[IS FEAR FROM MALPRACTICE CLAIMS AGAINST OBSTETRICIANS POSSIBLY RESPONSIBLE FOR THE RISE IN THE RATE OF CESAREAN SECTIONS?]

INTRODUCTION: In recent years there is a growing local, as well as global, tendency among obstetricians to end labor by cesarean section in various circumstances. Current literature suggests that the leading factor for this preference is closely related to the amount of malpractice allegations submitted against obstetricians. The extensive use of cesarean sections has its toll in reducing the skills of future obstetricians in handling breech, instrumental and vaginal delivery after cesarean section and vaginal delivery of twins, and other types of deliveries. The acceptance of the absolute autonomy of the parturient on her body, combined with rising prevalence of a cesarean section upon maternal request, has further added to the use of cesarean sections. In the present review, various aspects that led to the rise in the numbers of cesarean sections performed are discussed.

[PERINEAL TEARS THAT INVOLVE THE ANAL SPHINCTER - IS IT AN UNPREVENTABLE OBSTETRIC PROBLEM AND WHAT ARE ITS REPRECUSSIONS?]

INTRODUCTION: Perineal tears that involve the anal sphincter, especially those which are occult, are common in cases of vaginal delivery or instrumental deliveries. Parturients who experience such types of perineal tears may suffer from flatus or fecal incontinence and also fistula to various surrounding organs. There is no consensus in the relevant medical literature regarding the risk factors for the development of these tears, as contradictive results are presented in various relevant studies. Traditional methods for perineal protection, executed by midwives, such as perineal massage with oil, have also failed to be proven as an effective measure for that purpose. The only theme on which there appears to be a consensus is the fact that protective episiotomy is not helpful in protecting the perineum during vaginal delivery. The inability to predict which parturient will have a perineal tear that involves the anal sphincter, as well as the lack of predictive measures to avoid their occurrence, drive more and more women to demand and receive cesarean section by maternal request, which is accepted by most obstetricians nowadays.

[DENTAL CARE DURING PREGNANCY].

INTRODUCTION: Pregnancy is a period, in which, and due to hormonal changes, the prevalence of periodontal diseases rises. The causing organisms for these diseases may migrate to the uterus and cause premature delivery. The diet during pregnancy may also have a deleterious effect on the oral and dental health of the parturient woman, as well as to the teeth of her child. Some unique dietary, as well as pathological conditions, which may appear in pregnant women are known. These are referred to as pica and epulis. Physicians involved in taking care of pregnant women, such as dentists, obstetricians and family physicians, are normally reluctant to refer, or to perform dental care on a pregnant patient. The present review of the current literature suggests that there is no basis for this avoidance. This is because dental care has been found safe for both mother and fetus during the whole period of pregnancy. Furthermore, dental care is even recommended, if not mandatory, because it has been shown that such treatment may prevent early delivery and possible future damage to the newborn's teeth. Considering the lack of knowledge among those who are responsible for the welfare of both the mother and the fetus during pregnancy, we suggest a publication of an official recommendations paper for dental care during pregnancy, which will be issued by the relevant professional medical societies in Israel.

[THE MEDICAL CARE OF TRANSGENDER PEOPLE].

INTRODUCTION: The phenomenon of the discrepancy between a person's sexual self-perception and his/her genetic sex has been known to medicine since the mid-19th century. Initially, this discrepancy was considered to be a mental disorder. Over time, advances in medical abilities in surgery, hormonal treatment and infertility, have enabled physicians to help those who are affected to fulfill their wish. The present notion is that transsexualism is a solvable problem (whether the desired wish is for a man to become a woman or vice versa). Treatment is both complicated (surgery) as well as chronic (hormones). In this review the various medical aspects of the different possible treatments are discussed, excluding the psychological part of this intriguing condition.

[ADVANCED ABDOMINAL PREGNANCY].

INTRODUCTION: Abdominal pregnancy is a very rare obstetric complication which is seriously hazardous to the mother as well as the fetus. It poses a diagnostic challenge to this day. Both maternal and fetal mortality rates in such cases are high, as well as the malformation rate among the affected fetus. The best diagnostic tools are ultrasound and MRI. The availability of these instruments, and especially the latter, is scarce in developing countries, hence the higher rate of this type of pregnancy in these regions. The higher incidence of abdominal pregnancy in developing countries is also associated with the greater prevalence of low socioeconomic status, pelvic infections and infertility - all are more prevalent in these countries. Abdominal pregnancy may be primary - that is fertilization of an ovum in the abdominal cavity, or secondary - re-implantation following tubal abortion, perforation of the uterine wall during curettage or expulsion of pregnancy material through uterine rupture or dehiscence. Heterotopic pregnancies, in which one or both fetuses are found as abdominal pregnancy have been reported. Treatment is surgery. The issue of removing the placenta during the operation is controversial to this day. Treatment of the remaining placenta with methotrexate has recently been abandoned. Lately, conservative treatment by potassium chloride (KCl) injection to the fetal heart by sonographic guidance has been suggested.

[PLASTIC SURGERY OF THE VULVA AND THEIR CIRCUMSTANCES].

Plastic surgery of the vulva for aesthetic reasons is recently gaining popularity in the Western world, as well as in Israel. There are different methods of executing these operations with no meaningful difference in the surgical results and the satisfaction of the patients. There are also more complicated plastic operations, in which the vulva is involved. These are performed in cases of pseudohermaphroditism, various states of intersex, sex change operations and developmental defects of the genitor-urinary systems. These are considered successful procedures. Furthermore, the issue of the illegal mutilation surgery of the external female genitalia, on religious or cultural background, is mentioned. All the above-mentioned types of operations involving the vulva are discussed.

[On gods, snakes and staffs--the emblem of the medical profession].

The commonly accepted emblems of the Medical Profession are the staff of the Greek god of medicine--Asklepios (or Asclepius], on which one serpent is entwined. Later, around the 16th century C.E., the wand of the herald of the Greek Gods, e.g., Hermes, on which two snakes are entwined and facing each other, became popular as the emblem of the medical profession. We elaborate on the history of the evolution of these emblems as symbols of medicine, including earlier influences from the times of the ancient Egyptians and Babylonians, which were followed by Judeo-Christian traditions and concepts. The relevance of the use of the wand of Hermes as an emblem of our profession is further discussed.