Monthly Archives: May 2018

ADVICE TO PREGNANT WOMEN: HOW TO AVOID OVEREATING DURING THE HOLIDAYS

By Rebecca B. Singson, MD, FPOGS

Whenever it’s holiday time, it becomes challenging for people to maintain their weights because of the frequent social engagements and office parties loaded with mouth-watering, irresistible goodies. It becomes particularly challenging for the pregnant woman who has an increased appetite and feels she “is eating for two” but is already overweight. If you are slim and non-pregnant, gaining extra weight and eating high calorie but low nutritional food may not be such a great issue. But to the infanticipating woman, there may be more serious consequences if she is not meticulous in watching what she eats so here’s the why and how of being more prudent with your palate during party time.

WHY YOU SHOULD NOT GAIN TOO MUCH WEIGHT

Too many calories and extra pounds can put you at a higher risk for pregnancy complications such as hypertension or diabetes, and may make labor and delivery more difficult. Although you do need extra calories during pregnancy, particularly during the last trimester, you also need lots of extra nutrients, so those extra calories need to be chosen wisely. A woman who is not pregnant needs between 1,800 and 2,200 calories per day. When you are pregnant, contrary to popular belief, you only need to increase your calories by about 300 per day so keep in mind that its quality not quantity is what matters. Remember that if you gain way beyond the prescribed weight, your chances of having a large baby also increases, which in turn may also increase your chances of ending up with a Cesarean section.

Besides all that, the latest, and by far the most disturbing finding by researchers at Lombardi Cancer Center in Washington, DC, and in Finland is that women who gain more than 50 pounds during pregnancy, and did not losing the excess weight after pregnancy, can triple their risk of developing breast cancer after menopause. A lesser pregnancy weight gain of 40 pounds can still increase breast cancer risk by 40%. Knowing that should stimulate you to be more watchful of the weighing scale.

Researchers have shown that pregnancy weight gain has been linked to increased estrogen levels, which in turn is believed to increase breast cancer risk  in a similar way that postpartum obesity does too. Women who gained within the normal limit of 25-35 lbs. during pregnancy were not associated with increased breast cancer risk.

If despite eating moderately, you are gaining more than 2 lbs./wk., you must alert your obstetrician since any rapid weight gain, especially if associated with marked fluid retention and an increase in blood pressure and possibly protein in the urine, can be a marker for the onset of preeclalmpsia. This is a disorder that can be harmful, if not fatal to you and your baby.  

HOW MUCH IS TOO MUCH?

If you are of average weight, it is recommended that you gain is about 25 pounds during pregnancy. Only two to four pounds of that goes on during the first trimester. By 20 weeks, you should have gained 7-10 lbs. and the remaining weigt is added at about a rate of half a pound to one pound per week after that. Some women even drop their weight during the first trimester due to nausea and vomiting but usually recover the weight loss in the course of pregnancy. Underweight moms can afford to gain more weight, at least 28 to 40 pounds, so they don’t end up with a low birth weight baby. But if you’re already carrying an extra baggage of fat by the time you get pregnant, its best that you limit your weight gain to 15-20 lbs.

If you want to know where all that weight goes, here’s how the weight gain is ideally distributed:

  • Baby:   7 pounds
  • Placenta:   1 pound
  • Amniotic fluid:   2 pounds
  • Blood volume:   4 pounds
  • Body fluids:   3 pounds
  • Uterus:   2 pounds
  • Breasts:   1 pound
  • Fat & protein storage:   7 pounds

 

WHAT YOU CAN DO

So you can’t say no to these social obligations. At the same time, you’d hate to miss out on the fun. So here are tips to help you keep the scale from tipping over.

  • PRIORITIZE YOUR REQUIREMENTS. Make sure you meet your daily requirements first before you allow yourself the treats. Get your fill of the salads and protein sources while filling your healthy carbohydrate requirements. Ear your fruit first before you hover over the dessert table. Hopefully, that would have killed your craving for the pastry department.
  • AVOID STARVATION. It is truly difficult to control your appetite if you arrive ravenous during a party. You are bound to eat everything in sight! So before you go to the party, have a nutritious snack like a granola or muesli bar, veggie sticks with yoghurt-garlic dip or some dried fruits and nuts so you won’t be obsessing over the buffet table.
  • DRINK BEFORE YOU LEAP.  If you have the urge to splurge, gulp down a glass of water, fruit juice or some soup (preferable clear than creamed). That will instantly appease your grumbling insides and allow you to be more sane and prudent in your choice of food.
  • CHEAT SENSIBLY. If you must absolutely give in to your sweet tooth, at least make the wiser, more nutritious choice, lower calorie choice. An oatmeal or ginger cookie is better than an empty sponge cake or a fatty cheese cake.
  • IF YOU MUST INDULGE, EAT ONLY A PORTION OF IT.  If you cant resist the cheesecake, instead of gobbling up the whole slice, eat only half or a few bites of it. Remember, it doesn’t matter whether you have had fifty bites or only two. In the end, your mouth is empty. But the fifty bites will take your weight farther down the scale.
  • BURN WHAT YOU EAT.  Just because you are pregnant doesn’t mean you can’t exercise. As a rule, you can still continue your exercises, dance or low impact sports (swimming, golf, tennis doubles). Remember that brisk walking for 20 mins., will raise your metabolism the rest of the day and cause you to burn calories faster than if you did not exercise at all.
  • DON’T BE A STRESS CHOMPER. Holidays can be stressful times especially when you have to socialize and beat you office deadlines at the same time. So resist the impulse to munch away your stress. Be prepared with your arsenal of anxiety busters like yoga, meditation, massage (caution: masseuse must be trained on pregnant women or premature labor may be induced), instead of taking it out on food.

 

Remember that staying within your prescribed weight will insure a more favorable outcome for your pregnancy as well as prevent your risk for breast cancer. That’s really worth dieting for.

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MICRONUTRIENT SUPPLEMENTATION IN PREGNANCY

Rebecca Singson, M.D., FPOGS

Pregnancy is in the only time in the life of a woman when another human being becomes a parasite to her, depending on her body to provide the nutrients the fetus needs in order to grow. It is thus a critical time to be equipped with the necessary micronutrients to prevent damage to the growing fetus as well as to the mother herself. Nature protects the fetus so much that if the baby needs a nutrient that the mother does not have enough of for herself and her baby, the nutrient will be preferentially directed to the baby even to the detriment of the mother.

In this generation when we no longer plant our food the way our forefathers did, the nutrition we get from eating fastfood, bottled, canned, frozen food have become devoid of the nutrients we need to keep our bodies healthy, much less to support a healthy pregnancy. We need to insure ingesting at least the following nutrients to begin working towards an uneventful pregnancy.

FOLIC ACID. Folic acid can be found in foods such as spinach, parsley, broccoli, lettuce, lima beans, turnip greens, asparagus and beef liver. Folic acid supplementation is best taken even before planning your pregnancy since there is strong evidence that folic acid can reduce certain birth defects of the brain and spinal cord by more than 70 percent. These birth defects are called neural tube defects (NTDs). NTDs happen when the spinal cord fails to close properly.The most common neural tube defect is spina bifida which occurs when part of the baby’s spinal cord remains outside the body. The baby may have paralyzed legs and, later, may develop bladder and bowel control problems. The most serious neural tube defect is anencephaly when baby is born without part of its skull and brain, and eventually dies. For all childbearing ages, the Center for Disease Control in the U.S. recommends that all women of childbearing age take at least 400mg of folic acid daily but for all pregnant women, 1mg/day is recommended. Women with a history a child with neural tube defect should take 4 mg of  folic acid 1 month prior to conception and and all throughout the first trimester.1

IRON. According to the Cochrane review, rron supplementation appears to prevent low haemoglobin at birth or at six weeks post-partum.2 The availability or iron for our bodies to use depends on the food source. Heme iron, which is found only in meat, poultry, and fish, is two to three times more absorbable than non-heme iron, which is found in plant-based foods and iron-fortified foods 3.4. The bioavailability of non-heme iron is strongly affected by the kind of other foods ingested at the same meal. Enhancers of iron absorption are heme iron (in meat, poultry, and fish) and vitamin C; inhibitors of iron absorption include polyphenols (in certain vegetables), tannins (in tea), phytates (in bran), and calcium (in dairy products)5.6 . Vegetarian diets, by definition, are low in heme iron but can certainly be increased by careful planning of meals. The CDC recommends taking or low dose 30 mg/day) supplements of iron at the first prenatal visit. In the presence of anemia, treatment involves prescribing an oral dose of 60-120 mg/day of iron.7.

IODINE. This is essential for normal fetal thyroid function. If the mother lacks iodine, the baby may develop cretinsm (congenital hypothyroidism) of which mental retardation is a component. Cretins have abnormal looking faces with the tongue sticking out. Acc. to the Cochrane Review, iodine deficiency is the leading preventable cause of intellectual impairment in the world. Supplementation during pregnancy especially in areas with high incidence of cretinism results in reduction of this problem with no adverse side effects.8

The use of iodized salt is one way to prevent iodine deficiency. Salmon, tuna and seaweeds are excellent leading sources of iodine from food.

If using seaweeds as an iodine source it is best to use seaweeds that have been found to have a fairly consistent iodine content, such as kelp (kombu) or hijiki. It may be dangerous to consume more than 100g/year (by dried weight) of most seaweeds carries a significant risk of thyroid disorder due to iodine intakes in excess of 1000 micrograms per day.

Nori (the seaweed used to wrap sushis with) is low in iodine and several sheets a day can be eaten without any concern about excess iodine. Frequent addition of small amounts of powdered or crumbled seaweed to stews or curries while cooking, or to other foods as a condiment, is an excellent way to provide adequate iodine (in the absence of other supplementation) . 100g of dried hijiki or 15g of dried kombu or kelp in a convenient container in the kitchen provides one year’s supply for one person.

MAGNESIUM. Magnesium supplementation during pregnancy has been associated with fewer pre-term births and less intrauterine growth retardation. 9.10,11 Magnesium deficiency is associated with pre-eclampsia, and pre-term delivery and possibly with low birth weight.12 ,  coagulation defects 13, premature delivery14,15, intrauterine growth retardation 9.15,and muscle cramping16 Diets high in magnesium density would contain whole grains, lean meats, low amounts of fats and sugars, abundant fruits and vegetables, and low-fat milk. Diets low in magnesium density would contain refined cereal grains, fatty meats, high amounts of fats and sugars, few fruits and vegetables and sugar-containing soft drinks.

DHA. In the latest researches it has been found that supplementing pregnant mothers with fish oil may benefit brain and retinal development in their offspring particularly if born prematurely. Supplementing from mid-pregnancy to the 34th week was found to be perfectly safe and more importantly, may reduce the incidence of preeclampsia (pregnancy-related high blood pressure).17 It was found that breastmilk contains DHA whereas formula milk did not. Researchers at the University of Milan report that infants whose formula contains long- chain polyunsaturated fatty acids [especially Docosahexaenoic acid (DHA)] have better brain development than children who do not receive DHA in their formula. The observation supports earlier findings that there is a direct correlation between the DHA concentration in the red blood cells of infants and their visual acuity. The researchers recommend that infants who are not breastfed be fed on a DHA- enriched formula. Nothing is as complete as breast milk since it is already complete with the fatty acids necessary for good brain development.

VITAMIN D:

Vitamin D is produced by the skin and eyes from exposure to sunlight and can also be consumed from foods such as fish-liver oils, fatty fish, mushrooms, egg yolks, and liver. Thus nutrient has multiple functions in the body like helping maintain bone integrity and calcium homeostasis. During pregnancy, vitamin D deficiency or insufficiency may develop. Vitamin D supplementation during pregnancy has been suggested to safely improve pregnancy and infant outcomes. 

Research shows that the Vitamin D supplementation during pregnancy improves the women’s vitamin D levels, as measured by 25-hydroxyvitamin D concentrations at term and may reduce the risk of delivering a baby prematurely (less than 37 weeks of gestation), result in a lower risk of high blood pressure in women and reduce the risk of a low birthweight baby (less than 2500 g).19

MICRONUTRIENT INTERACTIONS.

There are some micronutrients that alter the absorption of others. For example, calcium can block the absorption of iron. Vitamin A may also contribute to anemia by interfering with iron although studies have shown that when given together, there is greater reduction in anemia. Iron supplements can also interfere with the absorption of zinc. On the other hand, vitamin C can increase the absorption of and zinc. Zinc in high doses may interfere with absorption of iron or copper.  But many studies still document achieving greater benefits with combined, rather than single, micronutrients therapy but many more studies are required to evaluate these interactions in malnourished populations. Because of the possibility that there may be multiple deficiencies in pregnant women in developing countries, UNICEF has concluded that a multivitamin–mineral supplement should be given during pregnancy20. By simply supplementing, many complications in the mother and infant during and after pregnancy may be avoided.

 

  1. Centers for Disease Control. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR 1992;41(No. RR-14)
  2. Mahomed K. Iron supplementation in pregnancy. The Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD000117. DOI: 10.1002/14651858.CD000117.
  3. Hallberg L. Bioavailability of dietary iron in man. Annu Rev Nutr 1981;1:123-47.
  4. Skikne B, Baynes RD. Iron absorption. In: Brock JH, Halliday JW, Pippard MJ, Powell LW, eds. Iron metabolism in health and disease. London, UK: W.B. Saunders, 1994:151-87. Bothwell TH. Overview and mechanisms of iron regulation. Nutr Rev 1995;53(9):237-45.
  5. Bothwell TH. Overview and mechanisms of iron regulation. Nutr Rev 1995;53(9):237-45.
  6. Siegenberg D, Baynes RD, Bothwell TH, et al. Ascorbic acid prevents the dose-dependent inhibitory effects of polyphenols and phytates on nonheme-iron absorption. Am J Clin Nutr 1994;53:537-41.
  7. Centers for Disease Control. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR April 03, 1998 : 47(RR-3);1-36
  8. Mahomed K , Gülmezoglu AM. Maternal iodine supplements in areas of deficiency. The Cochrane Database of Systematic Reviews 1997, Issue 4. Art. No.: CD000135. DOI: 10.1002/14651858.CD000135
  9. Conradt A, Weidinger H and Algayer H. Magnesium therapy decreased the rate of intrauterine fetal retardation, premature rupture of membranes and premature delivery in risk pregnancies treated with betamimetics Magnesium 4, 20-28, 1985.
  10. Spatling L and Spatling G. Magnesium supplementation in pregnancy: a double blind study British Journal of Obstetrics and Gynecology 95, 120-, 1988.
  11. Sibai BM, Villar L and Bray E (1989) Magnesium supplementation during pregnancy. A double-blind randomized controlled clinical trial American Journal of Obstetrics and Gynecology 161, 115-119.
  12. Chien PFW, Khan KS and Arnott N (1996) Magnesium sulphate in the treatment of eclampsia and pre-eclampsia: an overview of the evidence from randomized trials British Journal of Obstetrics and Gynecology 103, 1085-1091.
  13. Weaver, K.: A possible anticoagulant effect of magnesium in preeclampsia; in Cantin, Seelig, Magnesium in health and disease, pp. 833-838 (Spectrum Press, New York 1980).
  14. Conradt, A.; Weidinger, H.; Algayer, H.: Magnesium therapy decreased the rate of intrauterine fetal retardation, premature rupture of membranes and premature delivery in risk pregnancies treated with betamimetics. Magnesium 4: 20-28 (1985).
  15. Kuti, V.; Balazs, M.; Morvay, F.; Varenka, Z.; Székely, A.; Szücs, M.: Effect of maternal magnesium supply on spontaneous abortion and premature birth and on intrauterine foetal development: experimental epidemiological study. Magnesium- Bull. 3: 73-79 (1981).
  16. Hunt, S.M.; Schofield, F.A.: Magnesium balance and protein intake level in adult human female. Am. J. clin. Nutr. 22: 367-373 (1969).
  17. Connor, William E., et al. Increased docosahexaenoic acid levels in human newborn infants by administration of sardines and fish oil during pregnancy. Lipids, Vol. 31 (suppl), 1996, pp. S183- S87
  18. Agostoni, Carlo, et al. Docosahexaenoic acid status and developmental quotient of healthy term infants. The Lancet, Vol. 346, September 2, 1995, p. 638
  19. http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD008873.pub3/full
  20. UNICEF (1999) Composition of a multi-micronutrient supplement to be used in pilot programmes among pregnant women in developing countries.
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MINIMALLY INVASIVE SURGERY IN PREGNANCY

Five years ago, on her first pregnancy, I diagnosed  Mrs. J., with a 7×7 cm ovarian cyst. On her 4th month, an exploratory laparotomy was contemplated for the removal of the ovarian cyst. Her abdomen was cut open, way bigger than the usual, to be able to expose the pregnant uterus and at the same time, manipulation of the ovarian mass located behind the uterus. With this much bigger incision, the uterus with the delicate fetus inside was held forward by an assistant while I worked behind to remove the tumor. The scar stretched as the pregnancy grew to term. The pregnancy progressed without any problems and she delivered by spontaneous vaginal delivery to a healthy baby boy, who, 5 years later manifested with exceptional IQ. The surgery, however left the mother with a midline scar running up to her umbilicus, and going around it as shown in Fig 1.

Five years later, Mrs. J. refers an acquaintance, also pregnant for the first time at 16 weeks, with a 7×7 cm. ovarian cyst.  By this time, the technology of minimally invasive therapy through laparoscopy had come of age. I convinced the patient that laparoscopic removal was the best to do in this case. Three 1-cm incisions were made on the abdomen above the level of the umbilicus, the mass was visualized, excised and later evacuated by slightly enlarging the right hole where the instruments were being inserted. It was almost like removing a tennis ball through a keyhole.

Intraoperatively and postoperatively, the patient received no tocolytic medications to prevent premature labor.  She never manifested with premature contractions post-op. The baby was monitored until the patient was discharged the following day in good condition. The patient  and her whole family were extremely amazed and grateful for her small incisions and remarkable post-op recovery.

What is Minimally Invasive Surgery or Laparoscopy?

In non-pregnant women, laparoscopic removal of ovarian cysts involves making a 1-cm incision in the umbilicus, inserting a tube telescopic rod attached to a video camera and a fiberoptic  light source. Carbon dioxide gas is then used to blow up the abdomen much llke a balloon to lift the abdominal wall from the intestines and create a working space. This gas is natural to the human body and is later absorbed and eventually removed by the respiratory system. Two other incisions are made on the left and right side of the lower abdomen to insert ports under camera guidance. This is where the instruments like graspers, scissors, etc are inserted into the abdominal cavity. Then, through a tv monitor to which the camera image of the abdominal cavity is seen, the surgery is accomplished with the instruments as a remote extension of the surgeon’s hands.

In pregnancy, the incision is made midway between the umbilicus and the lower tip of the breastbone to provide clearance to the uterus to insure that the pregnancy will not be injured upon entry of the ports and instruments.

WHAT ARE THE ADVANTAGES?

  1. Dramatically smaller scar, therefore, less post-operative pain and less need for pain medications.1
  2. Less hemorrhage thus reducing the chances of blood transfusion
  3. Less chances for wound infection due to reduced exposure of internal organs to possible external contaminants and due to a smaller skin area traumatized and exposed to skin bacteria.
  4. Less chances of  incisional hernias
  5. Increased chances of early mobilization because of minimal pain. The patient can usually go home the following day or even on the same day.
  6. Early mobilization also reduces the chances of thromboembolic complications post-operatively
    1. (formation of a clot (thrombus) in a blood vessel that breaks loose and is carried by the blood stream to plug another vessel either in the lungs (pulmonary embolism), brain (stroke), gastrointestinal tract, kidneys, or leg))
  7. Conventional surgery for ovarian cysts in pregnancy recommends waiting for the proper window of time to perform an open surgical exploration during the second trimester of pregnancy. This was because there was a reported 12% abortion rate associated with early exploration in the first trimester and up to 40% increased risk for premature labor if surgery is done in the 3rd trimester. In contrast, research has shown that laparoscopic surgery in pregnancy may be done any time in the 1st, 2nd or early 3rd trimester without increased risk from the usual operative risks.3,1,4 Since there is less or no manipulation of the uterus, which contains inside the developing baby. This leads to less uterine irritability which leads to less chances of abortion or premature labor.8
  8. Due to decreased need for narcotic pain medications post-operatively,  there is less chance of depressing the heart rate and placental perfusion and metabolism of the fetus.
  9. Due to decreased need for narcotic pain medications post-operatively,  there is less chance of depressing the heart rate and placental perfusion and metabolism of the fetus
  10. Unlike conventional surgery where the pregnant patient is placed in a supine position, the gravid uterus places pressure on the inferior vena cava resulting in decreased venous return to the heart. This decrease in venous return results in the drop in blood pressure of the mother, reduced output of the heart by 10% to 30% and decreased flow of blood to the placenta during surgery5,6,7. In performing laparoscopic surgery, the patient may easily be kept in a left lateral recumbent position. This will shift the uterus to the left of the vena cava, thus, improving venous return and cardiac output5.6, 14.
  11. The patient can go back to work sooner.9,10,11
  12. No growth or developmental delay was found in eleven children followed up till 8 years after lap surgery on the mother12.

WHAT ARE THE RISKS COMPARED TO OPEN SURGERY?

  1. All laparoscopic surgeries are done with a double set-up. This means that should there be a complications arising in the course of laparoscopic surgery preventing the surgeon from proceeding, the surgeon may convert to an open surgery.  
  2. The most significant risks are from insertion of the initial trocar since this is usually a blind procedure. There may be blood vessel or bowel injury particularly if the patient has had a previous surgery. Blood vessel injury can result in hemorrhage that may require blood transfusion. Bowel injuries, especially if unrecognized, can lead to delayed peritonitis. 8
  3. Since carbon dioxide is insufflated into the abdominal cavity to raise the abdominal wall enough to see the abdominal organs. Upward displacement of the diaphragm with air in the abdominal cavity or pneumoperitoneum in a pregnant patient can cause a decreased lung volume and functional capacity, which may possibly impair the delivery of oxygen to the tissues and to the fetus.
  4. Very rarely, patients have sustained electrical burns unseen by surgeons who are working with  electrocautery machines, the electrodes of which leak current into surrounding tissue. The resulting injuries can result in perforated organs and can also lead to peritonitis.
  5. Patients may experience shoulder pain afterwards which can result from a pocket of CO2  gas rising in the abdomen.  This can end up pushing against the diaphragm, putting pressure on the phrenic nerve which can produce a sensation of pain extending to the shoulders and can make breathing very uncomfortable. Luckily, this phenomenon is transient and will disappear once the CO2  is absorbed by the tissues and eliminated through respiration. 13

Advanced technology has made minimally invasive surgery a preferred mode of intervention particularly for removal of benign ovarian cysts. In pregnancy, it becomes even a superior procedure compared to open surgery because of the reduced discomfort for the mother post-operatively the minimal to absence of manipulation of the uterus plus the tinier scars that are left with the patient as a reminder of her surgery during pregnancy.

 

  1. Curet, M.J., et al., Laparoscopy during pregnancy. Arch Surg, 1996. 131(5): p. 546-50; discussion 550-1.
  2. Curet, M.J., Special problems in laparoscopic surgery. Previous abdominal surgery, obesity, and pregnancy. Surg Clin North Am, 2000. 80(4): p. 1093-110.
  3. Reedy, M.B., B. Kallen, and T.J. Kuehl, Laparoscopy during pregnancy: a study of five fetal outcome parameters with use of the Swedish Health Registry. Am J Obstet Gynecol, 1997. 177(3): p. 673-9.
  4. Oelsner, G., et al., Pregnancy outcome after laparoscopy or laparotomy in pregnancy. J Am Assoc Gynecol Laparosc, 2003. 10(2): p. 200-4.
  5. Elkayam U, G.N., Cardiovascular physiology of pregnancy. Cardiac Problems in Pregnancy: Diagnosis and Management of Maternal and Fetal Disease, ed. G.N. U
  6. Clark, S.L., et al., Position change and central hemodynamic profile during normal third-trimester pregnancy and post partum. Am J Obstet Gynecol, 1991. 164(3): p. 883-7.
  7. Gordon, M.C., Maternal Physiology in Pregnancy, in Obstetrics: Normal and Problem Pregnancies, S.G. Gabbe, J.R. Niebyl, J.L. Simpson, Editor. 2002, Churchill Livingstone: Philadelphia. p. 63-91
  8. Janie Fuller, DDS, (CAPT, USPHS), Walter Scott, Ph.D. (CAPT, USPHS), Binita Ashar, M.D., Julia Corrado, M.D. FDA, CDRH, Laparoscopic Trocar Injuries: A report from a U.S. Food and Drug Administration (FDA) Center for Devices and Radiological Health (CDRH) Systematic Technology Assessment of Medical Products (STAMP) Committee,  Finalized: November 7, 2003
  9. Andreoli, M., et al., Laparoscopic surgery during pregnancy. J Am Assoc Gynecol Laparosc, 1999. 6(2): p. 229-33.
  10. Shay, D.C., K. Bhavani-Shankar, and S. Datta, Laparoscopic surgery during pregnancy. Anesthesiol Clin North America, 2001. 19(1): p. 57-67.
  11. Oelsner, G., et al., Pregnancy outcome after laparoscopy or laparotomy in pregnancy. J Am Assoc Gynecol Laparosc, 2003. 10(2): p. 200-4.
    Elkayam. 1982, New York: Alan R Liss. 5..
  12. Rizzo, A.G., Laparoscopic surgery in pregnancy: long-term follow-up. J Laparoendosc Adv Surg Tech A, 2003. 13(1): p. 11-5.
  13. Abdominal pain after laparoscopy: the value of a gas drain. Br J Obstet Gynaecol. 1987 Mar;94(3):267-9
  14. 65. Clark, S.L., et al., Position change and central hemodynamic profile during normal third-trimester pregnancy and post partum. Am J Obstet Gynecol, 1991. 164(3): p. 883-7.
    66. Gordon, M.C., Maternal Physiology in Pregnancy, in Obstetrics: Normal and Problem Pregnancies, S.G. Gabbe, J.R. Niebyl, J.L. Simpson, Editor. 2002, Churchill Livingstone: Philadelphia. p. 63-91.
  15. Reedy, M.B., et al., Laparoscopy during pregnancy. A survey of laparoendoscopic surgeons. J Reprod Med, 1997. 42(1): p. 33-8.

 

The key element in laparoscopic surgery is the use of a laparoscope. There are two types: 1)a telescopic rod lens system, that is usually connected to a video camera (single chip or three chip) or a digital laparoscope where the charge-coupled device is placed at the end of the laparoscope, eliminating the rod lens system.[1] Also attached is a fiber optic cable system connected to a ‘cold’ light source (halogen or xenon), to illuminate the operative field, inserted through a 5 mm or 10 mm cannula or trocar to view the operative field. The abdomen is usually insufflated with carbon dioxide gas to create a working and viewing space. The abdomen is essentially blown up like a balloon (insufflated), elevating the abdominal wall above the internal organs like a dome. The gas used is CO2, which is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures.

5-10mm diameter instruments (graspers, scissors, clip applier) can be introduced by the surgeon into the abdomen through trocars (hollow tubes with a seal to keep the CO2 from leaking).

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URINARY TRACT INFECTIONS IN PREGNANCY

REBECCA B. SINGSON, M.D, FPOGS

 

Urinary tract infections (UTI) are one of the most common infections that women consult their doctor for. When you are pregnant, you are particularly more susceptible to urinary tract infections, the incidence being as high as 8 percent (8%).  

WHY ARE UTI’s MORE COMMON IN PREGNANT WOMEN?

There are several reasons for this. From the 6th week  of gestation onwards and especially during weeks 22 to 24, the higher levels of the hormone progesterone  relaxes the muscles of your ureter, (the tube connecting the kidney to the bladder) causing it to stretch and dilate in 90% of the time, a condition known as hydronephrosis of pregnancy. Your growing uterus may also compress the ureters, making it difficult for urine to flow through them as quickly and freely as it normally does. Then later in pregnancy, the baby presses on your bladder, making it hard to empty it completely when you pee. The result of these changes makes it longer for urine to pass through your urinary tract, giving bacteria more time to multiply and attach to the lining of the bladder before being flushed out.1 It also does not help that up to 70 percent of pregnant women allow sugar to pass through the tubules of the kidney (glucose is normally sieved and saved). This encourages bacterial growth in the urine; add to that the effect of increased hormones passing out through the urine like progestins and estrogens which may lead to a decreased ability of the lower urinary tract to resist invading bacteria, and you have the ingredients increased susceptibility to infection during pregnancy.

There are actually 3 clinical presentations of UTI in pregnancy: asymptomatic bacteriuria, acute cystitis and acute pyelonephritis

ASYMPTOMATIC BACTERIURIA

As much as 10% of pregnant women can actually have urinary tract infection without showing signs and symptoms.4.5 That is why it is recommended that on the 1st prenatal check-up, your doctor should subject you to a routine urine culture or urine gram stain since a urinalysis by itself may not reveal an infection. A finding of >100,000 cfu/ml with one or more organisms in two consecutive mid-stream urine specimens or one catheterized urine specimen clinches the diagnosis. 

It is important to recognize and treat asymptomatic bacteriuria during pregnancy because not doing so can have disastrous results for you. It can lead to the development of symptomatic cystitis in approximately 30 percent of the time and can lead to the development of pyelonephritis (the infection ascending to your kidneys) in up to 50 percent.4 Asymptomatic bacteriuria is associated with an increased risk of intrauterine growth retardation and low-birth-weight infants.

Treatment should be initiated once asymptomatic bacteruria is detected. The choice of antibiotic should address the most common infecting organisms and at the same time be also be safe for you and your baby. Historically, ampicillin has been the drug of choice, for UTI in pregnancy but due to increasing resistance, this drug is no longer recommended.8 Nitrofurantoin (Macrodantin) is a good choice because it is highly concentrated in the urine. Alternatively, cephalosporins such as cephalexin and cefuroxime are well tolerated and are effective in treating the important organisms. Fosfomycin (Monurol) is a new antibiotic that is taken as a single dose. Sulfonamides can be taken during the first and second trimesters but, during the third trimester, the use of sulfonamides carries a risk that your baby may develop kernicterus (brain damage from excessive jaundice), especially if your baby is premature. There are other common antibiotics that you should be extremely wary about taking while you are pregnant (e.g., fluoroquinolones and tetracyclines) because of possible toxic effects on your baby. A seven- to 10-day course of antibiotic treatment is usually sufficient to eradicate the infecting organism(s). Some authorities have advocated shorter courses of treatment–even single-day therapy. Fosfomycin is effective when taken as a single, 3-g sachet.

After completing treatment, you are required to have a repeat culture to check if bacteriuria has been successfully eradicated.

ACUTE CYSTITIS

Acute cystitis is distinguished from asymptomatic bacteriuria if you are experiencing other symptoms such as painful urination (dysuria), frequent urination (urgency), and even blood in the urine (called hematuria), without any fever or evidence of systemic illness. Up to 30 percent of patients with untreated asymptomatic bacteriuria later develop symptomatic cystitis.6  It is also vital to treat acute cystitis while you are pregnant to prevent ascent of the infection to the kidneys.

The following antibiotics are recommended for acute cystitis in pregnancy:

  • Cephalexin  250 mg two or four times daily
  • Erythromycin  250 to 500 mg four times daily
  • Nitrofurantoin  50 to 100 mg four times daily
  • Amoxicillin-clavulanic acid  250 mg four times daily
  • Fosfomycin (Monurol)  One 3-g sachet
  • Trimethoprim-sulfamethoxazole160/180 mg twice daily (to be avoided during the 1st and 3rd trimester of pregnancy)11.12.13
  • Treatment is recommended for 7-10 days because shorter treatment regimens have resulted in recurrence of infection.

ACUTE PYELONEPHRITIS

Acute pyelonephritis can occur in 2% of pregnant women and is diagnosed when the presence of bacteriuria is accompanied by fever, chills, nausea, vomiting and flank pain. Symptoms of lower tract infection (i.e., frequency and dysuria) may or may not be present. It is a serious systemic illness that can progress to maternal sepsis, preterm labor and premature delivery. Up to 23 percent of these women have a recurrence of infection during the same pregnancy.10

Early, aggressive treatment is important in preventing complications from pyelonephritis. Hospitalization, although often indicated, is not always necessary. However, hospitalization is indicated for patients who are exhibiting signs of sepsis, who are vomiting and unable to stay hydrated, and who are having contractions. However, if you are able to take oral antibiotics and there are no signs and symptoms of sepsis, you may be treated as an out-patient. Treatment duration is 14 days. 6

WHAT HAPPENS IF MY UTI REMAINS UNTREATED DURING PREGNANCY?

Not treating a UTI during gestation can have devastating maternal and neonatal complications for you. Aside from the possibility asymptomatic bacteriuria developing to cystitis which may progress to pyelonephritis, it may also lead to intrauterine growth retardation and low birth weight infants. 4.7  A study by Schieve and associates shows that the presence of UTI was associated with premature labor (labor onset before 37 weeks of gestation), hypertensive disorders of pregnancy (such as pregnancy-induced hypertension and preeclampsia), anemia (hematocrit level less than 30 percent) and amnionitis 14 While this does not prove a cause and effect relationship, randomized trials have demonstrated that antibiotic treatment decreases the incidence of preterm birth and low-birth-weight infants.15  In addition, acute pyelonephritis has been associated with anemia.16

Disastrous outcomes for your baby aside from the risk of low-birth weight may be sepsis and pneumonia (specifically, group B streptococcus infection).17,18 UTI also increases the risk of prematurity (less than 37 weeks of gestation at delivery) and preterm, low-birth-weight infants (weight less than 2,500 g and less than 37 weeks of gestation at delivery)14.

WHAT CAN I DO TO AVOID UTI?

Majority of UTIs are caused by the bacteria, E. coli, which comes from the anus, contaminating and ascending up to your bladder to cause infection. The following tips will help you therefore prevent UTIs:

  1. After a bowel movement, wash and wipe yourself in a front to back direction to prevent bacteria from the stools from contaminating the urethra. Use your forefinger and middlefinger for the vaginal area and the ring and pinky fingers for the anal area to avoid contamination.
  2. Wash with lactic acid based vaginal wash (not soap since it is the wrong ph for the vaginal) before intercourse and urinate immediately after intercourse to prevent the organism from ascending through the ureter to the bladder.
  3. Never douche during pregnancy. Not only does it mechanically remove your protective bacteria, it can be potentially fatal since it  can cause air embolism. 4. Avoid feminine sprays or powders and soaps that can irritate your urethra and genitals and make them a better breeding ground for bacteria. And don’t use douches during pregnancy.
  4. Never ignore your urge to pee. Keep the urine in the bladder encourages bacterial multiplication and increases the chances of the bacteria adhering to the lining of the bladder causing infection.
  5. Drink plenty of water, at least eight 8-ounce glasses a day to keep urine dilute.
  6. Drink cranberry juice. Studies show that cranberry juice can reduce bacteria levels and discourage new bacteria from taking hold in the urinary tract. (Drinking cranberry juice won’t cure an existing infection, though, so if you’re having symptoms, you still need to see your doctor immediately to get a prescription for antibiotics.) 19-20

Recommended doses range from 90 to 480 milliliters (3 to 16 ounces) of cranberry cocktail twice daily, or 15 to 30 milliliters of unsweetened 100% cranberry juice daily. 300 milliliters per day (10 ounces) of commercially available cranberry cocktail (Ocean Spray®) has been used in well-designed research.

Other forms of cranberry used include capsules, concentrate and tinctures. Between one and six 300 to 400 milligram capsules of hard gelatin concentrated cranberry juice extract, twice daily by mouth, given with water 1 hour before meals or 2 hours after meals has been used. One and a half ounces of frozen juice concentrate.21

UTIs during pregnancy are a common cause of serious maternal and perinatal morbidity. However,  with appropriate screening and treatment, you can limit its morbidity and avoid the dreaded complications.

  1. Patterson TF, Andriole VT. Bacteriuria in pregnancy. Infect Dis Clin North Am 1987;1:807-22.
  2. Mikhail MS, Anyaegbunam A. Lower urinary tract dysfunction in pregnancy: a review. Obstet Gynecol Surv 1995;50:675-83.
  3. Lucas MJ, Cunningham FG. Urinary infection in pregnancy. Clin Obstet Gynecol 1993;36:855-68.
  4. Kass EH. Pregnancy, pyelonephritis and prematurity. Clin Obstet Gynecol 4970;13:239-54.
  5. Gratacos E, Torres PJ, Vila J, Alonso PL, Cararach V. Screening and treatment of asymptomatic bacteriuria in pregnancy prevent pyelonephritis. J Infect Dis 1994;169:1390-2.
  6. The Philippine Clinical Practice Guideline on the Diagnosis and Management of Urinary Tract Infections: A Quick Reference Guide for Clinicians. Report of the Task Force on Urinary Tract Infections 1998. http://www.psmid.org.ph/vol31/vol31num1topic5.pdf
  7. Harris RE, Thomas VL, Shelokov A. Asymptomatic bacteriuria in pregnancy: antibody-coated bacteria, renal function, and intrauterine growth retardation. Am J Obstet Gynecol 1976;126:20-5.
  8. Peddie BA, Bailey RR, Wells JE. Resistance of urinary tract isolates of Escherichia coli to cotrimoxazole, sulphonamide, trimethoprim and ampicillin: an 11-year survey. N Z Med J 1987;100:341-2.
  9. Antimicrobial therapy for obstetric patients. ACOG educational bulletin no. 245. Washington, D.C.: American College of Obstetricians and Gynecologists, March 1998;245:8-10.
  10. Gilstrap LC 3d, Cunningham FG, Whalley PJ. Acute pyelonephritis in pregnancy: an anterospective study. Obstet Gynecol 1981;57:409-13.
  11. Duff P. Antibiotic selection for infections in obstetric patients. Semin Perinatol 1993;17:367-78
  12. Krieger JN. Complications and treatment of urinary tract infections during pregnancy. Urol Clin North Am 1986;13:685-93
  13. http://www.aafp.org/afp/20060915/985.html
  14. Schieve LA, Handler A, Hershow R, Persky V, Davis F. Urinary tract infection during pregnancy: its association with maternal morbidity and perinatal outcome. Am J Public Health 1994;84:405-10.
  15. Romero R, Oyarzun E, Mazor M, Sirtori M, Hobbins JC, Bracken M. Meta-analysis of the relationship between asymptomatic bacteriuria and preterm delivery/low birth weight. Obstet Gynecol 1989;73:576-82.
  16. Gilstrap LC 3d, Leveno KJ, Cunningham FG, Whalley PJ, Roark ML. Renal infection and pregnancy outcome. Am J Obstet Gynecol 1981;141:709-16.
  17. Mead PJ, Harris RE. The incidence of group B beta hemolytic streptococcus in antepartum urinary tract infections. Obstet Gynecol 1978;51:412-4.
  18. Wood EG, Dillon HC Jr. A prospective study of group B streptococcal bacteriuria in pregnancy. Am J Obstet Gynecol 1981;140:515-20.
  19. Lee YL, Owens J, et al. Does cranberry juice have antibacterial active? JAMA. 2000;283(13):1691.
  20. Avorn J, Monane M, et al. Reduction of bacteriuria and pyuria after ingestion of cranberry juice. JAMA. 1994;271(10):751-754.
  21. http://www.mayoclinic.com/health/cranberry/NS_patient-cranberry
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TEEN PREGNANCIES

By: REBECCA B. SINGSON, M.D, FPOGS

The sexual revolution has ushered in a period in which the average adolescent experiences tremendous pressures to have sexual experiences of all kind. Pinoy teens get a higher exposure to sex from the internet, magazines and tv shows, movies and other media than decades ago, yet without any corresponding increase in information on how to handle the input. So kids are pretty much left to other kids for opinions and value formation when it comes to sex. Sexual misinformation is therefore equally shared in the group.1 Parents at home and teachers in school feel equally inadequate or uneasy to discuss the topic of sex with youngsters. The problem mounts because the barkada has a more profound influence than parents do.2 and they exert pressure and expect the adolescent to conform to the rest of the them.1 In fact, female adolescents whose friends engage in sexual behavior were found to be more likely to do the same compared to those who do not associate with such peers.3 If the teen perceives her peers to look negatively at premarital sex, she was more likely to start sex at a later age.4

Statistics in the U.S. show that each year, almost 1 million teenage women–10% of all women aged 15-19 and 19% of those who have had sexual intercourse–become pregnant5 and ¼ of teenage mothers have a second child within 2 years of their first.6 In the Philippines, according to to the 2002 Young Adult Fertility and Sexuality Study by the University of the Philippines Population Institute (UPPI) and the Demographic Research and Development Foundation, twenty-six percent (26%) of our Filipino youth nationwide from ages 15 to 25 admitted to having a pre-marital sex experience. What’s worse is that 38% of our youth are already in a live-in arrangement.

The 1998 National Demographic and Health Survey (NDHS) reveals that 3.6 million of our teenagers (that’s a whopping 5.2% of our population!) got pregnant. In 92% of these teens, the pregnancy was unplanned, and the majority 78% did not even use contraceptives the first time they had sex. Many of the youth are clueless that even on a single intercourse, they could wind up pregnant.

There are many reasons why teen pregnancies should be avoided. Here’s a low down on the facts:

Risk for Malnutrition
Teenage mothers tend to have poor eating habits and are less likely to take recommended daily multivitamins to maintain adequate nutrition during pregnancy. They are also more likely to smoke, drink, or take drugs during pregnancy, which can cause health problems for the baby.7

Risk for Inadequate Prenatal Care
Teenage mothers are less likely to seek regular prenatal care which is essential for monitoring the growth of the fetus; keeping the mother’s weight in check; and advising the mother on nutrition and how she should take care of herself to ensure a healthy pregnancy. According to the American Medical Association, babies born to women who do not have regular prenatal care are 4 times more likely to die before the age of 1 year.7

Risk for Abortion
Unplanned pregnancies lead to a higher rate of abortions. In the U.S, nearly 4 in 10 teen pregnancies (excluding those ending in miscarriages) are terminated by abortion. There were about 274,000 abortions among teens in 1996.8

In the Philippines, although abortion is illegal, it would shock you to know that we even have a higher abortion rate (25/1000 women) compared to the U.S. where abortion is legal (23/1000 women). For sure, there a lot more abortions that happen in our country that are not even reported. Backdoor abortions are resorted to with untrained “hilots” with questionable sterility procedures, increasing the possibility for tetanus poisoning and other complications.

Risk For Fetal Deaths
Statistics of the Department of Health (DOH) show that fetal deaths are more likely to happen to young mothers, and that babies born by them are likely to have low birth weight.

Risk For Acquiring Cervical Cancer
The Human Papillomavirus (HPV) is a sexually-transmitted, wart-forming virus that has been implicated in causing cancer of the cervix. This is the most common cancer in women secondary to breast cancer. Women who are at increased risk for acquiring this are those who engage in sex before 18, have a pregnancy at or younger than 18, or have had at least 5 sexual partners, or have had a partner with at least 5 sexual partners. If you start sex at an early age, you have a higher likelihood of going through several sexual partners before you settle down, thus increasing your exposure to acquiring the virus and acquiring cervical cancer. The men can get genital warts from this virus and can certainly pass it on to their partners, thus increasing her risk for cervical cancer. Is that something you would want to gift to your wife with on your honeymoon? There is a way to test women (HPV Digene test) but no test for the man so you can’t know if you have it. Using the condom does not confer protection against acquiring this virus since the condom cannot cover the testes where the warts can grow and proliferate.

Risk of For You to be More Disadvantaged
Mothers who do have a teen birth are more disadvantaged, on average, than are other teens.

  • Teenage pregnancies are associated with an increased rate of delinquent behaviors including alcohol and substance abuse.
  • To begin with, majority of them belong to the low income group. Teenage births are associated with lower annual income for the mother, 80% of whom eventually rely on welfare.
  • In the U. S. , 7 in 10 teen mothers complete high school, but they are less likely than women who delay childbearing to go on to college. They are more likely to drop out of school and only about one-third obtain a high school diploma.
  • With early termination of formal education there are also limited employment opportunities.9.10 However, they have the responsibility of having to fend for their children before they even before they ever planned to. In hiring, an employer may lean towards someone without a child versus someone who is already with one just because there are more chances of absences with the latter when her child becomes sick.
  • They face greater financial difficulties and marital conflict. With a lower capacity for earning and less emotional maturity, relationships are under more stress for breaking.
  • Young unmarried mothers also face social stigmas that can have harmful
    psychological and social impact.

Risk for Your Baby to be More Disadvantaged
The children of teen moms also face negative health, cognitive, and behavioral outcomes.3 This may result from lack of maturity, and emotional quotient or simply from ignorance due to a lack of life’s experiences

  • Children born to teenage mothers are less likely to receive proper nutrition, health care, and cognitive and social stimulation. As a result, they may have an underdeveloped intellect and attain lower academic achievement.
  • Children born to teenage mothers are at greater risk for abuse and neglect.
  • Boys born to teenage mothers are 13% more likely to be incarcerated.
  • Girls born to teenage mothers are 22% more likely to become teenage mothers.

WHAT ARE THE DETERRENTS TO TEEN PREGNANCY?

  1. Keep them at home with an intact family set up. The social institutions surrounding the youth jointly form a web of influence that either shield or lay them open to the lure of sexual risk-taking. The family is one such social institution. An intact family with both parents raising the child was found to be correlated to less risk taking behavior by teens. Those who left home early or were raised by separated parents were noted to engage in sex early and other risk taking behaviors. Family supervision and a stable parental union are definitely associated with lesser chances of engaging in premarital sex.11
  2. Keep them in school. The other social institution that shields the youth from engaging in risk taking behavior is the school.
    Leave school at an early age are more likely than other women to have their first sexual experience outside of marriage. 12
  3. Keep talking to them. Increased parental communication consistently predicted a decrease in the likelihood of young Filipinos to engage in sexual risk-taking activities. 13 It has been found that the mother, in particular has a special role because monitoring by the mother as well as communication lines with her daughter were found to be associated with less frequent intercourse and fewer sexual partners.14
  4. Keep them morally and spiritually grounded. Over 80% of the 502 teens in the September poll told re-searchers that religion is important in their lives. Regardless of gender or race, survey results revealed that teens who attend religious services frequently are less likely to have permissive attitudes about sex. 15 Orienting them with the proper values early helps them imbibe it in their lives and keeps them from succumbing to peer pressure.

    Preventing teen pregnancies requires a concerted effort on the part of the parents, the school and government to insure the right information is transmitted to the children even during their pre-teen years and insuring that they are well-monitored and supported emotionally and psychologically. We can’t watch what our kids do all the time, but then again, we won’t have to if they are equipped to make better decisions for themselves.

  1. Onyango, Francis O.. “Adolescent Perspectives on the Social Consequences of Premarital Sex and Pregnancy in Urban Kenya.” Paper prepared for presentation at the Annual Meeting of the Population Association of America, 1-3 April 2004, Boston,Massachusetts, U.S.A.
  2. Ujano-Batangan, Maria Theresa D. “The Context of Sexual Risks among Filipino Adolescents: A Review of Literature.” Philippine Population Review 2 (1): 1-21.
  3. Billy, John O. G., Joseph Lee Rodgers and J. Richard Udry
    1984 “Adolescent Sexual Behavior and Friendship Choice.” Social Forces 62: 653-
    678.
  4. Onyango, Francis O. 2004 “Adolescent Perspectives on the Social Consequences of Premarital Sex and Pregnancy in Urban Kenya.” Paper prepared for presentation at the Annual Meeting of the Population Association of America, 1-3 April 2004, Boston,
    Massachusetts, U.S.A
  5. AGI, Teenage pregnancy: overall trends and state-by-state information, New York: AGI, 1999, Table 1; and Henshaw SK, U.S. Teenage pregnancy statistics with comparative statistics for women aged 20- 24, New York: AGI, 1999, p. 5.
  6. Kalmuss DS and Namerow PB, Subsequent childbearing among teenage mothers: the determinants of a closely spaced second birth, Family Planning Perspectives, 1994, 26(4): 149-153 & 159.
  7. http://www.womenshealthchannel.com/teenpregnancy/index.shtml
  8. AGI, Teenage pregnancy: overall trends and state-by-state information, New York: AGI, 1999, Table 1; and Henshaw SK, U.S. Teenage pregnancy statistics with comparative statistics for women aged 20- 24, New York: AGI, 1999, p. 5.
  9. Werner-Wilson, Ronald Jay 1998 “Gender Differences in Adolescent Sexual Attitudes: The Influence of Individual and Family Factors.” Adolescence 33 (131): 519-531.
  10. East-West Center 2002 The Future of Population in Asia. Honolulu, Hawaii: East-West Center.
  11. Cruz, Grace T., Elma P. Laguna and Corazon M. Raymundo
    2002 “Family Influences on the Lifestyle of Filipino Adolescents.” Philippine Population
    Review 1 (1): 39-63.
  12. Choe, Minja Kim, Hui-Sheng Lin, Chai Podhista and Corazon M. Raymundo
    2001 “Sex and Marriage: How Close are They Related in the Philippines, Taiwan and
    Thailand?” East-West Center Working Papers, Population Series No. 108-14.
  13. Marquez, Maria Paz N. 2004a “The Family as Protective Factor in Sexual Risk-Taking Behavior among Filipino Youth.” Paper presented at the Annual Meeting of the Population Association of America, 1-3 April 2004, Boston, Massachusetts, U.S.A.
  14. Miller, Kim S., Rex Forehand, Beth A. Kotchick 1999 “Adolescent Sexual Behavior in Two Ethnic Minority Samples: The Role of Family Variables.” Journal of Marriage and the Family 61 (1): 85-98.
  15. http://www.basapa.com/virola-of-national-statistics-4800-babies-born-per-day-in-the-philippines/
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THE DENTAL PREGNANT PATIENT

REBECCA B. SINGSON, M.D., FPOGS

Dental problems that may arise during pregnancy are given attention since it may also potentially affect the growing fetus. Here are some facts and problems for the dental pregnant patient to know

ARE DENTAL CARIES CONSIDERED AN INFECTIOUS DISEASE?

Dental caries is considered an infectious disease since it is caused by a bacteria called Streptococcus mutans which can be can potentially be transmitted to the fetus. If a pregnant mother has multiple caries in her mouth, it is not sufficient to do restorations or extractions since it won’t solve the problem. Unless she takes therapeutic measures during her pregnancy to diminish the bacterial load causing caries in her mouth, the baby is at risk of infection through the transplacental route.  Vertical transmission of the mutans strep bacteria can occur from mother to child occurs after the eruption of the primary teeth.

WHAT ARE THE COMMON GUM DISEASES?

Normally, millions of microscopic monsters called bacteria make your mouth their home feeding on food particles left on our teeth. These bacteria produce acid as a result of their feasting and it is this acid which eats into tooth enamel creating cavities. If this wasn’t bad enough, the bacteria also pour out volatile sulfur compounds creating embarrassing bad breath. Normally bacteria are found within a mesh of mucus and debris known as plaque. Without regular dental hygiene these bacteria will multiply and pour out toxins causing gum inflammation leading to the following conditions:

  1. Pregnancy gingivitis can affect quite a number of pregnancies, some authorities saying at least half and other authorities saying even as much as a hundred percent of pregnant women. The changes in the gum are brought about by hormonal changes which alter the rate at which estrogen and progesterone are metabolized in the gums plus the change in prostaglandin synthesis. These affect the pregnant immune system altering the pattern and rate of collagen production in the gums which in turn, reduces the pregnant woman’s ability to repair and maintain gum tissue. Studies have shown that women with chronic gingivitis have an increased risk for preeclampsia, which is a pregnancy complication marked by swelling of the leg due to marked fluid retention, a rise in blood pressure and protein in the urine. The condition may lead to the more serious eclampsia where the pregnant woman goes in to convulsions compromising the fetus in the womb.
  2. Periodontitis – a chronic gingivitis may progress to a more serious condition if uncared for, where the infection can go beyond the bone and the tissues supporting it, leading to periodontitis. This can have serious implications on the pregnancy because research has shown that women with periodontitis are seven times more likely to have a premature delivery. Treating the condition can significantly decrease the risk because another research showed that pregnant women with preiodontitis who were treated with plaque & tartar removal called “scaling & planning” had significantly less preterm babies than women who were not treated.

SHOULD I TAKE FLOURIDE SUPPLEMENTS DURING PREGNANCY?

Most clinicians are not prescribing supplemental fluorides to pregnant women due to lack of evidence of efficacy for the unborn child. Also, it is important to note that current scientific evidence has demonstrated that prenatal fluoride supplements are not beneficial in preventing caries in the child’s primary dentition, and therefore are not prescribed to pregnant women. It was previously thought that fluoride could not pass through the placental barrier, but studies have shown that it does indeed cross the placental barrier. However, it is still not known how fast fluoride can transfer to the fetus by. Perhaps because fluoride gets diluted in the amniotic fluid, research shows that there is rapid maternal clearance with only a slight increase in fetal blood fluoride concentrations.  

Since 1966, the Food and Drug Administration in the U.S.A. has banned the use of advertising and labeling of fluoride supplements for “prenatal use”. It has also banned claims that these supplements will prevent or reduce decay in the offspring of women who use them. The ban, however, does not prevent the prescription of fluoride supplements for pregnant women; it just restricts advertising claims until more solid evidence is available.

HOW CAN I CARE FOR MY TEETH DURING PREGNANCY?

  • Brush your teeth at least twice daily. If you can brush after every meal and especially after indulging in sweets. An electric toothbrush cleans better than a manual toothbrush. Research shows that more dental plaque is dislodged with an electric toothbrush in 2 mins. than a manual toothbrush removed in 6 mins.
  • Floss at least once a day as recommended by the American Dental Association. Flossing removes the bacteria that escape brushing by hiding in the tiny spaces between the teeth. Brushing without flossing is like washing only 65% of your body. The other 35% remains dirty!!
  • Rinse with mouthwash or warm salt water. Warm salt water can help to soothe inflamed tissues.
  • It is certainly best to visit your dentist regularly for professional teeth cleaning especially if you are contemplating a pregnancy. If you are already pregnant and have not ever seen a dentist, it is never too late. Make sure you tell your dentist you are pregnant and how many weeks of gestation so she may tailor your treatment without jeopardizing the baby.

You may not realize how important dental hygiene is to insure a non-complicated pregnancy. Healthy gums and healthy teeth in a pregnant mom is a vital component in having a healthy baby.

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A DOCTOR’S POINT OF VIEW: CAN ABORTION HARM YOU?

Rebecca B. Singson, MD, FPOGS

In a Catholic country such as the Philippines where abortion is illegal, it is disgraceful to know that our abortion rates are even higher than in countries where abortion is freely and legally available. In the U.S.A, the reported abortion rate is 16 abortions/1000 women whereas in our country, the rate is a whopping is 20-30/1000 women. Some 400,000 abortions occur in our country every year. There is no question that backdoor abortions occur frequently such that 80,000 women per year are estimated to be treated in hospitals in the Philippines for complications of induced abortion.

HOW ITS DONE
Since the procedure is illegal in this country, you would think it would be very rare to find a doctor performing the procedure. However, a recent survey of health professionals in the Philippines suggests that about one-third of women seeking an abortion obtain it from a doctor or nurse which has reduced the proportion of complications requiring hospitalization in the last two decades. However, the majority of women still consult traditional practitioners or attempt through the use of prostaglandin medications to induce the abortion themselves. Based on the health professionals survey done in 1996, it is believed that untrained abortion practitioners in our country have increased their use of hormones and modern drugs aside from using traditional methods, such as abdominal massage.1 Usually midwives or hilots do the procedure in a house or sometimes clinic where they perform lower abdominal massage over the uterine area, prescribe some bitter herbs from quinine, or ask you to take some tablets orally or to insert some tablets vaginally to soften the cervix allow it to dilate. If that effects the bleeding, they may tell you to go to an obstetrician to complete the abortion or wait for spontaneous expulsion. If that does not work, the more dangerous procedure is to insert a rubber catheter (normally used for draining urine from the bladder) inside the uterus and keep it there for several hours to induce bleeding. It can be a painful experience since the foreign body in the uterus is intended to cause uterine contractions which feels like severe cramping or dysmenorrhea. Bleeding is always a desired result to effect expulsion of the products of conception.

THE DANGERS
Women who undergo abortion were found by research to be linked to certain behaviors such as smoking, drug abuse, eating disorders and promiscuity which all increase their risk for health problems. Teenagers comprise one-third of those who undergo abortion and are even at a much higher risk of suffering both immediate and long-term abortion-related complications.3 It was found that if the partner was present but not supportive, the miscarriage rate is more than double and the abortion rate is four times greater than if he was present and supportive. Absence or abandonment by the partner increases the abortion rate to 6 times greater.4

IMMEDIATE COMPLICATIONS:
Approximately 10% of women undergoing elective abortion will suffer immediate complications, of which approximately one-fifth (2%) are considered life threatening. The nine most common major complications which can occur at the time of an abortion are: infection, excessive bleeding, embolism, perforation of the uterus, anesthesia complications, convulsions, hemorrhage, injury to the cervix, and endotoxic shock. The most common “minor” complications include: infection, bleeding, fever, second degree burns, chronic abdominal pain, vomiting, gastro-intestinal disturbances.5
partner is present and not supportive, the miscarriage rate is more than double and the abortion rate is four times greater than if he is present and supportive. If the partner is absent the abortion rate is six times greater.” 5

HEMORRHAGE
Excessive bleeding due or after abortion may happen in the presence of cervical lacerations, uterine perforation, uterine atony or disorders in blood coagulation.

INFECTION
With the introduction of any foreign body into the uterus, the potential risk for infection increases. Post abortion, the patient may be at increased risk for infection of the uterus (endometritis), of the fallopian tubes (salpingitis) which may lead to ectopic pregnancies. Of patients who have a chlamydia infection at the time of the abortion, 23% will develop PID within 4 weeks. Studies have found that one-fourth to one-fifth of patients seeking abortion have a chlamydia infection and one-fourth of them will develop Pelvic Inflammatory Disease within 4 weeks. In the absence of Chlamydia, post-aborters will still develop PID.(11)

UTERINE PERFORATION
Between 2 and 3% of all abortion patients may suffer perforation of their uterus through the use of instruments,.The chances even increase
for those who were under general anesthesia during the abortion procedure or for those who had multiple deliveries.(5) (6) Damage to the uterus may eventually evolve into problems requiring a hysterectomy, if not reproductive or pregnancy problems.

CERVICAL DAMAGE:
During an abortion, the cervix may be forced open by an inexperienced practitioner causing cervical tears or permanent damage such as cervical incompetence leading to habitual abortion or premature delivery or labor complications.(7)

ECTOPIC PREGNANCY:
Abortion is significantly related to an increased risk of subsequent ectopic pregnancies. Ectopic pregnancies, in turn, are life threatening and may result in reduced fertility.(10)

CANCER RISK
Women with one abortion face a significant risk for cervical cancer, liver and ovarian cancer. One reason for this may be the due to the disruption of the hormonal changes which accompany a pregnancy..(4)

PLACENTA PREVIA:
Abortion increases the risk of placenta previa in later pregnancies. Abnormal development of the placenta due to uterine damage increases the risk of fetal malformation, perinatal death, and excessive bleeding during labor.(8)

Having an abortion can lead to many complications that can threaten the life of a woman and even ruin her chances of having a baby in the future. Remember that preventing a pregnancy can be much safer than trying to get rid of one.

  1. S. Singh, D. Wulf and H. Jones, “Induced Abortion in South Central and Southeast Asia: Results of a Survey of Health Professionals,” International Family Planning Perspectives, 23:59-67, 1997.
  2. Ibid.
  3. Wadhera, “Legal Abortion Among Teens, 1974-1978”, Canadian Medical Association Journal, 122:1386-1389,(June 1980).
  4. Ney, et.al., “The Effects of Pregnancy Loss on Women’s Health,” Soc. Sci. Med. 48(9):1193-1200, 1994; Badgley, Caron, & Powell, Report of the Committee on the Abortion Law, Supply and Services, Ottawa, 1997: 319-321.
  5. Frank, et.al., “Induced Abortion Operations and Their Early Sequelae”, Journal of the Royal College of General Practitioners (April 1985),35(73):175-180; Grimes and Cates, “Abortion: Methods and Complications”, Human Reproduction, 2nd ed., 796-813; M.A.
    Freedman, “Comparison of complication rates in first trimester abortions performed by physician assistants and physicians,” Am. J. Public Health, 76(5):550- 554 (1986).
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WHY SOME WOMEN DON’T BREASTFEED

Dr. Rebecca B. Singson, MD, FPOGS

  1. No pre natal preparation – many women get poor advise, or even no advise from their obstetrician during their prenatal check up. On the 1st meeting, ideally, the mother should already start psychological preparation for breastfeeding by reading books on breastfeeding, accessing websites on pregnancy & breastfeeding. It is never too early because those mothers who decide to breastfeed during the pregnancy are those who end up successfully breastfeeding. Especially with pregnancy adolescents, the chances of getting them to breastfeed increases over fourfold if they are given. Younger women and women with moderate to poor emotional support visitor were less likely to still be breastfeeding at three months.(Hodinott)
  2. No intrapartum/postpartum support – women who had a rough labor, prolonged labor and end up with a C-section usually want to sleep to recover from the exhausting experience and prefer to defer breastfeeding for a later time. Studies also show that mothers who spent 1 night in the hospital were almost twice as likely to breastfeed than mothers who spent 2 or 3 nights in the hospital. This may mean that hospitals, perhaps because of the Nursery set up, tend to separate the mother from the baby unless rooming- in occurs.(Margolis).
  3. Poor latch on – Women who experience pain when the baby starts to breastfeed and try to withstand the pain it instead or re-latching. can end up with cracked and sore nipples. This can result from wrong positioning of the baby. The mother & baby should ideally be in the tummy-to-tummy position with the ears of the baby directed to the ceiling. The baby’s mouth should include not only the nipple but the areola too and must not be allowed to tug on the nipple. Upon  withdrawal of the nipple, it must not assume the shape of the end of a lipstick but should be a round structure.
  4. Wrong feeding pattern – Some women think that babies should feed only every two or 3 hours and only for 10-20 minutes. Babies should be fed on demand because it may take up to 2-4 weeks to establish a good milk supply. Most babies will gain weight if they are fed on demand or at least every 1 1/2 to 2 hours. Waiting more than 2 hours may cause the breasts to become engorged and painful. This decreases milk production.  Women who think they will gradually build up breastfeeding by supplementing with formula or glucose water are setting themselves up for a higher likelihood of failure to establish breastfeeding. This is because introducing alternatives to breastmilk in the first 6 months will cause the baby to become full and decrease its demand of breastmilk which in turn will decrease its supply.
  5. ”Did not produce enough milk” – so many women are so insecure and so unempowered to believe that if nature had allowed them to bear a child, nature would also equip them with the means to keep their baby alive. It is all based on supply and demand. The moment you start to mix fix with formula, the demand for breastmilk decreases since the baby is fuller for a longer period of time. Logically, this is because the proteins of formula milk stay undigested for upto 60 mins  (allowing the proteins to reach the intestines and cause major allergies) while breastmilk is digested within 15 mins.
  6. Unrelenting frustration – Women who end up with a comedy of errors that can start with a poor latch on then end up frustrated when she gets sore nipples or baby rejects her. The problem is the moment Mom gets stressed, she won’t release the hormone prolactin which is released from her pituitary gland at the base of the brain & is responsible for the milk let down reflex. .
  7. Poor home support – Some of the first people who may discourage you from breastfeeding may be your very own mother, aunt, or relative who grew up in a generation brainwashed by ads to believe that formula is superior to breastmilk. Some overbearing Moms may find it ridiculous why you should make like difficult for yourself when there is formula milk to free up your body and your time. This may lead one to believe that since your family members didn’t breastfeed you won’t be able to either (so untrue).
  8. Illness/infection – Sometimes a hospitalization for a serious illness, a fever or infection can prompt your pediatrician to shift you to formula feeding. Even during a fever or an infection, as long as it is not AIDS or active tuberculosis, one may continue to breastfeed. Research suggests strongly that any risk of transmission associated with breastmilk is negligible compared to the high risk of exposure to maternal blood and body fluids at birth. However, cracked or bleeding nipples or lesions with serous exudates could possibly expose the infant to infectious doses of Hep B.. (Stevens & Harvey)
  9. Work Interference – Many women stop breastfeeding once they go back to work 6-8 weeks after delivery. Leaking breasts can be embarrassing during a corporate meeting or the stress of the work itself can jeopardize the release of prolactin essential to the milk let-down reflex.
  10. Simply don’t want to – Some Women, however, who pregnant under adverse circumstances, like after a rape, are not  psychologically prepared to breastfeed since they feel further violated..
  11. fear of pain – Those who imagine themselves being bitten on the nipples or have seen the suffering of some women with engorged nipples are afraid to undergo the experience themselves.
  12. uneasy with the thought – women don’t have the confidence that they have it within them to keep their baby alive through their natural faculty of breastfeeding.
  13. suits her lifestyle – some women don’t want to be tied down at home because of work or leisure reasons. Breastfeeding just simply cramps her style. The truth is, we can bring the baby everywhere and feed as needed. With a drape over your breast and the baby’s head, one can continue to breastfeed without even being noticed. All the baby really needs after all is is to be fed and changed.
  14. Our breastfeeding culture has disappeared – We live in a society where we do not see women breastfeeding if public. So if you haven’t grown up seeing women around you breastfeeding successfully, if it’s something that’s hidden away, then it becomes even harder for you to succeed yourself. Many women feel embarrassment with public exposure.

What Can Be Done?

  1. Consult a lactation consultant – a breast massage with lactation counseling does wonders to make your milk flow within the hour. Contact them through ReBirth Spa at 7719206/09178063339.
  2. Inquire about donated breast milk –  If despite lactation counseling and best intentions, the milk is inadequate, (evidenced by less than 6-8 wet diapers per day after the 1st week, less than 3 stools in 24 hours or birth weight is not regained after the 10th day), you can ask your pediatrician or friends to patch you up with other breastfeeding moms willing to donate breast milk to you. It has been done and you can make it happen if you so desire.

Hoddinott P, Pill R, Hood K. Identifying which women will stop breastfeeding before three months in primary care: a pragmatic study. Br J Gen Pract 2000;50:888-91

Margolis LH, Schwartz JB. The relationship between the timing of maternal postpartum hospital discharge and breastfeeding. J Hum Lact 2000;16:121-8

Beasley PR, Shiao I-S, Stevens CE, Meng H-C . Evidence against breastfeeding as a mechanism for vertical transmission of Hepatitis B, , Lancet 1975;ii:740-41

Woo D, Davies PA, Harvey DR, Hurley R, Waterson AP . Vertical transmission of hepatitis B surface antigen in carrier mothers in two west London hospitals, , Arch Child Dis, 1979;54:670-75

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HOW CAN YOU BE SO WRONG ABOUT BREASTFEEDING!

REBECCA B. SINGSON, M.D, FPOGS

In a third world country such as the Philippines where more than 50% of the population live below poverty line (defined in terms of a least-cost consumption basket of food that provides 2,016 calories and 50 grams of protein per day and of nonfood items consumed by families in the lowest quintile of the population) it is so disheartening, not to mention shocking to know that the minimum wage earner spends 26% of his wage buying formula milk when breast milk can guarantee less malnutrition, less diarrheal and upper respiratory infections for the neonate translating to less hospitalizations and best of all is available at no cost at all.

DID YOU KNOW?

Breastmilk is such a dynamic fluid that it is absurd to think that any brand of formula milk can even come close to it. The main proteins in milk are casein and whey (the more digestible between the two). The proportion of whey to casein differs in colostrum, in mature milk and in late lactation. The composition of breastmilk also varies during the time of the day and during the feeding. The hind milk (in the latter part of breastfeeding) has a much higher fat content than milk produced during the beginning portion of the feeding.(1) In fact, if your baby was premature, your breastmilk has a composition appropriate for premature babies. Furthermore, the odor and/or taste of breastmilk may change depending on the mother’s diet. Food preferences in adulthood are apparently developed in infancy so breastfeeding may actually help infants get used to different tastes and help prevent them from being picky eaters when they grow up.(2) How can any artificial milk formula duplicate these properties?

So dynamic and perfect is breastmilk as your baby’s food that you don’t need for any formula, glucose water, water, pacifier, teas, juices or vitamins during the first six months. Human milk has over 300 ingredients, including interferon, white blood cells, antibacterial and antiviral agents, while formula has only 40 ingredients. Breastmilk favors the growth of beneficial bacteria so breast-fed infants have a level of lactobacillus that is typically 10 times greater than that of formula-fed infants. This is the reason why they are better protected against diarrheal diseases. Because of the protective antibodies, your baby will have a much lower incidence of pneumonia and urinary tract infection if fed with breastmilk. In fact, adding formula milk in the first three months of life has been proven to triple the baby’s risk of getting admitted in the hospital for pneumonia (3). Furthermore, infants fed formulas of intact cow’s milk or soy protein compared with breast milk have a higher incidence of atopic dermatitis and wheezing illnesses in early childhood.(4)

BREASTFEEDING PROTECTS AGAINST CANCER

Did you know that breastmilk goes even so far as protecting the child from cancer before the age of 15? The risk of artificially fed children was 1-8 times that of long-term breastfed children. (5)  And if that’s not reason enough for you, breastfeed for your own sake because breastfeeding confers some protection to you against uterine cancer (6), ovarian cancer(7) and breast cancer if you breastfeed for at least 2 years (but some benefit is already seen even if you only breastfed for 6 months). A study by Yale University researchers showed that women who breastfed for two years or longer reduced their risk of breast cancer by 50 percent (8).

LOCAL RESEARCH

In Baguio General Hospital & Medical Center (BGHMC), research shows that when they shifted over in 1975 from a practice of separating the mother and infant immediately after birth to a policy of immediate rooming in and breastfeeding, within two year time, breastfeeding increased from 40% to 92%. This simple practice also brought a dramatic reduction of mortality and morbidity because by 1977, the incidence of diarrhea droped from 27.5 to 1.5 per 1000 newborns and the mortality rate from diarrhea dropped from 8 per 1000 babies to none at all!(9)

KILLING THE INSTINCT TO BREASTFEED

Living in a civilized society has also killed our human instinct to breastfeed. Women are embarrassed to breastfeed in public and people are likewise uncomfortable to see a woman breastfeeding in public. Hospitals whisk out the baby to the nursery soon after birth separating the mother and baby. Although the Dept. of Health has implemented the Baby Friendly Initiative among hospitals to mandate rooming in immediately after birth, patients are made to sign waivers, oftentimes, without even explaining to them that the document they are signing is a consent NOT to room in the baby to actually allow milk formula to be given to their babies. In fact, soon after birth, the pediatrician is already discussing with the Mom what milk formula she would prefer to give the baby!! Family support is so hard to find since the now Mom’s own mother will discourage her from breastfeeding with words like “Bakit magpapakahirap ka pa eh may bote naman!” Many of our common practices with babies end up driving a wedge between Mommy and baby and keeps them separated. We create a separate Nursery room in the house for baby to stay in with her crib. We use a stroller to transport the baby instead of carrying her on a harness or sling like tribal societies do so the baby can sleep and breastfeed at will.

LACTATION SUPPORT

It is important that women feel supported during breastfeeding since many insecurities about her motherhood abilities surface when the going gets rough. Breastfeeding can cause a lot of distress to a Mom when her baby continues to cry despite giving her breast. Babies cry for many other reasons than hunger but Moms usually misinterpret this to mean, “I don’t have enough milk. My baby is starving.” The mere anxiety will interrupt the release of hormones that cause the letdown reflex of breastmilk thereby, decreasing the milk supply. In fact, research in Sweden has shown that every second mother experienced transient lactation crises on at least one occasion (the crisis group). The crises were mostly caused by emotional disturbances in the mothers (e.g. anxiety, stress and discomfort), or by the infant’s refusal to suckle, by unmotivated crying, or by illness. Within the crisis group no significant difference was found between the infants’ intake of breast milk during the crises compared with control measurements one week later. Nor had the crises any immediate impact on the growth of the infants. (10)

Research has shown that lactation counseling improves the rate of breastfeeding of women. (11)

The key to successful breastfeeding is the right preparation prior and during pregnancy, constant hydration and supplementation to sustain it, and when the going gets rough, seeking help from lactation therapists or other more experienced fellow breastfeeders.

  1. Lawrence RA and Lawrence RM. Breastfeeding, A Guide for the Medical Profession, 6th Ed. Elsevier Mosby, Phila, PA. 2005: p6-12, p73-86, p105-214, p377-388, p397-405, p747-749, p832-993
  2.  Mennella JA and Beauchamp GK. Maternal diet alters the sensory qualities of human milk and the nursling’s behavior. Pediatrics. 1991: 88(4): 737-744.
  3.  J.A. Cesar et al, Impact of Breastfeeding on Pneumonia on admission in the postnatal period in Brazil: Nested case control study,  British Medical Journal, 1999 318:1316-20.
  4. Friedman NJ, Zeiger RS. The role of breast-feeding in the development of allergies and asthma..J Allergy Clin Immunol.2005 Jun;115(6):1238-48.
  5. Davis, M.K. Infant Feeding and Childhood Cancer. “Lancet 1988.
  6. Brock, K.E., “Sexual, Reproductive, and Contraceptive Risk Factors for Carcinoma-in-Situ of the Uterine Cervix in Sidney.”Medical Journal of Australia, 1989.
  7. Schneider, A.P. “Risk Factor for Ovarian Cancer. “New England Journal of Medicine, 1987.  
  8. Tongzhang Zheng, et al., Lactation Reduces Breast Cancer Risk in Shandong Province, China. American Journal of Epidemiology Vol. 152, No. 12 : 1129-1135.
  9. Relucio-clavano N, How can hospitals encourage breastfeeding? Example from the Philippines. Mothers Child. 1982 Spring 2(2):4-5.
  10. Hillervik-Lindquist. Studies on perceived breast milk insuffienciency. A prospective study in a group of Swedish women.. Acta Paediatr Scand Suppl.1991;376:1-27.
  11. 11. Aidam BA, et al. Lactation counseling increases exclusive breast-feeding ratew sin Ghana. J Nutr. 2005 Jul;135(7):1691-5.
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15 TIPS FOR CLUELESS DADS-TO BE

Dr. Rebecca B. Singson, M.D, FPOGS, FPSCPC

Many Dads get excited about the thought of having a baby yet are unaware of what it takes to support their wives during the pregnancy and postpartum process. Here are a few tips on how to maximize your role in the childbirth process:

  1. Suggest taking childbirth classes with your wife. It is a very empowering experience since it defines your role during the childbirth process.
  2. If you are unable to because of time constraints, just read up on books and the internet about the pregnancy and most especially, about the breastfeeding process so you can support your wife all the way through.
  3. Accompany your wife, whenever you can, to her pre-natal checkups.
  4. If you’re a first time Dad, practice carrying a baby using a doll so you won’t be too afraid to handle your own baby on the day of delivery. Ask your Mom, aunt, cousin or sister who is knowledgeable to teach you.
  5. Help your wife prepare her birth plan and, organize the things required on the day of labor, and what type of hospital room to choose.
  6. Moms experience a lot of discomfort and mood swings which may be hormonally related. Acknowledge her complaints and ask her what she would like you to do to help her. Most of the time, she just wants to be heard but is not looking for you to solve them. Be sympathetic at all times.
  7. Surprise her by sending her flowers or a nice basket of fruit (or a combination of both) on the day of her delivery with a love note telling her how much you appreciate her for fulfilling your life by bearing your child.
  1. Moms are so insecure about how they look during pregnancy, labor and after childbirth so keep reassuring her that she is just as beautiful and sexy in your eyes.
  2. Have a routine with your baby at a certain time like a feeding activity, or bathing with him daily or a regular playtime so you don’t feel left out.
  3. If you are still feeling left out, talk with your partner about it instead of harboring ill feelings and keeping it to yourself.
  4. Don’t be afraid to express your emotions. Talk to her doctor about your fears and concerns, if any. It’s also ok to cry as an expression of extreme joy at seeing your baby for the first time. For us women, it is not perceived as a sign of weakness but rather as a positive sign of sensitivity, which many men sorely lack.
  5. Support your wife throughout the breastfeeding process by encouraging her and letting her know how proud you are. Defend her from negative comments from well-meaning relatives about breastfeeding. Many relatives still carry the mistaken notion that cow’s milk is just as good or is even superior to mother’s milk.
  6. Your wife is in for years of many sleepless nights. Treat her to a pampering pre-natal or postpartum lactation massage. Rebirth Spa has therapists that can relax and support your wife through with her back pains and leg pains prior to giving birth as well as offer her lactation massage and counseling in the postpartum period. You may reach them through 7719204/06 or 0917-8063339. She will love you for it!
  7. If you have other kids, attend to them while Mom is attending to the baby. Your wife will appreciate your efforts in minimizing her distraction. Teach your kids that Mom needs to be in a relaxed state so the milk will flow to feed the baby. When Mom is tense, this can cut off the milk supply. That way you empower your kids to support Mom, too.
  8. Take out your wife to a romantic dinner without the kids at least once a month to help her regain her focus as wife and not just as a mother. She will appreciate the time away with you alone.

Having babies is a magical way of cementing your relationship and creating a stronger foundation of togetherness. Don’t let experience heighten your insecurity as a father or husband but rather use it as a platform to evolve to another level of maturity with your spouse. It can certainly do wonders in helping your relationship last a lifetime!

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