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Breast Cancer Detection and Treatment

The first recorded case of an inflammatory breast cancer: Persian empress Atossa (550 BC to 475 BC), daughter of Cyrus the Great, wife of two Achamenian kings, Cambyses and Darius.

“Cancer may have started the fight, but I will finish it.” 

Introduction

Since cancer-prevention is not possible, the saying, “prevention is the cure” is amended to “early detection is the cure.”

Only about 10% of cancer deaths are because of primary tumour. Most of the deaths are because of metastasis – spreading of the cancer to other parts of the body. Once metastasis happens, it is difficult to treat the cancer. Early detection of cancer is therefore of utmost importance.

Early Detection

Several ways of early detection:

  1. Self-examination of Breasts

More than 80% cancers are detected by women doing self-examination of breasts. The examination should be done every month, 5-7 days after menorrhoea. Look for the following:

  • Lumps in breast (less than 20% are cancer) or in lymph nodes in armpits.
  • Thickening of breasts
  • One breast becoming larger than other
  • A nipple changing position or shape or becoming inverted
  • Discharge from nipple
  • Constant pain in part of breast or armpit
  • Swelling beneath the armpit or around the collarbone

‘Breast cancer self-check’ images and videos are available on internet. In case of palpated anomaly, consult your gynecologist.

The limitations of self-examination are:

  • Only 20% women do self-examination of breasts.
  • The tumour/changes are large by the time they are felt and this delay in detection can adversely affect the treatment outcome.
  1. Imaging Techniques

Early detection of cancer is required and is possible by using Imaging Techniques. Six Imaging Techniques are available:

  • X-rays examination. Small neoplasmatic tissue formations can be seen.
  • Sonography (Ultrasound)

Sonography is done in addition to Mammography to rule out possible cysts and to estimate the size of the tumour. However, tumours smaller than 5 mm cannot be detected.

  • MRI

MRI is used to detect if the breast has been affected by more than one tumour.

  • Computer Assisted Detection (CAD)

CAD is used to point out possibly diseased regions. It is used mainly as a second opinion to the report of the doctor.

  • CT-scan

CT-scan is most often used to see if breast cancer has spread to other organs.

  • PET

A PET scan is used to detect the cancer cells in the body. It is often combined with a CT scan (known as a PET/CT scan).

Limitations of Imaging

  • Imaging techniques magnify the tumour much as the magnifying glass magnifies the letters in a book. If the font size is very small, a letter cannot be identified even with the magnifying glass. In a similar way, the imaging techniques cannot identify tumours that are very small.
  • The QUALITY of cancer is more important than the QUANTITY. A small tumour can be more dangerous than a large tumour.  Imaging can tell the quantity of the tumour, that is, its size, but cannot tell the quality of the tumour.
  • Most of the time, Imaging cannot even tell whether a tumour is cancerous or not.

Confirming Cancer

The only absolute way to confirm cancer is by biopsy: a small tissue from the tumour is taken and microscopically examined to check for cancer.

Types of Biopsy

  • Punching Biopsy. Done in a locally sedated state.
  • Needle Biopsy. Done with a syringe and a special needle. As painful as venepuncture.
  • Advanced Breast Biopsy Instrumentation (ABBI). Done with X-ray to ensure localisation of target. Only a few doctors are experienced in this technique.

Microscopic examination of biopsy is sufficient; but in a few rare cases specialized lab tests are required.

Treatment

Even small localised tumours have the potential of metastasis and therefore need to be treated. The treatment is surgery, medications (hormonal therapy and chemotherapy), radiation and immunotherapy.

Surgery offers the single largest benefit. Used along with chemotherapy and radiation, the local relapse rate is reduced, and the overall survival rate may increase.

Surgery

  • Mastectomy:  remove whole breast.
  • Quadrantectomy: remove quarter breast.
  • Lumpectomy: remove small part of breast.
  • Endoscopy-assisted breast-conserving surgery (EBCS), which has the advantage of a less noticeable scar, was developed more than ten years ago.
  • Breast Reconstruction Surgery or breast prostheses: to simulate breast.

Neo-adjuvant, that is prior to surgery, and Adjuvant that is after and in addition to surgery, medication is used as part of treatment. For example, Neo-adjuvant use of aspirin may reduce the mortality from Breast Cancer.

Adjuvant Therapies

Radiation (negative effect on normal cells) to kill cancer cells in tumour bed and regional lymph nodes that may have escaped surgery. It reduces the risk by 50 – 66 % (i.e., 1/2 to 2/3 reduction of risk). It is confined to region being treated. But only solid tumour can be treated.

Therapies using drugs/agents etc.

  • Chemotherapy (negative effect on normal cells). Uses drugs, usually two or more drugs in combination, to destroy cancer cells.
  • Targeted Therapy that became available in 1990s that uses drugs that inhibit enzymes.
  • Monoclonal Antibody Therapy in which the agent is an antibody
  • Immunotherapy that uses patient’s immune systems to fight cancer using drugs.
  • Hormone Blocking Therapy. Uses Estrogen Receptors (ER +) Tamoxifen and Progesterone Receptors (PR +) Anastrozole that block the receptors.

Experimental Cancer Treatment

  1. Gene Therapy
  2. Ultrasound Energy.

Complementary and Alternative Cancer Treatments

Alternative cancer treatments do not cure cancer. But they may lessen signs and symptoms – such as anxiety, fatigue, nausea and vomiting, pain, difficulty sleeping, and stress  – caused by cancer and cancer treatments. Hypnosis, massage, meditation, relaxation techniques, yoga, acupuncture, aromatherapy, music therapy, and Tai chi – alone or in combination may be beneficial.

But many alternative cancer treatments are unproved, and some may even be dangerous.

Type of Treatment Given

Patients with good prognosis are offered less invasive treatment – e.g. lumpectomy + radiation + hormone.

Patients with poor prognosis are offered more aggressive treatment – extensive mastectomy + radiation + chemotherapy + adjuvant medication.

Treatment Success Rate

If the cancer is detected early, that is at Stage 1, prognosis is excellent and usually chemotherapy is not required.

If detected in Stage 2 & 3 prognosis is progressively poorer with a greater risk of recurrence.  Surgery, chemotherapy, and radiation are required.

If detected in Stage 4, that is metastatic cancer (spread to distant sites), prognosis is poor.  Surgery, radiation, chemotherapy, and targeted therapies are used. But the 10-year survival rate is 5% without treatment and 10 % with optimal treatment.

In India, more than 60% of the BC’s are diagnosed at stage III or IV. Hence the low survival rate.

Psychological and Emotional Aspects

Cancer patients need psychological and emotional support. Besides the family, such support can be given by support groups who are trained and experienced in giving such support. ‘Cancer Sahyog’ is one such support group in India.

Conclusion

Cancer is a 3200-year-old disease. It is endogenous, a part of life-process. So, it can neither be eradicated, nor prevented, nor cured. As yet.

Late detection of cancer is fatal. The causes for late detection are many but lack of awareness is the principal cause. Other main causes are patient being shy, social stigma and doctors’ ignorance because of which the treatment is delayed. An awareness program will address all these issues.

Will some radical discovery in the future make cancer prevention and cure possible? We do not know. But we can always hope.

Because as Richard Causer, Director, NCI, USA, says about the future of cancer cure, “There are far more good historians than there are prophets.”

Breast Cancer Awareness

 

“The only person who can save you is you” – Sheryl Crow

Introduction

Breast cancer is the most common, and the biggest killer, cancer in women in India and worldwide. In India, one woman is diagnosed with breast cancer every three minutes, and one woman dies of breast cancer every six minutes. Out of one hundred breast cancer women, forty-fifty die within five years in India, but less than five die in the US. The difference in death rates is because in India women come for treatment late, when cancer has advanced to  Stage III or IV, and has low survival rate.

Rise in Breast Cancer

Breast cancer in India is rising at a rapid rate. And is affecting younger women, those in 30s and 40s. In 2018, breast cancer had 1,62,468 new registered cases and 87,090 reported deaths. By 2030, the number of cases will rise to about 200,000 a year and deaths to about 100,000 a year. Twenty-five years ago, about 30% patients were blow age fifty. Now, about 50% are.

Improving Survival Rate

Breast cancer survival rate in India is among the lowest in the world because it is detected late. Late detection is because of lack of awareness of breast cancer. Increasing awareness can reduce the death rate. Even if we start a cancer awareness program today, 20-30 years will pass before its effect becomes discernible.

Breast cancer cannot be prevented. But its incidence can be reduced by a few simple lifestyle changes; and the survival rate can be improved by early detection. But let us begin with what is cancer and what is breast cancer.

What is Cancer

Our body is composed of many different types of cells. These cells grow and divide in a controlled manner to produce more cells as required by the body. Also, the older cells and the damaged cells die.

However, sometimes, the genetic material of one cell gets damaged or changed [mutation] and the cell becomes immortal: that is, it will not die. When this ancestor cell dividesits descendant cells are also immortal. This gives rise to a limitless number of immortal descendant cells. The number of cells is far more than what the body needs. The extra cells then form a mass that is called a tumour.

These immortal cells are called cancer cells. The cancer cells are immortal; capable of limitless division, and thus of limitless growth in the number of cells; and capable of spreading [Metises] to other parts of the body through blood and lymph system.

There are more than 100 types of cancers. Not all cancers form tumours. Cancers of the blood and the bone-marrow [leukaemia], for example, do not form tumours.

Most cancers are named for the body part in which they begin: colon cancer, prostate cancer, ovarian cancer, breast cancer and so on.

What is Breast Cancer

Breast consists of lobules (milk producing glands), ducts (tiny tubes that carry the milk from lobules to the nipple) and blood and lymphatic vessels. Breast cancer is a malignant tumour that starts in the cells of the breast. It begins in the ducts; sometimes in the lobules:  and rarely, in other cells of the breast. It then spreads through the breast lymph vessels to lymph nodes under the arms and thence to other parts of the body

Who is at risk of Breast Cancer

Every woman is at risk of breast cancer. In India, one in 28 women will get breast cancer. Certain factors increase the risk of BC.

  • Cancer is a disease of old age: most cancers begin to strike at age 60 and above. But now cancer is also striking, though only rarely yet the teenagers. Risk of breast cancer, for example, is about 0.25% for a 30-year-old woman but increases to about 11% in a seventy-year old. In different countries, breast cancer risk in a 70-year-old is 54% to 154% higher than in a 30-year-old. Thus, as longevity has increased, so has the cancer incidence.
  • Heredity. If first degree relatives [mother/father/brother/sister] had cancer, the risk of cancer is increased.
  • Genetics. A person can be genetically predisposed to get cancer. A woman who has a family history of breast cancer is statistically more likely to get breast cancer. However, only a small percentage, less than 0.3% of population, is genetically disposed to get cancer. And less than 3-10% of all cancers are because of genetic predisposition. In women with BRCA 1 and BRCA 2, the probability of getting breast and ovarian cancer is more than 75%. Mutations in a few other genes [PTEN, CDH 1, TP 53 etc.] also increase the risk though not as much.

Angelina Jolie, Producer | Director | Actress had both her breasts removed in 2013 to reduce the risk of breast cancer because of a gene mutation (BRCA1) she has.

  • Obesity.  In obese postmenopausal women breast cancer risk is twice that of the non-obese women.
  • Diet.Diet contributes to up-to 80% of cancers of colon, prostate and breast; and contributes to cancers of pancreas, lung, stomach and esophagus. Alcohol, red meat, sugar increase the risk of cancer.
  • Smoking, night work, no children or child born after age 30, recent use of oral contraceptives (reverts to normal on stopping), HRT, and Chemicals in environment – increase the cancer risk.
  • Menopause. Late menopause increases the risk.

Reducing the Risk

Healthy weight, physical activity – brisk walking, cycling, swimming – 45-60 minutes five or more days a week, breast feeding, no red meat, less sugar, and less alcohol lowers the risk.

Controversy about whether diet rich in whole grains, fruits, vegetables and legumes and low in total fat (butter, oil), more vitamins, Marine Omega 3 fatty acids (found in seafood (e.g. fish oils) and in walnut, seeds, flaxseed oil etc.), and antiperspirants and bras reduce the risk.  Abortion and Breast Implants have no effect.

Selective Estrogen Receptor Modulators such as tamofoxien reduce breast cancer risk but increase the risk of thromboembolism and endometrial cancer.

So, eat well and exercise and you would have done your bit to reduce your cancer risk.

Depression in Pregnancy

Depression, suffering and anger are all part of being human. – Janet Fitch

Depression is the inability to construct a future. – Rollo May

SYNOPSIS

Depression is a mood disorder, a biological illness, which affects 14-23% of women during pregnancy. Depression makes a woman feel sad, bleak, helpless, anxious, irritable, fatigued and lacking in energy.

Depression can be treated. Left untreated, it can lead the woman to poor nutrition, drinking and smoking causing the babies to be born premature, less active, and have developmental problems. Antenatal depression is a strong precursor to Postpartum Depression.

Depression treatment is psychotherapy, medication, and self-care. Cognitive behavioural therapy (CBT) is the often used psychotherapy. A woman can do it herself after suitable instructions. Medication is antidepressants. These pose a very small risk to fetus. A few supplements are also claimed to help. But these should not be taken without doctor’s advice. Self-care involves proper diet, adequate sleep, exercise, and pregnancy-yoga.

Several women have depression during pregnancy. So, you are not alone. Do not therefore hesitate to speak to your doctor at the first appearance of the symptoms of depression.

INTRODUCTION

Pregnancy is a joyous period for women. But for a few the joy is clouded by mood swings. We all have transitory mood swings. But if these last a few weeks or a few months, then these signal depression.

DEPRESSION

Depressions are biological illnesses caused by changes in brain chemistry. Such changes may be triggered by the hormonal changes during pregnancy. This is called antenatal depression. But except in name, it is similar to clinical depression.

SYMPTONS

Symptoms of depression vary from person to person. But if you have one or more (usually five) of the following symptoms for most of the day, nearly every day, for two weeks or more, it signals depression:
• feelings of sadness, bleakness, hopelessness, and anxiety;
• lack of interest or pleasure in doing anything;
• feeling tired or having little energy;
• difficulty concentrating;
• difficulty remembering.
• feeling emotionally numb.
• extreme irritability.
• sense of dread about everything, including the pregnancy.
• feelings of failure, or guilt.
• trouble getting to sleep, waking up in the night or sleeping too much;
• overeating or decreased appetite.
• weight loss/gain unrelated to pregnancy
• low self-esteem, or feelings of guilt or failure
• fidgeting a lot, or moving and speaking very slowly
• loss of interest in sex.
• thoughts of suicide or self-harm may occur.
• inability to get excited about the pregnancy, and/or baby
• feeling of disconnection with the baby, and an inability to form/feel a bond with the developing baby.

RISK

Anyone can have depression. But the following factors, or a combination of these, increases the risk of getting depression:

• Family history of depression. Risk of suicide also goes up.
• Personal history of depression or anxiety in the past – like during an earlier pregnancy or after the birth of a previous child. Also the risk of postpartum psychosis, a rare but very serious condition that involves hallucinations, increases.
• Life stress events, such as financial problems, the end of a relationship, the death of a close friend or family member, or a job loss.
• Lack of support like having relationship problems or an unsupportive partner or having your baby on your own, or if you feel isolated from friends or family
• Unplanned pregnancy finding out you’re pregnant when you didn’t plan to be.
• Domestic violence and emotional abuse that tend to get worse when you’re pregnant.
• Infertility treatments
• Complications in pregnancy

TREATMENT

Antenatal depression is treatable with psychotherapy, medication and self-care.

Psychotherapy

• Cognitive behavioural therapy (CBT) is the often used psychotherapy. It helps the mother recognise her emotions and counter her negative thoughts. She is encouraged to do CBT herself after step by step instructions in CBT through books and talks; or she may be advised do it in sessions with a therapist.

Medication

• She may also need antidepressants. Not enough evidence is available that these are completely safe to take in pregnancy. A few of these pose a very small risk of birth defects that include fetal heart and skull abnormalities. Doctor weighs the risks and benefits to the mother and to the baby to decide on antidepressants. If the mother was on mental health medication before pregnancy, she should not stop these without asking the doctor. Also, she should not start any medication, including herbal medication, without asking the doctor.
• Supplements. Several supplements such as St. John’s wort, SAMe, Saffron extract, 5-HTP and DHEA are being marketed as being helpful in depression. These seem to help some people but sufficient evidence is not available for their efficacy. A few of these can interfere with prescription medications or cause dangerous interactions and may be unsafe. Consult your doctor before taking any supplements or herbal medication.

Acupuncture

Acupuncture is claimed to help relieve depression. But the evidence for its effectiveness is ambiguous or outright contradictory. The World Health Organization has recognized acupuncture as effective in treating mild to moderate depression. – Dr Andrew Weil in ‘Depression, Health, World, Organization.’

Self-care

Diet, sleep, and physical activity are just as important as medication and therapy — sometimes more so.

Diet and nutrition.

Diet is so important to mental health that a new field of medicine called nutritional psychiatry has grown around it. Many foods have been linked to mood changes, the ability to handle stress and mental clarity.

• Foods to avoid are:

o Alcohol: it depletes serotonin, which makes people prone to anxiety, depression and panic attack.
o Caffeine: It lowers serotonin and increases the risk for anxiety, depression, and poor sleep. Reduce intake of coffee, tea, and hot cocoa.

• Foods to take are those rich in:

o B12 and folate. These prevent mood disorders and dementias. Sources: beetroot, lentils, almonds, spinach, liver (folate); liver, chicken, fish (B12)
o Vitamin D. Its deficiency is associated with different mood disorders. Sources: sun exposure; breakfast cereals, breads, juices, milk; high-quality supplements.
o Selenium. It decreases depression. Sources: cod, Brazil nuts, walnuts, poultry.
o Omega-3 fatty acids. These improve cognitive and behavioral function. Low levels of omega-3 fats leads to mood swings and depression. Sources: cod, haddock, salmon, halibut, nut oils, seeds, walnuts, and algae; high-quality supplements
o Endorphins. These enhance mood and promote a sense of well-being. Source: dark chocolate

Sleep

Lack of sleep (insomnia), or disturbed/obstructive sleep (apnea) are linked to depression. People with insomnia are 10 times more likely to have clinical depression and 17 times more likely to have clinical anxiety, and people with apnea are five times more likely to have clinical depression, than people who sleep normally. To help get sleep, lower room temperature, follow a schedule, avoid naps during the day, listen to relaxing music, try a low carb/high fat diet and eat 3-4 hours before sleep time, exercise, and practice yoga and meditation.

Exercise

Exercise releases endorphins, natural cannabis-like brain chemicals, and other natural brain chemicals, that enhance your sense of well-being. Depression causes tiredness and lack of energy. It may therefore be difficult to begin exercising. So begin with a walk for five or ten minutes and gradually increase to 30-45 minutes a day for three to five days a week. Results will appear after a few weeks because exercise is a long term treatment. Therefore pick up an exercise – walking, cycling, swimming – that you enjoy.so you will continue to do it

YOGA

Yoga focuses on the balance between your mind, body and breath. This balance is created through:

• physical exercises and postures (asanas)
• breathing exercises (pranayama)
• relaxation
• meditation

Yoga improves your physical, mental and emotional wellbeing. It helps you to:

• Improve your circulation, muscle tone and flexibility; to keep the body supple and relieve tension around the cervix by opening up the pelvic region. This prepares to-be-mothers for labor and delivery.
• Alleviate the effect of common symptoms such as morning sickness, painful leg cramps, swollen ankles, lower-back pain and constipation.
• Stay mentally agile through relaxation, breathing and meditation.
• Train you to breathe deeply and relax consciously, helping you to face the demands of labor and childbirth.
• Feel calm, and ease muscle tension.
• Recover faster post-delivery.

If you are already doing Yoga, you may continue to do pregnancy yoga during pregnancy. Since most miscarriages happen during the first trimester, you may, as a precaution, decide not to do Yoga during that period. Although there is no evidence that doing yoga, or any other exercise, during the first trimester will harm your pregnancy.

If you have never before done Yoga, then do not begin it in the first trimester. Begin in the second trimester, after 14 weeks of pregnancy. Join a pregnancy Yoga class. Your instructor will start you gently and slowly and modify the posture to suit the stage of your pregnancy.

Avoid these:

• Lying on your back after 16 weeks.
• Breathing exercises that involve holding your breath or taking short, forceful breaths.
• Strong stretches or difficult positions that put you under strain.
• Lying on your tummy (prone).
• Upside-down postures (inversions).
• Back bends.
• Strong twists.

A study published in Obstetrics & Gynecology in December 2015 found no evidence of fetal distress in any of the 26 postures attempted. These included downward facing dog and savasana. But avoid any poses that feel uncomfortable.

The Art of Living recommends only nine asanas (postures) for pregnancy Yoga. These include Shavasana (Corpse Pose) and Yoga Nidra (Yogic sleep).

You may restart postpartum yoga six weeks after a vaginal delivery; and a longer period after a Caesarean section as advised by your doctor. The postpartum asanas help combat back and neck aches and also help breastfeeding mothers.

ADDITIONAL

To help yourself handle depression:

• Talk about your concerns with your partner, family and friends. They may offer you a proper perspective or practical help. And simply talking about your problems makes these seem more manageable.
• Take time to relax. Give yourself some “me time.” Read, take a calming bath, lunch out with friends, watch an entertaining movie or play. In short do anything that takes your mind away from your concerns and gives you physical and mental relaxation.

DOWNSIDE

Untreated depression can lead to poor nutrition, drinking and smoking. These can cause premature birth, low birth weight, and developmental problems. Babies of ‘depressed’ mothers may be less active, have lower attention span, be more agitated, have behavioral problems and delayed cognitive and language development as compared to babies born to normal mothers.

Antenatal depression is a strong precursor to Postpartum Depression: a major depression in the weeks and months after childbirth. It affects mother’s health and quality of life and also the well-being of the baby. It can cause bonding issues with the baby and can contribute to sleeping and feeding problems for the baby.

CONCLUSION

If you have symptoms of depression, remember, you are not alone. Between 14-23% of women struggle with some symptoms of depression during pregnancy. Antenatal depression can be treated and managed. Most women recover with a few weeks, or a few months, of treatment.

So do not feel shy. Speak to your doctor at the first appearance of the symptoms of depression.

REFERENCES

1. Depression During pregnancy
https://www.babycenter.com/0_depression-during-pregnancy_9179.bc#articlesection1
2. Depression In pregnancy

Depression in Pregnancy


3. Facing Depression During Pregnancy
https://www.webmd.com/baby/features/facing-depression-during-pregnancy#1
4. Depression during pregnancy: You’re not alone
https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by- Antenatal depression
5. Antenatal depression
https://en.wikipedia.org/wiki/Antenatal_depression
6. Prenatal Yoga for women to do during pregnancy | The Art of Living …https://www.artofliving.org/in-en/yoga/yoga-for-women/yoga-and-pregnancy
7. Introduction to Pregnancy Yoga – Verywell Fit
https://www.verywellfit.com › Fitness › Yoga › Yoga and Your Health
8. Pregnancy yoga for beginners – BabyCentre UK
https://www.babycentre.co.uk/a1033238/pregnancy-yoga-for-beginners
9. The Complex Relationship Between Sleep, Depression & Anxiety …
https://sleepfoundation.org/excessivesleepiness/…/the-complex-relationship-between-sl…
10. Depression & Sleep – National Sleep Foundation
https://sleepfoundation.org/sleep-disorders-problems/depression-and-sleep
11. Can Acupuncture Treat Depression? – Scientific American
https://www.scientificamerican.com/article/can-acupuncture-treat-depression/
12. Natural remedies for depression: Are they effective? – Mayo Clinic
https://www.mayoclinic.org/…/depression/…/natural-remedies-for-depression/faq-200.
13. Depression and anxiety: Exercise eases symptoms – Mayo Clinic
https://www.mayoclinic.org/diseases…/depression/in…/depression…exercise/art-20046.
14. Exercise is an all-natural treatment to fight depression – Harvard Health
https://www.health.harvard.edu/…/exercise-is-an-all-natural-treatment-to-fight-depress..
15. 20 Simple Ways to Fall Asleep as Fast as Possible – Healthline
https://www.healthline.com/nutrition/ways-to-fall-asleep

Painless Childbirth

The pain of childbirth is not remembered. It’s the child that’s remembered.

Words cannot express the joy of new life.

SYNOPSIS

Labor pain can be excruciating. Many women have low pain thresholds and are unable to bear such pain. For them, painless delivery may be a need. In this procedure, once the active labor begins, an injection of epidural is given. Epidural makes the delivery almost painless. But epidural has certain side effects. Also, it often results in forceps or vacuum delivery. And both these pose risks of injury to the mother and the baby. But natural birth is also not without risks. For example, unrelieved labor-pain is associated with postpartum depression, post-traumatic stress disorder, and chronic pain. Your gynecologist in Delhi looks at many factors, including the health and emotional well-being of the mother, and then recommends the optimum childbirth procedure for you. Follow her advice.

Labor Pains

Childbirth is a joyous but painful experience for women. Labor pain is the mother of all pains, it is said. But labor pain is different for each woman; and different for each pregnancy of the same woman. And no one can predict what your labor will be like. It can range from mild to extreme. For some women, labor may be almost painless, or mild, or just irritating, or a dull or mild hurt. For others, pain may be excruciating, all-encompassing, cramps going from the top of the stomach down to pubic area, radiating to lower back and rectum, each contraction like a punch in the stomach that knocks all the air out; pain may be burning, and in stabs; pain may be in legs and hips.

Keeping fit during pregnancy and learning relaxation techniques – rhythmic breathing, visualization, meditation, and self-hypnosis – can help handle the pain. HypnoBirthing – practice, and use of a combination of music, visualization, positive thinking and words to relax the body and control sensations during labor – may help keep you keep calm and keep the muscles loose. Changing positions may help reduce the pain. Massage and walking may also help.

Total natural Birth

Many women believe that pain cements the bond between them and the baby. They also fear the side effects of medicated births and epidurals and decline even the painkiller injections that are usually given during labor. That is, they opt for ‘total natural birth (tnb).’ It, ‘tnb,’ is the worldwide trend these days.

But unrelieved childbirth pain is associated with postpartum depression, post-traumatic stress disorder, and chronic pain. Women should be aware of this when opting for tnb. And if during tnb, or natural birth, the pain becomes unbearable, they should not hesitate to opt for pain relief medication. They should ‘differentiate between pain and suffering. Pain can be managed, but if it becomes overwhelming, medication may prevent suffering.’

The stages in childbirth are:

  • Early labor (up to eight hours or longer): cervix dilates, or opens to 3 to 4 centimeters, and begins to efface (thin). Mild-to-moderate contractions, 30 to 60 seconds long, occur every five to 20 minutes and progressively become stronger and more frequent.
  • Active labor (approximately two to eight hours): Contractions continue to become longer, stronger and closer together; the cervix dilates to 7 centimeters. This is when most women request pain medication, though sometimes it’s given earlier.
  • Transition (up to an hour): Cervix dilates to about 10 centimeters, pain is strongest, contractions are intense and closely spaced, you may feel pain in your back, groin, even your sides or thighs, as well as nausea.
  • Pushing (a few minutes to three hours). Intense pain is eclipsed by major pressure as you feel a great urge to bear down and push your baby out—some women describe it as “like pooping a watermelon or bowling ball.” Although pain continues, many women say it’s a relief to push because it helps relieve the pressure. When the baby’s head crowns, or becomes visible, you may experience a burning, stinging sensation around the vaginal opening as it stretches.
  • Placenta delivery (up to 30 minutes): This stage tends to be relatively easy, as mild, crampy contractions ease the placenta out. At this point, you’re focused on your new-born anyway.’

Painless Delivery

Several women have low pain-threshold. And in a few women, anticipated pain and discomfort may cause anxiety. These women may opt for ‘painless delivery.’ A few others may opt for it because it is the flavor of the month.

In painless delivery, the woman has to bear the ‘early labor’ pain which can be mild to acute depending on the individual. These ‘early labor’ pains can be managed with warm showers, massages, and exercises.

When labor reaches the ‘Active labor’ stage, an injection of epidural is given in the spinal cord by the anesthetist. He tops up the epidural from time to time as the labor progresses. Epidural takes 10 minutes to place and another 10 to 15 minutes to begin to work. Epidural greatly reduces the pain during the ‘Transition’ and ‘Pushing’ stages and makes ‘Placenta delivery’ nearly painless.

Disadvantages of Epidural

The disadvantages of epidural are that labor is prolonged, the woman is unable to self-help, and the chances of delivery through forceps or vacuum increase. In one study, these chances increased from 16.4% in non-epidural to 37.9% in epidural delivery. Forceps or vacuum delivery has certain risks of injury. These are explained to the patient at length before she opts for natural or painless delivery.

Common side effects of epidural are:

  • Itching
  • Nausea and vomiting
  • Fever
  • Soreness
  • Low blood pressure
  • Difficulty urinating

A few rare side effects of epidural are:

  • Breathing problems
  • Severe headache (1%)
  • Infection
  • Seizure
  • Nerve damage (extremely rare, 1 in 4,000 to 1 in 200,000)

But gynecologist in South Delhi says that ‘there’s lots of misinformation [about epidural etc] — the risks and complications are overblown, and women suffer unnecessarily.’ And that epidurals and other pain-relief drugs are quite safe.

Forceps Delivery Risks

The risks to the baby from forceps delivery, though rare, are:

  • Minor facial injuries due to the pressure of the forceps
  • Temporary weakness in the facial muscles (facial palsy)
  • Minor external eye trauma
  • Skull fracture
  • Bleeding within the skull
  • Seizures

 Forceps delivery risks to mother are:

  • Pain in the perineum — the tissue between your vagina and your anus — after delivery
  • Lower genital tract tears
  • Difficulty urinating or emptying your bladder
  • Short-term or long-term urinary or fecal incontinence (involuntary urination or defecation) if a severe tear occurs
  • Injuries to the bladder or urethra — the tube that connects the bladder to the outside of the body
  • Uterine rupture — when the uterine wall is torn, which could allow the baby or placenta to be pushed into the mother’s abdominal cavity
  • The weakening of the muscles and ligaments supporting your pelvic organs, causing pelvic organs to drop lower in the pelvis (pelvic organ prolapse)

Most of these risks are also associated with vaginal deliveries, but these are more likely with forceps delivery.

Vacuum Extraction Risks

The risks of vacuum extraction to the mother are:

  • Tears and damage to the tissue in the lower genital tract
  • Pain after labor and delivery
  • Blood loss and subsequent anemia
  • Muscle and ligament weakness around the pelvic organs
  • Urinary or fecal incontinence, which may be temporary or permanent

Risks to the baby are:

  • Bleeding and wounds on the scalp.
  • Stretching of the nerves along the neck, which can cause Erb’s palsy or a brachial plexus injury.
  • Bleeding under the skin or in the brain.
  • Bleeding in the eyes.
  • A skull fracture.
  • Neonatal jaundice.
  • Brain damage, which may lead to permanent disability.

Natural Birth Risks

Natural births have risks too. Especially if the mother has a medical problem, or if an issue prevents the baby from naturally moving through the birth canal. Other concerns are:

  • tears in the perineum (area behind the vaginal wall)
  • increased pain
  • hemorrhoids
  • bowel issues
  • urinary incontinence
  • psychological trauma

Labor and delivery during natural birth can be eased with:

  • massages
  • acupressure
  • taking a warm bath or using a hot pack
  • breathing techniques
  • frequent changes in position to compensate for changes in the pelvis

The optimum method of childbirth for You

When advising you about the optimum method of labor and delivery for you, the Obstetrician will consider:

  • overall health and emotional well-being of the mother
  • the size of the mother’s pelvis
  • the mother’s pain tolerance level
  • the intensity level of contractions
  • size or position of the baby

Conclusion

Hopefully, the information in this write-up will help you make an informed decision, in consultation with your obstetrician, about the optimum method of childbirth for you:  total natural birth, natural delivery, painless delivery, or a caesarean section.

References:

  1. Natural vs. Epidural: What to Expect

https://www.healthline.com/health/pregnancy/natural-birth-vs-epidural

2. Pros and Cons of Painless Delivery

https://medium.com/health-care-for-women/pros-and-cons-of-painless-delivery-2c25e5d82e11

3. 8 Ways to Manage Labor Pain

https://www.parents.com/pregnancy/giving-birth/pain-relief/manage-labor-pain/

4. Painless Normal Delivery: Watch You Tube https://www.youtube.com/watch?v=zgcUvdEOMb

5. Pregnancy and birth: Epidurals and painkillers for labor pain relief

https://www.ncbi.nlm.nih.gov/books/NBK279567

6. Using Epidural Anesthesia During Labor: Benefits and Risks

https://americanpregnancy.org/labor-and-birth/epidural/

7. Side effects – Epidural

https://www.nhs.uk/conditions/epidural/side-effects/

8. Risks of Epidurals During Delivery

https://www.healthline.com/health/pregnancy/pain-risks-epidurals

9. Natural Childbirth V: Epidural Side Effects and Risks

https://chriskresser.com/natural-childbirth-v-epidural-side-effects-and-risks/

10. Labor Pain Explained: Stages, Symptoms and Pain Relief

https://www.parents.com/pregnancy/giving-birth/labor-and-delivery/understanding-labor-pain/

11.Women’s experience of pain during childbirth

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093177/

12. Methods of Childbirth

https://www.webmd.com/baby/guide/delivery-method

13. Forceps delivery

https://www.mayoclinic.org/tests-procedures/forceps-delivery/about/pac-20394207

14. What moms should know about forceps and vacuum deliveries

https://utswmed.org/medblog/forceps-vacuum-delivery/

15. The long term effects of forceps delivery on a baby

https://www.teeslaw.com/article/long-term-effects-forceps-delivery-baby

15. Forceps or vacuum delivery

https://www.nhs.uk/conditions/pregnancy-and-baby/ventouse-forceps-delivery/

16. Does Pain After Childbirth Increase Postpartum Depression Risk?

https://www.healthline.com/health-news/does-painful-childbirth-increase-post-partum-depression-risk

17. Less Labor Pain, Lower Postpartum Depression Risk?

https://www.webmd.com/depression/postpartum-depression/news/20161026/less-labor-pain-lower-postpartum-depression-risk#1

18. Feeling depressed after childbirth

https://www.nhs.uk/conditions/pregnancy-and-baby/feeling-depressed-after-birth/

19. Vacuum extraction

https://www.mayoclinic.org/tests-procedures/vacuum-extraction/about/pac-20395232

20. Vacuum-Assisted Vaginal Delivery

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672989/

21. Vacuum-Assisted Delivery: Do You Know the Risks?

https://www.healthline.com/health/pregnancy/risks-vacuum-assisted-delivery

22. Vacuum Extractor Injuries

https://www.cerebralpalsyguidance.com/cerebral-palsy/causes/vacuum-extractor-injuries/

Pelvic Inflamatory Disease (PID)

Every human being is the author of his own health or disease.
– Gautama Buddha

SYNOPSIS

Pelvic Inflammatory Disease (PID) is an infection of the female reproductive organs. It is caused by many types of bacteria. If not treated, it can cause complications such as ectopic pregnancy and infertility.

PID affects women in reproductive age. Peak incidence is in women of 15 to 24 years age. India is estimated to have at least one million episodes of PID each year.
Risk of PID increases with risky sexual practices: multiple sexual partners, sex with a person having PID, starting sex at a very young age and having sex without a condom.
PID often has no signs or symptoms. But a few of the symptoms that may appear are: pain in lower abdomen or pelvic pain, heavy or foul periods, bowl discomfort and pain in urination.

There is no single test to diagnose PID. It is diagnosed from symptoms and from gynaecological examination. Urine and blood tests, ultrasound, and laparoscopy may also be used. Because of absence of symptoms, and because the symptoms are similar to those of other diseases, PID diagnosis is often delayed. Woman’s recent sexual partners also need to be tested and treated.

A mixture of antibiotics is used for treatment and is successful in most cases. But a few cases may need laparoscopic or surgical intervention. Removal of intrauterine devices (IUDs) is not necessary.

Because of difficulty of diagnosis, and serious consequences of delayed treatment, empirical treatment may be initiated in at-risk women if symptoms of PID appear. Having regular medical care throughout lifetime maximizes the chances of early diagnosis and treatment of PID.

Improved education, routine screening, diagnosis, and empirical treatment of PID will reduce the incidence and prevalence of PID and its long-term sequelae.

INTRODUCTION

PID, if not treated, can cause ectopic pregnancy, infertility, chronic pelvic pain, cancer, peritonitis and tubo-ovarian abscess – the latter two can become life threatening.

In the US, more than one million women have PID, and more than 100,000 become infertile each year because of PID. In industrialized countries PID-incidence is 10 to 13 per 1,000 in women in 15 to 39 years age-group, with a peak incidence of about 20 per 1,000 women in 20 to 24 years age group. India is estimated to have more than one million PID episodes each year.

CAUSE

PID is an infection of the female reproductive organs – vagina, uterus, fallopian tubes, ovaries, and of womb lining (endometrium) and lining of the inside of the abdomen (peritoneum).

It is a bacterial infection. Many types of bacteria can cause it but in about one in four cases it is caused by sexually transmitted infection (STI) such as chlamydia or gonorrhoea. Sometimes normal, harmless, bacteria in the vagina get past the cervix and into the reproductive organs and cause PID. This can happen when the cervix is damaged after childbirth, miscarriage, abortion and inspection of the womb; or by an earlier PID.

In many cases, the cause of PID is unknown.

RISK FACTORS

Any woman can get PID. But the risk of getting it is increased by:
• Being sexually active and younger than 25 years age
• Having multiple sexual partners
• Having a new sexual partner
• Being in a sexual relationship with a person who has more than one sex partner
• Having a history of PID or STI
• Having sex without a condom
• Douching regularly, which upsets the balance of good versus harmful bacteria in the vagina and might mask symptoms

Having an intrauterine device (IUD) does not increase the risk of PID. Potential risk, if any, is within the first three weeks after insertion.

SYMPTOMS

PID often has no signs or symptoms. But one or more of these symptoms may occur:

• Pain in lower abdomen
• Pelvic pain — especially during a pelvic exam
• Heavy or foul or painful periods with an unpleasant odor
• Unusual vaginal discharge, especially if it’s yellow or green
• Abnormal uterine bleeding, especially during or after intercourse, or between menstrual cycles
• Pain or bleeding during intercourse
• Fever, sometimes with chills
• Painful or difficult urination
• Bowel discomfort
• Nausea and vomiting

See your doctor if you experience any of the above symptoms.

Vaginal discharge with an odor, painful urination or bleeding between menstrual cycles can be associated with STI. If these signs and symptoms occur, stop having sex and see your doctor soon. Prompt treatment of an STI can help prevent PID.

DIAGNOSIS

There is no single test to diagnose PID. It is diagnosed from symptoms and from gynecological examination.

Gynecologist in Delhi will talk about your medical and sexual history and do a pelvic examination to check for any tenderness and abnormal vaginal discharge. This examination may be discomforting, especially if you have PID.

Swabs may be taken from the inside of your vagina and cervix to look for bacterial infection and identify the bacteria responsible. A positive test for chlamydia or gonorrhoea supports the diagnosis of PID. Most women test negative but this does not rule out PID.
Other tests may, therefore, be required to look for signs of infection or inflammation, or to rule out other possible causes of your symptoms. These tests may include:

• a urine or blood test
• a pregnancy test
• an ultrasound scan, which is usually carried out using a probe passed through the vagina (transvaginal ultrasound)

In a few cases, especially the more severe cases, and where there may be other possible causes of the symptoms, such as appendicitis, laparoscopy may be used to look at the internal organs and, if necessary, take tissue samples to diagnose PID. Laparoscopy can also be useful in disproving cases wrongly labelled as chronic pelvic disease.
Recent sexual partners also need to be tested and treated to stop the infection recurring or being spread to others.

Diagnosis of PID can be missed or delayed because of absence of symptoms in the earliest, most curable stage. When symptoms do occur, they can be similar to symptoms of certain other diseases, such as appendicitis, food poisoning or food borne illness, ruptured ovarian cyst, diverticulitis, and ovarian torsion. Therefore have regular medical care throughout lifetime to maximize the chances of early diagnosis and treatment of PID.

TREATMENT

If diagnosed early, PID is treated with antibiotics for 10-14 days. A mixture of antibiotics to cover the most likely infections is given as tablets and injections. Complete the antibiotic course and avoid sexual intercourse during the treatment period to ensure the infection clears completely.

Antibiotics alone are successful in 34-75% of cases. Patients who do not improve in 72 hours are re-evaluated for laparoscopic or surgical intervention and for other possible diagnoses. Laparoscopy should be used if the diagnosis is in doubt. Laparoscopic pelvic lavage, abscess drainage, and adhesiolysis may be necessary. Laparoscopy gives direct visualization of internal organs and of the pelvis and obtaining of cultures for more accurate bacteriologic diagnosis. However, laparoscopy is not always available in acute PID; moreover, it is costly and requires general anesthesia.

If surgical treatment is required, attempt is to conserve reproductive potential with simple drainage, adhesiolysis, and copious irrigation or unilateral adnexectomy, if possible. Further surgical therapy is needed in 15-20% of cases so managed.

Most tubo-ovarian abscess (60-80%) resolve with antibiotic administration. Laparoscopy may be used to identify the loculations of pus requiring drainage. Unresolved abscesses may be drained by colpotomy, laparoscopy, or laparotomy. In patients with recurrent PID, dense pelvic adhesions may render surgery difficult.

Removal of intrauterine devices (IUDs) in acute PID cases is not necessary. But close clinical follow-up is mandatory if the IUD is left in place.

More research is needed to optimize PID diagnosis and treatment; and to improve patient and doctor’s compliance to guidelines.

COMPLICATIONS

Untreated PID may cause scar tissue, and collections of infected fluid (abscesses) in the fallopian tubes, which can damage the reproductive organs.

Other possible complications are:

• Ectopic pregnancy. The scar tissue prevents the fertilized egg from moving through the fallopian tube to implant in the uterus thus causing a tubal (ectopic) pregnancy that can cause massive, life-threatening bleeding and that may require emergency medical attention. PID is a major cause of ectopic pregnancy
• Infertility. PID may damage the reproductive organs and cause infertility. Delaying the treatment, or frequent PID, dramatically increases the risk of infertility. In the US, 1 in 8 women with a history of PID has difficulty getting pregnant; and 15% of infertility cases are because of PID.
• Chronic pelvic pain. Pelvic inflammatory disease can cause pelvic pain that may last for months or years. Scarring in fallopian tubes and other pelvic organs can cause pain during intercourse and ovulation.
• Tubo-ovarian abscess. PID might cause an abscess — a collection of pus — to form in uterine tube and ovaries. If left untreated, this could develop into a life-threatening infection.

PREVENTION

To reduce the risk of PID:

• Practice safe sex. Use condoms every time you have sex, limit your number of partners, and ask about a potential partner’s sexual history.
• Talk to your doctor about contraception. Many forms of contraception do not protect against the development of PID. Using barrier methods, such as a condom, might help to reduce your risk. Even if you take birth control pills, it’s still important to use a condom every time you have sex to protect against STIs.
• Get tested. If you’re at risk of an STI, such as chlamydia, make an appointment with your doctor for testing. Set up a regular screening schedule with your doctor if needed. Early treatment of an STI gives you the best chance of avoiding PID.
• Request that your partner be tested. If you have PID or an STI, advise your partner to be tested and, if necessary, treated. This can prevent the spread of STIs and possible recurrence of PID.
• Don’t douche. Douching upsets the balance of bacteria in your vagina.

INCIDENCE

In a 1995 U.S. study, 8 percent of all women in their reproductive years were being treated for PID. The numbers have steadily reduced. In 2015, the annual visits for PID were down to about 90,000 a year.

Enough data on incidence of PID in India is not available. In one study about 11.55% of the study subjects were diagnosed with PID. In the industrialised world, the incidence is 1 to 2 per cent per year among sexually active women. On that basis, India will have about one million PID cases per year.

REDUCING THE INCIDENCE

Because of difficulty of diagnosis, and serious consequences of delayed treatment, it is recommended that empirical treatment should be initiated in at-risk women who have lower abdominal pain, adnexal tenderness, and cervical motion tenderness. That overtreatment be preferred to no or delayed treatment.

Women with PID should be counselled to abstain from sexual activity or use barrier protection strictly and appropriately until their symptoms and those of their partner have fully abated and they have completed their entire treatment regimen.

Improved education, routine screening, diagnosis, and empirical treatment of PID will reduce the incidence and prevalence of PID and its long-term sequelae. Education should concentrate on strategies to prevent PID and STIs, including reducing the number of sexual partners, avoiding unsafe sexual practices, and routinely using appropriate barrier protection. Adolescents, being at an increased risk for PID, should be advised to delay the onset of sexual intercourse until age 16 years or older.

Awaiting Surgery? How to Choose the Surgeon

Surgery outcome is better if the surgeon is female.
– BMJ, number 2 in the list of top medical journals of the world

“Patients have a right to know how good a surgeon is,”
– Dr. Fiona Godlee, editor in chief of the BMJ

Surgeon Rating

The US has websites that rate the surgeons. A patient can use these to choose the surgeon. Also, in May 2015, three major hospital systems in the US implemented the “Take the Volume Pledge” that prevents surgeons and hospitals from doing surgeries in which they have “low volume.” Surgical “volume” is the number of times a surgeon/hospital has done a specific surgical procedure in a defined time period.

India will not have surgeon-rating websites for many, many years to come. And surgeons/hospitals do not have any guidelines to prevent them from doing surgeries that they have little experience or currency of doing. How may the patient in India choose the surgeon?

Surgeon’s Experience

For over two decades researchers have acknowledged that the outcome of a surgery is related to the surgeon’s experience. This was confirmed by a recent Harvard University study that analysed surgical performance in 14 countries with a total of more than 17,000 surgeons and 35 different procedure types. Analysis of data on more than one million surgeries has shown that the more procedures a surgeons has performed, the better her patients’ outcome, at least until she hits a learning plateau. The plateau is reached after 25 to 750 procedures depending on the complexity of the surgery.

“Low Volume” surgeons’ patients have higher mortality, morbidity, intraoperative and postoperative complications, readmissions to hospital, and mortality within 30 days of surgery, as compared to “high volume” surgeons: for example, in pancreatic cancer surgery, annual death rates were nearly four times higher; in certain other surgeries, death rates were three times higher; in endocrine surgery, complication rates and reoperation rate were about two times higher; in gastric bypass surgery, risk of serious complications fell by 10 percent for every additional 10 cases per year the surgeon performed.

Choosing the Surgeon in India

In India, search engines like Google, Bing and Yahoo may be used to find a better surgeon. But Google is the best and the most widely used search engine. Let us say you are looking for a Gynaecologic laparoscopy surgeon in Delhi. Search “Best Gynae laparoscopic surgeon in Delhi.” Take the first ten names on the list and look at their average ‘rating’ and the number of persons who have given it. The higher the average ‘rating’ and the greater the number of persons giving it, the better: a surgeon with a rating of 5/5 given by 100 persons is likely to be better than the one with 4.7/5 rating given by 40 persons.

Next, look at the Google search pages. Page 1 is usually full of ads and sites of big hospitals and agencies like Practo, Lybrate, Quora and so on. You will find surgeons at page two onwards. Visit their website and check:

a. Their performance in medical school and later. Academic brilliance is often indicative of good professional competence.
b. Whether they have done specialised training and whether they have done it at a reputed, highly selective, institute. Specialisation is even more important than “volume.”
c. Whether they are keeping current with the latest technology by visiting Centres of Excellence in developed countries like the US, UK, Germany etc.
d. Browse her Blogs

Next, schedule a consultation with the selected surgeon. At the consultation ask the surgeon:

i. How many years’ experience she has in doing the specific surgical-procedure. A minimum of five years’ is preferred.
ii. How many total specific surgical-procedure she has done. Depending on the complexity of the procedure, minimum of 25 to 750 is suggested.
iii. How many specific-procedure she has done in the previous two years. For complex surgery, a minimum of 30 per year is suggested.

A good surgeon will not mind such questions and will not give incorrect information.

And finally, surgeon’s communication skills and trust-building ability are of singular importance.

Now ask yourself: “Was I comfortable talking? Did she answer my questions well? Did she ask good questions of me? Was she caring? Is she someone I can trust my life with?”

If possible, ask the surgeon’s other patients about their experience; and other doctors about surgeon’s expertise.

Before taking a final decision, seek a second opinion. In complex cases, about 1 in 5 second opinions are different from the initial treatment recommendation.

Conclusion

Every surgery has the potential for life-threatening complications. “Even in the best of circumstances, bad things can happen.” Occasional bad outcome are inevitable; but many surgical injuries are avoidable.

Minimize the probability of bad outcomes by choosing the right surgeon and the right hospital.

 

Gooney Bird

Weapons that most helped end World War II: “the bazooka, the Jeep, the atomic bomb and the Dakota.” – General five star (later US President) Dwight D Eisenhower, Supreme Commander Allied Forces (SHAEF), World War 2

Vintage DC-3/Gooney Bird ‘Parshurama’

Yesterday, 04 May 2018, Rajeev Chandrasekhar, MP, gifted a flying DC 3 vintage aircraft to the Indian Air Force. The gift, accepted by Air Chief Marshal B S Dhanoa, Chief of the Air Staff, will join the Harvard and the Tiger Moth vintage aircraft in the Hindon-based Vintage Air Craft Flight of the IAF.

The gift-DC 3, tail number VP 905, now named ‘Parshurama,’ was produced in 1944 and retired from the IAF in 1974 after three decades of service. It was picked up from IAF museum in 2012 and restored to flying at a cost of £580,000 (₹ 5.26 cr) after six years’ of work in England. It flew from England to Hindon airbase in Ghaziabad – 7000 km, crossing five countries, in seven days – for the gift ceremony.

And thus, 30 years after the DC 3 retired (1988) from the IAF, it re-entered, still flying majestically.

Self on the Captain’s seat in Gooney Bird ‘Parshurama,’ 04 May 2018, Hindon Airbase – handing over ceremony of the flying vintage DC 3 to the Vintage Aircraft Flight of IAF

A few tit bits about the DC 3.

Gooney Bird as the American’s call it, or Dakota or Dak as we and the British call it, are but two of the over two dozen nicknames of this legendary aircraft.

Gooney Bird, like the albatross – a giant seagull-like bird noted for its powers of flight and unflattering but safe landings – a bird which aerodynamically should not be able to get off the ground but is so stupid it doesn’t know that and flies anyway. Similarly, the Dak is so stupid (a goon) that it doesn’t know it is not supposed to do the things that it does.

And what things they are, were!

In June 1943, a Dak was attacked by eight Junkers Ju 88 over Bay of Biscay. It still ditched safely on the sea and all aboard survived the ditching, but were killed by repeated attacks by the Junkers.

On 27 may 1952, the Dak became the first plane to land at North Pole. On 31 October 1956, it became the first plane to land at South Pole, putting the first person at the South Pole since Robert Scott’s party more than four decades ago.

First aircraft to land at the South Pole, 31 October 1956, DC-3 Dakota

A Dak ran out of gas over Missouri in 1957. Everyone bailed out. The Dak glided over the horizon and made a perfect unmanned landing in a cornfield! The Dak can fly by itself! It is forgiving and psychic – anticipates pilot-errors and compensates for these.

Landing on an airstrip in a jungle, one quarter of the right wing of a Dak was damaged and it became un-flyable. The enterprising crew cut off one quarter each of both the wings and lo and behold! The Dak flew back home.

Designed to carry about 30 people, in 1975 in Saigon, Vietnam, it carried 106!

Dakota Number “728” retired in 1975 having spent more than 9 1/2 years in the air covering over 12 million miles, the equivalent of 25 trips to the moon and back.

Air Chief Marshal B S Dhanoa, Chief of the Air Staff, and self at the Reception 04 may 2018, Hindon Airbase – handing over ceremony of the flying vintage DC 3 ‘Parshurama’ to the Vintage Aircraft Flight of IAF

Dak’s doings in the Indian Air force were no less startling. Inducted in September 1946 in No 12 squadron, it demonstrated its mettle almost immediately. Just one year after induction, on 27 October1947, it carried Army’s 1 Sikh Regiment to Srinagar to halt the tribal Lashkar launched and backed by Pakistan. It then bombed, day and night, the Pakistani/tribal positions in Poonch sector. Later, it began landing on a hastily prepared, short, 600-yards kuccha strip at Poonch to carry troops and supplies. “The Dakota is the reason why Poonch is still with us,” says Pushpindar Singh, military historian.

Dakota’s next stellar role was to supply the army in Ladakh and in North-East. In Laddakh, it landed at Kuchha air strips at Kargil, Leh, and Thoise, at altitude of 10,000 feet; and at Chusul (13,000 ft) and Fuk Che (13,500 ft). It would have certainly landed at Daulat Beg Oldi (DBO) airstrip, 16,614 ft, to set the record for ‘world’s highest aircraft landing at the time;’ but this record was set by Squadron Leader C.K.S Raje with the first landing at DBO in a Packet (C 119) aircraft on 23 July 1962.

In NE, the Dak landed at Along, Daporijo, Inkiang, Tuting, Anini, Zero, Walong – all short, 7-800, yard strips nestled in hills, a few on miniature plateau with a sheer drop at one or both ends of the strip. All the airstrips with very difficult approaches. Only a Dak could land at these strips till the special STOL aircraft like Caribou, Otter, and C 130 J came along.

Chandrasekhar, the man behind the DC 3 ‘Parushrama’ restoration and handing over to the IAF, and self.

On a sunny but crisp and cool afternoon on 17 December 1935 in Santa Monica, California, the DC 3 (DST) sat at the edge of the runway for about five minutes, its engines running; then at full throttle, it ran down the runway and was airborne. The first time the DC 3 was in the air. Eighty-two years later, it is still in the air: six of them are in airline service with Buffalo Airways of Canada doing regular flights to NW Territories! One of these six is DC-3 C-GWZS which also flew in the D-day (6 June 1944) in the invasion of Normandy in WW 2.

At a total of 17,273 produced in various avatars, the DC 3 remains the most-produced airliner; the next is Boeing 737: 10,000 produced. As of September 2008, about 1,400 DC-3/Dakota airframes remained worldwide.

I am sure on 17 December 2035, its 100th birthday, the Gooney Bird will still be in the air. Because the only replacement for a DC 3 is a DC 3.

Daughter of Uttarakhand Award

DAUGHTER OF UTTARAKHAND AWARD

 

Dr Monika Pant (Vice President, BJP, Delhi) and Dr Rashmi Malhotra – my two nieces – accepted the Award for me since I was away; and Dr Monika read out my speech.

Extract from my acceptance speech at the Daughter of Uttarakhand Award;

“I’m an Uttarakhandi. But born in Lucknow, medical education and practice in Kanpur and in the US and in Delhi. My only connect to Uttarakhand was summer vacations in Nainital during my schooldays.

Then came the Uttarkashi earthquake, 1991. I spent a few weeks there to oversee the relief work undertaken by Swami Rama. That brought me face to face with the plight of the people in my home-state living in the villages perched on steep mountains.

I then founded Family Welfare Foundation of India to bring some medical care to the doorsteps of the villagers. The Foundation’s USP was that it neither sought nor accepted any donation from any one – individual, institution or govt.

In 1999, we became one of the few NGOs from India to be accredited by the United Nations (UN). Till date, we remain the only NGO in the UN system that does not accept donations from any one.

I also did bit of work for the setting-up of Swami Rama medical college, now HIHT University, at Rishikesh. I was a Professor in the college and trained the faculty in Minimally Invasive Surgery (MIS).

My work in Uttarakhand has been the best part of my life’s journey.”

26 April 2016

Laparoscopic & Robotic Gynec Surgeon

“I treat the patient, not the diagnosis”

Dr (Prof) Sadhana Kala
Laparoscopic & Robotic Gynec Surgeon
See: www.drsadhanakala.com