Cont'd - Dangerous Obstetrics

Yesterday, we had quite a crowd in our Labour Room. Over the last 5-6 months, we've had a fall in our Labour Room statistics. We presume that the fall has been due to the opening of multiple nursing homes and hospitals in the small towns from where patients usually came to NJH. Most of these hospitals are manned by nurses or junior doctors, but has names of consultants from the nearby cities on their rolls. 

Of course, we still continue to have our share of eclampsia and rupture uteri. Yes, I've sort of stopping writing about them for some time. You can read the following posts which I had put up some time back about our high risk obstetric patients. 

1. Dangerous obstetrics. 

2. Maternal health care . . . quo vadis.

3. Obstetric Care stories . . . cont'd

4. Weekend diaries

5. Best posts on RCH

We continue to have such patients regularly, although I've not written about them of late.

However, I was quite surprised by yesterday's rush. We had 6 labour patients coming in of which we ended up managing 5 of them. 

The first to arrive was SabD, a 32 year old G6P5L3D2 who had a Cesarian section to deliver her last child. She was in labour and had been trying to deliver at home. By God's grace, she had progressed to quite an extent. But her hemoglobin was only 8 gm%. Considering the prolonged labour, I offered to do an emergency Cesarian section if blood was arranged. The family went to arrive blood. However, the lady progressed well and delivered vaginally by late morning. 

We were glad, but the family was downcast. The reason - - the baby was a girl and the family already had 3 girls, and no boy. They were expecting a male baby. I counselled them to do off a tubectomy, but the family nor the patient would have nothing of it. 

The second patient was PrD, a 20 year old who was pregnant the third time. She had lost one baby earlier due to premature delivery and one was spontaneously aborted in the 2nd trimester. 

To our horror, PrD was leaking for more than 2 days. She was being managed elsewhere, was told that everything is fine and was discharged. Soon after discharge, she started to have fever. The family thought of a second opinion. PrD had a hemoglobin of 9 gm% and she was in full blown sepsis - -  a total count of 40,000/cu mm. She was only 136 cms tall and on per vaginal examination, there was hardly any space along the pelvic outlet. We had to do a Cesarian. 

Per operatively, on opening the uterus, the entire endometrium and the baby was stinking. It was hard to believe that the baby was still alive. So far, the mother and the baby have done well. 

The third patient was SanD, a 23 year old primi who had an uneventful labour and delivered normally. 

The fourth patient was AnwD, a 20 year old G2P1D1, who had a previous LSCS, but no live issues. She had been trying to deliver at home since evening and had ended up with a rupture uterus. The rupture was quite a bad one and very uncharacteristic of previous Cesarian ruptures which usually occur only along the suture line. 

Below is the snap of the rupture after the suturing was done. Since she has no issues, we have not done tubectomy. We pray that she will conceive and deliver a healthy baby later. 

The fifth patient was RekD, a 25 year old, G2P1L1 with previous Cesarian section who came in with labour pains as we were doing surgery on PrD. According to her dates, she was only of 32 weeks gestation. The baby looked quite small and I thought of suppressing her labour. However, the pains just increased. We had told the relatives of the non-availability of specialist facilities should she deliver. 

She did not respond to any of our treatment, but, almost after 6 hours of good pains, she was not progressing. There was a danger of going into rupture uterus. The doctor on duty thought of screening her by ultrasound and found that the baby was in fact term. Yes, the baby appeared to have low birth weight. 

Off went RekD for Cesarian and she delivered a Low Birth Weight baby. RekD had a hemoglobin of only 7.8 gm%. She is yet to receive a blood transfusion.

There was one more patient - the sixth one who did not stay on with us. IikD, a 26 year old wife of a army jawan. The poor lady was leaking since the last 2 days. They were trying for a normal delivery at home. She was G3P2L2 with the first delivery done by Cesarian and the second one a home delivery !!!. Her husband wanted an assurance that we would ensure that she has a normal vaginal delivery. 

I told him that that assurance cannot be given. The family went off in a huff with the jawan shouting all obscenities about the staff and the hospital. It was sad to see that an army jawan just not understand my reasoning and wanted to rather have his way without looking at the possible adverse outcomes. 

Now, all except one patient were very very high risk obstetric patients. 

In fact the 5 of the ladies who delivered yesterday, had lost a total of 4 babies earlier (5 if you include the present rupture uterus too).

5 families . . . 14 pregnancies . . . 5 dead babies . . . one more could have died if we had not intervened on time (PrD).

As I mentioned in one of my previous posts, the status of obstetric care in the region is so bad that we've not still got into the process of looking at neonatal outcomes. 

I'm proud that we've been entrusted by the UNICEF with the responsibility of supervising obstetric care in the district. 

However, to do justice to this responsibility, I need more help. One of the major challenges we have is the unavailability of an obstetrician and pediatrician. And there is always the dangling sword of the Clinical Establishment Act and non-understanding officers who could stop us managing such patients in the near future. 

Please spread word about the urgent need for consultants in the specialities of Obstetrics, Pediatrics and Anesthesia without which quite a number of hospitals such as ours would not be able to be the sort of blessing we are now to many a families. 

Living on the edge

It's sometime that I've written about the high risk obstetric patients that we continue to have at NJH. Of course, winter is considered to be off-season for obstetric care. 

The first one was TB. TB was into her fourth pregnancy. Her first 2 deliveries were at home. The third one was a Cesarian section done 5 years back. She had no clue on why the surgery was done. 

She came in with labour pains since about 12 hours. They were trying to deliver her at home when someone thought that something was amiss. On arrival, we were quite convinced that she had ruptured the uterus. 

On opening, there was something funny. The rupture was not along the previous suture line. The rupture had happened along the lateral aspect of the body of the uterus.

There can be only one diagnosis. The gravid uterus was massaged and thus the rupture happened. On finishing the surgery we asked the relatives whether some sort of massage was done. They were quite surprised that we found that out without their telling it to us. 

TB's 3 children are lucky to have their mother alive. 

The next patient, whose story I am going to narrate is not yet out of danger. SD, a young mother of a one year child came around the 8th month of her pregnancy. The problem was she was bleeding. 

We could tell that clinically, her hemoglobin did not look beyond 3 gm%. She had a complete placenta praevia. It was horrifying to note that she had spotting on and off and her relatives never thought that the condition could be life-threatening. 

More on SD in my next post . . . 

Ending 2013

We had amazing last few hours in the labour room on December 31, 2013.

3 patients . . . and they made our day.

All of them very very high risk patients who should have gone on to a tertiary centre. All of them poor and . . . coming here just because they could not afford a trip to Ranchi. They trusted us . . . wrote the high risk papers . . . we could only pray . . . and the Lord gave them deliverance and healthy live babies.

The first one, JB, who had come around noon-time. She was one of our regular ante-natal care patients. We had told the family that it would be good to have her delivery in Ranchi. The reason – she had lost her first baby. But, the family could just not afford to go ahead. To make matters difficult during admission she had couple of high blood pressure readings. Thankfully, the BP stayed normal after admission. She responded well to induction and delivered a girl baby just before the clock chimed 12 midnight.

The second one, SD had all of us in tenterhooks for quite some time. SD had lost both her babies the previous time and the family did not seem it worth to get her a regular antenatal care when she was pregnant a third time. And both the previous pregnancies had delivered by Cesarian section elsewhere. A G3P2D2L0 with both previous Cesarians. The only saving grace was that her haemoglobin was 11 gms%. After the customary high risk papers were signed, we sent off the relatives for one pint of blood. I took a decision to operate only if I’ve a pint of blood. We’ve had previous experiences of patients bleeding heavily when they’ve had a Cesarian elsewhere.

To our horror, SD went into full fledged labour pains. She had terrible lower segment tenderness. We decided to take her for Cesarian without the blood having arrived. We were afraid that she would rupture. To our surprise, we found that she had dilated fully by the time we took her to theatre and to cut the story short, she delivered normally. The baby and the mother are doing fine.

The third one, TB came from another centre after she was referred for pre-term labour. We found out that she was in fact term. But, there were issues. Her haemoglobin was only 7 gm% and she was in sepsis. She had been leaking for almost 48 hours which the family had ignored. She also progressed so fast that the baby was delivered normally and the mother has done well so far.

It was so satisfying to finish the year having been part of the management of these three ladies all of whom had come to us expecting a miracle.

We thank the Lord for using us to be a blessing to these families. 

Lost Pregnancies

Over the last 3 days there were 6 obstetric patients in the Acute Care Unit. All of them of course high risk. 

The first one was PrD, who had been on the ventilator for over 2 weeks. She recovered miraculously and has since been shifted out to the general ward. 

The second one was BaDe a twin pregnancy with eclampsia who had delivered normally. It is very rare for a mother and her twins to have come out alive after few episodes of seizures. Her blood pressure has since been controlled. 

MD was pregnant for the fourth time and had come to us after having been searching around hospitals who were ready to take up a previous Cesarian. When we operated, her previous scar was already giving way. The baby was lucky to have survived. For, MD has lost 2 of her previous babies to early neonatal illness.  

The fourth lady, SumD was delivered elsewhere. She had Post Partum Hemorrhage after the twin delivery. The bleeding was so much that the people where she had her delivered just packed her vagina tight with roller gauze and bandage. We removed that pack only after we got fresh blood. Thankfully, it was only an atonic PPH which had taken care of itself. 

The lady in the fourth bed was ManD. She also had delivered by Cesarian. And of her four pregnancies so far, this was only her second live child. The rest two had died during childbirth. She was also almost rupturing when we operated. She had been going around different hospitals in 2 districts, in labour, before she reached NJH.

The last patient of this story, MarB was the most unlucky. She had already lost 2 babies earlier. The present one was her fourth pregnancy and she had lost that too. As she had a Cesarian for the previous pregnancy elsewhere and there was scar tenderness, we had no option but to do a Cesarian section for the dead baby. Again, the uterus was just giving way. 

All the six ladies could have ended up dead. Some are alive because they were referred at the right time.

If you leave the two twin pregnancies . . . and look at the rest of the four families of PrD, MD, ManD, MarB . . .

Four families . . . 13 pregnancies and 8 dead babies . . . PrD (1 dead baby), MD (2 dead babies), ManD (2 dead babies), MarB (3 dead babies) . . .

Can you believe this? 

It was so difficult to comprehend that all these families had gone through so much of a heartbreak . . . 

At least 2 of the babies would have died if we had not intervened on time when they arrived this time. . .  And as I mentioned earlier, all the six mothers could have ended up as maternal mortality statistics . . .

We write in our consent forms . . . there is no obstetrician, pediatrician, anesthetist or a surgeon in this place . . . there is no blood bank in NJH . . . if we have to operate with a low hemoglobin, we give authorization to do the surgery without blood . . . the responsibility of getting blood is with us and not with the hospital . . . 

Most of our patients sign this without any second thought. Many of our patients are too poor to take a decision to move on to a higher centre . . .

I wish we had some more co-workers join us and be a part of NJH. Yes . . . consultants in all the above four specialties is something we would love. 

Maddening Obstetrics

I thought that the 2 rupture uterus patients had given us enough trouble for the next 24 hours. 

I was terribly wrong. 

At 2 am early morning today, came a lady nearing term in very early labour. Thankfully, she had come 2 months back at around 32 weeks to us. And she had our documents. 

Documents . . . which made me shudder. 

G3P2D2, the first one a still birth and the second one a late neonatal death, with a hemoglobin of 4 gm% at 32 weeks whom we had referred to Ranchi as the pregnancy was so so precious. The second delivery was a Cesarian section. 

Clinically, the hemoglobin did not look any better. Her conjunctiva was papery white. 

The family did not take her to Ranchi when we had referred them to a higher centre 2 months back. They had gone home. 

The family wanted me to do whatever I could. With hemoglobin of 4 gm% and the rules on blood transfusion making UDBT totally illegal, I had to refer them. 

I wonder where they have gone. They are from a nearby village. Therefore, I will be able to find out if they really went. Or if they went home and she had a miracle delivery or ended up as another maternal death. 

The tamasha continued later in the day too. 

I just came back from Labour Room after admitting a 21 year old G2P1L1 at term who had a previous LSCS for eclampsia. She was in the ventilator for quite some time and she lost her baby too later. 

This lady had her antenatal care elsewhere. She had consistent values of hemoglobin values less than 6 throughout her antenatal period. The family appeared to have no clue. Or did they want to convince me that they had no clue. 

When I did per-vaginal examination, the situation turned for the worse. She had ruptured her membranes and the liquor was heavily meconium stained. And she had a badly contracted pelvis. 

Shivnath, our lab tech, called me and told that the hemoglobin was only 4.6 gm%. 

The relatives were so poor to take her elsewhere. 

I've send them to Daltonganj for at least 2 pints of blood. 

I wonder if I would get a healthy baby. I can only pray. 

By the way, thanks for remembering KD in your prayers. She held on with a pre-operative hemoglobin of 7 gm%, in spite of periods of shock, till her relatives turned up with one pint of blood late in the afternoon. 

Urrgghh . . . UDBT

From today, we start a unique experiment with regard to first calls in NJH. It's just Dr. Shishir and me for taking first calls for the next one week. The arrangement is that we are going to do alternatively 12 hours of first call . . . The reason being that both of us in the wrong side of 35 seems to do better with periods of 12 hour rest. 

May sound a bit hilarious, but I thought that the harsh early winter and our poor respiratory systems would benefit from such a system of taking calls. 

Leave that alone . . . I wanted to talk about UDBT again. Oh . . . how I wish that this was legal? 

The story was that we had a lady with a rupture uterus today afternoon, KD, who had a hemoglobin of 7 gm%. She was hemodynamically stable. We got assurance from the relatives that they would arrange for blood from Daltonganj as soon as possible. 

The relatives were quite a few and therefore we thought that we would get the blood soon and we decided to take her up for surgery. Dr. Shishir did the surgery and the post-operative period was uneventful. However, the promised pints of blood never came. 

As soon as KD's surgery was over, we had another lady with a rupture uterus, SD, who also a very similar history. 

The team on duty was busy managing SD. It was only late evening that we realized that KD's blood never reached. Then, our nurses started asking them about what was happening about the pints of blood. Then to our chagrin, we found out that KD's relatives have not even gone to Daltonganj for getting blood. We had given them a request at 2:30 pm and while this was going on, it was past 8 pm. 

I came to know that there was a problem at around 10 pm, when the Acute Care nurse called me saying that there was fellow shouting and threatening everybody. 

I reached the Acute Care to find out a burly middle aged man in a agitated state. He wanted to know who ran the hospital and who the doctor was. He said to me that he will ensure that we drew blood. He then threatened to file a case against me for obstructing blood donation in the hospital. 

He went on ranting. I thought it was a matter of time before he hit me. I thought I'll give him a chance to slap me. Maybe, this was the moment I would get to bring up UDBT into the headlines of the country's media. 

That was when the whiff of country liquor clouded my senses. The fellow was drunk. The sniffles of winter had kept the smell of alcohol in his breath away from me. 

I remarked to a onlooker on how a drunk can be allowed into the hospital. The mention of the word 'drunk' had him make a hasty retreat. 

However, I'm still in a quandary. I've a rupture uterus lady with 7 gm% hemoglobin operated upon without a chance of getting even a pint of blood in the next 12 hours. I can only pray that she'll make it through the night. 

After the drunk relative was gone, I called another relative who was thankfully sober and explained about the problem. He apologized for allowing the drunk fellow come in. But, it was too late into the night. The dipping temperatures and the possibility of being looted ensured that no vehicle owner was ready to ply till early morning. 

Before I end, the common history of SD and KD. 

Both of them had delivered by Cesarian sections before. Their families were attempting home deliveries since yesterday night. In fact, KD's relatives told me that her abdomen was been regularly massaged since the last 2 days and it was so surprising that the baby did not deliver normally. 

I told KD's relatives that I find it surprising that KD is alive. 

Please pray that the relatives will get blood by early morning. 

And also a wish that UDBT would soon be legal for hospitals such as ours . . .

The Short Lady

Today early morning, we had a lady who came with a neglected previous Cesarian. She was brought in quite late. SwrD had started to contract sometime late evening yesterday. They lived quite away from a place where a Cesarian section could be done. It was midnight by the time she reached a place in our nearest town. Being Dussehra, there was no doctor there. They reached NJH today dawn (15th October, 2013).

SwrD, about 25 years old was 125 cm tall. It was quite obvious that the labour was obstructed. Her haemoglobin was only 8 gm%. Titus send off the relatives to get blood. He also got consent to operate without blood. It may look very foolish but that was the only option considering that she was fully dilated, the baby was stuck and very much alive.

The problems started after he opened up the uterus. Till the delivery of the baby, there were no obvious problems. However, as soon as Titus started to suture the uterine opening, he realised that there was a problem. There was torrential bleeding from below the uterine incision. That was when he realised that the previous Cesarian scar was quite low and it had given way.

With a hemoglobin of 8 gm%, it was only a matter of minutes before she got drained of her blood. We acted quite fast. I realised that the prolonged labour had made the proximal part of the uterine opening quite friable. We somehow got her sutured up and achieved hemostasis. However, there were very much evident signs of shock.

We were blessed to have the relatives come quite fast from Daltonganj with one pint of blood. We had asked for two. 

By God's grace, she responded well to whatever we offered her. It's midnight now as I write this. She has been shifted to the general ward from acute care. 

This is a typical case where a UDBT would have helped the patient and given a peace of mind for the doctors involved in her treatment. If the relatives were not that forthcoming, only a UDBT would have saved her. I later found out that the relatives had someone known within the blood bank . . . and that was the reason they got a blood bag fast. They had also taken someone to donate.

I understand that the government is considering to legalise UDBT. Hospitals like us would definitely benefit . . .

Rupture Uteri . . . and the luckiest of them

Over the last 1 week, we’ve had 4 patients with rupture uterus.

Two of them were previous Cesarian sections who tried to deliver normally elsewhere. One of them continues to be very sick. Today we found out that she has developed a vesicovaginal fistula too.

However, the luckiest of the lot seems to be Kanti Devi, a 28 year old lady who had a twin pregnancy after 2 previous successful pregnancies, both of whom needed Cesarian sections.

Now, for the present twin pregnancy which she was not aware about (as she did not have any sort of antenatal care), she started to have pains since about 3 pm on Friday afternoon. 

The kept her for some time at home after which by around 8 pm, they took her to a nearby private clinic.

At the private clinic, she delivered a baby by normal vaginal delivery. However, after that the people in the private clinic waited as they most probably diagnosed a second baby.

They waited for almost couple of hours after which they realised that something was amiss.

The relatives brought her to NJH with a diagnosis of undelivered second twin.

Dr. Shishir, who was on duty did not need to ponder much to diagnose a rupture uterus. 

The surgery was uneventful.

I’m sure that this would be a very rare presentation of a rupture uterus - a patient with 2 previous Cesarian sections who in her third pregnancy conceives twins. She delivers a live baby by normal vaginal delivery and then ruptures her uterus and loses the second baby. 

And here is Kanti Devi with the surviving twin . . . 

The snap has been taken after obtaining consent from the family including the patient. 

Patient follow up .. . ..

Below is the snap of a mother and her baby which is quite a major encouragement for us at NJH.

This is UD and her baby. I hope you remember the baby with the gory face in the post. Yes, this is the same baby whose face was all lacerated. And she was quite sick when she was delivered.

We also thank the Lord for BD and GD, both of whom are recovering well. BD had a very bad rupture uterus which was neglected for long. And GD had come with severe eclampsia and pulmonary edema. We look forward to discharge both of them in a couple of days. I'm sure that I'll remember forever the sight of GD's uterus after we ended up B-Lynching it twice. 

Well, the stories of neglected pregnancies continue. I write this just after coming back from theatre after an unsuccessful attempt to save a baby whose hand prolapsed. The mother has never had antenatal check ups. There was no pain. However, I doubt the history as there was hardly any liquor inside the uterus. Rather is was quite dry. We ended up putting a inverted T shaped incision over the uterus to deliver the dead baby. It was a fresh still birth. In fact, we had got a heartbeat before the surgery.

As I mentioned in one of my previous posts, we are yet to explore the devastation of neonatal deaths. caused in our surrounding communities.

In addition, we also had 3 cases of eclampsia of some form or the other over the last 48 hours. However, all 3 mothers are doing fine. Although the babies dies. Well, one of them has been a diagnostic dilemma which I would narrate in my next post. 

Well, the final shot .. .. .. the patient RN, on whom we had done a repeat Cesarian. It turned out that the patient was registered in the hospital in the name of the first wife who is dead since 4 years. Our nurses realised it when RN did not respond to calling her name. In one sheet, she had accidentally told her original name. Someone thought about calling her that name. And she responded to the call. 

My friends in RSBY . . . I hope you have read this. It may be a odd case but has made a very interesting story on how we can be easily fooled.

(Consent has been obtained before taking the photograph. The patient has been given a concession of approximately 25,000 INR (The total bill for both mother and baby was approximately 40,000 INR). However, the family has been informed that there is no compulsion on her to allow us to take this snap and use it for field publicity efforts aimed at getting specialist healthcare staff with a heart for caring for the marginalised to join hospitals like NJH)

Neglect and . . . Issues to contempate

Yesterday late night, we had a patient which is a prototype of the sort of patients we get here. 

We shall call her RN, a 30 year old lady who came at around 8:30 pm. 

From an antenatal point of view, a high high risk patient. A Cesarian section done about 18 months back. She was never taken for any antenatal check up. No hemoglobin values, no blood group, no body willing to donate blood . . . leave alone an ultrasound.

We usually follow the dictum of getting one pint of blood ready in spite of a normal hemoglobin value when the patient is a previous Cesarian section. We agreed to take her if the relatives could arrange one unit of blood. 

We waited for almost 3 hours for the blood. Which never came. 

Around 11:30 pm, the relatives started to make a big fuss on why the surgery was not being done. Our doctor on duty explained the reasons. They could not agree on what was being explained. 

I got called. I explained to them. They were ready to get the surgery done without any blood. With the consent that 'there can be unexpected complications which could be fatal to the patient'. The husband was ready to sign that even if his wife and child dies, he would have the surgery done at NJH. 

Meanwhile, the patient was in severe pain. There was severe scar tenderness. It was very obvious that the husband just wanted to get the surgery done somehow. He was hardly interested in the welfare of his wife or baby. 

He started to talk very rudely and was joined by 3 other male bystanders who also started berating the quality of care and our attitude. It seemed now that we were responsible for the sad state that this poor lady.

We all very well know that we were only facility where repeat Cesarian after a previous Cesarian was done for a radius of more than 80 miles. If I send her off, she will go to the nearest district hospital from where she would be refused any management. She could end up with a rupture. . . and could even die. 

And if she dies, there would not be much tears shed for her. Her husband will find another wife.  

We took a decision to take her in for surgery without blood. I could only pray that she would not have any complications. The lower segment of the uterus was very much thinned out. She could have ruptured in another hour if we had not intervened. 

Then, the nurse told me that she has got a Smart Card (RSBY). Well, this was her second pregnancy and therefore the Smart Card was swiped. 

Inside the theatre, I asked the lady why she never bothered to get a check up in spite of the fact that she lived within 10 miles of the hospital. She replied that her husband never bothers. She is his second wife and this child would be his 6th child. His first wife had died few years back after being managed in the village for fever. 

The surgery was thankfully uneventful. 

Now, questions that lingered in me - - - 

1. A patient who has regular ante-natal check ups in easier managed with regard to costs as well as predictability compared to a patient who never had any antenatal care. Should RSBY rules include a clause which makes it mandatory for patients to have at least 2 or 3 antenatal check ups in the facility where she plans to deliver? 

2. For RN's husband, this will be his 6th child. For RN, it is only her 2nd pregnancy. So, do we put her under RSBY or do we exclude her and make the family pay? 

3. What can be done to address the neglect that women and children face from their menfolk. I'm sure that it goes without a doubt that until our women and children especially girl child is cared for, our society is not going to progress much. Stories about of such neglect . . . but there seems no light at the end of the tunnel. 

On maternal care . . .

This quickly written post is in response to a couple of phone calls about why there has been a sudden fall in posts related to clinical care especially complicated obstetrics which started off this blog. 

The straightforward answer is that we have quite a lot of patients. Maybe I've become a bit lazy to put them in. That's all. 

As I write this, our 6 bed acute care unit has 3 patients with some form of eclampsia, 1 patient with viral hemorrhagic fever, 1 patient with a krait bite (on ventilator) and 1 elderly lady with severe pneumonia. 

Stories about one of the 3 eclampsia patient. We shall call her NB. Pregnant for the first time, NB never had any antenatal care. She started to have convulsions sometime at dawn yesterday. As usual, she was taken by her relatives to the nearest hospital headquarters where a consultant obstetrician told them that she be taken to Ranchi. The family was poor and therefore came to NJH. 

She reached NJH by around 3 pm. She already had 15 episodes of seizures. With a GCS of 7-8 and oxygen saturation of 80%, I was quite doubtful of her surviving. To make matters worse, nobody knew her dates. Clinically, she looked about 30 weeks. Ultrasound showed 32 weeks gestational age. The cervix was unfavourable. 

The encouraging aspect was a family who was poor although willing to go the extra mile. One of the male members was off to Daltonganj after the relatives could not find a match among themselves.

Meanwhile, with the patient showing features of deterioration, we had no choice but to go ahead with the surgery. The surgery was uneventful. The baby was of course sick. Dr Johnson did quite a commendable job resuscitating the baby. The patient was on the endotracheal tube till today morning. Now both the mother and baby is doing well. 

But, last week we had a maternal death. AD, a G3P2L2 residing within city limits of our district headquarters, Daltonganj. Both the previous deliveries had occured by Cesarian section. The only problem was that the last delivery was 9 years back. Somewhere she was told that since the surgery was done quite a long time back, she should not have much problem with the present pregnancy. 

The family attempted for a home delivery. She was also given injections to increase the pain. She was taken to the nearest district hospital from where they referred her. She went to a nearby private hospital. All this travel took place in the dead of the night. 

They arrived at NJH early morning 3 AM. She was in shock and with severe anemia. The clinical decision of a rupture uterus was made quite early. One of the relatives donated one pint of blood. As she was in shock, we transfused the blood. However, to operate we needed more blood. 

The relatives were in no position to take the patient further. They sent frantic word to their relatives in town. By the time couple of potential donors arrived, it was too late. Dr Johnson was trying to resuscitate her after she collapsed once again mid-morning. Her frail body did not respond. 

The family was well off. As I talked to the husband while filling the Maternal Death Review forms, he was aghast that nobody had bothered to tell him that she should have undergone a Cesarian section. 

Sometimes I feel that I've forgotten to mention about the umpteen number of babies we lose at NJH due to delay in decision making. 

Last week, we had 3 babies who died for no reason. All of their mothers were attempting deliveries at home for more than 12 hours. Drowned in their own meconium, the babies have hardly any chance of survival.

Well, the icing of the week was 30 year old DD. A G3P2L2, who again had 2 previous Cesarian sections came to us last week with seizures. The best part was that the patient started to have seizures since 7 am and she was at NJH by 12:30 pm. Something we don't commonly see. Her blood pressure was 210/120 and she had a Glasgow Coma Scale of 8-9. We took her up for Cesarian section. And lo, we had twins. Both term . . .  Having had no antenatal check ups, it was a surprise for the family. And a relief to us that the Cesarian section went off uneventfully with the presence of so much risk factors. 

Well, the current week is going to be exciting. We already have 9 students from the MGM Medical College, Jamshedpur and 2 students from Medical College, Gaya on an exposure visit. And today evening (13th November), we have the Founder's Day dinner. Our Founder's Day is on 20th November . . . but considering that we have a local holiday on 13th, we've decided to celebrate it early. 

More on the above 2 things in my next post. 

Images of an unusual Rupture Uterus . . .

(This post is purely of medical academic interest and contains snaps which could be offensive. 

User discretion strongly advised)

I hope you remember this image from my earlier post. This is RD's baby who came in with a hand prolapse after she was diagnosed earlier with a transverse lie. It was only after Dr. Titus read the post that he told me that I had forgotten to mention that RD had a previous Cesarian. 

I did not know that since I was not directly involved with RD's management. 

Talking of previous Cesarian Section, about a week back we had another patient with a previous Cesarian who came in with a Rupture Uterus. Below are the snaps taken per-operatively. Kindly excuse for the messy background as we were in quite a hurry to finish the surgery as the patient was quite sick. 

Area of rupture which was along the left lateral wall of the uterus, into the broad ligament.

Another view of the ruptured area after we started to suture it up. 

Hematoma from the ruptured region which extended along the mesosalpinx

The avulsed round ligament . . .

The surprise . . . The intact uterine scar of the previous Cesarian section which was marked very clearly by the bleeding which tracked along the suture line. We double checked it to ensure that there was no breach of the incision.  

It was quite amazing that the uterine incision of the previous Cesarian section was intact and the rupture was through the lateral wall into the broad ligament. One can only imagine the pain that the lady went through. 

However, by God's grace, she had an uneventful post-operative period and was discharged yesterday.

Bizarre Obstetric Care . . .

As I write up about the different patients to come to us for care, I always pray that things get better as each day passes. Unfortunately, it does not seem so. The number of patients with rupture uterus and eclampsia continue unabated. Of course, on and off, we get patients who were saved from certain death because of timely intervention . . . 

But, one lady who came yesterday broke all limits of imagination on how careless and ignorant can people be when it comes to obstetric care. . . 

I was in Out Patient yesterday (13th April, 2012) when at around 2 pm, a lady with a distended abdomen was wheeled in. The history was that she had a normal delivery on 10th April elsewhere following when the abdomen got progressively distended. They also told me that somebody had diagnosed her to have a rupture uterus following the delivery . . . 

The lady has been married for 12 years. . .  and the family did not have children for about 8 years. The first delivery was a tragedy. For reasons unknown, she ended up with a Cesarian section, but lost the baby. . . The next two deliveries were normal . . . and one done at home and the other in hospital ! ! ! In between, she had 2 abortions. 

Then came the fourth one, they tried a home delivery . . . but started to have difficulties, for which they came to the district hospital. She ultimately delivered normally. The baby was dead but she started to become sick. She was brought to us in a terrible shape on 11th April, 2012. So, she was P4L2D2A2. 

It was obvious . . . the uterus had ruptured. Her Hemoglobin was 4 gm%. We asked the relatives to get blood. She had about half a dozen male relatives but nobody was ready to give blood. 

It was fine, if there were no relatives to donate blood or if all the relatives got their blood group checked and then none of them matched. In such a situation, many of us from among staff have donated blood to patients. 

We told the relatives that they better take the patient to Ranchi. They did not hesitate to take her away. 

We had forgotten about her. 

And then they came back yesterday. We shall call her AD. Now, it took some time for me to discover that AD was the same patient who came to us on 11th April, 2012 and was supposedly taken to Ranchi. 

So, I was quite inquisitive to find out what happened after the relatives took her from here on the 11th. It seems they took her to the district hospital in the adjacent district. They told her everything will be fine once blood is transfused. And they managed to get hold of 3 units of blood. . . Nothing else was done. 

It was obvious that the patient was deteriorating. Later, someone told them that this sort of patient can only be managed at NJH or Apollo. And, therefore, she was brought here a second time. 

The patient was obviously sick. The hemoglobin was 10 gm%. She was dehydrated. We were sure that we will operate only if we had at least one pint of blood. Unfortunately, the relatives were not relenting. It required quite a lot of counselling from our side. I'm glad that they arranged one pint of blood today morning (14th April). As I write this, Dr Nandamani would have started operating. 

We pray that she will do well . . . 

Now, major lesson learnt here - lack of adequate medical facilities within the country. I had written quite a mouthful on a new act which is going to be implemented soon. What will patients like AD do when such a act is implemented?

Maternal Near Misses - Previous Cesarians

Doing Cesarian section in hospitals located in remote locations of developing nations used to be quite unpopular. Quite a lot of obstetric procedures developed in the good old days which were designed to prevent Cesarian sections.

I never understood the gravity of the problem of doing Cesarian sections in remote areas such as ours till an incident during my previous stinct at NJH during 2004-05.

I had gone to one of the remote villages as part of the community health outreach programme. After I reached quite a remote village, someone informed me that there was a woman in one of the houses who was having a delivery. Quite fresh from home in Kerala, where attempting a home delivery was unthinkable, I dreamt of myself being a messenger sent at the most appropriate time to help out this poor lady attempting a home delivery.

I rushed to the house where the delivery was taking place. Just as I reached, I realised that the baby was already out. I was not allowed into the house as it was quite filled with women of all ages and a very old woman came out with blood caked all over her hands and sari. She muttered something in Hindi and then there was a big cheer all around.

Hardly anybody was bothered about any of us standing around. Later, one of our lady staff volunteered to request one of the family members to have me look at the lady who delivered the baby. Quite fresh and brimming with enthusiasm, I was prepared to do a good postnatal examination. To my horror, the first thing I noticed was a long scar which run through the middle of her lower abdomen.

When I asked about the same, the husband happily informed me that the first baby was delivered by a Cesarian section. He also told me about the indication. She was taken to NJH as she developed seizures and had bloated up - most probably eclampsia. The baby was delivered alive but died soon after. It's been 2 years and for the present pregnancy, she has not even had a single ante-natal check up.

But for the family - the present pregnancy was a success. They had avoided a institutional delivery and had a healthy boy baby.

Unfortunately, the attitude towards Cesarian sections has not improved much. Over the last week, we had two pregnancies who had previous Cesarian sections, who came quite few days after the expected date of delivery.

The first one allowed us to do the Cesarian section as soon as she came in. When Dr. Nandamani opened the uterus, this was what he saw.

The second one was more horrible. The lady did not allow us to admit her the same day and came with much hesitation the next day. I was operating and Dr Nandamani had his video camera on.

In the olden times, procedures such as symphysiotomy and cervical incisions used to be quite commonly done. I wonder if any of the present trainees in the speciality of Obstetrics know much about them.


Both the women could have died - both near maternal misses. it was a miracle for both of them to be alive and more miraculous to have live healthy babies.


Talking of obsetetric procedures, another gruesome procedure is Craniotomy - which has also become not a common procedure in recent times.

Well, I hate doing craniotomies but almost ended up doing one couple of days back. More on that in the next blog...