Tips and tricks in rural gynecology & obstetrics 97 2003

DR.SHANTANU ABHYANKAR

Dr. Shantanu Abhyankar

• A qualified Homeopath who does not believe in homeopathy.

• Later on passed MBBS and MD (Ob & Gy) from BJ Medical College.

• Practicing in Wai since 1997



• Member Rural Member Rural Obstetrics committee Obstetrics committee and Safe Motherhood and Safe Motherhood Committee; FOGSICommittee; FOGSI

• A well known speaker A well known speaker • Contributed chapters Contributed chapters

to books on rural to books on rural obstetrics and medical obstetrics and medical disorders in pregnancydisorders in pregnancy



• On the editorial board of the IMA journal.

• Edited the souvenir for MASTACON 2005

• Freelancing on issues related to public health


Dr. Shantanu AbhyankarDr. Shantanu Abhyankar

• Known for innovations like – A bangle breaker

– An obstetric petticoat

– Tubectomy using a Laryngoscope and Band Applicator

– A Urethral Hoist for Stress Incontinance etc



• The last two presented

at FIGO 2006,

Kuala Lumpur

Malaysia.



WAS AWARDED THE

DR.ANANDIBAI JOSHI GAURAV PURASKAR

FOR CONTRIBUTION TO

WOMEN’S HEALTH

BY THE

GOVERNMENT OF MAHARASHTRA

TIPS AND TRICKS IN RURAL GYNECOLOGY & OBSTETRICS


M.D.



RATIONAL MEDICINE

• ILLITERACY• POVERTY• TRADITIONAL

PRACTICES• LOW SOCIAL STATUS

OF WOMEN• POLITICS• CASTE• DEARTH OF MEDICAL

INFRASTRUCTURE• AWARENESS OF CPA


ANTE-NATAL CLASSESFOR PATIENTS.

(ANKUR INITIATIVE.)A BOON IN RURAL PRACTICE,

A ROAD LESS TAKEN, A PATH UNTRODDEN.


HOW DOES ONE FACE THIS CHALLENGE?

• BUILDS CONFIDENCE• IMPROOVES

COMPLIANCE• WORKS AS

EXCELLENT, CLEAN PUBLICITY STRATEGY

• THE PLACE IS ALL SPRUCED UP

• EDUCATIONAL MATERIAL

• PATIENTS POSE FRANK QUESTIONS


HOW DOES ONE GO ABOUT THE TASK?

• INVITATIONS BY POST• COVERED TERRACE IS THE VENUE• LECTURES, DEMOS, SLIDES, VIDEOS• WIDENING AUDIENCE; MALE

PARTICIPATION IS VERY IMPORTANT.


COURSE CONTENT

• ANATOMY & PHYSIOLOGY

• MINOR AILMENTS OF PREGNANCY

• DIET EXHIBITION, EXERSICE, TRAVEL TIPS, REST, SEX.


COURSE CONTENT

• LAB & OTHER TESTS

• ‘LESS-PAIN’ LABOUR.


COURSE CONTENT

• BFHI, NEONATAL CARE.

• SPACING METHODS, ‘MORNING-AFTER’ PILLS,

• ‘DO-IT-YOURSELF’ ABORTION PILLS

• FA & RUBELLA PROPHYLAXIS FOR THE NEXT KID IN LINE


LET PARAMEDICS SPEAK…

• MORE INFORMAL

• MORE NATIVE TONGUE

• ‘DOCTOR’S TRUSTED AIDS’

• THEY TRY AND UPDATE

• COMMITTING A CERTAIN LEVEL OF CARE


BENEFITS FOR THE DOCTOR

• DOES AWAY WITH THOSE ‘SAME OLD ADVICE’ SESSIONS

• TIME TO CONCENTRATE ON CLINICAL ASPECTS

• SPEEDS UP OPD• PATIENTS BECOME

WISER, MINOR COMPLAINTS ARE NOT TOLD.


BENEFITS FOR THE DOCTOR

• EXPLAINATION OF UNTOWARD OUTCOME IS EASIER

• EASIER TO SEEK A ‘TRULY’ INFORMED CONSENT


ONE WORD THAT COUNTS…RAPPORT


MERE HATHON ME NAU NAU CHUDIYAN HAI


Bangles to keep track of DFMC

10 loose fitting plastic bangles.… to be moved from one wrist to another.… to report if she fails to transfer all by the end of the day.

Because bed rest is impracticalBecause bangles are culturally loaded with

good omen


MERE HATHON ME NAU NAU CHUDIYAN HAI


IDEAL METHOD….

• BANGLES CAN BECOME A CAUSE OF DEATH

• SAFE AND ATRAUMATIC FOR THE PATIENT AND THE HEALTH CARE PROVIDER.


ALL THAT IT NEEDS IS…

• RINGS USED FOR HAND EMBROIDERY

• THICK SEE THROUGH PLASTIC BAG

• SIX INCH METAL SCALE

• WOODEN ROD (ROLLING PIN!!)


DO IT YOURSELF…


THIS IS THE WAY TO USE IT


OBSTESTRICS IS BLOODY BUSINESS

• SOILING OF TABLE AND FLOOR IS COMMON

• SPILLS AND SPURTS OF HIGH RISK BODY FLUIDS IS COMMON

• USE OF UNIVERSAL PRECAUTIONS IS PRACTICALLY UNKNOWN


PROBLEMS IN CURRENT PRACTICE…

• IMPERMIABLE COVERINGS ON THE TABLE PROTECT THE TABLE BUT CAUSE BLOOD TO SPILL FROM ALL THE FOUR SIDES.

• HEADLOW LEADS TO SOILING OF PATIENTS’S BLOUSE AND HAIR

• PATIENTS KEEP WRITHING DUE TO PAIN AND DISCHARGES DON’T DROP IN THE BUCKET UNDER THE LITHOTOMY SECTION


THE NEW PETTICOAT…• THE LONG

DISCHARGE DIRECTOR CARRIES EVERYTHING STRAIGHT INTO THE DRUM.

• FLOW IS ALONG THE DISCHARGE DIRECTOR AND NOTHING DROPS AND SPLASHES FROM A HEIGHT.


THE NEW PETTICOAT

• NOTHING GOES BEYOND THE WAIST BECAUSE OF THE STRAP

• IS STRAPPED TO THE PATIENT.SO MOVES WITH THE PATIENT.


TUCK IN A SEE THROUGH PLASIC SHEET AND

WORK WITH YOUR HANDS UNDER IT

OBSTESTRICS IS BLOODY BUSINESS


• THERE ISN’T ANY!!!

BLOOD; I MEAN.

AVAILABILITY IS THE PRIME PROBLEM.


THE ANSWER IS STORAGE UNITS.

• IDEAL FOR REMOTE AND RURAL AREAS.• CAN CERTAINLY BE SET UP.

ST O RAGE C ENT ER ST O RAGE C ENT ER

BLO O D BANK

ST O RAGE C ENT ER ST O RAGE C ENT ER

BLO O D BANK

RBT C


PROBLEM(S) VIS A VISBLOOD TRANSFUSION IN

RURAL SET-UP


• IN MAHARASHTRA

– 419 TALUKAS

• 274 BLOOD BANKS

– ONLY 17 BLOOD BANKS AT TALUKA PLACES

– 257 IN CITIES!!


THE ANSWER IS APPROPRIATE USE OF BLOOD.

• ‘SAFE BLOOD STARTS WITH ME’

• EARLY DIAGNOSIS & TREATMENT OF ANEMIA– Hb @ FIRST VISIT &

NEAR TERM– ANTIHELEMENTHICS

FOR ALL.– CHEMOPROPHYLAXIS

FOR MALARIA.– INJ.Fe


BATTLING BLOOD LOSS SANS BLOOD.BATTLING BLOOD LOSS SANS BLOOD.

• STOP ANTI COAGULANTS BEFORE SURGERY.STOP ANTI COAGULANTS BEFORE SURGERY.

• CONSIDER OTHER REPLACEMENT FLUIDS CONSIDER OTHER REPLACEMENT FLUIDS FOR ACUTE LOSS. THEY MAY BE AS FOR ACUTE LOSS. THEY MAY BE AS EFFECTIVE, SAFER & CHEAPER.EFFECTIVE, SAFER & CHEAPER.

• GOOD ANAESTHESIA.GOOD ANAESTHESIA.

• GOOD SURGICAL TECHNIQUE.GOOD SURGICAL TECHNIQUE.


BATTLING BLOOD LOSS SANS BLOOD.

• RESTORE AND MAINTAIN ADEQUATE BLOOD RESTORE AND MAINTAIN ADEQUATE BLOOD VOLUME. STARCH SOLUTIONS PREFFERED.VOLUME. STARCH SOLUTIONS PREFFERED.

• MAINTAIN SUFFICIENT OXYGEN CARRYING MAINTAIN SUFFICIENT OXYGEN CARRYING CAPACITY. KEEP HER INTUBATED, IF NEED BE, CAPACITY. KEEP HER INTUBATED, IF NEED BE, TILL BLOOD IS AVAILABLE.TILL BLOOD IS AVAILABLE.

• SECURE HEAMOSTASIS. AT TIMES OPERATING SECURE HEAMOSTASIS. AT TIMES OPERATING WITHOUT BLOOD IS SAFER THAN AWAITING WITHOUT BLOOD IS SAFER THAN AWAITING BLOOD.BLOOD.


SOME PRACTICAL TIPS• CUT A BOTTLE OF NS AT IT’S BASE & KEEP JUST CUT A BOTTLE OF NS AT IT’S BASE & KEEP JUST

100ml OF NS100ml OF NS

• ADD 1000iu INJ HEPARINADD 1000iu INJ HEPARIN

• POUR SALVAGED BLOOD THROUGH 6 LAYERED POUR SALVAGED BLOOD THROUGH 6 LAYERED GAUZEGAUZE

• MIX WELLMIX WELL

• INFUSEINFUSE


THINK OF AUTOLOUGUS DONATION/TRANSFUSION

• FORESEEABLE NEED OF TRANSFUSION.

• FORESEEABLE SCARCITY.

• RARE BLOOD GROUPS.• IRREGULAR

ANTIBODIES.• MULTIPLE PREVIOUS

TRANSFUSIONS.


THINK OF AUTOLOUGUS DONATION / TRANSFUSION

• ANY WOMEN WITH NO OTHER ANY WOMEN WITH NO OTHER CONTRAINDICATION FOR CONTRAINDICATION FOR DONATION & Hb OF 10+ & PCV DONATION & Hb OF 10+ & PCV 35%+ MAY DONATE BLOOD35%+ MAY DONATE BLOOD


THINK OF AUTOLOUGUS DONATION / TRANSFUSION

• ADVANTAGES– NO MISMATCH

– NO TTD

– NO GRAFT V/S HOST REACTION

– MEDICO LEGAL SAFETY

• RISKS– CLERICAL ERRORS

– SENSITIVITY TO STABILISERS

– CONTAMINATION


USE THE LEAP FROG TECHNIQUE• DRAW A BAG

• 7 DAYS LATER…TRANSFUSE THE STORED BAG AND DRAW TWO

• 7 DAYS LATER TRANSFUSE ONE OF THE STORED BAG AND DRAW TWO, LEAVING THREE IN STORE.


REDEFINING HIGH RISK

• DISTANCE FROM THE BLOOD BANK,

• DISTANCE FROM THE ANAESTHETIST,

• DISTANCE FROM OTHER EXPERT HELP,

(IN TERMS OF DURATION OF TRAVEL)


IF ALL THESE ARE FARTHER THAN AN HOURS TRAVEL…

NOT JUST A FEW

CASES BUT YOUR

PRACTICE ITSELF IS

HIGH RISK.


RCOG GUIDELINES• USE STARCH SOLUTIONS TO PRE-LOAD

THE PATIENT PRIOR TO SPINAL ANAESTHESIA.

• ADMINISTER O2 ON MASK THROUGHOUT THE SURGERY, SINCE THE SpO2

INVARIABLY DROPS WITH SEDATION (PENTAZOCINE).

• A CONTINUOUS TRICKLE CAN KILL THE PATIENT.

• NEVER FORGET THE FOURTH STAGE OF LABOUR.


ON ADMISSION…

INSIST ON THE PRESENCE OF A RESPONSIBLE MALE RELATIVE.

ALWAYS LOOK FOR ICTERUS.

DRAW BLOOD THROUGH A WIDE BORE SCALP/CANULA. KEEP IT IN SITU FOR I/V ACCESS.

KEEP 5cc IN A LABELED PLAIN BULB. THIS WILL BE USEFUL FOR A CROSS MATCH IF NEEDED. WATCH THIS FOR CLOTTING.

GET Hb DONE REGARDLESS OF PREVIOUS VALUE

RCOG GUIDELINES FOR ALL PTNs IN LABOUR


INSIST ON A BT, CT, PC, AND PT(IF POSSIBLE EVEN APTT).

OBSERVE THE CLOT VERY KEENLY AND FREQUENTLY.

IF IT FORMS AND DISSOLVES, WARN OF MORTALITY,

EVACUATE FIRST THE UTERUS AND

THEN THE PATIENT.

RCOG GUIDELINES

IN HIGH RISK PATIENTS…


RCOG Protocol for CS for placenta previa


INTRA–OP

• EXTERIORISE THE UTERUS

• AORTIC PRESSURE


INTRA–OP

• POSTERIOR PLACENTA– BLEEDING BED

• HOT MOPS & FIGURE OF EIGHT SUTURES


INTRA–OP

• ANTERIOR PLACENTA – BLEEDING ‘ROOF’

• CIRCUMFERNTIAL SUTURES ALONG THE EDGES

• IF NOT CONTROLLED…


INTRA–OP

• PROGRESSIVE DEVASCULARISATION– OVARIAN VESSELS

– UTERINES• CHECK BLEEDING…SOS

FROG LEG POSITION

– INTERNAL ILIAC LIGATION

• CHECK BLEEDING


INTRA–OP

• IF BLEEDING CONTINUES…

• OBSTETRIC HYSTERECTOMY– SUBTOTAL MAY NOT SUFFICE– REMAIN INSIDE THE UTERINES

• IF ONLY PARTIAL CONTROL…


INTRA–OP

• PACKING– UTERUS– PELVIS; POST HYSTERECTOMY

• BALLOON – S.B. TUBE– RUSCH– CONDOM


INTRA–OP

• B-LYNCH SUTURE

• HAYMAN SUTURE– VERTICAL AND

HORIZONTAL CERVICO-ISTHUMIC SUTURES

• CHO MULTIPLE SQUARE SUTURES– HAVE DIAGRAMS IN

PPH KITS


INTRA–OP

• B-LYNCH SUTURE

• HAYMAN SUTURE– VERTICAL AND

HORIZONTAL CERVICO-ISTHUMIC SUTURES

• CHO MULTIPLE SQUARE SUTURES– HAVE DIAGRAMS IN

PPH KITS


• YOUR INSTRUMENT SET FOR CAESARIAN MUST CONTAIN AN EXTRA GOWN, KOCHER’S CLAMPS AND MIXTERS.

RCOG GUIDELINES BE TUNED TO IIL/OBST. HYST.


Tight rope walk

• Poor paramedical support Poor paramedical support

• No health insuranceNo health insurance

• Shoestring budgets and packagesShoestring budgets and packages

• Monsoon economyMonsoon economy

– Farmer suicidesFarmer suicides


Fundal pressure

• Ventouse and Forceps… only after you have tried Biceps and Triceps

• WHO says…– Level C recommendation– Proper pressure, direction and timing


NT, sos biochemical markers

• Consider maternal age (30%)

• Do an NT scan at 11 to 13+6 weeks ( 75%)

• If more than 3mm consider – Nasal bone (90%)– Biochemical markers (95%)


RCOG guidelines for Thal screening

• High RBC count

• Low indices• RBC > 4.5

• MCV < 72

• MCH < 22


Necessity is the mother of invention

• Economy

• Unavailability

• Mosquitonet as mesh– Dr. Tongaonkar– Dr. Bramha Reddy

• Reusing disposables• Water for glycine• Air for CO2

• Kangaroo care

• Surgeons as anaesthetists• Vg hyst under local!!!• UBDBT



TO ERR IS HUMAN

TO FORGIVE IS

ABHYANKAR’S URETHRAL HOIST

USE OF VAGINAL BALL BEARING:

AN EFFECTIVE AND COST-EFFECTIVE METHOD TO TREAT POST PARTUM SUI AND

EVEN THAT EMBARRASING PASSAGE OF GAS PER VAGINUM.


Introduction

• SUI, A COMMON CLINICAL PROBLEM.

• AN EPIDEMIC WAITING TO HAPPEN.

• DOCTORS ARE RELLUCTANT TO OFFER TREATMENT

• PATIENTS HARDLY SEEK TREATMENT..

GRANDGRAND


Plevnik’s vaginal cones• 20, 32.5, 45, 60 and 75gm.


NECESSITY IS THE MOTHER OF INVENTION

• ON THE NET– EXORBITANT COST

• SO BALL BEARINGS– THOSE USED FOR TRUCKS AND TRACTORS.

– CHEAP

– 20 gm TO 100 gm WEIGHT.

– READILY STERILISED.

– THEY DISCOURAGE ‘VALSALVA’ & ENCOURAGE ‘KEGEL’

– BUT

– TOO SMALL AND TOO LARGE


HOW TO GO ABOUT IT…

• CONFIRM SUI, ETC:• BE SURE THAT VAGINAL

WEIGHTS WILL HELP.• GIVE DETAILED

EXPLANATION.• START WITH THE ‘PASSIVE

WEIGHT’.• ENDOWS CONFIDENCE.


FINER POINTS

• 20 gm INCREMENT / DAY.• 15 TO 20 min OF WALKING

WITH WEIGHTS IN SITU. • NO SQUATTING OR SITTING

TO BEGIN WITH.• LATER PERMIT SITTING

AND EVEN SQUATTING.• THERAPY AT HOME GOOD

ENOUGH.


Vaginal dumbbells• 80, 100, 120, 140 & 160gm• Some how found to be

better and faster than ball bearings.

• Thread adds to the security.• May be the

bulbocavernosus too is brought into play.

• Many reported better sexual pleasure following dumbbell use.


• VAGINAL WEIGHTS IS A CHEAP, EFFECTIVE, SAFE, VAGINAL WEIGHTS IS A CHEAP, EFFECTIVE, SAFE, NON-INVASIVE THERAPY AIDING PELVIC FLOOR NON-INVASIVE THERAPY AIDING PELVIC FLOOR REHABILITATION.REHABILITATION.

• THE ‘FLICKS’ HAVE TO BE PRACTICED THE ‘FLICKS’ HAVE TO BE PRACTICED SEPARATELYSEPARATELY

• BETTER COMPLIANCE IF YOU MENTION THAT BETTER COMPLIANCE IF YOU MENTION THAT THIS ENHANCES SEXUAL PLEASURE!!THIS ENHANCES SEXUAL PLEASURE!!


PLEASE, PLEASE,

PLEASE, PLEASEn

TALK SEX!!!


• ALL PEOPLE HAVE SOME ALL PEOPLE HAVE SOME QUESTION OR THE OTHER QUESTION OR THE OTHER ABOUT SEX, SOME TIME OR THE ABOUT SEX, SOME TIME OR THE OTHER IN THEIR LIFE!!OTHER IN THEIR LIFE!!

• SO THE POTENTIAL CLIENTALE SO THE POTENTIAL CLIENTALE IS 100% OF THE POPULATION. IS 100% OF THE POPULATION.

• SEXOLOGY PRACTICE IS VERY SEXOLOGY PRACTICE IS VERY REWARDING, EVEN REWARDING, EVEN ECONOMICALLY.ECONOMICALLY.


FOOLS STEP IN WHERE ANGLES

FEAR TO TREAD.


• A GYNECOLOGIST’S CONSULTING ROOM IS PERHAPS THE BEST PLACE TO START.


LET YOUR ABILITIES BE KNOWN.

‘A FRANK TALK ABOUT YOUR SEXUAL PROBLEMS IS WELCOME!

MAY BE THE DOCTOR CAN HELP.’


HAVE SOME BOOKS FOR SALE…• HELP DEFINE THE

BASICS, SAVE A LOT OF TIME.

• YOU CAN SAFELY ASSUME SOME BACKGROUND KNOWLEDGE.

• REDUCE EMBARRASSMENT TO A GREAT EXTENT FOR BOTH THE PARTIES.

• PROVIDES ‘STANDARD’ VOCABULARY


COUPLES ARE EXPECTED TO PROOVE THEIR FERTILITY WITHIN A YEAR OF

MARRIAGE.

WOMEN WILL NEED SPECIAL PERMISSION FOR REGULAR

FOLLICULOGRAPHY.

BBT; A FORGOTTEN METHOD THAT NEEDS TO BE REVIVED






SEMEN ANALYSIS• MEN WILL NOT VISIT• WILL NOT SUBMIT TO ANY

EXAMINATION• MAY NOT AGREE TO SEMEN CHECK• MAY FALL PREY TO DEMAND

IMPOTENCE• NO PROPER SEMEN COLLECTION

ROOMS• USE TADALIS

TUBECTOMY USING LARYNGOSCOPE AS AN ILLUMINATOR

(TULI) &

THE ABHYANKAR’S BAND APPLICATOR

(ABA)

(TULI-ABA)



TUBECTOMY…

• FORMS THE MAINSTAY OF CONTRACEPTIVE SERVICES IN INDIA.

• IT IS PREFFERED OVER VASECTOMY FOR SOCIO-POLITICAL REASONS


GOVERNMENT RUN PRIMARY HEALTH CENTERS…

• SHOULDER A MAJOR BULK OF ALL TUBECTOMIES DONE

• PERFORMANCE OF THE MEDICAL AS WELL AS THE PARAMEDIC STAFF IS JUDGED ALMOST EXCLUSIVELY DEPENDING ON THEIR ACHIEVING PRESET TARGETS



GOVERNMENT RUN PRIMARY HEALTH CENTERS…

• SHOULDER A MAJOR BULK OF ALL TUBECTOMIES DONE

• PERFORMANCE OF THE MEDICAL AS WELL AS THE PARAMEDIC STAFF IS JUDGED ALMOST EXCLUSIVELY DEPENDING ON THEIR ACHIEVING PRESET TARGETS



TECHNICAL PROBLEMS…

• NO SHADOWLESS LAMPS.

• FREQUENT POWER FAILURES

• TABLES OFTEN PROPPED UP WITH BRICKS TO ACHIEVE HEAD LOW POSITION.



TECHNICAL PROBLEMS…

• NO SHADOWLESS LAMPS.

• FREQUENT POWER FAILURES

• TABLES OFTEN PROPPED UP WITH BRICKS TO ACHIEVE HEAD LOW POSITION.



PROBLEMS GALORE…

• NO GA (RELAXATION)

• THE PROCEDURE BETTER BE QUICK

• ASSISTANTS OFTEN ARE ILL-TRAINED.

• FOR 78% DOCTORS TUBECTOMY IS THE ONLY ABDOMINAL SURGERY THAT THEY KNOW OF.




PROBLEMS GALORE…







PROBLEMS GALORE…







COMPLICATIONS…• ACCIDENTAL OPENING OF THE BLADDER

• AVULSION OF THE TUBE

• RARELY– INFECTION

– BOWEL INJURY


ESPECIALY AT THE PHC LEVEL…

• MORE & MORE COUPLES ARE ACCEPTING THE TWO CHILD NORM.

• REVERSIBILITY IS AN ISSUE WORTH A THOUGHT.


THE SOLUTION…

• TUBECTOMY USING LARYNGOSCOPE AS AN ILLUMINATOR &


‘OPEN BAND APPLICATION INSTEAD OF MPM’

• A MINI VERSION OF THE LAPAROSCOPIC BAND APPLICATOR FOR BANDING THE TUBES.



ADVANTAGES

• THE LARYNGOSCOPE PROVIDES RETRACTION, ILLUMINATION AND GOOD PNEUMOPERITONIUM.

• TUBES NEED NOT BE HOOKED OUT OF THE ABDOMEN. NO FEAR OF AVULSION.

• LESS PAINFUL.


ADVANTAGES

• QUICK.

• MORE REVERSIBLE.

• BAND APPLICATION AT THE ISTHMUS IS EASIER THAN WITH MPM.

• IT KEEPS THE LARYNGOSCOPE IN GOOD WORKING CONDITION.


Promote Vasectomy

• FAMILY PLANNING = TUBECTOMYFAMILY PLANNING = TUBECTOMY• BUT VASECTOMY SCORES ON EVERY BUT VASECTOMY SCORES ON EVERY

COUNT.COUNT.• VASECTOMY IS OUT OF FAVOUR, VASECTOMY IS OUT OF FAVOUR,

MORE FOR SOCIO POLITICAL MORE FOR SOCIO POLITICAL REASONS THAN FOR SCIENTIFIC REASONS THAN FOR SCIENTIFIC REASONS.REASONS.

• TALK OF THE IDEA….TALK OF THE IDEA….


India is a land of festivals…

• Menarch

• Engagement

• Marriage

• Honeymoon

• Pregnancy

• Childbirth

• Naming ceremony


But…..

• Termination of fertility…..


Rural practice is a subspeciality in itself…

• Low cost high risk practice.• One wo/man show.• You are forced to be alert, to be innovative,

to be an electrician, a plumber, a nurse and a doctor all rolled into one

• Diploma in rural medical practice• Dip. M.P.R.P.S.





THINK OF ME….





E-Mail:- [email protected]

Mobile:-

98220 10349


SPECIAL THANKS TO…

• DR.VIDYADHAR GHOTAWDEKAR• DR MRS.LATA PATIL• DR VILAS PARAMANE• DR.VINAY JOGALEKAR• DR. R. L. MARATHE• DR. SANJAY SHIWADE• AND MANY MORE WHO HAVE DARED TO

SERVE THE RURAL MASSES RISKING SO MUCH FOR SO LITTLE…

Documents

Tips and tricks in rural gynecology & obstetrics 97 2003