Write to: Dr Seng Shay Way c/o Q&A Ask ObGyn, MotherNeeds, 141 Lentor Street, Singapore 786838, or fax us at 6456-0031, or email info@motherneeds.com with "Ask ObGyn" as your subject heading.
Please limit your queries/questions to a maximum of 150 words.

Doris will select 2 letters to be answered every month. Selected letters published here win a S$12 gift certificate for purchases at our MotherNeeds online store.

Dr Seng Shay Way is a consultant obstetrician-gynaecologist at a private practice in Gleneagles Medical Centre. Dr Seng has been practicing and teaching for over 12 years.

In his spare time, Dr Seng enjoys photography and cooking.

Learn more about Dr Seng Shay Way.

Question 1:
Dear Dr Seng,

I am now 18 weeks into my pregnancy and have recently undergone the triple test screening. My test results unfortunately indicated that my baby is at a high risk of Down syndrome. Although my husband and I have no family history of genetic disorders (particularly Down syndrome), we are still very distressed by the results to say the least. I understand that one can opt to undergo amniocentesis to ascertain if it is just a false alarm, although there is also a risk of miscarriage should there be complication during the procedure. Is there any other test, that bears a lower risk of miscarry, that can be done to rule out this possibility? We are at a loss now.

Thank you.

Genevieve Ong

Answer 1:
Dear Genevieve,

I do empathize with you and your husband on this matter; I do have several patients with exactly the same problem and feel the same way as you do. It is a very difficult decision and choice to make. However a genetic history of Down's syndrome is not common and accounts for less the 5% of Down syndrome cases.

It is very important to remember what a screening test is before getting one performed. Screening tests do not look only at results from the blood test. They compare a number of different factors (including age, ethnicity, results from blood tests, etc.) and then estimate what a person's chances are of having an abnormality. These tests DO NOT diagnose a problem; they only signal that further testing should be done.

It is important to remember that the triple test is a screening test and not a diagnostic test. This test only notes that a mother is at a possible risk of carrying a baby with a genetic disorder. The triple screen test is known to have a high percentage of false positive results. The triple test can detect approximately 60 percent of the pregnancies affected by trisomy 21 (Down's syndrome), with a false-positive rate of about 5 percent.

Abnormal test results warrant additional testing for making a diagnosis. However A more conservative approach may involve performing a high definition screening ultrasound. You must also understand the limitation of doing an ultrasound, as some Down syndrome babies may not manifest any ultrasound markers. If the testing still maintains abnormal results, a more invasive procedure like amniocentesis may be performed.

Invasive testing procedures should be discussed thoroughly with your Doctor and between you and your partner.

Performing further testing allows you to confirm a diagnosis and then provides you with certain opportunities:

Pursue potential interventions that may exist (i.e. fetal surgery for spina bifida);
Begin planning for a child with special needs;
Start addressing anticipated lifestyle changes;
Identify support groups and resources;
Make a decision about carrying the child to term.

Some individuals or couples may elect not to pursue testing or additional testing for various reasons:

They are comfortable with the results no matter what the outcome is;
Because of personal, moral, or religious reasons, making a decision about carrying the child to term is not an option;
Some parents choose not to allow any testing that poses any risk of harming the developing baby.

It is important to discuss the risks and benefits of testing thoroughly with your doctor. Your doctor will help you evaluate if the benefits from the results could outweigh any risks from the procedure.

All the best,

Dr Seng Shay Way

Question 2:
Dear Dr Seng,

I am now in my last trimester of my second pregnancy. I delivered my first child with an episiotomy, and ended up with in an infection at the episiotomy site, as I was sensitive to the topical anti-inflammatory spray that was prescribed. I was finally advised to soak in a basin of salt water for several minutes over the next few days, and to alleviate the pressure by sitting on an inflated ring cushion. Given that the wound was raw, there was nothing I could do to relief the pain and itch until it was completely healed.

I would like to avoid another situation like this. I had not questioned the necessity for the episiotomy during my first delivery, but having gone through the infection, I am now questioning if such a procedure was called for. If I opt out of it, and wind up with lacerations during my next delivery, how would the healing of the lacerations compare with that of an episiotomy wound? Is an episiotomy absolutely required?

Thank you.

Melanie Chen

Answer 2:
Dear Melanie,

Episiotomy is a procedure very commonly performed on women in Singapore. Between 50 to 90% of women giving birth to their first child undergo this procedure. For decades, episiotomies have been performed on a routine basis to help speed delivery during the second stage of labour; as well as to prevent tears to the mother's vagina, especially serious tears that may stretch to the urethra or the anus. The procedure was also thought to lessen trauma to the baby and protect the mother's vaginal muscles. Tears that involve the urethra and anus can be very difficult to repair and can also lead to long term complications like faecal or urinary incontinence or strictures. However if a tear is small it can be less traumatic than an episiotomy. The call to perform an episiotomy is usually made by the obstetrician during labour. Infection to any wound is always a risk this includes lacerations and if the anal canal is involved the risk of infection is almost unavoidable.

Currently, there is disagreement in the medical field regarding the necessity of an episiotomy. Therefore it is important that you discuss this with your obstetrician and he/she would advise you on whether there is a necessity for such a procedure. However episiotomies maybe necessary under the following conditions:

Labour is too fast. If you are unable to stop pushing and slow your labour, some health care providers believe a clean cut may help prevent a serious tear.
Fetal or maternal distress. An episiotomy may speed delivery if you or your baby are experiencing complications.
Instrumental deliveries e.g. forceps or vacuum assisted deliveries.
Extremely large baby. An episiotomy may help ensure a safe delivery by widening the vaginal opening.

However if you do have an episiotomy for your next delivery you may find these tips helpful in relieving the discomfort of the wound.

Take stool softeners and eat lots of fibre to prevent constipation.
Perform Kegel exercises. Squeeze the muscles that you use to hold in urine for five minutes, 10 times a day, during your regular activities.
Ensure that the perineum is clean at all times. After using the toilet, take a mug of lukewarm water pour it slowly between your legs while sitting on the toilet. Urinating while bathing will help reduce the pain. After this dry gently with a soft towel.
You can bath as and when you feel like. Use water with or without antiseptic or salt will do just as well.
Replace maternity pads as often as you need.
Use disposable panties or comfortable cotton panties with a high waist.
While sitting down make sure you sit on something soft.
You can try using gel pads; these can be used easily like a panty liner. These are specially made to reduce the discomfort and pain most women feel after delivering.
Try to move around as much as you can. It may be difficult and painful at first, but this will increase blood circulation, decrease swelling and speed up the healing process.
Take medications like, a non-steroidal anti-inflammatory, to help relieve pain.

Your stitches do not need to be removed since your body will absorb them. Normal activities, such as light office work or housecleaning, can be resumed within a week after giving birth. Tampon use, intercourse, or any activity that might rupture the stitches, can be resumed in about a six weeks.

Is there anything you can do to avoid an episiotomy? An episiotomy cannot always be avoided. Your obstetrician will decide if you should have the procedure based on the conditions of your labour. There are, however, activities you can do to strengthen the perineum, and these may lower your chances of undergoing the procedure. Practice Kegel exercises during your pregnancy; perform prenatal perineal massage (massaging the perineum for four to six weeks before birth makes it stronger).

All the best,

Dr Seng Shay Way

*We regret that only 2 letters will be answered by Dr Seng every month.

Neither the information nor any opinion expressed constitutes a medical consultation or prescription or treatment of a medical or health condition. This column is prepared for general viewing and is published for general information only. It does not have regard to the specific medical or health condition, and the particular needs of any specific person who may receive this information. Persons needing medical attention should seek advice from his/her healthcare practitioner regarding the appropriateness of information discussed or recommended in this column. Should you have a pressing question or issue concerning your medical or health condition, please consult your healthcare practitioner.

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