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Gynae/Obs

Location: OPD: Old building Chamber 16

Birthing Center: Block C Level 2

Maternity Ward: Block C Level 3

The Maternity Unit of JDWNRH was up graded to a full-fledged Department of Obstetrics & Gynecology in 2005. It handles the highest number of institutional births in Bhutan. The current total births per year are about 2300. It caters to the local population of Thimphu Dzongkhag and receives all referral obstetric and gynecological cases from all over Bhutan. Since the Department is newly formed it will take sometime for many proposed services to be functional. Following is the futuristic departmental structure.
Staff Member
Name of the Specialists Qualifications Designation
Dr Phurb Dorji MBBS (Uni. Dhaka), FCPS (Obs & Gyne)
Trained in Maternal Fetal Medicine & Obs Gyne Ultrasound (New Zealand)
Technical Advisor: Perinatal Medicine Project
Consultant
Dr Ugyen Tshomo MBBS (India), MD (Italy)
Trained in Colposcopy & LEEP
Technical Advisor: Pap Smear Program
Consultant
Indoor Service Unit
  • Delivery Unit open 24 hours and serviced round the clock
  • Inpatient Unit Both Obs and Gyne patients. All kinds of cases are cared for.
  • Routine Operations: Every Wednesday and Friday. Emergency operations are done round the clock.
  • Types of surgery done here:
    Most of the gynecological operations are done here. Exception for all for gynecological cancer surgeries, which are not done here but are being referred to Kolkata, India
  • Caesarean section
    Here the babies are delivered through the abdomen by making an incision on the mother’s lower abdomen, when the baby cannot be delivered from below in the normal way for fetal or maternal reason.Tubal ligation services
    Tubal recanalisation
    Loop Eletro- surgical Excision Procedure (LEEP)
    Laparoscopic Gyne surgeries ( at present mainly for diagnostic use)
  • Laparoscopic surgery
    Out-patient Service
    Reproductive Health services
    Antenatal and Postnatal care
    Family Planning services
    All temporary methods of family planning
    Vasectomies (need appointment).
    Tubal ligation is offered as part of indoor service
    Cervical cancer screening ( Paps smear)
    Colposcopy
    General Obs and Gyne service
Laproscopic Surgery Graph Doppler Studies
  • Timing:
    Mondays, Tuesdays, Thursdays & Saturdays.
    Patients usually need to register one day before for consultation due to the large number of patients seen. Referred patients are given priority as they have already seen by a Medical Officer or a Health Worker.
  • Place:
    Chamber 15 & RHU
Perinatal Medicine service
This is a new service being introduced from 2005. We are mainly concerned with screening in the high risk group of pregnant women for fetal problems, counseling and continuation of care to those with fetal problems or maternal problems during pregnancy and delivery.Dr Phurb Dorji is the Consultant and Sister Pema Lham is the Nusre Incharge of this service. Advance appointments are necessary with her for any of the service.

Perinatal scan:
Timings: Tuesday and Thursday Afternoons 12 – 3pm.
Type of Scan offered: As screening for fetal congenital abnormality

Nuchal Translucency ( 11 – < 14 weeks)

This scan looks at the Nuchal skin fold thickness between 11 weeks to 13 weeks 6 days. Thickened Nuchal skin fold is a risk factor for the baby to have chromosomal or structural problems and it needs further investigation.
Nuchal Fold
Anatomy Scans ( 18 – 21 weeks)
Scans are done to see whether the fetus has any structural abnormalities. If any pregnant women need any ultrasound, then this is the most important scan. Both dating and anatomy can be seen from this single scan.

Fetus with cleft lip and palate
Basic Fetal ECHO ( 23 weeks)
The commonest structural problem in the fetus is usually found in the heart. Heart has complex developmental process where some steps can go wrong. We look at the structure of fetal heart for defects.
Ventricular septal defect (right) & Normal heart (left)
Other perinatal scans
As screening for high risk patients
Uterine Artery Doppler ( 24 weeks)

Follow up of high risk groups
Biophysical Profile (BPP)
Fetal Growth
Umbilical Doppler
Fetal Vascular Doppler studies

Perinatal Consultation/ Counseling:
  • Monozygotic twin pregnancy
    All pregnancies with ongoing problem (in mother or fetus) are seen on Thursday morning 9 am – 12 noon. For example pregnant mothers with heart disease, high blood pressure and fetus with structural problems are seen in this clinic. This group also includes pre-pregnancy counseling for potential parents, who has family history of problems or with past bad obstetric history.
Operation Theatre Monozygotic twins
Gyne Nuchal Normal Heartbeat
  • Amniocentesis / Chorionic Villous Sampling:
    These are invasive diagnostic tests that are done in pregnancies with suspected fetal chromosomal problems. At present we donot have laboratory back up services here and these tests will be done in near future when a regional referral laboratory will be identified.

For all appointments related to Perinatal Medicine, advanced bookings are necessary for effective planning of care and service delivery.

Contact: Sister Pema Lham, phone 322496 ext…256)

Colposcopy Unit
  • This service was introduced from 2000 as a back up to pap smear program. We have two gynecologists (Dr Ugyen Tshomo & Dr Duptho Wangmo) trained in Colposcopy. Colposcopy is required for women with abnormal Pap smear reports.

Timing: Tuesdays and Thursdays.
Appointments must be made before hand for Colposcopy.

General Patient Information:
  • Preparation at home for admission into Hospital
    All patients should have a shower at home and then put on clean clothes while you come to hospital.
    What things to bring, when you are coming for admission to the hospital
  • Bring clean, comfortable day clothes, nightwear, footwear and toiletries. As storage space is limited please do not bring unnecessary clothing. You need to bring your own plate and cups. You can also bring clean sheets, blankets and quilts. Please make arrangements with a family member or friend to wash your personal clothes.

You must also bring all your relevant old medical documents for which you have received treatment in this hospital or in any other hospital.

  • Admission Procedure
    All patients before admission need to complete an undertaking about the rules and regulations of the ward and the hospital. If you are literate you can read the sheet and sign and return to the nurse on duty. If you cannot read, it will read to you by some one on duty and you have to print you or your guardian’s thumb impression.
    Admissions usually take place in the afternoon, unless it is an emergency.Food not allowed in Labour Room.
    No food and drinks are allowed in labour room. We allow only fluids in cups for the patient only.
  • Visitors
    Generally the main support person may stay with the patient at all times except in the morning when the doctor does ward round. Visiting hours in Maternity ward are from 6.00am – 8.00 am and 5.00 pm to 8.00 pm. For further details, please check with the Maty staff on duty.
  • Visitor Restriction to Labour Room
    Due to lack of space, we donot have separate labour rooms. We have five labour tables separated by curtains in the single labour room. At times all the tables are occupied. We donot allow more than one attendant in the labor for each patient. The support person can be the male partner or a female relative. We can allow only one support person in the labour room because it will cause increased risk of infection and also to ensure some privacy to other laboring women.
  • Hospital Fees
    Bhutanese citizens are provided with free health care services. Exception applies to Cabins. All cabins need to be booked and pay in advance with the Hospital Administration Officer.
  • Cash and Valuables
    Please do not bring valuables (including valuable items of clothing) into the hospital with you unless absolutely necessary. The hospital does not accept responsibility for lost of cash, ornaments, watches or other valuables.
  • Smoking and Alcohol
    Smoking is not permitted on the hospital campus. Alcoholic beverages or illegal substances must not be brought into the hospital buildings or grounds.
  • Telephones
    During day time there is a public telephone booth outside the Emergency Department easily accessible from the Maternity Ward across the parking area. In emergency cases and during the night, the phone in the duty room may be requested for making an urgent call.
  • Ward round hours
    Everyday a consultant does the ward round from 9 am to 12 noon. During this time all attendants are requested to wait outside the ward.
  • Blood Donors
    All patients going for any operation requires blood. You need to bring at least two donors to the blood bank and get them screened for blood donation in advance, in case if you or your patient needs blood. When there is an emergency, blood is given from the blood bank if there similar group is available in stock, but you must replace all units used by you before you are discharged from the hospital.
Concerns of the Obs & Gyne Department
  • Cancer of Cervix

CANCER PATIENTS REFERRED TO CALCUTTA
1995 – 2003 (Total Number 346)

Stage of Disease Actual No Percentage
I 29 8.10%
II 87 24.40%
III 92 25.80% 64.50%
IV 38 38.70%
Informations

I.
Cervical cancer is one of the leading causes of death of women in Bhutan. It is easily preventable by doing a simple Pap smear of all women after sexual exposure between the ages of 20 to 65. Screening can detect pre-cancerous stages and there is effective treatment before it evolves into frank cancer. Without an effective screening system, so far about 65% of diagnosed cervical cancer is in stage III or IV which are very late for any curative treatment.II. Annual Health Conference 2000 has endorsed expansion of cervical cancer screening in three districts as pilot study. This is going on in Paro, Mongar and Trongsa.
III. Patients with early stage of cancer live longer with proper treatment.

Symptoms of frank cervical cancer are:
i. Abnormal vaginal bleeding ( intermenstrual or postcoital or postmenopausal)
ii. Foul smelling vaginal discharge
iii. Lower abdominal pain.

Any women with any of the above symptoms alone or in combination should come to the nearest health facility for check up.

Most common cancer diagnosed in Bhutanese women. It is caused by Human Papilloma virus (HPV) which is sexually transmitted. Our women get this cancer mainly because they do not have Pap smear, which has helped bring down cervical cancer in the developed countries.
Pap smear is a simple test done on women who are or were sexually active (age range 20-60 years) to see who is at risk of getting cervical cancer. If two tests are negative, repeat every 3 years. If abnormal, you must undergo colposcopy to confirm. If you are likely to get cancer, treatment is offered to remove that part of cervix which might become cancer. At present, we offer 4 types of treatment in JDWNRH.

1. Cryptotherapy
Here, we freeze cervix with a gas (carbon dioxide). No need of electricity or anesthesia. It can be done as outpatient method, and also by non-physicians like ANMs

2. LEEP/LLTEZ
Here, we cut the cervix with a wire loop through which electricity is passed. The loop cuts and coagulates at the same time. Any bleeding present is controlled with cautery and application of Monsel’s solution. The vagina is tightly packed and the pack is removed the next day. Patient may go home after a few hours if no bleeding and come back next day for pack removal. This is done in OT at present under short GA (general anesthesia). It can be done under LA (local anesthesia) also as an outpatient method. Electricity is needed. It must be done by doctors who have undergone special training in it.

LEEP Equipments
The other 2 methods, conization (cutting cervix with cold knife) and hysterectomy (removal of uterus) are rarely used nowadays. They are invasive, costly and complications occur more with these procedures.

Leep Equipments
Maternal Death
  • From 2001, Annual Health Conference (ANC) endorsed active investigation of all maternal deaths in the country. A Technical Committee has been formed and investigation forms have been developed and distributed. The main aim is to reduce preventable maternal deaths in Bhutan.Number of maternal deaths reviewed
Year Number of maternal deaths investigated
2001 14
2002 21
2003 21
  • The keys messages :
  • 1. Every year an estimated 255 maternal deaths/100,000 live births occur in Bhutan.
    2. All pregnant women must come for antenatal care. Everyone must know the danger signs of pregnancy
  • i. Vaginal bleeding
    ii. Unconscious or convulsions/fits
    iii. Severe headaches/ blurred vision
    iv. High fever
    v. Labour prolonged for more than 12 hours
    vi. Any fetal part coming out other than the fetal head.3. Every relative or friend must encourage and assist women during pregnancy and delivery to seek timely care in a health center to prevent a maternal death.
Infertility
  • As seen from the OPD data, we have a significant number of patients coming for consultation for either primary or secondary infertility problems. Infertility investigation and counseling is a long procedure for each patient. It is not possible to manage them along with general patients in a busy clinic.Therefore, we feel that we should train one gynecologist in Reproductive Endocrinology & Infertility management sub-specialty and provide a separate Infertility Clinic, where basic minimum services like postcoital test and Intrauterine Insemination can be offered, at least at this national referral hospital.

Important message for the young people to prevent such a problem in future is to keep away from sexually transmitted disease and to have timely treatment if you get one. Condom use can prevent STD/HIV.

Human Resource Constraints
  • The patient load is increasing every year. We have acute shortage of nurses and we couldn’t yet separate Delivery Unit from the general ward. For smooth functioning, we need more nurses, one more gynecologist and one GDMO. This will ensure quality of service.

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