STI: Natural birth risk low after C-section

Dec 16, 2004
Natural birth risk low after C-section

BOSTON - Pregnant women who try a natural delivery after an earlier Caesarean section face greater risks - but still very low ones - compared with those who opt for a second C-section, a large study suggests.

The lead researcher said the chief risks - a torn uterus in the mother and brain damage in her newborn - are so unlikely that this study may boost the slumping rate of attempted natural births after C-sections. 'I think it will certainly open up the dialogue once again,' said Dr Mark Landon of Ohio State University.

The study was released on Tuesday before publication in this week's New England Journal of Medicine. It was carried out at 19 teaching hospitals nationwide, with collaboration and funding from the National Institutes of Health. It is the most elaborate effort yet to examine the safety of natural birth after Caesarean section, researchers say.

The medical community has long debated the merits and safety. Surgical C-section brings its own set of risks, like haemorrhaging and infection. Vaginal deliveries involve less hospital time and expense. In 1980, an NIH committee encouraged natural birth attempts in carefully selected women with a history of C-section. The rate of natural births after C-section peaked at 28 per cent in 1996.

Since then, reports of uterine ruptures have pushed down the rate. Many hospitals, nervous about the liability or need for surgical teams on standby, stopping doing such deliveries. By the end of last year, the rate had dropped to 11 per cent.

Doctors and patients often elect repeat surgery for fear that the uterus, weakened by scarring from the previous Caesarean, will rupture under the strain of natural labour and birth. That can seriously endanger both mother and child.

In this study, the researchers identified 33,699 women who had previously delivered by Caesarean section. Their subsequent pregnancies were monitored as they chose either to attempt vaginal deliveries or opted for another C-section. More than half of those chose to try natural delivery. Of that group, a quarter encountered problems and had to switch to Caesarean section.

In the end, 124 women who started with natural labour, including the C-section transfers, suffered uterine ruptures - less than 1 per cent of cases. There were no ruptures in the surgeries - only the cutting itself.

Seven babies suffered brain damage from uterine rupture, including two who died, according to the findings. Excluding pre-term deliveries where other factors come into play, one in 2,000 natural birth attempts ended with a brain-damaged or dead child as the result of a ruptured uterus.

There was no significant difference in the rate of maternal death between the natural-birth and surgical groups.

Researchers and doctors agreed that the findings can cut in favour of either kind of delivery, depending on the risk tolerance of particular patients.

Some doctors, however, cautioned that the study was conducted in leading hospitals, so the risks might be somewhat higher elsewhere.  --  AP

STI: Sorting out X from Y

Nov 29, 2004
Sorting out X from Y

In this age of increasing choices in many aspects of life, more couples are considering choosing the sex of their child too. Improved technology has added to this possibility.

Talk to your gynaecologist and consult with several fertility clinics before you go ahead with any procedure.

An increasing number of fertility specialists and reproductive endocrinologists perform procedures like sperm-spinning. This procedure is based on the principle that sperm determines the sex of the child. Sperm selection produces a sample of semen with a changed proportion of X or Y-bearing sperm.

In the technology called flow cytometry - used for farm animals and adapted to humans - sperm are tagged as bearing X chromosomes (that determine females) or Y chromosomes (that determine males) with different dyes and sorted in a machine into different batches used for artificial insemination or in-vitro fertilisation.

Another technique combines the parents' eggs and sperm in a petri dish and then tests the embryo to see its chromosome make-up, and implants the desired one in the woman's womb.

These are methods only done in fertility clinics under medical supervision.

Some sperm separation methods claim to affect the birth ratio. Some clinics using this procedure have claimed up to an eight in 10 chance of conceiving a desired child.

There are no guarantees, but some clinics are currently testing the effectiveness and safety of the process.

The procedures are also expensive.

Some experts say the odds of having a girl can be boosted by taking the fertility drug Clomid. But there are potential side effects to this and any drug.

Some calendar methods claim success, under the principle that having sex on certain days of the menstrual cycle matter, as the chemistry of the endometrium changes.

People have tried changing the chemical balance of the vagina. Some have tried using vinegar or baking-soda based douches. Scientists do not agree with these methods.

Using various positions in sex has also been tried, with various ideas including one that the Y chromosome is more delicate and therefore needs to be more firmly implanted in the vagina to enter the tubes, suggesting that the woman's hips be lifted in the air.

Some people have tried herbs. Others have turned to drastic diets to try to alter the chemistry of the vagina.

Medical associations are hesitant to endorse any as a tried and true method.

Dr Judy Kuriansky is a New York-based clinical psychologist, marital counsellor, certified sex therapist and professor at Columbia University Teachers College. Her books include The Complete Idiot's Guide To Dating, The Complete Idiot's Guide To A Healthy Relationship and The Complete Idiot's Guide To Tantric Sex.

STI: Eye see now

Nov  21, 2004
Eye see now
by Teo Cheng Wee

THE next time you see someone enter the wrong toilet by mistake, you could blame that on his vanity - and myopia.

A recent survey reveals that vanity and the inconvenience of carrying spectacles or wearing them to play sports are among the reasons people opt out of optical aids.

There's no point seeing well if you can't look good, says almost one in five people here with low myopia.

This has resulted in mishaps such as flagging the wrong bus (20 per cent), being hit by a ball while playing racket sports (4 per cent) or entering the wrong toilet (7 per cent).

The survey was conducted by a research company on 200 people with myopia of 150 degrees or less last month. One in six says he does not wear glasses at all while the rest only put them on half the time on average.

Among the latter is Mr Jacques Servant, 28, who has worked here for four years as a credit analyst. The Frenchman, with myopia of around 125 degrees since he was 19, doesn't wear glasses unless he's driving or watching movies.

But he got increasingly annoyed over the last two years because of his inability to see clearly: 'I had to squint a lot to see signs and accidentally ignored people waving at me because I couldn't see their faces. It made me irritable.'

He wanted to go for Lasik but was told that the amount of correction for mild myopia attained through the surgery may be minimal.

Contact lenses weren't an option either, as he 'didn't like to put things in my eyes'.

But help is at hand for people like him.

In June this year, the Singapore National Eye Centre (SNEC) launched the NeuroVision programme.

About 200 people, including Mr Servant, have undergone treatment so far.

The non-invasive therapy treats mild myopia below 150 degrees. Based on clinical trials, the success rate is 80 per cent, for people aged 18 to 55.

The most likely reason the other 20 per cent sees no improvement is the lack of motivation, as concentration and discipline are needed when training the brain, says Dr Jerry Tan, an ophthalmologist in private practice.

It works like this: Patients sit 1.5m from a 17-inch computer screen and sort out two images flashed on it by clicking a computer mouse.

The exercise becomes more difficult as the images become more alike. They are also flashed across more quickly.

NeuroVision trains the brain to see better, says Dr Chan Wing Kwong, a senior consultant and head of refractive surgery service at the SNEC.

Instead of improving the image that the eye sends to the brain with the help of glasses or surgery, the brain is taught to sharpen the blurred image the eye sends.

The physical defect that causes myopia - usually an eyeball that is too long - is not eradicated. Patients go through three sessions a week and about 30 in total. Each lasts about 30 minutes (see other story).

NeuroVision can also treat amblyopia, or 'lazy eye', with more complicated exercises.

The technology was pioneered by Israeli doctor Uri Polat 20 years ago, though NeuroVision, the company he set up in 1999, is now based in the United States.

Singapore is the first country where the technology is available to the public. The company chose Singapore due to the high myopia rate of 80 per cent.

After three months, Mr Servant can now make out smaller letters on the eye chart. That has made him less tired and irritable.

Another happy customer is fellow Frenchman Roderic Proniewski, 38, who also underwent the programme at SNEC.

The managing director of a wine company, who has been here since 1989, is most excited about seeing better underwater when he goes for his next dive trip.

To wear or not to wear

PERHAPS the most commonly debated topic for people with low myopia is: Should one wear glasses?

One camp says no because that may cause your eye to become lazy, dependent and hence increasingly short-sighted.

But the other camp says yes, because not wearing will strain your eye more, possibly worsening the short-sightedness.

So who is right?

Dr Lee Sao Bing, an associate consultant from The Eye Institute at the National University Hospital, says it won't make any difference to adults as their myopia would have stabilised: 'If they choose not to wear glasses, they just won't see distant objects clearly. Their short-sightedness won't worsen, whether they wear glasses or not.'

Dr Jerry Tan, an ophthalmologist in private practice, says the best treatment is simply wearing glasses with the right power.

'If your degree is below 75 degrees, you can choose not to wear as you should be able to see almost everything clearly,' he says.

'Above that, though, you should wear glasses. Don't go around without them and suffer blurred vision, or wear glasses that are 'overpowered'.

'Make sure your glasses are correctly powered. I don't think anyone can argue with that.'

STI: For crying out loud, give baby a rub

Nov 8, 2004
For crying out loud, give baby a rub
by Teo Cheng Wee

HANDS up, those parents not getting enough sleep because of wailing babies.

Now, bring down those hands and massage your baby.

This can reduce the number of times the baby wakes up at night by 33 per cent, according to a recent study conducted at Brown University in the United States.

Each massage takes about 15 minutes and is done all over the body.

The babies in the study were massaged before being put to bed, but the rubdown can also be done at other times with the same benefits.

Mrs Jacqueline Tan, 31, found out the hard way after enduring a few difficult weeks when her daughter Odelia was two weeks old.

'Odelia kept crying and nothing we did would make her stop. It was depressing,' says Mrs Tan, an information systems executive and first-time mother.

She sought help at Thomson Medical Centre, where Odelia was born, and was advised to sign up for a $30, hour-long infant massage class.

Since she started giving her child daily massages, Mrs Tan says the four-month-old now sleeps through the night and is less irritable during the day.

Says Dr Judy Owens who handled the study at Brown: 'Massage reduces stress hormones and relaxes the body, making it easier for the babies to sleep well.'

The study, conducted on 45 babies, was initiated this year and is still ongoing.

'Massage can start at any age and be done up to the age of eight,' adds Dr Owens, who is also an associate professor of paediatrics at Brown Medical School.

She was in town the last few days for the Regional Sleep Alliance, a discussion with fellow paediatricians on topics like baby massage and sleep problems in Asian babies.

Babies spend more than half the day sleeping and sleep trouble has been linked to developmental and behavioural problems.

By the age of four months, they should be able to fall asleep without assistance (such as rocking or sucking on a pacifier) and sleep continuously through the night.

While there is no one pioneer of massage, Dr Tiffany Field from the US was the first to drive research related to its clinical benefits.

The Touch Research Institute was set up under her guidance at the University of Miami in 1992.

It was the first centre in the world devoted to the study of touch and massage and its application to the well-being of babies or children.

Still, Dr Owens doesn't think that many parents practise it regularly in the US.

Here, baby massage is taught in all nine maternity hospitals.

Exact figures are unavailable but Associate Professor Daniel Goh, a senior consultant at the Children's Medical Institute of National University Hospital, does not think it is commonly practised.

But as the doctors are now working towards a set of Asian Sleep Guidelines to promote good practices for Asian babies, young parents can look forward to kissing sleepless nights rock-a-bye-bye.

Hands-on training

Step 1: Legs

Rub your hands till they are warm

'Pull' from the thighs down to the feet, like you're milking them

Rub the soles

Gently pull the toes one by one

Step 2: Arms

'Pull' from the shoulders down to the hands

Rub the palms

Gently pull the fingers one by one

Step 3: Stomach

Using your palms, gently rub the stomach in circular motions

Step 4: Back

Using your palms, stroke from the top to the bottom

Cup your palms slightly and tap the baby's back

Step 5: Face

Using your thumbs, stroke the eyebrows from the inside to the outside

Move on to stroke the cheeklines around the nose

Continue to the jaw, stroking from the chin to the ears

STI: Going cold turkey

Jul 7, 2004

Going cold turkey
by Loh Keng Fatt

ABNORMAL, the results showed.

That was the e-mail from my doctor who had analysed the results of my recent annual medical check-up.

He was referring to one red-alert indicator from the treadmill stress test.

It seemed that the heart was not getting enough oxygen towards the later stage of the nine-minute test.

This could imply clogged blood vessels which affect the supply of oxygen and nutrients, and might signal a risk of heart attacks.

But not to worry, he added in the e-mail. Just take it easy on the aerobic activities. He would see me again and refer me to a cardiologist.

That was on a Friday. My weekend was shot. Should I tell the family or keep quiet until I was more certain of the state of my health?

I can never hide a secret at the best of times. And I believe that fathers should level with their family for it's the least they deserve, especially considering that health is a matter of life and death.

So I told them gently, on the same day itself, that the medical had picked up something which might or might not be bad news.

I said matter-of-factly that human bodies are not immune from wear and tear, but if certain parts become wonky, there are ways to get the system back into working order.

But, at the back of my mind, I was worried. Parents want to stay healthy to be there for their children, at least well into their young adulthood.

We want to be there at all the major milestones - from playing football for the first time for their school to graduating from university.

Parents also dream of playing grandparents.

In my case, I try to increase the odds of survival. I aim to live healthily.

I exercise. My workplace has a gym and I do spend time there regularly to sweat out all the body's impurities and inject tone and flexibility into the muscles and joints.

Now that I often have to drive my son to his school early on Saturday, I visit the nearby Bukit Timah Nature Reserve to find peace trekking through its many serpentine trails.

I do not smoke or drink. I eat the basic three meals a day and have no desire to pig out on sweets, soft drinks or snacks.

In fact, I could put on a few more kilos without the doctor giving me a dirty look.

For these reasons, I have always thought I was safe from the ravages of disease and advancing age.

Horror writer Stephen King thought he was immune, too. In his preface to Gunslinger, which he rewrote because he said that was done when he was in his college days, he explained how he now saw the book's characters differently.

Life at 18 is different from life at 55 or 65, he said.

When you are young, you think you are invincible. But sooner or later, he noted, that guy with the twisted sneer and cruel knife catches up with you.

And so, it seemed to me, too, that that bogeyman had caught up with me when the word 'abnormal' screamed out from my health report. IT'S scary to think about your own mortality. The reaction, in the face of bad news, is to clutch at anything which can possibly explain away the imperfection.

Was I too physically tired, I wondered, before I did the treadmill test?

Two days before, I had laboured up the Dairy Farm trail on Bukit Timah. There's a stretch with about 200 steps cut into a fairly steep incline.

It was probably not a good idea to put the weary body through the treadmill test two days later, I reasoned. This was what explained the abnormal reading, I concluded with some hope.

They say there's always a silver lining behind a dark cloud. I found it in my sons' reaction to the troubling news.

They showed their love and common sense. They warned me in no uncertain terms to stay away from any exercise, at least for a while.

They took charge of a bit of my life, and I saw in them the men I hope they will grow up to fully in years to come.

They said: 'You tell us not to do this and that, and we comply, so now we expect that you do the same.'

I had no choice but to obey though exercise junkies would know that it's not easy to slow down. We are all addicted to the rush of well-being that comes from a good workout.

But I did not want to let the boys down so I went cold turkey on the exercise.

It would be ridiculous if I were to collapse just for the sake of crafting more muscle out of the body.

I did consult the cardiologist in due course. The good doctor calmed me somewhat by saying that the results of the stress test are never 100 per cent accurate.

It was more like 60 per cent.

He suggested a second test, but with scans of the heart before and after.

I did well this time. The images showed a heart pumping away with full force.

I SMSed the elder kid later - 'doc says i m ok'.

He replied: 'What about Dad, leh?'

He thought that it was his mother who had SMSed him - I was using her mobile phone.

I was touched, but was also put off by the word 'leh' (mmm, after all these years of teaching him to use proper English?).

But it did prove one thing. Life's like that.

When everything's okay, you agonise over the silliest, tiniest, most inconsequential thing.

STI: A baby at any age? Many here think so - mistakenly

May 24, 2004

A baby at any age? Many here think so - mistakenly
by M. Nirmala

A HIGH number of singles and married couples here are convinced that advances in medical technology can help them have babies at any age, according to the finding of a survey that even has fertility experts surprised.

Six out of 10 Singaporeans polled believe procreation can happen at will, and that 'fertility can be turned on and off like a tap', said the Ministry of Community Development and Sports (MCDS) which commissioned the survey.

The responses from the 6,000 Singaporeans polled, half of whom were married, reflected an over-confidence placed in technology to overcome problems in conception.

The notion, which is at odds with long-standing medical evidence that fertility declines with age, even prompted Community Development and Sports Minister Yaacob Ibrahim to say that 'fertility is not on tap'.

'Singaporeans seem to think that with better medical technology, it is no longer difficult for older couples to conceive; that age is no longer a criterion. This is not true.'

A 35-year-old father, who spent about $100,000 on in-vitro fertilisation (IVF) so he and his wife could have a child, agreed and urged couples not to wait: 'We thought we could let nature take its course, but we were wrong.'

The survey between July last year and February this year will help guide policy planners looking into ways to boost Singapore's population.

They have already taken on board other MCDS findings, including that a lack of money, time and energy is what couples say holds them back from achieving their dream family size of three children.

According to the fertility survey, more than half - 65 per cent - of career women polled believed a woman could conceive at any age with a fertility treatment programme.

Eight out of 10 of these women - who see work as central to their identities and lifestyles - knew, however, that fertility treatment programmes were a painful and expensive undertaking.

KK Women's and Children's Hospital's head of reproductive medicine Sheila Loh was surprised by the results.

'It is a myth. Science is there to help to a certain extent. No matter how healthy a woman is, her eggs would be older as she ages,' she said.

Associate Professor P.C. Wong, who heads the National University Hospital's obstetrics and gynaecology department, added: 'Women should use science and medical advancement as a fall-back plan or backup and not to use it as a lifestyle choice.'

Doctors said the percentage of women who could have babies using technology drops with age.

For those who use the IVF method, the chances of women aged 35 and below, conceiving is about 50 per cent.

But for women above 40, there is only a 10 to 15 per cent chance, said Prof Wong.

Of those who become pregnant, 20 per cent can suffer miscarriages, said doctors.

The MCDS will step up education efforts through radio talk shows and public seminars as 80 per cent of those interviewed want advice on fertility issues after marriage.

Ms Charlotte Beck, director of MCDS' family policy unit, said the ministry will also work with voluntary groups that can better connect with the ground.

One such organisation is the newly set up Alife Pregnancy Assistance and Counselling Services.

Founder member and gynaecologist Peter Chew said their counselling included tips on how frequently couples should have sex. This approach had helped 16 out of 100 couples to have babies.

'We use low-cost simple methods to get across messages that even if Hollywood stars can have babies when they are old, there are many, many women who cannot do so, even after spending a lot of money and going through a lot of pain.'

STI: When science can't hatch a baby

May 24, 2004

When science can't hatch a baby

HER fertility doctor gave her drugs to stimulate ovulation but she ended up bleeding non-stop for a year.

'I became very weak. I couldn't do anything to stop it,' says the 33-year-old civil servant of her six-year ordeal to get pregnant.

She and her husband, a marketing executive, spent over $100,000 on fertility treatments.

The scary part is that when she started trying for a baby, she wasn't even old enough to fret about her biological clock.

What is even more frightening is the fact that many more women and men believe age poses no barrier to a couple's ability to have children. Science has all the solutions, they believe.

A new Community Development and Sports finding shows that over six in 10 believe that fertility can be turned on like a tap at any age thanks to medical technology.

Insight's interviews with young women in their late 20s bear out this perception. A 26-year-old executive's answer that she will only think of having babies when she is in her 30s is typical: 'I'm not worried. When I hear about other people's suffering, I think, it is their story, not mine.'

Singapore's in-vitro fertilisation or IVF programme which started in 1982 to help childless couples, has made groundbreaking advances in the field that have appeared in reputable medical journals. But paradoxically, the advances may have had an unintended consequence of lulling Singaporeans into a false sense of security.

The survey finding only adds to the complex web of issues the procreation policy committee has to tackle before it delivers its recommendations in August.

How to persuade couples that delaying parenthood could mean not ever having children? How to make them recognise the risks involved in taking the petri-dish route?

For a start, the facts should make them sit up. The harshest one first: Doctors warn for women aged 40 and above, fertility might well be an exercise in futility. Fertility levels start dropping around the age of 30, slides down dramatically at 35 and then again after 40.

The second reality check: While IVF treatments are said to be more effective in helping couples who have difficulty conceiving, it is not so with age-related fertility problems.

Hence, doctors say couples should turn to medicine as a last resort and not in their frontline.

One fertility expert, Professor Ariff Bongso, notes that because of poor egg quality, the pregnancy rates for women after 40 years of age go down to as low as 10 per cent.

'It is very difficult to make an old egg younger even through research,' he says.

Other experts say that as women age, they are more likely to have gynaecological problems such as endometriosis and fibroids which also reduce fertility.

Some eggs will be blighted and even a fertilised egg might fail to attach itself to the uterus. When pregnancies occur, miscarriages are more likely.

A Danish study in 2001 of 600,000 women found that at age 22, a pregnant woman faces an 8-per-cent chance of having a miscarriage. But, from age 45, that possibility jumps to 75 per cent.

There are other risks. At 25, a woman has a 1 in 1,250 chance of having a baby with Down's Syndrome, a combination of mental retardation and physical abnormality. At age 45, she has a 1 in 26 chance of giving birth to such a child.

Infertility is not just women's problem but men's as well. The quality of men's sperm 'Maybe the nurses do this job everyday and become insensitive. But, I didn't want to be treated like some zoo animal.'

He and others in their late 30s to 40s interviewed agreed that they should have paid more attention to what one American academic calls 'the creeping non-choice factor'.

Academic Judy Friedlander used the phrase to describe how women believe they can have both career and baby but end up losing out on the baby part because they ignored their biological clocks.

Singaporeans' confidence that science can beat that clock is widely shared among Americans too.

In the United States, similar sentiments have been documented by Ms Sylvia Ann Hewlett, an economist and author of Creating A Life.

In her 2001 nationwide survey of the top 10 per cent of high-earning American women, she found that childlessness haunts their executive suites and many lived with regret for not finding a way to have children.

For many, the fertility industry lulled them into a false sense of security that they can get pregnant, deep into middle age.

Among the women aged 28 to 40 she surveyed, almost 9 in 10 believed that they would be able to get pregnant into their 40s.

However, the older corporate females aged 41 to 55 found that while they wanted to have children, their preoccupation with their careers meant that by the time they were ready to have a baby, their bodies had given up on them.

Among this age group, only 1 per cent had a first child after age 39.

Highly-hyped Hollywood pregnancies, Ms Hewlett adds, have also sent a dangerously misleading message that women can wait to have children because science will be there to save them.

But she points that for every 52-year-old woman who make the headlines, thousands more waste an inordinate amount of time, energy and money.

Fertility experts and family counsellors say it is time for Singapore's young adults and couples to know fully the risks of having babies late. They are not in it for the campaign to boost Singapore's baby numbers, they add.

Rather, they want to spare couples the deep physical and emotional pain and anguish they have seen in their clinics and counselling rooms that can drive some couples into depression and even divorce.

Young couples should realise the limits of medical advances, which can improve their chances if they are infertile but cannot guarantee them babies.

Yes, there are new areas of research opening up, says Prof Bongso, but these are still in their early stages.

One such attempt is to store eggs through freezing, he says, adding: 'In this way couples can postpone having babies.'

Member of Parliament Lily Neo, who is a medical doctor, feels strongly that messages about fertility need to be factual with people being told about the risks and dangers of having a baby late in life.

'But we need to be careful because any form of public education can result in a backlash, especially for the young who do not like being told what to do,' she says.

If Singapore women are to learn from their American peers, they need to look at how they are paying the price of motherhood because of their chase of high-altitude careers.

Ms Hewlett, who discusses the empty promise of high-tech reproduction, urges women to figure out early what they want their lives to look like at age 45.

Stressing that the choice lies with the individual, she urges them to choose a career that will give them time to also have a family.

Other experts suggest that women have their babies early and return to the career track when the children get into school.

Will Singapore women listen? What about Singapore men? Too little has been done to focus on them, whether it is their emotions in dealing with childlessness, or how their own decisions in their careers affect their wives' choices.

Whatever the answers, with the latest survey findings, the procreation committee's work just got more difficult.  --  Additional reporting by Azrin Asmani