fruit juice or water to flush out your bladder

• Eat well - especially cereals, fruit and vegetables that will provide vitamin C to help you heal and roughage to help your bowels open easily

• Limit the number of visitors you have so that you don’t get over tired

• Ask for help - from whomever and whenever! The visitors you really want are the people who will make you meals, keep the house clean and tidy, and go to the shops for you!

• Enjoy resting after your Caesarean. This is time you can spend with your baby without having to take responsibility for housework and day to day chores.

Can I breastfeed after a Caesarean Section?

It’s perfectly possible to breastfeed if you’ve had a Caesarean. It’s just a question of making yourself comfortable while you’re feeding your baby. You can do this by tucking his body under your arm and supporting his head with your hand so that he doesn’t press on your tummy when he goes to the breast. Or you can lie on your side in bed and bring your baby up to the level of your breast with pillows.

The drugs you are having for pain relief will pass in minute quantities to your baby through the breast milk, but they shouldn’t affect him very much and the important thing is for you to be without pain so that you can hold and feed him comfortably. If you don’t have adequate pain relief, you won’t feel like feeding at all!

If you are having any difficulties with breastfeeding, ask immediately for help. It’s much better to get problems sorted out as soon as they occur, rather than waiting until your nipples have become very sore and your baby is frustrated and unhappy.

How soon is it safe to get pregnant again?
Standard recommended pregnancy spacing is at least 18 months but less than 60 months. Having said that you should make sure you feel totally back to yourself and check with your doctor before you start trying.

Will I have to have another Caesarean if I have another child? When you do have another baby, you won’t necessarily have to have another Caesarean. There has been a great deal of research into vaginal birth after Caesarean which has shown that most women could achieve a vaginal delivery after a previous section.

Of course, if the reason why you had a Caesarean first time round is still valid, for example if your womb is an unusual shape, your pelvis is exceptionally small or you have a heart condition that would make labour too stressful for you, then you should probably elect for another Caesarean.

However, if the reason for your first Caesarean was perhaps ‘failure to progress’ (the cervix didn’t open up properly) or even ‘suspected cephalo-pelvic disproportion’ (there was some doubt whether your pelvis was big enough for your baby), the likelihood is that your next birth will be straightforward.

If you had your first Caesarean because your baby was breech or became distressed during labour, there is every reason to think that your next labour will be a normal one ending in a vaginal birth.

Will my scar rupture if I try to have a vaginal delivery following a caesarean section?

Many women who have had a Caesarean worry that a subsequent natural birth will rupture the scar, but this is very rare. The NICE Caesarean Guideline quotes a rate of rupture during VBAC as 0.35%, which is taken from an audit carried out in 2000. This audit also found the rate of rupture at a repeat caesarean to be 0.12%. Even in the serious cases, the woman's uterus is usually repaired and her baby unharmed.

If you are concerned about uterine scar rupture, discuss it with your doctor.

How many caesareans can I have?

There is no set limit on the number of caesareans that can be carried out on an individual woman. People have been known to have even up to 7 caesarean sections!!

Should I undergo tubal sterilization during my operation?

The general recommendation is to have the sterilization procedure done at least six months following delivery. Do not feel pressurized to be sterilized just because you are having an operation. Discuss the matter with your doctor at least a week before the surgery.

Is my bleeding normal? How do I know if I am bleeding too much?
Even though you did not delivery vaginally, you will still experience some significant vaginal bleeding as part of your recovery. This is called lochia. Most women will bleed heavily for at least the first two weeks of their recovery - but if you experience so much bleeding that you must change your pads every hour or pass a clot larger than a golf ball, then you should contact your doctor immediately. 

When can I start exercising?
This will depend on your body. Most doctors tell their recovering caesarean section moms that they can start back at their regular activities after 6 weeks (again, please check with your own doctor).

How soon can I go swimming?
If your lochia (vaginal bleeding) has stopped and your scar is totally closed, you can swim. Swimming is one of the best forms of exercise for those recovering from sections because it puts so little stress on your body. 

When can I drive a car?
The answer to this one seems to vary a great deal from doctor to doctor. Women have reported everything from 2 weeks to 6 weeks, though usually with an answer somewhere in the middle. This is another issue that depends a lot on your own body and how you are feeling.

When can I resume sexual intercourse?
The short answer is when you feel ready. Most doctors seem to lean towards 6 weeks. Some women are recovered enough after 2 weeks, others take 3 months before they would even think about it. 

 On the physical side you need to consider how much pain you are experiencing in your abdomen. Is your scar healing well? Are you experiencing any sensation of pulling from your scar?

Another thing to keep in mind is that there is more to this than just your physical recovery. For many women who have just had a child, sex is the last thing on their mind - and their partners need to understand that between sleep deprivation and hormones, a woman's body is a bit of a war zone for a while after delivering a baby. Each couple must work through this particular issue in relation to the physical and emotional state of the new mother.

How soon after the delivery do I need to use contraception? 

If you are practicing exclusive breast feeding you might have protection up to 3 months but please do discuss this with your doctor.

Remember that even if you are breastfeeding or your cycle seems not to have returned yet - you can still get pregnant again if you do not use some form of birth control.

Will I ever get feeling back around my scar?
 It will take time. Maybe up to 3 months or more. Everyone experiences some numbness and tingling in their abdomen after the surgery.

What are some feelings that I may have after the Caesarean?

It is important to remember that ALL new mothers go through emotional changes as the baby is born. They can be happy that their baby is there safely, disappointed that they did not achieve their "dream" birth, mad at the circumstances or some people, disconnected from the baby, or just relieved to get it over with.

Medical Jokes

A man goes to his doctor and says, "I don't think my wife's hearing isn't as good as it used to be. What should I do?" The doctor replies, "Try this test to find out for sure.

When your wife is in the kitchen doing dishes, stand fifteen feet behind her and ask her a question, if she doesn't respond keep moving closer asking the question until she hears you." The man goes home and sees his wife preparing dinner. He stands fifteen feet behind her and says, "What's for dinner, honey?" He gets no response, so he moves to ten feet behind her and asks again. Still no response, so he moves to five feet. still no answer. Finally he stands directly behind her and says, "Honey, what's for dinner?" She replies, "For the fourth time, I SAID CHICKEN!"

---

"Doctors at a hospital in Brooklyn, New York have gone on strike. Hospital officials say they will find out what the Doctors' demands are as soon as they can get a pharmacist over there to read the picket signs!"

---  

The difference between a neurotic and a psychotic is that, while a psychotic thinks that 2 + 2 = 5, a neurotic knows the answer is 4, but it worries him.

---  

A List of Things You Don't Want to Hear During Surgery:

·         Oops!

·         Has anyone seen my watch?

·         Come back with that! Bad Dog!

·         Wait a minute, if this is his spleen, then what's that?

·         Hand me that...uh...that uh.....thingy

·         What do you mean he wasn't in for a sex change!

·         Damn, there go the lights again...

·         Everybody stand back! I lost my contact lens!

·         Well folks, this will be an experiment for all of us.

·         What do you mean, he's not insured?

·         Let's hurry, I don't want to miss "Bay Watch"

·         What do you mean "You want a divorce"!

·         FIRE! FIRE! Everyone get out!

 ---  

A man goes to his doctor for a complete checkup. He hasn't been feeling well and wants to find out if he's ill. After the checkup the doctor comes out with the results of the examination. "I'm afraid I have some bad news. You're dying and you don't have much time," the doctor says. "Oh no, that's terrible. How long have I got?" the man asks. "10..." says the doctor. "10? 10 what? Months? Weeks? What?!" he asks desperately.

"10...9...8...7..."

---  

The seven-year old girl told her mom, "A boy in my class asked me to play doctor." "Oh, dear," the mother nervously sighed. "What happened, honey?" "Nothing, he made me wait 45 minutes and then double-billed the insurance company."

Poems by doctors  (Shows the tender hearts beating within!)

ENCOUNTER ON THE STAIRS
By Warner V. Slack, MD

Next to Children’s Hospital, in a hurry
Down the stairs, two at a time
Slowed down by a family, moving slowly
Blocking the stairway, I’m in a hurry
I stop, annoyed, I’m in a hurry
Seeing me, they move to the side
A woman says softly, “sorry” in Spanish
I look down in passing, there’s a little boy
Unsteady in gait, holding onto an arm
Head shaved, stitches in scalp
Patch over eye, thin and pale
He catches my eye and gives me a smile
My walk is slower for the rest of the day

---

Silent Burial
By Janet Greene, RN

Loving in secret takes its toll.
Afraid to discover my twisted soul
which loves things without beauty,
I close the door hoping to find shelter.
Feeling the chill from the wind of people’s voices,
I wrap my sweater to me,
And tuck my hands carefully in the cuffs.
Quietly I cherish someone others loathed to touch.
Her mind grew like a crooked branch,
And her laugh had a silly shrill.
Restless eyes betrayed her childish spirit
That earned no wisdom over time.
Distance keeps my secret even in death.
May the earth
Gently bury my untidy companion,
And let me mourn in peace.

(In Memory of Bertha Ann, 1984)

---

EVENING OF LIFE
By Anupama Gangavati, MD

Inside the nursing home
In a small corner
There…I saw her
Eyes dark and dried of tears
Wrinkled face
Reflecting fatigue
Her gray hair in a total mess
Like the evening of her life.

“I lost my best friend…of eighty years”
She said
“I hope my time will come soon”
Overwhelmed, I got confused
Didn’t know how to react
I even lost my own smile
And now,
In my solitude,
The silence of the night
Seems to be telling me something
That I hate to believe
Perhaps a sheer reality

And now,
Those dark eyes haunt me
As I close my eyes
And ask myself
“Does old age bring miseries?”

And now,
The silence of the night
Leaves me wondering
And just wondering….

---

The Baby Killer
Susan Lane, RN, MSN, MBA

Pain… searing
Belly… throbbing
There is no baby.
There will be no baby.
Endometriosis!

---

 

Finding meaning while on call in early daily light savings time…..
By Booker T. Bush, MD

I remember teaching some of you
How to be on call
‘Not an architect, but a fireman be’.
Round early
Before the family
Who will
Express their need and wanting
Their time usually after noon
You must grant, but can avoid
By,
Rounding early

And the white cloud
Granted’ on Friday an easy evening
With no calls,
So much so that you tested your beeper,
And Saturday evening and night,
Shortened
By an act of a cowardly congress,
Made you arise early, to meet
A woman
Admitted with delirium
Perhaps due to too much medication for pain
Who said
While tearing at her hair,
(there is a witness, an intern enthralled)
I am in pain and you withhold it from me,
isn’t there an in-between place with the medications…?
Something between pain and confusion
And we stood barriered,
For she had this before done.
But while tearing at her hair
(straightened though
Black but now returned to not)
said I have my lung cancer,
And my breast disfigured
But one of my daughters, has just been told
She also, has a breast that must be removed,
And another, who has been told,
That both breasts must
Be removed
And another who also must
Sacrifice her uterus…
And perhaps her breasts also
Finding meaning…

I raised them
As best I could
I gave them
My all, and now there is this
Only tears
And pain,
And no imbetween
Daughters with
No breasts,
No uterus
And you withhold
My pain medication

And we can only listen
And listen
And she becomes more calm
And she apologizes
And she becomes calm
And we listen.
And she begins to heal
And because of the white cloud, and
Because of the easy evening,
And because of a cowardly congress.

I go to church to sing
Corelli
And I have time to think,
Before seeing more patients.
This is what we do,
We listen, we take the time
And the Corelli.

So I won’t write of the call
About the cats, biting toes
That 2 Percoset
Every 4 hours
Can’t heal
It is the time,
Unimbursed that the architect, nor the Fireman
Wishes to offer.

Thank God,
For the time
For the Corelli

---

Emotions
By Nagma KC, RN

With an inspiration to heal
Eyes open up without much sleep
Rushing, off I go towards my journey
Heart full of love and care
hands full of divine touch
less load, alas! no
much work there is,
and so is hope

I try my best to heal
Lessen the sorrow and erase
the inner soul with pain
Easy work it isn’t,
Emotionally drenching it is,
My heart is filled with pain
Seeing the moans, and the groans
helplessness and shrill cries
Oh Lord! I whisper
Please Help Him/ Help Her
Dear God, I say
take away their sorrow,
Oh Please! take away their pain

Doctors are called, medicines are given
Eyes become teary and my heart heavy
Why is there so much pain, I ask
Everyday, every hour, every second
Hazy my view becomes
I quit! I say
A hand on my shoulder
A smiling face, it's my colleague
It's the Nurse
It's okay she says,
You can do it

With a new vision, off I go
Helping again, the sick
8 hours are gone, now is the time
Mercy Lord, I survived I say
And, I healed and spread love
Tired, sad, happy
I leave for home
Will be back tomorrow, I say
Will do a better job, I dream
Help us all, I pray
Dear God! Dear Lord
take away all sorrow and pain!

FAQs on Vaginal Discharge

“Unusual” Vaginal Discharge

I am noticing a discharge that is unusual. It is clear or white in color, but it has the consistency of (for lack of a better word) snotty. There is a slight odor to it, however I am not experiencing any pain, or itching. I have no idea what this is, but I would like to clear it up very soon. I am thinking of getting an over-the-counter yeast infection medication because I can't get in to see my doctor for another month. Do you have any ideas as to what this may be, or if the yeast infection medication will help?

This doesn't sound like a yeast infection because you don't describe vulvar itching and burning or a whitish thick discharge usually characteristic of yeast. Therefore I don't think using yeast medication will help.

Itching and dry skin - is it yeast?

I think I have early signs of a yeast infection. I felt itchy and noticed that I had some dry flaky skin. The skin is red but I assume it's a result of scratching. The itching is not severe and it's once in a while but enough for me to notice and check it out. I actually noticed the itching in the midst of my period. There's no bleeding or broken skin in the area where it has dry skin. I guess I'm a little concerned and was wondering if anyone has experienced something like this. I've had yeast infections before but I don't recall getting dry skin.

Itching is often a sign of a contact allergy. The fact that it is happening during your menses would prompt me to ask if you are wearing any type of pads or liners (as opposed to a tampon). Could you be sensitive to a certain brand? Yeast usually produces burning rather than itching but not always. Sometimes there are other fungal infections such as tinea species that can produce itching on the "dry" skin. If this persists or worsens it should be checked out.

nonoxynol 9 could be a reaction

I recently started using a different brand of condoms (well my partner) and It contains nonoxynol 9 could be a reaction to that?

It can be. We see reactions to vaginal foam that contains nonoxynol 9 but it's hard to tell if its that specifically or some of the other carrying agents used. The only way to tell with the condom is either going back to a brand you previously used or abstinence for long enough to tell if the problem goes away. This is an area where you will need to be your own detective with trial and error of different materials/substances that that area comes in contact with.

Odorous vaginal discharge 

I've been having abnormal discharges (thick and have an odor) for a while now...is this vaginitis? and since I've had this problem for so long...could I have become sterile? Is there any medication that I can use to help that does not require a prescription? I don't feel comfortable talking about this with my parents let alone my doctor...please reply back with your suggestions and input...it would be greatly appreciated.

An odorous vaginal discharge can sometimes be a symptom of bacterial vaginitis. It should be checked out. I know you may feel uncomfortable talking about this with your doctor, but that's what the doctor is there for. This is a common problem that your doctor has heard many times before. If you avoid bringing it up, the poor doctor will go out of business! In general, vaginitis doesn't cause sterility. If you get a sexually transmitted disease, that can cause sterility. The doctor checks for that by doing a cervical culture or smear at the time of a vaginal exam. As far as home remedies, the only thing I know of would be douching. In this process you are rinsing out any vaginal or cervical secretions so that bacteria have less material on which to produce odorous causing chemicals. There actually is evidence that regular douching seems to increase the incidence of vaginal infections. However, if you already have a problem, douching is often effective in reducing the symptoms. Betadine douche is one still recommended by many physicians. If the symptoms don't clear up after douching 3/week for one or two weeks, you really should see your doctor.

Recurring yeast infections - milky white discharge

I am 29 and I have been on the pill from 1986 until 1994. I got pregnant in August 1994 and had to terminate the pregnancy. I got back on the pill in the summer of 1995. At the end of 1995 I started having yeast infections on a regular basis. In 1996 I had 8 of them throughout the year. I also had a bacterial infection once that year. Almost all the time when I have a yeast infection, I also have a skin rash, the same kind I've been having off and on since I was little. I put hydrocortisone cream on the rash and it will go away with that. For yeast infections, I take Fluconazole. This helps for that moment but I have to take a higher dose every time I take it, probably because my doctor told me to take it every month just to prevent it, and I might have become resistant to it. A few weeks after taking Fluconazole, the yeast infection comes back and I have to start over again. I have stopped taking Fluconazole on a regular basis now. For my feeling, the recurring yeast infection started after I got back on the pill in 1995. Spotting is not happening anymore but the yeast infections keep coming back. I eat healthy (low fat, high fiber) although I have a sweet tooth. I eat fruit and yogurt everyday and take vitamin supplements daily. I exercise 3 times a week and take a shower right after that. I wear cotton underwear and don't douche, wash my vagina only with water and don't sit in the bathtub. My partner and I have been together since the beginning of 1995 and we are in a monogamous relationship. We both tested negative for HIV and I have tested negative for diabetes. Also my partner has used the OTC yeast infection cream which didn't make a difference. He has been checked for yeast but was negative. Right now, I am on the 15th day of my cycle and I have a milky white discharge. When I go to the bathroom I see 1/2 inch big drops of discharge. Is this normal or is it yeast again?

A milky white discharge is usually normal. It represents cervical and vaginal secretions that contain old vaginal wall cells (epithelium). As long as there is no vulvar burning/itching, this does not represent a symptomatic yeast infection.

Could it be possible that the yeast infection is an allergic reaction to something?

Allergic reactions (contact) of the vaginal or vulvar epithelium are often confused with yeast infections because they cause a histamine release in the skin of the vulva with subsequent itching or burning. That is one reason why culture for yeast is so important because you may assume it's a yeast infection when in fact it is allergic. The most common allergens are feminine hygiene sprays, contraceptive foam and jelly, even carrying agents in anti-yeast preparations, lubricants on condoms, or soaps or bath oils. It doesn't sound as if these are a problem in your case but you have to be your own detective with allergens.

Are there any other things I can try or am I just "doomed" to take yeast infection medication on a regular basis for the rest of my life?

Make sure this is yeast. Sometimes women with sensitive skin will react to any normal vaginal secretions when they get on the vulva because the secretions are naturally acidic. You can try petrolatum jelly (Vaseline) to coat the vulva (a small layer) to protect it from acidic discharge or you can use a tampon to block the discharge from getting to the vulva and irritating it. These would be tests to see if it is just an acidic (but normal) discharge you are reacting to or a yeast infection. These things will usually not prevent the reaction to a yeast infection.

Could it help to stop taking the pill?

Some women will get more yeast infections on certain birth control pills. I think it has to do with the specific progestogen in the pill. Sometimes when we have women discontinue pills, recurrent yeast infection gets better; other times there is no difference in the rate of infection. It would take a 3 month trial off of the pills to tell.

Boric acid as treatment for recurring yeast infections

What about boric acid?

Boric acid vaginal suppositories have been used in the past for resistant, recurrent yeast infections. Many experts in vaginitis clinics use them still. Unfortunately in the U.S. we don't have any commercial vaginal suppositories with boric acid. Perhaps in Europe there are some if that's where you are. We have to have the pharmacist mix them up. Find an experienced pharmacist who remembers the formulation. These recurrent infections usually run their course after several years. Something in the biochemistry of the vagina changes and they disappear or at least get much less frequent as long as there is not an underlying disease. Have hope. At the risk of losing you due to repetition, make sure this is recurrent yeast infection by culture and not just by visual diagnosis of the physician. I can't count how many women I've seen who thought they were having recurrent yeast infection when in fact their cultures were negative and their discharge was just irritative, but not infectious.

Resistance to Fluconazole

I'm 29 years old and for the last year and a half I've been having yeast infections almost every other month. One of my doctors told me to take Fluconazole every other week for a few months and then every month just to prevent. Now two weeks ago I had another yeast infection and my doctor gave me a prescription for Fluconazole. I had to take 3 times the normal dose of Fluconazole to make the yeast go away. Is it possible that my body is immune to Fluconazole now? The yeast infection went away but now, 3 weeks later, I have one again. I'm so desperate! Is there anything else I can try? I'm taking the pill now, but I want to try to stop taking it to see if that might make a difference. Please help me!!

Resistance of Candida (yeast) species to Fluconazole are becoming more and more a problem, probably because it is being used so much to treat yeast instead of topical, vaginal medications which usually don't develop as many resistances. That being said, it is still extremely important to make sure of the diagnosis. Vaginal and vulvar irritation can be due to causes other than yeast. (See our news about cultures for yeast. Assuming that you and your doctor are absolutely sure of the diagnosis of recurrent yeast infection and there are no predisposing factors such as diabetes, antibiotic use, immune disease or immunotherapy use, then the treatment becomes problematical trial and error. You need to work with the physician to find medication to use periodically to keep it in check. Dietary change and douching may also play a role.

Clumpy vaginal discharge with white cells

Hello, I am 24 and for the past 4 months have noticed that my discharge is not like it used to be. I was on an anovulatory cycle for about 9 months because of hyperprolactinemia. I started taking bromocriptine and started my usual cycle about 8 months ago. After I started my period, I stopped taking the bromocriptine because it makes me so ill. Well I have been pretty regular except the bleeding for the past couple of months have been for 8 days instead of my normal 6 days and for the past 4 months my discharge has changed. The whole week after my period it will be light and a little clumpy, and then the clumpiness will go away almost totally during my mid cycle, and then about a week before my period starts it will become very thick and clumpy. When my period starts it goes away and the cycle continues. There is no odor and no itching. I thought it was a yeast infection at first. I have been to three doctors and they all tell me that my tests come out normal on vaginal cultures. On wet mount they find epithelial cells and Lactobacilli along with an elevated amount of WBC's. I keep asking them that if there is so many WBC's then it means I have a vaginal infection or something but they keep telling me that it may be normal for me. I am wondering if my hormones have anything to do with this problem because I have been wondering if I should get a fourth opinion. I thought that you go to the doctor if something is out of the norm and I do but then they tell me it is normal. I am really stressing out over this.

Vaginal discharge varies in its nature and consistency from one person to another and even for one person throughout the menstrual cycle. Commonly the discharge is grayish white or clear. The cells come from the vaginal lining and fluid from the vagina and the cervix. It often gets thin (non clumpy) at mid cycle of the menses because the cervical mucous is thin and copious if ovulation has taken place that cycle. In the 2nd half of the cycle it becomes thickened and sometimes clumpy under the effect of progesterone. These are all normal mechanisms to help a woman become pregnant at the mid cycle time of ovulation and then "block" the cervix in the 2nd half of the cycle so that if a pregnancy occurs there won't be any ascending infection. When a woman is anovulatory, there is less discharge and not the monthly variation in consistency. It sounds as if, in some respects, what you describe is normal now (for ovulation) and was just different when you were anovulatory. The white cells in the discharge change things a little. Usually there are not too many white blood cells (WBCs) in vaginal discharge. It's difficult to know if what your doctor has seen is "too much" or not. WBCs can indicate infection but usually of the cervix, not the vagina. If the cervical mucous is clear or white, not yellowish, there usually is not an infection that needs treatment. All that being said, there have been instances where doctors have just treated with antibiotics for a "cervicitis" just because of the amount of vaginal discharge. Sometimes it gets better and other times it doesn't change because there really wasn't any infectious process in the first place. Usually, if I see numerous white cells on vaginal wet prep, I treat with an antibiotic cream vaginally or and erythromycin oral antibiotic as an empirical trial. I would say it clears up the problem about 50% of time.