Maternal near misses continued . . .

My last duty was a bit stressful. I had to do 3 Cesarian sections back to back. And to make things quite difficult there were the 3 malaria patients in the ACU and the terribly burnt patient which Nandamani kindly agreed to manage.

The first one was SD who came in at around 10:00 pm with a hand prolapse per vagina. I somehow hoped to do an internal version. However, she being a primi – it was quite a tough ask. And when I examined her, it was obvious that I would not be able to do the internal version. The uterus was in a state of tonic contraction without any moment of relaxation.

Per operatively, I was glad that I did not try the internal version. The lower segment was on the verge of a rupture. Later I found out that she had recieved intramuscular pitocin injections from her village.

However, what I wanted to bring to your attention was the fact that SD had been diagnosed to have breech presentation on arrival in the Leslieganj PHC and she had a referral letter dated the same day at 5:00 pm. But, the relatives decided to stay on whatever the consequence is. There was a high risk consent absolving the PHC doctor of any complication if she did not go ahead to a higher centre.

The hand prolapsed occurred on the way. The baby was freshly dead. Maybe, we would have got a live baby if she had turned up early.

The second one was AD, who came in sometime late morning. It was AD’s first pregnancy and she lived adjacent to the District Hospital at Daltonganj. Interestingly, till the day of admission her family never thought about taking her to the District Hospital for an Ante-Natal Check Up.

On the day of her admission to NJH last Monday, sometime in the early hours of the morning, AD threw a fit out of the blue. There were no warning signs. No swelling up of the body or no blackouts. Taken straight to the neighbouring district hospital, she was referred to NJH. Unfortunately, on arrival at NJH, AD was quite groggy and had 5 episodes of seizures.

The problem was that according to her dates, she was just in the middle of 32 weeks of gestation. Her blood pressure was 160/100, and Urine Albumin was 2+. As always is the case, we explained the limitations we had in terms of not having an obstetrician, a paediatrician, anesthetist, medicine consultant, ventilator, blood bank…everything I could think of. Armed with a high risk consent, I told them that I shall try for a normal delivery – without any sort of guarantee for the mother/child.

Over the next two hours, her blood pressure had become controlled and I was sort of confident of somehow getting the steroids to act on the baby’s lung tissue by waiting for 24 hours before we acted. I also induced her with Misoprostol.

As evening progressed, with the malaria patients and hand prolapsed, my thoughts were on how AD is doing. In between the surgery for SD who came in with the hand prolapsed, the nurse in the Labour Room informed me that there was a rise in AD’s blood pressure and her Urine Albumin is 4+. I knew that I had to act.

I posted her for Cesarian section immediately after SD’s surgery. AD delivered a healthy boy more of a Small for Gestation Age baby rather than premature weighing about 2 kgs. The mother and baby have done well so far.

It was quite a paradox that within a week of my post about non-availability of proper medical facilities, here was a patient who totally ignored getting herself at least one ante-natal check up and ended up with a complication and another one who ignored an advice to go to a higher centre.