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I have been having heavy periods for the past one year. Ultrasound examination of the pelvis is normal. My gynaecologist suggested that I should have the Mirena inserted in my womb. He said this would reduce the blood flow. What is Mirena? How does it work? Any side effects? A. Mirena is a small T-shaped plastic intra-uterine device (IUD) (see figure) which is inserted by the gynaecologist into the womb for contraceptive purpose. It releases progestogen, a hormone similar to the natural progesterone produced by the ovaries and can be used in the treatment of patients with heavy menses. Every month, the lining of the womb(endometrium) thickens during the first half of the menstrual cycle to prepare for ovulation. If ovulation takes place and the egg is not fertilized, the endometrium is shed off as menstrual flow. The progestogen which Mirena releases acts on the endometrium and reduces its thickness. With less thickening of the lining, the menstrual flow is thus reduced. After a year of Mirena insertion, menstrual flow may stop completely in one out of five women.Side effects of Mirena include: · Irregular vaginal bleeding: For the first 3 to 6 months, the monthly period may become irregular. There may be frequent spotting or light bleeding. After a while, these episodes become less frequent and menses may completely stop. · Pain or bleeding may occur during or immediately after the insertion.· Ovarian cyst: About 12 out of 100 women may develop cysts in the ovary. These cysts are non-cancerous and usually disappear on their own in a month or two. Occasionally, the cysts may persist and cause pain requiring surgical removal. · Pelvic inflammatory disease (PID). IUD users may get pelvic infection which is usually sexually transmitted. If left untreated, life-threatening sepsis may occasionally set in.· Perforation. Very rarely, Mirena may go through the wall of the uterus in a condition known as perforation. This may cause abdominal pain. · Expulsion: Mirena may be expelled by the womb and may no longer prevent pregnancy. Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/.

In recent years, eating the placenta (placentophagy) after delivery appears to be a trendy affair as it has been popularized by the media and celebrities. The placenta can be eaten raw, cooked, roasted, dehydrated, encapsulated or through smoothies and tinctures. There has been no standardized method of preparation but the most frequent way appears to be encapsulation into pills after steaming and drying the placenta. What is placenta?Placenta, also known as afterbirth, is a disc- shaped organ that develops in the womb during pregnancy. It provides oxygen and nutrients from the mother to the growing baby and removes waste products from the baby's blood. (see figure). It is expelled from the womb after delivery. Almost all mammals eat their placentae raw soon after delivery but no contemporary human culture has incorporated consuming placenta postpartum as part of its traditions.Advocates of placentophagy argue that since dried human placenta (Zi He Che 紫河车) has been used for centuries in Traditional Chinese Medicine and term placenta has been found to contain various nutrients and hormones, consuming it after delivery should have positive health benefits. They claim that it can prevent postpartum depression, reduce post-delivery pain, boost energy levels, improve lactation, promote skin elasticity, enhance maternal bonding and replenish iron in the body. Recent researches have proved otherwise.Although some nutrients and hormones are found in term placenta, their maintenance and stability in raw tissue and in preparation have yet been tested.In a review published in American Journal of Obstetrics & Gynecology (2017), the authors concluded that “there is no scientific evidence of any clinical benefit of placentophagy among humans, and no placental nutrients and hormones are retained in sufficient amounts after placenta encapsulation to be potentially helpful to the mother postpartum”. In a recent case of a new-born baby who developed repeated bacterial infection after the mother had eaten contaminated placenta capsule, the Centers for Disease Control and Prevention, USA has also recommended that the intake of placenta capsules be avoided. They have issued a warning against such practice.Most women who want or expect to feel good after eating placenta do feel that way. But that may be just be a placebo effect.Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/.

I have Graves' disease and my GP told me that I may be infertile. Is that true? I am in my mid-twenties and am getting married next month. Graves' disease is a medical condition when the thyroid gland becomes overactive and produces an excessive amount of thyroid hormones(hyperthyroidism). The thyroid gland is a butterfly-shaped organ situated at the base of the neck and in front of the throat. It releases hormones that play an important part in many bodily functions, including reproduction. Together with the sex hormones produced by the ovaries, thyroid hormones balance and maintain the normal function of the reproductive system. If the thyroid gland releases too much hormones, maturation of the egg and ovulation will be affected. This may result in irregular scanty periods, absent periods and infertility. Even if conception occurs, the risks of miscarriage and adverse pregnancy outcomes, such as high blood pressure in pregnancy, poor growth of the baby and premature delivery, may occur. In men, hyperthyroidism can cause a marked reduction in sperm count and abnormal sperm motility, resulting in infertility. The sperm count usually returns to normal once the thyroid condition has been treated. Since you have Graves’ disease, you should have it treated before embarking on the journey to parenthood. With treatment and careful monitoring during pregnancy, many complications can be avoided or minimised. Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/.

I am 30, a first-time mum and am 32 weeks pregnant. I had bleeding and labour pains a few days ago and was admitted to hospital. The bleeding and contractions have since subsided after medications. I was also given a steroid injection. What is it for and does it carry any risk to the baby? A. From your description, you may have had a threatened premature labour. The steroid injection you received is probably the corticosteroids. Babies born premature are at risk of having breathing difficulties and other serious health problems at birth. The steroids given are to help the lungs of your baby mature more quickly, thus reducing the risk of the baby dying or suffering from breathing problems called respiratory distress syndrome(RDS) at birth. The steroid is usually given by the intramuscular route. The most common one used is betamethasone. It is given in two doses of 12 mg each, at 12 hours apart. The medication is most effective from two to seven days after the first dose. With this treatment, the risk of baby having RDS is reduced by half and the chances of survival improve by up to 40 percent. Other complications in the baby such as bleeding in the brain and damage to the intestines are also less. Although studies in animals have suggested that steroids given to mothers during pregnancy can affect the immune system, neurological development, and growth of their offspring, such effects have not been seen in human studies. Long term studies of infants whose mothers were given steroids during pregnancy until the children were twelve years old did not show any adverse effects of the drug on the child's physical growth or development. For the mother, corticosteroid injections do not appear to increase the chances of infections of the womb. The use of this drug is an important recent advance in caring for pregnant women at risk of premature birth. The American College of Obstetricians and Gynaecologists has recommended that a single course of corticosteroids be given for pregnant women between 24 weeks and 34 weeks of gestation who are at risk of preterm delivery, within 7 days, including for those with ruptured membranes and multiple gestations. Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/. Related articles: what-causes-premature-birth-what-are-the-immediate-health-issues-of-the-baby? What-is-a-short-cervix?

The number of twin pregnancies has increased in recent years. This is due to the fact that women are having babies late and consequent fertility treatments using IVF procedures.There are two types of twins, identical (monozygotic) and non-identical (dizygotic). About a third of all twins are identical and the rest, non-identical.Identical twins occur when a single fertilised egg (zygote) divides in two, creating twins that share the same genes, same sex and almost similar appearance. The cause of identical twins is not well understood. All pregnant women have approximately the same chance of having identical twins – about 1 in 250. Identical twins do not run in families.Non-identical twins happen when two separate eggs are fertilised by two separate sperm. Unlike identical twins, there are some factors that make having non-identical twins more likely: • Ethnic groups: twinning rate is highest among Nigerians and lowest among Japanese • Age: Older mothers are more likely to release more than one egg during ovulation. • Family history: There is a hereditary tendency for twinning to occur in some families • In vitro fertilisation (IVF): During the procedure, more than one embryo is usually transferred.Often, identical twins can be inferred in the womb, as they often share one single placenta. For nonidentical twins, it can be deduced if they are of different genders (a boy and a girl) or if they have different blood types. However, the only reliable way of identifying whether the twins are identical or not is by genetic DNA testing.

This subject was unclear until recently when a growing body of evidence suggests that a foetus does feel pain early in pregnancy. According to research studies in the field of prenatal surgery, an unborn baby can feel pain in first trimester. By the 20th week of gestation, the baby not only feels pain, but has a higher pain sensitivity than adults. In a study of foetal pain, it was found that a foetus has receptors of pain at 7 weeks gestation. These receptors develop around the mouth and then spread to the whole face, palms and hands by 11 weeks, the trunk and upper arms and legs by 15 weeks, and the rest of the body by 20 weeks. The part of the brain that responds to pain, the neocortex, also begins developing at 8 weeks, and is fully formed by 20 weeks. By then, the foetus will react to pain by moving away from the stimulus in the same way as adults do. The nervous pathway responsible for the most primitive response to pain, the spinal reflex, is in place by 8 weeks of pregnancy. This is the earliest point at which the foetus experiences pain. By 8-10 weeks, many of the neural connections are formed. This indicates that the brain has “wired” itself in the first trimester. Another study has found that under minimal anaesthesia, the foetus withdrew from the scalpel and visibly flinched when touched by the knife. By increasing the amount of anaesthesia, flinching or other signs of foetal pain disappeared. With painful stimulation, the body will react with the production of beta endorphins, cortisol, and noradrenaline. This stress response can be elicited by needling foetal tissues at 20 weeks gestational age. The umbilical cord with no pain receptors will not respond this way when it is similarly treated. Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/.

Here is an abstract from what may be called a symptom diary: “March 1: Menstruation begins. As usual, a slight tummy ache on first day. “March 16: Getting tired. Insomnia last night. No appetite today. Tummy feels bloated. “March 20: Feeling miserable. Forgetful. Breasts are painful. Tearful for no reason. “March 22: Unable to concentrate. Feeling anxious and panicky. “March 23: having loose stools. Breast tenderness getting worse. Upset with colleague. Feeling depressed. “March 29: Menstruation starts again. No more negative feelings. No more breast pain.” This account is by F, 23 and single, who had been instructed to chart her symptoms daily for three months. The physical and emotional symptoms fluctuated in intensity and timing but they were cyclical, occurring one to two weeks before menstruation and disappearing soon after. Some of the symptom were debilitating and caused disruptions in F’s lifestyle. After excluding other psychiatric conditions, she was diagnosed as having premenstrual syndrome (PMS). PMS is a mixture of physical and emotional symptoms linked to the menstrual cycle. It is common, affecting about 75 per cent of females of reproductive age. It occurs mostly in teenagers and women in their early 20s. Common physical symptoms are abdominal distention, headaches and breast tenderness. Psychological symptoms include fatigue, forgetfulness, poor concentration, irritability and depression. To confirm the diagnosis, the patient has to chart her symptoms daily. These emerge about two weeks preceding menses and resolve completely when menstruation starts. In pregnancy and menopause, when menstrual cycles are absent, patients are completely symptom-free. While symptoms may be particularly intense in some months, they may only be slightly noticeable in others. For most women, symptoms are not severe enough to affect their daily routines and activities but in a small proportion of women (about 5 per cent), they can be severe and disabling. The exact cause of PMS is still unknown. Recent research indicates that women vulnerable to premenstrual mood changes do not have abnormal levels of hormones or disturbances in hormonal regulation. It is probably a result of the brain’s sensitivity to normal cyclical hormonal changes. There is an abnormal transmission of serotonin, a brain chemical that plays a crucial role in mood regulation. This may explain why symptoms such as irritability, moodiness or depression, sleep problems and food cravings are associated with PMS. During our counselling sessions, I gave F relevant information about her condition. This is important in PMS management as studies find that women educated about its biological basis have an increased sense of control over and relief of the symptoms. F kept a symptom diary. This helped her to identify the triggers and timings of symptoms so that behavioural intervention could be implemented. Psychotherapy, using behavioural cognitive therapy and stress management, may also ameliorate or eliminate symptoms. In addition, F kept to a structured sleep schedule with consisted sleeping and waking times during the second half of menstrual cycles. This was to ensure that she had adequate rest as sleep disturbances would affect her mood. She was advised to exercise regularly in gym. Women with PMS who did aerobic exercises reported fewer symptoms. F was encouraged to eat healthy, balanced diet rich in fruit, vegetables and wholegrain carbohydrates. This promotes good health and a sense of well-being. Dietary changes were suggested, including salt restriction to minimize bloating, fluid retention and breast swelling and tenderness She was also told to avoid caffeine to reduce irritability and insomnia. Evening primrose oil supplements were added although there is no general consensus on their benefits. After two months of these lifestyle adjustments, F’s physical symptoms improved although emotionally, she still had occasional panic attacks and depression. I prescribed a small dosage of Zoloft during second half of her cycle. This is a psychiatric drug from the group Selective Serotonin Reuptake Inhibitors. Numerous double-blind, randomized studies support its effectiveness. F responded very well to the drug and is now on her way to recovery.

Mrs. T, 45, a mother of three, anxiously related the following to me during her recent visit to my clinic. “Two months ago, after my husband and I had sex, I noticed light pink stains on my underwear. “I did not pay much attention as the spotting stopped the next day. The spotting recurred a few times, usually after sex. I did not think it was serious as the stains were very light. I thought it was due to stress on my part. “When the spotting continued last month and became heavier, I began to worry and came see you straight away.” She sees me every year to have her Pap smear done. This is a simple screening procedure in which cells from the neck of the womb (cervix) are scraped by a wooden spatula or small brush and smeared on a microscope slide. The cells are examined for pre-cancerous or cancerous changes in the cervix. The test is not intended to detect other female cancers such as those of the ovary, vagina or uterus. When I examined Mrs. T, the cervix looked inflamed and red. It bled slightly on contact with the brush and there was a yellowish vaginal discharge. The Pap smear result indicated the presence of cancerous-looking cells. I decided, on a further investigation using a type of microscope called a colposcope, to inspect the entire area of the cervix under magnification. To do this, the cervix was stained with a harmless dye to detect any abnormal tissue. A directed biopsy was taken and a pathological examination revealed pre-cancerous abnormal tissues or lesions. As Mrs. T had decided not to have any more children, she and her husband opted to have her womb, including the cervix, removed (total hysterectomy). This was successfully done by key-hole surgery. Pre-cancerous changes of the cervix are a state of abnormal cell growth which may progress to cervical cancer and usually develop in women between the ages of 25 and 40. Only some of the women with these changes will develop cancer after several years. Every year, about 200 women in Singapore are detected with cervical cancer and about 100 die from the disease. It is the sixth most common cancer affecting women here – after cancers of the breast, large intestine, lung, ovary and uterus. A number of factors may increase the risk of cervical cancer. These include previous infection with the human papilloma virus (HPV), early sexual contact, multiple sex partners, a weakened immune system (the body’s natural defence system), cigarette smoking and taking birth control pills. Almost all cervical cancers are related to HPV, a group of viruses that is transmitted usually through sexual contact. HPV infections are very common and condoms do not offer full protection. About 50 to 80 per cent of women will acquire a genital HPV infection in their lifetime. There are over 100 types of HPV but only 15 types are known to cause cancer. HPV types 16 and 18 cause more than 70 per cent of all cervical cancers and are known as “high-risk” types. “Low-risk” HPV virus types do not cause cancer but can lead to genital warts. HPV infections do not cause any symptoms and most will clear up by themselves. In a small number of women, the virus survives for years. It can then convert some cells on the surface of the cervix into pre-cancer cells. These changes happen very slowly and eventually lead to invasive cancer. Women with many sex partners or whose husband are promiscuous have a higher risk of developing cervical cancer. This is related to higher-than-average exposure to HPV infections. Among women who are infected with the HPV virus, HIV infection (the virus that causes Aids) or taking drugs that suppress the immune system also increase the risk of cervical cancer. Smoking cigarettes increases the risk of cervical cancer. Mrs. T had been smoking for the past 20 years. Taking birth control pills for five or more years may also increase the risk of cervical cancer. Symptoms do not usually show up in pre-cancerous stages and early cervical cancer. Some women experience bleeding in between their periods or during and after sex, as in Mrs. T’s case. Recently, two vaccines – Cervarix and Gardasil – have been developed to prevent pre-cancerous lesions. They are found to be highly effective when given at adolescence. Besides preventive vaccination, early detection and prompt treatment remain the cornerstone in managing cervical cancer. A key feature of cervical cancer is its slow progress. This presents a window of opportunity for prevention. If pre-cancerous lesions can be detected and treated promptly, cervical cancer can be prevented.

The other day, AG, a 28-year-old accountant, came to see me about her menstrual cramps. She has been suffering from it since puberty. “ I had my first period at 12. The pain wasn’t too bad, and it was relieved after a hot shower. But by my late teens, it was getting more severe and I had to take Panadol regularly,” she recalled. When she was in university, Panadol and other pain killers were not effective anymore. Her family physician suggested oral contraceptives pills. “My mum was not convinced so she took me to her gynaecologist. I was just 20.I remember the gynae saying that I had primary dysmenorrhoea and that it would disappear after I had given birth,” she continued. “Do you have the pain on the first day or throughout your period,” I interrupted, as primary dysmenorrhoea refers to menstrual cramps which occur only on the first day and usually last for a few hours. “I cannot recall,” she replied. “Anyway, I was prescribed oral pills. I took them for a few months but stopped because of the side effects. The cramps became worse and I was completely incapacitated. On one occasion, I almost passed out.” “Any investigation done?” I asked. “Yes. An ultrasound scan and the result was normal. The gynae then suggested an operation where a telescope was inserted through my belly button to check my womb (laparoscopy). I reluctantly agreed as the pain was getting unbearable.” “What were the findings?” I asked. “My gynae found small chocolate-coloured spots of menstrual blood at the back of the uterus and ovaries which she removed during the operation. My pain went away and I was symptom-free for the next few years until recently when I experienced pain during sexual intercourse. The backache and menstrual pain returned and I had pain when I passed motion during menses.” When I examined AG, her uterus was tender to the touch and relatively immobile. An ultrasound scan showed an ovrian cyst about the size of a tennis ball on her left side. It was subsequently removed through key-hole surgery and was confirmed to be an endometriotic cyst or “blood cyst”. Endometriosis is a common and troublesome disease affecting about one in 10 women of reproductive age. In women with fertility problems, the number may be as high as 50 per cent. It is also a progressive disease, as is the case for AG. The lining of the womb (endometrial tissues) is spilled into other parts of the reproductive organs including the fallopian tubes, ovaries and the back of the womb. These abnormal and wayward tissues bleed every month during menstruation. The surrounding areas become inflamed and form scars which pull on the nerve endings and cause pain. But some women will have little or no pain despite having extensive disease while others may have severe pain with only a few small affected areas. The endometrial tissues trapped in the ovary will bleed and lead to the formation of the dark, thick and chocolate- coloured cyst known as “chocolate cyst” or “blood cyst”. It may leak and form adhensions (abnormal tissues that bind organs together). The adhensions can block the fallopian tube and interfere with ovulation, causing infertility. The exact cause of endometriosis is not well understood. A familiar association exists as it can affect many siblings in a family. Past pelvic infection can also be a cause. Common symptoms of endometriosis include menstrual cramps, backache and pain during sexual intercourse. Menstruation may be irregular, with staining before or after menstruations. There may also be clots in the menses. An ultrasound scan may be misleading in the diagnosis of endometriosis. It is usually normal if there is no cyst formation as in the case of AG when she consulted the first gynaecologist. The diagnosis is based on clinical suspicion and confirmed by laparoscopy. A blood tumour marker test (CA125) is also not very helpful as the level may be normal or raised. When a cyst is present, surgical removal and microscopic examination is the only way to confirm the diagnosis as in AG’s case. The recurrence of endometriosis is very common. It will only dry up after menopause when the lesion is no more stimulated by ovarian hormones. Pregnancy has a beneficial effect on endometriosis. Hormonal changes cause the diseased areas to become inactive. As infertility may be a consequence of endometriosis, I discussed with AG and her husband the possibility of their conceiving a baby. They heeded my advice and AG is now pregnant.

She had swinging fever of over 38 deg C. Her breasts were swollen, hard, painful and extremely tender to touch. Mrs. B, a first time Mum who had given birth three days ago, was suffering from severe breast engorgement. Her skin over the breasts was taut, shiny, inflamed and red. Lumps appeared under her armpits and both her hands and fingers were numb. However, she was keen to breastfeed her child. Using hot towels, she gently massaged the breasts before feeding. This stimulated the let-down reflex and softened the sore and swollen breasts. The fever gradually subsided. With encouragement from her husband, she finally succeeded in breastfeeding her newborn. Breastfeeding is the natural way and human milk – made specifically for this – is the best source of nourishment for the infant. Breastfeeding’s health benefits are well known and extend beyond basic nutrition. In addition to having all the vitamins and nutrients the baby need, breast milk is packed with disease-fighting substances that protect the baby from gastrointestinal trouble, respiratory problems and ear infections. It also reduces the risks of the child developing food allergies and obesity, and boosts his intelligence. That is why the World Health Organisation recommends a minimum of two years of breastfeeding, with exclusive breastfeeding for the first six months. The American Academy of Paediatrics and Singapore’s Health Promotion Board have similar recommendations. Breastfeeding is also beneficial to the mother. It helps her to shed weight more quickly and lowers her stress levels by releasing oxytocin, the hormone which promotes relaxation. Many studies affirm that breast feeding protects women against breast and ovarian cancer. I am an advocate of breastfeeding and I believe that most mothers are capable of doing so. When I was a junior doctor more than 30 years ago, breastfeeding was a taboo. Nowadays, it is popular again. This is probably due to improved socio-economic status, increasing affluence and better public awareness and education. Successful breastfeeding begins from pregnancy. If I could provide first-time parents with prior knowledge of breastfeeding and how it is done, they would be less apprehensive after the delivery. Studies have found that counselling during pregnancy results in more mothers breastfeeding exclusively and for much longer too. Breastfeeding is a natural act it can also be learnt behaviour. In Mrs. B case, her husband’s support and encouragement form close family members got her off to a good start. In such cases, the wife is also more likely to breastfeed longer. In fact, many young parents today have concerns about breastfeeding, such as fear of the baby not getting enough milk, sore nipples and engorgement and of sagging breasts. This is in spite of the availability of many articles and books that deal with the concerns and dispel the myths. One piece of advice I strongly give is to put the baby to the breast as soon as he is born. The baby is more alert and the suckling reflex is the strongest in the half hour after birth. Research has shown that many babies take only minutes to latch on and will start breastfeeding all by themselves. Caesarean birth is no barrier to breastfeeding. The mother can still hold her baby against the breast soon after birth, with some help from the midwife or husband. The skin-to-skin contact keeps the baby warm. The baby may smell the breast, lick it or nuzzle it all this will help establish and promote breastfeeding. Another key to successful breastfeeding is getting the baby to latch on properly. The first step is to position the baby at the breast in a comfortable and relaxed position. Brush his lips with the nipple to encourage him to open his mouth wide. Then bring him quickly to the breast and not the other way round. A baby who latches on poorly has more difficulty getting milk. This may cause the mother to have nipple pain. If the baby does not get milk well, he will usually stay on the breast for longer period, aggravating the pain and causing more problems. This article is dedicated to all breastfeeding mothers – whose milk is the best gift for their children.

K and her husband looked at me pleadingly: “Can we hold and touch our baby for a while, please? It means so much to us.” A 31-year-old housewife, K had just delivered a premature stillborn baby. I could not think of a way to console her and gently placed the dead baby boy on her abdomen. He appeared normal and seemed to be sleeping peacefully. His parents wept silently over their loss. K was infertile for many years and had three previous miscarriages. When she was into her 25th week of pregnancy, I admitted her to hospital for observation as she had frequent contractions. Then, one morning – a few days after admission – she felt that her baby was not moving. She prodded her tummy which usually helped but there was no response this time. She quickly called the midwife. The baby’s heartbeat could not be heard on a Doppler machine, and an ultrasound scan soon confirmed an intra-uterine death. Devastated, K went into premature labour that night. The length of human pregnancy is normally 40 weeks from the firth day of the last menstrual period. Premature birth is defined as childbirth occurring earlier than 37 completed weeks of pregnancy. It is estimated that 7 to 15 per cent of babies are born premature. Among these, about 6 per cent are born at fewer than 28 weeks of gestation. Such babies are deemed extremely premature and their chances of survival after delivery are very low as many organs are too immature to function well. The cause of premature labour is unknown in about 40 per cent of the cases. In other cases, causes include maternal illness such as hypertension, diabetes and heart diseases, multiple pregnancy (twins or triplets), cervical incompetence (laxity of the neck of the womb) and foetal abnormalities or death. Any history of miscarriage, abortion and premature delivery may also increase the risk of premature labour. Vaginal infections are a potential trigger. A common infection is Group B streptococci. The bacteria cause inflammation in the placenta. Chemicals are released which then stimulate the womb to contract. One can reduce the risk of premature labour by screening for and treating such infections with antibiotics. There is also growing evidence that stress can induce labour, particularly when it is sudden or severe, as in K’s case. The precise diagnosis of pre-term labour is not easy. The only proof is progressive opening of the neck of the womb. Once this occurs, it is usually too late to arrest the process. The painless contractions which K had prior to labour are called Braxton Hicks contractions, which many women experience from the late second trimester of pregnancy onwards. They are not related to premature labour. Many methods have been used to treat premature labour. However, there is no general consensus regarding their effectiveness. Drugs that stop contractions (tocolytics) may help in some cases, but rarely work for more than 48 hours. I did not prescribe any medication for K as the foetus was already dead. I allowed nature to take its course. In a situation when the foetus is alive, steroid injections may be given to the mother to help mature the baby’s lungs. This may reduce the severity of potential lung complications of newborn. K tried IVF (test-tube baby method) twice subsequently but failed. She and her husband have since moved to another country and adopted a child. In her last e-mail to me a few years ago, she thanked me for the chance to hold and touch her stillborn, which helped lessen the pain of losing her child. “The grief is less now, as I am feeling like a real mother every day,” she said.

The concentration of the hair dye that is absorbed into the scalp is usually not significant. It should not affect the quality of the breast milk.