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 . . . 

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. 

Risky . . .

(This post was written on yesterday, 13th October, 2013)

We had a very high risk delivery in our Labour Room yesterday (12^th October, 2013).

SD had come in almost in second stage sometime late afternoon. It was her first delivery. She had been in labour since midnight elsewhere. The family felt that the labour was not progressing. After doing the per-vaginal examination, I also felt that she may not deliver normally. However, there was a minimal amount of malrotation of the head. We took a decision to wait for an hour for a normal delivery.

As I went to talk with the male relatives, I got another history which the female relatives accompanying SD did not give. (In our labour room, female relatives accompany the patient inside.) SD had been having very high fever since the last week. She was on treatment on and off. When I came back, the nurse on duty told me that SD was febrile. We send off the basic blood investigations. Anyway, we planned to wait an hour before we took her up for a Cesarian section.

The lab guys were in a frenzy to get back with the report. The major issue was that SD had Vivax malaria and her platelet count was only 20,000. Meanwhile, there was the call from labour room saying that SD is delivering. I could only think about SD bleeding to death soon after the delivery. The whole team knew we could be in for a maternal death.

Over a space of 10 seconds, we had a plan put in. Roshine, our medicine consultant was going to overlook the general well-being of the patient, Titus was going to take care  of the baby, the lab guys were trying to arrange for a fresh pint of blood, I was going to take the delivery. The plan was to put a vacuum without an episiotomy. The justification that a episiotomy could result in freshly cut vessels which could bleed. And then, there was a prayer on everybody’s heart that we would not lose the mother or the baby.

Everything went according to clockwork. The baby was as predicted sick. Titus and his team of nurses did a superb job. Roshine was happy that she did not have to do anything heroic. There were few small lacerations which were bleeding. We initially thought that we were not getting the bleeding controlled. Off went a call to Dr. Shalini, our obstetric consultant at EHA Central Office, who advised us to just keep pressure on the lacerated areas. And to try to get at least a pint of fresh blood.

We had our nursing students who enthusiastically kept guaze pads pressed on the lacerated areas for almost an hour. She was still oozing. Someone suggested that we pack the vaginal vault with guaze. It worked.

Now, the question was about getting some fresh blood. Her blood group was A positive. Before one of us could volunteer, we thought of asking the relatives to donate. The effect was that all the male relatives expect one old man disappeared in no time. Nobody wanted to donate.

However, SD was doing good. It did not look like she had a platelet count of 20,000. However, it was true. Couple of people had double-checked it.

We thought of not giving her a fresh pint of blood. It was risky for her. However, it was illegal too to give UDBT (Unbanked Direct Blood Transfusion). The fact that her relatives did not want to donate blood made us take the tougher stance of no staff donating the blood.

It’s more than a day since she delivered.

A UDBT would have given us a bit of comfort. I could have easily requested one of the staff to donate blood.

I hope our decision will stand vindicated. However, the plight of this lady is quite same as those whom I mentioned in my previous post. Blood donation is something about which more awareness needs to be made. And UDBT is something that would do quite a lot of good for hospitals like ours. But, with poor awareness about blood transfusions, even UDBT would be of not much use.

At the end of the day, I’m thankful to God. I’m certain that its patients such as SD that make mission hospitals quite a great place to be.