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 RuralMember Rural
Obstetrics committeeObstetrics committee
and Safe Motherhoodand Safe Motherhood
Committee; FOGSICommittee; FOGSI
• A well known speakerA well known speaker
• Contributed chaptersContributed chapters
to books on ruralto books on rural
obstetrics and medicalobstetrics 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 CLASSES
FOR 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 impractical
Because bangles are culturally loaded with
good omen

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 R A G E C EN TE R ST O R A G E C EN T E R
BLO O D BA N K
ST O R A G E C EN T E R ST O R A G E C EN T E R
BLO O D BA N K
R BT C

PROBLEM(S) VIS A VIS
BLOOD 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 FLUIDSCONSIDER OTHER REPLACEMENT FLUIDS
FOR ACUTE LOSS. THEY MAY BE ASFOR 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 BLOODRESTORE AND MAINTAIN ADEQUATE BLOOD
VOLUME. STARCH SOLUTIONS PREFFERED.VOLUME. STARCH SOLUTIONS PREFFERED.
• MAINTAIN SUFFICIENT OXYGEN CARRYINGMAINTAIN 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 OPERATINGSECURE HEAMOSTASIS. AT TIMES OPERATING
WITHOUT BLOOD IS SAFER THAN AWAITINGWITHOUT BLOOD IS SAFER THAN AWAITING
BLOOD.BLOOD.

SOME PRACTICAL TIPS
• CUT A BOTTLE OF NS AT IT’S BASE & KEEP JUSTCUT 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 LAYEREDPOUR 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 OTHERANY WOMEN WITH NO OTHER
CONTRAINDICATION FORCONTRAINDICATION FOR
DONATION & Hb OF 10+ & PCVDONATION & 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

• 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 supportPoor 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 ERRIS 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 FLOORNON-INVASIVE THERAPY AIDING PELVIC FLOOR
REHABILITATION.REHABILITATION.
• THE ‘FLICKS’ HAVE TO BE PRACTICEDTHE ‘FLICKS’ HAVE TO BE PRACTICED
SEPARATELYSEPARATELY
• BETTER COMPLIANCE IF YOU MENTION THATBETTER COMPLIANCE IF YOU MENTION THAT
THIS ENHANCES SEXUAL PLEASURE!!THIS ENHANCES SEXUAL PLEASURE!!

PLEASE,
PLEASE,
PLEASE,
PLEASEn
TALK
SEX!!!

• ALL PEOPLE HAVE SOMEALL PEOPLE HAVE SOME
QUESTION OR THE OTHERQUESTION OR THE OTHER
ABOUT SEX, SOME TIME OR THEABOUT SEX, SOME TIME OR THE
OTHER IN THEIR LIFE!!OTHER IN THEIR LIFE!!
• SO THE POTENTIAL CLIENTALESO THE POTENTIAL CLIENTALE
IS 100% OF THE POPULATION.IS 100% OF THE POPULATION.
• SEXOLOGY PRACTICE IS VERYSEXOLOGY PRACTICE IS VERY
REWARDING, EVENREWARDING, 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

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.

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 EVERYBUT VASECTOMY SCORES ON EVERY
COUNT.COUNT.
• VASECTOMY IS OUT OF FAVOUR,VASECTOMY IS OUT OF FAVOUR,
MORE FOR SOCIO POLITICALMORE FOR SOCIO POLITICAL
REASONS THAN FOR SCIENTIFICREASONS 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.

E-Mail:-
shantanusabhyankar@hotmail.com
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…

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