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I attended a workshop on “vaginal rejuvenation” procedure in Seoul recently. It is simple and is done by passing the laser beam via a narrow rod-shaped device inserted in the vagina. It takes 15 to 20 minutes to complete and the patient is discharged on the same day. Vagina or “birth canal” is the passage through which the baby is born .It is a hollow stretchy organ with a firm thick wall. With repeated childbirths, growing age and declining levels of hormones, it loses its elasticity and becomes lax. This leads to a “loose vagina” or vaginal relaxation syndrome (VRS) VRS may have physical and psychological problems such as a decline in sexual satisfaction and desire for both the female and her partner. She has less contact with the penis and may not have orgasm. Occasionally, she passes gas during sex. This dampens her mood and causes further embarrassment. As the laxity worsens, her womb and the urinary bladder move downwards and bulge to the outside. She may have a heavy sensation or feel a “lump” at the private area. Urinary incontinence and incomplete emptying of bowel may appear. The treatment of VRS includes Kegel exercise, hormone cream or spray to tighten the pelvic muscles and vagina. These are simple methods but may not be effective. Surgery is usually done in severe cases. It is permanent but recovery is longer. It may also have complications such as vaginal scarring and pain during sexual intercourse. Vaginal rejuvenation is the latest mode of treatment for early VRS. The passage of laser would stimulate and toughen vaginal tissue and renews the cells of its wall. The procedure is simple, easy to learn and is done as an outpatient without anaesthesia. It is painless except for an occasional warm feeling. It does not damage the vagina and has no complications such as bleeding or infection. Results from centres in Europe, USA and Korea are good. With an aging population in Singapore, this procedure offers an option for the prevention of severe VRS.

Q. I am 30 years old and have been married for 3 years. Recently, I am trying to conceive. My menses are rather irregular occurring once every 6 weeks to 2 months.  My gynecologist thinks my menstrual irregularity is due to my being overweight as my BMI is 27. He advises me to lose weight if I want to become pregnant. How does obesity affect fertility? I have difficulty losing weight. I have tried taking appetite suppressant drugs. I lose weight temporarily but I become fat again as soon as I stop taking medicine. I am rather depressed. Can you help? Will surgery to reduce stomach help? A. Normal menstruation essentially depends on the balance of two hormones (estrogen and progesterone) produced by the ovary. These hormones, in turn are influenced by pituitary gland (a small gland at the base of the brain) as well as other centers in the brain. There are two sources of estrogen in the body. The main source is the ovary while an indirect and small source is from the adrenal gland (a small gland on top of kidney). The ovary produces estrogen directly and cyclically while the adrenal gland produces estrogen indirectly through the fat cells. In obese patient, the erratic inflow of estrogen from the fat cells interferes with the cyclical estrogen production of the ovary. This ultimately results in disturbance in ovulation and infertility. Another reason for obese patients to be infertile is its association with a disorder called PCOS (polycystic ovarian syndrome) where there is excess of male hormone (testosterone) and a diabetic-like state in the body. This deranged biochemistry makes the ovary unlikely to ovulate or produces poor quality eggs. There is no easy and quick-fix way to weight loss. An approach involving lifestyle changes through proper diet, exercise, behavior modification, stress reduction together with medications is found to be most effective. The key to successful weight loss lies in your brains, not in your stomach. You may consider the following: • Joining a slimming group. Group work, with regular weigh-ins and sharing of experiences, can help motivation. • Learn your own weaknesses and food triggers: look for ways to beat them • Tell people you are dieting - you might bore them, but it helps you to commit to the idea • Do not be overambitious - a gradual loss of 1kg max a week is the most you should expect. Medical research has shown that a reduction of 10% of body weight in obese patients may correct the hormone and metabolic derangements. This will increase the chances of conception. Stomach stapling is not advisable in your case as you are not extremely obese. It is an invasive procedure and carries surgical risks. It should be used as a last resort.

I am a first-time mom. My baby is now 2 months old and still on full breast feeding. My husband wants to have sex with me, but I am frightened of pain. Besides, I have no desire. Can I resume sex now? Will it be painful? My friend told me that as long as I breast feed my baby, I cannot get pregnant. Is it true? Sexual intercourse may be resumed after the red or brown vaginal discharge called lochia has stopped and stitches at your vagina healed. Usually, most women would have recovered by 6 to 8 weeks after delivery. Several factors can affect your sexuality besides the fear of pain. · You may be suffering from lack of sleep and exhaustion attending to your baby’s endless needs. · You may be so tired by the demands of being a new mother, that you have little time for your husband. · Sex seems like another physical demand on your body that you may not want to connect with your husband emotionally. · Fear of another pregnancy may also be an inhibiting factor. · Breastfeeding suppresses ovulation. This would reduce the amount of female hormone (oestrogen) circulating in your body to below normal levels, causing vaginal dryness and a general dampening of sexual desire. However, every woman is different, and some nursing mothers report that breastfeeding does not affect their libido. Physically, you may notice a change in the size and shape of your vagina after birth. For the first few times, sex may be painful due to vaginal dryness. Use a water soluble lubricant such as K-Y jelly or Femglide, and try positions that allow you to be in control of penetration. You may experience "let down"(leaking of milk) during sex. This is normal and there is no way to prevent it. While it is true that on average, most women who breastfeed fully would not be fertile for about six months after childbirth. It is not a foolproof way of contraception. You can become pregnant again even before you have your first period.

When Mrs M stepped into my consulting room, she was tense, anxious and almost in tears. “Doc, please try to save my baby,” she pleaded. Married for five years, Mrs M, a 32-year-old housewife, had had difficulty conceiving. She was eight weeks pregnant when she came to see me that day. The bad news was fresh vaginal bleeding that morning. Eight months earlier, a blood cyst in her left ovary had been removed by key-hole surgery. She subsequently conceived after receiving injections (GnRH agonist) to suppress her hormones. When I examined her that day, there was bleeding from the vagina. The neck of the womb (cervix) was closed and the baby’s heart beats were present on the ultrasound scan. She was immediately admitted to hospital for observation. Then, that night, I received an urgent call: Mrs M was having intense abdominal cramps and had passed a large amount of blood with clots. I rushed to the hospital. Mrs M was in a state of shock, crying incessantly and calling out the name she had chosen for her child as soon as she knew she was pregnant. By then, the cervix was open and foetal tissues ware passing through – it was a miscarriage. What was needed now was an emergency operation to empty the uterus to stop the bleeding. Traumatic as the miscarriage (the loss of a foetus in the first 20 weeks of pregnancy) was for Mrs M, it is a fairly common occurrence. Let me explain. The American College of Obstetricians and Gynaecologists( ACOG) says that about 15 per cent of known pregnancies end in miscarriage. The actual number is probably much higher because many miscarriages occur so early in pregnancy that a woman does not even know she is pregnant. More than 80 per cent of the time, it happens in the first three months of pregnancy (first trimester). In most cases, a miscarriage cannot be prevented because it is caused by random genetic or chromosomal change that occurs during conception and / or early foetal development. In few cases, a mother’s health condition – such as uncontrolled diabetes, thyroid diseases, infections, or problems with the uterus or cervix – may lead to miscarriage. Certain factors like being an older mother (above 35), smoking, drinking, and previous history of miscarriage put a woman at higher risk of having a miscarriage. A number of terms are used to explain miscarriage. An inevitable miscarriage is bleeding and cramping with sighs that the cervix may be opening. An incomplete miscarriage, as in the case of Mrs M, is when the uterus expels the foetal tissues partially. This can lead to heavy blood loss. A blighted ovum is one that has occurred so early that no clearly defined foetal tissues have formed. A missed miscarriage is when there is foetal demise and the uterus does not expel the tissues for a while. Spotting and staining are common. Finally, a recurrent abortion is when a woman miscarries two or more consecutives times. Mrs M came back for a check-up one week after her miscarriage. She was grieving and kept blaming herself for not resting adequately. She blamed her husband for shifting and changing furniture in her bedroom. “Doc,” she asked, “could the miscarriage be due to renovation in my baby’s room?” I reassured her, saying there is no medical evidence that all these activities caused her miscarriage. Losing a pregnancy is always heart- breaking. It is like the loss of a loved one. A patient should be treated with the respect and dignity she deserves. Telling her “You can always have another” or “It was just miscarriage” usually does not help. Consoling would be better: “I’m so sorry for the loss of your baby”. I suggested to Mrs M that she should take her time to grieve so that she could heal emotionally and physically before trying for another pregnancy. Mrs M is now 23 weeks pregnant and both the mother and baby inside her womb are well.

Q.I am in my late twenties. Unfortunately, I had been recently infected by my ex-partner with genital herpes. I am in great psychological and mental distress. I am still unmarried and am worried that I will infect my future husband who is uninfected and also affect my children in future. I am really confused and deeply saddened as I'm planning to get married soon. (1) Can I have sexual intercourse without wearing condoms with my husband when there are no sores present and not infect him? (2) Can I have healthy babies and children in future? What if there are sores attacks during pregnancy? A. Genital herpes is an infection of the genitals, buttocks, or anal area caused by two types of herpes simplex virus (HSV). They are • HSV type 1 commonly infects the mouth and lips, causing “fever blisters” or cold sores. It spreads by direct contact or kissing. • HSV type 2 is the usual cause of genital herpes, but can infect the mouth through oral sex. Herpes is not curable. Once you contract the virus, it settles in a bundle of nerves near your spine FOREVER and may surface again and again. The virus can be active even though you do not notice any visible sores or symptoms. During these times, asymptomatic (without symptoms) shedding of the virus may occur at or near the mouth, penis, or vagina, or from unnoticeable sores. In this way the virus spreads and infects your partner without your knowledge. Using condoms during sexual activity may decrease transmission, but infection can still occur. Recently, antiviral medication has been shown to reduce transmission of genital herpes to an uninfected partner. However, this is not full proof and the medication has to be taken continuously by the infected person. Herpes can infect baby in various ways. If mum-to-be get infected for the first time during pregnancy, serious defects in the baby’s nervous system can result. She is also at increased risks of miscarriage and premature birth. Since you have previous infection already, it is unlikely your child will be affected in this way. The biggest concern is that you may transmit the virus to your baby during labor and delivery. Though newborn herpes is relatively rare (risk is less than 1 percent, according to the Centers for Disease Control, USA), the disease can cause serious brain damage, mental retardation and death. Infection usually occurs when the baby comes into contact with the virus in the birth canal during delivery. Your obstetrician should be informed of your previous infection. He can then examined you with a strong light at the onset of labor. This is currently the best way to detect herpes lesions. A viral culture can also be taken. If you have sores or symptoms at delivery, the safest option is a Caesarean section to prevent the baby from coming into contact with active virus. If you do not have herpes lesions at the time of delivery, the standard of care recommended by the American College of Obstetrics and Gynecology (ACOG) is vaginal delivery  Your baby may have some natural protection against the virus from your previous infection. Antibodies in your blood cross the placenta to the baby and help protect the baby from getting infected.

Men may experience menopause, just like women. The condition is variably termed andropause, testosterone deficiency, androgen deficiency, or late-onset hypogonadism. It is related to the gradual decline of the male hormone, testosterone, with age. Testosterone is a sex hormone produced by the testes. It plays many important roles in men, including regulation of sex drive (libido), bone mass, fat distribution, muscle mass and strength, and the production of red blood cells and sperm. Its levels peak at about 20 and start to decline gradually. It is estimated that the levels decline by about one percent every year after the age of 40. Unlike female menopause, the development of symptoms in andropause is more gradual as testosterone levels decline slowly over a long period of time. The symptoms are only present in about 30% of men in their 50s. They include the following: · Low energy, lethargy, constant fatigue, · Depression or sadness, · Decreased motivation, lowered self-esteem, · Difficulty in concentrating, · Insomnia, · Increased body fat in the tummy area, · Irritability and mood swings, · Osteoporosis (brittle bones), · Loss of sex drive, · Erectile dysfunction, · Reduced muscle mass and feelings of physical weakness, · Gynecomastia, or enlargement of breasts, · Loss of body hair, · Hot flushes, · Decreased bone density, · Infertility. It is important to note that many of the symptoms associated with andropause are also a normal part of aging. Andropause is usually diagnosed by correlating the symptoms with a low testosterone level in the blood. Many men do not seek treatment as they think they can manage the symptoms themselves without treatment. Oftentimes, many patients also feel too intimidated or shy to discuss sexual topics with their doctors. Treatment usually involves making healthier lifestyle choices which include: · Eating healthily, · Exercising regularly, · Getting enough sleep, · Reducing stress. Medication or a psycho-therapy, such as cognitive behavioural therapy (CBT) may help if symptoms of stress and anxiety get more severe. Sexual counselling and medications may help in erectile dysfunction. Hormone replacement using testosterone is another treatment option. This treatment may provide relief from the symptoms and help improve the quality of life in many cases. Testosterone is given in the form of tablets, patches, gels, implants or injections. But there are concerns regarding the side effects of testosterone such as the risks of developing prostate cancer. Testosterone should not be taken by any man with prostate or breast cancer. If the patient has heart disease, is taking some medications such as blood thinners, has an enlarged prostate, or has kidney or liver disease, he should discuss with the doctor the pros and cons of testosterone therapy before deciding on the treatment.

I have varicose veins during pregnancy. Are there ways to minimize these unsightly veins? Will they go away after delivery? Varicose veins are swollen veins under the skin. During pregnancy. they are usually found in the legs but occasionally, they may extend around the vulva and vagina. Usually, they do not have any symptoms other than the blue and purple bulging veins in the legs. Sometimes, they may cause itchiness and make the legs feel tired and uncomfortable. Varicose veins around the vulva may cause swelling and may bleed profusely when injured accidentally. Factors which contribute to the development of varicose veins in pregnancy include: · The blood volume of the mother increases, while the blood flows from the legs to the heart decreases. This results in the increase in pressure on the leg veins which become swollen. · The increased levels of progesterone, the pregnancy hormone may dilate or open the veins. · The growing womb is pressing on the pelvic veins. The back flow of the blood further contribute the formation of varicose veins. Fortunately, varicose veins tend to improve after delivery. This usually happens within three to four months though sometimes it may take longer. However, they are less likely to disappear if the patients had varicose veins before pregnancy, have had multiple pregnancies, have a family history of varicose veins, are overweight, or tend to stand for prolong periods. To minimize the occurrence of varicose veins, the following steps may help · Exercise regularly. Try to do brisk walking. This will help the circulation, · Wear maternity support hose or compression stockings. These are tight at the ankle and get looser as they go up the legs. They help prevent swelling and may keep the varicose veins from getting worse, · Raise the feet and legs whenever possible. Keep the feet elevated on a pillow when lying down, · Sleep on your left side. This will help relieve pressure on the big veins that drain the blood from the legs to the heart, · Reduce sodium intake to minimise swelling of the veins, · Avoid sitting or standing in the same position for long periods of time, · Avoid wearing high heels. Wearing lower-heel or flat shoes will work the calf muscles thus improve leg circulation, · Avoid crossing the legs while sitting.

Until the beginning of her third trimester, Mrs. C, 26 and having her first baby, would have said her pregnancy was pretty normal. Things were progressing smoothly and she was busily preparing her home for her soon-to-be-born son. Then, at the 30th week of pregnancy, she noticed a sudden weight gain; both her legs were swollen too. She gave me a call that day and promptly came to see me. She looked anxious and was very concerned. Her face was puffy and her ankles were swollen from water retention. She told me that her shoe size had increased since her last appointment three weeks ago, and she was a larger size now. Even those felt a little tight on her. I checked her blood pressure and it was alarmingly high at 200/100mm Hg. Her usual blood pressure was normal at 120/70mmHg. A large amount of protein was also found in her urine. A routine ultrasound scan to chart the baby’s growth showed that he was small, with all his growth parameters below average. I told Mrs. C she had preeclampsia and that she should admitted to hospital at once for her surveillance and also that her baby. We began anti-hypertensive therapy straight away. Hypertensive disorder in pregnancy (often referred to as preeclampsia) is a fairly common condition. It affects about 10 per cent of first pregnancies and can be very dangerous to both mother and baby even if the mother does not feel sick. Severe hypertension, as in Mrs. C’s case, can lead to maternal death and foetal demise. The causes of preeclampsia are still unknown. Certain medical conditions such as chronic hypertension, chronic kidney disease and diabetes are associated with higher risk of developing preeclampsia. It is also more likely to develop in women who are pregnant with their first child, those who are younger than 20 and older than 40, those with multiple pregnancy and those who have had preeclampsia during a previous pregnancy. Symptoms include persistent headache, blurring of vision, nausea or abdominal pain, and swelling of the hands, face and legs and reduced volume of urine. If the blood pressure is too high, the mother can die from epileptic type of fits, coma, stroke, and heart, kidney and liver failure. The baby may die from premature birth or premature separation from the placenta. There is usually restriction in the growth of the baby from malfunction of the placenta as in the case of Mrs. C. She was started on medication and her blood pressure was monitored closely. Mrs. C required maximal dosages of oral medication, some of which made her sick. She was lying in bed most of the time and got up only to have her meals or to use the toilet. Even so, her blood pressure remained very unstable and difficult to control. Sometimes, she would get bad headaches and nausea. Her blood tests also showed that her kidneys were affected by the blood pressure. I had frequent discussions with her and her husband. They were alerted that if the blood pressure was too high and threatened the mother’s life; the baby would have to be delivered regardless of his chances of survival. The optimal outcome would be to deliver a healthy baby. In this situation, the obstetrician is like an acrobat walking a tight rope and this can be distressing to him. Meanwhile, Mrs. C’s baby had frequent and regular ultrasound scans to monitor his growth. His heat beat was measured electronically by cardiotocograms (CTG) to ensure adequate oxygen supply. Malfunction of the placenta can cause sudden death to the baby. Steriod injections were also given to the mother to help improve the baby’s lung function. At the 32nd week of her pregnancy, all the parameters indicated that the oxygen supply to the baby was diminishing. It was decided that the baby would benefit from medical support at the neonatal intensive care unit rather than the womb’s “hostile” environment. The baby, weighing 1.28kg, was delivered by caesarean section and immediately admitted to the intensive care ward. When Mrs. C awoke from the anaesthesia, her husband told her how painful it was to see the baby hooked up with so many tubes and wires. It was a wrenching sight as the baby was no bigger than a kitten. They prayed that the baby he would pull through. And pull through he did – he is now a bubbly, feisty four-year-old boy

I have been taking contraceptive pills (Diane 35) for the treatment of pimples. How does the pill work? Will it affect my fertility in future? A. Diane 35 is an oral contraceptive pill containing a female hormone (oestrogen) and another hormone(anti-androgen) which works against the male hormones (androgen). Androgens are produced by men as well as women. They stimulate the growth of the skin glands that produce oil (sebum). If the body produces too much androgen, excessive sebum will form. This will eventually block up the hair follicles, resulting in acne spots which can get infected or inflamed. The anti-androgen in Diane 35 will reduce the levels of male hormones produced by the ovary as well as counteract the effects of androgens on the skin. The treatment of acne using this drug is very effective. With regards to whether the drug will affect your future fertility, the answer remains unclear. Previous studies have shown that oral contraceptive pills do not cause infertility. Most women will experience normal cycles within one to three months after stopping the pills and many will conceive within six months to a year with well-timed intercourse. But a recent study of more than 2,200 women attending antenatal clinics in England in 2017 has suggested otherwise. The hormones in the pills could upset the reproductive system for months or even years after women stop taking them. The study has found that former pill users took twice as long to conceive than those who had used condoms. The longer they had been on the pill, the longer it took to conceive. The risks appear to be even greater among women who are over 35, or obese, or suffer from irregular periods. Over-35s who had taken the pill took two-and-a-half times as long to conceive as those in the same age group who had used condoms. The researchers believe that in some women, the hormones may stop the ovaries from releasing the eggs normally and may take some time to wear off.

There are many old wives’ tales surrounding pregnancy. A myth that has been around for a long time is that one can predict the baby’s gender by listening to its heart rate. The “prediction test” states that if the foetal heart rate is above 140 beats per minute(bpm), the baby is more likely to be a girl. If the heart rate is below 140 bpm, the chances are that the baby will be a boy. But does the “Prediction test “work? No. Unfortunately, the heart rate of the fetus cannot predict its gender. Research studies have shown that the baby’s heart starts beating around 5-6 weeks of gestation. It usually begins beating at a rate of around 85 bpm and increases by 3 bpm each day until it reaches about 175 bpm around the 9 weeks of gestation. After that, the heart rate slows to between 120 and 160 bpm. In one study, the average heart rate for baby boys in the first trimester was 154.9 bpm (+/- 22.8 bpm) and for baby girls 151.7 bpm (+/- 22.7 bpm). There was no significant difference between male and female heart rates during early pregnancy. Thus, the heart rate of the baby is an unpredictable way to determine its gender. Heart rate depends on the activity of the baby, being higher when the baby is moving and slower during sleep. This means the baby’s heart rate can be different at different times of the day, regardless of the gender

Piles or haemorrhoids are swollen veins in the final segment of the large intestine (rectum). When these blood vessels become unusually swollen and engorged with blood, soft lumps may be felt protruding out of the anus. They are very common after a vaginal delivery and can range from the size of a pea to that of a grape. Symptoms include pain, swelling, itchiness around the anus and rectal bleeding especially after having a bowel movement. Why are haemorrhoids common during pregnancy? Haemorrhoids are common during pregnancy for the following reasons: · The growing womb(uterus) puts pressure on the big veins in the lower abdomen. This pressure slows down the blood flow from the rectum causing the veins to swell · There is an increase in the levels of pregnancy hormone, progesterone which tends to relax the walls of the veins, allowing them to swell more easily. · Progesterone also slows down the muscles of the intestinal tract resulting in constipation. This may further cause or aggravate haemorrhoids during a hard bowel movement. · Haemorrhoids may also be formed when one strains and pushes the baby out of the birth canal during labour. After delivery, haemorrhoids may get worse because many mothers consume confinement foods which are considered “heaty” in nature. These foods may harden the stools and make the bowels difficult to move The tears or episiotomy cut at the perineum- the area between the vagina and anus- during delivery may cause pain and soreness. As the skin is still healing, it may hurt when one poops. The fear of moving the bowels may result in further constipation and hardening of stools. This vicious cycle will aggravate the symptoms of haemorrhoids further What can one do to ease the haemorrhoids? · Clean the anus gently with wet wipe rather than dry toilet paper, · Apply ice pack on the haemorrhoids, · Soak the perineum with sitz bath (a basin filled with warm water and salt). This will soothe and help haemorrhoids shrink, · Sit on a pillow or air ring to relieve pressure on the haemorrhoids, · Apply haemorrhoid creams, ointments, suppositories, sprays and painkillers for pain relief, · Take a stool softener to prevent hard stools, · Take more dietary fibres by eating fruits e.g., prunes, papaya and vegetables to prevent constipation, · Drink plenty of water, · Do Kegel exercises to strengthen the muscles around the perineum, · Have adequate rest but go for a slow walk every day. Moving the body helps move the bowels, · Avoid using scented toiletries, · Avoid sugary and processed foods. Haemorrhoids are usually experienced during pregnancy. Symptoms usually improve about 6 weeks after delivery. Occasionally, if pain and rectal bleeding persist after that, medical attention including a colonoscopy may be necessary to rule out more serious problems such as tumour in the large intestine.

I am 34 weeks pregnant. I had a last trimester ultrasound scan recently and was told that my baby’s umbilical cord was wrapping round the neck. Is this a serious condition? Do I have to undergo Caesarean section? please advise. A: The umbilical cord is a flexible tube-like structure that connects the developing baby to its mother. It is attached to the baby’s belly button (umbilicus) at one end and to the mother’s womb through the placenta at the other. It is the lifeline for the foetus as it carries oxygen and nutrients from the mother to the baby and transfers carbon dioxide and waste products in the opposite direction to the mother to be excreted. The umbilical cord is formed around the fifth week of pregnancy and can grow up to 50cm long at birth. It is a tough, sinewy cord with a soft, gelatinous filling called “Wharton’s jelly”. This jelly is designed to support the blood vessels running in the cord and to prevent them from being compressed. It also keeps the cord from forming knots when the foetus moves or somersaults in the mother’s womb. The foetus is constantly moving in the womb. These movements may cause the umbilical cord to wrap round the baby’s neck either once or multiple times. This condition is called the nuchal cord. It is present in about 25 to 40% of babies at birth. As in your case, most parents are anxious to know whether the nuchal cord will compromise the oxygen supply to the foetus and should caesarean section be done for safe delivery. Amazingly, in most cases, the blood vessels in the cord are not compressed and the foetal well being is not affected. Normal delivery can be accomplished if the foetal heartbeat is properly monitored during labour. Caesarean section is only indicated during labour if the cardiotocograph (CTG), an electronic means of monitoring foetal heart rate and uterine contractions, indicates that the baby is in distress. In rare occasions- one in 2,000 births- the nuchal cord may form a “true knot”. This may pose certain risks during delivery. However, in the majority of cases, the cord would not tighten too much and normal delivery can still be achieved.