MATRUDEVOBHAVA

Ethical, Moral and Philosophical Aspects of

OBSTETRICS & GYNAECOLOGY

An Indian Perspective

By

DR R. ANJANEYULU, MD, DGO, FCPS

Emeritus Professor of Obstetrics and Gynaecology
B.J. Medical College and Sassoon Hospitals, Pune
Maharashtra State, India

Foreword by
Dr. K. Bhasker Rao, M.D., F.R.C.O.G., F.M.S.
Emeritus Professor of Obstetrics and Gynaecology
Madras Medical College
(Formerly Director, Institute of Obstetrics and Gynaecology,
Govt. Hospital for Women and Children, Egmore, Madras)

R. Anjaneyulu; M.D., D.G.O.; F.C.P.S.

MATRUDEVOBHAVA
Mother
The Universal Mother is in the form of Bhoomata who bears all
of us ! She is the Prakriti or Shakti or energy without whom the world
cannot exist. She is the same Shakti in the form of Goddess of
Learning; Saraswati who helps Lord Brahma to create this world; in
the form of Goddess Lakshmi; Goddess of wealth who helps
Bhagwan Vishnu to protect the world bestowing health, happiness,
prosperity and well-being of the people; in Goddess Parvati; she
gave Shakti or energy to Lord Shiva to destroy the world.
She is the same Mother to whom we also pray as Durga during
Navaratri, to destroy the evil forces and cut the knot of ignorance in
our heart and also the quality of Ahamkara in us and bestows upon
us knowledge and wisdom!
`The Universal Mother has many other manifestations in the
form of Gayatri she protects us; as Ganga Bhavani she gives us
water for survival; as Gomata (cow) she gives us milk for health the
nourishment and as Mother Geeta (Bhagavadgeeta)whose door is
open to any one who knocks and seeks refuge in distress in her
bosom.
Stree or Ammai is the incarnation of Shakti Swaroopa.
Mother gives herself to the development of the child and works hard
and sacrifices for the safety and survival of her children. It is this
spirit of Tyaga or sacrifice that makes the value of motherhood great!
In this world, no other person deserves to be more respected than
MOTHER.
It is to the feet of all mothers of the world and the Supreme
Mother that offer my Pranam and salutations while attempting to
write this book.
SARVAMANGALA MANGALYE, SHIVE SARVARTHA SADHIKE
SHARANYE TRIAMBAKE GAURI, NARAYANI NAMOSTUTE

Oh Mother Durga, wife of Lord Shiva looking after the welfare of

everybody and fulfilling all the desires, cherished by one and all, I am
under your shelter and offer my Namaskarams to you !
3

MOTHERS BENEDICTION
May you live long

`May you live long blesseth me my mother,

Even as the shadows of death draw nigh,
In bed, a sinking soul, almost breathless,
Still she blesseth me - `May you live long.
A mothers love who can fathom? In death agony
She blesseth - `May you live long
It is her parting wish her legacy
To her son, in clear tone she says `Live long.
Alas! She musters all her strength and says
`May you live long to give that benediction
Happiness enlivens her face; by that sweetest
Utterance, she makes the lord of death tremble.
To approach her, for who would bless her son
After she hakes off her mortal coil,
To bless `live long its a mothers right!
She wants to control fate by her benediction.
This noble soul! This mould of sacrifice,
Mother Dear Amma who soothes all our pain,
Who begets, suckles brings up bears all woes,
Is she not the mortal symbol of God!
To worship thee, kiss the dust of the feet,
Is the greatest duty of a true son.
Not all the pomp and power of the world
Can rival the glory of the mothers love.
Almighty Lord who created this Treasure
A mothers heart so tender and divine
Who bears all suffering for her progeny
To me, O Lord! Thou art the True Mother!
4

Alas! As she slowly sinks, still in low

Accent says `My child, may you live long!
All the riches of a mothers true heart
Her rich blessings, she showers as she parts.
`May you live long!, a boon she gives outright
`Live Long! the highest benison and grace,
Mother! Mother! Mother! Through all ages,
Thou art praised, For Mother is the Lord!

Written by my father Late Rebbapragada Subba Rao just

before his mother (my grandmother) passed away.

FOREWORD

Most medical books written by physicians are meant for the

benefit of the medical fraternity: physicians, medical students, nurses
or paramedics. This book entitled `Matrudevobhava extolling the
mother is written by a senior obstetrician of India who has a vast
experience both as a skilled clinician and as a popular post-graduate
teacher for over 40 years. Through this volume he not only brings out
so lucidly the scientific and technical aspects of obstetrics and
gynaecology as a whole but also enlightens us with lot of his wit and
philosophy (with appropriate quotes from Adi Sankara to
Shakespeare and Sri Satya Sai Baba) on the social, moral and
ethical aspects of the problem of human reproduction. To support
some of his observations, he cites liberally from the Upanishads the
Geeta and the Bible. He makes a strong case that the mother who
nourishes, labours, protects and gives her all to her child (sometimes
even sacrificing herself in the process) deserves to be treated much
better than what she gets in our society today. Though the
exhortation `Matrudevobhava (taken from the Taittreya Upanishad)
is to respect and treat mother as God if only perhaps we given her
right from birth, love and affection, proper nutrition, and education
and the health care she needs in reproductive years and after, to a
small extent we may be able to repay the enormous debt we owe
her.
Dr. Anjaneyulu rightly warns that the line of demarcation
between physiology and pathology of pregnancy and labor are
not clear cut; and accidents (or even tragedies) may be due to the
neglect by her family or her physician. Therefore, prenatal care and
vigilance during labor is quite essential. His brief essays on sexdetermination, sex-education, abortions, family planning, normal and
abnormal menstruation, cancer of uterine cervix and menopause
are so succinct and educative that the book will be useful both
for medical and the lay public. His warning to the profession and
the public about the alarming rise in the caesarean section and
hysterectomy rates should be heeded and reflected upon.

He rightly emphasises that the obstetrician of today should take

the responsibility to supervise womens health in the widest sense of
the term from childhood, through adolescence to menopause. In
India, over 100,000 mothers die annually due to complications of
pregnancy and childbirth. Most of these deaths are preventable.
When the Safe-Motherhood has become the watch-word with UN
Agencies (like WHO, UNICEF) and the Government of India, this
book is most timely and educative to promote the cause of womens
health in our country.

(K. Bhasker Rao)

9th August 1994
Madras

PREFACE

`In All His Dispensation God is at work for our good

In Prosperity He Tries Our Gratitude
In Mediocrity, Our Contentment
In Misfortune, Our Submission
In Darkness, Our Faith.
Under Temptation, Our Steadfastness
And At All Times..
.Our Obedience and Trust In HIM.

How true it is that the Lord is at work for the good of the
universe in all His dispensations. For the survival of the human
race the Lord has instituted several safeguards for pregnancy
and to make childbirth such a spectacular and wonderful event.
It is His Will and Blessings that gynaecologist one can do his
best but ultimately it is only His rule which has the final say.
The discipline of Obstetrics and Gynaecology clearly highlights
the role of the mother, her qualities to bear and forbear, persistence
and perseverance and the supreme sacrifice or Tyaga even at the
expense of her own health for the sake of progeny and for bringing
up of children. The foetus in its manoeuvres during the birth process
as well as after birth, has given the message of a code of conduct
and the Vedantic aspect of life. The gynaecological conditions point
out to the precepts handed over by elders from times immemorial
and to the conditions that occur and are observed in everyday life.
No other branch of medicine teaches so many ethical and moral
values.
What I have learnt and imbibed all these years, either while
treating the patients or teaching students, the good qualities I have
observed from everyone I have tried to present in this book in my
own humble way the message of the Lord.
8

It is not my intention to write a regular text-book. As such, this

book is meant not only for the medical profession in every discipline
and practising doctors, but also for everyone including non-medical
persons as it concerns the ethical moral and philosophical aspects of
life. While so doing I have dealt, to an extent with the technical part
of the subject in as simple a way for the easy understanding of
everyone. I have not gone beyond the extent necessary to convey
the message it imparts. Each chapter is an entity by itself though
various subjects have been described.
Spiritual and moral teachings imparted by my parents in my
childhood and `Mothers Benediction, the poem incorporated in this
book written by my father, Late R. Subbarao and read to all our
brothers and sister, have had a lasting effect upon me. I am ever
grateful to my eldest brother Late R. Ramananda Rao without whose
encouragement and financial assistance I would not be what I am
today. It was my brother that handed over the above divine message
of the Lord to be observed and followed at all times. Both my father
and brother greatly influenced my attitude and working in my life.
I have been greatly influenced by Late Swami Chinmayananda
whose inspiring lectures at the Geeta Gyana Yagnas had a deep
impact on my outlook. In my own subject, I owe everything to my
teachers who taught me as a student and also in the formative period
of my training and to the writings of great teachers like A.L. Mudaliar,
R.K.K. Thampan, M.K.K. menon, Ian Donald, Munro Kerr and J.
Chasser Moir, F J Brown, Johnstone and Eastman, Joseph P De Lee
and Greenhill, Profs Jeffcoate and Wilfred Shaw, Keller, Novak and
Joe V Meigs, Dewhurst, Masani, Studd from whose books I have
learnt and taught my students. I have quoted these authors without
reservation in this book.
While invoking the blessings, of the Lord I want to make it clear
that this is not a religious book. There is only one God Lord
Almighty or Brahman. Swami Sivananda described the diety Lord
Iswara at Kedarnath as having Formless Form. How true are his
words. The Lord has no form and all are his forms as every one of
us is the swarupa of the Lord. He is most secular as he is the in the
heart of every body.
10

Sarvasya ca ham hrudi Samnivisto

(Geeta Chapter 15)
I am seated in the hearts of all.
Call the Lord by any name, Allah, Jesus, Rama or Krishna
One is referring only to the Divinity. Even the meaning of the words
points to the same divinity. The word Allah Al-Divinity, Lah to
become laya or merge in it; Similarly Jesus (Yesu) means Ye One
and Su Divinity. Rama constitutes three components of sounds Ra
Aa Ma. Ra signifies Twam i.e. Brahma or Divinity, Ma signifies
Twam; i.e., Thou, the Jiva or the individual and Aa connotes the
kinship of identity of the two i.e., the Jiva and Brahma. The Lord is
also secular in that the responds to anyone meditating on his name
with purity and devotion in any language or religion. Thus Divinity is
only one and the paths to reach Him are different.
I have quoted quite often from the Divine messages of
Bhagvan Sri Satya Sai Baba in this book including the above
paragraph. His teachings are so lucid and simple that even a lay man
like myself can understand and comprehend the essence or core of
what is written in Geeta, Upanishads or Vedas. One sees in his
preachings a combination of Hindu concept of Vedic cosmic
awareness, the Islamic concept of Allah as universe, the one who
sustains us all and the Buddhist and Christian compassion. Truly a
great teacher and in the real sense, Guru, (one who removes
ignorance from everyones mind). President Shankar Dayal Sharma
said that Bhagwans mission is to bring change in Naitika, Dharmika
and Adhyathmic thoughts so that all of us strive to realise our own
true nature; i.e. That Thou Art. I pray and seek Bhagwans Blessings
in writing this book.

11

Acknowledgements
While constraints of space does not permit me to include the
names of all my professional colleagues, well-wishers and friends
who have inspired me to formulate my thoughts to make this book
possible, I would be failing in my duty if I do not mention the
enormous influence on my outlook and thinking by at least some of
them.
At the outset, I would like to pay my obeisance to Late Dr (Mrs)
PK Devi who as a senior colleague encourage me from the very
beginning of my professional career.
Late Shri SAL Narayana Row, erstwhile Chairman Board of
Direct Taxes was always a friend philosopher and guide to me.
My brother-in-law, Dr B Dayananda Rao, is not only an eminent
neurosurgeon but an erudite scholar of English Literature. I have had
the good fortune of his having gone through the entire manuscript of
this book and the benefit of his advice.
Dr Banoo Coyaji has, since he time I came to Pune been a
source of great inspiration. A true karmayogi, her pioneering work in
all aspects of maternal health and Safe Motherhood have throughout
been the cardinal example to follow.
I have gained immensely from the discussions I have had with
Pandit KL Gautam, a renowned Sanskrit and Hindi scholar and Dr
Padmakar Vartak, who has an indepth knowledge and understanding
of our traditions, philosophy and medicine. Both of them gave me
valuable advice and information which I have duly incorporated in the
book.
I have also had fruitful discussions with Doctors Sudhikumar,
Mrs Rajlaxmi, Mrs Asha Joshi and Mrs Rashmi Gapchup. Mrs
Jyotsna Apte had very kindly undertaken to make the line drawings.
Dr Nishikant Shrotri and Dr Mrs Aparna Shrotri have given me
valuable help and advice in printing the book. My grateful thanks to
all of them.

12

I owe my gratitude to Dr K Bhaskar Rao, Emeritus Professor of

Obstetrics and Gyanaecology, Madras Medical College and Formerly
Director, Institute of Obstetrics and Gynaecology, Govt. Hospital for
Women and Children, Madras, an internationally renowned
gynaecologist and author of several books, for having consented to
write the Foreword and giving me several valuable suggestions.
Last but not the least, I have to acknowledge the support and
cooperation I received from my wife R Krishnaveni, who has been
the true inspiring force behind writing this book.

13

MATRUDEVOBHAVA
CONTENTS

Cha
pter
s
1.

Intricate Role of Nature in the Survival of Mankind

21

2.

Pregnancy Essentially a Physiological Process

32

3.

The Foetus can listen and react from Mothers Womb 42

4.

Anaemia in Pregnancy

49

5.

Abortion Problem

59

6.

Onset of Labour Still an Enigma

70

7.

Labour Hard Work on Part of the Mother

78

8.

Shortest & Arduous Journey in Life

85

9.

Vagaries of Uterine Contractions during Labour

90

10. Baby in the Womb My Guru

98

11. What do the First Breath and Cry of Baby Indicate

104

12. Still Births and Neo-natal Deaths Duty of the 108

Obstetrician
13. Each Pregnancy and Childbirth Rebirth for the 111
Mother
14

14. Pre-Pregnancy Care The Need of the Day

115

15. Breast Feeding

119

16. Sex Determination and Sex Differentiation

125

17. Ethical Aspects of Induced Abortion

136

18. Infertility

148

19. A I D Adoption : Ehical Consideration

157

20. Ethical Problems IVF & Surrogate Mother

167

21. Hormones in Normal and Pathological Conditions

172

22. Amenorrhoea

176

23

Dysmenorrhea

182

24. Endometriosis

186

25. Genital Prolapse

191

26

Ovarian Tumours

197

27. Cancer of Cervix

201

28. Diseases of Urinary System

206

29. Premenstrual Tension

210

30. Menopause

212

31. Cancer of Breast

217

32. Sex Education

222

33. Family Planning

227

34. The Womb A Saga of Ecstasy and Sacrifice

237

15

35. The Obstetrician and Gynaecologist Trimurti or 246

Dattatreya
36. Epilogue

253

INTRICATE ROLE OF NATURE IN THE SURVIVAL OF MANKIND

Conception occurs at the outer end of the fallopian tubes and
after passing through various phases of development the fertilized
ovum gets itself implanted into the endometrium (mucosa lining
uterine cavity) at the upper part of the womb after 6 - 7 days. From
then on the embryo grows up to 40 weeks of gestation into a fully
grown child.
All human beings get their genetic and chromosomal material
both from father and mother. But the baby is developing in the
uterine cavity of the mother. Hence the baby has some antigenic
material in it which is foreign to the mother. Such a foetus is regarded
as Graft attached to the mothers womb by he umbilical cord and
placenta and the mother is called Host.
It is a common phenomenon that when a graft with different
antigenic make up is implanted the response in the host is cell
mediated. Antigens from the graft are taken up by tissue
macrophages processed in the reticulo-endothelial system and are
presented to the immune system of the mother consisting of two
types of cell lines 1. T-cells 2. B-cells.
T-cells reach the graft via the blood stream, invade it, attract
phagocytes by secretion of lymphokines and initiate graft destruction.
B-cells on the other hand produce antibodies LGM, IGA and IGG in
the host.
Such a type of graft destruction is expected in all pregnancies.
In each pregnancy mother and foetus are exposed to over an area of
10-15 sq. meters of placental surface to each others potentially
foreign antigens. Each pregnancy should have ended either in
abortion, retardation of foetal growth or even intrauterine death of the
16

foetus. Yet the baby survives and at birth there is no evidence of

graft rejection.
Two major blood antigens are present in humans (1) ABO and
Rh (2) HLA-Human Leucocyte Antigens. Antibodies (both cellular
and humoral) are produced in mother for both and with each
pregnancy and delivery the antibody titre is increased especially for
the human leucocyte antigens, and yet no damage occurs to the next
pregnancy. Even today grand multiparity of 8-10-12 is common in
certain countries (one patient even delivered a twenty-third child),
and these women deliver full term healthy babies.
In short, even though the baby is developing in a
immunologically hostile environment yet the baby escapes
immunological rejection what is it that is protecting the baby?
Many scientific explanations have been given to show that at
every stage of development of the baby, Mother Nature is protecting
it.
(a) Role of Zone Pellucida : Immediately after conception
the fertilized ovum till it gets implanted in the uterine cavity is
protected by a thick membrane Zone Pellucida.
(b) Role of Uterus or the Womb :
Mother nature has
created uterus or the womb as the ideal place for implantation
and continuation of pregnancy. One often wonders what would
happen if the pregnancy occurred in other organs. Experiments
have shown that such pregnancies have been rejected. It is the
only one organ that can grow and expand to such a size to
accommodate the fully grown baby at term and return back to
its normal size after delivery. Even the location of the womb is
in the bony basin of the pelvis so that it is well protected from
any trauma especially in the vulnerable early period of
pregnancy. At the time of delivery with the bony pelvis it forms
a birth canal so that the baby passes through easily in its travel
from the uterine cavity to the outside world. Hence the uterus is
called the most privileged site for the continuation of pregnancy.

17

(c) Barrier between maternal circulation and foetal

circulation: To minimize the antigen antibody reaction, the
foetal circulation and maternal circulation though very close
to each other in humans, do not usually mix because of the
placental barrier.
However leaks do occur in the barrier,
the foetal red cells may be seen in maternal circulation as
early as 8th week of gestation. But there is lack of transfer of
maternal leucocytes into the foetus (even if it occurs that is very
occasional) and this is also a major factor in protecting the
foetus by maternal immune action.
(d) Role of the Mother and the Foetus: Changes occurring
in maternal circulation in pregnancy namely lymphopenia
and increased production of adrenal steroids, ovarian and
placental hormones oestrogen, progresterone and chorionic
gonadotrophic hormone all these exert an immunosuppressive activity in the mother and help in the continuation
of pregnancy. The foetus in turn is immature and does not
express its antigenicity for quite sometime in the intra-uterine
life.
Apart from the above many interesting phenomena occur at the
time of the implantation of the fertilized ovum into the decidua or
mucosa lining the uterine cavity. All round the fertilized ovum a
structure called trophoblast (also amed chorion) is developed which
when fully grown forms the placenta and is responsible for the
nutrition and welfare of the growing foetus inside.
These trophoblastic cells in the process of embedding into the
uterine cavity destroy the decidua, form a pool of blood in which the
ovum bathes and this is limited to the base of decidua. Here both the
trophoblast and decidua play a very crucial role.
In the decidua at this time, there are large granular
lymphocytes of maternal origin. These belong to the natural killer
type of T-cells. In normal course of events these decidual
lymphocytes would have destroyed the implanting of fertilized ovum
by producing cellular immune reaction. Yet they do not do it. This is
because they do not recognise the trophoblast as a foreign antigen
and see in it their self, think that it is one of their own and hence do
18

not destroy it. On the other hand they help in limiting the
trophoblastic invasion so that implantation occurs properly. The
trophoblast also controls its own invasiveness. Other wise the ovum
would have dug its own grave in the process of implantation.

Immunological Tolerance
Trophoblast is of foetal origin and has antigens of paternal
type. In the blood flowing through the chorio-decidual space there are
both foetal cells from the trophoblast and the maternal cells. Yet the
antigens on the trophoblast are either masked, shed, or modified at
the cell surface and do not express their antigenicity. On the part of
the mother (as described above) the maternal cells in decidua do not
produce immune response in spite of the production of the specific
antibodies (humoral or cellular).
In short, maternal cells and foetal cells develop tolerance to
each other and this is classically known as Immunological Tolerance
of Pregnancy. In this way no antigen antibody reaction occurs
thereby preventing rejection of the graft foetus by the host mother,
which in fact accepts the foetus.
Immunological Enhancement.
The other important phenomenon that occurs in normal
pregnancy is that the humoral antibodies (LGG) unite with the helper
T-cells and blocks and protects the placental antigens and renders
them immune from the T-cells (killer cells) attack. These antibodies
are known as blocking antibodies and the phenomenon as
Immunological Enhancement. Such protection from blocking
antibodies is not observed in abnormal reproductive states like
abortion or toxaemias of pregnancy.
Surrogate Mother
A Mother takes upon pregnancy in her womb where the ovum
and sperm of two different people are fertilized outside and later
implanted in the uterus of the surrogate mother. Here the antigens
are foreign both from the paternal and maternal side. Yet even in
19

these (mother) the uterus accepts the pregnancy without rejecting it

and takes it to term.
If one ponders over conception, implantation and continuation
of pregnancy, one cannot but wonder that the impossible has
occurred. All scientific explanations can only take us to that extent to
say that on one side foetal antigens do not express antigenicity and
the mother does not produce immune reaction by the antibodies. But
the why of it seems beyond the scope of science; why should nature
do like that? Is not nature violating its own laws? (violating the laws
that are made is the prerogative of the present day administration.
Some people preach laws only to be observed by someone else but
the laws do not apply to them). No one can explain. This is where
science ends and spirituality begins. It is all done by the handy work
of the Lord Almighty. The Maya of the Lord Vishnu so that the
human race survives.
Preservation and welfare of not only human beings but
also life at lower levels does not escape the attention of God.
Even the most stringent laws of physical nature are
compromised in the process. The best example one can think of
is the fact that contrary to the normal effect of cold contracting
bodies, cold below 4 degrees centigrade expands the volume of
water so that the resulting solid ice even icebergs float
rather than sink to the depth by their weight. God, in his
benignity, so relaxed the law of nature to save the marine life
underneath which would otherwise be crushed under the very
weight of the sinking blocks of ice. Can there be a greater
wonder!
In the protection and survival of the human race, the Lord has
taught one important lesson; i.e. Tolerance and Acceptance.
Unfortunately one does not see this trait in day to day life. People
cannot tolerate one another even for very small things. If one is
coming up in life others do not tolerate it and in turn they develop
jealousy and hatred. All of us are Swarupa of the Lord any wrong
one does to another is in effect doing wrong to himself. As in
immunological enhancement for he common good of continuation of
pregnancy, helper T-cells join hands with immune antibodies to
protect the placenta from immune attack from the killer T-cell. In
20

short, for any good purpose which is meant for the welfare of
mankind everybody should forget their differences and work together.
One feels sad to read every other day in the newspapers
regarding a daughter-in-law being tortured by the in-laws; either she
is being driven to commit suicide by hanging or burning herself or
she is forcibly killed by the in-laws for not getting enough dowry etc.
In many more cases, though not to the same degree, constant
harassment is the rule; being insinuated by every one in the house,
she is being treated as an alien or foreign from the immunological
point of view i.e. as a graft only to be killed by the killer cells and to
be discarded or rejected.
Every one should learn a lesson from what mother nature is
doing to preserve mankind. The fertilized ovum could have been
easily killed or thrown away at the time of implanatation. Uterine
large granular lymphocytes do not show any immune reaction and
accept the ovum and the trophoblast. After all, the daughter-in-law is
also a daughter in someone elses house and she should be treated
as their own daughter in the in-laws house. It is this initial acceptance
of the daughter-in-laws that reflects later in life the attitude of the
daughter-in-law towards her in-laws. If only the attitude of tolerance
and acceptance is observed in any home then only there will be
happiness prosperity and above all peace in that house.
Even our religion and Vedas stress the same. In Atreya
Upanishad it is written that woman accepts the sperm as its own
body and the sperm also accepts the womens body as its own body.
Swami Vivekananda in his address to World Parliament of
Religions (Sept 11th 1983) exhorted I am proud to belong to a
religion which has taught that world both tolerance and
acceptance. We believe not only in universal tolerance but we
accept all religions as true.
While it is true that all religions preach tolerance yet,
today there is just enough religion to hate each other.
Bhagwan Sri Satya Sai Baba in his Divine message said
Peace and Truth are our own swarupa. To know one self is truth and
21

to enjoy one self in the bliss is ananda. Every thing good or bad
depends upon our own behaviour. If it is in the right direction then
only Krishna will give us happiness. For all these we must take
Sahana or tolerance as a holy and powerful weapon. It is because
Dharmaraja took this tolerance as a weapon that he could achieve
success.
Tolerance should not be taken as weakness or cowardice but
should be seen and observed in its true sense. The power and shakti
present in sahana one cannot see in any other weapon. However,
sahana should be observed not just in an individual but in a collective
form. That is why Vedas start with Sahana Vavatu, Sahanau
Bhunaktu. Let us grow up together, let us live together, there should
not be jealousy, kalaham or fights or misconceptions among people.
Everyone should live harmoniously and happily as children of one
mother.
Lastly, even so-called very bad and cruel people do have in
them a spark of divinity which is clearly shown in the part played by Tkiller lymphocytes at the time of implantation of the ovum. They
preserve and protect the ovum instead of destroying it. As Bhagwan
Sri Satya Sai Baba says `From a hunter one can transform one self
to Maharashi Valmiki with the kripa of the Lord if one adopts to this
holy and powerful weapon of Sahana (or Tolerance and
Acceptance).

22

PREGNANCY
ESSENTIALLY A PHYSIOLOGICAL PROCESS

(DIVINE NATURE DOES EVERYTHING FOR THE WELL BEING OF

the Mother AND BAbY)
Certain physiological and anatomical changes occur in the
mother as a consequence of pregnancy. They are a temporary
adaptation and revert back to normal after delivery and purperium
and produce no deleterious effects on the mother. If the mother is
healthy and adequate nutrition is maintained, these changes are not
a strain on mothers well being. Many women in fact feel better and
happy in pregnancy. These changes start occurring very early in
pregnancy and are a positive adaptation and precede any positive
demands of the foetus.
The implantation of the fertilized ovum is usually in the fundus
of the uterus and this is facilitated by the action of the hormone
progesterone which acts like physiological sphincter on the circular
muscle fibres of the isthmus and cervix. This sphincteric action may
be of importance to restrain the ovum and the growing embryo within
the uterus and also help continuation of pregnancy to term.
Sufficient production of this hormone is ensured by the corpus luteum
of pregnancy which in turn is maintained by the chorionic
gonadotropic hormone produced by trophoblast which is all round he
fertilized ovum.
The non pregnant uterus is geared up by increase in size and
weight to contain and accommodate the products of conception. Its
musculature undergoes hypertrophy and hyperplasia, progressive
softening occurs, and the arrangement of the musculature helps in
the fulfilment of two objectives:
Formation of the Parturient Canal during labour for the easy
descent of the foetus and secondly the all important control
of bleeding after delivery i.e. post partum haemorrhage. It
is achieved by the contraction and retraction of the muscle
23

fibres of the upper segment of the uterus as well as the interlacing fibres of the uterine musculature which go as figure of 8
round the blood vessels at the placental site and act as living
ligatures.
Prevention of infection: The genital tract is rightly divided
into three compartments during pregnancy. The uterus
containing the foetus, liquor and membranes is the aseptic
cavity or compartment. No infection can ascend to the uterine
cavity as the cervical canal is blocked by a thick plug of
mucous produced by the proliferative cervical glands and this
plays a vital role.
The upper part of the vagina is the antiseptic compartment, the
vaginal discharge is highly acidic (pH varying from 3.5 to 6)
because of production of lactic acid as a result of the glycogen in the
epithelial cells being acted upon by the Doderleins bacillus.
The lower part of the vagina and the vulva contain all
saprophytes and pathogenic organisms this is called the septic
tract.
It is amazing that in the process of delivery the foetus comes
from the aseptic cavity through the antiseptic tract and later through
the septic tract in its journey to the outside world. Nature is not
content with that. Before the birth of the baby the bag of water in front
of the baby ruptures so that organism at the vulva and vagina are
washed out. After the birth of the baby the liquor comes out in a gush
and finally the after birth (or) the placenta mops up all the organisms
as it comes out.
While this is so with nature the obstetrician (if proper care
and antiseptic and aseptic precautions are not taken), can cause
pelvic infection. Any examination during delivery or any operative
procedure causing trauma to the genital tract predisposes to pelvic
infection as all these carry infection from septic tract through
antiseptic and ultimately to the aseptic cavity.
Mother nature has also seen that the baby is surrounded all the
time in the uterine cavity by amniotic fluid. This fluid, during
24

pregnancy, serves several important functions. It provides a medium

in which the foetus can freely move, cushions the foetus against any
possible injury, helps to maintain an even temperature and not the
least, it provides useful information to the doctor regarding health and
matuity of the foetus.
The Maternal Internal Environment is Altered to Create Conditions
favourable to the Foetus and the Changes are in Apparent Excess of
the Needs of the Foetus.

is

25

(a) The blood volume is increased during pregnancy. Plasma

volume increases by 45% upto 1250 ml in primigravida and
1500 ml in multigravida. Increase of red cell mass occurs upto
400 ml (18%) in women given iron supplements and 250 ml
when not given iron supplements. The blood volume increase
essential to maintain uteroplacental circulation and the
haemodilution caused by the increase of plasma volume
causes less of blood viscosity and the peripheral resistance is
reduced, which in turn helps to keep the blood pressure under
check. From a teleogical point of view if by any chance there is
loss of blood after delivery more plasma is lost and the
haemoglobin and red cell reserves are not affected.

The cardiac output is increased by between 27 64% far more

than necessary to provide for the increased blood flow to the
uterus, breast and other organs. Even the renal blood flow
is show to be increased to as much as 50% as early as ninth
week of gestation.

Maternal hyperventilation is a normal feature of

pregnancy. This lowers the PCO2 in the maternal arterial
blood. This lowered partial pressure of CO2 in the blood
on the maternal side of the placenta then facilitates the
transfer of CO2 from the foetus t the mother. Also, instead
of preserving `milieu interior which is the most common
endeavour of the body in all other situation, the physiological
adaptation of the mother creates a constant changing
environment appropriate to the successive changes of
pregnancy and to provide conditions most favourable for the
growth and development of the foetus.
The mother accumulates fatty reserves in anticipation
of the future needs of the foetus. 4Kg of fat is deposited
in the anterior
abdominal wall back and thigh. This
stored fat provides energy which may be needed in late
pregnancy, labour and puerperium and in cases of nutritional
deprivation.
Changes in the breast include growth and proliferation of
the glandular and duct system and half-way through the
pregnancy, secretion of colostrum begins. The breasts are thus
anatomically and physiologically prepared to take on the task
of lactation and of supplying the infant with milk and essential
nourishment once it is delivered.
ROLE OF THE PLACENTA
Placenta has diverse functions during pregnancy apart from
production of hormones essential for continuation of pregnancy. Its
main role is in maintenance of nutritution of the foetus. A liberal
supply of carbohydrates is essential for foetal energy production,
since the foetus derives energy almost entirely from this source. All
26

the supply of glucose to the foetus is obtained by the passage across

the placenta. Some lipids essential for growth and development are
transferred across the placenta in early weeks of pregnancy while
others are synthesized by the foetus in the latter weeks. Protein
transfer ism for the most part, achieved by the breakdown to amina
acids o the maternal side of the placenta followed by the active
transport.
Essentials concerned with maintenance of bio-chemical
homeostasis like water, electrolytes, oxygen and CO2 are transferred
by simple diffusion taking only a few minutes while other nutrient
materials transferred by active transport take only 30 minutes or so.
The rate of growth of a cell depends upon the availability of
nutrients. In the foetus this depends upon the maternal blood arriving
at the placenta and the transfer of the nutrients across the placental
membranes to the foetus. The concentration of nutrients in the
maternal blood is the same except in extreme condition of starvation.
Even here nature sees that important centres of the foetus like brain,
liver and heart are well supplied with nutrients and are thus well
protected.
Yet pregnancy can be trying and requires a lot of forbearance on
the part of ther mother.
Though from a biologic point of view pregnancy and
labour represent the highest function of female reproductive
system and a priori should be considered normal; yet the
manifold changes in the maternal organism during pregnancy
described above however render the borderline between health
and disease less distinct and slight derangement of but little
consequences in ordinary circumstances may presage
pathologic conditions that seriously threaten the life of mother
or child or both.
While everyone else at home is happy to observe early
morning sickness (occurs in 50% of cases) as a symptom of
conception, yet for the patient it causes so much of unpleasantness
and discomfort. She is at her wits end unable to take anything, even
the smell of food becomes unbearable, the patient becomes weak
27

and exhausted. If neglected the condition many drift unnoticed into a

condition of hyperemesis with all its dangers to life.
As the pregnant woman recovers from this symptom and the
pregnancy advances she feels well and is in good frame of mind and
spirit, she observes gradual distention of the abdomen by the
enlarging uterus and develops pigmentation on the abdomen,
breasts which also become heavy and occasionally pigmentation on
the face. Her skin becomes thickened and the features becomes
coarse.
There is a great diminution of the bowel peristalsis probably
due to smooth muscle hypotonia which becomes more pronounced
in pregnancy and constipation can be troublesome in some patients.
Iron supplements may make constipation worse. Haemorrhoids
occasionally first appear during pregnancy and bleeding may result in
loss of sufficient blood as to cause iron deficiency anemia.
Oedema of feet and legs may occur as a result of increased
venous pressure and the pressure of the pregnant uterus on the
pelvic veins. Oedema alongwith proteinuria and rise of blood
pressure constitute the triad of symptoms/signs of pregnancyinduced-hypertension occurring in 5 to 7% of cases. Pregnancy
predisposes to varicose veins in the lower extremities and symptoms
may vary from cosmetic blemishes with mild discomfort at the end of
the day to severe discomfort or occurrence of superficial
thrombophlebitis.
Physiological changes in the urinary tract during pregnancy
predispose to acute pyelonephritis leading to urinary tract infection.
During the latter months of pregnancy cramps in the calf,
abdominal wall, back and elsewhere are not uncommon. Relaxation
of the cardiac sphincter and reflex of gastric contents into lower
oesophagus referred to as Heart-burn of pregnancy is often a
distressing symptom. Palpitations, insomnia fatigue, dizziness and
faintness are occasional symptoms.
As a result of marked softening of the ligaments and an
increase in the synovial fluid, there is a considerable mobility in the
28

sacrococygeal, public and sacro-iliac joints. In some cases the

relaxation may be so great that the patient experiences incapacity,
pain in the joints and finds it difficult if not impossible to walk. The
relaxation of the pelvic joints also causes a degree of pelvic
instability, so that the woman in late pregnancy adopts a
characteristic waddling gait. The increased protruberance of the
uterus causes a progressive shift of centre of gravity anteriorly; so as
to prevent herself from falling forwards; pregnant woman throws her
shoulders backwards, straightens her back and neck and there is of
necessity a compensatory increase in lumbar lardosis causing
severe backache. All this is designated as Pride of pregnancy. The
pregnant woman deserves all the respect and consideration that she
demands. But unfortunately it is very much lacking today.
Scriptures say that women have to play a many faceted role in
life that of a lover, wife, mother, friend, advisor and as
sahadharmacharini (in respect to the husband). Here it is the
acceptance of the motherhood which is essential and necessary for
safe pregnancy. Women should have a positive attitude towards
pregnancy and the anticipated child. The pregnancy has been
planned and was happily accepted when its existence became
certain. She should have a manifestation of pride in self identity as
a mother or mother to be. Any denial of this may psychologically
lead to various problems enumerated above like vomiting, pregnancyinduced-hypertension and repeated abortions etc.
Equally important are the qualities of to bear and to forbear
which are the watch words. Mother nature does everything for the
safety of the mother and foetus. Yet a determination to remain
healthy and normal with a minimising of discomforts and acceptance
of anatomic and physiological changes with minimal physical
disabilities is an essential prerequisite on the part of the mother. One
should not feel helpless and leave everything to God that He should
only look after and protect. (it is just like leaving alighted candle
outside in the open and pray to the Lord to see that the flame is not
put off).
All the above disconforts the pregnant woman forbears and by
judicious and timely advice regarding details of personal hygiene, the
medical attendant can do much to obviate such disturbances and to
29

prevent them from developing and constituting a serious menace to

health. The expectant mother is usually well and in a respective
frame of mind and will follow all the health measures advocated
which are of benefit for her child and for herself.
Til til jeevan dekar til til badhana
Mother gives up her nutrition and strength like a til oilseed to
make her foetus grow in the womb.

30

THE FOETUS CAN LISTEN AND REACT

FROM MOTHERS WOMB
It is said in the Bhagvatam that Rani Leelavati wife of King
Hiranyakasapu was pregnant Sage Narada taught her the
Narayana Mantram. Prahalada in the womb listened to this Mantra
and soon after birth started saying Hari (Narayana) of course much
to the annoyance to his father.
In the Mahabharata Arjuna was one day teaching his wife
Subhadra about Padmavyuham (chakravyuham) (a strategy of war).
But he could not complete it as Lord Krishna came and taunted
Arjuna for telling a pregnant lady about war strategies. Abhimanyu,
who was in the womb, listened to all that was told to his mother by
the father to the extent of how to enter into Padmavyuham and fight
but not how to come out. Later in his life he ad no chance to learn
from his father the complete strategy. During the Mahabharata war
when Dronacharya planned Padmavyuham Krishna and Arjuna were
not there and when challenged, Abhimanyu came forward to fight in
spite of protestations from everyone including his mother Subhadra.
Abhimanyu said that when the enemy had come and challenged for
fight, not go is a disgrace or Apakirti worse than death and took his
mothers permission. He died fighting, not to go is a disgrace or
Apakirti worse than death and took his mothers permission. He died
fighting, not knowing how to come out of it. Abhimanyu got
veeraswargam (Heaven meant for noble warriors) and is
remembered even today for his valiant death.
When Kahoda was reciting Vedas, the child in his wifes womb
who was listening to the same could not bear the wrong
pronunciation and told his father that there were eight mistakes. The
father not realising that the child in the womb could speak, mistook
his wife for the same. He got angry and cursed his wife that the child
would be born with eightfold contorted body. That was how
Ashtavakra was born.
The above three examples indicate that the foetus can and
does hear when in the womb, can remember the same after birth and
the behaviour and actions depend upon what it is exposed to listen
while in the womb. The three gunas Satvic, Rajasic and Tamasic
31

qualities after birth may also depend upon what it is subjected to hear
in the antenatal period. If the mother reads religious books, hears
songs of bhakti and devotion during pregnancy, the child after birth
and later in life will also be inclined to hear the same and his
behaviour and character will be in the same way. In a family where
there are fights and quarrels and baby in the womb listens to these
the child may imbibe he same.
Even the latest research confirms this view. `It is observed that
certain behaviours of the infants in response to environmental
change has been called Orienting Response. As a new stimulus is
received in the auditory and or visual or other sensory field, the infant
becomes more alert, with suppression of spontaneous movement,
with a likely turning of the head towards the stimulus and with
physiological changes in heart rate. There is a tendency for the heart
rate to decelerate when the baby orients to a more or less familiar
stimulus, whereas acceleration occurs when a totally unfamiliar and
noxious stimulus is received. When a substantially unchanging new
stimulus becomes repetitive, the orienting response rapidly
habituates; there is less startle reaction or cardiac acceleration and
as the stimulus becomes familiar, cardiac deceleration may
supervene. (Nelsons Paediatrics). Foetal electro-cardiographic
studies show, where foetus is stimulated (Accoustic Stimulation test),
there is tachycardia. This test is done to distinguish whether a baby
is anoxic or at rest (sleep).
Bonding : `It is the social milieu of the parents, the mothers
experiences during pregnancy (representing hopes and fears of
the parents) and events surrounding labour and delivery all these
experiences have the effect of bonding the parents to the child
after the child is born. Bonding consists of those emotional ties
that characterize the relationship between each parent (or other
participants in this social event) and the infant who becomes a central
figure. During the next few hours, days, weeks and months the infant
reciprocates this bonding with his or her attachment to the significant
persons in the environment to whom he or she will turn to in future for
protection, nurturance and love. (Nelsons Paediatrics).
All parents want their children to become cultured, obedient,
intelligent and patriotic citizens when they grow up. The ideal time to
32

inculcate in a child is during the prenatal period. Prenatal Thought

Radiation Experiments (Conducted at Hospital For Peace of Mind
Lonavala) have given positive results. Seventh month of the
pregnancy is chosen as suitable as by this time all growth
parameters are completed and the response of the foetus o thought
process is better. The main feature of the experiment is transmission
of thought waves on a particular plane by the researcher.
Concentration of the parents and a state of equilibrium is brought
about and the foetus is suggested to a prayer. Also when the foetus
is informed about the colour the mother is concentrating upon
foetal pulse rate may show variations depending upon his/her likes
and dislikes. This can be detected at a very early foetal stage of
development and his/her good qualities reinforced. Even
psychologists now a days judge the nature of a person on the colour
he chooses and remedial measures are suggested based on the
colour.
Similar programme is also conducted by the National Institute
for Habitat Management, Bhubaneshwar where pregnant women are
trained to teach their offspring a whole lot of things while they are in
he womb. The training here is however offered between the fourth
and fifth month as the infants brain would develop in the second
trimester. During the process which is called psychosomatic reaction
between mother and child through blood circulation, the brain of the
offspring would become powerful to receive signals through the
mother.
All this is based on the hypothesis that the Foetus can be
positively influenced in utero. A study in 40 cases has shown that
physical condition, milestones in development and qualities of
courage and peace (obedience, good memory, understanding,
cooperation, satisfaction and love) observed in 60% while qualities of
fear and rage occurred in 30% of the children followed for seven
years after the birth. These tests seem to be of great value in building
a cultured, courageous and tension free future generation.
What our scriptures say regarding the influence on the foetus
and child.

33

Prakriti is the muladhaara (source) for Shakti. One must do

puja to Prakriti and through it get the blessings of the Lord. The first
depends upon mans earnest desire and trial and the second one is
the grace of the Divine. Prakriti and Paramatma are like negative and
positive currents. Even if the Paramatma is the positive and all
powerful. Yet without the negative Prakriti there is no Shrushti
(creation) of the world. For this Shrushti, Prakriti is the muladhara.
Even if one has good seeds, unless one puts in the earth one does
get any results.
In the same way womb is likened to Prakriti or Bhumata. If the
beeja or seed which is put in is good, then good healthy children are
born. If one puts neem seeds in the earth, how can be expect to get
a mango grove. Any good seed or beeja always come from the type
of nutrition we take naturally whether it is Satvic, Rajasic or Taasic. It
the mother indulges in smoking or excessive drinking this is reflected
in the growth of the child. Growth retardation was reported in
smokers and in cases of foetal alchohol syndrome.
Secondly, even if the seed is good if the bhumi or earth is not
good, the produce will not be good. It is our elders advice that all the
weeds should be removed from the earth before sowing the seeds.
Thus environment is equally important. Similarly, good, nourishing
environment in the uterus is essential for the proper development of
the foetus.
Thirdly, the thoughts prevalent in the mother throughout
pregnancy have also a positive effect on the type of baby born. Even
the teachings and training of the children and the samskaras given
by the mother in childhood also play a great role in the personality of
the children. In short, Mother is the first Guru for anyone in life. Rama
became God and attained name and fame because he was born to
and brought up by Kaushalya. Lava and Kusha were similarly
brought up by Sitamahasadhvi and hence hey attained greatness.
Chhatrapati Shivaji attained greatness because of the teachings and
bringing up by Jijabai. Gandhi became Mahatma because of his
mother Putlibai. At all times and at all moments because of the
protection of the Mother, mankind is spreading its perfume. The
hand that rocks the cradle is the hand that rules the world. (WR
Wallace).
34

The final development of the child, as he grows in age also

depends on the prevailing environment which it faces. To cite an
example the father of Ravikiran, the child prodigy of Carnatic music
wanted that his son should develop into a musical genius and so
right from birth he saw that the child was exposed continuously to a
musical environment. The result is that even at the tender age of
three years Ravikiran was able to identify all the ragas in Carnatic
music and later developed in a musical prodigy.
In a similar analogy Bhagwan in his divine message in
Bhagwad Geeta (Chapter 13) says that our (human) body is Prakriti
or kshetra and the Lord in us (Paramatman) is the Purusha or
Kshetragnya. In mans endeavour to realise Bhagwan he must see
that all the vasanas (attachment to sense objects) should be
removed first. Then only the Kshetra will become pure with good
thoughts words and deeds and only thereafter can one aspire for
Moksham (Bhagwan Sri Satya Sai Babas Divine message).

35

ANAEMIA IN PREGNANCY
(Mother Helps in Development of Foetus
At the Expense of Her Own Health)
In our country anaemia in pregnancy is a major public health
problem. It is one of the commonest causes of high maternal
mortality rate. Anaemia is directly responsible for 20% of all maternal
deaths and in about 20% it is a pre-disposing factor.
If the haemoglobin level is below 11 gms% during pregnancy, it
is indicative of anaemia (SHO). If the level falls below 8.5 gms% it is
moderately sever and various complications occur. Below 5 gm% of
haemoglobin, the anaemia becomes very severe and especially
during their trimester of pregnancy cardiac failure occurs and the
patient requires hospitalization. Statistics have shown that moderate
anaemia in pregnancy occurs in 40-70% in different parts of our
country. Moderately severe anaemia (Hb<8.5gm%) is seen in 10% of
cases and the incidence increases with parity. (Post Graduate
Obstetrics & Gynaecology IV Edtn).
Physiological anaemia of pregnancy: There is an increase in
maternal blood volume by 50% during pregnancy. Both the plasma
and erythrocytes increase yet as there is a disproportional increase
in plasma volume (35%) compared to the increase in red cell volume
and haemoglobin mass (13%). There is a positive haemodilution.
This leads to a decrease in haemoglobin and haematocrit levels and
has led to the term physiological anaemia of pregnancy. This
physiological anaemia can be prevented and the haemoglobin level
can be kept above 11gms% with iron supplements. However if the
haemoglobin but definitely pathological.
Nutritional deficiency is the main cause of anaemia in our
country. Of this, iron deficiency alone is by far the commonest. There
is associated folic acid deficiency in 30-40% of cases.
Iron deficiency anaemia: Iron content in an average Indian
diet is 20-22 mg., but the diet is deficient in vitamin C, calcium and
proteins which are essential for iron absorption. Also the diet
contains phytates which inhibit iron absorption. At least 10% of
dietary iron should be absorbed to maintain iron balance. But only 336

5% of dietary iron is absorbed as shown by radioactive studies. To

maintain iron balance in pregnancy a minimum of 4-6 mg. should be
absorbed. If the dietary iron contains 40-60 mg. of iron then only the
desired level of iron can be met with. Even the best of diets do not
contain this amount of iron.
Most women in our country enter pregnancy with little or no iron
reserve. They are poor and malnourished; they suffer from worm
infestation especially that of hook worm which leads to iron loss.
They lose blood due to haemorrhoids. Iron is lost every month to the
extent of 15-30 mg during menstruation and many women suffer from
menorrhagia i.e. excessive bleeding during periods. They have
repeated and closely spaced pregnancies and also bleed after
delivery (post partum haemorrhage) which again deplete iron store
with each successive pregnancy.
All this is reflected in higher incidence of anaemia in high parity
group.
Iron absorption and utilization is also hampered by infections of
urinary and gastro-intestinal tracts which also adds to the increased
demand of iron during pregnancy thus aggravating iron deficiency.
The baby in the latter months of pregnancy makes a heavy
demand on maternal iron and the average foetal requirement is
about 375 mg.
Folic acid deficiency: This causes megaloblastic anaemia of
pregnancy which occurs in 10-20% of cases. In the diet folic acid is
present in green leafy vegetables, pulses, liver and meat. As such
Indian diet is a poor source of folic acid and our cooking methods
tend to destroy folic acid to a considerable extent. In women who
have haemoglobin level less than 8.5gms% there is not only iron
deficiency but also in 60% of these the bone marrow has a
megaloblastic reaction and such anaemias are called as dimorphic
anaemias. Vitamin B12 is present in all animal foods and in countries
where animal food is scarce vitamin B12 deficiency occurs.

37

Effects of Anaemia on Pregnancy

The symptoms are often not pronounced in mild and moderate
forms. Progressive deterioration of haematological status occurs with
each succeeding pregnancy. Symptoms when present in severe
cases consist of fatigue, dyspnoea, palpitation, loss of appetite and
digestive upsets. The patient typically presents a picture of pallar of
all mucous membrances-eyelids, tongue, lips and the nails show
cholinechia (spoon shaped) and there will be marked oedema of the
lower extremities and occasionally the rest of the body as well.
Folate deficiency in the early weeks of pregnancy has been
associated with abortion and congenital malformations of the foetus,
especially neural tube defects. Other complications like accidental
haemorrhage, toxaemia of pregnancy, increased incidence of urinary
tract infection, prematurity, still births and neonatal deaths also occur
in cases of megaloblastic anaemia of pregnancy. Severe forms of
anaemia in the third trimester are invariably associated with cardiac
failure.
Labour in severe forms of anaemia can be premature and
precipitate but not in mild and moderate cases; but accidents of
labour especially those involving haemorrhage and shock, are
rendered correspondingly more serious. After complications like
Antepartum haemorrhage (abruption placenta or placenta praevia),
even a little loss of blood in the post partum period will tip the scales
towards a state of collapse. Patients who come into labour with
haemoglobin level of 8.6gms% or less are at serious risk in this
respect. Those with haemoglobin 5 gms% or less have an already
over functioning heart develop severe decompensation (acute
heart failure) either during the 2nd state or immediately after labour. A
woman approaching labour with a haemoglobin of 65% (9.6 gms%)
or less faces it with some perils and all ante natal conditions
producing fatigue exaggerate the effects of labour itself. Her ability to
cope up with infection in the puerperium is much undermined by
anaemia and they are also prone to have a high incidence of
thrombophlebitis and thromboembolic phenomenon. Her recovery in
the post natal period will be greatly retarded to such an extent that
she may now face years of chronic sub health.
38

Effects on the foetus: In mild and moderate cases the foetus is

born with full compliment of haemoglobin. The foetus takes every
thing from the mother irrespective of her haemoglobin level in short
it is like a parasite. But in very severe cases and in those of low
income groups it was observed that the foetal stores of iron, folate
and B12 is only 50-60% of the affluent population. Their birth weights
are low as a result of prematurity or some of them are actually small
for date. Since breast milk in these people may not provide all
nutrients, they run the risk of developing anaemia very early in
infancy as well as infections.
Prophylaxis: While appropriate treatment is given and
individualised in each case depending upon the type and severity of
anaemia and the period of gestation and also the presenting
symptoms the most important aspect is that of prevention. Study
group in nutritional anaemia recommended 60 mg of elemental iron
with 500 micrograms of folic acid should be given as supplement in
the last 12-16 weeks of pregnancy for all cases. At this level of iron
the side effects are minimal with less chances of gastro intestinal
irritability and intolerance when given on empty stomach. There is a
false belief that iron should be taken after meals but it is observed
that absorption is reduced by 1-4% after a full stomach. With the
supplement, levels of haemoglobin are not only maintained but also
bring about an increase above pre-supplement levels in about 90%
of women. However in 8-10% of cases the haemoglobin levels are
still low in spite of therapy and this cannot be explained. As low as 5
mgs of vitamin B12 are recommended to maintain pregnancy
requirements. All this of course in addition to the prescribed dietary
regulations suggested in normal pregnancy as well as repeated
haemoglobin estimation for the early diagnosis of anaemia.
Anaemia may antedate conception, it is often aggravated by
pregnancy and accidents of labour may precipitate it. It is one of the
prime concerns of ante natal care to forestall it for the safety of
labour may precipitate it. It is one of the prime concerns of ante natal
care to forestall it for the safety of labour and puerperal state, let
alone the future health which in a large measure depend upon the
state of patients health.

39

As I write about the subject of anaemia in pregnancy my

thoughts go back to all the cases seen and treated during all these
years. Most of these patients belonged to the low socio-economic
group, never attended ante natal clinics usually multiparrae with
rapid succession of pregnancies without spacing and also had some
other obstetric problem. Some had twin pregnancy, others admitted
for antepartum bleeding. In many of them haemoglobin was less than
5 gms% and in a few it was just 2-3 gms%. They were admitted with
dyspnoea, breathlessness tand palpitation. Some had gastrointestinal upset like diarrhoea and others with severe oedema and
had severe hypoprotinemia in addition. They looked very pale and
were cyanosed and on examination presented incipient signs of heart
failure due to dilated heart. Some could not stand labour and
developed acute heart failure and died during the end of second
stage or mostly after delivery of the placenta or thereafter due to
collapse or obstetric shock.
Some of the patients belonged to the working class yet the
husband used to drink, gamble, beat the wife and take away all what
she used to earn. Even when told that the patient required blood for
transfusion etc, the husband and relatives not only refused to donate
blood but used to run away from the hospital leaving the patient to
the hospital care and never bothered about her welfare afterwards.
While the above state of affairs are still prevalent in rural areas
and in uneducated people yet a much similar situation though not to
the same extent, is observed today in semiurban or even urban
population like people living in slums. The mother of the house is the
most neglected of the whole lot. She has to care for the needs of the
husband, children, in-laws and whether the lady is pregnant or other
wise, she does not get proper nutrition. Many of the mothers have
never fully regained a good blood picture and anaemia may follow
from one pregnancy to the next without respite. They tend to feed
their children at the expense of their own nutrition so that they are
consequently very short of vitamins and first class proteins. They are
too busy to attend to their own health and in a rapid succession of
pregnancies and periods of lactation are likely to become seriously
depleted of their calcium. No wonder they suffer from dental caries,
bone and joint pains and from oesteomalacia in severe forms of
calcium deficiency. So many posters are put in the ante natal clinics
40

(and also advertised in the TV) as to what is the ideal diet for
pregnant patient including proteins, cereals, leafy vegetables and
how much of milk they have to take daily. Even low cost diets giving
same calories and proteins etc are also suggested. Yet one wonders
how many people are able to afford the same since the cost of living
is going up everyday. Even middle class people with fixed incomes
cannot afford to buy enough milk, let alone other food supplements.
What is surprising is the number of cases of anaemia observed in
patients belonging to the affluent families. Probably eating fast foods
has become the fashion of the day and their diets are not nutritious. It
has become routine practice to give or prescribe all ante antal
patients iron and folic acid tablets. Yet many patients cannot afford to
buy and in others even if they could buy or the tablets are given in
hospitals the patients do not take them regularly as occasionally
the tablets cause diarrhoea or constipation. Non compliance of taking
the medicine or haphazard way of taking is a very common feature in
our present day set up. This applies to all people pregnant or other
wise.
In any household, rich poor or middle class, the most important
person is the mother. She is the centre or hub round which all the
activities take place. Her health care is of utmost importance all the
more so during pregnancy. Pregnant mother is the custodian of the
future health of the nation. If she is anaemic, the offspring will also be
anaemic though not at birth but definitely later. They will not keep
good health and are prone to infections. During the entire period of
pregnancy and childbirth and later in bringing up of children the
mother sacrifices everything of hers for the welfare of the family.
Mothers have even sold their jewellery for the education of their
children and all this they did in the spirit of duty and not expecting
any return as said in Bhagawad Geeta (Chapter 2):
Karmanye va adikaraste; ma phaleshu kadachana.
Mothers sacrifice is likened to the sacrifice of the Lord.
Whenever He is born, it is for the welfare of humanity
(Lokakalyanam). Take the life of everyone of the avataras. Lord
Rama sacrificed to uphold the order given by his faterh, Lord
Krishnas life is one of tyaga from the time he was born in the jail,
had to be brought up by foster parents, always being threatened by
41

the wily Rakshasas and even in the end he serves as a Sarathi for
Arjuna. The Lord himself has no qualms about doing service to
humanity. Bhagwan Gautam Buddha relinquished the entire kingdom
in search of truth. Even so, Lord Jesus life is full of sacrifice, mercy
and compassion from the beginning. (Bhagwan Shri Satya Sai Baba).
It is a sorry state to see that many mothers are being neglected
by children when they grow up. Not only mothers are not being
looked after, they are made to work and kept with them as long as
they are found useful. In short, there is no retirement for mothers in
life. It is a pity to observe children who grew up from poor or middle
class families and achieve high position later in life sometimes feel
below their dignity to introduce their parents to others. Some even go
to the extent of sending their parents to Vriddhashrama (home for the
aged)! It is sad the grand children are deprived of the company,
affection and love of grandmothers (parents). The impact of the
stories which often point out to moral values heard from the
grandparents cannot be replaced or substituted by any story books. I
only pray for the day when the homes for the aged are scrapped and
the old parents are looked after by their children.

42

ABORTION PROBLEM
(LOVES LABOUR LOST

Abortion is termination of pregnancy before the period of

viability. Incidence of spontaneous abortion is considered 10 to 15%
of all pregnancies. The aetiological factors are divided into two main
causes.
1.
2.

Defective germ cells.

Faulty maternal environment.

In a high proportion of cases which abort the abnormal foetal

development may manifest itself as a blighted ovum which
describes an empty sac in which the embryo has not developed
beyond a small clump of cells or there may be a clearly recognizable
foetal abnormality. The abnormal development of the embryo or the
foetus may be due to a structural abnormality or chromosomal
abnormality. It is also possible that genetic defects leading to the
absence of a specific enzyme could cause abortion. Chromosomal
abnormalities account for a large proportion of aborted concepts in
about 50% of cases. Commonest is autosomal- trisomy affecting
16,22,21 and 15 chromosomes. Monosomy X chromosome
accounts for 1/5th of all abnormal karyotypes. Triplody and tetraprody
are also seen with reasonable frequency. Structural abnormalities
like neural tube defects may be present in other cases.
The other important cause of spontaneous abortion is faulty
maternal environment. It may be that the corpus luteum and the
developing placenta do no produce enough progesterone and
oestrogen for proper nidation and the decidua is poorly developed
not giving enough nutrition for the developing embryo. There is a
correlation between maternal diet and foetal development. Vitamin C,
P and Folic acid are essential for nucleic acid production and
deficiency of these can cause defects in the developing embryo.
Anatomical uterine defects like double uterus, septate uterus or
bicornuate uterus in all these the fertilized ovum may not only not
43

get proper nutrition but the growth is also affected by the abnormality.
Even if the pregnancy continues for some time all these also have
an incompetent cervix and pregnancy gets terminated later in second
trimester. Implantation over a submucus myoma or over a scar again
leads to nutritional deficiency and failure of growth. Hypertension in
pregnancy causes changes in the decidual vessels and results in
less blood supply ad nutrition.
In both the above two causes of abortion, most often the
embryo or ovum dies first and the abortion is only the end process.
Mother nature does not want defective children with various
abnormalities to be borne and live in the world. Abortion in such
cases is a protective phenomenon on the part of nature to get rid of
such foetuses. However it is not known why some chromosomal
anomalies like Trisomy 21 (Downs Syndrome) or Mongolism of
Monogamy X (Turners syndrome) lead to abortion in some cases
and proceed to term in others. It may be that those who abort have
some other abnormality in addition to chromosomal defects which
precipitate abortion. How one wishes that this should happen in all
cases! Probably those who go to term and deliver have still some
Karma left to be done in this world. But one also feels sad not only
for them but lifelong misery for the parents. May be they have done
something in the past life to get such children in this present life. This
is what is called Runanubandha (a bondage between the parent and
the child) and the parents have to pay off this debt to the child in this
present birth by serving and looking after it.
Although early pregnancy loss is often considered to be less
important than the loss of baby in later pregnancy this attitude is
inappropriate. The loss of wanted baby is always distressing to the
mother irrespective of timing and this probably is more true in
recurrent abortion. In spite of assurances many young mothers feel
that there is something wrong with them and feel let down Loves
Labour is Lost.
The second cause of faulty maternal environment as a cause of
abortion only stresses the place of a good environment in the healthy
growth of an individual. Even if the child is good and intelligent if he/
she is brought up in unhealthy environment they shall not come up in
life in the right direction as is seen in children born in an atmosphere
44

lacking in peace and morality. Their manners and attitudes are

different. The children do not study nor do they attend the school
regularly, fail in the examinations and latter on drop out from the
school. They develop bad habits and be in the company of bad
people. If the social structure is changed and all these children are
brought up in a healthy atmosphere given proper nutrition,
guidance and training in right direction and be in the company of
studious, well mannered and good students, all these people will also
come up well in life. It is observed such children thus brought up are
equally intelligent and do well in their examination as well as career.
They play written by Bernard Shaw (Pygmalion) only shows how a
lady on the streets can be changed and transformed in such a way
that she is taken as a princess by everyone. For upward evolvement
in life our ancient scriptures stress on right company right Satsanga
(The company of good-minded persons).
Habitual Abortion & Repeated Reproductive Failure
(Can be Trying on the Part of the Mother and Requires Patience and
Perseverance).
Habitual abortion refers to three or more consecutive abortions.
In addition to the factors enumerated in the aetiology of abortion
there are other factors like maternal syphilis, infections like
toxoplasmosis, incompatible blood group like ABO and RH
incompatibility, hypertensive conditions like pregnancy induced
hypertension, nephritis, essential hypertension and incompetent
cervix. In other pregnancy may go beyond 28 weeks of gestation and
the patient either has premature delivery or intrauterine death of the
foetus.
While in some of these cases the cause can be determined, in
many the cause can be multi-factorial and is not known.
Unexplained recurrent abortion or reproductive failure is a term
covering an assortment of mechanisms, varying with current
knowledge and intensity of investigations but still amounting to
around 50% of repeated foetal loss. In such cases the cause can be
immunological.
While the mechanism leading to the mother accepting the foetus for
continuation of pregnancy is not fully understood it has been
suggested that a failure of a normal immune response could be an
45

important factor in the aetiology of repeated abortions. Such a

phenomenon is not confirmed in all the cases.
Cases of repeated abortion are treated with complete bed rest
sometimes extending throughout whole course of pregnancy, and
with hormone treastemtn with chrionic gonadotrophic hormone/
progesterone; Isoxysuprine tablets given to prevent contractions; folic
acid and B complex with vitamin C prescribed from even before the
start of pregnancy and continued for 3 months or more and in
additional good nutritional supplements are given. Cervical circlage
done after confirming there is no abnormal foetus by ultrasound in
the second trimester of the pregnancy; antibiotics are given to treat
infections like syphilis, toxoplasmosis and for bacteruria of pregnancy
and urinary tract infection.
In the later weeks of gestation careful foetal surveillance is
done by routine examination whether the uterine size corresponds to
the gestational age; regular check up done for detecting early raise of
blood pressure and if so, treated; Blood sugar as well as urine
examinations are done to rule out diabetes. Volume of liquor and
whether there is intrauterine growth retardation observed by
sonography and later followed by non-stress test etc. for the well
being of the foetus.
It is sad to see these patients who become more and more
apprehensive with each foetal loss and the obstetrician is at his wits
end in the management of these cases. Yet with the determination
and will power and perseverance and willingness to accept the
stresses of pregnancy the patients are often rewarded with a live
child. A report covering 195 couples with recurrent abortion
emphasizes how extraordinary good results would have to be to
carry conviction. In 37 couples with 3 consecutive, spontaneous
unexplained abortion 32 (86%) had a successful pregnancy with
Tender Loving Care alone. There is no evidence that a patient who
have habitual abortions; when she finally carries pregnancy to term
delivers an abnormal child.
The saddest part of all these is while the mother patiently
undergoes all the stresses throughout pregnancy and finally gives
birth to a live child after either vaginal delivery or after caesarean
46

section, the relatives including the husband and the in-laws etc. asks
the first question How is the child? They are only happy to know
about its well being. Many a time they are even depressed when the
baby is a female. Yet nobody bothers or cares for mothers health. It
is not sad! Is the mother made to only undergo all the torture!
In my own professional experience I have had occasions to
treat patients who had abortions varying upto 6 to 10 times, some in
the first trimester and some in the second trimester. In most of them
the cause was unexplained. I used to keep them at complete bed
rest in the hospital for periods varying from 5 months to 10 months.
In a few I kept them in the hospital for quite some time after the
delivery. I had learnt one thing; i.e. one should not leave hope in
these unfortunate cases. With a little cooperation and willingness on
the part of the patient to take bed rest (of course the only time real
bed rest women get is in the hospital) and with sympathy, assurance,
etc. one can take these patients to term so that they can be blessed
with a live healthy baby.
I am reminded of the story of Robert Bruce who saw a spider
climbing a wall, which could not do so for 6 times and in the seventh
time succeeded. Taking this clue he himself succeeded in his
endeavour which he could not do for many a time. In the same way
the obstetrician as well as the patient should not leave any stone
unturned and strive for successful continuation of pregnancy and
labour.
Views regarding occurrence of abortion : Role of
consanguinity in the causation of congenital abnormalities, abortions
and stillbirths is ambiguous. Scientific research showed that cosanguinity or kinship increases the likelihood hat a couple will share
autosomal recessive gene. First cousins share 1/8 of their genes and
second cousins share 1/16. Even if there is no family history of
autosomal recessive disorder, yet the couple can be carriers of
deleterious gene and here is an increased risk for genetic disorders,
miscarriages, and stillbirths in the offspring of first cousin marriages.
But the risk is relatively low. Matings of individuals more closely
related than first cousins, involves significant risk of congenital
anomalies and naturally this practice is proscribed by law. Several
investigations have established the risk for anomalous children to
47

brother and sister or parent and child matings to be as high as fifty

percent. (Williams Obstetrics 1993). While this is so, in practice one
does not observe the same in all consanguineous marriages.
Marriages among first cousins or marrying maternal uncle is still
prevalent in certain communities and all the offspring not only were
normal but have high intelligence and academic brilliance. Anomalies
were observed only if the co-sanguine marriages are repeated in the
next generation.
It is a common observation that children born our of marriages
between different races or nationalities are usually very brilliant. This
factor seems to be the basis for research in agriculture and animal
breeding producing more productive seeds and better animal
progeny. One cannot explain why ? It is the genetic disparity which is
responsible? Surprisingly in such marriages the incidence of PIH
(Pregnancy Induced Hypertension) is more, which is not observed in
consanguineous marriages.
Even now Sagotra marriages are not advocated. Unfortunately
many marriage proposals are discarded on this ground. But clinical
experience and research does not support it.
Another unconfirmed but strongly held belief is the marriage
between people belonging to two difference castes. In anuloma
where the husband belongs to a high class or strata and the wife of
lower strata the offspring will be good while it is reverse in
pratiloma when the wife belongs to a higher caste and husband to a
lower caste but in practise one sees that a Pandita-putra (son of a
great scholar) need not always be brilliant and in fact most of them
are the other way around. The oft quoted example of anuloma is that
of Vidura in the Mahabharata who was born to Vedavyasa and a
maid, was a great scholar who was the Prime Minister and
administered the country on principles of dharma (Vidura Niti) which
even today have relevance.
Indeed there are many phenomena which cannot be explained!
To give an instance the occurrence of twinning in cases where the
ovum is starved; ie deprivation of nutrition and or oxygen to the
developing fertilized ovum, if not lethal by itself may result in the
production of twins or abnormal births depending upon the timing of
48

such deprivation (Stockard Williams Obstetrics Ed Eastman). It is

not strange! Starvation is a stimulating factor which our elders
prescribed and preached for a spiritual progress of man.
Except in a very few rare cases, the chances of a child
developing congenital abnormalities, pregnancies ending in
miscarriage or stillbirth or children after birth being normal, brilliant or
otherwise depend upon many factors most important of which is
the praarabdha (effect of ones Karma in past life, but the One which
overrides everything else is the Kripa or the blessing of the Lord
Almighty). All other factors are unpredictable. Bhagwan Lord Krishna
(Stanza 14 Chapter 18) in Bhagwad Geeta said that there are five
essentials for the successful accomplishment of all actions.
The seat of action Adhishthanam or the seat; (ie the physical
body).
Karta or agent (i.e. personality or the empirical ego).
Karanam or instruments or organs the 10 indriyas or sense
organs, manas, buddhi and ahamkaara.
Chesta efforts and functions of Prana or vital energies or
breaths in the body.
Lastly even if all these are present the fifth one, i.e. Daivam
or Providence or Bhagwans will at work is essential as He is
the regulator of all work. So in the ultimate analysis one will
be successful in any work only with the blessings of the Lord
Almighty.
The valuable contributions of the Late Dr VN Shirodkar in
respect of treatment of cervical incompetence, ( a very important
cause of mid-trimester abortion) need special mention. He was the
first to suggest cervical circulage in the management of these
patients which has resulted in several patients going to term. Even
today, in many East European countries, whatever the procedure
done, it is designated as Shirodkars stich as a tribute to his
contribution. Why should not we in our own country honour him
similarly?
49

ONSET OF LABOUR : STILL AN ENIGMA

When the child is grown fully and the mother cannot continue
to provide him with enough nourishment, he becomes agitated,
breaks through the membranes and incontinently passes into the
external world

Hippocrates

I is truly one of the mysteries of nature that life starts as a

single fertilized cell which develops into a fully grown baby
nourished all through in the uterine cavity till full duration of gestation.
The uterus suddenly becomes active and within a short span of time
expels the foetus. This is true for all species whether the foetus
weighs a few grams of a 21 day pregnancy in a mouse or whether it
weighs several hundred pounds at the end of 640 days pregnancy as
in the elephant labour begins at a specific time. The factors
regulating this highly synchronized sequence of events are obscure.
Labour can neither be initiated nor stopped at will. The old adage
When the fruit is ripe, it will fall, symbolizes the extent of our
knowledge of labour.
The fundamental question is not what initiates uterine contractility (as
they are there already) but how these painless random contractions
are converted into exquisitely coordinated efficient contractions that
dilate the cervix and expedite expulsion of the child. Of the main
theories regarding the onset of labour none alone affords an exact
explanation but each, in all probability, plays a role.
Uterine Stretch Theory: This is the oldest theory and is based on the
presumption that any hollow viscous tends to contract and empty
itself when distended to a certain point uterus is no exception.
In conditions where the uterus is markedly distended like multiple
pregnancies and polyhydramnios labour occurs earlier. Uterine
50

distention cannot be the primary cause as when the foetus dies and
the volume of the products actually decreases usually terminates
in spontaneous onset of labour at the completion of normal gestation
period.
Hormonal Theory:
Progesterone
is
essential
for
the
establishment and maintenance of pregnancy in all mammalian
species. Csapo proposed an attractive hypothesis that the
progesterone produced by placenta entails the production of a
myometrial block at the placental site. As the production of
progesterone by the placenta drops, the block is removed and this
withdrawal of progesterone is an essential prerequisite for the onset
of labour in humans.
Neurohypophysial Hormones:
Oxytocin given to the mother
in late pregnancy produces strong uterine contractions. It appeared
logical to relate the spontaneous onset of labour to indigenously
produced oxytocin. Blood contains an enzyme oxytocinase that
probably inactivates oxytocin. There is a drop of this enzyme just
prior to the onset of labour. Experiments showed that there is
secretion of oxytocin both by mother and foetus at the time of active
labour and both are likely to act synergistic ally. Also, there is a
several fold increase of oxytocin receptors in the myometrium of
uterus, sensitizing the uterine musculature to oxytocin activity. There
is increased oxytocin-like activity in blood observed during labour and
highest concentration is found during the second stage of labour.
Prostaglandins: Prostaglandins are potential myomertial
stimulants. At full term, lysosomes in the decidua become unstable
and release phospholipids which in turn release the precursors of
prostaglandins synthesis. There types of prostaglandins are
produced : PGF2x, PGE2 (prostacyclin). All these were found to
increase during pregnancy and labour. PGE2 probably acts on cervix
reduces its resistance, makes cervix more soft and ripe and helps
in effacement and the dilatation of cervix during labour. PGF2 is the
effective prostaglandin in spontaneous onset of labour. PGI2 is a
vasodilator and seems to protect the vascular endothelium from
damage during the powerful uterine contractions during labour. This
may be important to ensure blood flow during labour. However,
whether the rise of prostaglandins precedes the onset of labour or is
51

a result of uterine contractions far from clear. The result of uterine

contractions if far from clear. The prostaglandins are easily
metabolized and levels cannot be accurately measured in blood.
Though uterine prostaglandins may participate in labour, there is no
proof that they trigger the onset of labour.
Role of foetus: There are many reports to show that foetal adrenals
may be responsible for triggering the onset of labour. In anecephaly
where the adrenals are very small and in congenital adrenal
hypplasia there is prolonged gestation. In sheep, prolonged
pregnancy results from foetal hypophysectomy. Also, administration
of corticotrophin or corticosterioids stimulated premature delivery.
Cortisol levels in both foetal and maternal blood is higher in
spontaneous labour than induced labour or caesarean section.
However, in humans, whether the rise of corticosterioids is the rigger
to onset of labour or the rise is as a result of stress, is not clear. The
role of corticosteroids as the protective mechanism for maturation of
foetal lung is not clear.
It may be said that all the theories enumerated above may
collectively bring about the onset of labour. Change in the steroid
hormones levels oestrogen and progesterone at the cellular level,
removal of the progesterone block, building of oxytocin receptors in
myometrium of uterus, synthesis of prostalglandins due to instability
of lysosomal membranes, production of corticosteroids and oxytocin
by the foetus, all these sensitise the myometrium to maternal
oxytocin and lead to myometrial contractions causing effacement and
dilatation of cervix. Also, the increase in myometrial activity is
synchronized by synergistic action of oxytocin and prostaglandins
and increased intrauterine pressure results in rupture of bag of
waters and in the final expulsion of foetus through the effaced and
dilated cervix. The release of oxytocin and prostalglandins continues
after deliver and helps to prevent and control any post-partum
bleeding. Thus oxytocin is more important for the initial phase of
labour and increased synthesis of prostalglandins for the progression
of labour. But in the present state of our knowledge, what triggers the
release of oxytocin is not known (Post graduate Obstetrics and
Gynaecology, 4th Edition).

52

We are still in the dark as to why, in each case, labour and

delivery occur at a particular time on a particular day. When not
expected, suddenly a patient gets admitted in premature labour and
when everything points out that labour is imminent, the pregnancy
gets postponed and becomes postmature. Both premaurity and postmaturity can cause problems for the mother and the baby. Even in
those who advocate delivery by appointment so called day time
delivery, onset of labour can elude them. The question is often asked
as to whether it is ethical to induce labour for the convenience of the
doctor or the patient, even when everything points out for successful
induction. There is no evidence that inducing labour in such cases
improves the outcome for mother and baby. Moreover, in some
cases it was observed that the induction may lead to `induction for
caesarean section and unnecessary operative delivery. Hence the
conscientious opinion is that such induction should not be done. In
cases which require genuine induction of labour for any maternal or
foetal condition, labour may fail to occur in spite of oxytocin drip or
even prostaglandins. Even in a seemingly normal labour when
expected to deliver early, the labour may be prolonged and end in
operative delivery; while in some others, the labour may end
surprisingly in a very short time.
All these prove t say that we have no control over onset of
labour and the time of delivery. As described above, still one does
not know what triggers the release of oxytocin for initiation of labour.
These only confirm that conception, onset of labour and time of
delivery are pre-determined and controlled by the Lord Almighty.
I am reminded in this respect of what Late Swami
Chinmayananda exhorted when giving a discourse on chapter 15 of
Bhagawad Geeta; i.e. Purushothama Yogam. While explaining the
significance of the sentence Karmanu Bhandhini Manushya Loke
meaning thereby that our past karmas in the previous birth bind the
person for birth on this earth, he said human beings have no control
over anything in life. We have no control where we shall be born
we have no control over our future parents let alone the date time
and place of delivery. Similarly we have no control over the time and
the date of death and the manner and the mode of death. Anything
else in life we can cancel or postpone but not death. No one can
come to our rescue and no recommendations work here. As we
53

come so shall we go. Bhagwan Shri Satya Sai Baba. In that

context Bhagwan exhorts every person that they alone can get
evolved by prayer, puja, namasmarana, good deeds and finally,
meditation. As Bhagwan puts it Doctors speak of vitamin deficiency.
I will call it the deficiency of vitamin `G and recommend the repetition
of the name of God with accompanying contemplation of the glory
and grace of God. That is vitamin `G this is he most important
medicine.
Relevance in day to day life : In any hierarchy, be it Government or
any other Institution, if the goods have to be delivered either for future
development and for the welfare of people or for the progress of the
nation, a coordinated effort by everyone is essential. For this to occur
all blocks have to be removed that come in the way. Progesterone
is good and essential for continuation of pregnancy and yet unless
progesterone block is removed, normal labour cannot occur. In the
same way there are many a block in day to day administration. To
put it in simple words it is red-tape that comes in the way of good
functioning. Some projects are shelved; some work as a block
and do not clear the projects; others do not take any decision let
alone clearing them. Swami Vivekananda exhorted that hard work,
character, conduct, dedication and sacrifice are essential for the
building of a strong independent India. Initiation of labour pains
and the successful completion of labour set an example of how
coordinated effort of many factors are involved. It is the hard work on
the part of the mother and the character of the uterine contractions
that are dedicated for the purpose of normal labour coupled with
the sacrifice on the part of he passages especially the cervix to give
up its ego and undergo effacement and dialatation and the right
conduct of the baby throughout and the judicious management of
the obstetrician that culminate in safe confinement. So should be the
level of coordination in the several wings of an organisation for the
completion of any project be the organisation Government, private,
or even personal.

54

LABOUR
HARD WORK ON PART OF THE MOTHER
If I put one flower at the feet of Goddess I shall put two flowers
at the feet of mother in labour. These were the remarks of Dr Sudhir
Kumar when as a resident (in my unit), was posted in the labour ward.
Labour is the process by which the products of conception
foetus, placenta, membranes and liquor are all expelled entire from
the uterine cavity at term. There are three factors involved in the
physiology of labour:
1.
2.
3.

Forces of uterine contractions

Passages the uterus and pelvic passages
Passenger or the foetus.

During labour because of forces of contractions the uterus

divides itself into two segments upper and lower segments and the
cervix of the uterus opens up and dilates and the passenger or foetus
descends from the upper segment to the lower part of the uterus and
then traverses through the pelvic cavity and it ultimately delivered.
True labour is usually heralded by the contractions of the
uterus. These contractions during pregnancy are painless and they
become painful and hence called labour pains. They start from the
back and come to the front of the abdomen and go downwards. In
the beginning hey occur after long intervals and last for rew seconds.
They gradually increase in frequency and duration. In an established
labour 2 to 3 contractions occur every 10 minutes. Labour is also
heralded by the presence of show blood stained mucoid discharge
due to cervix (mouth of the womb) opening up and the membranes
covering the uterine cavity getting separated from the cervix.
Traditionally labour is divided into three stages:
First stage is devoted to opening up of the mouth of the womb
called cervical effacement and dilatation of cervix. The upper part of
the cervix called internal os, gets obliterated and drawn up into the
lower part of the body of uterus and lower part of the cervix start
dilating. At the end of first stage there is no cervical rim and cervix is
55

one with the body of the uterus above and the vagina below
forming a parturient canal so that the foetus can descend very easily.
All these changes are brought about by the strong uterine
contractions. The end of first stage more often than not coincides
with the rupture of bag of membranes.
In the early part of this stage the pain is less the patient walks
about. She may complain of backache and leg pain. After sometimes
the patient prefers to lie down. As the labour pains become more
frequent and severe the patient in most cases begins to cry during
the pains seeks relief by sitting or bend forwards or leaning against
some piece of furniture. Pressure on sacrum gives her slight ease.

Second stage is the stage of expulsion of the foetus. Not only

the uterine contractions become more strong and sustained, the
abdominal and thoracic musculature are brought into play and the
character of the pains change they become bearing down pains or
expulsive pains.
The patient utters of peculiar cry she feels that there is a
body in the pelvis which she must force out. She closes her glottis
having fixed the chest in inspiration, braces her feet against the bed
and by powerful action of abdominal muscles drives the foetal head
against the perineum. During contraction the uterus becomes boardlike in consistency. The parturient is working hard and indeed the
process is rightly called labour. Her pulse is rapid, veins of the neck
stand out, the face is furgid and the body may be bathed in seat. As
the pain passes off, she relaxes the spasm of the glottis and
diaphragm and takes several deep breaths. She will request for
relief; holds the doctor or the attendants had tightly begs the doctor
to deliver her immediately even if it means operative delivery.
Excruciating pain occurs with the actual delivery of the foetal head as
the vulva and introitus dilate to such an extent the perineum
stretches up and becomes thin and nerve endings markedly
compressed.
Third stage is also known as the placental stage wherein the pain
continues, though not in the same intensity. After the birth of the
placenta the uterus contracts and retracts so that there is no post
56

partum haemorrhage.
Labour is work and work mechanically is the generation of
motion against resistance. The forces involved in labour are those of
the uterus and abdomen which act to expel the foetus and these
must overcome the resistance offered by the cervix to dilation and
the friction created by the tissues of birth canal during the passage of
the presenting part. In addition the forces of resistance may be
exerted by the muscles of pelvic floor and perineum.
It is this hard work coupled with the pains of the childbirth
(which have been the stock and store of intimate conversation
amongst women since time immemorial) that many young women
approach childbirth in the dread of the ordeal. It is this fear that leads
to tension and tension in turn causes pain. These mind and tense
cervix go together. It is this Fear Tension Pain (so called F T P
syndrome) that makes the cervix more resistant to dilatation which
in turn makes the uterine contractions stronger and cause more pain.
Thus Fear is in some way the chief pain producing agent in an
otherwise normal labour. It is no easy task to dispel this age-old fear
of pain during labour and delivery. While it is true that the attitude of
the woman towards delivery has a major influence on the ease of
labour yet during pregnancy right from the first parental visit it is he
moral duty of the obstetrician and all persons involved, to explain and
emphasize that labour and delivery are physiological processes. It
must be explained to her what exactly happens during the labour.
The obstetrician must instil in her not only confidence but also the
feeling that he is her medically wise friend, seriously desirous of
sparing her all possible pain within the limits of safety for herself and
her child. The very presence of such a doctor itself is a potent
analgesic. These qualities result only from the experience of long
nights in the labour room coupled with understanding and sympathy.
They are at once the essentials of good clinical medicine and the
safest and the most welcome obstetric anodynes. Years before
Oliver Wendol Holmes wrote The woman about to become a mother
or with her new born infant upon her bosom should be the subject of
trembling ease and sympathy whenever she bears her tender burden
or stretched her aching limbs. God forbid that any member of the
profession to which she trusts her life, doubly precious at that
eventful period, should hazard it negligently, unadvisedly or selfishly.
57

The woman in labour is sensitive to every work spoken in the labour

room and any casual remark may cause worry in her regarding the
safety of her child (Williams Obstetrics-Eastman).
From a philosophical point of view one often wonders why
mother nature had made the process of childbirth painful and hard
work on the part of the mother. Is it to prove and substantiate the
dictum in Sanskrit Kashtay Phalay (Kashta Hard work, Phalam
Fruit). Unless one works very hard the fruit of it cannot be obtained or
enjoyed. It is pleasant to see the happiness and the smile on the face
of the mother after hearing the cry of the baby; the affection she
shows when the baby is shown to her or kept on her abdomen and
the tender way she touches the baby which gives her the supreme
satisfaction of contributed to the progency in the family.
Tulsidas in his Ramayana wrote that the suffering and pain
during childbirth cannot be appreciated by anyone else including an
infertile lady. In Yaksha Prashna of the Mahabharata
Yamadharmaraja, the Lord of Death asked Dharmaputra, the eldest
of the Pandavas What is happiness? The reply was Happiness is
the result of duties discharged and it should be soul satisfying. The
woman forgets all she has suffered during the course of labour. She
only concentrates on the well-being of the baby copes with
sleepless nights that follow after the delivery as most of the babies
are awake at night.
If asked how she went through the whole process she says that
she would not like to go through it again. This is called Prasuti
Vairagya.
One only has to see and observe how proudly the young
mother walks holding her child in any marriage or party with a pride
that she has achieved and brought into this world a live healthy child.
Her esteem in the family increases and the love and affection and the
understanding between her and her husband increases as the child
is the cementing force.

58

THE SHORTEST & MOST ARDUOUS JOURNEY IN LIFE

During the process of labour the foetus has to pass through the
birth canal the pelvis a distance of 10 to 12 cms for it to come
from inside the uterine cavity to the outside world. In the first
pregnancy the babys head in most cases is already in the pelvic
cavity and he baby has to travel only 6 Cms probably the shortest
distance a human being has to travel in life.
Mother nature has taken care to see that no damage occurs to
the baby during this process. The foetal head is designed in such a
way that it consists of two parts. The base of the skull with strong
bones, in which no changes occur during labour, contains the brain
stem and the floor of the fourth ventricle in which are the vital centres
including respiratory centre and these are protected. The vault of the
skull in which the cortex of the brain is contained the bones are laid
in membrane, they are not united suture lines rare present between
the bones and where three or more meet there are fontanelle; the
most important of which is bregma (called anterior fontanelle).
Certain amount of compression of the foetal head occurs during
labour and because f the pliability of the bones of the vault, no
damage occurs to the brain in a physiological normal labour. In 96%
of deliveries the babys head is low down in he uterine cavity so that
the lower part of the head; i.e. vertex leads in the journey through the
pelvic passage. Mother nature has also seen that in majority of
women the pelvis the size and the shape is ideal for childbirth.
Pelvis the size and the shape is ideal for childbirth. Pelvis is broad
and shallow diameters wide enough for the baby to pass through.
At the inlet of the pelvis the transverse and the oblique diameters are
loner and they allow the head of the baby to get engaged while the
antero-posterior diameter is longer at the outlet of the pelvis for easy
delivery of the foetal head.
As is well known, no two pelves are he same as also no two
foetal heads. In the same person the pelvis being the same the
size and the shape of the foetal head vary in each pregnancy and
delivery. Pelvis has its own configuration and angulations as also
the foetal head. It is amazing how the foetal head adjusts to the
pelvis. Firstly, the head which is already in a flexed attitude becomes
more flexed to allow the small diameter of the head to pass through
59

the inlet of the pelvis making the occiput lead during labour. The
head also gets moulded by compression of its diameters for easy
passage. During the descent in the cavity of the pelvis, the head of
the baby takes a rotation by twisting of the next (without damage) so
that the occiput and the vertex of the head can pass through easily in
the anetro posterior diameter of the outlet of pelvis which is longer.
In the process of delivery the diameters of the head emerge in such a
way that no damage occurs either to the head or to the maternal
passage. It is this adaptation of the foetal head to the maternal pelvis
ad the various movements the head takes during the process of
delivery which is called mechanism of labour.
On the part of the pelvis, as the baby is coming down through
the birth canal, the bones and the joints of the pelvis widen to
become more mobile so that there is less resistance for the foetus
and this is called Give of the pelvis.
In the whole process of labour it is the journey of 6 cms (from
the ischial spines to the perineum) in the second stage which is the
shortest but most dramatic and full of events with two main hazards
for the bay i.e. hypoxia and trauma. It is also the time of greatest
physical strain for the mother and the baby and is aptly called worst
journey in the world. (Apsley Cherry Garrard 1922). But it is also
the grand finale of a process started with fertilization. Immunologists
describe implantation of the fertilized ovum into endometrium as
Immunological grandioseness. But that we cannot see. Certainly
one cannot but admire (sometimes with awe and anxiety but many
times with pleasure), what a wonderful phenomenon each child birth
is.
It is also a stage that requires a mature judgement and insight
on the part of the obstetrician. In his anxiety trying to achieve the
goal of delivery over hasty intervention may lead to instrumental
delivery which may be either unnecessary or more difficult that that
what was expected. Extreme delay may also carry dangers. The
object is to strike balance between expectancy and intervention
keeping in mind that the final delivery method should be easy and
non-traumatic, more so in the presence of hypoxia and signs of foetal
distress.
60

Fortunately in 90% of all deliveries the labour is normal

culminating in a healthy mother and child. In 10% of cases
abnormalities can occur like non descent of head, non-rotation f the
head causing arrest of head; occasionally the uterine contractions
are no strong enough to push the baby down through the pelvic
cavity or the contractions are abnormal and strong, causing severe
moulding and compression of the foetal head producing a caput
(bump on the head) making this shortest journey ardouous and
difficult resulting in operative delivery.
It should be understood that he foetal head sustains a pressure
compression of 16 lbs in the first stage and 32 lbs in the second
stage of labour (Munro Kerr & Moir) by the uterine contractions and
also withstands hpoxia which always occurs during the acme or
height of uterine contraction in the second stage of labour. From a
philosophical point of view Bhagwan has already put the child to test
and certified that the child could stand stress and strain even
through the later stages of life. Bhagwan knows that life is not a bed
of roses. Even if it were so that rose has thorns. Vicicitudes of life are
such that trauma (need not be physical and can be mental) and
hypoxia (deprivation of anything that is most essential) can occur any
time in life and one should always be prepared for them. Just like the
baby which could stand the arduous journey, everyone in life should
be geared up for the same with supreme faith in ones own inherent
strength and the blessings of the Lord Almighty.
Even so it is a common observation that the female babies
stand the strain of this arduous journey better than the male babies
even in difficult deliveries. This is because they have 44 + 2X
chromosomes which gives them the strength to sustain the stress.
Is it a prelude that women in life have to undergo many more
hardships than men and that mother nature has endowed them with
this inherent strength or Shakti and the will-power to face any
eventuality!

61

VAGARIES OF UTERINE CONTACTIONS DURING LABOUR

Uterine contractions are synonymous with labour pains. They

are called uterine forces and help in complete opening up and
dilatation of the wombs mouth or cervix in he early or first stage and
later for the descent and delivery of the baby and also for the
expulsion of the afterbirth or placenta and for control of bleeding.
The contractile function of the uterus is largely due to humoral
and myogenic factors. Contractions spread from cell to cell through a
syncytium. Gap junction formation between the cells appears to be a
key to synchronization of uterine contractions. This is oestrogen
dependent and these junctions provide low resistance pathways for
conduction of electrical activity from cell to cell. Electromyographic
recordings made in women indicate increasing synchronization with
advancing labour.
Study of uterine contractions showed a physiological
coordinated pattern essential for safe and normal delivery and the
features include:1.

Triple Descending Gradiant

a.
All contractions start from the corneal portion of the
uterus on both sides involving the fundus or upper part of
the uterus and travel to the middle and lower part of the
uterus in 20 seconds.
a.

They are strong and intensity is more in the fundus.

b.

Contractions are more sustained at the upper part

of the uterus and the fundus.

The above three features called Triple descending gradient

show a fundal domination during labour.
2.
There is polarity i.e. reciprocity between the uterus and cervix.
During the whole course of pregnancy uterus is relaxed and could
expand to full term and cervix is closed. (If the cervix is to closed or
62

tight called incompetent cervix, premature termination or abortion

occurs during mid-pregnancy period). During labour uterus contracts
and cervix dilates.
3.
The contractions are peristaltic in nature i.e. there is relaxation
between them. This is essential as relaxation gives rest to the
mother, restores oxygenation to the foetus and relieves the
compression on the foetal head.
4.
As labour progresses the contractions become more frequent
and the duration and intensity increases.
5.
The uterus forms two segments during labour. The upper
segment and the lower uterine segment.
6.
The upper segment contracts and also retracts becomes
thicker pushes the baby into the lower segment which expands and
the mouth of the womb cervix opens up and dilates fully so that the
baby can pass easily through the birth canal.
7.
The pain during labour is due to compression of nerve endings
and also due to resistance of the cervix to open up and dilate fully.
Spontaneous uterine activity during labour exerts a pressure of up to
60 mm or even more of mercury.
8.
After full dilatation of cervix- the contractions become more
strong and sustained and help in the delivery of the baby.

ANOMALIES OF UTERINE ACTION

1.

PRECIPITATE LABOUR

In rare cases, the uterus becomes over active culminating in

the whole labour ending in 2 3 hours (normal duration 18 20 24
hours). Such contractions are no good either for mother or baby.
Trauma to mother and baby and also severe bleeding from the
uterus after delivery occurs as the uterus loses its power of retraction
so essential for control of bleeding after the delivery of the foetus.
63

2.

INEFFICIENT UTERINE ACTION

Two types of inefficiency of uterine action are observed:
a.
b.

Hypotonic inertia
Incordinate uterine action (dysfunctional labour)

In recent terminology based on partograms the above two

types from a clinical angle have been designated:1.
2.
3.

Prolonged latent phase

Primary dysfunctional labour
Secondary arrest.

In the Hypotonic Interia the contractions of the uterus are not

strong they occur after long intervals. They are not helpful in the
opening up and dilatation of cervix thus leading to prolongation of
labour.
In cases of Incoordinate Uterine Action there is no
coordination between one part of the uterus to the other as in
physiological labour. Even though the upper part of the uterus; i.e.
upper segment is contracting well the lower part of the uterus i.e.
lower segment is hypertonic tense and does not expand. In other
cases though the two segments are contracting well, there is spasm
of the cervix and it does not open up or dilate a condition called
cervical dystocia. Very rarely contractions occur in different parts of
the uterus they are colicky in different parts of the uterus they are
colicky in nature and the mother is distressed with severe pain. All
these again cause prolongation of labour.
One of my teachers used to compare these two types of
inefficient uterine action to two types of students (Medical or
otherwise). In the hypotonic type the uterus is sluggish takes it own
time to get back to normal activity. It is like a student who does not
attend the classes does not read spends his parents money and
whiles away his time and takes a long time to complete his medical
or any other course. Instead of 4 years I may take as long as a 6 to
7 or even more years for a student to complete the medical course.
Some of the students occasionally grace the lecture class only to see
64

and certify whether the teacher is properly doing his job or not.
The hypertonic type is compared to the second type of student.
Hese students are always regular attend all classes study in the
library for a late period at night. In their anxiety to score well and get
good rank or high percentage of marks (as unfortunately this is the
criteria for getting admission o the desired course or subject for postgraduation). These students are always under tension and worry
and they cannot concentrate. Even though they know he subject, yet
their performance in the examination is poor and some may even fail
in the examination thus taking a prolonged time in completing the
course. It is this type of students who often resort to drugs etc., and/
or commit suicide due to frustration.
The treatment for both these types of students is the same as
in the two types of uterine action. The hypotonic uterus requires a
whip or stimulation for good performance. While in cases of
incoordinate uterine action or dysfunctional labour sedation to relieve
the tension is given first, along with advice and encouragement for
study.
The normal and abnormal uterine action point out to another
important observation in todays working of persons. Either in
Government or in any concern, for efficient running or working the
coordination of the entire staff is essential. In physiological normal
labour, the fundus of the uterus is dominant while the lower segment
and cervix cooperate with it. In the same way there should be one
head to control and coordinate all the activities of a department or an
Institution. I the hypertonic lower segment or cervical dystocia, the
fundus of the uterus in working normally but the lower segment and
cervix do not listen to it. They have developed tension in their heads
do not cooperate with the fundus behave in a different way leading
to prolonged labour requiring operative delivery at times. It is a
common observation in these days of deteriorating standards when
each institution or department have become Samsthans
(conglomerates) the staff in these departments come late to the
office, are either lazy and do not work as in cases of hypotonic
uterine interia. Others who become proud and arrogant do not
cooperate with the superiors and cause obstruction for proper
functioning. Both these two types of people if advised to correct their
65

behaviour accuse the authorities for harassing them.

I am reminded of how my Professor of Physiology classified his
assistants 1. Equine quick and sure, 2. Assinine slow and steady
and 3. Elephantine dull and non- co-operative.
It is in the primi gravid patient that anomalies of uterine actins
are more often observed. The primi gravida approaches labour with
apprehension hearing the experiences of others like one who had
a prolonged labour, or still birth (baby died during course of labour)
and/or an operative delivery. All these tell upon her mind and cause
fear of the unknown. Fear in turn lead to tension in mind and tension
causes pain. A tense mind has always a tense cervix and/or lower
segment. Tense lower segment does not expand and tense cervix
does not dilate leading to cervical dystocia. Ultimately they end in
prolonged labour and operative delivery. Such labour is observed in
highly educated, nervous and high strung persons but not in rural
people and tribals. These people take pregnancy and childbirth as a
physiological process as in everything else in life. Faith and supreme
confidence that she will have a safe confinement in her Obstetricians
hands will go a long way in minimizing these types of anomalies of
uterine action.
At times one often wonders and becomes perplexed as to why
the pregnant uterus should behave in this way during labour. Where
one expects a prolonged labour, the labour is so smooth and easy. In
others when everything is normal, there are no contractions at all or
they are incoordinate or in the beginning of labour they are normal
and strong but half way through interia occurs and there is arrest of
labour.
A helpless obstetrician often feels like doing puja to the uterus
and request for strong contractions and the cervix to dilate a little
more so that the babys head can come down and delivers normally.
I often wished that if only I could recite an Ashtottara (108 names
recited in the praise of the Deity) of the Goddess uterus to help me
out of this impasse.
A common misconception is that women in general are
unpredictable in their behaviour. Do the vagaries of uterine action
66

reflect the nature of women? Observations however show that men

are even more unpredictable and unbelievable than women. In short,
the vagaries of uterine contractions points out the nature of the
human behaviour observed in day-to-day life. My Professor Late Dr
Thampan used to compare the uterine contraction as the most
unpredictable factor in labour. `Presentation, position and pelvis may
be normal, but pains may fail! He used to say, No one can predict
the minds of women or the luck or prosperity of men and finally, the
contractions of the uterus!.

67

BABY IN THE WOMB - MY GURU

In over 96% of pregnancies at the time of onset of labour

the babys head will be low down at the upper part of the birth
passage. Also the baby lies in a way that the back of baby is arched
and lies anteriorly and the head of the baby is flexed, so that the chin
is nearer to chest (sternum) all the parts of baby are close to one
another. This above is said in obstetric language Attitude of
Universal Flexion and the presentation of baby called Vertex
presentation. (Vertex is the area between the anterior fontanelle
(maadu in vernacular) to the occiput behind and on both sides the
parietal eminences). During the course of labour the head of the
baby still flexes so that he smallest diameter of babys head passes
through the pelvis, the occiput leads and by this normal delivery is
achieved.
In 10% these vertex presentations, the back of the baby is
posterior and the occiput lies near to the maternal vertebral column,
(called occipito posterior position). In this the back of baby will be
straight (not arched as in the above), and this attitude of the baby is
called Military Attitude. Consequently the head of the baby cannot be
completely flexed and slightly longer diameter of the head presents
at the birth canal at the onset of labour. In cases where the delivery
ends normally, the head of the baby gets flexed, small diameter
engages the birth canal, though the length of the labour will be
slightly prolonged. In some, the labour may become arrested and
end in operative delivery.
(a) Flexion Humility
(b) Partial Flexion Ego Military Attitude
(c) Partial Extension Indifferent Arrogance
(d) Extension Gazing Stars Arrogant

Rarely the head of the baby lies in a more deflexed attitude and
this presentation of the baby is called Brow (he forehead lies lower
most) and normal delivery is impossible in this and baby has to be
delivered by Caesarean section. When the head of the baby is
completely extended it results in Face presentation. Though
68

occasionally the delivery can be spontaneous yet many end up in

operative delivery.
All the above only shows that the baby in the uterus knows
what is good for it for safe delivery. By adopting the attitude of
flexion, labour ends safely in respect of both mother and itself.
Even in those cases where the buttocks of the baby delivery
first called Breech delivery the delivery is more smooth if the head
of the baby which is delivered last is in an attitude of flexion. If the
head is extended (not flexed) called Stargazing foetus labour will be
more complicated and hence requires Caesarean section.
Years ago, during my training period my teacher Late Professor
Dr. R.K.K. Thampan impressed upon us the importance of Attitude of
Flexion in ones daily life. He said that everyone should adopt this
attitude of flexion. He compared the medical students in their training
period to the baby in the uterus. The first MBBS 1 years to the
first trimester of pregnancy, second trimester the next 1 years and
the third trimester to the last 1 years. Students with the flexion
attitude have smooth course throughout and at the final examination
have a safe delivery. In those who do not observe this, the students
will have to pass through a prolonged course failing in he
examinations. Of course, some of students are being salvaged by the
examiners by application of forceps.
What has been said regarding the medical students applies to
all of us. While walking, if the head is not flexed one may miss to see
something below may slip on a banana peel, or fail in a it; all these
happen definitely in those who adopt a military attitude as in occipito
posterior and one can imagine what will happen to those who walk
with a head looking high up stargazing.
If one views the above philosophically, with a Vedantic aspect, when one thinks of flexion attitude it is not only related to the body
but also related to the attitude of mind. Flexion attitude refers to
vinayam (bent of mind with humility) God fearing and respect to
elders. Unfortunately one does not observe this attitude in people
now a days. It is all the more sad that some students after
graduation, or more so after post graduation, change their attitude
69

towards their own teachers. In life, many who come up and reach a
top position become head strong and think no end of themselves.
I had been conditioned to observe this attitude of flexion every
since the early part of my training in obstetrics. I was applying
forceps to deliver a baby whose mother was having eclamptic
convulsions. I could not apply the blades when the senior sister of
the labour ward pointed out that the presentation was Brow. I could
not make that out. The difference between vertex and Brow is such
as pointed above one of slight deflexion of the head. In vertex vaginal
delivery can be accomplished and for the brow Caesarean Section
had to be done. (Of course, the baby was delivered by the procedure
of turning the baby called internal podalic version as it was in vogue
at that time). From that time, all these years I have learnt many good
things from every one right from the aaya, assistants and nursing
staff in the labour ward and the operation theatre, students, post
graduates, colleagues and from seniors. Good things can be learnt
from any one in life if one looks for them.
I always felt that the post graduate training should be like that
of discourse between the teacher and the taught, like Krishna-Arjun
Samvaada (discourse) as in Bhagwad Geeta. The teacher should
not get upset when he findings of the post graduate become correct
on the operation table. Some of the pos graduates may later
specialise in a particular field and the teacher should not feel below
dignity to learn a new procedure from his own student. Nor the
student should feel proud and assume a military attitude. After all,
learning is a continuous process and there is no age bar for it. I am
always reminded what Late Dr S Radhakrishnan, one of the greatest
philosopher cum statesman our country ever produced said A good
teacher is always a good student and if he ceases to be a student, he
ceases to be a teacher.
This throughout my professional experience till today the
Foetus has been my Guru. Bhagwan has taught me to follow the
baby in the uterus. Whenever I changed this attitude due to
ignorance or pride or ahamkara I used to get a hit on my head
telling me to keep my head as well as my attitude flexed.

70

Bhagwan Rama Maharashi said that if one has to evolve and

achieve moksha one must Erase the Ego or Ahamkara and an
attitude of flexion is very essential for this. It is said that the
Ahamkara or Ego for any human being is in their hair. People in the
south offer their hair (by getting the head completely shaved) to the
feet of Lord Ventateswara. In so doing they are offering or submitting
their ego.
Whenever one pays his/her respect to elders it is always with
head in full flexion, the brow touching the forehead on all devout
muslims who regularly perform Namaz is the best example of this act
of obeisance.
Regarding he importance of the attitude of flexion the great
Obstetrician Ian Donald wrote For a successful delivery an attitude
of good flexion on the part of foetus is essential. Flexion is the
essence of normal labour (nay essence of life). In flexion after all, we
come into this world and bent up in old age, we go in flexion to our
graves. Flexion is the alpha and omega of life it is the beginning
and the end.

71

WHAT DO THE FIRST BREATH AND CRY OF BABY INDICATE

Normally as soon as baby is born it starts to breath and more often
than not, to cry. By ultrasound studies, it is observed that foetal
breathing movements do occur even during pregnancy and it has
been suggested that these may be associated with lung maturity. All
factors involved in the first breath of the baby have been difficult to
elucidate. Undoubtedly subtle stimuli contribute simultaneously for
the same.
(a) Physical stimulation such as handling the infant during
delivery and contact with relatively rough surfaces provoke
respiration through stimuli reaching the respiratory centre.
(b) Compression of the thorax during second stage of labour
forcing some fluid from the respiratory tract and the expansion
that follows delivery may be an auxiliary factor in initiation of
respiration.
3.
However it is the deprivation of oxygen and accumulation of
carbon-dioxide that may stimulate respiration. Experiments have
shown that intrauterine decrease of pO2 diminishes or abolishes
respiratory movements, whereas elevation of pCO2 increases the
frequency and magnitude of foetal breathing movements. For the
foregoing reasons the foetus-infant in fact most likely responds to
hypoxia and hypercapnia (which occur during second stage of labour)
the same way in utero and after birth. (Williams Obstetrics 1993).
Thus, a babys first breath is a remarkable phenomenon and it
clearly calls for a very great and intensively concentrated effort. If this
does not occur, the baby develops the condition of asphyxia which
may cause is death. Even if the baby survives, it may be left with a
legacy of disorders. There may be only delay in the normal
milestones regarding growth and behaviour of some infants. Others
manifest convulsive states, mental deficiency, spastic paralysis,
ataxia and disorders of speech etc. In the intellectual field all
gradations from mental backwardness to personality disorders and
epilepsy may originate from lifes first critical quarter of an hour and
the obstetrician resuscitating the new born is fighting not only for the
childs survival but for its very wits (Ian Donald).
72

While the onset of first breath is explained as above, no proper

explanation is given for the babys first cry. Why should it cry t all
even as every one is happen at this event of hearing the first cry?
One cannot forget what Shakespeare in King Lear says When we
are born we cry that we have come to this great stage of `Fools but
he is nearer the physiological explanation when he adds that the first
time when we smell the air, we wail and cry. Poet John Keats
in Ode to a Nightingale wrote that the child cries as it gets aware of
the sory state of the world in which it is emerging a world
Where men sit and hear each other groan
Where but to think is to be full of sorrow.
There is a famous saying in Urdu which runs When I came into
this world, I cried and others laughed. Now when I leave this world I
must laugh and others must cry
It is written in the Bhagwatam that while in the garbhashaya
(womb), that the jeeva (foetus) sees the Brahman (Lord and prays to
the Lord to grant him His darshan after birth. Unfortunately after birth,
he cant see the Lord and so he cries kahan kahan (Where is He?
Where is He?). If one closely observes the cry of the new born and
that of a child, there is a difference in the type of cry. The cry of the
new born is more like Kau Kau instead of Bau Bau of the child.
Bhagwan Sri Satya Sai Baba in his divine message says that in the
babys first cry the baby is saying Ko-ham meaning Ko = who; Ham
= I am that is who am I? and Bhagwan adds that lifes
purushartham (purpose) is to realise So ham; i.e SO = That HAM =
I am; i,e, - That I Am. In short, ones life objective is to realise That
Thou Art!
On this first cry of the bay, Bhagwan Gautam Buddha preached:

Ask of the Sick The Mourners Ask of Him

Who Totereth on HIS Staff Lone and Forlom
Liketh They Life; They Say
The Baby is Wise Weepeth Being Born
73

..Light of Asia
These preachings were given years ago. They are more valid
today than even before. The child at birth knows what is in store for it
in this world a world full of deceit, corruption where sincerity and
hard work have no place; where muscle power and money power are
the pillars of strength and can achieve anything in life. The baby is
also aware that there is no escape and ones own birth is due to
ones own past karmas as said by the Lord in the Bhagwad Geeta
(Chapter 15):
Karmanubhandhini Manushya Loke.
It may be that keeping these in mind Bhagwan Adi
Shankaracharya in Bhajagovindam requests the Lord to save
mankind from the samsara of births and deaths.
Punarapi Jananam Punarapi Maranam
Punarapi Janani Jathare Shayanam
Iha Sansare Bahu Dukkhare
Kripaya Pare pahi Murare
Birth again, death again
Again laying in the womb of the mother
In this world full of misery
Kindly protect me by Your bliss
O Lord! I am under your shelter.

74

STILL BIRTHS & NEONATAL DEATHS:

DUTY OF THE OBSTETRICIAN

`Published studies on still births and neo-natal deaths indicate that

many women who had peri-natal deaths wished that they would
have liked to have been told of their babys death when it occurred.
They also expressed that it would have helped them to bear the
loss if the doctor had explained why their babies had died. Many felt
dismayed when the junior doctors in the hospital intimated the same
instead of the senior doctor, Grief reactions in these patients showed
emptiness, restlessness, numbness, sadness, fatigue, shock and
disbelief; loss of self esteem, and self blame for disappointing their
husbands and everyone in the family and doubted whether they will
ever be able to have a baby. In some cases, being under anaesthesia
or heavy sedation at delivery, mothers had not seen or touched the
baby in cases of still birth.
In most cases there may not be any warning during pregnancy
that he baby might die. Because of societys abhorrence of a still
birth she may feel being avoided by the doctor, husband and the
in-laws and friends and a feeling of isolation occurs. In cases of neonatal deaths mothers never forget sequence of all the events from
the birth of the baby to its death and this includes the role of the
doctors, nurses, attendants and everyones behaviour and attitude.
Perinatal deaths may even affect the surviving children at home.
When the parents are depressed, preoccupied and irritable, the
children feel abandoned and unloved. They conceal their emotions
when told that the baby was Taken by the God or asleep to account
for the babys absence.
Women who have lost their babies in the perinatal period need
help. Telling the parents about their childs death should not be
postponed. Ethically and morally it should be done by the obstetrician
himself or otherwise they will lose their faith in him. Simple
explanation of why the baby died may help to relive guilt and may
allay fears about the future. In cases of unexplained intrauterine
deaths one may not be able to find out the cause. However all
questions should be answered patiently and they should be assured
that nothing he/she did (or failed to do) was the cause of the death.
75

Sympathy and an understanding attitude, may help the bereaved

couple to tide over the mourning period. After some period,
meanwhile allowing the mother to readjust from the thinking of
herself being incomplete and deprived of fulfilment, the couple should
be suggested to have another pregnancy; i.e. So called `replacement
child syndrome (Poznaski 1972).
It again shows that in spite of all the care taken by the
obstetrician mishaps do occur even in the best of hands as there is
one Super Power beyond our conception which guides the destiny of
all of us. Thus he obstetrician will also have to face not just moments
of pleasure all the time but also of pain as well, as pleasure and pain
(sukha and dhukhkha) go together. Such cases are a test for him
only to make him more mature and understand the need for
meticulous attention required in every case right from the beginning
of pregnancy till safe delivery. It also calls for a great control, restraint
and understanding on the fellow obstetricians and they should try to
place themselves in a similar situation before pronouncing their
opinion. (This applies equally in cases of maternal deaths).
After all the care the obstetrician bestows, it is He that
ultimately decides. As they saying goes, `We treat - He cures.

76

EACH PREGNANCY & CHILDBIRTH IS

A REBIRTH FOR THE MOTHER
(The inherent Risks of Pregnancy to the Mother
are not well appreciated)
Years ago, the daughter of a famous obstetrician died of acute
rupture of ectopic pregnancy (pregnancy in the fallopian tubes) even
in the first pregnancy. A colleagues daughter whose pregnancy was
apparently though to be normal, developed convulsions (eclampsia)
due to sudden rise of blood pressure. In clinical practice it is to
uncommon to observe prolonged labour or obstructed labour
ending in operative delivery some times resulting in the death of
the bay (still-birth) or even death of the mother.
Such cases are seen today in patients who had no ante natal
care and admitted to the hospital as emergency cases (unbooked
cases) especially in semi-urban and rural areas.
The delivery can be obstructed because of the malposition and
presentation of the baby and the uterus can rupture due to a large
sized baby or cephalopelvic disproportion even of a mild variety.
After a very easy vaginal delivery the uterus may become atonic
(there is no contraction or retraction of uterus essential for control of
bleeding at this stage). The patient can die of severe post partum
haemorrhage. In a matter of few minutes so much blood can be lost
leading to shock and collapse of the mother. The often quoted
example is that of Empress Mumtaz, wife of Emperor Shah Jahan
who died of severe post partum bleeding at her fourteenth
confinement. This is indeed the unforgiving stage of labour and
there lurks more unheralded treachery than I both the other two
stages combined. The normal can within a minute become abnormal
and a successful delivery can turn swiftly into disaster.(Ian Donald).
Very rarely sudden death can occur due to amniotic fluid embolism.
Deaths due to puerperal infection were very common before the
advent of the antiseptics and antibiotics.
However the above risks usually occurred in women who had a
parity eight or more and these women were designated Grand
Multiparae or Dangerous Multiparae. Unfortunately these dramatic
77

complications are all the more dangerous because they occur

unsuspected.
With the adoption of family planning one may not see such
Grand Multiparae as before. Even so in rural areas or taluka places
still women with parity 4 or 5 are encountered and in them the above
mentioned complications are observed. Munro Kerr and Moir wrote
`Robustness of body and mind, however is no insurance against the
disturbances and complications of pregnancy and child birth. And
that parity beyond four is associated with ever increasing dangers.
When the first pregnancy and delivery were normal people
and patients think that everything will go on well in the second and
subsequent pregnancies. As the number of pregnancies increase the
incidence of anaemia is more than double, hypertensive disorders
increase, haemorrhages of all varieties e.g. abortion, ectopic
gestation, vesicular mole in early weeks, placenta praevia and
abruption placenta in later weeks are more commonly encountered.
In short any complication can occur at any time unexpectedly. The
obstetrician should be on the watch for any eventuality from the time
a woman misses the period till she delivers safely. The course of
pregnancy and delivery each time may be entirely different from the
previous one. As our elders have aptly described that safe pregnancy
and child birth gives the women `Punar-Janma or Rebirth and this
applies to each and every pregnancy. Also nothing is more apt than
what Solomon (1934) wrote 60 years ago that Practice makes a
person perfect does not apply to pregnancy and child birth.
Having done clinical trials personally regarding the usefulness
of Prostidin. (15-S 15 Methyl PGF2- ) in the prophylaysis and
treatment of post partum haemorrhage, I feel that it is the moral duty
of all obstetricians to keep not only the above drug but also other
essential drugs handy at all times in the labour room.
Increasing experience serves only to sharpen ones attitude
during this stage and there is no room for complacency in any case,
however normal, until the placenta has been delivered for at least
half and hour with the uterus well contracted and with minimal
bleeding (Ian Donald).
78

Then only can one aspire for and ensure Safe Motherhood.

79

PRE-PREGNANCY CARE : THE NEED OF THE DAY

No aspect of the subject of obstetrics and gynaecology will be

complete without a consideration regarding pre-pregnancy case. In
order to achieve the goal Health for All, actual care and preparation
of the parents for child bearing should start before conception i.e. preconceptional or pre-pregnancy care. The obstetrician will have a
clear idea of the couples biological and social background, race and
genetically inherited propensities. If the physical examination reveals
a medical condition, the couple and the doctor can discuss the likely
effects on the pregnancy when it occurs and also on the progress of
the disease process. It would help a lot better if proper advice is
given before pregnancy. Once pregnancy has started, there will be
only two options left for the couple either to let the pregnancy
continue or get it terminated. If the consultation could take place
before pregnancy started, the couple may elect to remain childless,
thus completely avoiding the risk. There are some couples who are
having a very happy married life and are content without having any
children. Their love and affection is such, childlessness will not affect
them. Many others may adopt a child to satisfy their maternal and
paternal love.
In some well developed countries pre-pregnancy care has
become apart of health education and is being advocated right from
the school-going period even before the girls get married. The care
also includes advice regarding diet, anaemia, heart disease
(haemotogical problems), alcohol and smoking in a few, or sex
education and contraception and the importance of pregnancy
spacing when they do have children. An equally important aspect of
the care pertains to the effect of infections like German measles,
toxoplasmosis etc. on pregnancy and also sinister effects of sexually
transmitted diseases like gonorrhoea, syphilis and even AIDS
(Acquired Immuno Deficiency Syndrome) on their health if they
become pregnant, and the effects on the offspring.
In married persons, advice pertains to recurrent foetal loss due
to congenital abnormalities or previous pregnancy ending in late
abortion or early pre-term labour and the chances of the baby getting
Downs Syndrome in a mother in late reproductive age. Such an
80

advice given or taken in this field produces rewards equal to (or even
more than) those resulting from ante-natal care.
In one report concerning cases of diabetes with pregnancy, prepregnancy care involving tight control of maternal blood glucose
concentration before and in early weeks of pregnancy, has given
good dividends in a highly significant reduction in the risk of serious
congenital abnormalities in the offspring.
As a logical sequence of this pre-pregnancy care, it is also
obligatory on the part of general practitioners, physicians (for that
matter every consultant in medical field) and obstetricians and
gynaecologists in particular, to tell the parents or even the to-bemarried girl or boy, if sufficiently mature and grown up, and advice
them against getting married when they are found suffering from
some incurable disease or defect or have severe medical or surgical
problems like heart disease etc, which may endanger their life. A
considered opinion of the specialist in different fields of medicine
should be taken before hand.
Unfortunately there is a tendency amongst parents to hide any
defect in their children before marriage and somehow get their
children married only to end in disastrous results, ruining the life of
the boy or the girl or both. Many marriages are broken in a short
time; still worse, many have become widowed at a very young age.
Sometimes in the case of the girl, they are either pregnant or have
just delivered. Indeed it is very sad to hear about such cases and one
just cannot imagine what the future of the girls would be. There is an
old saying One can tell one hundred lies if that is going to help in
getting someone married. Such a thing is immoral and unethical and
the present motto should be It is only right and correct that one
should tell the truth to the parties concerned and prevent (in fact he is
helping them) such a type of marriage. Thus pre-pregnancy care is
the first step in the right direction for safe motherhood.
Late Dr. D. Subbarao, Professor of Hygiene (Preventive and
Social Medicine) stressed the importance of pre-conceptional
conferences nearly fifty years ago when I was a student at the
Andhra Medical College Visakhapatnam.
81

BREAST FEEDING : BREAST MILK IS BABYS BIRTH RIGHT

A calf after its birth, even as the mother cow cleans it by its
tongue, though not able to stand properly, tries to get up and goes
straight to the udder and to drink milk. Who has taught it where the
udder is? certainly not by practice but by Sanskara (inherent
tendency); i.e., certain things one brings along with oneself with
birth. Breast feeding is a natural sanskara and breast milk is babys
birth right.
Apart from other things, three aspects of life have been
specially mentioned which bless both the one that gives and one that
takes. The first is Daan (parting with what one has without repayment)
especially vidyadaan (parting with ones knowledge): where the
teacher and the taught are both blessed and there is no reduction of
knowledge by it. The second is Mercy. As Shakespeare wrote in the
Merchant of Venice The quality of Mercy is not strained; it is twice
blessed; it bless him that gives and him that takes. The third is duty.
Conception and childbirth are part of duty, without expecting any
reward. But beast feeding is a duty where mother and child are not
only blessed but also benefited.
Immediately after birth, breasts secrete a yellowish thick fluid
called Colostrum. A new born does not need anything other than
colostrum. It is rich in vitamins A and K, and contains many
antibodies which give the baby its first Immunization to protect it
against most bacteria and viruses which may cause life threatening
infections. It also contains growth factors which stimulate a babys
immature intenstines to develop and to digest and absorb milk.
Colostrum is also a laxative and helps the baby to pass meconeum
(the first dark stool) which in turn helps to prevent jaundice.
Colostrum also protects the baby from getting allergic disorders like
asthma and eczema later in life.
Breast milk is the ideal and inimitable milk and is the sheet
anchor of nutrition. Throughout the first 4-6 months of life, breast milk
safely and adequately meets all nutritional needs of the infant. The
amazing part is that more suckling by an infant makes more
production of breast milk.
82

Apart from being hygienic and sterile breast feeding is

cheaper. It costs eight times more to feed a baby on a formula and
four times more to feed a baby on cows milk in comparision to breast
milk. Non breast fed infants are 11-16 times more likely to die from
diarrhoea, 3-6 times more likely to die from respiratory ailments and
2.5 times more from other infections, when compared to breast-fed
infants.
On the part of the mother, breast feeding helps with involution
of the uterus and helps the mother to regain her figure faster. Cancer
of the breast and ovary is less likely in mothers who breast feed
compared to those who do not. Breast feeding can delay the return of
ovulation and menstruration. Hence, it is an important way to delay a
new pregnancy. Lactational Amenorrhoea of family planning
(LAM). Years ago, when the concept of a small family was not in
vogue, breast feeding and lactational amenorrhoea helped many
women to space their families. I recall quite a few patients had
menstrurated only for a few times during their reproduction period as
lactational amenorrhoea is usually followed by the physiological
amenorrhoea of pregnancy.
In addition to the above benefits to mother and child, breast
feeding helps the mother and baby to develop a close loving bond.
This goes a long way in helping a child to develop normally in every
respect, especially its attitude towards others in terms of give and
take and a good relationship. Even on the part of the mother, as a
saying in Telugu goes more than kanna prema, the penchina prema
is greater which means that the love and affection of a other who
breast feeds a baby and brings it up is said to be much greater than
the affection of a mother who delivers a baby and does not breast
feed. The oft quoted example refers to the prema or love and
affection and tyaga of Yashoda who had breast fed Lord Krishna and
brought him up is far greater than that of mother Devaki who
delivered Lord Krishna but unfortunately could not feed him and
bring him up.
However, successful breast feeding depends upon the well
being of the mother and her nutritional status. Most mothers in our
country are malnourished and anaemic. Nutritional supplements with
83

iron and calcium and a balanced diet are of utmost importance for
safe motherhood and successful lactation.
Inherent attitude and a positive approach of mother (and would
be mothers) for breast feeding is equally important. Many of our
educated and working women want to do their best for their children.
What they lack is information on the benefits of breast feeding and
also the practical advice as how best to integrate breast feeding in
their modern lives. Such an education should be imparted to them by
everyone concerned with maternal and child health care.
It is gratifying to note that so much is written in the lay press about
the benefits of breast feeding and the encouragement given to the
slogan `Breast feeding is the need of hour. The Government of
India and agencies like UNICEF have taken concrete steps so far
in promoting the same yet if what is suggested below is observed, it
would go a long way in the success of the programme:
(a) All working women should have paid maternity leave for a
minimum of six months after delivery. This itself would go a
long way in restoration of maternal health after delivery and for
successful lactation.
(b) Provision of crches at places of employment so that
women can breast feed their babies during working breaks.
(c) For working class, employers should make it easier rather
than more difficult for breast feeding women to work,
especially in arranging working hours.
Establishment of Human Milk Banks is in vogue and in some
states have been started, and human milk is being stored for selling
purposes. Ethically and morally one feels a bit sceptical unless these
are run with all the care that is required and Government should
regulate the process, before they become a menace too difficult to
contain, as in case of semen banks.
In the end it must be stressed and emphasized that breast
feeding is time honoured and not old fashioned and to breast feed a
baby is a natural instinct on the part of women. If one observes an
84

infertile woman taking a small baby in her lap, she puts it very close
to her breast and hugs it. In some cases, even secretion of milk
occurs when they feed a baby, let alone the recurrence of secretion
of milk after a long gap in women who have had children before. In
mothers who are actually feeding, with the cry of the baby the intense
desire makes them produce milk instinctly even before suckling of
the baby; even the baby recognises the mothers touch and stops
crying immediately. The intense desire to breast feed transgresses
even the species. There are on record occasions where dongs have
breast fed kittens and wolves have breast fed an abandoned human
child and brought him up.
Whatever it may be, as our elders have stressed, that breast
milk is the best for the baby and only confirms the oft quoted saying

85

SEX DETERMINATION & SEX DIFFERENTIATION

Sex of an individual is a hereditary trait and depends upon the

nature and structure of the chromosomes of the fertilized ovum. The
number of chromosomes contained in the cell nucleus is constant in
every species; e.g. in man every cell contains 22 pairs of autosomes
(or body chromosomes) and one pair of sex chromosomes. Both egg
and spermatozoon undergo a reduction division for maturation which
leaves them with half the number of their original chromosomes. In
the human species the two sex chromosomes in the female have
identical structure (termed XX) but the structure of chromosomes in
the male differ (termed XY). It is therefore obvious that after the
maturation division all the eggs would contain 22 autosomes and one
X chromosome while he spermatozoon would contain 22 autosomes
but either X or Y chromosome. If the fertilizing spermatozoon is X
containing, the embryo will possess the cells with a pair of XX sex
chromosomes and be a genetic female. Impregnation of an ovum by
Y containing spermatozoon produces a cell with a pair of XY sex
chromosomes, thus determining the development of the embryo as
genetic male. According to this concept sex determination in humans
depends upon the structure of the sex chromosome in the fertilizing
spermatozoon and not on the nuclear structure of the ovum.

After the sex is determined by the chromosomal mechanism,

the unravelling of the anatomical sex is done by the process of sex
differentiation. The process of sex differentiation has two phases:
(a) Differentiation of the gonads
(b) Differentiation of the accessory sex organs.
Normally in accordance with the genetic sex, an orderly
sequence of changes bring about transformation of a bisexual
embryo into either a male or female.
Round about5-6 weeks of intrauterine life, whatever the genetic
sex of the embryo may be - the first gonadal primordium that appears
has two major components;
viz. the outer cortex and the inner
medulla. The cortex has a potentiality to develop into ovary and the
86

medulla has the potentiality to develop into testis. These two

components produce inductor substances which in turn are
controlled by male determining genes M present on the autosomes
and
Y-chromosome and the F for female determining genes
present on the X-chromosome. At the time of fertilization there is
established in the zygote a complex of genes in which quantitative
superiority of the female or male genes determine the sexuality of the
individual. In other words it is the genetic balance that plays the
determining role in deciding which component in a given individual
should differentiate to form a gonad. Normally in genetic male the
medulla develops into a testis. In a genetic male round about 7th or
8th week of intrauterine life Y-Chromosome and the male
determining genes on Y-Chromosome produce a substance known
as H-Y antigen (formally called Testicular morphogenetic hormone)
a plasma membrane protein and this is closely related to testicular
differentiation. When the testes develop and function normally in an
early embryo the embryo will develop as a male. Should the testes
be absent or if they do not function normally the embryo will become
a female morphologically whether ovaries are present or not. It would
be realised that male development is concerned with having testes
and female development with not having testes.
Testes carry out their intrauterine function by producing two
substances:
a.
b.

Testosterone
Anti-Mullerian hormone.

In every individual, there are two types of system of ducts

present Wolffian ducts are responsible for the development of male
accessory sex organs and Mullerian ducts for the development of
internal genital organs in the female i.e. uterus, fallopian tubes, broad
ligaments and upper three fourths of the vagina. The external genital
organs in the female are developed from urogenital sinus.
In the male, the testosterone gives rise to the development of
external genitalia and the Wolffian system whilst the anti-Mullerian
hormone inhibits the development of Mullerian structures, which are
always present and capable of development. Anti-Mullerian hormone
is a glycoprotein produced by sertoli cells of the testes. Anti87

Mullerian hormone has a unilateral action so that each testis appears

to produce the hormone which results in the regression of the
Mullerian structures on its own side. The sensitivity of the Mullerian
structures to anti-mullerian hormone is present only during the first 8
weeks of gestation.
To utilize testosterone effectively the external genital organs
must convert testosterone into dihydrotestosterone through the
action of an enzyme 5- -reductase it is necessary for these
substances to be bound to receptors in the cytoplas of the cells.
Hence, deficiency of 5- -reductase and ineffective binding of
testosterone lead to abnormal sex differentiation known as androgen
insensitivity and this can lead to intersex problems.
It is a traditional belief among our people that they must have at
least one son in the family not only to keep up the family name but
also to save hem from a particular kind of Hell called in Sanskrit
punnaamanarakam. It is also ingrained that the son only should lit
the funeral pyre of the parents when they die. It is for the above
reasons that those who do not have any children do lot of pujas and
prayers and observe austerities so as to evoke the prasanna of the
Lord to bless them with a son.
However, sex of the baby in the womb is determined by which
of the sex spermatozoon meets the ovum and fertilizes it. If one
containing Y fertilizes the ovum the resulting child will be a male. If
the one containing the X fertilizes, the child will be a female. Nobody
can predict except perhaps those with super-natural powers what will
be the sex of the future baby. It does not depend upon the wife; nor
does it depend upon the obstetrician, nor upon the nursing home
where the patient is going to deliver and there is little that the
husband can do about it as he has no control over the spermatozoon
that fertilizes the ovum. However people indeed have a wrong but
strong belief in this respect. If two or three daughters are delivered
successively the blame is put on the daughter-in-law as if it as if it is
her fault and she is tortured for the same for no fault of hers. No one
can predict which one among the millions of spermataozoa will meet
and cause impregnation. We hear cases where the husbands has left
wives and the children and/or divorced the wife for the same reason.
People have changed the obstetrician and the nursing home for the
88

next confinement.
As stated elsewhere, conception, sex of the baby, day and time
of birth and even death, are predetermined and are in the hands of
Lord Almighty: what all one can pray for is for a healthy child
physically and mentally either boy or girl.
Much research is going on trying to separate the sperms with
Y-chromosome and yet it is too early to say anything regarding this.
So also much is in vogue these days regarding gene alternation and
designing of he babies including their sex, colour etc. Preconceptional sex selection is condemned as an example of positive
eugenics that is an attempt to improve (as defined by the
Perpetrator) the inborn qualities of the human race. Sex selection
offers the possibility of avoiding female infanticide and second
trimester abortions. While this seems attractive, the conscientious
opinion in our country and many argue (which is more ethical and
moral) that what is needed is an elimination of inequality, not of baby
girls. Also a change in social values is required which would result in
an obstetrician offering congratulations rather than commiserations
on the birth of healthy female child.
Lay public consult astrologers who give hem different kinds of
advise regarding the month they have to conceive or advise them
to do certain pujas or give them lockets etc for this purpose. Chinese
have a calendar prepared to advise the couple as to when and in
which month conception should occur to predict the sex of a future
child. None of these help.
What unfortunately is happening today is that by the chorion
sampling or amniotic fluid examination for chromosomal analysis or
by ultrasound examination the future sex of the baby can be detected
(but not determined!) and many terminations of pregnancies are
done if the foetus inside is a female. Still worse, in some parts of our
country they make the mother kill the female baby immediately
afterbirth on the pretext of lot of dowry has to be given at the time of
marriage of the girl. Mother killing the girl baby is like the fence
eating the produce of the land which it is supposed to protect. What a
sad state of affairs! While both the above are unethical, on whom
should one put the blame - The husband, wife, obstetrician or indeed
89

society itself. Rightly the Government has framed laws regarding the
banning of the tests for sex determination. Even so many are done.
Even otherwise, many a couple request for termination of pregnancy
when they already have two girl babies. As written elsewhere the
obstetricians are only helping these women from falling into the
hands of quacks. Ultimately it is the society and the prevalent social
fabric which is responsible for our present day ills. So much is talked
on T.V., press and advertisements etc. about the protection of the girl
babies. However, in day to day life one sees exactly the reverse
happening. The people who exhort so much and talk about are the
same people who want and demand lot of dowry from the parents of
the girl at the time of the marriage. And this is the root cause of the
evil.
For a male foetus to develop and survive and preserve its sex,
the quantity and quality of these hormones testosterone and
Mullerian-suppressing hormone are essential. Male baby has to
survive in mothers womb surrounded by so many of the female
steroid hormones produced by the placenta. If and when the
testosterone is not produced or not being utilised by the end organs
because of enzyme defect then only the sex differentiation into
female occurs or may occasionally lead to problems of indeterminate
sex. This is what Prof. Jeffcoate wrote Woman is a woman not
because she has ovaries. She has ovaries because she is a woman
or better still she is not a man.
It is also seen from the above that both males and females
have in them the remnants of the sexual apparatus of the other. In
males the Mullerian apparatus that ultimately leads to the
development of womb and female sexual genitalia are suppressed by
the testosterone and the Mullerian inhibiting hormone. Whereas in
women, the Wolffian duct and other apparatus responsible for
development of male genitalia are suppressed. There is much to be
aid that femininity is neutral state and masculinity is superimposed
characteristic. A seen in daily life many men are effeminate and
many women are slightly masculine in bearing and outlook. A men
may be smooth skinned and fastidious about his clothes and a
woman may be slightly flat chested and have hairy legs without being
significant. These are also reflected in their character, behaviour and
their outlook in life. In short, the borderline between the two-male and
90

female if not on the physical plane but on the mental plane, is vague
and impossible to define. Even experiments have shown that
castration of male species in early life has lead to the development of
female person. Castration after birth also (as in eunuchs) makes
them behave like females. Probably it is for this reason, in order to
safeguard the zanana or ladies in the palaces that Kings used to
keep eunuchs (after forcibly castrating men) to guard them. Even
today, this unethical practice of castrating forcefully healthy males
after kidnapping them is done by the Hijras or eunuchs themselves,
behaving like a mafia, which is indeed deplorable.
Female genital mutilation, misleadingly known as female
circumscision entails the total or partial cutting away of the female
external organs including clitoris. This custom is prevalent in subSaharan Africa, the Arab world and in some other Islamic countries.
Whatever be the reasons underlying this, one feels sad to note that
women who escape mutilation are stigmatised and are not sought in
marriage, which helps to explain the paradox that the victims of this
practice are among the strongest proponents (as in case of the
eunuchs). It is the ethical and moral duty of everyone, including
organisations like the WHO to work together and educate the people
in effectively eliminating such needless practices.
Transexualism is defined as a disturbance of gender identity in
which persons anatomically of one sex have an intense and
persistent desire for medical, surgical and legal change of sex, so
that (Freedman et al 1976). In these people castration is done first
and a functioning vagina is then created and female hormoses
administered for the development of breast etc. and they lead a sex
life of women. The only instance in our mythology we read about
change of sex is that of Sikandi. Here Amba a princess prayed to the
Lord so that she could be born and brought up as a man in order to
take revenge against Bhisma Pitamaha, as he refused to marry her
because of the vow he took that he will never get married. Bhisma
also vowed that he will not fight a lady in the form of a man. But we
did not read anything like males wanting to get their sex changed to
that of females. Whatever may be the explanation, the desire or
disturbance of gender identity or orgenic imbalance in favour of
females, yet one cannot apprehend or appreciate such a change. Is it
ethical!! Probably this sort of desire is due to the effect of Kaliyuga!
91

Hindu mythology believes that the Divine aspect or power is

only one. On the male side it is represented as a Lord Brahma, Lord
Vishnu and Lord Maheshwara. On the female side, as Goddess
Saraswati, Goddess Laxmi and Goddess Parvati. It is said the Lord
Vishnu has Goddess Laxmi in his chest (Vrakshoviharini manohra
divya moortey) and Bhagwan Shiva appears as Ardhnariswara giving
half of this body to Goddess Parvati. It is shows that ht Lord Purusha
and Prakriti or Shakti or energy are equal. Probably this is the
highest form of philosophy saying how the Bramhan can manifest
and can be worshipped.
And finally, whispering a word of wisdom again in every bodies
ears, not to be choosy in the sex of the child to be born. Nature has
created two different sexes for continuation of the species. Why
disturb the balance of the nature!

92

ETHICAL ASPECTS OF INDUCED ABORTION

The old order changeth yielding place to new

Lord Tennyson.

There is no aspect of Obstetrics and Gynaecology which has

aroused more controversy than the termination of pregnancy. It
arouses personal emotions, involves ethical considerations and as
such cannot be considered ion medical terms alone. From the time of
Hippocrates the consensus of medical opinion was opposed to
induced abortion. Even as late as 1948 Dee Lee and greenhill in their
textbook Principles and practice of Obstetrics wrote, `One of the
saddest commentaries on modern civilization is the prevalence of
criminal abortion. A young physician will not be in practice very long
before he is approached with a request in a hundred open or
concealed ways to perform criminal abortion. All arguments are
brought to bear; friendship for a family, disgrace of a child born under
untoward circumstances, the impossibility of caring for large number
of children, ill health and eugenics. The physician should not permit
anyone of these supposed factors to influence him to perform
abortion because:
(a) It is murder.
(b) It is a criminal offence punishable under law
(c) Performed in the way most of these operations would
have to be performed, infection is most likely to follow and
perhaps death of the patient with a possible prison term for the
perpetrator.
(d) Accidents such as perforation of the uterus and anaesthetic
deaths are not uncommon.

93

(e) If the physician does it once he is a lost man as the woman,

no matter how firmly she is bound to secrecy will tell her friends
and soon his reputation as an abortionist will be established.
As such, abortion was done only as a therapeutic procedure.
Even here the moral and religious aspects were considered and in
life threatening conditions induction of abortion was done as
conservating operation saving the mother and not sacrificing the
child!.
This prevalent attitude in those days led many young women to
commit suicide. Haemorrhage and infection after procurement of
abortion by quacks, unqualified persons, perforation of uterus and
the viscera, etc. were common. If delivered secretly mother used to
cause infanticide or left the baby in some place. In more
sophisticated people abdominal hysterotomy was done in the name
of appendicitis operation. All these were of common occurrence
years back. Induced septic abortion was the highest cause of
maternal mortality. The most important cause of death is due to gram
negative organisms aerobic or anaerobic or in some clostridium
welchii infection causing gas gangrene or clostridium Tetanii, causing
tetanus. Even today unfortunately in abortions done illegally many
women are lost as a result of haemorrhage and infection or if alive
suffer from a legacy of complications.
Considering this aspect of high mortality due to illegal septic
abortion on the recommendation of a committee appointed for this
purpose, the Parliament liberalized abortion laws and passed MTP
Act in 1971 which came into force in April 1972. Abortion is permitted
one medical and socio-economic grounds as listed below:
(a) The Act permits termination of pregnancy by a registered
practitioner where the length of pregnancy does not exceed
12 weeks and by two acting together where the length of
pregnancy is between 12-20 weeks of gestation.
(b) Termination of pregnancy can be provided if the doctor is of
the opinion:

94

(i) Continuation of a pregnancy would pose a risk to the

life of a pregnant woman or cause injury to her physical or
mental health.
(ii) There is a substantial risk that if the child was born it
would suffer from physical and mental abnormalities as to
be seriously handicapped.
(iii) The pregnancy is alleged by the pregnant woman to
have resulted after rape.
(iv) The pregnancy occurred as a result of failure of any
contraceptive method used by the woman or her husband
for the purpose of limiting the number of children.
Further the Indian Law permits some consideration of pregnant
womans actual or reasonably foreseeable environment.
Thus the law is quite liberal and is in consonance with the
health and demographic needs of the nation. It is so liberal that under
the law any pregnancy can be terminated in the pretext of anyone of
the above regulations and raises suspicions in the mind of the people
that the Act can lead to wholesale termination of pregnancy; i.e.,
destruction of human life (Bhroonhatya). In Christianity especially
amongst Catholics, termination of pregnancy is not permitted as in
their view life is life, either very early pregnancy or after birth. In the
Muslim world even a diagnostic curettage in the latter part of the
menstrual cycle is not permitted unless pregnancy is excluded by
immunological test or by ultrasound. Even small foetus expelled in a
spontaneous abortion was given traditional burial. But considering
the number of deaths due to illegal septic abortion especially of
healthy young women in the prime of life, any right thinking person
will surely feel that it is better that the abortion is done legally instead
of illegally by quacks. The risk of dying from sepsis after illegal
abortion is considered to be as much as 50 times greater than after
legal abortion. Likewise, septic abortion is still the most common
obstetric cause amounting to nearly a third of maternal deaths.
Comparatively, legal abortion is a safe surgical procedure with a low
death/case rate.
95

If the pregnancy occurs as a result of rape is the woman at fault

and to be condemned? If an unmarried girl is ditched is she to suffer;
or for that matter the family has already have enough children and
cannot afford to have any more because of poverty. Probably all
these must have been considered by the committee and subsequent
endorsement by the Parliament.
While any registered medical practitioner can terminate
pregnancy the burden most often falls upon the shoulders of the
obstetrician and gynaecologist. While the act gives legal protection if
the procedure is done according the regulations prescribed, the
doctor I am sure will in his heart of heart have the lurking feeling that
he is doing sin in terminating many pregnancies. This feeling is
bound to occur as one sees in the departments of Obstetrics and
Gynaecology many terminations are done day in and day out. As one
being the Head of Department of Obstetrics and Gynaecology it fell
to my lot not only to start the OPD MTP centre at BJ Medical College
and Sassoon Hospitals and also at J Group of Hospitals, Bombay. I
was also instrumental for the training of the staff, postgraduates and
also Medical Officers from the districts posted for the same. I did 2 or
3 Swamijis whether what I was doing was right or wrong. I did not get
a convincing reply.
Anyway my conscience was clear. We followed the orders of
the Government as duty bound. Even otherwise when the couple
comes and requests for MTP, to any doctor, the decision for the
termination was taken by the couple and the gynaecologist is only
completing the procedure. One should take it that probably in such
cases it was His will and the gynaecologist is only a nimitramatra
provided he does so with all due care and precautions so that the
mother is not endangered. He will only be guilty if he takes undue
advantage of the situation especially in termination of pregnancy in
unmarried girls. Unfortunately even today many seek the services of
illegal abortionists because of lack of awareness of the abortion
services available, lack of privacy and impersonal atmosphere,
reluctance of unmarried women and widowed women to go to
hospital for MTP, and lack of financial resources on the part of the
rural population to reach hospital in urban areas as it is seen that in
only 1 in 10 primary health centres have facilities for MTP.
96

ICMR study shows that majority of the abortion seekers belong

to the middle income group married and have one or two living
children and are educated. Unmarried teen-agers for form 5-6% of
the cases. Drugs taken for postponement of menstruation or
medicines prescribed for any physical ailment of X-rays taken for the
investigation and diagnosis in all these the patients are becoming
very apprehensive regarding the safety of the future child and
seeking abortion services.
Number of patients coming for 2nd trimester for termination is
gradually coming down yet still they constitute a sizeable number of
cases. Majority are unmarried, teen-agers or widows. Most of them
are from the rural areas. Ignorance of being pregnant or inability to
take decision regarding termination of unwanted pregnancy appear
to be the major factors responsible for the delay. The risk to the
mother is 10 times more than when the termination is done in the first
trimester with the same setting. While in MTP in first trimester the
mortality is considerably lower than those associated with
continuation of pregnancy and delivery, data shows that legal
abortion is one of the safest surgical procedures and both immediate
and late complications following MTP are low.
Hence what is more ethical today is how best to make the
procedure safe and prevent immediate and late complications and to
see that MTP emerges as an important maternal health issue. With
that in view, the following should be observed:
(a) MTP for unmarried girls should not be done unless ABO
and Rh grouping is done. Even as little as 0.1 ml ccc of blood can
cause sensitization and mar her future chances of having a
child. Anti D-Gamma globulin should be given to all RhNegative women as a prophylactic measure.
(b) Always rule out Ectopic gestation by clinical as well as (if
necessary by Ultra Sound) before termination. It is imperative
that all gynaecologists should train themselves in USS
technique to confirm that the pregnancy is in the uterus.
Patients especially unmarried girls will be reluctant to go to
radiologist or ultrasonographers for this investigation.
97

(c) In married young patients never do MTP unless in

exceptional circumstances. The fact that the lady is pregnant
shows that both of them are fertile and this should be
impressed upon. In spite of all care tubal block can occur after
the procedure and the couple may have to go from pillar to
post to conceive again.
(d) Though Menstrual Regulation without anaesthesia is ideal
for upto 6 Weeks of pregnancy, chances of failure rate are
high especially if there is congenital malformation of uterus
etc. Waiting for 2 more weeks is ideal and better to do suction
evacuation. This waiting does not increase the complication
rate.
(e) Suction evacuation is better than the conventional
dialatation and curettage (or
evacuation). The latter is
followed by more bleeding, incomplete evacuation or if drastic
curettage is done can cause intra-uterine synaecia later.
Also vacuum aspiration may be a safer method as fewer
side effects and greater efficiency than Prostaglandins for
first trimester termination. This may not apply to RU 486 and
miniprostrone where high success rate is reported without
surgical intervention.
(f) While giving local paracervical block, be careful not to
inject into blood vessels. Adding Buscopan or Epidosin and
pitocin to the anaesthetic solution helps in smooth dilatation of
cervix. Back up sedation is essential when doing under local
anaesthesia.
(g) Minimizing trauma to the cervix is an essential aspect
of suction evacuation. Keeping Laminaria tent or isabgol
tent four hours before the procedure helps easy dilatation of
cervix. They are very good adjuants contrary to the belief the,
complication rates like infection are often very les.
(h) Perforation of the uterus can occur with ease even in expert
hands No one should be overconfident MTP operation should
not be taken lightly. Everything should be ready in the theatre to
deal properly and the condition dealt with immediately.
98

(j) Second trimester terminations are more hazardous

complication rate is very high, the risk to the mother being as
much as 10 times higher than in early trimester.
(k) Select a procedure which is safe, does not have any
contraindications even in high risk cases and which gives
reasonably good and quick results especially in nullipara in
whom surgical interference should be avoided.
(l) Extra amnhiotic procedures are easier and safer than
intra-amniotic procedures. Avoid intra-amniotic injections of
hypertonic glucose or hypertonic saline. They have lost favour
as they cause infection, hypernatremia and disseminated
intravascular coagulation.
(m) The period of pregnancy between 12-14-16 weeks is a
grey area; difficult for suction evacuation from below and may
not respond to drugs. Prior dilatation of cervix with laminaria or
isabgol tent may help.
(n) Most gynaecologists would limit the using of vaginal
termination first trimester. Some advocate vaginal termination
even in second trimester. Because of the large size of the
foetus bony parts of the foetus may have to be crushed before
removal. There is no doubt that many would feel that the
procedure has crossed the limits of what they consider to be
ethically acceptable.
(o) Until newer and safer methods of non surgical termination
of mid trimester pregnancy become available, hysterotomy
with tubectomy might be an acceptable alternative for parous
women requiring mid-trimester termination and concurrent
sterilization in the prevailing conditions.
(p) It is easier to motivate women for contraception at the
time of MTP. As per an ICMR Report, before MTP only
25% of abortion seekers used some sort of contraception.
At time of MTP 25% accepted tubectomy 29% IUD and 9%
oral contraceptives. Thus MTP has brought 2/3 of abortion
99

seekers into effective contraceptive care. Do a lamaroscopic

sterilization or mini laparotomy with MTP. There is no increase
in mortality or morbidity. also tubectomy is very useful in
overcoming domestic problems of parous women. Thus
an unwanted pregnancy might act as a first step towards
compulsory contraceptive use in future.
(q) Legal abortion should not be considered as a population
control method. It is mainly for safeguarding maternal health.
However the positive association between the two may be
further strengthened when abortion services are provided
as apart of the integrated maternal and child health and
contraceptive care.

Emotional Support
Unwanted pregnancy can be a cause of acute emotional
stress. Many of those who seek abortion are young and unmarried.
They very often do not know that when they miss a period it could be
pregnancy. Here comes one essential aspect of sex education (they
must be told that if they miss the period after intercourse probably
they may be pregnant (see chapter on Sex Education). There is a
great danger and resentment because the young girl has been
abandoned by her boyfriend when the pregnancy occurred.
Discussion and emotional support may help the young patient to
come to terms with her feelings. The young patient is afraid of
termination but even more afraid of telling her parents.
Following termination of unwanted pregnancy many women
report a sense of relief that their immediate problem is solved. Others
report a feeling of guilt and depression. Women having a MTP
because of foetal abnormality may have a grief reaction. In both the
above a sympathetic concern and support helps to go a long way for
the speedy recovery of the patient.
In the end, patients should be cautioned regarding the
sequelae of repeated and frequent terminations. Repeated
terminations are not good; cervical tears, cervical infection, increased
incidence of gynecological problems like menstrual irregularities and
100

secondary infections could occur and could lead to blocked tubes

and infertility. In those who conceive, repeated abortions and
premature labour etc are long term sequelae.
I am always reminded of what may Prof MKK Menon used to
say regarding MTP : `At one time students in the examination were
asked what are the indications for termination of pregnancy. It should
not happen now that the students be asked as to what are the
indications for continuation of pregnancy.

101

INFERTILITY
The desire for children by the normal woman is stronger than
self interest in beauty and figure, stronger than the claims of a
career. Childlessness is generally a tragedy to the married woman
and it can be a cause of marital upset as well as personal
unhappiness and ill health. It may result from recurrent abortion and
still birth but the commonest cause is failure to conceive. Sterility
(infertility) is an absolute state of inability to conceive.
- Jeffcoate
Sterility was formerly regarded as a disgrace, as a mark of divine
displeasure, as a ground for divorce or marital breakdown or even
suicide (on the part of woman only); in this she is goaded and
haunted by constantly being called barren and the insinuations
by every one in the family and relatives. To propriate children,
Sastras have suggested various rituals like prayers, sacrifices
and the like. Awareness of male infertility is of recent time and
therefore man used to marry two or more wives for the sake of
children. When childlessness affected the King or national heads
it had often changed the whole course of history and it still does
so even in everyday life in families. Unfortunately the sorrow of
childlessness is kept by the couple to themselves. Only now a
days, with the dissemination of knowledge, an altered outlook and
the availability of various tests, advice and treatment, infertility is
freely admitted and therefore appears common.
Fertility and sterility: Fertility is a relative rather than absolute
state. If a couple gets married and conception occurs, they are
considered as fertile. However majority of people fall into the
category of neither fully fertile nor sterile. In such cases low fertility
in one can be balanced by high fertility in the other and the fertility
of a marriage is the sum of the fertilities of the two partners. But if
both the partners are low in fertility then sterility occurs.
Fertility varies from time to time in the same individual. At one
time it was thought that except in childhood males are fertile
throughout life time even in old age. Of late because of stress of
modern day to day life, smoking, worries etc sub-fertility is
102

commonly observed in men. Physiological sterility or sub-fertility is

usually low till age of 16-18 years (even though menstruation is
occurring regularly) probably because the menstrual cycles are
anovulatory. Maturation of genitalia is also a prerequisite before
they become fully functional. They explain why in rare cases
fortunately conception does not occur in case of rape or abuse.
Low fertility during pregnancy and lactation give women some
reprieve. Fertility again falls after the age of 40 due to infrequent
ovulation.
Familial disposition: Genetic constitutional factor; no explanation
can be given as to why some families have a high and others
a low conception rate. Some families have only one child. If
that person grows and gets married, the couple has a sixty
percent chance of pregnancy; even if it occurs, they have
only one child. Sub-fertility is often observed in obese, heavy
build and women with masculine traits and this underlines a
constitutional abnormality. Height and weight are not direct causes
of childlessness nor athletic prowess and pursuits lower fertility.
Occupation and Environment: Fertility is high in country dwellers
rather than town or city dwellers. It is also high among people who
live by manual labour than in those whose work depends upon
mental activity. Though statistics show that fertility does not vary
with social class yet it is a common observation that higher the
social class, less the number of children. It is due to late marriages
in higher class or voluntary sterility one marriages in higher class
or voluntary sterility one cannot say. Diet plays no part in fertility
unless it is so deficient as to interfere with ovarian function.
Anxiety and Apprehension: Nervous temperament and extreme
anxiety leads to lower fertility. Tension can lower fertility through
the action of hypothalamus or by causing spasm at uterotubal
junction. It is often stated that when a couple adopt a baby they
tension is relieved and they are likely to have one of their own
afterwards.
Contraception: Usually does not lower fertility unless it is
practiced for a long time and the method not a commonly harmful
one. Postponement or delay of childbearing does however mean
103

that time is passing on and the age factor is operating.

Incompatibility: It was observed that some couples failed to
reproduce but when they separate and marry someone else they
have children. Though incompatibility as such is not demonstrated
but possible immunological reaction of a woman to a particular
semen can be present as evidenced by presence of sperm
agglutinins in circulation.
When to investigate a case of Infertility
A highly fertile couple take an average 6-7 months to achieve
pregnancy and 80% (4 out of 5) conceive within one year of
marriage and 95% after 2 years. In younger age group failure to
conceive during 2 years of adequate opportunity is acceptable for
justifying full investigation. For others a period of twelve months is
justifiable especially if the woman is in her late twenties or in her
thirties.
Ethically, should investigations be done in a case where one or
both partners are HIV positive? The conscientious opinion is
Infertile HIV infected patients need and should be given careful
counselling, within the limits of current knowledge, about the
infectivity, pregnancy, breastfeeding, parental illnesses likely to
occur during pregnancy including danger to life before one
embarks on initial investigations.
It is advisable to follow the guidelines given below in handling
cases of infertility.
(a) Unless the couple is very young, all married couples should
be advised `dont delay the first if they conceive it means
they are a fertile couple and every one in the household will be
happy.
(b) Never prescribe O.C.s (oral contraceptives) for a long time
postpone pregnancy. If they do not conceive they blame the pill
and the doctor for not conceiving though there may be other
factors responsible for infertility.

104

(c) If the periods are irregular and scanty from puberty all the
more reason not to prescribe O.C.s for contraception. They
can cause post-pill amenorrhoea. These people should be
encouraged to conceive as early as possible.
(d) Reassurance may be all that is necessary when couples
complain of infertility too soon. A simple explanation of the
physiology of conception and that ovulation occurs between 818 days in a 28 day cycle so that the couple follows natural
inclination.
(e) Remove the following misconceptions:
(i) Many women have a wrong notion that unless they
experience orgasm they will not conceive. If it were
so, pregnancy should not result after rape. Orgasm
may however eliminate tubal spasm, stimulate cervical
activity and encourage secretion which are favourable
for the upward migration of spermatozoa and encourage
conception.
(ii) After coitus most semen escapes from the vagina
and patients often think it to be the reason for sterility.
Floursemenis is normal and never a cause of infertility.
There is always enough semen left to fertilize. Yet to
reassure advice her to lie down for 10 minutes or more
after intercourse with a pillow under her buttocks, so that
the semen is in contact with the cervix.
(iii) Overwork, anxiety, stress and strain of life and
in addition smoking and heavy drinking, exposure to
sexually transmitted diseases as also to some toxic
agents in the workplace all these affect fertility.
Attention to these must be given. A long care-free
holiday may sometimes be the remedy.
(f) There is a wrong impression that if the couple live separate
for a few months and later their reunion will be fruitful. If the
cause of infertility is immunological then the levels of sperm
agglutinins in the wife will fall and she may conceive. Otherwise
this brings no more pregnancies than uninterrupted married life.
105

(g) Coital problems are probably related in 3-4% of cases. AT

one extreme it may be impotence in male, or, due to premature
ejaculation or vaginismus and severe dyspareunia in female
that coitus occurs rarely. If one is to assume that normal
ovum can be fertilized in terms of fertility is upto 72 hours in the
fallopian tube coital frequency of less than 3 times a week
may in its own right contribute to difficulty in conception.
(h) There is an increasing pressure to investigate and treat
infertility and the pressure may lead to unnecessary and
repetitive investigations.
(j) It is ethical to investigate the husband first. Years before, the
wife was always sent for investigation. Many husbands used
to refuse getting semen examined. They equate satisfactory
intercourse with fertility. Much to everyones dismay they used
to find that the cause lies in them for infertility.
(k) It is sad to see patients going from pillar to post.
Investigations
like
laparoscopy,
hystero-salpingo-gram,
endometrial biopsy and hormonal investigations repeated over
and over again and seeing the patient waiting in the queue
with a full bladder at ultrasound clinic for ovulation studies. It
is always better to complete all investigations in a short timerather than a protracted time taken for the same. (Non-invasive
procedure like trans-vaginal sonography are gradually replacing
laparoscopy in the diagnosis and treatment of infertility cases).
(l) Patient should be advised not to abandon treatment
especially if clomiphene is given for induction of ovulation. If
conception does not occur after three months it should not be
taken as a failure. Treatment should be extended for some
more time with or without other drugs. Surprisingly in some
cases conception occurs after stoppage of treatment.
(m) In the end, optimism should be the keynote even when
investigations suggest that the prospects for pregnancy are
poor.
(n) Even if both husband and the wife after investigations
were found normal in every respect and there is no absolute
106

cause, yet in some, conception does not occur such are

called cases of unexplained infertility and are a monument to
medical ignorance and a cause for concern. In the absence of a
determined cause, there is a logical sequence i.e no treatment.
In spite of IVF and embryo transfer, some do not conceive,
which only shows that unless Lord Almighty blesses whatever
one may do, success will not occur.
End Results of Treatment
(a) Whatever treatment or advice is given to an infertile couple
conception will not occur in certain cases this is inevitable
by the laws of chance that govern conception.
(b) It is all too easy to claim a coincidence as a dramatic cure.
Gynaecologist should only do his part in the treatment to the
best of his ability and judgment and leave it it is for the Lord to
decide.
(c) Gynaecologist should not feel humbled to refer the
patient to an institute where sophisiticated procedures like
microsurgery, endoscopic surgery or IVF and ET are done if
the patient requires and can afford the treatment. (However
it is only ethical in all these procedures that one has to take
into consideration technological limits, financial resources and
complication rate. Likewise, IVF and ET should be conducted in
such centres where everyone is well trained and devoted solely
for this purpose).
(d) The occurrence of pregnancy after a treatment does not
mean that fertility is raised.
(e) Two thirds of the couples who produce one pregnancy
after a phase of infertility find it impossible to repeat the
performance. (Only in those cases of unexplained infertility that
after a gap of a very long time the patient can conceive two or
three children). It is therefore unwise to claim a cure for any
form of treatment of sterility.
(f) While treating the patient should not be made to
concentrate on the problems of infertility; otherwise the
107

complaint of infertility becomes an obsession and causes

profound unhappiness and may even lead to estrangement of
partner in marriage.
(g) It is for this reason, treatment should never be unduly
protracted and complicated. Treatment should be as rational as
possible and if not successful within a reasonable period should
be abandoned and the couple referred to other sophisticated
centres.
(h) All the same there is always an optimum time to call a halt
and a desperate woman requires protection from those whose
enthusiasm clouds their sense of proportion and their scientific
outlook.
(j) When at last pregnancy occurs to a woman who has waited
too long it carries with it certain risks like ectopic gestation,
abortion and PIH (Pregnancy Induced Hypertension), and
high incidence of foetal malformations. Hence its management
demands almost rigorous attention.
Ultimately it is the Divinity that decides even the fruits of fertility.

108

AID ADOPTION : ETHICAL CONSIDERATIONS

If in the course of investigations an irremediable barrier for

fertilization is found in the husband, the gynaecologist should
explain the hapless predicament to the barren couple and in a
sympathetic way, guide the couple to adjust their married
philosophy to that of a childless union. There are of course two
alternatives neither of which should be suggested by the
gynaecologist. They may decide to adopt a child or have the wife
to submit to heterologous artificial insemination (AID).
Donor insemination may be suggested by the sterile couple
who argue that it is better that they should have a child which is
Half theirs than adopt one which neither has any personal or any
genetic link. Usually the woman is guided by her powerful
maternal instincts, while the man feels very responsible for his
wifes unhappiness and truly suppresses any personal objections
to the idea. Often it is the husband who is more insistent on
insemination. Arguments and persuasions of this kind are
inevitable and the following should be considered by the physician
before embarking in the procedure:
1. Thought he procedure is widely termed semiadoption and
therapeutic insemination - yet he procedure is considered socially
unorthodox, genetically tricky and morally unacceptable by many.
2. Legally the procedure is equivocal. O statutory requirements for
the procedure exists in as much as the law has not formally
accepted the inevitability and desirability of semi adoption. But on
the other hand there is no law that specifically forbids the practice.
Also it is not clear regarding the legal status of the child and thus it
may jeopardize the emotional adjustments of the child. Even if the
physician obtains the written consent of the couple yet it may not
satisfy all the questions likely to be raised in the court room.
Prerequisites for Heterologous Insemination
(a) Male partner must be azoospermic, serverely oligospermic,
necrospermic or has a transmissible hereditrary diseases.
109

(b) Doctor must evaluate the marital situation, carefully as AID

cannot be used by the sterile couple merely as an adhesive
agent to glue together a cracked marriage.
(c) He must insist on a waiting period for the couple to think
thighs over and make sure that the couple are mature and
well adjusted in a stable marriage.
(d) No AID should be done without the husbands consent in
writing. If done it may merely amount to an act of adultery and
will be accepted as grounds for divorce.
(e) Donor should be healthy, mature male of proven fertility,
with a favourable hereditary background and without clinical
or laboratory evidence of gonorrhoea, syphilis, AIDS and any
transmissible disease.
(f) The donors intelligence should match with that of the
parent and he should be of similar physical proportions to the
husband.
(g) For social and phychological reasons the donor be unknown
to the barren couple and all steps be taken to preserve his
anonymity. Also the procedure must be kept secret.
(h) The wife must be known to be potentially fertile and the time
of insemination must coincide with that of her ovulation.
The reaction of the couple after the birth of a child resulting
from AID cannot be foretold by themselves or by their medical
attendant. Even though before the procedure the man is the one
to insist, yet it is the an act of self effacement on the part of the
man whose pride had been wounded by the discovery that he is
the sole cause of the fruitless union. These sentiments are not
enduring and they disappear. Afterwards the man is likely to be
jealous even though he may hide it. Moreover during a marital tiff
one or other partner may sooner or later use conception
circumstances to hurt the other; and there after it can never be
forgiven. A child born by AID rarely succeeds in saving a marriage
which is floundering and the child then suffers.
110

As written above no statute or law exists to clarify the status of

children covered by AID:
(a) Can the child be registered in the name of husband?
(b) Are they legitimate or illegitimate as AID offspring are not
children of mothers partner?
(c) Should the child be told about his/her origin? Otherwise the
whole family life will be based on a lie. But many couple wont
agree with this.
(d) In a marriage breakup the wife may deny the ex-husbands
access tot the child on the ground that the child is not his. Or the
husband latter could refuse to pay maintenance for the same
reason.
(e) Also of concern is the inheritance, should the husband die
`intestate.
(f) What is the relationship of the donor and the offspring? Can
they seek access to the offspring they fathered or a legislation
should be enacted to remove any rights or responsibility of donors.
(g) Equally important ethical problem is can an AID be done on a
woman who has no partner, yet she wants a baby all the same.
All the above are unanswered questions. Hence many
advocate against performing AID even if done in good faith in the
interest of the couple because of ethical, religious and legal
objections.
Yet in the developed countries, in many states laws are being
enacted to remove the legal impediments. With the new technique of
cryo-preservation of sperms, and establishments of sperm banks
many infertile couples are treated with AID. Even preservation of ova
or sperm by freezing can present problems with the gynaecologist.
Any damage to the tissue in the freezing process may constitute
negligence. However there are more than quarter million donor
children in USA, alone and an additional one lakh in the rest of the
world.
111

ADOPTION
Individual outlooks differ regarding adoption of a child. Some
couple find the idea attractive and others cannot tolerate it. Only the
former make good foster parents, even though the venture may not
always bring the happiness expected. Hence adoption as a solution
to the sterility problem deserves cautious approach and initiative
should come from the infertile couples and not from the
gynaecologist. Pros and cons should be discussed regarding for or
against the procedure and the couple must also be made to realize
that they may later on have a child of their own especially in a cases
of unexplained infertility or even in cases of idiopathic oligospermia. It
is surprising, while wanting to adopt many a couple prefer a female
child instated of male. This is exactly opposite to their expectation
after a normal delivery. Is it because they feel that the female babies
look after their parents well in their old age? There is an old saying,
`son is a son till he gets married and a daughter is a daughter
forever.
Insemination with mixed semen (AIHD)
`In order to quieten conscience of the couple and to provide
hope, mixing of the husband semen with that of donors semen is
suggested. If the woman conceives the origin of the fertilizing
spermatozoa then remain in doubt. If the husband is not sterile this
procedure is not justified and if he is, the method has all the
objections of AID.

112

WHAT DO OUR SHASTRAS SAY REGARDING AID?

It is interesting to know the view prevalent in our Puranas and

scriptures. It was a regular accepted procedure to call some male to
fertilize the woman in case the man was impotent and this is called
Niyoga. This applied even to kings. In Mahabharata King Santanus
wife Satyavati requested Vedavyasa to impregnate Amba, Ambika
and Ambalika, when their husbands died without leaving any
progeny. That was how Dhrutarashtra and Panduraja were born.
Unfortunately Panduraja was cursed by a Rishi couple (when he
mistakenly killed them) that he would die the moment he tries to
enjoy with his wives Kunti and Madri. Pandu told Kunti to have
children from whomsoever she desired. Kunti was given five boons
(varas) by Rishi Durvasa Mahamuni when she served the Rishi
before her marriage. In her ignorance Kunti wanted to test the boons
or varas. She thought of Bhagwan Surya and when the Lord really
came she was stunned. Karma was born then. It was written by
Vedavyasa in Mahabharata that Karna was born not of
consummation of marriage but by Parthenogenesis or self
fertilization. It is the solar energy that was responsible. In the same
way, after marriage, when Pandu told Kunti to have children from
someone else, she refused. Keeping in mind the boons she prayed
to Yama Dharma Raja; i.e. lord of Death. He typifies the energy
which hold the universe and is protector of Dharma like Lord Brahma.
That was how Dharmaraja was born. Kunti then prayed to Lord Vayu
Deva the energy which is blowing and present everywhere just like
electromagnetic waves and Bhima was born. Arjuna was born from
the blessings of Lord Indra who represents the Atman. Lord said He
is Indra among all devatas. Then Kunti requested Ashwini Devatas to
bless Princess Madri. Ashwini Devatas are twins who represent
energy one as a positive charge and other as a negative charge,
without which current cannot pass through. By the blessings these
Devatasi Madri gave birth to Nakula and Sahadeva. It must be
emphasied again that Pandavs as well as Karna were Varaputras
and also born by parthenogenesis. In his sankalpa to be born again
and again whenever there is a deterioration of Dharma Lord Almighty
takes birth on the earth, as He has promisedSambhavami Yuge
Yuge. He had taken the birth of Lord Jesus again through
113

Parthenogenesis. So Kunti, Madri and Virgin Mary are all

incarnations of purity and virtue.

Present status of AID in our country

AID acquires an entirely new dimension in our country in view
of the threat posed by sexually transmitted disease (STDs) and
especially the dreaded AIDS (Acquired Immuno Deficiency
Syndrome). It comes as a rude shock to anyone regarding the
unethical and immoral ways AID is practised:
(a)`In several parts of our country AID is practised by fake
babas, hakims, sex specialists and quacks. In the name of
putting vibhuti or sacred ash and also doing some rituals, many
infertile women from rural areas and uneducated class are
being exploited and fall a prey to their unethical ways. It could
mean the end of their normal healthy life more so because of
the threat of contacting infections which looms large over an
ignorant populace.
(b) Even in medically assisted conception (with the use of
sperm from third party) where women bring semen from outside
for insemination with mutual consent; it is shocking to note that
in some places quacks and pathologists are providing them
with unhealthy poor quality semen and naturally poor genetic
material.
(c) The situation has become so deplorable that in some
places semen is collected from those very people who are
professional blood donors. Most of them are drug addicts, STD
carriers, sick slum dwellers in the cities and these essentially
belong to working labour class, beggars and vendors. In
short professional blood donors, have now become semen
donors. Who so ever pathologist/gynaecologist is either selling
or inseminating semen from such people is virtually, selling
sexually transmitted diseases and indirectly spreading AIDS,
thus rendering them infertile for life. These women have no
chance to live atleast a decent life even at the cost of staying
without having offspring.
114

(d) It is now mandatory that semen should be tested for HIV

and if found to be negative, semen should be frozen and
quarantined for a period of three months; i.e. window period
and tested again for HIV before it is considered fit to be used in
a recipient even if the specimen is from good healthy and well
educated donor. Sadly this practice of freezing and retesting
the sperm after three months window period is not followed in
all sincerely even in well established laboratories.
(e) Unfortunately it is found that it is the woman who gives
in and arranges to have her being inseminated for fear of
being rejected by her spouse and his family not realizing the
consequences that such a procedure could mar all her chances
of a future pregnancy and it could be a source of worry rather
than joy.
(f) According to a recent estimate as many as 600 people
could be getting artificially inseminated in National Capital alone
in a month. One can imagine what would be the problem on a
national level.
(g) It is a dismal truth that no proper guidelines have been
issued by the government for setting up sperm banks, buying
and selling semen for reproductive purposes. There is a great
need to establish such banks which would provide healthy and
rich genetic material.
(h) Unless the steps are taken to contain the menace at the
beginning that is right now, the casualties will be surmounting
and no one will be able to stop the HIV epidemic from engulfing
the country.
Rightly it is said, Prevention is better than cure - so be the
watch word.

115

ETHICAL PROBLEMS OF IVF & SURROGATE MOTHER

The problem of infertility has now entered the mainstream of

medicine and the treatment of infertility involves the gynaecologist,
infertile couple and those which involves a third party as donor of
egg or sperm or embryo or as a surrogate mother. In short the
concept Artificial family is becoming increasingly familiar and widely
discussed.
IVF In-vitro fertilization and embryo transfer Ethical
objections to the use of IVF treatment arise because of the fear of
fertilizing the egg and the sperm in the laboratory or it is extensively
expensive given comparatively few people who benefit from it and as
it involves certain health risks; also whether super ovulation is
necessary to the success of the IVF; what is the optimum number of
embryos to be inserted in the uterus with the best hope of successful
implantation and what is the risk of the occurrence of multiple births.
In the bargain there is also a risk to the gynaecologist i.e. handling
the ovum of embryo may lead to deformity or a genetic muddle can
occur and the consequent negligent claim.
IVF today is used in cases of blocked tubes, unexplained
infertility and mild endometriosis. Analysis of data in world literature
has shown that IVF has not proved to increase the likelihood of
pregnancy over no treatment, except where Fallopian tubes are
blocked. Also unfortunately, some clinics are recommending IVF to
couples after a very short duration of marriage, without due trial for
natural methods.
Other ethical objection is regarding the embryo (zyote)
research which is done with a view to improve the success of IVF
procedures. The research includes observing fertilization and early
development of zygote under different conditions and using different
culture media while at the same time zygotes are treated with
respect. This pertains to the left over embryos in the IVF and the
embryo transfer. Some people argue that the embryo after
fertilization is a human `person and must be guaranteed full
protection of the laws and not used for research even with parental
116

permission. However, one has to make a distinction between 4 cell or

8 cell or 16 cell embryo and a fully developed child and they should
not be equated. Gynaecologist who is professionally committed to
caring for women should convince and change the moral feelings of
the people that if research is in jeopardy, all kinds of desirable
improvements in the field of infertility will be at risk; and by the
powers of persuasion should allay some of the ignorant and alarmist
fears.
Surrogate mother (proxy motherhood and womb leasing) : In
the case of surrogacy using IVF, the child is genetically the child of
`commissioning people. The surrogate is simply acting as a living
incubator, and hence ethical problems are confined to those relating
to the surrogate. At the centre of the ethical question is the
question whether it is right to use one person as a means to the ends
of another, however estimable these ends may be~. Does it amount
to exploitation of the surrogate even if she has expressed her
willingness? Is she not being put to risk of pregnancy and child birth.
If the surrogate is being paid, is she not being used for Service
Undertaking? Has the surrogate sold her body or sold her own child
(son or daughter) even though she entered willingly thinking that it
will produce nothing but good.
One the other hand if the surrogate offers her service willingly
enjoys being pregnant and is in good health, psychologically tough
enough to withstand pregnancy and labour and hands over the baby
she has given birth to the commissioning people, who have been
desperate perhaps for years to have a child which they will now
have in some sense the surrogate brings in lot of happiness in the
life of the couple.
There are other questions that may arise. Can couples who are
not infertile make use of surrogacy or AID? Probably when there is
evidence of some malfunction or when the risk of passing on an
inheritable disease is so great then only IVF or production of an
artificial family should be attempted.
Should the surrogacy be kept as a secret from the public and
the child that is born and lastly upto what age can a surrogate mother
be treated with IVF (lot of controversies being discussed nowadays
117

when a 59year old lady surrogate mother gave birth to twins and a 63
year old woman became pregnant after being inserted with the egg
taken from a young woman). Can the surrogate mother refuse to
hand over the child and make it a ward of court. Problem of consent
may arise if the surrogate mother requires an abortion: whose
consent is necessary? To the gynaecologist the patient must come
first. But should he take the consent of the biological parents for the
destruction of the child.
These are thorny, difficult and controversial problems. All these
point out that a gynaecologist who recommends surrogacy has a
tremendously difficult decision to make and he/she has moral
responsibility for four persons infertile couple, surrogate and the
resulting child.
Fortunately in our country it will be quite some years hence that
the ethical problems of surrogacy will arise.
IVF Was Known and Practised in Ancient Times
IN the Mahabharata, Gandhari, wife of King Dhritarashtra,
conceived but the pregnancy prolonged for nearly two years; then
she delivered a mass (?Mole). Bhagwan Vyasa found that there were
101 cells which were normal in the mass. These cells were put in a
nutrient medium and were grown in vitro to full term. Of these, 100
developed into male children (Duryodhana, Duhshasana and the
other Kauravas) and one as a female child (Dussala).
There are other well quoted examples which refer to not only
IVF but that a male can produce a child without the help of a female.
Saga Gautama produced two children from his own semen a son
Kripa and a daughter Kripi, who were both test tube babies. Likewise,
Sage Bharadwaj produced Drona, later to be the teacher of the
Pandavas and Kauravas.
The story relating to the birth of
Drishtadyumna and Draupadi is even more interesting and reflects
the super natural powers of the Great Rishis King Draupada had
enmity with Dronacharya and desired to have a son strong enough to
kill Drona. He was given a medicine by a rishi and after collecting his
semen, processed it and suggested that AIH should be done for his
wife, who however refused. The Rishi then put the semen in a
118

yajnyakunda from which Dhrishtadyumna and Draupadi were born.

While the above are quoted as examples of IVF and
parthenogenesis, there is another story which refers to embryo
transfer. This was regarding the seventh pregnancy of Devaki, by the
will of the Lord, the embryo was transferred to the womb of Rohini,
the first wife of Vasudev, to prevent the baby being killed by Kansa.

119

HORMONES IN NORMAL AND PATHOLOGICAL CONDITIONS

The female hormones oestrogen and progesterone and the

male hormone testosterone though produced from different organs
are all synthesised from the blood cholesterol. All have a common
chemical ring. Depending upon the number of carbon atoms,
testosterone 19 and oestrogen 18 carbon atoms. The synthesis of
these hormones is done by simple but different enzymatic processes.
In the synthesis of oestrogens, progesterone or pregnanelone are
produced as an intermediate step and either they are converted to
oestrogen directly or at time male hormone androstenedione is
produced and then converted to oestrogen. This shows that these
hormones are very much inter-related. Either by removal of hydrogen
atom or by hydroxylation etc. by the enzymes, one or the other
hormones is produced. Also in the testosterone if one carbon atom
is removed at 19th position, it is called 19-nortestosterone. But the
action will be that of progesterone. If there is any fault in
steroidogenesis e.g. aromatization in the production of oestrogen,
more of androgenic hormone is also produced.
Another factor which governs the production of hormones by
the endocrines is what is called feedback phenomenon. At the
beginning of menstrual cycle the steroid hormones are low.
FSH follicle stimulating hormone produced by the pictuatary
acts upon the ovarian follicles and makes them produce oestrogen.
Oestrogen in turn inhibits FSH production, promotes LH (Leutinizing
Hormone) secretion which causes ovulation and corpus luteum
formation. Progresterone, which is produced by the corpus luteum
formation. Progesterone, which is produced by the corpus luteum
inhibits the further production of LH. In the absence of conception
both hormones oestrogen and progesterone are withdrawn and this
results in changes in the endometrium ultimately leading to
menstruation.
Menstruation is the end product of a chain of reactions starting
from hypothalamus in the brain acting upon the anterior pituitary
which produces two hormones FSH and LH and these in turn act on
120

gonads; i.e. ovaries which produces oestrogen and progesterone

acting upon uterine endometrium. If there is a break in this
hypothalamic pituitary gonadal uterine axis either the
menstruation does not occur producing a condition called
amenorrhoea (suppression of menstruation) or the periods may
become very profuse menorrhagia or they become irregular and
produce a condition called dysfunctional bleeding.
Menstruation is usually preceded by ovulation and corpus
luteum formation. For some unknown reasons this does not occur
and anovulatory menstrual cycles occur. Anovulatory cycles are
common in adolescence and before the menopause and the bleeding
is excessive and prolonged. Anovulatory cycles, if they occur during
the child bearing period cause infertility.
It should be noted that oestrogenes are called hormones of the
female. The growth and development of the female genital tract
depends upon the oestrogens. The feminity, the contours, texture of
the female skin and hair and the shape of the female form and the
development of the breasts are all due to oestrogens.
The growth and vascularity of the uterus and various
physiological changes in pregnancy are due to oestrogenes. By their
controlling effect on blood cholesterol oestrogens protect women
during reproductive period from myocardial infarction. While it is so
yet when the oestrogen production is not counter-checked, ovulation
and corpus luteum formation and progesterone production do not
occur. This leads to hyperoestrinism producing anovulation and
infertility, Stein-Leventhal syndrome or polycystic ovaries on one side
and endometrial hyperplasia producing abnormal and profuse
bleeding called dysfunctional uterine bleeding can occur at any agepuberty, child bearing period and premenopausal years. While
reversal of the condition with resumption of ovulation and
spontaneous cure occurs at time of puberty, and treatment with
drugs to induce ovulation and occurrence of pregnancy cures the
condition in child bearing period, only complete cessation of ovarian
function through a spontaneous or induced menopause cures the
condition at the premenopausal years. In extreme cases
hyperoestrinism can produce adenomatous hyperplasia and later
atypical leading to occurrence of the carcinoma of the endometrium
121

and ultimately leading to occurrence of the carcinoma of the

endometrium. Also if the oestrogens are taken continuously as in
hormone replacement therapy for menopausal symptoms, carcinoma
of the endometrium can occur.
This only shows that persons who are normally good and do lot
of good for others for some unknown reasons can change
especially when power comes to them and when cannot be checked,
Cause a number of problems. This only implies that one should work
within the limits prescribed but when once they cross the
physiological limits, they can become erratic in functioning and
behave pathologically.
Other hormones are also associated with hypo-or hyper-clinical
state. But oestrogens differ from others in that they produce and are
responsible for so many varieties of clinical conditions anovulation,
DUB, fibroids, endometriosis and carcinoma of the endometrium and
even carcinoma of the breast.

122

AMENORRHOEA
Amenorrhoea means without menstruation or absence of
menstruation. It is physiological before puberty and periods of
amenorrhoea lasting for 2-12 months during the first 1-2 years after
menarche are common in 50% of girls without any effect on their
fertility. Pregnancy is the commonest cause of secondary
amenorrhoea and suppression of menstruation is the leading
symptom of early pregnancy. Menstruation is usually suppressed for
varying periods after abortion and labour but especially by lactation
when the hypothalamic-pituitary system concentrates on the
production of prolactin rather than gonadotropins. Menopause comes
about when the ovaries, with all their Graffian follicles disappear and
fail to react to the gonadotrophic stimulus.
Pathological amenorrhoea : Amenorrhoea is a symptom and
not a disease. It is divided into 2 groups primary when periods are
not established by 16-17 years and secondary when a patient had
periods before and subsequently the periods have stopped.
Primary amenorrhoea most often is caused by gross errors in
the development of uterus and ovaries as following:
(a) Congenital absence or gross hypoplasia of the uterus a
pitiable condition where the growth, height and weight of the
patient are good, looks entirely feminine with good development
of a breasts etc and for no faults of hers the uterus is not
developed.
(b) Congenital aplasia of the ovaries Turners syndrome
due to chromosomal anomaly. These patients have only 45
chromosomes (instead of 46) including XO sex chromosome.
In many cases mother nature causes death of the fertilized
ovum leading to abortion. Those unfortunate who fail to abort
and continue to term and deliver, later in life present with this
syndrome which has the following features webneck, gross
carrying angle of the forearms, no development of secondary
sex characters and present with amenorrhoea.

123

(c) Congenital obstructive defects in the genital tract especially

non-canalization of the vagina called atresia of the vagina and
often associated with absence of the uterus.
(d) Other causes include intersexual disorder like testicular
feminization syndrome, hypopituatary dwarfism and hypothyroid
dwarfism.
In all the above nothing can be done and the patient has
to reconcile to her fate; except in 3 conditions:
(i) Atresia of the vagina : where a functioning vagina
can be made for sexual purpose but the patient cannot
conceive though she can have a very happy sexual life.
(ii) Imperforate hymen causing cryptomenorrhoea or
concealed menstruation but the patient presents with
amenorrhoea.
(iii) Testicular feminization, where the end organs are
insensitive to the male hormones and hence signs of
feminization occur.
From clinical and a ethical point of view it is the duty of every
gynaecologist to insist and do a pelvic examination and ultrasound
scanning in girls past 16 or 17 years presenting with a symptom of
primary amenorrhoea. Then only one can diagnose atresia of the
vagina or testicular feminization syndrome. Secondly, to advise the
parents not to get the girl married without letting the other party know
about her condition as in many cases this leads to the break-up of
the marriage. A functioning vagina should be created only a few
months before the marriage with the clear understanding on both the
sides that she will not have menstruation and that she cannot
conceive but can have a very happy sexual life.
PATHOLOGICAL AMENORRHOEA
The causes of Pathological Amenorrhoea are legion and
varied; and they reflect what we observe in every day life.

124

(a) Too much or too little or faulty production is not good. In

primary ovarian failure, too little of hormones are produced;
in premature ovary failure ovarian follicles get exhausted and
hence no hormone production occurs. Too much production
of oestrogen as in metropathia, functioning tumors of ovary or
excessive production of progesterone by corpus luteum cysts
produce amenorrhoea. Enzyme defects causing abnormal or
faulty steroidogenesis produces the syndrome of polycystic
ovaries.
(b) Under-nutrition or over-eating are both bad for health;
severe anaemia and malnutrition on one side, obesity and
diabetes on the other side, produce secondary amenorrhoea.
Slimming is good but enforced slimming to keep up the figure is
not good as in anorexia nervosa. Tuberculosis (Kshaya Roga)
gradually lessens the body resistance and completely destroys
the endometrium as well as the tubes of the uterus.
(c) Breast feeding is good both for mother and the baby. But
agin in prolonged lactation the hormones are suppressed
leading to a syndrome of amenorrhoea galactorrhoea called
Chairi-Frommel syndrome. In a similar way oral contraceptives
taken for a long time inhibit the hormone synthesis causing
amenorrhoea.
(d) Co-ordination is the keynote for successful accomplishment
of any work. A positive response is essential. In resistant
ovarian syndrome, ovaries do not respond to gonadotropins
from pituitary and endometrium can be refractory to the steroid
hormones and the end result is amenorrhoea.
(e) Stress tension and worry are the order of the day.
Amenorrhoea due to stress of work, tension before
examinations or stoppage of periods after hearing a shocking
or bad news are too commonly seen. Shock occurring after
obstructed (complicated child birth) labour or severe bleeding
after delivery (PPH)-produces necrosis of the anterior pituitary
by causing thrombosis/spasm of blood vessels supplying
the pituitary leading to pituitary failure and amenorrhoea.
(Sheehans syndrome).
125

(f) Overanxiousness to conceive in patients nearing menopause

as they know the time is running out may produce subjective
symptoms of pregnancy like amenorrhoea, morning sickness,
breast secretion, feeling of foetal movements. All these
imaginary symptoms occur in pseudocyesis where psychic
factors related to denial of the feminine role play a part in one
way or other.
(g) Amenorrhoea can be due to iatrogenic causes. Excessive
vigorous curettage probably after induced abortion leading
to destruction of the endometrium producing intra-uterine
synaechiae called Ashermans Syndrome which causes
amenorrhoea. Many illiterate woman complain of amenorrhoea
after an operation. On examination LO!! The uterus is absent as
it was removed and the patient was not aware of it.
(h) Lastly loss of love object has been reported to be
responsible, in vulnerable women, for raised emotional tension
leading to repression of the ovarian cycle and oligomenorrhoea
(Masani 1966). The hypothesis is strengthened by the
observation that large number of displaced persons from
Pakistan during the partition of India suffered from secondary
amenorrhoea. Loesex(1943) made a similar observation
in case of missed periods following aerial bombardment of
London in the 2nd World War.
Still the aetiological causes of pathological amenorrhoea are
incomplete. Only those relevant and observed in day to day life have
been listed.

126

DYSMENORRHOEA
Dysmemorrhoea means painful menstruation popularly
known as spasmodic dysmenorrhoea.
Pain is a subjective symptom and hence cannot be assessed
objectively. Different women react to the same pain in different ways
and in the same woman, the perception of pain varies with her
mental state.
Slight discomfort and pain during menstruation is common. In
dysmenorrhoea the pain is severe and colicky in nature accompanied
by abdominal distress, backache and radiates towards the thighs. In
very severe cases, in addition there may be nausea, vomiting,
migraine, tachycardia, anxiety attacks; the patient may go into a state
of shock or dissociative fits or fainting spells.
The incidence of dysmenorrhoea is affected by social status,
occupation and age. The inherent pain threshold varies from one
individual to another. N women who belong to the high social class,
who are delicate and suffer from emotional tension and anxiety and
are high strung, the pain threshold is low. Even a slight discomfort is
experienced as sever pain. A girl who is only child is more likely to
suffer from dysmenorrhoea.
Faulty outlook and upbringing play a very important role in
dysmenorrhoea. It is often said that A dysmenorrhoic mother usually
has a dysmenorrhoic daughter. Her outlook towards menstruation is
wrong. She is trained to treat menstrual period as an ill-time of the
month. The expectation of pain is fostered by over-anxious parents.
This is because the girl has not been explained and educated
regarding the physiological nature of menstruation. This knowledge
of physiology of sex, if given to the girl before menarche, the first
period does not come as bolt from the blue as she is mentally
prepared.
In some parts of our country she is also treated as an
untouchable, kept outside and segregated and is made to think that
she is not fit to mix up with people, let alone partaking in any religious
function. Is it not unfortunate that such a false belief should still exist
in our society? The girl gets a feeling of disgust and revolt and is
127

psychologically upset and this adds to the causation of pain.

Circumstances which lead to nervous tension make
dysmenorrhoea worse, even if they do not cause it. These include
unhappiness at home or work fear of losing an employment and
anxiety over examinations. It is said that marriage and child birth cure
dysmenorrhoea. Certainly marriage may cure by removing tension of
a long engagement and by providing happy security. Of late, may
patients are complaining of dysmenorrhoea for the first time after
marriage. Maladjustment, dissatisfaction with married life, ill
treatment by the in laws, impaired adaptation in the family are
important causes. Dysmenorrhoea is the outer manifestation of an
inner revolt or suffering. Denial of the feminine role in some cases
and in others dysmenorrhoea acts as a defence against being a
woman.
The problem of dysmenorrhoea is not the same everywhere.
Incidence of girls complaining of dysmenorrhoea considerably
decreased in the west due to various socio-cultural changes. The
increased freedom in expression of sexual needs and behaviour in
the west has lessened the psychological burden formerly imposed on
women. In the east, dysmenorrhoea is still a very commonly
encountered menstrual disorder. Considerable evidence has been
presented to suggest that dysmenorrhoea is likened to the
suppressed sexuality and social constraint on the expression of the
sexual needs in the eastern society. In one study, two thirds of the
patients complained of unsatisfactory sexual relationship along with
intense craving for sex. This may be so in married individuals.
In our country cases of dysmenorrhoea occur in young girls at
an age where their concentration is not so much on sex but on
academic courses and examinations etc. The dysmenorrhoea may
even be an excuse to avoid something which is disliked. Proper
upbringing of the children is very essential. And they also must be
taught the physiology of menstruation and that menstruation is the
sign of good health and not a period of ill health.
Dysmenorrhoea is also observed in women who are unmarried,
having a career or working in offices and leading a sedentary life.
Some of them have to work in order to support the families and may
128

be the only earning member. Parents in turn also do not even think of
getting them married. In a way it is a sort of sacrifice on the part of
these women. As our elders say that every thing should be done at
the correct time, so the marriage of girls at the right age is no
exception.

129

ENDOMETRIOSIS

Endometriosis is a condition when th3e endometrium is present

outside its normal habitat i.e. the mucous membrane lining the uterine
cavity. If the endometrium is present in the musculature of the uterine
cavity it is called as uterine endometriosis or Adenomyosis. If the
endometrial tissue is present outside the uterine cavity it is called as
the extra-uterine endometriosis. Extra uterine endometriosis can be
pelvic or extra pelvic and occurs in the following:Pelvic

Extra pelvic

Ovaries, tubes

umbilicus

pelvic peritoneum

laparotomy scars

cul-de-sac,

intestine, bladder

uterosacral ligaments

limbs (arms)

rectovaginal septum

sigmoid colon
Appendix thorax lung
Pleura endocardium

Of all the sites in the pelvic, ovarian endometriosis is the

commonest and next in order is in the pouch of Douglas. These are
the sites on which endometrium can fall and get implanted, when
there is retrograde menstruation through the fallopian tubes into the
pelvic cavity (Implantation theory). When once it gets implanted and
survives endometrium has a unique property; i.e in the prliferative
phase of menstrual cycle (first half) the endometrium proliferates and
in the secretory phase, it un dergoes secretory change and during
menstruation it bleeds. In that process it produces an inductor
substance and spreads to the surrounding areas. In the ovary it
invades the cortex of the ovary and burrows into it and forms a cyst
and as a result of repeated menstruation this cyst becomes enlarged
and is known as chocolate cyst of the ovary.
130

In the pelvic cavity in extreme cases the whole pelvic

peritoneum is affected with areas of haemorrhage followed by
puckering and scarring and the whole pelvis and become a frozen
pelvis as a result of endometriosis. As a result of these changes the
patient suffers from severe pain during periods i.e. dysmenorrhoea,
profuse bleeding i.e. menorrhagia and dyspareunia (pain during
intercourse). Even in remote areas like umbilicus it forms a nodule
which becomes gradually bigger with each menstruation and the
same occurs in other areas. If it affects the bladder there will be
haematuria during menstruation. It can produce symptoms of
intestinal obstruction if it affects small or large intestines or rectum.
In the uterus itself, bleeding of the endometrial glands in the
musculature of the uterus causes reactionary hypertrophy and
hyperplasia of the uterus. Uterus becomes bulky and enlarged and
may contain occasionally a tumour called endometrioma or
adenomyoma in the musculature. All these changes, as in cases of
pelvic endometriosis produce symptoms like menorrhagia and
dysmenorrhoea.
Endometriosis is essentially a disease of the child bearing
period. It does not occur before puberty and regresses after
menopause i.e. ovarian function is essential for its occurrence.
Whatever be the initial genesis of endometriosis, its further
development depends upon the presence of hormones mainly
oestrogens.
Apart from the implantation theory described above the theory
of coelomic metapalsia propounded by Meyer and Ivenoff explains
the occurrence of endometriosis. it is a strange embroyonic fact that
germinal epithelium of the ovary and the periotoneum musculature
and mucous memberane of the tubes and uterus is derived from the
same analge of the coelomic epithelium. Under some unknown
stimulus endocrine or otherwise, the peritoneal or gonadal epithelial
cells become differentiated and get invaginated to resemble uterine
mucosa or tubal mucosa. Meigs and Goodal suggested that the
cause of metaplasia of the coelomic epithelium is a continuous
hyperoestrinism a physiologic response to abnormal uninterrupted
menstrual cycles. They believe patients should not menstruate as
often as they do without a period of amenorrhoea associated with
131

pregnancy. They think that endometriosis is the penalty of our

present civilization and the economic factors which prevent early
marriage and frequent child bearing. They point out that we are
allowing young women in the privileged class to avoid pregnancy.
This in turn is conducive to sterility and endometriosis. In support of
this theory they brought out the well recognized fact of frequency of
endometriosis among patients of higher social and economic strata
of society as observed in private hospital records (4 times more) in
contrast to it incidence amongst patients in charity hospitals. Prof.
Meigs used to exhort all young women to get married early and have
the first baby early.
Thus endometriosis is a scourge of the private patients. These
women and others in the higher social group are also those likely to
postpone child bearing and present with symptoms of endometriosis.
Pregnancy causes atrophy of the endometirum chiefly through higher
progesterone level and cures the condition.
What was said nearly 40 years back by Prof Meigs is valid
even today. At one time endometriosis was not a problem in our
women but of late the incidence of pelvic endometriosis has
increased considerably in our own country because of late marriages
and conception.
Thus endometriosis is one of the most mysterious and
fascinating disorders. The disease owns a unique pathology of being
a benign proliferative growth process having the propensity to invade
normal surrounding tissue like a cancerous growth. Even in its own
house (swasthaan) it can invade the wombs musculature like a
cancer (or a carbuncle) and start producing problems even though
the endometrium and the musculature are derived from the same
coelomic epithelium. What is more, it can occur in the remote and far
off places in the body like thorax and upper limbs etc.; like cancer
metastasis as if the endometirum seems to be all powerful and
omnipresent.

132

GENITAL PROLAPSE
Prolapse is downward descent of vagina and uterus and is a
common and disabling condition.
The occurrence of prolapse implies failure of one or more
supports of the uterus or vagina. In 95% of cases of prolapse the
patient is multiparous implicating child bearing as an important
casual factor.
Supports of the uterus: There are two main supports of the uterus:
(a)

Muscular

(b)

Ligamentous

Muscular: The pelvic floor consists of two levator ani muscles.

These muscles have three parts Pubococcygeus, iliococcygeus
and ischiococygeus. The pubococygeus is the most important of the
three. Inner fibres of this (called peubo-rectalis) decussate below the
rectum and form a sling and these along with the anal sphincter that
contract and help at the end of defecation in everyday life.
They have no rest and relaxation and no spacing in between
pregnancies. Naturally their muscular and ligamentous strength will
be poor.
(c) Injury during child birth: Undue stretching of the pelvic floor,
application of foreceps or (vacuum) before full dialation of the cervix
causing overstretching or tear of the ligamentary supports; downward
pressure on the fundus during attempt to deliver the placenta;
laceration of the perineal body if unsutured will widen the hiatus
urogenitalis and also the delivery of a big baby. All these have
naturally an effect on muscle and money power; either the power is
weakened or exhausted in which case prolapse is bound to occur.
(d) Raised intra-abdominal pressure as it occurs in large
tumors like fibroids and ovarian cysts or sometimes due to chronic
cough etc. makes the power being pushed down by a heavy weight
constantly pressing downwards.

133

(e) Most of the prolapse cases usually occur after menopause.

Until that time the supports (both muscle and money power) remain
adequate but the atrophy which follows cessation of the ovarian
function is the final straw and is followed by prolapse within a few
years.
All the recent work point out to the conclusion that parturition
has the capacity to cause partial denervation of the pelvic floor and
that this is a substantial fact in the aetiology of prolapse.
Mother nature has provided a cushion of endopelvic facia for
the other two organs bladder and rectum which are put to the strain
of stretching (expansion and contraction) during everyday life. In
addition pubocervical ligaments support the bladder and the
puborectalis supports the rectum. If these are damaged during child
birth along with the uterus they also prolapse. If the bladder comes
down it is called cystocele and if the retum prolapses it is called
rectocele. If the levator plate is cut even complete rectal prolapse
occurs.
PREVENTION
This is one of the conditions where bad obstetrics leads to
gynaecological conditions. Proper care during pregnancy, careful
supervision and management of second stage of labour including
timely episiotomy or low forceps delivery if there is any delay at this
time; avoidance of Credes expression of the placenta in the third
stage and timely proper suturing of he perineal tears go a long way in
the prevention of prolapse. Early ambulation and post natal exercises
and advice regarding family planning and spacing are essential after
the delivery. In my opinion a maternity leave of three months is quite
inadequate and all pregnant women who are working in different
spheres should get at least six months of paid maternity leave to
recoup their health and also to look after their children.

134

MANAGEMENT

Of the many operations performed today for the treatment of

prolapse, vaginal hysterectomy and repair of the vault and pelvic
floor constitutes one of the most commonly accepted procedures.
Occasionally one may have to do a vaginal hysterectomy for a
benign condition called dysfunctional haemorrhage. In both the
above as we proceed from below we have to cut and suture the
uterosacral ligaments first, then Mackenordts next and the broad
ligaments afterwards to remove the uterus. In short, uterus can only
be removed after severing all its supports. As we cut each one of the
supports uterus comes more and more down. After removal of the
uterus, the gap has to be reconstituted by bringing all the ligaments
on both the side, and suture them together so that a buttress is
formed which prevents vault prolapse and after that the vagina is
sutured.
The same thing is being observe din todays practice more so
in politics. If any one has to be brought down all his supports are
withdrawn (ir cut) either by hook or by crook. In short the money and
muscle power withdrawal is the first essential step in the process.

135

OVARIAN TUMOURS
Cystic enlargement of one or other normal ovarian structures
is so common as to be regarded as physiological. It is rare to see the
ovary of a child or adult woman without one single cyst in it. The
mere finding of a small cyst in a ovary should not be regarded as
indicative of any significant pathology. Failure of the surgeons to
recognize this fundamental fact has led to many women having a
normal ovary removed in the course of appendicectomy. Many more
ovaries have been sacrificed for possessing a normal corpus luteum
Jeffcoate
Of late ultrasound scanning has become so frequent for the
diagnosis of various gynaecological conditions. The report often
shows one or other ovary slightly enlarged and cystic. It requires
a great understanding of the physiology and pathology of the
ovarian tumours before one should advice any surgery on these
patients.
OVARIAN NEOPLASMS
The ovary consist of sex cells which are totepotential and of
mysenchymal cells which are multipotential. So when the ovary
becomes neoplastic almost any sort of tumour can result. O other
organ in the whole body has this unique property. Some tumours
called Teratoma contain all types of epithelium ectodermal,
entodermal and mesodermal. The ovum has got the property of
even self fertilisation (parthenogenesis) and even chorionic tissue
or foetus can be present in the tumour. Is it not amazing?
Ovarian tumours can occur at any age and can be of any size
upto 50 kg or more. Malignancy does not depend upon the size of
the tumor. No ovarian tumor is to be taken as benign unless the
histological examination of the tumour is done.
OVARIAN TUMOURS
These can either be solid or cystic and some are both cystic
and solid. They can be benign or malignant. So long as the
tumour is within the pelvis it may not produce any symptoms. But
when the tumour grows-becomes moderate in size-then it
136

develops a pedicle and raises above the level of the pelvic brim.
Then the tumour acquires a much greater degree of mobility and
is therefore more prone to undergo torsion or axial rotation. It is
not uncommon for the tumour to be rotated through three or more
complete circles. Tumour becomes congested, internal
hemorrhages occur, adhesions form to intenstines or ormentum
and the cyst may become infected. These adhesions can
contribute to a new blood supply to the tumor, which when
severed from its original connection then becomes a parasite.
As I teach the subject to the students I am always reminded of
what is happening and what we see in everyday life. Whatever
may be the type of tumour-so long as it is in the protection of the
pelvis it does not undergo torsion; only when it develops a tail or
pedicle and when it comes out of pelvis and acquires mobility then
only this complication occurs. So long as the children are under
the protective influence of the parents (usually upto 10-12 class)
students do well. But once they go to the college, they get a
pedicle or a tail usually a moped or a motor cycle. The
atmosphere in the college is also such that they have so much
freedom to move about. Also the students who stay in the hostel
for the first time feel that they have freedom from the strict
observance at home. Then one sees all the complications like
torsion or axial rotation observed ion the ovarian tumours also
occurring in the students. The rock and rool starts, the twist
occurs, the break dance and disco follow leading some
unfortunate ones giving into the habit of taking drugs ec. And
ultimately leaving the parents and becoming one in the company
of others like the parasitic tumours. Howe easy it is to fall into bad
company! Most of the times it is the parents to be blamed for such
a mishap. They are occupied in their own social activities and
parties and the children often get neglected. In this most
vulnerable and crucial period in a students life the guidance and
attention of the parents are very essential if they want their
children to achieve something worthy in life.

137

CANCER OF CERVIX
Cancer of the Cervix is a disease with fascinating aetiology.
The exact cause of the cervical cancer is not known. However it is
interesting to understand the evolution of this cancer.
The vaginal portion of the cervix is lined by squamous
epithelium and the cervical canal by the columnar epithelium. The
demarcation between the two epithelia is the squamo-columnar
junction at the external os of the cervix. For some unknown
reason a war of attrition goes on between these two epithelia. In
the intra-uterine life in the earlier weeks the canal is lined by
transitional (squamous) epithelium. In the latter weeks of gestation
the columnar epithelium pushes the squamous epithelium right to
the external os and it times beyond the external os giving rise to
what is termed as congenital erosion of cervix.
When the woman grows up and gets married and becomes
pregnant, because of excessive production of hormones there can
be marked proliferation of the columnar epithelium, again
producing vascular erosion of cervix. As a result of infection of the
cervical anal the squamous epithelium becomes denuded, but is
quickly occupied by the columnar epithelium. However when the
infection is treated and the patient recovers, the squamous
epithelium pushes back the columnar epithelium into the cervical
canal. It does so by undermining the columnar epithelium. While
so doing, at times it blocks or invades the cervical glands. Thus
the junction of the two epithelial zones is a labile transformation
zone. Cervical carcinoma begins in this zone. The reserve cells
lying beneath the columnar epithelium at the squamo columnar
junction form metaplastic cells in the transformed into mature
epithelium but in some instances there is epithelial unrest and
become atypical change that precedes dysplasia and cancer.
This is how the cervical intracellular neoplasia starts. The
dysplasia is mild in the beginning, then becomes marked and later
becomes severe leading to carcinoma-in-situ or preinvasive
cancer and subsequently frank invasive cancer.
Cervical cancer is more common in low socio-economic class
and virtually non existent in celibate population. Its incidence is
138

more common in women whose coital activity and child bearing

start early.
There is an association of the disease with sexual behaviour
and although the age of first pregnancy, parity and promiscuity
all seen to be relevant aetiological factors, it is likely that an early
age of first intercourse is the most important factor.
An equally important factor is the number of sexual partners
and this appeared to be the case quite independent of the age of
first sexual intercourse. Rare incidence in nuns, Jews in whom the
male partners are circumcised indicate diminished risk of
exposure to smegma-though there is no evidence that smegma is
carchnogenic.
Again, high incidence is observed in women attending venereal
clinics due to Herpes Simplex virus and Human Papilloma virus.
Erosion of cervix, ectropion, trauma, endocervicitis are all
precursors of cancer of cervix.
It is unfortunate that in the pre-invasive stage there are no
symptoms at all. By the time symptoms like bleeding appear,
cancer already becomes invasive. The bleeding that occurs in
inter-menstrual bleeding superimposed on normal periods and it
also occurs after intercourse.
I really wonder as to why the Lord made spotting/bleeding as
the first symptom. Irregularities of periods is so common at this
age, many women think such type of bleeding is common before
menopause and the patient delays consulting the doctor. Also
many or our women are reluctant to get themselves examined and
are treated with drugs to control bleeding for quite some time and
in the end only to know that the disease is already advanced.
Pain is the last symptom to appear it occurs when the cancer
spreads to parametrium and affects the nerves splanchnic
plexus or when the cancer spreads to viscera like bladder ureter
or rectum. If only the Lord made pain the first symptom, many
women would have come to the hospital/gynaecologist earlier;
and the condition would have been diagnosed and treated at a
very early stage. Mysterious are the ways of Lord.
139

It is also the one cancer that by virtue of its accessibility can be

readily diagnosed even in the pre-invasive stage and if treated in
early stages can often be cured. Papinacalou who gave his name
to this Papsmear laid the foundation for preventive medicine at its
best. But how many practising doctors are doing a simple
speculum examination (visual screening) for their patients? By this
alone as many as 70% of cases of cancer cervix can be detected
at an early stage and many lives can be saved. If a routine
Papsmear cannot be done as a screening process it should be
done in all high risk cases and in those who have post coital
bleeding or there is bleeding after making a pelvic examination.
Any precancerous lesion like marked epidermadization,
dysplasia and basal cell hyperplasia and also in those women
having a severely infected cervix with marked erosion-especially
in women over 45 yrs of age, demand a hysterectomy.
What is amazing is that the two epithelia, the squamous
epithelium lining vaginal portion of cervix and the columnar
epithelium lining the cervical canal are both derived from the
same ceolomic epithelium children of the same mother. Even
then they are at war with each other from the beginning and the
line of demarcation or actual line of control is the squamocolumnar junction. This is what exactly is happening at our
countrys (Indo-Pak) borders today. In trying to take control of
others land some reserve cells which are normal otherwise
become militant grow up and this ultimately leads to insurgency
and finally develop into cancer.

140

DISEASES OF URINARY SYSTEM

There is a close relation between genitalia, urinary organs and
the uterus and its appendages during early intrauterine life.
Urinary tract anomalies are often associated with genital tract
developmental anomalies.
Anatomically, the bladder lies between the uterus and the
symphysis pubis, being separated from the body of the uterus by
the utero-vesical pouch of the peritoneum. The urethra passes
downwards and forwards from the base of the bladder behind the
symphysis pubis to end into the external meatus. The external
urinary meatus opens into the vestibule of the introitus below the
clitoris.
It is this closeness to the introitus that makes the urethra
vulnerable to infections like gonorrhoea, Chlamydia, trichomonas,
and candida and sexually transmitted diseases. Urethritis is a
common accompaniment of all these infections. Vigorous and
frequent intercourse often aggravates the problem. Honeymoon
cystitis is a distinct clinical entity following coital injury to urethra
and bladder base. Menopausal women who suffer from thinning of
the vaginal epithelium and mucosal lining due to oestrogen
deficiency are also susceptible to trauma and infection leading to
urethritis.
It is because of the same nearness of the urinary tract to the
genital tract that in certain gynaecological and obstetric conditions
like haematocolpos, retroverted gravid uterus, pelvic haematocele
in ruptured ectopic, tumours either fibroid or ovarian cysts
impacted in the pelvis or even in cases of marked procedentia of
the uterus, that retention of urine occurs.
The urinary system derives no benefit from pregnancy and
occasionally the reverse. Certain physiological and anatomical
changes occur as a result of pregnancy which may bring latent
pathology to light and may encourage the development of a fresh
urological handicap. In a previously healthy woman, control of
micturition may be undermined and subsequently recurrent
attacks of urinary infections originate in the urinary stasis an
141

inevitable part of normal physiology of pregnancy.

It is again due to the same nearness of the urinary tract, trauma
can occur during labour leading to descent of bladder cystocele,
urethrocele, etc. giving rise to various symptoms. An extreme form
of trauma can occur due to contracted pelvis or cephalo-pelvic
disproportion. In these cases the bladder gets compressed
between the foetal head and the pubic symphysis followed by
ischaemic necrosis of bladder. When the slough sepaerates, a
vesico-vaginal fistula occurs and the patient complains of constant
dribbling of urine and there is no control over the act of micturition
i.e. true incontinence of urine. Injury to the bladder followed by the
vesico-vaginal fistula can also occur after obstetric and
gynaecological operations. The duration of incontinence varies
from a few weeks in one patient to even as long as 25 years in
another patient. It is a miserable condition as the woman smells of
urine throughout and is often boycotted by her family and society.
This type of obstetric fistula is totally preventable by care during
pregnancy and labour.
The above condition denotes one thing, that the bladder cannot
stand any insult. It immediately stops functioning leading to
incontinence of urine irrespective of the fistula being a small or a
big one but the amazing part is even after so many years of
incontinence if the bladder can be cajoled and the fistula is
repaired and sutured successfully, bladder regains its tone
immediately and starts functioning. In short there is no disuse
atrophy in case of the bladder an exception to the rule.
It is also a paradox to observe that the bladder gets lazy when
day in and day out it is not evacuated (emptied) at regular
intervals as it occurs and is observed in working women who, for
some reason or other, had no time to go to the toilet the whole day
leading to so called Lazy Bladder Syndrome. These women are
being trained how to empty their bladder by exercises or
occasionally even by catheterisation. Does the above confirm the
old saying `A bladder makes a good servant but a bad master
and bad habits are easily acquired!.

142

It has been said in our Shastras there is a particular type of

dosham (blemish) called sahavasa dosham (blemish arising from
proximity). This occurs by being very close to someone, one may
have to suffer from the ill-effects of the other as is seen in case of
urinary tract subjected to infection and trauma by being very close
to the genital tract.
`Unequal combination is always disadvantageous to the
weaker side; said Oliver Goldsmith in Vicar of Wakefield in this
case, the urinary bladder.

143

PREMENSTRUAL TENSION

Most well adjusted women experience minor psychological and

somatic changes for a few days preceding menstruation. These
menstrual molimina give way to a sensation of well-being once
menstruation is established. Psychoneurotic woman incorporate
menstruation into their disorder, as they do unpleasant somatic
stimuli with the result that its general manifestations become
exaggerated to constitute a premenstrual or menstrual tension
state.
The condition is often observed in women aged 30-45 years.
The symptoms start 7-10 days premenstrually. The complaints are
varied and include irritability, lassitude, malaise, headache (a type
of migraine), gastro-intestinal upset such as colonic spasm and
constipation, frequency of micturition and a feeling of fullness in
the breast, abdomen and they also complain of insomnia,
emotional outburst and congestive dysmenorrhoea.
Whether the premenstrual tension is the cause of the individual
misery and family disharmony or the result of the above is not
clear. Certainly the stress of modern life, soaring cost of living and
one mans income not being sufficient to meet the expenses of the
household, all these tell upon the women there is nearly always a
fundamental constitutional and inherited weakness which makes
the individual fail to cope with the ordinary day to day stresses of
life.
In a few, the symptoms can be traced to some nervous shock
or domestic upset or a lurking suspicion about the husband being
unfaithful to her, trying to ring up and find out about his
whereabouts. In the bargain she nags and scolds the children and
becomes upset over even very small trivial things. These periodic
outbursts and moods result in quarrels between the husband and
wife which make the situation worse. It is the imaginative woman
living in her nerves who is most likely to suffer.
The third type of woman is a working woman who toils the
whole day in the office and has to work hard again in the house
144

looking after the husband and the children and in-laws who show
no sympathy for her.
Actual cause of PMT is not clear whether it is due to high
oestrogen or low progesterone or an imbalance between the two;
other factors include deficiency of vitamin B6.
Whatever be it, one should know that day to day life consists of
little things and one should not get upset and make a big mountain
of a mole hill. There will be periods of suffering and hardship; and
one should know how to bear them. There is no pleasure without
pain and they go together. At all times one should be content with
what one has (Santushtam satatam yogi Bagavad Geeta Ch. 12)
and the supreme faith in the Lord Almighty makes one cross over
the various hurdles of life.

145

MENOPAUSE

Menopause and climacteric are often used synonymously.

Menopause means cessation of menstruation and climacteric
means `ring of the ladder meaning crucial period of life.
Climacteric is the equivalent of perimenopause which may start 510 years before menopause and continue upto 5-10 years
afterwards.
The most characteristic symptom of the climacteric is the hot
flush: an uncomfortable and sometimes unbearable feeling of
intense heat of sudden onset usually arising in the trunk spreading
upwards towards the neck, face, and forehead and sometimes
over the whole body followed by intense sweating. When this
occurs at night, the patient is woken up and may be more aware
of sweating and complains of night sweats. Other symptoms
include headache, insomnia, depression, tension, irritability,
aggressiveness, nervous exhaustion, fluctuations in mood sense
of frustration and feeling of decreased energy and drive, reduced
powers of concentration and feeling of inadequacy and loneliness.
Many factors influence the approach to menopause like the
woman being single or married or childless or is surrounded by
grandchildren and happy family. For the barren and unmarried
woman menopause represents the end of the reproductive era.
Married women sometimes get worried by the idea that
menopause means the end of sexual desire and physical love.

Psychological response depends upon the social and cultural

background. In Arab countries menopause is welcome because
women are no longer regarded to be contaminated by menstrual
blood. In our country women with their philosophical attitude
welcome menopause as they are free from the periods
(menstruation is thought as a curse inflicted upon women) and
become no more untouchables and now fit for any religious
function (some temples cannot be visited by women in their
reproductive period). Women in this age group are being
146

respected and regarded as elders, and so also in some African

countries. Even so, because of ignorance and fallacious ideas
many women approach menopause with dread. They fear of
insanity, loss of feminity and beauty, loss of their husbands
affection and associate menopause with the development of
cancer. It is considered as a finger-post to old age.
As with the case of women with Premenstrual Tension
Syndrome, menopause is also a period of stress in the home.
Children are at an age when they cause much anxiety, (often
needless) and increasing expenses; they also go abroad for
higher studies, and the presence of girls yet to be married also
adds to the stress of their life. The husband as usual is busy with
his office/professional work. Women get a sense of frustration,
feeling of decreased energy and drive, reduced power of
concentration and feeling of loneliness and isolation Empty nest
Syndrome. All these are reflected in the changes of mood like
irritability, depression and tension etc.
In some, the thought that many of lifes expectations in terms of
money, marriage and position may never have been fulfilled. Truly
the patients problem is one of a mixture of hormone dependence
and life stress syndrome. It should be emphasized to women that
menopause represents a change of life and not the end of life.
Unless willed otherwise libido remains unchanged, women can
have satisfactory sex and menopause will not result in women
being suddenly looking aged and unattractive.
This period should not be regarded as the Vanaprastha(the
stage of life when elders retreat from family responsibilities and go
to live in forests in search of spiritual solace). Women should
utilize their time reading, attending religious discourses, doing
social work, spend time with the grandchildren, moulding them to
be good citizens of tomorrow. The attitude of the obstetrician in
general should be one of great sympathy and understanding in
removing their doubts and innate fears and impress upon them
that this is a period for achievement and maturity.
There is a gradual increase in aging population. It is expected
that by 2000 A.D., 5% in developing countries and 13% in
147

developed countries will be over 65 years of age. Women live

longer and it is important that their health status during 20-30
years of post menopausal period of life, is reasonably well
maintained. To that extent there is need to establish Mature
womens Clinics or Menopause Clinics where a physician,
psychiatrist and obstetrician and gynaecologist will look after
these women. The aim of these clinics is not only to treat
menopausal symptoms with hormone replacement therapy, (but
also prevent fractures and myocardial infarcts to which they are
more prone), also with a positive aim of enabling and encouraging
women to keep physically and mentally fit and to maintain
confidence, interest and zest for life so as to be better able to
enjoy a full and happy life into advanced age.
The syndrome of menopause is not confined to women only.
Men in their advanced age are also prone to the same reactions in
life. Perhaps the sudden though not unexpected retirement
with a drop in ones social status are factors comparable to the
problems of menopause that women face in their life.

148

CANCER OF THE BREAST : VITAL ROLE OF

GYNAECOLOGIST IN SCREENING & EARLY DIAGNOSIS
The thought of cancer of the breast reminds me of four cases.
Surprisingly three of them were doctors (of these, two being
gynaecologists) and the fourth the wife of a doctor. All of them
were hardly 40-45 years of age at the time of diagnosis. One of
the gynaecologists kept her condition secret (probably for fear of
publicity), to such a late stage, that bone metastasis occurred in
the vertebra. She had a pathological fracture while applying
forceps in a delivery case.
While it is so in doctors or with doctors wives, one can only
imaging how many more cases are being missed or diagnosed
late in other educated people, let alone uneducated and lay
people. Compared to other cancers, such as cancer of the cervix
or cancer of the ovary, the diagnosis should be easy and early as
the breasts are easily accessible for examination but it is not so
why? Is it because women neglect a small lump thinking it is of no
significance or do they feel shy to get their breasts examined or
they are afraid that if it turns out to be malignant, others will come
to know about it. Whatever may be the reason for late diagnosis,
one feels sad about it.
The breast is a part of the reproductive system and therefore
concerns the obstetrician and gynaecologist. One in five seeks
medical consultation for breast problem and one out of fifteen
patients is likely to develop breast carcinoma at some time during
her adult age. Considering that breast carcinoma is the second
commonest cancer (next only to cervical carcinoma) in our
country, the gynaecologist is in the best position to undertake the
responsibility of detecting suspicious lesions of the breast.
The mature female breast is vulnerable as it is a dynamic
endocrine target organ profoundly influenced by the fluctuations of
hormones oestrogen and progesterone of even the normal
menstrual cycle. It is again the hyper and/or continuous oestrogen
unchecked by progesterone that plays an important role in the
aetiology of breast cancer as it is evidenced that carcinoma of the
breast is more common in nulliparous women; women who had
149

early menarche or late menopause; association with endometrial

carcinoma and lastly, high incidence in those where there is
misuse of oestrogen in the desire for retaining feminity for ever. In
addition to the above, there is sufficient evidence to show that
cancer of the breast runs in families, implicating a genetic predisposition.
The gynaecologists role starts from advising the girls as to
the right age to get married; to have the first child at a younger age
and also encouraging the mother regarding breast feeding, as these
are protective factors against development of breast cancer.
The gynaecologist provides primary health care to many
women as it is he whom women consult whatever their problems are,
which include infertility work-up, contraceptive counselling, family
planning, pregnancy and lactation and any gynaecological problem at
the time of pre and post menopausal period. These offer an
important opportunity to provide women with the latest information
concerning breast diseases, more so to discuss risk factors regarding
breast cancer.
Physical examination of the breast and motivating the patient
for performing self-examination and to refer her to mammographic
screening are prime important things to be done for early diagnosis
of breast cancer.
Recent data have shown that breast self-examination is related
to earlier detection of cancer and improved survival rates. Herein lies
the importance of the gynaecologist to assume the role of an
educator in teaching women on systemic approach to selfexamination. These include advice as to when to do the examination
(preferably following menses as the breasts will be less tender and
enlarge), position of the patient, duration of palpation or search
period, the correct palpation technique of all quadrants of the breast
and the discrimination between normal and abnormal tissue and also
to encourage the patient to continue periodic and regular selfexamination. Importance of attention to areola and nipple should be
told. If present, the discharge should looked for quantity, viscosity,
colour and presence of blood and a cytological examination of the
discharge is imperative in such cases. Breast self-examination
150

should be made habit-forming by the age of twenty in high risk-prone

cases and certainly by the age of 35-40 in all women, and should be
mandatory in all who are on hormone replacement therapy for
menopausal symptoms.
It is now well established that mammography as a screening
method is the most accurate technique for detecting early stage
cases. Even lesions less that one centimetre and also clustered
microcalcifications associated with malignant lesions can be detected
by this imaging technique, while ultrasound is useful in differentiating
solid and ultracystic lesions and in enabling successful aspiration and
fine needle biopsy. Basal mammography at 35-40 years (and earlier
in patients at risk) and later every two to three years, upto the age of
fifty years and annually thereafter is advised.
What is needed today is to make people in general and women
in particular aware and conscious of how simple non-invasive
procedures like breast self-examination and mammography can
detect lesions of the breasts at an early stage. Stress should also be
laid on not neglecting even a tiny small nodule in the breast, even if
there are no symptoms and that any lump in the breast at any time
should be removed and biopsied Save the breast from cancer
campaign should be started and probably the establishment of the
institutions to care exclusively for the problems of the breast may go
a long way in saving most women who fall a victim to this most
common and dreaded condition of cancer of the breast.
In a broader perspective, safe motherhood should not only
involve in reduction of maternal mortality and morbidity but it should
encompass the total health care of all women including nutrition,
literacy, health education, family planning, community development
and integration of traditional and modern health-care systems
including prevention and early diagnosis of malignancies of female
genital tract and breast and thus should aim at improving the quality
and safety of the lives of girls and women.

151

SEX EDUCATION

Any consideration of sex education requires the understanding

of the changes that occur during adolescence and puberty.
Adolescence is the period of life during which a carefree child
becomes a responsible adult. The modern description of the
adolescence is the Teen ager. Puberty is a growth phase
characterised by physical sexual differentiation and by the onset of
activity of sex organs. It is really the first part of adolescence, the
remainder being concerned with mental and emotional adaptation to
sex function and with the development of full maturity. The menarche
is the onset of first menstruation and is one of the manifestations of
puberty.
Three important phenomena occur during this period:
(a) Physical growth; i.e. sudden spurt in stature just before or
after menarche.
(b) Sexual differentiation i.e. development of the breasts
and pubic and axilliary hair, the body contour change by the
deposition of fat.
(c) Development of the genital tract.
(d) The phase of active physical growth makes the girl
temporarily confused and embarrassed regarding the
change and she becomes awkward in her movements. Her
figure becomes more full and feminine as a result of surge
of hormones and her voice changes from the shrill voice
of childhood to that of slightly deeper and more melodious
of the adult. Soon she develops self consciousness, is
interested in her appearance, becomes more curious and
imaginative and also may be moody and secretive. Sex
gender identity occurs and as she grows up the curiosity
about sex increases and the sex urge becomes gradually
manifest.

152

While the girl regards herself as fully grown up, she looks for
independence and wants to assert herself in receiving and
obeying orders. She does not like to be snubbed. Yet physical and
emotional maturity are not attained until several years after
menarche.
Tact, proper advice, kindness, sympathy and due consideration
given for her views at the same time strictness within limits, go a
long way to ensure that a balanced adult emerges from this
testing period. Affection and trust should take place of commands.
She should be encouraged to be continually occupied in either
work or healthy recreation. The girls become very sensitive for any
comment regarding their figure, looks and the development of the
breasts. All parents must be ready to accept these changes and
guide them, and train them so that their daughter can in future
fulfil the role of a wife and as a mother. As such it is the parents
duty to explain to the girl regarding the onset of menarche, the
physiology of menstruation and the phenomena that accompany,
so that the girl can be primed as to what to expect and can accept
these with pride.
The onset of menstruation in a girl who is uninformed arouse
emotions of fear and shame and gives her a psychological shock
from which she never fully recovers. She should also be instructed
regarding the hygiene of menstruation. It should also be
emphasized that the first menstrual period is a sign post on the
road to maturity. She must be made to realise that though she
may look like a little girl, she is a woman because her body is old
enough to bear children and that menstruation is the outer
evidence of the reproductive cycle. Failure of the adolescent to
realise the implications of and potential dangers of sex can lead to
tragedy. Hence sex education should come naturally and
perceived through childhood. Any questions they may ask or the
doubts they get, should be answered simply but truthfully. Mothers
at home and teachers can play a great part in this and indeed sex
education should also be a part of general education of the child.
Children are never too young to learn something about sex and
they are especially curious about the matters of sex education
from a quite young age. If sex education is not imparted, pit-falls
can occur due to innocence and ignorance of sex, while others
153

many suffer from over emphasis of sex education. The uninhibited

adolescent who thinks she knows everything may also succumb
because she is not mature and cannot understand the implications
of sex. At any rate it should be emphasized that it is the girls who
always suffer from uninhibited and unprotected sex and they must
be imparted the knowledge of all the pitfalls which attend
unbridled urges.
Apart from the above some girls experience severe
dysmenorrhoea because their education and outlook is faulty. The
expectation of pain is fostered by over-anxious parents and by
curtailment of normal activities during menstruation. Later after
marriage the person can suffer from vaginismus causing severe
spasm of the sphincter vagina and thus the lower vagina is
practically closed and is the cause of dyspareunia. This often is
also accompanied by frigidity. One of the factors in the causation
of vaginismus and frigidity is faulty sex education. Other factors
include ignorance, initial painful and clumsy attempt at coitus (an
unfortunate experience such as criminal assault), or guilty
conscience over premarital sex experience, feat of pregnancy and
child birth and dread of veneral diseases. Most often in all these
nothing more than sex education of both the partners is all that is
necessary.
Unfortunately today sex education is being equated to what is
shown in the movies and films and young girls are being lured to
imitate the same not knowing the future consequences. Many
indulge in sex not realising that if they miss the period it is
probable that they are pregnant and do not consult the
gynaecologist till it is too late. Others take care by taking oral
contraceptive pills. Many more are undergoing medical
termination of pregnancy. It is appalling to see the number of
unmarried girls undergoing MTP the number is increasing day
by day.
What is essential today is:
Sex education in schools should be undertaken with great care.
Stress should be laid on emotional, philosophic and teleological
aspect of sex.
154

Nature intends the sex act to be sublime and instrumental in

keeping two human beings bound together and for the
continuation of species, and this more laudable objective seems to
have escaped the attention of the educators. Momentary sex
without emotional background is anti-social and against nature.
Studies in the west have clearly shown long term ill effects of the
modern culture there, resulting in divorce, suicide and drug
addiction amongst youth. It is the duly of the Government, the
parents and the teachers to inculcate our ethical values in sex
education in schools.

155

FAMILY PLANNING
Primary health care reaching the whole population is central to
the strategy for Health For All and family planning is an essential
element of this Primary health care.
- W.H.O.
The extensive differences that exist in cultural, religious and
personal attitudes as well as health and socio-economic status, tend
to reinforce the need for as wide a range of fertility control methods
as is technologically possible. Such measures must be personally
and culturally acceptable, convenient to use, safe, inexpensive, easy
to distribute and store, and sufficient in number to encompass the
change of life situations that may be experienced by the couple as
the partners progress in their respective years.
Despite the numerous advances in family planning that have
taken place in the last two or three decades, the need for highly
effective and acceptable method of contraception still exists.
There is no method which is 100% effective, completely
reversible, totally acceptable and absolutely free from side effects.
However unfortunately, contraception and sterilization are subjects
that have generated lot of controversy. What is written here is
designed only for the clinical gynaecologist and obstetrician but not
for others like sociologists, moralists and the like.
The Indian programme has relied heavily on sterilisation until
now as a measure of family planning. This approach is unlikely to
achieve the desired objective in population growth. It seems that
effective spacing methods should receive great emphasis in future
and every couple must make an informed choice as what they should
choose at different times i.e. for postponing the first child after
marriage, to space the second birth, limitation by a reversible method
for 5-8 yrs and then perhaps sterilization.
Regarding postponing the first childbirth after marriage a
caution has to be given. If the couple gets married late even. If the
couple gets married late even if they come for the advice for
postoponement of first child birth-out duty is to advise them to have
156

the baby early. As one knows the fertility rate drops with the advance
in age and conditions like endometriosis and fibroids etc are common
in these women. Even in young couples better to advice them some
sort of barrier contraceptive like a condom etc as they do not disturb
the normal menstrual cycle; even if they fail and the couple
conceives it is good for them. Also one should think twice before one
prescribes the oral contraceptives in women who have irregular and
scanty periods. While the pills produce a regular cycle, the bleeding
at the time of the period becomes less and scanty and these women
may develop the so called post pill amenorrhoea. They may even
blame the doctor for her not becoming pregnant even though the
cause can be some thing else. Oral contraceptives can be prescribed
for short periods in those having heavy periods and dysmenorrhoea
and in these women they have definitely a beneficial effect; even
here there is much to be said for the motto dont delay the first as
an axiom for al newly married couples as today very early marriages
are rare (except in one or two communities). If the couple conceive,
they not only proved to be fertile but it is a source of great
satisfaction and happiness in parents and in-laws. It is also equally
important that loop is strongly contra-indicated and should never be
prescribed in women seeking contraception before the first child
birth. In which cases it may produce PID (Pelvic Inflammatory
Disease), no one can predict and the tubes can get blocked in these
cases and the couple remain infertile later.
Regarding the second one i.e. spacing the second birth and
limitation by a reversible method by 5-8 yrs, here intra-uterine device
is ideal as it is a one time procedure. The patient can be motivated
well and persuaded by dispelling her apprehension regarding the
side effects. It is also seen that all pills are not the same and once a
particular patient has decided to use a contraceptive pill, the
physician has to advice them on the correct choice of pill suitable for
that particular individual. And of course a careful follow up of these
patients and advising them correctly on the various side effects they
produce is equally important.
Much controversy dogs regarding the use of injectables i.e long
action steroid preparations. They are attractive both to the physician
and the patient because of the convenience of use (as injectables
like Depomedroxy progesterone acetate are given once in 2-3
157

months). Of course they cannot be self administered, treatment

cannot be reversed in a very short time, often accompanied by
irregular bleeding, as well as a long and a variable delay in return to
fertility.
Subdermal implants containing progestins are being tried. The
advantage is that implants can deliver contraceptive levels of
progestin for upto five years or more. However apart from the side
effect of irregular bleeding, as the implants have a limited surface
area six or more rods must be used to achieve appropriate blood
levels of the hormones. This means several unacceptable surgical
sites for the users.
For science to progress and in trying to find out what is the best
and ideal and easily acceptable contraceptive such trials should go
on as in the case of indictable steroid preparations and intradermal
implants. Yet it is only ethical to explain to the patients and convince
them before embarking on these trials. In countries where these are
being used people have been happy. Howe the Indian population will
take them one has to wait and watch.
Another option in fertility control is to use drugs which act as
competitive inhibitors of progesterone, termed as `Morning After Pill.
Pregnancy can be prevented by giving large doses of oestrogens
within 72 hrs of unprotected coitus in the mid-cycle especially when
pregnancy is not desired. In spite of intense side effects like nausea
and vomiting which are of transitory nature the treatment proved
useful in 99% of cases.
Medicated intravaginal rings and intracervical pessaries are
being tried and oestrogens are added to progestin to circumvent
break-through bleeding. Yet again in the long term the effect of direct
release of oestrogen on vaginal mucosa and cervix is not known.
Much is in vogue regarding the usefulness of non-steroidal
contraceptives. Though quite encouraging results have been
published, it is too early to assess their potential for general
acceptance.
Regarding sterilization upon which the entire programme is
depending, there is no doubt that post partum tubectomy is ideal and
158

simple. It is easy to approach the tubes with a small incision as the

fundus of the uterus is high up in the abdomen. It is good in those
women having three or more children. Many young couple are
requesting today for the sterilization operation even after only one
child, basing their argument that to have one more child is a luxury
that they cannot afford in these days of escalating cost of living. In
these one has to think twice before doing tubectomy, in the
immediate post partum period as it is not a reversible method. It is
better to advice the couple to use either barrier method or pill or loop
till the children grow and develop resistance and do an interval
sterilization by doing tubal ligation by the laparoscopic method. It is
not uncommon to hear that the only child of a couple either died as a
result of accident or disease.
None is against the target oriented and mass sterilization
operations done in camps. It looks as though to tell the public that so
many operations are being done by various agencies organizing
them (Governmental or voluntary) and for the operating surgeons
(each one of them) to say and claim to have done so many per day
and one vying with the other for the shortest time taken for each
case. Every one would like to compliment them. But in the bargain,
overconfidence and the quick turnover led to the round ligament
being cauterized or clipped and thus resulting in many failures. Also
in these camps the patients are not being screened properly as to
whether they are fit for the operation or not, adequate sterilization
safeguards are not adopted and also the patients are not properly
looked after in the post-operative period. No wonder quite a few post
tubectomy deaths are still reported even now and imagine what will
happen to the family and the fate of the kids who become motherless
and nobody will be there to look after them. It is all the more tragic as
usually these patients are very young and healthy and have no other
complaints and the operation is just done only for family planning.
What is more important today is not only the number operated in the
camps but also the quality of service given and the care of the
patients taken.
Occasionally the question arises as to the role of hysterectomy
as a family planning procedure. I cannot add anything more then
what is written in Wiliams Obstetrics 1993 regarding this for a
woman who desires no more children hysterectomy has many
159

theoretical advantages. The only known potential of the uterus, other

than child bearing is to harbour disease. In the absence of uterine or
pelvic disease, hysterectomy for sterilization at the time of
Caesarean delivery, early in puerperium or even remote from
pregnancy is difficult to justify. Mortality rates from hysterectomy vary
from
5-25/10000 in women in the age group of 35-44 (Wing &
Colleagues 1985). With Caesarean hysterectomy blood loss nearly
always is greater than Caesarean plus tubal sterilization leading to
much more frequent use of transfusions and their sequelae. Urinary
tract injury is also appreciably more common.
As such, hysterectomy as a family planning procedure is not
ethical or moral and one should not do it. However the question is
asked whether hysterectomy can be done in mentally retarded
patients who though their chronological age is 20 yrs or more yet
they have a mental age of three or four years. They cannot look after
themselves in day to-day living and cannot observe menstrual
hygiene. In such cases if the parents request the obstetrician and
gynaecologist, and the psychiatrist opines regarding the mental
status of the patient, hysterectomy can be done. Here the
obstetrician or the gynaecologist is only helping the parents to look
after their child better. Of course, it is not done as a family planning
procedure but as health measure giving due consideration to the
mental of the patient.
Lastly it is very disturbing to note that many of our people
prefer to have an MTP rather than using any one of the family
planning procedures. It is very sad to observed the number of
terminations done. MTP is advocated as a health measure but not as
a family planning measure. In the interest of the mothers health
concurrent contraception should be advised/insisted ethically and
morally by the obstetrician and gynaecologist whenever he does an
MTP.
Vasectomy in the male at one time was a popular method. It is
a matter of concern that there is a decline in the number of men
opting for vasectomy today. Is it not more ethical to persuade men
and make them accept this procedure which is simple and can be
done as an out patient procedure under local anaesthesia. But men
still have a lingering feeling and doubt, that their virility gets
160

diminished after the operation and it is indeed a great task convincing

them and dispelling their apprehension and make them agree for this
simple and harmless procedure.
Since many years trials are going on regarding the possible
role of use of vaccine against HCG (Human Chorionic Gonadotrophic
hormone) as a contraceptive measure. HCG is very essential for the
induction of ovulation (as it has the same action as LH (luteinising
hormone) and also for the survival of corpus luteum and production
of progesterone which is very essential for continuation of pregnancy.
Vaccine against CG theoretically should be an ideal method for
conception control. Trials in India showed very promising results and
control of conception was achieved. Results from abroad were not
encouraging and they also pointed out that because of the cross
reaction with LH in the body some possible long term side effects
may occur. Even though there is a lot of apprehension regarding the
use of vaccine, yet it is only fair to continue the trials in well-informed
volunteers prepared for the trials and such trials cannot be called
unethical.
Family planning should become a way of life for all of us.
Importance of family planning and family welfare should be stressed
and ingrained in everyones mind today. There is no salvation for our
country unless the population growth is checked. It is the ethical and
the moral duty of everyone in our country (whatever may be the
sphere or walk of life, to observe and propagate family planning.
However it must be said that family planning and integrated child
health programme should and must go hand in hand if one wants to
achieve the objective meant for i.e. HEALTH FOR ALL.
There have been several surveys around the world indicating
that female education achieves two important goals increasing the
age of marriage; enhancing employment opportunities thus raising
their economic status. In short, female education is the best
contraceptive and is the master key to the problem of population
growth. The above is amply illustrated in the highly literate states of
India like Kerala, Maharashtra and Tamil Nadu, which have a low
birth rate.

161

At the end I cant but resist to mention what Late Dr VN

Shirodhar in his characteristic humorous way regarding family
planning giving the example of the three monkeys See not evil, hear
not evil, speak not evil and the last one make not evil.
N.B.: There was a big hue and cry regarding the hysterectomy
operations performed on young mentally retarded girls. No text book
of gynaecology mentions that hysterectomy should be done in such
cases. I have already explained there is nothing unethical in doing
hysterectomy to such unfortunate ones provided the psychiatrist
approves and when the parents come and request for the same. The
above operations should be done in the routine course as it is the
prime duty of everyone to help these unfortunate girls. It is written in
our scriptures that while trying to help somebody, even the left hand
should not know what the right hand is doing and much help can be
given quietly without any fanfare etc.

162

THE WOMB - A SAGA OF ECSTASY AND SACRIFICE

Situated nicely in the female pelvis the womb or uterus (along
with its intimate friends the fallopian bubes and the ovaries) enjoys a
special status. It is supported by two broad ligaments and round
ligaments which attach it to the lateral pelvic wall and also be the
muscle levator ani and the special structures called retinacula which
keep it in its position.
As the child grows the womb along with the obaries grows so
as to be ready for the purpose for which they are created (to play a
great part in reproduction); so that this progeny (parampara) goes on
and on and the world consists of live human-beings. If the uterus is
not developed or absent no pregnancy occurs. Mother nature has
designated the uterus as the most privileged organ to carry the
pregnancy to term.
To achieve the above goal, from the time of puberty the
uterus cooperates with the ovaries and also with the pituitary and
hypothalamus in the brain forms what is called Hypothalamuspituitary-ovarian-uterine axis. Every month the lining membrane of
the uterus ie endometrium reacts to the hormones produced by the
ovary produces a nice bed for the fertilized ovum to come and get
implanted. However when the ovum is not fertilized the uterus gets
disheartened and weeps and produces bleeding called menstruation.
Women menstruate because they do not conceive. Every month this
goes on and on till the woman gets married and plans to conceive.
After marriage along with the cervix and vagina it helps to
produce secretions, relaxes and stretches so that the couple can
enjoy fully the marital bliss. The uterus is so obsessed in its desire to
get and beget children, that when it is deprived of pregnancies it
consoles itself with myomas or fibroids (tumours of the uterus). Prof
Jeffcoate puts it, fibroids are the result of virtue and babies are the
fruit of sin.. He has further added, Deferment of pregnancy
encourages fibroids and fibroids then discourage pregnancy.
When once conception occurs and the fertilized ovum gets
implanted in the endometrium, the uterus gears up to take the
pregnancy to full term of 40 weeks (9 months and 7 days). To that
163

extent it enlarges and distends with each month of pregnancy, comes

out of the pelvic cavity so that the foetus has enough space to move
about. In the process the musculature of the uterus becomes soft
and elastic losing its firmness; the blood vessels become engorged
giving more blood supply to the growing uterus so that the baby
gets all nourishment for its growth and development. The mouth of
the womb ie cervix is a closed organ with its muscle and fibrous
tissue having a grip and provide tight security so that pregnancy does
not get terminated prematurely.
When the patient goes into labour, the uterus with its
musculature rearranges and acts in such a way that the uterus
develops in two segments for the descent and for accommodating
the foetus. The action of the uterus is so synchronous that the upper
segment contracts, pushes the baby down and the lower segment
expands to accommodate the baby and the cervix loses its identity
upper part, internal os becomes one with the uterus above and the
lower part, external os dilates fully so that the uterus cervix and
vagina form what is called parturient canal for the safe passage of
the foetus from inside the uterine cavity to the outside world the
shortest journey (a human being takes in life) by the most vulnerable
journey in life, because on the safe delivery lies the future well being
of the foetus.
AS soon as the labour is over, the uterus and its musculature
contract in such a way that no danger occurs to the mother from the
bleeding that follows after delivery. In a short time of two months the
uterus gets involuted and become small and comes back to the
original state. No organ in the whole body is so unique in its various
diverse functions such as helping a married life, protecting the child
and safely delivering a healthy child for the happiness of the couple
and one and all.
While the ovarian hormone oestrogen is responsible for the
feminity of the women like soft skin, contours of the body,
development of the breasts, growth of the hair on the head etc the
uterus is also given an equal share in all these. People have a
conception that everything the women has ie physical body as well
as mental attributes are due to the uterus. Their anger, the change of
mood, the temperament, the vanity, jealousy, pride and intolerance
164

for other women are thought to be originated because of the uterus.

It is often said in the Army that the wife of the colonel behaves like a
brigadier. Even so in civil life the same thing happens in the
behaviour of the women with regard to their attitude towards
subordinate staff. AS seen in the vagaries of the uterine contractions
during labour, all these are attributed to the unpredictable nature of
women. Anyone having such attributes and behaviour are called
hysterical. (Hysteria means uterus).
Frailty thy name is woman says Shakespeare in Hamlet. One
wonders if vanity also goes with frailty. It is a common observation
that most women put their plait in front (even if it is small like a ponytail). Does it also indicate vanity and ego which sustain them in spite
of the odds and vicissitudes they have to go through in life. Perhaps,
their very strength lies in their frailty.
While giving happiness to the lady, none realizes what troubles
the uterus has to undergo; the trauma and the torture it has to bear. If
the periods do not occure (amenorrhoea), if they are painful
(dysmenorrhoea) and the periods are profuse (menorrhagia) in all
these the fault is somewhere, yet the uterus is blamed and the
operation of D&C (Dilatation of cervix & curettage) is done on the
uterus, rightly or wrongly. MTP permissible under law, has become
the fashion of the day and repeated curettings are done. While so
doing, the cervix also gets traumatized. Occasionally a drastic
curettage can cause intrauterine adhesions and periods may stop.
The uterus and the cervix are the targets of infection by sexually
transmitted diseases which, sometimes produce severe transmitted
diseases which, sometimes produce severe damage to the entire
female generative tract.
Certain amount of trauma occurs to the cervix even after
normal vaginal delivery more so after operative procedures. All the
supports of the uterus become slack and their tone becomes less.
Uterus normally requires a rest period to recoup after delivery.
If the pregnancies are not spaced and the tone of the muscles is not
restored it may lead to descent of the uterus ie prolapse.

165

The uterus also bears the insults inflicted upon it. In case of
premature deliveries a stitch is put on cervix. If the labour is
prolonged, operative delivery like forceps application can cause
trauma to the uterus and cervix. Sometimes the baby is delivered by
caesarean section with an incision in lower uterine segment. If timely
help is not rendered uterus may even rupture. One if a caesarean is
done, because of the danger of the rupture of the scar repeat
caesarean is performed.
If the patient is having backache and white discharge and if the
cervix is infected or an erosion is present, in the name of treatment,
the cervix is burnt with electric or diathermy cautery. At times cone of
the cervix is removed.
In patients who are infertile, if per chance the uterus is
backward in position (retroverted uterus), operation is done to make
it anteverted. It has to bear with patience procedures like
salpingogram or even hysteroscopy let alone endometrial biopsy or
curettage done as investigative procedures. Surgical operations like
myomectomy (removal of fibroid), and plastic operations for
correction of uterine and tubal anomalies are done all for in the
name of treatment of infertility.
After delivery in the name of family planning loop is introdueced
in the cavity of the uterus. Uterus does not like it yet it accepts it.
The loop in turn causes local disturbances and produces more
bleeding during periods and also occasionally causes infection of the
genital tract.
After delivery in the name of family planning loop is introduced
in the cavity of the uterus. Uterus does not like it yet it accepts it.
The loop in turn causes local disturbances and produces more
bleeding during periods and also occasional causes infection of the
genital tract.
As the woman becomes older and comes to the age of 35 to 40
years the stress and strain of life today is such that they get
premenstrual tension, oedema, heaviness in the breasts and
irritability etc and the uterus is blamed for these. After tubectomy
operation done as part of family planning procedure if there is a
166

abdominal pain the operation as well as the uterus are blamed.

Lower abdominal pain can be due to problems in the gastro-intestinal
or urinary tract yet the fault is ascribed to the uterus. Irregular profuse
and prolonged bleeding occurs in some women at the
perimenopausal age. The uterus is only slightly bulky yet though the
cause is hormonal the brunt fall s on the uterus.
In both the above, if there are two children or more in the family
the uterus is thought to have served its purpose for which it is
created and is discarded and a hysterectomy is done in many a case
in the name of treating the patient as well as in the prevention of
development of cancer of the uterus. If there is an erosion on the
cervix the uterus is removed in the name of possible development of
cancer of the mouth of the womb ie cervix.
Many a times the uterus is sacrificed for no reason or for a very
trivial one. The uterus is made the scapegoat for all women troubles.
If she is having constant headache, gases, uneasiness and pain in
the lower abdomen, white discharge even if it is due to vaginal
infection or constant backache-in all these the uterus is at fault.
Removal of the uterus has become a panacea in the treatment for all
women troubles. Even in the modern technique of laparoscopic
hysterectomy uterus was pierced and tramatized first before it was
removed. My Guru Dr BN Purandare, a master in vaginal surgery
used to remove the uterus through the vaginal route in a very short
time without any scar. I cannot just understand why we should
traumatize it while removal. However removal of the uterus has
become a status symbol in women. Women who got operated feel
that they belong to a different and higher class than others! In most
of the cases where hysterectomy is done even for bleeding cases the
pathological report often shows the uterus, endometrium and the
cervix normal.
Uterus, more than any organ in the human body except,
perhaps vermiform appendix and tonsil is most susceptible for
operative removal for no justifiable reason clinically or pathologically.
The number of hysterectomies that are being performed now are
colossal. In some parts of our country it is often rare to meet a
woman over thirty with her uterus in its place! It should not be that
while teaching the students regarding the indications for
167

hysterectomy, presence of the uterus as an indication and absence

of the uterus as a contra-indication.
Whenever I think of the role of the uterus, I am reminded of the
story of a tree and a young boy narrated by Osho Rajneesh in one of
his discourses. The tree loved the boy so much that it allowed him to
play on its branches and give fruit to him. Later when the boy, now a
man, was in need of money, it asked him to pluck its fruit and sell
them. When he wanted to build a house, the tree asked him to cut its
branches and use the wood for the roof. Later, the tree even allowed
him to cut its trunk to make a boat so that the man could go to far off
places to earn. In the bargain the tree was reduced to a small trunk
and yet, it was always thinking of the safety and welfare of the man.
The tree sacrified everything of itself for the man and did not take
anything in return. This tree is like to proverbial Kalpavriksha in our
mythology and like it, the uterus too wants to give and does not want
to take and a even prepared for any sacrifice including its own
removal if that be in the interest and the welfare of the person. What
applied to the uterus by and large applies to the women in
general and mothers in particular. Their role in day-to-day life is one
of Nishkam Karmayoga. They only given and do not take. They have
their periods of ecstasy and periods of suffering and sacrifice.
Nishkam Karmayoga indeed gives all your duties an essence of
sacrifice, be it a success or a failure! Everything is devotedly
dedicated to Him! That is how the uterus also is functioning in the
cause of Humanity. Like a sthitaprajnya, it continues to function
regardless of success of pregnancy or sex of foetus!

168

THE OBSTETRICIAN & GYNAECOLOGIST : TRIMURTI OR

DATTATREYA

Obstetrics and Gynaecology is a fascinating innovative and

progressive branch of medicine encompassing two acute specialities
and combining medicine and surgery with the excitement of
midwifery.
In no other branch of medicine one gets the chance to play a
unique triple role except inobstetrics and gynaecology. In assisted
reproduction in cases of infertility he plays the role of Lord Brahma
(Creator), in helping pregnant women to pass through safe
pregnancy and labour he plays the role of Lord Vishnu(protector) and
by terminating pregnancy in cases of congenital foetal anomalies or
even in medical termination of pregnancy or occasionally to save
mothers in case of obstructed labour he may have to do destruction
of foetus and thus playing the role of Lord Shiva (Destroyer). In that
way he is thrice blessed and indeed he is three in one TRIMURTI
or DATTATREYA.
The transcendent objective of obstetrics is that every
pregnancy be wanted, and that it culminate in a healthy mother and a
healthy baby. Obstertircs strives to minimize the number of women
and infants who die as a result of the reproductive process or who
are left physically, intellectually or emotionally injured from the
process. Obstetrics is further concerned with the number and
spacing of children so that both mother and offspring, indeed all the
family, may enjoy optimal physical and emotional well-being. Finally,
obstetric strives to analyze and influence the social factors that
impinge on reproductive efficiency.
Williams Obstetrics 19th edition 1993
With the advent of ultrasound, more than ever before the
present day obstetrician is able to look for and diagnose congenital
anomalies of the foetus, intra-uterine growth retardation, placenta
praevia etc and initiate appropriate line of treatment.

169

Gone are the days when masterly inactivity and wait and watch
policy of tincture of time; they are now replaced by active
management of labour. With the help of Doppler (foetal monitor() he
can recognize foetal distress early, by careful examination and follow
up with help of partograms, will be able to detect dysfunctional
labour, dilatation of cervix and descent of the presenting part, and
can ensure the treatment at the right time. The problem today is to
maintain a balanced perspective towards vaginal and abdominal
route of delivery in complicated cases. Obstetrician must never
assume that parturition is normal until after safe delivery. One should
not be led away by the request for speedy delivery. The obstetrician
is likened to a mridangam (drum), which is beaten on both the sides.
He can be blamed for too early or to late intervention. Only be
experience and a balanced consideration of all circumstances will the
obstetrician learn how to act in a particular case, and each case is a
specific problem. It would be a sad day for prospective mothers if
caesarean sections were to run prior and indiscriminately employed
for complications which can as well be treated by ordinary vaginal
procedures.
In obstetric emergencies, where one has to deal with very poor
risk cases (for example cases of acute rupture of an ectopic
gestation, uncontrolled eclamptic convulsions, severe cases of
antepartum haemorrhage or cases of rupture of uterus as a result of
obstructed labour, severe post-partum haemorrhage after labour or
even trying to deliver a breech baby, - the obstetrician has to walk on
a razors edge (between devil on one side and deep sea on the other)
and take a mature judgement in these cases. In all such case the
`attitude of the obstetrician should be one of calm, cool and collected
like a cucumber and he should not get perturbed and should do
everything possible to save the patients. Whatever be the outcome in
a particular case his/her mind should be clear. I am remined of what I
read as a student Polonius advised his son (in Shakespeares
Hamlet) The above all to thine own self be true. And it must follow as
the night the day. Thou canst not then be false to any man.
Everything he or she does should be perfect and conform to the
situation. Even if one has to apply forceps either for prolonged
second stage of labour or for foetal distress, I always kept in my mind
what late Prof FJ Brown (a great teacher) advised keeping the
170

blades in hand the obstetrician should put the question to himself

whether all conditions are satisfied for safe application. The two
blades of the forceps are meant one for the foetal distress and one
for maternal distress. I wish to add that one is for foetal health and
the other for maternal health. For the preservation of safe
motherhood, it is also the duty of the obstetrician to train and arrange
courses for birth attendants, midwifes and MCH doctors at the
corresponding level of care in the prevention and management of the
causes of maternal death. He should also supervise their work and
take overall responsibility with regard to the obstetric care of the
patients.
Let alone this because of things as they stand today, the
tendency is to practice defensive medicine. Unfortunately the whole
medical profession is caught up in the web of defensive medicine,
which is its own creation. It is painful to see the number of needless
tests or investigations done for any case today and the attitude of
taking no risk is one of the main reasons for the increasing number of
caesarean sections done today and trainees in obstetrics are
deprived of the skilful art of obstetric manoeuvres. When I was a
house surgeon a bell was rung whenever a caesarean section was
done so that every doctor could come and see it. Days are not far off
when a similar bell would be rung in future when a normal delivery is
going to take place. It is the duty of the teaching faculty of our
speciality to uphold the traditions on one side and learn the newer
methods and techniques on the other side and hand over them to the
younger generations. It is also equally important that the teaching
and treating the patients should go together. It is unethical to teach
one thing and not follow the same in treating the patients. There is an
old proverb Yatha Raja, Tatha Praja (as the King so are the People).
Days have come when all practising obstetricians should get
well acquainted and have thorough training in the wide spectrum of
non-invasive diagnostic gadgets, especially sonography (including
trans-vaginal method. This helps in a long way not only in the
prophylaxis but also in the detection of various obstetric and
gynaecological conditions at a very early stage.
Also, it is imperative that those who intend to specialise in
endoscopic surgery should get thorough training in all respects in
171

well recognized Institutes where there are updated facilities including

trained surgeons anaesthetists and nursing personnel. This is all the
more applicable to teaching staff in all medical colleges and hospitals
who in turn should impart training in their respective institutes. It is
gratifying to note that so many workshops are being arranged for
giving training in endoscopic surgery. However, it is only ethical that
there should be set guidelines regarding the type of surgical
procedure to be performed endoscopically and the expertise level to
be required of those who would like to practice them. Patient
selection and surgeons own assessment of his surgical skill and
critical approach are very important. It is only then that this type of
qualified medical care will be available to a vast majority of the
people which in present day seems to be quite inaccessible.
By properly giving the appropriate contraceptive advise and
advising the patient to take post natal exercises and good nutrition,
the obstetrician gynaecologist can maintain and preserve maternal
health after delivery.
In the present day context the word gynaecology conveys no
conception of disease and hence no more disease of women of
diseases of female generative tract. The word Logas is interpreted as
lore. Hence gynaecology is the lore of women and understanding,
a far as possible, of their psychological, physical and functional
phenomena from cradle to grave, but specifically of the delicately
balanced epochs of puberty, pregnancy and menopause. To this
must unfortunately be added their pathology, but this should not be
permitted to dominate the problem picture of womens whole life and
well-being. In this respect the obstetrician gynaecologist with proper
understanding of their problems and by giving appropriate treatment
with kindness sympathy and affection, can to a great extent alleviate
their problems. Thus the obstetrician gynaecologist can contribute
positively for maintenance of maternal health. All women whatever
their age may be, are mothers some are mothers of the future,
some present and others continue to be mothers. No consideration of
maternal health is complete without an integrated child health
programme and only the combined health of both represents the
health of the nation.

172

Every surgical operation is a delicately conducted experiment

in physiology with the greatest solicitude of the welfare of the patient.
- J. Jefferson, Neurosurgeon.

173

EPILOGUE
A philosopher, when once asked as to what is the most
important event that is occurring in the world, his immediate reply
was Change and that change is the essential phenomenon that
occurs at all times in every field. Old order old ideas are discarded
and replaced by new ones.
Even in the field of medicine new diagnostic tools have been
invented, concepts regarding causation of diseases changed, let
alone thinking and management. We are entering an era where
robots are going to play a very important role in future.
Amongst all these changes and in new innovations, there is
only One Person, The Lord or Paramatma or Brahman, in this
universe who has no change, no birth nor death, Who is beyond
time and space and controls the Maya or illusion and Who is allpervading, and Who has taken seat in the hearts of every being and
along with Prakriti is responsible for the occurrence of every thing
including the very existence of this universe.
A review of what has been written only points out that without
His Divine Dispensation and Grace, conception and pregnancies
do not occur. For the preservation and welfare of mankind (so as
to protect and prevent the foetus in utero being immunologically
rejected, the Lord does not mind violating His own laws if that is
essential for the continuation of human race. Lord always thinks
of Lokakalyanam (universal welfare) and while doing so He taught
the world the importance of two powerful weapons Tolerance and
Acceptance.
What determines the future sex of a baby is not known nor
does one know what exactly is the cause of onset of labour. This
only shows that man has no control on anything in life. One cannot
select their future parents, let alone the place and time of delivery and
equally important the time and mode of death. All these are in the
hands of the Lord Almighty and all one should do is to prayer, puja,
namasmarana, mediation and good deeds in this life which, to some
174

extent, helpto get the grace and blessings of the Lord.

Prakriti or Shakti or the energy plays an equally important role
in the survival and continuation of the human race. Pregnancy is
physiological and mother nature does everything for its safety. Yet
stree or mother which represents Prakriti has to bear and forbear
throughout; at times the period can be trying on the pat of the mother
and requires lot of patience and perseverance. Pregnant mother is
the custodian of the future health of the nation and mother sacrifices
everything for the welfare of the family.
Mothers influence on the foetus starts from the time of
conception. Her food, thoughts, type of books she reads and the
music she listens to and the atmoshphere at home all these have a
great influence on the foetus.
Labour is hard work and painful, yet mother takes it as a duty
and bears all the kashta; ie. hard work to achieve and fulfil the goal of
having contributed to the progeny of the family.
Of all the events that occur in the world today certainly one
cannot but admire the various phenomena occurring during labour. A
co-ordinated effort on the part of uterine contractions on one side, the
cooperation and erasement of ego on the part of cervix in effacement
and dilatation as well as the give of the birth canal and the part
played by the foetus all contribute in successful termination of
labour. Certainly one cannot but admire (sometimes with awe and
anxiety and many a time with pleasure) what a wonderful
phenomenon childbirth is? It is amazing to observe the movements
of foetus during the process of the shortest but the arduous journey
in its life from inside the uterine cavity to the outside world. In that
process the foetus knows what is good and adapts an attitude of
flexion which is essential for safe delivery. While so doing the
o\foetus has given the world a golden rule to be observed by
everyone at all times i.e the attitude of flexion which depicts the
qualities of vinayam, humility, respect to elders and last but not the
least to erase ones ego. Non observance of this golden rule leads
one to become proud and arrogant which ultimately end in remorse
and disappointment.
175

The baby after birth cries and in that first cry lies the whole of
Vedanta. Baby laments for being born in this world as it is fully aware
of the hardships that lie ahead; exhorts everyone to do Ajapa-Japa;
i.e. (spontaneous japa done during breathing) Soham-saying that
the ultimate Paramartha in life is to know THAT THOU ART; and at
the same time pleads the Lord to salvage from the samsara of births
and deaths.
While one learns all this and more from obstetrics, all the
gynaecological conditions reflect and point out the various precepts
handed over by elders from time immemorial.

Similarly too much of anything a in over-eating or under-eating

is not good for health. Both obesity and starvation cause pathological
amenorrhoea. Continuous medication without supervision in some
cases is bad for health as exemplified in continuous taking of
oestrogens for hormone replacement therapy may lead to carcinoma
of the endometrium.
Two people can be close, but occasionally one may have to
suffer because of too much closeness as the urinary tract suffers
being too close to the genital tract.
Everyone in life expects to be respected and treated well. If
such a person is made to undergo trauma and insult he or she will
naturally revolt as it occurs in case of bladder during child birth and
ureter in gynaecological surgery.
For peace to prevail countries should respect each others
territorial integrity; same applies also to states, cities and even
villages. Unauthorized occupation or fighting for land or estate or
property is a common observation. In one and the same family, let
alone between two neighbours, fights go on for the sake of property.
Such scenes can lead to disorders or at times insurgency, as typified
mostly in endometriosis and carcinoma of the cervix.
Coordinated action of everyone is essential for smooth
functioning in an organisation. If someone who is good initially takes
to his head and tries to dominate others, he can become pigheaded
176

and erratic, he may pose problem for the organisation itself.

Oestrogens are the hormones of the female, yet hyperoestrinism
(if not counterchecked by progesterone) leads to conditions like
anovulation, dysfunctional bleeding, fibroids, endometriosis and even
carcinoma of the body of the uterus and of the breast.
Even temperament in sukha or dukhkha is advocated.
Adjustment to the changed circumstances and living life with
contentment is a boon (santushtam satatam yogi). If one does not
have these qualities or virtues, they make their life miserable as
applied to cases of premenstrual tension syndrome and menopause.
All these singly or combined are manifest in various
gynaecological problems described.
What is more, the discipline of obstetrics and gynaecology
stresses the importance of the ethical and the moral values to be
observed in management and treatment of various conditions. It also
stresses that the obstetricians attitude in the management of labour
and emergencies, should be one of kindness, compassion and
sympathy as his decisions may have to vary and confirm moment to
moment living, but always keeping in mind that his essential duty and
role is for the preservation of safe motherhood. Over-confidence on
one hand and delay and decision on the other hand have no role
whatsoever.
I have often wondered as what it is that this discipline has not
taught and stressed about various moral aspects in life? Probably
Bhagwan in His Sankalpa for the good of mankind has put al the
precepts in this branch of medicine and given His Divine Message.
More important than anything else, the stress is laid one the Nishkam
Karmayoga (Karma done for dutys sake without expecting any
reward or fruits of it) on the part of Matru stree; and is all the more
great because the karma is done with the spirit of tyaga, sacrifice,
benediction and love which makes Motehrhood the greatest virtue at
all times.
Janani janmabhumishcha swargadapi gareeyasi
(Mother & Motherland are regarded like Heaven)
177

178

179