Tragedy . . . And a Paradox

Before you can start of imagine what could be the tragedy – yes, another maternal death.

SD, aged 22 years and married for the last 3 years was brought to our labour room in the wee hours yesterday with history of leaking and seizures since midnight. She was unconscious and threw another episode of fits in the labour room. She had already been to one of the private hospitals in Daltonganj. We were not sure of what all medications she got there – but she was told that something can be done only in NJH.

According to dates, she had one month more to go before being full term. I noticed that she was contracting quite violently. Looked like she received an intramuscular pitocin, which is quite common management in many places in India. And the uterus also was looking elongated and very much suggestive of an obstructed labour too.

The pervaginal examination confirmed my worst fears. She was in fact terribly obstructed. However the baby was alive. I wanted to see if the baby had passed meconium – but I could not go anywhere beyond the edematous scalp which was firmly wedged in the pelvis. There were no signs of any fetal distress.

Considering that SD had eclampsia and an obstructed labour, I talked to the relatives about the pros and cons involved in the surgery. Ultimately – telling them that there is a remote possibility that we could lose SD as well as the baby in the process. All done including the informed consent, I set out for the surgery – the first one in an ultimately busy day which saw 2 more cesarian sections.

The initial part of the surgery was uneventful including the delivery of the baby although the liquer was thick with meconium. The baby had a good Apgar score. The trouble started from then onwards. The uterus was refusing to contract. No amount of Prostodin and Pitocin would do the trick.  Ultimately, it contracted.

I somehow closed the incision and came out only to find out that the uterus has once more gone into a state of relaxation. SD was losing blood in enormous amounts. The relatives were running from pillar to post for blood.

By late morning, we realized that we were losing her. We removed her off the ventilator at around 1:30 in the afternoon.

As she was taken off the ventilator, a group of SD’s husband’s friends had turned up to donate blood. They became somewhat agitated. They started shouting at me – telling that I did the surgery without the necessary facilities. I calmly explained to that that all options had been well explained. When I showed them the consent forms – they dispersed without making any more fuss.

Since the meeting on maternal death monitoring, we have been quite prompt in sending the necessary reports to the district level. I had to call SD’s father to find out more details before I fill in the report. One of the details we had to fill in was about the occurrence of any danger signs.

I was shocked to find out that SD had swelling of the body since the last 20 days and has not been feeling very well since then. Nobody had taken it quite seriously. Then came the biggest shock. It was a dramatic moment. I asked SD’s father, if the local Sahiya (ASHA) or the ANM knew about her pregnancy and if she had not told her about the danger signs. It turned out that SD was the Sahiya for the village.

The incident spoke volumes about Maternal health care in the district. I could not initially believe my ears. The lady who was responsible for quite a lot of the maternal health care in her village could not diagnose a danger sign in herself and did not take any effort to present herself to a doctor.

We have miles to go before we can claim any sort of success in the area of maternal and child healthcare. It is unfortunate that SD had gone into atonic post-partum hemorrhage. I do not think that anything could have been done even in the best of centres. However, if an early diagnosis was made of her pre-eclampsia and her obstructed labour at a later stage, SD may have survived.

This is the second time within a period of two months that we were having a maternal death due to uterine atony. Maybe, I should be taking the option of opening a blood bank seriously. There are enormous stipulations to be met before I can even think of a blood bank. I recently heard from one of our sister units how and much more troublesome it is to maintain rigorous stipulations required for a blood bank. However, the paradox is that we have licensed blood banks which supply substandard blood and get away with it.