IN MEMORY OF DR MAPELA

 The other day one of my colleagues sent me an interesting photo from 2017. It is me in Chris Hani Baragwanath with my senior unit registrars. The image is captured as we are walking in one of the wards, and we accidentally happen to be wearing matching blue scrubs. I was thrilled to be working in Bara. Being exposed to a lot of different cases and growing well in my clinical and surgical skills.

A specific registrar who is standing in the front was Dr Mapela. We rotated together for a major part of our registrar training. I learned a lot from him. He was much older than the other registrars I had worked with. He had a lot of knowledge and skill. He would often challenge the other seniors and consultants in the ward round, pull out the latest piece of evidence, and win the arguments.

I remember he was on call for gynae and I was cutting caesarean sections. I had offered to do any gynae emergency cases so I would get more experience in that field. The one ectopic case I started doing happened to be in the isthmus part of the fallopian tube I called him for help and he showed me how to do a wedge resection and achieve haemostasis.

We later rotated in Rahima Moosa Hospital together and had a good time in late Dr Bera’s obstetric unit. I ended up in a different gynaecology rotation from Dr Mapela but still kept in touch, I knew that his gynae theatre list was on Mondays. After a Sunday shift if the night had not been busy I would usually join him for the second gynaecology case. We would do a hysterectomy together. He would do his side with the ligature and I would do my side the old-fashioned way trying to master the art of tying knots.

There came 2020, the covid pandemic, and everything went upside down. I was in my second year of registrar training and Dr Mapela was doing his last year. he stayed in Potchefstroom, and had requested to finish his time with the Klerksdorp rotation in December 2020. when he was busy with a difficult Caesar in a Covid-positive patient he got infected, was admitted to ICU, and passed away in January 2021. We were all devastated. He will always have a special place in my heart. I am where I am today because of him. 

 

 

 

 

 

 

 

 

SEX AFTER PREGNANCY

 Seeing the post-partum women with their happy and healthy bundles of joy in the consulting rooms is the most rewarding thing. They are glad to be out of the house, most of them bring the little one and some leave them with the grandparents or a caregiver. The dads usually accompany the moms, if it is their first baby they often look exhausted and overwhelmed. Some dads ask the eager question of whether it is safe to have sex again!

Pregnancy and childbirth are transformative experiences that affect every aspect of a person’s life, including sexual well-being. Despite this fact, most clinicians ignore sexual well-being. All we address in the six-week visit is emphasizing the importance of breastfeeding, pap smears, and contraception. Sexual health does not only affect individual well-being; it is an important part of relationship satisfaction. It is common that in the post-partum period the frequency of sexual engagement and desire declines. A lot of women report changes in arousal, orgasm, and sexual pleasure and sex is associated with pain most of the time.

Many factors can contribute to post-partum sexual issues, including hormonal changes, body image concerns, and mental health conditions. Women who are breastfeeding experience amenorrhea which benefits them with post-partum blood loss, but it also causes vaginal dryness and reduced sexual arousal due to hormonal shifts.

The health care providers need to understand the importance of this topic and try to create a safe environment for the patients to start the conversation about sex. Using simple and non-judgemental statements such as saying “Many people notice changes in their sexual desire or pleasure after childbirth. Has anything like this happened to you or your partner?” can encourage women to share their concerns.

Assessing the importance of sexual problems can help direct the need for any intervention. Following up on these concerns and offering support, through counseling, pelvic floor physical therapy, or referral to a sexual medicine specialist or a sex therapist can be some of our interventions. Our women need to know that it is not Ok to feel pain during intercourse in the post-partum period. We are the first caregiver whom they encounter and we need to look for potential problems.

 

 

 

 

 

 

 

FIRST DAY OF PLAY SCHOOL

 As parents, we experience various milestones with our babies from birth. The most delightful milestone of my baby was when she was about two months and she smiled at me for the first time! It was very rewarding after weeks of feeding, changing nappies, and sleepless nights she smiled at me and all the post-partum fatigue went away. Around four months she started crawling and I put her on the couch and she fell within 5 minutes, luckily she did not sustain any injuries, but I knew that she could crawl and move around and I needed to watch her.

She has grown up so much, she can run around and climb and play. The other day I caught her standing on the table in the balcony and bending over the railing. Luckily I saved her and put the table away. Her favourite activity is watching Coco Melon, running outside, dancing to music, and playing with water. We had a short trip to Suncity and she slipped and fell in one of the shallow kiddie pools. She was very scared that day and had a fright. She is afraid to go inside the pool, but I often take her to the poolside to play with her toys. I either swim myself or relax and listen to music. Toddlers get bored very easily, so to have them busy with some activity is a blessing.

I made the decision to put my little one in school, at the end of last year. We stay in a good area and most of the schools look fancy. The other criterion was to have the closest school to our house, so we could cope with the drop-offs and the pick-ups in the peak traffic hours. I had a lot of stress in December before she started school. She is very attached to me and had a bit of separation anxiety when I used to drop her off by the grandparents on weekends. Even if I have to go to the bathroom she follows me and I sleep with her during the night. I have read things about sleep training in toddlers. I feel like everyone is different and I will give her time to understand and be able to sleep alone.

The first week of school went well. The teachers and my work colleagues were very supportive. She was able to settle, eat, play, nap, etc. There is an application where all the daily activities are updated from the nappy changes and the things the children have eaten during their meal and snack time. I am happy to see her sitting with other kids and having food. We are lucky it is currently summer in the southern hemisphere, so hopefully there will be fewer viral illnesses making kids sick in school. The mornings are also nice and bright, which makes the days less sad.

 

WORKING IN THE FESTIVE SEASON

 I have been working in South Africa’s healthcare system for 9 years now, during all the festive seasons except for December 2022, when I was on maternity leave. I willingly made this choice, mostly because my family does not celebrate Christmas. I feel happy to know that my colleagues who celebrate during this time can spend time with their families. We know that we are part of a team and can support each other and fulfill our duties.

We have to take extra care and consideration for the patients who are also in the hospital during the festive season. Some patients might show up to casualty with vague complaints just because they didn’t want to be alone. We have even had women coming to maternity complaining of decreased fetal movement, and not initially disclosing to us that she has been a victim of gender-based violence. There are those patients who delay presenting to the hospital with their illness and they present very ill, in need of resuscitation, blood transfusion, or ICU admission.  

We have to bear in mind that being a doctor during the holidays means that we are working while other people are busy celebrating because illnesses and injuries and in my case childbirth does not take a break! When we are in medical school we tend to have a great break after the exams, but things start to get busy from internship when the interns learn that working on holidays is part of the medical work. They are still young and do not have committed relationships or children as yet which makes them adapt easily.

For those doctors who feel the tug of family, a virtual call can help them stay connected especially with little children who miss their parents. We must also remember to take care of ourselves and make sure we are eating right, taking breaks, and are able to manage stress. 

This is me and my Rahima Moosa registrars and interns on Christmas Day 2024

END OF YEAR 2024

 It is that time of the year when things tend to slow down, and we have time to reflect on what has happened through the past eleven months. Looking back, I have a good feeling about this year. We have been happy and healthy and trying our best to survive. I want to elaborate on the different aspects of my life.

My health journey: I have not had any major health issues this year besides those intense dentist visits and getting crowns for my teeth which cost a fortune. My pap smears and blood tests are up-to-date. The thought of having to do mammograms in my 40s from next year is scary. Mentally there are those days when I feel overwhelmed, overstimulated, and exhausted, but I am trying to give myself precious time to journal, read a book, and relax. Physically, I have not been successful in my weight loss journey this year, but I hope to do better next year. We cannot eat what we used to eat in our 20s and have the same figure.

Work has been going well. The first half of the year was spent on job hunting filling out application forms and praying for interviews. My prayers were eventually answered and I managed to get a job in a hospital that is much closer to my house and has a better academic environment. I started working there in July and so far have been enjoying it and growing well, professionally. For me, a job is not merely something that pays the bills, and I don’t ever dream of having enough money to sit at home and go shopping sprees and drink smoothies every day. My job gives me purpose and meaning and I love it.

Family is everything. That is what fills the rest of my heart besides my job. Hubby and I have survived another year without killing each other! There have been good days, bad days, loving days, and disagreements here and there. The good has been more than the bad, hence we are surviving and doing our best to raise our little daughter. I am thankful to the grannies and uncles who have helped us in every aspect this year, especially my mom for looking after the baby most of the days.

We are thankful for another blessed year, and wish everyone a prosperous new year. looking forward to next year with more exciting content on women’s health in this blog. 

 

 

WORLD AIDS DAY

 The 1st of December is marked as World ADIS Day. The purpose of this is to raise awareness about HIV/AIDS and honour those who are affected by the disease. This year’s theme is “Collective Action: Sustain and Accelerate HIV Progress “. The day was first observed in 1988, and since then significant progress has been made in addressing HIV/AIDS through advancements in medical research, increased access to treatment and prevention, and a broader understanding of the virus.

The objectives of dedicating a day to HIV/AIDS is to:

Raise awareness about the disease's impact

Support the affected groups

Promote HIV testing and prevention

Advocate for policies and programs that support research, treatment, and prevention

 

We can all get involved by:

Wearing a red ribbon, which is the symbol of the world AIDS day

Sharing information about HIV/AIDS on social media

Participating in local events and fundraisers

Supporting organizations that work on HIV/AIDS research, treatment, and prevention

 

Here is a passage from Laura Bush’s biography explaining her visit to African countries in 2006 like South Africa and describing its effects. “Many African nations like South Africa have lost a vast portion of their population to AIDS. They were economically devastated and coping with massive human suffering. The tragedy was compounded by the fact that for well over a decade people across the African continent were not tested for AIDS. A positive test was a death sentence because there was no medication available. “

 

Let’s work together to create a world where everyone has access to HIV prevention, treatment, and care.

 

 

ADVANCED MATERNAL AGE

 There is a demographic shift towards later childbearing, and it has become a major health concern. There are numerous associations between advanced maternal age and pregnancy complications. Many women are focusing on their careers and by the time they are on the right path they might have some time to deal with the harsh dating world to find the right man. I was extremely career-oriented in my twenties and felt like I could survive without a child. All I wanted was to be financially independent and not rely on any man to feed me. I immigrated in my late twenties and by the time I was settled in a specialization program, I was about 33 years old. By then I really wanted to settle and have a family. I got married at 35 years old and had a baby at the age of 37.

Women over 35 have decreased fertility which means it may take them a longer time to fall pregnant. They have higher rates of pregnancy failure, miscarriage, and ectopic pregnancy. This is mainly attributed to a progressive decrease in oocyte numbers and their quality. With all this, we also have an increased risk of chromosomal abnormalities such as trisomy 21(down syndrome), trisomy 13, and 18.

Older women are more likely to enter pregnancy with pre-existing hypertension which can cause morbidity in mom and fetus. Gestational hypertension and pre-eclampsia are also more common in this age group, especially if the women are primigravida, having the baby with a new partner or the spacing of the pregnancy is more than seven years. The guidelines suggest that women of advanced maternal age are screened for gestational diabetes at 24 weeks with the oral glucose tolerance test. It is important to counsel women with gestational diabetes and hypertension that even if the blood pressure and the blood sugar are within the normal range six weeks post-partum, they are at increased risk of becoming hypertensive or diabetic in the next five to ten years and they have to keep an eye on it.

The reasons for the underlying trend of older mothers are complex, but decisions about the timing of childbearing may often be dictated by factors beyond the women’s control. Despite all the various evidence for an overall increase in poor outcomes, the absolute numbers experiencing complications are small and most women over 35 have a straightforward pregnancy and birth. At present, there are no effective strategies to reduce the incidence of adverse outcomes such as stillbirth.

 

 

 

 

MY BABY IS TURNING TWO

 I wasn’t always sure if I wanted to be a mom. Now that I have a daughter, I am enjoying every minute of it. There are difficult moments here and there. Some nights when we have a sick child and haven't slept the whole night and still show up at work the next day. Weekends are crazy with a toddler, by the time I am up and showered and dressed baby and myself and prepared breakfast, I feel exhausted and still have a long day ahead.  It has been an overwhelming journey for me and my husband, from trying to conceive to pregnancy loss and all the way to having a happy and healthy girl!

She has been amazing through these two years. She is growing well and is above the growth chart for her age. Her milestones have been reasonable. She atrted sitting at around eight months and started walking around 15 months. She follows instructions. She is still not very vocal and only says a few words. It may be due to the bilingual atmosphere in the household. She enjoys watching Cocomelon, stealing our phones and playing with them, running in the open and splashing in the swimming pool, or playing with the other kids and she is starting to show interest in books. Her favourite books are Peppa Pig stories and the ones with pictures of farm animals. I love it when I set up her toys and books and she goes and grabs the book and starts paging through it.

She doesn’t like me and her daddy arguing, she hates separating from mommy, she doesn’t like her legs being covered with a blanket at night and recently she has no interest in food and loves to say no to everything.

She stays with my mother while I am at work. We are in the same complex and I drop her off every morning there is no stress and I pick her up whenever work is finished. I am planning to put her in crèche next year for three days per week. I think she might go through a hard time separating from me and adjusting to the new place, but in the end, it will be worth it because she can play, make friends, be more stimulated, and learn new skills.

 

 

 

 

 

GRATITUDE

 The day-to-day life may seem boring with the same routine of waking up and going to work. The demanding workplace, and the usual problems, the traffic, back home is the cooking dinner, bathing the baby, and putting her to sleep. We might think that we are not making much progress in life, but there are times when I actually have the time to sit back and reflect on my life journey and I realize that I have come a long way. This happened the other day when I was shortlisting doctors for a medical officer post in our hospital. I realized I was in the job hunting position just a few years ago trying to write my exams and get into the specialisation program.

I have come a long way and tried to enjoy the journey and have fun. The job market for doctors has become very competitive. It is hard to believe that thousands of doctors in South Africa struggle to find a government job after they finish their community service. One of them actually made a touching video on social media to make people aware of the doctor unemployment crisis. A couple of our registrars who also finished specializing are going to be without a job until they figure something out.

As humans, our brain tends to drift towards negativity. We tend to spend a lot of time thinking about the things we don’t have and not wanting what we already have. I was listening to a program where Oprah Winfrey was talking about happiness in life. She pointed out that, during challenging times in her life, she often sits down and starts writing in her gratitude journal. And the one time she wrote seventy-two things that she is grateful about.

I know my workplace is not without problems but I am truly grateful that I have a full-time job that is meaningful and I can support my family. I know I still need more experience regarding surgical procedures, or I still want to do a fellowship but I am happy I have come all this far and specialized in the first place! And I love my job!

This is me about 20 years ago when I just started medical school, preparing for one of my exams. the photographer was my brother running around the house with his new digital camera and capturing every moment

 

THE GOLDEN HOUR

 The “Golden hour” is a term used to describe the first hour after birth. This is a crucial time when the mother and baby share their first intimate moments, initiating an emotional bond with significant health benefits. It is during this hour that the first breastfeeding usually occurs. Breastfeeding during the golden hour helps the baby stabilize its heart rate, breathing, and blood sugar. It also keeps the baby warm and helps the mother and baby develop a strong bond. The benefits of breastfeeding extend far beyond the golden hour.

I had a normal vaginal delivery with an epidural, my husband was present as a companion which meant a lot to me and added extra support. The epidural anaesthesia helped me be calm and cooperative during the second stage of labour. The baby was delivered with the assistance of a vacuum because my pushing efforts were not adequate and I’m sure my gynae did not have enough patience to wait for an hour for a primigravida to push this baby out. Everything went well. I was well and the placenta was delivered and I had a few sutures down there. The baby came out vigorous and crying! A paediatrician was also present to make sure the baby was breathing well, happy and pink, and safe to be with the mother.

Pregnancy and breastfeeding are protective against breast cancer in women. according to a report by the World Health Organization, the risk of breast cancer decreases by 6% for each year a woman breastfeeds. The reduction in cancer risk is thought to be due to changes in breast tissue that occur during lactation making the cells more resistant to mutations that lead to cancer.

Breastfeeding lowers the risk of cardiovascular disease and high blood pressure. It reduces the LDL levels which is the body’s bad cholesterol. It also reduces insulin resistance and the risk of diabetes. A study published in JAMA Internal Medicine found that women who breastfed for six months or more had a 47% lower risk of developing type 2 diabetes compared to those who did not breastfeed.

Breastfeeding is not always easy, and everyone will have a different experience. As healthcare professionals, we must provide help and support to mothers choosing to breastfeed their babies.  

 

OBSTETRIC HEAMORRHAGE

 Obstetric Haemorrhage is the leading cause of maternal morbidity and mortality worldwide. It is defined as excessive bleeding during pregnancy, childbirth, or the postpartum period. It is difficult to quantify the volume of blood loss. Still, most references suggest excessive bleeding of more than 500 ml after a vaginal delivery and more than 1000 ml after a caesarean section is significant. It also depends on how the mother has been optimized during the antenatal period to cope with bleeding. Anemia in pregnancy can on its own predispose pregnant women to postpartum haemorrhage.

We have made good progress in terms of training staff concerning the acute management of haemorrhage, maternal resuscitation, and the use of uterotonic agents. We believe that in the twenty-first century, we should not lose any woman with obstetric haemorrhage. Most of us know the tragic story of Mumtaz Mahal in 1631 who gave birth to her fourteenth child. Shah Jahan was devastated by her death and decided to build a magnificent mausoleum in her memory which is named the Taj Mahal in Agra, India. It took 22 years to be completed, and it is considered one of the seven wonders of the modern world. It is a testament to Shah Jahan's and Mumtaz Mahal's eternal love.

In the modern world, we have easy access to birth control. Most births occur in a level of health care facility. In our regional hospital, we still struggle to have access to a blood bank after 4pm, which is not ideal considering it is a mother-and-child hospital with about 1000 births per month. The other day we prioritized an elective caesarean section with a known placenta praevia to be done first thing in the morning while the senior doctors are on duty and the blood bank is available. We started the case with 2 units of blood in theatre and we also had the senior anesthetic consultant available. The fetal medicine unit had not found any ultrasound evidence of the anterior and low-lying placenta being morbidly adherent to the uterus. Intraoperatively the placenta was morbidly adherent and we had an obstetric haemorrhage and proceeded with a caesarean hysterectomy! The mom ended up in the ICU with a massive transfusion.

We try our best every day to decrease the incidence of obstetric haemorrhage and the morbidity and mortality that comes with it. A morbidly adherent placenta or a placenta accrete spectrum is on the rise due to a rise in caesarean section rate. We hope with recent advances in antenatal imaging we will be able to identify such cases and manage them appropriately in a tertiary-level hospital with experienced surgeons and, an anesthesiology team.