Ишемическая болезнь сердца-Ischemic heart disease

Who needs an episiotomy?

Episiotomy is a cut made towards the back of the vaginal opening (the perineum) to enlarge the outlet for delivery. Recent increased use of this procedure has caused much controversy. In the 1950s 20-30 per cent of women an episiotomy at childbirth. In the 1980s the rate (in labour wards) was 75 per or more; some obstetricians do episiotomy routinely.

Those in favour of routine episiotomy believe that it prevents perineal tears (which occur in half of all deliveries without it), damage to pelvic-floor muscles and injuries to the baby’s head. Opponents claim that it shouldn’t be done to the 50 per cent who wouldn’t tear.

When is it wise to do an episiotomy? When it’s obvious that the vaginal opening is stretched to its limit, it’s better to make a clean cut than to allow on more uncontrolled tears. Episiotomy can prevent much of the pelvic-floor damage and prolapse that we used to see before it was introduced. The cut heals better and sooner than a ragged tear.

Episiotomy is necessary for most hi and posterior (head facing frontwards) liveries, whenever forceps must be and to protect the soft head of a pre-term baby from too much compression during birth.

Whether the perineum is opened by tear or cut, it must be repaired by stitching. This is done soon after the placenta delivered and before the anaesthetic wears off. Stitches that are absorbed and don’t
need to be removed are generally used.

Pain from a perineal wound mars the postnatal period for many women. Symptoms are usually worse after tearing, when there is more bruising and swelling than after episiotomy.

The longer-term psychological consciences of perineal wounds on mother -child and partner relationships have been largely ignored until recently. One study has shown that three months after delivery 20 per cent of women who had stitched perineal wounds still had disturbing pain, one in three had diminished lido and one in five found sex painful or avoided sex.

What about the use of forceps?

The use of obstetric forceps, which are designed so that they can’t crush the baby’s head and in fact protect the skull by acting like a crash helmet, has saved the lives of many babies when labour is held up in the second stage, or when the second stage must be hurried because of maternal or foetal complications. The forceps draw the head through the vagina and over the perineum with the help of mother’s pushing. Babies delivered with the aid of forceps often have red marks on their faces: these disappear within a few days of birth.

Forceps are also used in pre-term and breech deliveries to protect the baby’s head. They may be needed to deliver the head when epidural block has been used, if the mother can’t feel to push with each contraction (though this doesn’t often happen).

Another method that helps deliver the foetal head during the second stage of labour is vacuum extraction, which uses a device called a ventouse. This consists of a flat cup attached to a vacuum apparatus. The cup is pressed onto the head, and a vacuum is created to hold it firmly in place. The obstetrician pulls on the handle of the ventouse to draw the head through the vagina and over the perineum. A baby delivered with the aid of a ventouse usually has a swelling on the crown of its head: this disappears within a few days. In Australia the ventouse is less commonly used than forceps.

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History of abortion

Abortion has been practised throughout history in almost all communities. Often it was sanctioned or even enforced by the community in times of famine and during treks, or if the pregnancy had been conceived with the ‘wrong’ man or was the result of incest or rape. Means of trying to induce abortion included a variety of drugs and magic rituals, introducing objects into the uterus and physical interventions such as lifting and carrying heavy loads and constricting or pummelling the pregnant woman’s belly.

Early Christian teaching permitted abortion before the ‘soul had entered the body of the foetus’, 40 days after conception for’ males and 80 days after conception for females (how the sex of the foetus was determined isn’t stated!). Later, abortion was allowed until quickening (movement) was felt by the mother during the fifth month of pregnancy.

The Church’s condemnation of abortion of an ‘animated’ foetus is based on a passage in the Bible (Exodus 21:22-3) dealing with assault on a pregnant woman leading to miscarriage. If no other harm was done to the woman, the attacker was fined to compensate her for the lost child. If the woman died, the attacker was executed, paying ‘a life for a life’. The (inaccurate) interpretation of this resulted in abortion being held as a crime against God.

Most civil laws making abortion criminal offence were not passed until nineteenth century. In 1869 Pope Pius decreed that any abortion was murder, and around the same time new legislation in Britain (and subsequently Australia) outlawed all abortions except those done preserve the life of the mother.

History shows that women in need seek abortion whether or not it is legal, even at considerable risk to their safety.
The anti-abortion laws resulted in the development of underground or ‘bасk-street’ abortion rackets. Clandestine, unsanitary abortions were performed by unscrupulous, often unqualified practitioners. Outrageously high fees were charged including large sums for police ‘protection’. Anaesthetic wasn’t used for painful procedures because recovery would have been too slow: abortionists didn’t want patients hanging around their premises No aftercare was provided.

The illegal abortion racket discriminated against the poor. Women who were well connected and well off could usually find and afford a doctor to perform abortion: poor women had to accept the less expensive services of unqualified people or try to induce their own abort using overpriced (and harmful or useless)
drugs or devices.

Many women died or suffered haemorrhage or infection and became chronic ill or infertile after illegal procedure their own attempts to abort. Women needing treatment of complications from abortion filled about half the hospital gynaecological beds (and still do where abortion remains illegal). They were treated as criminals. As one woman, now in her sixties, said: ‘The doctor said it served me right to be so ill’. The whole story of the illegal abortion racket is a disgrace to humanity.

Abortion law reform

Agitation for abortion law reform began in the UK in 1936, but it wasn’t until 1967 that the British parliament passed the Abortion Act which, though it didn’t repeal the previous criminal law, broadened the circumstances in which abortion could be lawfully performed. Abortion was regarded as lawful when the risk to the life, physical and mental health of the mother and of her existing family was greater if the pregnancy continued than if it were terminated. Abortion was also permitted when there was a risk that if the child were born it would suffer serious mental or physical handicap. To comply with this law, two doctors had to certify ‘in good faith’ that the conditions of the Act had been satisfied, and the operation had to be performed in registered premises. The decision was entirely in the hands of doctors and depended on their beliefs and trades.

In Australia criminal law is a State matter, and each State’s Crimes Act includes unlawful abortion as a criminal offence. In 1969 South Australia amended its criminal law on abortion in line with the 1967 UK Act. The changes made in South Australia also applied in the Northern Territory. No other State has amended or repealed its abortion laws, but rulings by judges in Victoria and New South Wales about 20 years ago have been used as precedents to extend the circumstances in which abortion is lawful. These can be broadly stated as a sincere belief, on reasonable grounds, that it is in the best interests for the welfare of the woman and her existing family to terminate the pregnancy. Social and economic factors, both present and future, could be taken into account in reaching this belief.

Since these rulings, abortion has become widely available in New South Wales and Victoria, and is now performed in Queensland, Tasmania and Western Australia in the hope that the rulings of New South Wales and Victoria would be taken into account if criminal charges were laid. However there is always the risk that the rulings could be overturned and the present criminal law strictly enforced.

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Intrauterine devices (IUDs) are inserted into and retained within the uterine cavity to prevent conception. The IUD was the first reversible contraceptive method that required just one action – its insertion -to provide long-term contraception.

History of the IUD

The first story (unverified!) concerns nomadic tribes in North Africa thousands of years ago, who are said to have placed stones in the uteri of camels to prevent pregnancy during long treks. Over 2000 years ago Hippocrates, the father of medicine, is reported to have recommended inserting objects into the uterus for contraception.

The first modern IUD dates from 1909, with descriptions of coils of silkworm gut used in Europe. The first widely used IUD was the Gräfenberg ring, developed in Germany in the 1920s. It was made of coiled silver-copper alloy wire. The ring gained a bad reputation at the time because of the high rate of infection and other complications when it was inserted by untrained operators, and also perhaps because contraception was strongly condemned by political authorities in Germany at the time. It has since been shown that, with proper insertion and care, the Grafenberg ring can be as safe as any other IUD and it remains the most commonly used device worldwide (because it’s so popular in China).

The first plastic device was introduced in 1962, the first copper-carrying device in 1969, and the first hormone-releasing device in the mid-1970s. Today it’s estimated that more than 60 million women worldwide used IUDs, over 40 million of them in China.

Because IUDs must pass through the narrow cervical canal to be placed in the uterine cavity, ingenious designers have come up with a variety of forms that may be folded, straightened or compressed in some way for insertion but are able to regain their shape within the uterus. The effects of adding copper or hormones to IUDs is described below.

How do IUDs work?

Nobody’s quite sure, but IUDs are believed to prevent pregnancy in the following ways.

• Their presence as a foreign body causes a reaction in the lining of the uterus that makes it unsuitable for implantation of a fertilised ovum.

• Recent studies suggest that the changes in the uterus – both in the fluid contained in it and in its lining – prevent sperm from swimming through its cavity to fertilise the ovum.

• Copper causes a foreign-body reaction together with other changes in the endometrium, making it even less suitable for implantation. Copper is also toxic to sperm.

• Progestogen-releasing IUDs alter the growth and development of the endometrium in each cycle. Progestogen also affects cervical mucus so that sperm are less able to pass through the cervical canal.

The contraceptive efficacy of plain plastic IUDs depends on the surface area of the device that is in contact with the endometrium. With the added effects of copper or hormones, smaller devices are as effective as larger plain devices.

How effective are IUDs?

For all devices used now, failure rates are 0.3-6 pregnancies per hundred woman-years. Copper and hormone-releasing devices are generally more effective. About one-third of failures are due to undetected expulsion of the IUD. The most important factor that influences efficacy (and other problems) is the degree of skill used in inserting the device.

Side-effects and j complications

The most common side-effects are heavier periods, longer periods, menstrual cramps and spotting between periods. These menstrual side-effects tend to be worse soon after insertion and usually, but not always, settle down after a few months. About 15 per cent of users have the device removed within two years because of its effects on menstruation.

Less common side-effects are cramps between periods and cramps or pain after orgasm. IUDs have no side-effects on the rest of the body.

There can be complications: the main worries are pregnancy and pelvic infection.

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Anyone writing about sex is confronted by the problem of what words to use. In spite of the wonderful diversity of English, I find it frustratingly difficult to find satisfactory terms for many of the organs, processes, sensations and emotions associated with sex.

Sex is a loaded subject in our culture, and this is reflected in our language. There’s no shortage of words to describe sex organs and actions, but the majority of terms are evasive, ambiguous, sexist, derogatory, guilt-ridden, or (especially in vulgar slang) violent, punitive or deliberately offensive. When it comes to the sensations and emotions of sex, our language is barren.

As a medical writer, I feel at ease using anatomical terms like ‘vulva’ and ‘penis’ and I shall do this throughout. I feel OK about ‘womb’ as an alternative for ‘uterus’ but most other commonly used terms are so ambiguous or offensive that I can’t bring myself to use them. (One must be so careful with the vernacular: words mean different things to different people. ‘Fanny’ is slang for buttocks in the USA but in Australian slang means ‘vulva’. To speak of giving someone ‘a pat on the fanny’ may be quite acceptable in the States: not in Australia!)

But how do my readers feel? Do they understand and feel at ease with anatomical terms? Some women still don’t know the difference between ‘vulva’ and ‘vagina’ and are uncomfortable with these words, preferring less explicit terms such as ‘down below’. Many still blush at the mention of ‘clitoris’: such is the power of guilt and shame attached to female sexual arousal and this erotic organ. How can we find a happy medium?

Finding suitable words for sexual intercourse is the most difficult task. My Macquarie Thesaurus gives 33 alternatives for sexual intercourse, all unsatisfactory in some way. They fall into categories of technical, evasive and coarse slang.

The technical terms are terrible. ‘Copulation’ is from the Latin ‘to couple’, which is also something you do to railway lines. ‘Coitus’ is a sharp word that sounds like a piece of machinery. And these terms really only refer to the penis-in-vagina part of sex.

Acne is a very common disorder of the oil (sebaceous) glands of the skin. It affects about eight out of ten of us at some time during our lives, mostly between the ages of 15 and 30 years. Acne describes everything from the occasional blemish through the spectrum of whiteheads, blackheads and pimples to its severest form, which affects about one in twenty people.

Most adults don’t take acne seriously enough. It’s often dismissed as a harmless disorder of young people that they’ll ‘grow out of in their twenties, but there are few diseases that cause so much misery. It occurs at a time of life when you have enough adjustments to make to your body image and ego without having to worry’ about a spotty face. At any time of life, but especially during adolescence, acne can make you feel self-conscious, ugly, inferior, insecure, guilty (‘Is it punishment for something I’ve eaten or done?’) and unwanted. Severe acne can be psychologically devastating.

You’ll probably think your acne is worse than anyone else does. Most young people can’t keep away from peering at their faces in the mirror to see what new horror has broken out. With such close scrutiny, you’re bound to find things that other people don’t notice. This may make you think that your parents or others are making light of something that worries you terribly when in fact it’s the whole you they see, not just your spots.

All acne – from a few blackheads to most severe – can be helped by proper treatment. Don’t think that you have put up with it until you grow out of it. Do something! Here’s some informal to help you understand and conquer the demon.

What causes acne?

Every hair on our bodies has a sebaceous gland just above its root. These glands produce a pale, oily section (sebum) that keeps the hair and I rounding skin soft and supple. At puberty
the sebaceous glands on the face, ne and front and back of the upper chest stimulated by androgens: the male hormones that are produced in increasing amounts by both males and females fro around 10 years of age.

Androgens cause the glands to increase the amount and change the composition of the sebum they make. These hormones also make the skin that lines the sebaceous ducts thicken. Hence the duct rows so that it’s harder for the sebum get out. If the skin closes completely over the duct the sebum builds up behind, forming the lump known as a whitehead. The sebaceous duct can also be blocked by a plug of thickened sebum. The surface of this plug darkens on exposure to air, resulting in a blackhead. When a gland with a blocked duct continues to produce sebum, it can be forced through the natural boundary of the gland into the surrounding tissue. Then bacteria normally present in the skin (and harmless under other circumstances) cause the sebum to break down into irritant chemicals that will inflame nearby skin; the result is a tender red lump we call a pimple. The pus formed by the inflammation usually pushes towards the surface to form a ‘head’ that breaks through the blockage of the duct, and the pimple quickly drains and disappears, leaving no scar. If the duct is very tightly plugged, the inflammation can spread to deeper layers of the skin, forming a ‘blind’ pimple. In the most extreme cases of sebum overproduction, cysts may form deep in the skin and raise purplish lumps that can take months or years to heal. This cystic acne is the most severe form of acne, and almost always results in some pitting and scarring.

Why is acne worse for some than others?

We all produce these hormones, but some people’s sebaceous glands are more sensitive to hormones than are others. Acne in teenagers is rarely caused by an excess of male hormone: the skin is just overreacting to the normal amount. This sensitivity seems to be inherited. Also, males produce more androgens than females, which is why boys often have more acne than girls.

Excess male hormone is only likely to be a cause in women who develop acne (or worsening of it) when they are well past puberty. In such cases there are usually other signs of masculinisation.

What else aggravates acne?

• Hot, humid weather, which causes skin cells to swell and thus increases the chance of blocked ducts. This is why face-steaming treatments are useless or harmful.

• Anything that stimulates extra growth of skin cells, such as rough scrubs, can block ducts.

• Emotional or physical stress can provoke an outbreak by increasing the output of androgens from the adrenal gland. This might explain why ‘whoppers’ tend to break out when you’re upset, doing exams, excited about a special date, or ill.

• Some women notice a breakout before periods, probably due to female hormones being converted in the body to androgens.

• Oily applications to affected skin usu-¹ ally worsen the condition.

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