Maternal Death . . . 3 Orphaned . . .

Yesterday, we had a maternal death. 

Not much to write about. Considering the previous death, this one was fast. 

We did not get much time to do anything. 

Because, she died within 15 minutes of arriving at the hospital. 

She was pale as paper and it was an obvious rupture uterus. Usually, we don't get many cases of rupture uterus who dies. Most probably, she was severely anaemic even before the rupture happened. 

The interesting thing about her. She did not have an intravenous line put on even though she had been to 3 hospitals. When we asked about the same to the relative . . . it was difficult to believe the reply. 'The patient's body is too swollen to put an intravenous line'. 

She had got couple of intramuscular injections throughout the day. Her contractions had started at 3 AM same day morning. Since, it was her fifth delivery, (3 children alive and one still birth), the family had decided to attempt a home delivery. 

Since nothing was happening, they took her to a hospital at around 9 AM. 

She reached at NJH a full 12 hours after that. 

The case sheet reads . . . Time of arrival: 9:30 pm, Time of death: 9:45 pm. 

There was no point in resuscitating as she was pale like paper. And there was no way we could get blood so fast. 

2nd maternal death of the month (February 2013) after a maternal death free month in January 2013. 

Last week, we were forced to tabulate the number of maternal deaths in 2012. Below are the numbers and the causes . . . 

Nos. of maternal deaths in 2012 (Jan-Dec)		CAUSE OF DEATH	Nos. of maternal deaths in 2011  (Jan-Dec)
•27 deaths •Total deliveries: 1544 •LSCS: 482	18	Eclampsia /Pre-eclampsia	11	•  24 deaths •  Total deliveries: 1280 •  LSCS: 439
	0	Septic abortions	3
	1	IUD	3
	1	Unknown	2
	0	Valvular heart disease	1
	0	Obstructed Labour	1
	1	Rupture Uterus	1
	5	Sepsis	1
	1	Malaria	1
	0	Severe anemia	0

Maternal near miss and a miracle

DD, was pregnant for the 9^th time in her life. To compound the problem, her blood group was O Negative. Her first 3 children were alive and the next 5 had died soon after childbirth. DD came to our Outpatient department for the first time yesterday. It was very obvious from the history that her children had all died because of Rh incompatibility. And she had hemoglobin of 7 gm%.

After having had a couple of bad experiences with patients who had a negative blood group, I made it very firm to the relatives that it would be better for them to go to Ranchi and have the delivery. The family was of the lower middle class, and not very poor. Our Outpatient department and the in-patient wing were bursting to the seams. We did not want another potential crisis in our labour room. In addition, we had an appraisal visit from the Central Tuberculosis Division exploring our preparedness for the start of the DOTS Plus programme. And Tuesday was Dr Nandamani’s operating day.

The relatives did not buy any of our arguments for referring the patient. They forced us to admit her to our labour room. She was in very early labour. Dr Nandmani was on duty on Monday. By around 4 am early today morning, she was about 4 cm dilated. I came in at around 8:00 am – she had progressed to only about 6 cm dilatation. The head seemed to be in an occipitoposterior position. I feared the worst. However, since she was a grand multipara, there was a chance that the head may somehow come out – but there was also a chance of rupture of the uterus.

We decided to take our chances. The relatives somehow wanted to deliver normally. We waited till 12:00 pm – not because we had to wait, but because the theatre was too busy. By around 12:30, we took her in – with no blood and very high consent of even death on the table. We also had explained to the relatives earlier about this baby also not making it because of the problem of Rh incompatibility.

Dr Nandamani did the surgery. The baby was well – he was in fact an occipitoposterior position and had failed to descend well. There was a bit extra bleeding from the uterus and we took up quite a lot of carboprostin for arresting the bleeding.

The miracle was that the baby’s blood group turned out to be O negative – the same as that of the mother. So, he will not have the problem with incompatibility.

After couple of hours of the operation, we were quite encouraged that the husband got hold of one pint of blood. Kindly pray that DD will recover fast and that we would get at least more pint of blood.