CARING FOR WOMEN

EVERY STEP OF THEIR LIVES

CARING FOR WOMEN

EVERY STEP OF THEIR LIVES

CARING FOR WOMEN

EVERY STEP OF THEIR LIVES

CARING FOR WOMEN

EVERY STEP OF THEIR LIVES

CARING FOR WOMEN

EVERY STEP OF THEIR LIVES

CARING FOR WOMEN

EVERY STEP OF THEIR LIVES

WELCOME TO DR PAMELA TAN MEDICAL CLINIC

LEADING FEMALE OBSTETRICS AND GYNAECOLOGY SPECIALIST IN SINGAPORE

Obstetrics

View our list of obstetric services available during your pregnancy, birth and beyond. Find out more.

Gynaecology

Learn about our comprehensive gynecologic care including infertility, bleeding issues and abnormal pap smears, & more.

LIKE YOU, WE CARE

Dr Pamela Tan is an obstetrics and gynaecology specialist practising at Thomson Medical Center in Singapore. Prior to leaving for private practice, Dr Tan was a female Consultant in the Department of Obstetrics and Gynecology, KK Women’s & Children’s Hospital.

She obtained her undergraduate medical degree at the National University of Singapore and her post-graduate MRCOG in London at the Royal College of O&G. She is a specialist accredited with the Specialist Accreditation Board (Ministry of Health) and is a Fellow of the Academy of Medicine, Singapore (FAMS). She is an accredited member of the Society for Colposcopy and Cervical Pathology of Singapore (SCCPS) with a subspecialty interest in colposcopy (for pre-cancer of the cervix and vagina) and vulval disease.

In further pursuing this interest, she was a fellow for pre-invasive disease at the colposcopy and vulval unit at the Whittington Hospital in the United Kingdom. She is a visiting consultant at KK Hospital for colposcopy and is still involved in research on computer imaging analytics for screening cervical cancer in low resource settings in a joint collaboration with the National University of Singapore.

While in the United Kingdom, she was also a fellow at the Assisted Conception Unit in Guys Hospital to learn the latest in reproductive techniques and approaches to infertility. She is accredited to perform advanced Level 3 minimally invasive keyhole surgery such as laparoscopic hysterectomy, myomectomy and cystectomy (womb, fibroids and cysts removal).

Her philosophy to doctoring is one that is focused on building relationships with her patients. She strives to deliver patient care that is warm, caring, professional and well advised. She is a believer of pro natural birthing and providing an optimal birthing experience as desired by her patients.

Dr Pamela Tan is an obstetrics and gynaecology specialist practising at Thomson Medical Center in Singapore. Prior to leaving for private practice, Dr Tan was a female Consultant in the Department of Obstetrics and Gynecology, KK Women’s & Children’s Hospital.

She obtained her undergraduate medical degree at the National University of Singapore and her post-graduate MRCOG in London at the Royal College of O&G. She is a specialist accredited with the Specialist Accreditation Board (Ministry of Health) and is a Fellow of the Academy of Medicine, Singapore (FAMS). She is an accredited member of the Society for Colposcopy and Cervical Pathology of Singapore (SCCPS) with a subspecialty interest in colposcopy (for pre-cancer of the cervix and vagina) and vulval disease.

In further pursuing this interest, she was a fellow for pre-invasive disease at the colposcopy and vulval unit at the Whittington Hospital in the United Kingdom. She is a visiting consultant at KK Hospital for colposcopy and is still involved in research on computer imaging analytics for screening cervical cancer in low resource settings in a joint collaboration with the National University of Singapore.

While in the United Kingdom, she was also a fellow at the Assisted Conception Unit in Guys Hospital to learn the latest in reproductive techniques and approaches to infertility. She is accredited to perform advanced Level 3 minimally invasive keyhole surgery such as laparoscopic hysterectomy, myomectomy and cystectomy (womb, fibroids and cysts removal).

Her philosophy to doctoring is one that is focused on building relationships with her patients. She strives to deliver patient care that is warm, caring, professional and well advised. She is a believer of pro natural birthing and providing an optimal birthing experience as desired by her patients.

Latest Blogs

Serving You the Facts on Cervical Cancer Screening in Singapore

Based on current estimates, there 429 women who are diagnosed with cervical cancer every year in Singapore and 70 die from it.  It’s alarming how a preventable disease remains to be among the top 10 cancers affecting women in the country today.

This makes screening an important topic for discussion because it draws the fine line from potentially fatal consequences and survival.

Cervical Cancer

Cervical cancer is a disease that stems from the cervix or the neck of the womb. The Human Papilloma Virus (HPV) has over 100 different strains and 15 of these are classified as highly likely to develop cancer. In most cases, cervical cancer is attributed to two types – HPV-16 and HPV-18 (high-risk HPV).

Most women infected with HPV do not develop cervical cancer since 90% of infections resolve on their own within 2 years. Those with persistent infection are the ones who have a higher risk of developing cervical cell abnormalities and eventually cancer. Even if a woman is infected with HPV within a few years after she first had sex, the incidence of cervical cancer peaks at around 45 years of age. This means that the progression from persistent infection and invasive cervical cancer peaks well into your 40s.

However, what’s so sneaky about it is that if the problem persists, there are no red flags on any abnormal changes. It is only when the problem has advanced that it starts to show symptoms.

Read: What You are Missing Out On When You Skip Regular Visits to Your Female Gynaecologist

Symptoms

Precancerous cellular changes and early cancers of the cervix are very discreet. These changes occur years before cancer develops, giving you a good window of opportunity for screening and early detection.

As the disease advances, it usually comes with the following symptoms:

  • Pelvic pain that is unrelated to your menstrual cycle
  • Heavy or unusual discharges that may be thick or watery with a foul odor.
  • Abnormal bleeding:
  • Between the regular menstrual period
  • After sexual intercourse
  • Pelvic exam
  • After douching
  • After menopause
  • Pain during urination
  • Pain during intercourse
  • Increased urinary frequency

These symptoms may also be related to other health problems aside from cervical cancer. Nevertheless, it is important that you seek medical advice if anything is out of the ordinary.

Cervical Screening

Pap Smears

Short for Papanicolaou Test, Pap-smears help detect cervical cancer in its early stages. Doing so makes it easier to be treated with surgery, chemotherapy, or radiotherapy. This gives you a stronger chance at survival.

How it is done:

During the procedure, you lie on your back with your knees up and bent while your feet are placed on stirrups. The doctor will then insert a small metal or plastic instrument called a speculum. This is used to open the vagina to properly visualise its walls as well as that of the cervix. This may be slightly uncomfortable, but it is tolerable.

Using a small cervical brush or broom, the doctor obtains a sample of the cervical cells.  A pap test should not be painful. So, if you feel any pain during the procedure, inform your doctor.

The samples are then sent to the lab and examined for abnormalities. An abnormal result doesn’t always mean that you have cervical cancer. This means that there is something that requires further evaluation by the doctor. A colposcopy may be done, which is an examination that uses a microscope to confirm if it is indeed cervical cancer.

While a Pap Smear test is a reliable tool for screening, it is not 100% accurate. It detects only about 55-65% of the time when there is an abnormality. This means that if there are 100 women who had cervical cell abnormalities, a Pap test will currently detect 55-65 and miss out on 35-45.

Cost of Pap Smear in Singapore

If you are not aware of this yet, you can get a Pap smear done free through the Singapore Cancer Society. Alternatively, you can also get it at an affordable cost because of the program rolled out by the Health Promotion Board. You can get it for $5 if you are a Singapore citizen (check your eligibility, here) and  $12.25 for Permanent Residents.

If you are a CHAS (Community Health Assist) card holder, your Pap test will have a subsidized rate of $2. However, this is only applicable to participating clinics and healthcare centres.

HPV Testing

Since a Pap Smear is subject to false negative and interpretation errors, HPV testing is regarded as a more accurate screening tool. However, it will not tell you whether you have cancer, rather it will detect the presence of HPV and what strain is in your system.

Having the knowledge of what type of HPV you are infected with allows you and your doctor to better decide on the next steps in your health care. If a woman’s HPV test is negative, it means that high-risk HPV types were not detected, she has a low risk of developing cervical cancer. A negative result will also mean that you don’t have to return for 5 years. If you tested positive, you will have to go back to your doctor every 6 months for monitoring.

How it is done:

The process is similar to a Pap Smear where a speculum is inserted into the vagina so the doctor can collect samples of your cervical cells. Sometimes, an HPV test is done at the same time as a pap test so that the doctor can obtain 2 samples for both.

A Help for Helpers

The country has widened its scope in a strong effort to help more women prevent or overcome this disease by making cervical cancer screenings free for foreign domestic helpers. It aims to lower the incidence of cervical cancer to these population of women who may not have access to it.

Cervical Screening Guidelines in Singapore

Who are advised to undergo screening?

  • All women who have ever had sexual intercourse are advised to have their first pap smear test from the age of 25.
  • Women who have never had sexual intercourse don’t have to undergo screening, but if they exhibit any symptoms, they should consult a doctor.

Frequency of Screening

According to the National Cervical Cancer Screening Programme, the frequency is as follows:

  • Age 25-29 years – Pap smear must be taken once every 3 years
  • Age 30-69 years – HPV test alone every 5 years for a negative HPV test. The reason for not testing girls younger than 30 is because almost a quarter will be HPV positive at that age and most will clear up within a year. It will not help doctors in triaging who is at a higher risk.

Under a non-national screening programme the options for those 30 years of age and above the following applies:

  • Pap Smear alone every 3 years
  • HPV test alone every 5 years
  • Co-testing with Pap smear and HPV test every 5 years

Discharge from Screening

Cervical cancer screening is not indefinite. If a woman has committed to regular screenings, she can already stop doing so at age 69 if she has:

  • 3 consecutive negative pap smear tests
  • Or 2 consecutive negative HPV tests in the last 10 years, with most recent test occurring within the last 5 years
  • Or 2 consecutive negative Co-tests (pap smear + HPV testing) in the last 10 years, with the most recent test occurring within the last 5 years.

Routine screening will continue for at least 20 years in women with a history of CIN2, CIN3 or AIS. It will still apply even if it extends beyond 69 years of age. You may visit our clinic for a thorough discussion on this.

Primary Prevention

Since HPV infection is necessary for the development of cervical cancer, it is only logical to give yourself a blanket of protection through vaccinations. Screening is only secondary prevention, but an HPV vaccination is considered the primary line of defense. Therefore, it is only right to add it into the discussion because screening and vaccinations go hand in hand so you can safeguard better.

An HPV vaccine not only protects you from cervical cancer, it also prevents other cancers like anal, vulva and mouth cancer. It can even protect you from genital and anal warts.

Who Gets the Shot?

Girls and even boys can get HPV vaccinations. Under the National Childhood Immunisation Schedule, the government encourages girls aged 9-26 to get vaccinated. In April 2019, all 13-year-old girls in Singapore (citizen and PR) can get the HPV vaccine for free. This is an opt-in scheme, which means that parents must give their consent.

The reason why this vaccine is encouraged to be given at a young age is because it serves as a preventive measure and not a treatment. It is advised that you get vaccinated before you become sexually active. When administered too late, it may not be effective in giving you protection. If you are above 26 and haven’t gotten the HPV vaccine yet, you may discuss this with your doctor to see if you are a suitable candidate.

Boys must also get into the movement because men can also catch and spread HPV. It can also cause cancers of the throat, genitals or anus in men. Unfortunately, there are no national healthcare programmes that will subsidise HPV vaccines for boys.

There are 3 types of HPV vaccines that are approved for use in Singapore at present and these are:

  • Gardasil 4 (4-valent vaccine) – protects against HPV-6, 11, 16 and 18; for boys and girls aged 9-26 years of age
  • Gardasil 9 (9-valent vaccine) – protects against HPV-6, 11, 16, 18, 31, 33, 45, 52, and 58; for boys and girls aged 9-26 of age
  • Cervarix  – protects against HPV-16 and 18; licensed only for girls 9-25 years of age

Vaccination Schedule and Recommendations

Gardasil

  • 3-dose schedule: 0,2 and 6 months for individuals 9-26 years of age.
  • 2-dose schedule: 0 and 6 months for individuals 9-13 years of age.

Cervarix:

  • 3-dose schedule: 0,1 and 6 months in females 9-25 years of age.
  • 2-dose schedule: 0 and 6 months in females 9-14 years of age.

Source: sccps.org

The protection you need against cervical cancer is already available today. You only need to make the first step; even the government is making efforts to help. Don’t allow yourself to be part of the statistic, seek the protection you need today.
If you have more questions, do give us a call so we can schedule your appointment. Let’s get into an in-depth discussion on this matter.

Gestational Diabetes Mellitus: Why It is No Sweet Talk

Diabetes mellitus, or diabetes, is a chronic condition where the body is unable to produce any or enough insulin resulting in excess sugar (glucose) levels in the blood. This may sound all too familiar, but it is mainly because of the sobering statistic in Singapore and around the world.

According to the International Diabetes Federation (IDF), there are over 606,000 cases of diabetes in Singapore in 2017. It could be your mom, a friend, or a workmate who has it. However, beyond the numbers is a string of health concerns that comes with it and could potentially result into. When it affects a woman in a vulnerable state like pregnancy, it warrants immediate attention to ensure the safety of both the mom and the baby.

So, if you’re expecting or planning on getting pregnant soon, it’s important that you’re also aware of the type of diabetes that strikes during pregnancy. It pays to keep your guard up because any woman could potentially develop it.

  • What is Gestational Diabetes Mellitus?
  • What Causes Gestational Diabetes?
  • Who are at Risk for Gestational Diabetes?
  • What are the Potential Complications?
  • How is GDM Screening Done in Singapore?
  • Why is an HbA1c not advised when screening and diagnosing GDM?
  • How is GDM treated?

What is Gestational Diabetes Mellitus?

Gestational diabetes mellitus (GDM) is a type of diabetes that develops during pregnancy, usually during the second or third trimester. Those who develop it usually don’t have diabetes before pregnancy, but it also goes away after giving birth. However, some women go on to develop Type 2 diabetes later in life.

While it is true that any complication in pregnancy is a cause for concern, the good news is that gestational diabetes is controllable. Appropriate management through regular diet, exercise, and insulin therapy lowers the risk of developing complications.

What causes GDM?

Insulin is the type of hormone that keeps blood sugar levels in check. However, pregnancy hormones can interfere with how the body uses insulin. An example would be the increase of human placental growth hormone at 15 weeks of pregnancy which increases blood glucose levels.

Normally, the body responds by making more insulin during pregnancy to meet the changing demands of the body. However, for some women, their system are unable to make enough insulin causing blood sugar levels to spike, eventually leading to GDM.

Who is at risk of GDM?

Women are considered high-risk candidates for GDM if they fall under any of these:

  • Have a pre-pregnancy BMI of more than 30kg/m2
  • Have a GDM history
  • Have pre-diabetes history
  • Have a history of polycystic ovary syndrome
  • Have delivered a baby that is 4kg and heavier
  • Woman is 40 years old or older

Women below the age of 40 can do an online diabetes risk assessment, here.

What are potential complications?

The main reason for controlling GDM is to avoid complications that can range from the mild to potentially fatal. It not only affects the mother, but the health and well-being of the baby even beyond the womb.

Maternal

  • Pre-eclampsia (high blood pressure during pregnancy)
  • Preterm labor
  • Polyhydramnios (excessive amniotic fluid)
  • Miscarriage
  • Severe vaginal tears due to a large baby
  • Heavy bleeding after delivery
  • Risk of type 2 diabetes in the future

Fetal

  • Premature birth
  • Stillbirth
  • Large for gestational age baby
  • Breathing problems
  • Jaundice (a condition where the skin, the whites of the eyes and mucuous membranes turn yellow)
  • Shoulder dystocia (an emergency when the head is delivered but the body is stuck)
  • Low glucose levels
  • Risk for childhood obesity
  • Risk of developing diabetes later in life

How is GDM Screening done in Singapore?

First Trimester

In Singapore, high-risk women are screened during the first trimester for undiagnosed pre-existing diabetes using non-pregnancy glucose thresholds. This is usually done around the 12th week prenatal visit together with routine pregnancy blood tests of infection screen, hemoglobin level and blood group. If results are normal, the woman is re-evaluated for GDM at 24-28 weeks of gestation.

24-48 Weeks

It is protocol that all women are screened for GDM within this period, including those who had normal results in the first trimester. It was found that there is increased resistance to gestational insulin at this stage.

To ensure proper monitoring Universal screening is preferred over Risk-Based screening because Asians generally have a high incidence rate of GDM. This allows healthcare workers to detect more GDM cases and improve outcomes for the mother and the baby.

They do the test by using the 3-point 75g Oral Glucose Tolerance Test (OGTT). An OGTT requires you to drink a glucose solution after a night of fasting. This is followed by the extraction of a blood sample at the onset, one hour after, and then two hours later. A GDM diagnosis is made if any of the criteria below is met.

GDM Diagnostic Criteria

Plasma Glucose Levels (values are in mmol/L)Previous RecommendationsCurrent Recommendations based on IADPSG
FastingMore than or equal to 7.0More than or equal to 5.1
1-Hour Post-OGTTNot applicableMore than or equal to 10.0
2-Hour Post-OGTTMore than or equal to 7.8More than or equal to 8.5

Post Pregnancy

Post pregnancy screening serves as a follow-up for women with a history of GDM in a bid to monitor if their condition has resolved. It is expected that 6 weeks after delivery, blood glucose will revert to pre-pregnancy levels. To check if it does, a 2-point (fasting and 2-hr) 75 g OGTT will be done within 6-12 weeks after delivery using non-pregnancy normal values. The same screening process is also done on women who are diagnosed with pre-diabetes or diabetes in their first trimester.

Women who received insulin treatment during pregnancy, or those who have a high risk of developing diabetes (e.g. obese or family history of diabetes), are also required to have frequent follow-up check-ups. In fact, in Singapore, all women with a history of GDM must be screened for diabetes once every three years.

Why is HbA1c Not Advised When Screening and Diagnosing GDM?

HbA1c is a glycated hemoglobin which occurs when glucose in the blood sticks to hemoglobin, a protein within red blood cells. The test will reveal a person’s average blood sugar levels for the last 2-3 months.

It should not be used to screen or diagnose GDM because it is not sensitive in detecting high sugar levels after meals. HbA1c levels will not provide accurate results because it is also generally lower during pregnancy due to increased red blood cell turnover.

How is GDM Treated?

Treating GDM comes down to controlling blood sugar levels. This is accomplished through the following:

Eating Wisely

  • Be mindful of your carbohydrate intake
  • Choose food options that have low glycaemic index (e.g. wholegrain bread, sweet potato, low fat yogurt, vegetables)
  • Go easy on sugar
  • Watch your food portions
  • Eat meals on a regular basis to control appetite and blood glucose levels

Regular Physical Activity

Physical activity is particularly helpful in controlling blood sugar levels by redirecting resources. It increases the glucose needed by the muscles for energy. An active lifestyle also helps the body use insulin more efficiently. To avoid injuries, be sure to do low-impact exercises that are tailored for pregnancy.

Medications

  • Metformin – an oral medication to help reduce the amount of glucose the liver produces; it helps insulin to work properly
  • Glibenclamide – an oral medication that stimulates the pancreas to make more insulin.
  • Insulin – an injectable hormone that allows glucose to enter the cells and be used for energy.

Take note that these medications must only be taken under medical advice. Like any other pharmacologic treatment, they still come with side effects and adverse reactions.

Managing gestational diabetes mellitus improves outcomes for you and your baby. Expectant moms, or even those who are still planning on getting pregnant, should not discount the importance of coming into this journey prepared. So, if you have more questions, book a consultation so we can discuss in detail and start with the necessary tests.  

Guide to Endometrial Cancer Risk Factors

Endometrial cancer is the 6th most common malignancy that plague women around the world, and the 4th most common in Singapore. A recent study showed that Singapore is among those countries where incidence rates and risks have increased over time.
Like any health risk, women must take this seriously even before it starts to do serious damage because early action results in a better chance of survival.
Being aware of the risk factors that predispose you to endometrial cancer allows you to make pre-emptive efforts. Having the knowledge allows you to be more aware of what to discuss with your doctor, and it will also help you make informed lifestyle and healthcare choices.
Below are basic information on the different risk factors which will be important points for discussion that you can flesh out later on with your doctor:

Family History

Studies have shown that the strongest predictor of endometrial cancer risk is genetics. Women with a first-degree family history of endometrial cancer have a higher tendency of developing the disease than those without it. This risk increases by 82% if you have a mother, sister, or daughter with endometrial cancer.

Abnormal genetic copy that reduces the body’s ability to repair DNA damage or regulate cell growth, resulting in a high risk of endometrial cancer, as well as colon cancer.

Never Having Been Pregnant

Nulliparity, or not having been pregnant, increases the risk for endometrial cancer. Pregnancy shifts hormones to produce more progesterone than estrogen. So, each pregnancy will give you a bit more protection from the disease by giving your body a short break from the hormone.

Endometrial Hyperplasia

Endometrial hyperplasia occurs when the endometrium (the lining of the uterus) becomes abnormally thickened. This usually happens when ovulation occurs infrequently eg in polycystic ovulation syndrome, causing the lining to build up and stop shedding. The cells that make up the lining stack up make it too thick.

However, not all types of hyperplasia predispose you to endometrial cancer. Mild or simple cases have a very small risk of becoming malignant. However, complex hyperplasia with atypia will show precancerous changes to the uterine lining upon biopsy. If not treated, it has a risk of becoming cancerous in up to 29% of the cases. Because of this high risk, surgery to remove the uterus (hysterectomy) is advised and often it can be done in a keyhole manner.

Obesity

Obesity is a state that breeds several health problems, like cardiovascular diseases and type-2 diabetes. It is also a known risk factor for a variety of cancers, and one that is strongly associated with it is endometrial cancer. Research claims that half of the cases of endometrial cancers are attributable to obesity.

High-fat stores increase the activity of a certain enzyme to convert androgen to estrogen which consequently thickens the endometrial tissue. Furthermore, obesity also places your body in a chronic state of systemic inflammation, creating certain molecular links to endometrial cancer. Together, estrogen metabolites and inflammation further contribute to DNA damage and genetic instability creating a conducive environment for tumor growth.

Achieving and maintaining a healthy body weight through diet and exercise is recognised as the ideal solution to endometrial cancer prevention. Recreational and moderate activity can help lower your endometrial cancer risk. Targeting hormonal imbalances also reduces the lifetime risk of endometrial cancer, but you should discuss this closely with your OB-GYN so you can adopt appropriate measures.

Sedentary Lifestyle

A lot of the jobs in Singapore involve desk work that goes on for hours. You may lead a busy life all day, and yet still be sedentary. But one study serves as a wake-up call as it reveals that highly sedentary lifestyles create a significantly higher risk for three types of cancer – colon, lung, and endometrial.

It was also revealed that TV viewing time has the strongest relationship with colon and endometrial cancer. Aside from predisposing you to inactivity, it is possible that TV watching is often associated with junk foods and sweetened beverages.

Exercise and limiting the time spent being sedentary has always been reiterated by health professionals. Not only are these measures important for health promotion, but also for disease prevention.

Diabetes

Studies suggest that diabetes may increase the risk for endometrial cancer by two-fold especially when combined with obesity and physical inactivity. Diabetes is associated with hypertension and physical inactivity, which in turn have been linked to endometrial cancer risk.

A better understanding of the impact of diabetes on tumor formation helps physicians determine which patients are at risk for endometrial cancer, and who would benefit from lifestyle modification measures, screening, and chemoprevention.

Polycystic Ovarian Syndrome (PCOS)

PCOS and endometrial cancer are linked by two mechanisms. If you stop ovulating, you no longer produce progesterone, which is a hormone responsible for cleaning up the uterine lining every month with the menses.
In the absence of ovulation, estrogen is produced causing the endometrium to continue to thicken. Since progesterone is no longer produced, there is nothing that can signal the endometrium to stop growing. Over time, you will start to experience irregular bleeding as the endometrium undergo cell changes which ultimately increases your risk of endometrial cancer.
The second mechanism involves insulin, which is a hormone that triggers cell proliferation. Some women with PCOS also experience insulin-resistance, which results in increased insulin levels in circulation. Elevated insulin levels continue to stimulate cells that line the uterine cavity thereby increasing the risk of developing endometrial cancer.

Prolonged Night Shifts

Evidence shows that women who work night shifts have a higher risk of breast and endometrial cancer. Losing nighttime sleep reduces the levels of melatonin which is a sleep hormone which contains properties that halt the spread of cancer. Experts claim that this is also vital for keeping ovaries working and producing eggs. However, carrying on long-term night shifts affects sex hormone levels which may lead to early menopause and endometrial carcinoma.

Advanced Age

The chance of developing endometrial cancer increases with age. Most women diagnosed with this disease are between the ages of 50-70 and are postmenopausal.

Chronic Use of Tamoxifen Treatment for Breast Cancer

The usual drug used to prevent and treat breast cancer acts as an anti-estrogen in breast tissues. But, it poses estrogen-like effects to the uterus. If you have gone through menopause, it can cause endometrial proliferation and endometrial hyperplasia, increasing your risk of endometrial cancer. This risk increases by two-fold in patients who are under extended therapy and the risk is increased up to 5 years after stopping treatment.

While it has been considered an effective treatment against breast cancer, women must also consider the risk against the benefits. This is a matter you should discuss with your breast doctor. You will most likely be advised to undergo yearly gynaecologic exams. Any abnormal bleeding, staining, or spotting must be promptly reported and immediately investigated as this could be a symptom of endometrial cancer.

PROTECTIVE MEASURES

Birth Control Pills

While the factors listed above all increase a woman’s risk for endometrial cancer, oral contraceptive pills (OCPs) do the opposite. The risk is lower in women who are on the pill, but the protection extends for at least 10 years after a woman stops taking oral birth control pills. However, you should not solely rely on OCPs for protection, rather you must balance the benefits from the potential drawbacks associated with prolonged use. Discuss this with your doctor so you can be properly advised.

If you are predisposed to some of the factors mentioned above, it is best that you bring this concern to your doctor as soon as possible. Early detection is key with endometrial cancer because when detected and treated early, there is a good chance of getting a good prognosis.

Book your consultation today if you are experiencing the followings symptoms :irregular periods, bleeding between periods, prolonged or heavy menstrual bleeding or post menopausal bleeding as these symptoms may be the first sign of endometrial hyperplasia or cancer.

The Ugly Side of Pregnancy: Post-Partum Changes to the Body

Pregnancy is a major milestone often celebrated with furor and enthusiasm. However, if you look beyond those rose-colored glasses, there is the real – and maybe not so attractive – part of pregnancy. This is not to discourage you, but to give you the real picture and to prepare better for it.

So, to help you out, here are some of the less desirable changes to the body during this special journey, and what you can do about it. Dr Coni Liu, Consultant Dermatologist from Dermatology and Surgery Clinic (Paragon) has kindly included some tips for new mommies keen to regain their body best postnatally.

Diastasis Recti

Diastasis recti is a medical term for abdominal separation. From the outside, this may look like you are still pregnant even long after you have given birth. To understand it better, we must first understand what makes up the structures that belies the abdomen and how it changes in response to pregnancy.

Our abdominal musculature is made up of the rectus abdominis muscles and the linea alba, which is a thin sheath of muscle tissue that stretches along the front midline of the abdomen. Pregnancy creates abdominal pressure which stretches and thins out the muscle sheath instead of it holding the rectus abdominis muscles in close proximity. This occurs to accommodate the growing belly.

While there is not enough information on the risk factors of diastasis recti, the following have been proposed factors:

  • High age
  • Multiparity
  • Caesarean section
  • Weight gain
  • High birth weight
  • Multiple pregnancies
  • Ethnicity
  • Childcare

Most women develop some extent of muscle separation in the post-partum period. Sometimes the tissue eventually heals on its own once your hormone levels return to its pre-pregnancy levels. However, if it fails to close on its own within 3-6 months, you could be left with a gap between your abdominal muscles which will become more obvious when you cough, sit up, or strain.

While abdominal crunches may seem like a likely solution, it can make your condition worse. However, depending on your level of healing and proper execution, you might be able to tolerate this exercise. It is necessary that you get the right help and guidance on how to engage your core muscles and do proper breathing.

In severe cases, it must be corrected to prevent concurrent abdominal bulging. Aside from aesthetic concerns, people with diastasis recti also complain of lower back pain and functional impairment. A surgical procedure called an abdominoplasty, popularly known as a tummy tuck is considered an effective management option.

How to check if you have abdominal separation:

  • Lie on your back with your feet on the floor.
  • Place your fingers above and below the belly button.
  • Do a small sit-up. If you feel a bulge between your fingers, it could mean that you have abdominal separation.

Post Natal Hair Loss

A lot of women experience noticeable hair shedding for the first 3-6 months after delivery. This is a condition also referred to as post-partum alopecia or post-partum telogen effluvium, and it has a lot to do with your pregnancy hormones.

This causes your hair to continue in an ongoing stage of growth resulting in thicker and more lustrous strands. However, once the placenta is delivered, progesterone and estrogen level out within 2-4 days causing your hair to temporarily shed. In some cases, it can be severe that it induces visible thinning.

What women must know is that telogen effluvium represents excessive hair shedding instead of actual hair loss. Treatment is not always necessary, but if the problem fails to resolve 6 months after giving birth, your hair loss could be a symptom of other underlying conditions which should signal you to get professional help. However, stress and other factors which can strain the body can also perpetuate the problem.

To improve hair health after pregnancy, here are some reminders:

  • A healthy diet high in protein to boost the hair growth process
  • Take your vitamins
  • Avoid over-styling your hair

Urinary Incontinence

Post-partum urinary incontinence is the involuntary leaking of urine which commonly occurs while sneezing, coughing, laughing or when doing strenuous activities. This is due to the pregnancy hormones that make your tissues more elastic for delivery. That, combined with the increasing weight of the baby,

Other causes of bladder control problems, in relation to pregnancy, include the following:

  • Injury or damage to the pelvic nerve that control bladder function due to a long or difficult vaginal delivery.
  • Forceps delivery which results in injuries to the pelvic floor and sphincter muscles.

It can take around 3-6 months, sometimes longer for some women, to regain complete bladder control. However, there are steps to manage this problem.

How to correct urinary incontinence:

  • Kegel’s exercise

Kegel’s is a popular exercise to strengthen the pelvic floor muscles. You can identify this muscle by attempting to stop your urine flow mid-stream. Once you identified the specific muscles, continue to practice on an empty bladder. Flex the muscle for 5 seconds at a time, then relax for 5 seconds – this makes one rep. Try 5 reps on your first day and then aim for 3 sets of 10 reps a day. The National Association for Continence warns to avoid flexing the muscles in your abdomen, thighs or buttocks. You must also be able to breathe freely while doing it.

  • Weight Loss

Based on research, weight loss after delivery is associated with a decreased incidence of urinary incontinence. This should encourage new moms to adapt a healthier diet not only to bounce back better but also to avoid aggravating urinary incontinence.

  • Bladder Training

You can also try bladder training by trying to urinate every 30 minutes at a time before you even have the urge to do so. Then you gradually extend the time between each urination each day.

  • Keep a High Fibre Diet and Increase Fluids

This is to avoid constipation after pregnancy because a full bowel can add pressure to your bladder.

  • Minimise Caffeine, Alcohol, Carbonated Drinks and Spicy Foods

These can irritate the bladder and can cause it to contract easily.

Piles

Piles or hemorrhoids are swollen blood vessels in the rectal area that is common during pregnancy and post-partum. The size can be like that of a raisin or a grape, and sometimes it protrudes through the anus like a soft, swollen mass. These are caused by increased pressure on the lower rectum, and it is common especially after a vaginal delivery.

Symptoms include:

  • Pain
  • Bleeding during or after a bowel movement
  • Swollen area around the anus
  • Rectal itching

Hemorrhoids resolve on its own, but on your way to healing, you can do something to gain relief. Here are some suggestions:

  • Do a warm sitz bath. It involves soaking your bottom in warm water in a tub or a sitz bath.
  • Use a cold compress. Covered in clean and soft cloth, apply the ice pack over the affected area several times a day to reduce the swelling.
  • Alternate treatments.  Use a cold compress and warm sitz bath alternately.
  • Ask for professional health. Seek help from your healthcare practitioner for a safe topical anaesthetic or medicated suppository.

Skin Changes

Pregnancy Acne

  • Hormonal changes in pregnancy cause the skin to secrete sebum that clogs pores and results in acne breakouts.
  • This clears up to a certain degree after delivery.
  • Severe cases can be managed with oral medications in combination with topical treatments, however, this must be consulted with your doctor first for safety especially if you are breastfeeding.
  • Non-medical modalities such as chemical peels, Silkpeel, or light treatment are safe treatment options.

Pigmentation

  • Melasma – also referred to as the “mask of pregnancy”.
  • It is associated with hormonal changes.
  • While it occurs during pregnancy, it can remain even after giving birth.
  • Proper differentiation between melasma and other pigmentation issues is necessary to arrive at an effective treatment, otherwise, the condition can only be worsened.
  • A combination treatment regimen can be tailored for each individual’s pigmentary concerns.

Stretch Marks

  • It forms due to the rapid stretching of the skin as a result of weight gain.
  • It is genetic in nature.
  • These are pink and purplish streaks during pregnancy and during post-partum it fades into silvery white grooves.
  • It usually runs down the breasts, abdomen, and/or buttocks.
  • Since it is unlikely to reverse the changes, treatment is aimed at reducing the appearance of these marks.
  • A combination of laser treatments can be used to stimulate collagen production.

Dull complexion

  • It may be a result of sleepless nights, hormones, or the lack of time to attend to your usual skincare regimen.
  • This can be managed with the help of aesthetic treatments like lasers to help brighten your complexion, shrink pores, and stimulate collagen for a firm and radiant appearance.

Spider veins

  • These are very small, reddish blood vessels that is commonly seen on the face, chest, arms and legs.
  • These form as a result of increased blood circulation during pregnancy.
  • While some resolve on its own after delivery, some may persist even through post-partum.
  • Vascular laser is an effective treatment.

Skin tags

  • These are small bits of extra flesh that appears like skin folds on the neck, armpits and groin.
  • It is possibly related to weight gain during pregnancy.
  • While these are harmless, it can be unsightly and may cause irritation as it rubs against your clothing.
  • It can be removed through electrocautery or cryotherapy.

Stubborn fat and loose skin on the tummy

  • Once stretched, the skin may not be able to regain its original shape.
  • Healthy weight loss can be achieved through a healthy diet and regular exercise.
  • Adjunct therapy may include treatments like cryolipolysis, skin tightening treatments, body wraps, or lymphatic massages.

Pregnancy may not always be rainbows and butterflies, but whenever the bad days roll in, it helps that you have someone reliable to guide you along. So, if you have questions and concerns, book your consultation with Dr. Pamela Tan today, one of Singapore’s female OB-GYNE.

What to Expect with IUI (Intrauterine Insemination)?

IUI has been an option for couples who struggle with conceiving. But like any potential solution, it comes with factors that require consideration. So, we’re laying down the facts to give you a heads-up on what to expect from this procedure.

So, if you’re interested in a consultation for IUI soon, here’s what you need to know.

What is IUI?

Intrauterine Insemination is the first line of defense for couples who face difficulty in conceiving. Also referred to as donor insemination or alternative insemination, it is done by placing the sperm in the uterus around the time you’re ovulating.

The Facts of the Matter

IUI is a relatively simple treatment. But like any other, it requires commitment and a full understanding of the procedure. This allows you to weigh its strengths and drawbacks for you to make an an informed decision. So, let’s start with the basics.

Tests

To ensure a safe process, you and your partner must first undergo a battery of tests. This will include the following:

  • Normal Pap smear in the past year
  • Hepatitis B, C, HIV, syphilis (VDRL), Rubella Ig G testing
  • Blood type and screen
  • Ultrasound scan to determine the size and number of eggs inside each ovary and to exclude abnormalities that may hinder implantation
  • Men providing a semen specimen must be tested for infectious diseases like HIV, syphilis, hepatitis B and C
  • Fallopian tube patency check eg Hysterosalpingogram
  • +/- Cervical swab cultures for chlamydia and gonorrhea

Process

IUI starts by obtaining the sperm from the male partner or donor. The sperm is then counted, washed, and concentrated before it is placed in a small syringe.

Semen analysis is important to the IUI process to accurately diagnose male infertility. This will involve sperm count and observation of sperm motility and morphology (shape). These semen parameters will assess quality, and its results will help predict IUI outcome.  The normal semen parameters according to the World Health Organisation reference ranges are as follows:

  • Volume of Semen: More than 1.5 ml
  • Sperm Concentration: More than 15 million sperms per ml
  • Sperm Motility: More than 40%, 32% forward progression
  • Sperm Morphology: More than 4% has a normal shape
  • White Blood Cells: less than 1 million per ml

Source: WHO 

Sperm Washing, also called sperm preparation or spinning, is the process of preparing the sperm sample before it is inseminated. It involves techniques to separate the sperm cells from other supporting fluid or cells. It also separates the motile sperm from non-motile ones. This process is done also to enhance the quality of the initial sperm sample.

Centrifugation follows once the appropriate washing medium has been mixed. A centrifuge is a machine the spins at a high speed to separate materials of different densities. From this, the sperm-rich fraction is obtained and loaded into a syringe.

To aid in the insemination process, a very small flexible catheter or tube is attached to the syringe. It is then inserted through the cervix and into the lower part of the uterus to deposit the sperm directly.

What it Feels Like

IUI involves the use of the speculum to properly visualize the cervix, similar to having a pap smear. It may create a slight discomfort, but it is not painful. However, IUI itself is reported to be painless because it only uses a small and flexible catheter.

Indications

  • Women with minimal or mild endometriosis
  • Mild male sperm abnormality
  • Unexplained infertility
  • Unsuccessful fertility treatments with medications alone
  • Couples with dual factor abnormalities eg ovulation and sperm abnormalities
  • Couples with abnormal mucus (IUI can bypass possible cervical factors)
  • If sperm donor is used
  • Couples who are unable to have vaginal intercourse due to reasons like physical disability or psychosexual problem

Contraindications

  • Severe endometriosis
  • Previous pelvic infection
  • Blocked fallopian tubes
  • Cervical atresia (a condition where the cervix is abnormally absent)

asian-couple-pregnancy-difficulty

Time and commitment are needed since the process involves several trips to the clinic.

The Heart of the Matter

The process itself may be reasonably straightforward, but the entire journey can take a lot from a woman or a couple who puts their efforts, emotions, and resources into it.

Time and commitment are needed since the process involves several trips to the clinic. You must follow this through very carefully as there is only a small margin of error that could put you off your schedule when timing your fertile period. It can be distressing for women when a cycle has been abandoned due to extraneous factors like work and conflicts in schedules.

What may also be frustrating to some is when they don’t ovulate in time which causes them to miss certain months. These instances are unavoidable since our bodies react to treatments differently. Furthermore, women who use medicines to stimulate the ovaries might also have to contend with unpleasant side effects.

The reality is that these are just some of the challenges which can test your resilience throughout the process. The preparation, the waiting, and sometimes unsuccessful results can take a toll on your resolve. However, it is important to remember that you can always find help and support.

First, your doctor is there to advise you on your next course of action. Therefore, finding a clinic you trust and a practitioner who understands your goals is important. You can also find a community online where you can reach out to others who are on the same journey as you. These support groups are not only  good avenues where you can find emotional support, but also one where you can learn from the experience of others.

IUI Success Rate

Success rates vary depending on different factors, such as:

A woman’s age – IUI success rate is higher in younger women, but it starts to decline after the age of 35.

Timing – If the timing of ovulation is not detected properly, the time of insemination may not be synchronized with the peak period of fertility within your cycle.

Fertility drugs – You are more likely to get pregnant if you take fertility drugs that can help stimulate your natural cycle. You can ask your doctor about them and how they can improve your odds of getting pregnant with IUI.

The status of a woman’s fallopian tubes – A woman interested in IUI should have at least one open unblocked fallopian tube.

The quality of the sperm sample – IUI is generally less successful in men with very low sperm counts or poor motility– less than 2 million total motile sperm of normal forms. Sperm motility is the ability of the sperm to move or swim efficiently.

The number of IUI cycles – Most women will have several cycles of IUI before they can conceive. This is also something to consider when you’re thinking about the costs of the treatment.

The couple’s general health condition – Couple must strive to improve their health as much as possible to maximize the success rate of fertility treatment with IUI. A healthy diet and lifestyle is important and chronic conditions like diabetes should be under control prior to treatment.

How Many Times Should You Do IUI?

Since IVF (In Vitro Fertilization) is an expensive option, IUI is often the first treatment suggested to those who wish to conceive. It is also less invasive and less demanding. But what should you do if you are still unable to get pregnant after several rounds of IUI? How many times should you try before moving on to the next option?

Some women are lucky enough to get pregnant after their first attempt, while others succeed after a number of tries. For this, doctors advise patients who are under 35 to try 3-6 cycles of IUI before trying IVF. Women above 35 may be recommended differently since fertility decreases at this age thereby reducing the chances of conceiving through IUI.

The process behind IUI may be a personal journey but it is best that you talk with your doctor and partner regarding your next step. It helps when you understand your limits and when it is still worth another try.

IUI Cost

IUI may be less costly than IVF, but couples who go through it would still have to consider the cost. IUI, for instance, may require more than one cycle. In singapore, MediSave for Assisted Conception Procedures (ACP) is a government subsidy to help defray the costs of procedures like IUI and IVF.

You can learn more about it, here.

The IUI journey may not be a walk in the park, but it pays to have the right knowledge, preparation and any manner of support. If you think IUI is an option you and your partner are willing to try, you can book a consultation with Dr. Pamela Tan today for a more in-depth discussion.

Tears During Delivery and How to Reduce Them

Your baby’s entrance to the world doesn’t have to leave you with a nasty tear down there. A normal birth can result in a tear to the vagina and its surrounding tissues, but it’s something that can be reduced. Brush up on some of these facts to help lessen any injury on your part and take this knowledge with you when you come in for your next consultation.

What are Perineal tears?

The perineum is the area between the vagina and the anus. It is a strip of soft skin which is prone to tears if it comes under significant pressure, especially during childbirth. This type of injury is referred to as perineal tears, perineal lacerations, or vaginal tears.

A tear occurs due to the pressure of the baby’s head as it passes through the vaginal opening. It could be that the baby’s head is too large for the vagina to stretch or the head is a normal size, but the vaginal opening doesn’t stretch enough.

How common are Perineal tears?

There is a high risk for perineal tears to occur in Asian women because the the skin and connective tissue have less laxity and does not stretch as easily as Caucasian women. The distance between the vagina and the perineum is shorter and this anatomical characteristic also increases the risk of perineal tears to reach the anus. A study showed that asian ethnicity is 2.2 times more likely than western populations to have more severe tears involving the anal sphincter injuries during childbirth and first vaginal deliveries have a 7 times relative risk compared to subsequent deliveries.

Types of vaginal tearing

1st Degree Perineal Tear – It is a shallow tear which involves the perineal skin. It causes mild discomfort and stinging upon urination. It may or may not need stitches because it typically heals within weeks.

2nd Degree Perineal Tear – This involves a tear to the skin and muscle layers of the perineal area. In some cases, it may even extend into the vagina. It will heal better if the tear is repaired with stitches. You can expect this to heal within a few weeks.

3rd Degree Perineal Tear – This tear goes through the perineal muscles and into the ring-shaped muscle that surrounds the anus (the anal sphincter). It is important to surgically repair this to reduce the incidence of flatus or bowel incontinence.

4th Degree Perineal Tear – This tear extends from the anal sphincter all the way to the anal canal or rectum. This type of tearing will require surgical repair. It may take around three months to completely heal or for the area to feel comfortable. 60 to 80% of women have no symptoms at 1 year post delivery after a tear involving the anal sphincter or canal.

What is an episiotomy?

An episiotomy is a small surgical cut made by the doctor during labour to help widen the vaginal opening and assist in the delivery of the baby. Traditionally, it was often performed as it was thought to reduce the incidence of a serious vaginal and perineal tear down to the anus. However, now the evidence that an episiotomy prevents severe 3rd or 4th degree tears is conflicting.

Studies such as those done by Hong et. al. suggest that an episiotomy doesn’t have to be a routine procedure for vaginal deliveries. Make an informed decision by discussing the matter with your doctor. You can even include this detail in your birth plan.

Reasons for an episiotomy

  • Forceps or vacuum delivery. It widens the vaginal opening when instruments are used to assist with the delivery. Having a forceps delivery without at episiotomy increases the rate of serious tears by 6.5 times where ares having an episiotomy increases the rate to only 1.3 times.
  • A complicated birth. An example is when the baby is positioned with the buttocks or feet first (breech) or when shoulders are trapped (shoulder dystocia) such that there is more space for further maneuvers to be performed.
  • To expedite delivery during fetal distress. This is a complication of labour where the baby’s heart rate significantly decreases before birth due to the lack of oxygen (hypoxia). This may be contributed by umbilical cord compression or strong uterine contractions coupled with the mother pushing. The baby must be delivered quickly to prevent the risk of birth hypoxia or stillbirth and performing an episiotomy can help shorten the crowning stage.

Types of episiotomy

  • Midline – It involves a vertical downward cut of the perineum that extends towards the anus. It may heal faster than a mediolateral incision.
  • Medio-lateral – This is a cut that goes downwards and diagonally. It is usually used for instrumental deliveries and has a lower rate of 3rd or 4th degree tears compared to the midline.

Each type of episiotomy comes with advantages and disadvantages. Only your doctor can make the judgment on which type would be appropriate at the time of delivery. However, you can always have a discussion on this during your antenatal check-ups. You can ask about repair, scarring, post-delivery pain, and healing, among many others.

Stitches for episiotomy or tears

Stitches are usually done soon after the baby is born. It is done under local anaesthesia so that you will not feel any pain. A local anaesthetic may no longer be necessary if you had an epidural because this already numbs the area.

In most cases, the stitches don’t have to be removed since these are dissolvable within 2 weeks. The tear or cut will heal within 3-4 weeks.

Recovering from an episiotomy

To help heal perineal tearing, you may do the following:

  • Rest and assume a side-lying position as much as you can.
  • Get in and out of bed on your side to reduce any strain on your perineum.
  • Keep the tear clean and dry by regularly washing and changing pads (every 4 hours) to prevent infection. You may also be prescribed an anti-septic spray or wash
  • Start with pelvic floor exercises 2-3 days after delivering the baby.
  • Always wipe from front to back after going to the toilet to avoid infecting your episiotomy site.
  • Take pain medications as prescribed by your doctor.

Immediately inform your doctor if you experience any of the following:

  • Bleeding from your episiotomy
  • Foul-smelling vaginal discharge
  • Fever or chills
  • Severe perineal pain

Baby Twins - Perineal Tear - Dr Pamela Tan

How to prevent tearing during childbirth

Since an episiotomy is an option, there are ways for you to avoid tearing or prevent serious ones during childbirth. You can do the following, granted that you are also advised by your doctor:

Nutrition: stay hydrated and drink plenty of water 2.5-3 L a day to ensure the tissues are also well hydrated. Vitamin C, omega 3 fatty acids and zinc are beneficial for skin elasticity and healing so foods like citrus fruit, avocados and nuts are beneficial.

Perineal massage: From 35- 36 weeks of gestation, there is a hormone relaxin that helps to make all the connective tissue stretchy and aids in delivery. Perineal massage during late pregnancy may encourage elasticity and reduce the risk of tearing during chldbirth. The perineum is the area between the vaginal opening and anus. Some women choose to use perineal massage as a way of hopefully reducing their risk of perineal trauma during childbirth. It also helps to accustom the woman to the sensation of stretching that she will feel when the baby’s head is born. Studies have found evidence that regular perineal massage towards the end of the pregnancy can reduce the risk of tearing in first time mothers. This research also identified that the benefits of perineal massage were greatest for women aged over 30 who had not previously given birth. Regular perineal massage during later pregnancy reduced the risk of perineal trauma that required stitches by 5% for first time mothers.

In general, it is advised to perform the massage 2-4 times a week if the woman is comfortable. If she is not comfortable, discontinue the method. It should also not be done if there is a vaginal infection, herpes sore or vaginal/ vulval conditions that may worsen with the massage.

Step 1: Find a quiet, private place to lie down. Use pillows to support your back so that you are in a semi-lying birthing position with your legs open. You may like to turn off the lights, and play some calming music to help you feel relaxed.

Step 2: Apply oil or lubricant to your fingers, thumbs and perineum. The lubrication should prevent discomfort.

Step 3: Next, insert two fingers around 3-4cm deep (2nd knuckle) into your vagina or as close to that as is comfortable. Gently, but firmly, apply pressure against the back wall of the vagina towards your anus. At the same time, gently pull your two fingers apart so that your perineum is being stretched both downwards and outwards. Keep applying pressure until you feel a slight tingling sensation, this is your perineum being gently stretched. This should not hurt, and you should not notice any burning.

Step 4: Imagine that your vaginal opening is a clock face. Next, pull your two fingers down to 6, then stretch them outwards and upwards towards 3 and then 9, applying pressure. The movement is a sort of U shape. Repeat this 20 or 30 times over several minutes. This is what a woman will feel as the baby’s head presses down before it starts to emerge from the birth canal.

Step 5: rub the perineum between the thumb and forefinger, one finger inside the vagina and one finger outside. You can use 1 hand or 2. Then place two fingers just inside the vagina, only to the first knuckle and gently stretch the perineum outward. Massage more with the thumb and forefinger if the tissue feels tight. Remember to consciously relax the muscles, using slow breathing if the sensation feels too intense.

Caution

Avoid touching the anus to reduce the risk of bacteria from the anal area entering the vagina. Avoid being too vigorous as it could cause bruising or swelling in these sensitive tissues. Avoid pressure on the urethra anteriorly as it could induce irritation or infection.

Epi- no

This is a device that helps with stretching the perineum especially if the massage is too awkward or uncomfortable. It can be purchased over the internet and is usually delivered in less than a week.  http://www.starnbergmed.com.sg/. From 36 weeks onwards, the device which is similar to a balloon connected to a hand pump is used and some mothers report the ability to stretch up to 8-10 cm dilation with use of the device. It also simulates the pressure feeling that occurs when the head is crowning hence users are better able to control their breathing for a slow delivery (read below). A user video can be found below:

From my own anecdotal experience, an estimated 95% of Asian ethnicity first time mothers will tear midline naturally if an episiotomy was not performed. Most of these tears are minor 1st or second degree tears that will heal well. The majority of first time Asian mothers who had an average sized baby and did not tear during delivery had prepared antenatally by either perineal massage or an Epi-No so I do believe that there is some protective effect.  

a.) Warm compress: According to some studies, applying a warm washcloth or compress on your perineum continuously in the pushing stage is associated with less tearing.

b.) Perineal Protection: Slow and controlled pushing during the final stage of labour is important to reduce tears. A hands on approach to protecting the perineal appears to have a protective effect on tears in some studies. This includes having the obstetrician guard the perineum with counter pressure whilst the other hand is placed on the fetus head to slow down the descent on crowning.  When the head is crowning, it is important not to push but breathe down and have a slow delivery to enable to perineal tissues and skin to stretch. Many patients have a strong pressure feeling that makes them wish to expel the fetus quickly. The head puts pressure on the rectum so they feel like they need to evacuate a bowel movement and hence they use the same muscles to push.

However, this is associated with a poorer outcome. If you can listen to your obstetrician’s instructions to slow down at the crowning phase and try to relax the pelvic floor muscles and breathe instead of push, the chance of a severe tear is minimised. Another helpful tip is to open you mouth to breathe or pant and say ‘ HA… ha….’ during crowning.

Now that you are more aware about perineal tears associated with childbirth and some tips to reduce the incidence, we encourage you to discuss this with your doctor. It is something you must prepare for because it may make things significantly easier and may also affect postpartum recovery.

For your concerns, you may book your consultation with Dr. Pam Tan today.

You may also call us at the following numbers:

Thomson +65 6254 2878
Suntec +65 6804 9580
Sengkang +65 6384 2759