Obstetrics . . . still on . . .

Couple of hours back, someone messaged me asking the reason for stories of high risk obstetric care vanishing from my blog. It's not that they have vanished . . . the fact is that the numbers almost remain the same although there has been a fall in the number of deliveries. 

I just returned from the labour room after being called for a lady who had come to deliver her first baby after she started to have pains since afternoon today. 

RD was from one of the nearby villages. In fact, married to someone in the nearby village. She was away at her mother's house which was more far away. The family had been waiting for her to deliver. 

They knew that she had completed her term almost a month back. We calculated her gestation age as 45 weeks and one day. The poor family also wondered aloud to me that it has been quite some time since she crossed term. 

I hope she has wrong dates. 

But, there was more to come. Blood pressure showed 160/110 mm Hg with a Urine albumin of 3+. She was blessed not to have thrown a seizure. On examining the abdomen, the uterine size just about corresponded to 28 weeks size. She was contracting. 

On per vaginal examination, she was in full blown labour. There was grade 2 meconium. 

Teenager with her first pregnancy, post-dated, severe intrauterine growth retardation, with meconium stained amniotic fluid . . . not an uncommon story that we've seen. 

RD was away at her mother's house till today morning. Her husband sighed that it would have been better for her to remain with him. But then, he had go far for work as a migrant laborer. 

She delivered within couple of hours. The baby weighed a measly 1400 gms, had meconium bubbling from the oral cavity and the nasal cavity. The heart rate was too slow . . . And while getting ready for resuscitation, we noticed that the pupils were already dilated . . . 

As RD was shifted to the ward, we had our next bad obstetric patient . . . a 24 year old mother of one who had delivered couple of days back at home, coming with severe lower abdominal pain and no urine output. She was in shock . . . no pulse or measurable blood pressure. She is in acute renal failure and she's pouring out pus from her uterine cavity . . . 

More on SD, if I find time . . . 

Hiding the horror

I’m sure that the sad story of SS is quite fresh in your minds. However, you’ll be stunned when you hear the story of RD who came to us few days back.

RD arrived sometime in the midnight. As is the protocol, the nurse on duty took the history which looked quite innocuous. RD, a primi was quite regular with her antenatal care check ups at NJH. The last time she came to NJH, she was already 5 days past her Expected Date of Delivery. 

The doctor in outpatient had asked for admission so that we could induce her. The family left with a promise to come back the next day. They did not turn up the next day, but arrived at midnight of this particular day which was about five days after her last visit to outpatient department.

According to the family, RD had started to have contractions from 6 pm – about 6 hours before she arrived at midnight. On per-vaginal examination, she was already 8-9 cms dilated. A perfect progress if not a fast progress of labour. The plan was put up for a re-assessment at around 3 am in the morning. There was only one thing which worried the team. The head was a bit higher than usual and a small caput had formed.

At around 2 am, the doctor on duty received a call to attend to another emergency. After that was settled, he decided to take a look at RD before it turned 3. Per abdomen, the head was still palpable. A repeat pervaginal examination showed that the head was still quite high and the caput had increased in size. During this pervaginal examination, there was a foul smell coming out from her vagina. The staff asked the patient once again about any leaking which started earlier.

The patient had been quite positive that there was no leaking. However, a new relative who had just come blurted out that she had been leaking for 3 days.

The family was conveyed the decision to take her up for Cesarian. And of course, the high chance of having a sick baby and septicemia in the mother.

Per-operative, the uterus appeared quite edematous and the liquer was stained with meconium. The baby was quite sick. Something was amiss.

The doctor closed the uterus and as is the usual protocol checked the posterior wall of the uterus. And what he got was the shock of his life. There was a hole in the posterior wall. Below is the snap of the posterior wall.

The patient was wide awake to talk. The team told her what has happened. The doctor told them that he suspected that she had been subject to abdominal massage and longer period in labour.

The story she told us unbelievable. After she returned from outpatient 5 days back, RD had gone gone to a quack who gave her some injections to increase pain. Nothing happened for the first two days. On the third day, she was again given injections and a massage of the uterus was done. She started to have contractions on the fourth day. When the contractions were quite good for about 6 hours, the quack did more vigorous massage with the intention to push the baby out. But, nothing happened.

One of the relatives realized that it may be better to go to hospital.

They had concealed the original history.

RD is lucky. The baby had very bad birth asphyxia and meconium aspiration. It was a baby boy. They have rushed the baby to a tertiary centre in Ranchi.

We pray that RD would recover without any problems. She was in florid sepsis when blood tests were done. And also remember the baby in your prayers. 

Making childbirth a horror

(The snaps in this post could be repulsive to many. Viewer discretion advised)

Last week, we had one of the worst rupture uteri we've ever seen. Worst in the sense that it was quite repulsive when we got the history. 

SS, a 30 year old lady with no living issue had become pregnant the third time. As with her previous two pregnancies, she had thought that she would deliver without any problem at home. Her previous two babies were born at home but died before they attained the ages of five.

However, the progress of labour in the third pregnancy was eventful. The baby just refused to come down as the previous two had come. The family sensing that something was wrong took her to the nearby government health centre. There was no doctor or nurse at the place. 

Someone suggested a 'reliable quack'. 

The quack gave her two injection and started to applied pressure with his bare hands on her bulging tummy. He was trying to somehow push the baby out of the uterus. He had not even done a per vaginal examination. After about half an hour of applying pressure on the abdomen, she felt something give way. 

But, there was no baby. The tummy still looked swollen. The labour pain had disappeared. But she started to feel quite nauseated and sick. By this time, one of her relatives who was a Sahiya had turned up. She realised that something had gone wrong. 

It was around evening when the family reached NJH with SS. As always, the diagnosis was quite easy . . . a rupture uterus . . . 

Snaps of the surgery and how it looked . . . A grim reminder of how archaic obstetric care remains for quite a lot of our fellow citizens . . .

Tried to get a snap of the abdominal contour in a rupture uterus.
There is fullness of the suprapubic and the epigastric regions. 

The surgical team led by Dr. Shishir . . . 

The baby appears like he's sleeping . . . 

The aftermath of the violent abdominal massage . . . 

The uterine rent well sutured . . .

Gullible Patients

Over the last few days, it has been quite busy. The reason that my blog was silent was partly because of laziness and partly because of my not being on call during these days. Winter is yet to leave us and the number of patients at night are not that much. However, we’ve had our share of very very sick patients, most of whom found healing.

One of the common things we find here are patients who have been rather embezzled of their money by doctors who are a shame to the profession.

We had a typical one today.

The lady, MeD, a 28 year old who’s being married for about 10 years came in labour. Although this was her third pregnancy, she did not have any live issues. Both her previous pregnancies had died, the first one died within a day of the delivery which had taken place at home; the second one died within a week of delivery in a clinic.

Both deliveries had one thing in common – the labour was a long affair and the baby had not cried at birth.

Well, I was surprised to see quite a hugh file being brought in by the relatives. She had been on treatment from one of the posh hospitals in a faraway city to ensure that this baby survived.

As I went through the records, I was stunned to find out that MD had undergone all possible evaluation for infertility . . . her second delivery was not even one year back.

The list of investigations was huge . . . I saw one bill which totalled about 20,000 INR. Even after she had conceived, she underwent serial ultrasounds . . . I asked the husband if he had any information on why the previous two babies died.

She also received quite expensive medications which I thought was not at all needed. 

He told me that he was told that the VDRL was positive. However, all the records of both husband and wife showed that VDRL was never positive. And it was so surprising that the husband was all praises for the doctor who was rather looting them.

It is so so sad to see a young poor couple taken for a ride like this by a clinician who had multiple degrees printed after his name. 

By the way, MeD delivered within half an hour of her arrival into the labour room. The mother and the baby has been doing fine so far and we thank the Lord that we could be part of the joy of this couple. However, I’m horrified at how this poor couple has been fleeced off quite a lot of their money and they being of the impression that they’ve had the best treatment possible to ensure a live baby.

The couple was all praise for the big hospital in the city who gave them all the 'world class expensive treatment' that has ensured a healthy baby . . . of course, the joy was immense as it is a boy baby. The previous two who died were also male babies . . .