3 adverse maternal events . . .

Today, I'm on first call after quite a long long time. Necessitated as we are just 3 of us running the hospital from Friday last. Many a time, I wonder about how long I shall shout about adverse maternal events in this part of the country. And every time, I get an answer about what to do . . . Yes, continue to shout about it till something happens. 

We had 3 mothers today . . . all of them had gone through adverse events. Of the three mothers, one was already dead by the time she reached us. The second one was . . .  from a medical point of view . . . a gone case . . . it would need a miracle for her to live. The third one came to us on time . . . she should live. 

Their stories . . . 

The first patient, AA, was a known case of pregnancy induced hypertension. She was supposedly under treatment. However, I did not see any records. Therefore, not sure. She had started to have convulsions today early morning. They had taken her to some hospital in the nearby district headquarters. From where they were asked to go to NJH. It was too late for her. She was dead by the time she arrived. 

The second patient, BB, a primi mother had been having contractions since the last 3 days. When she did not deliver by today morning, they took her to a hospital nearby where she delivered a macerated baby. But, then her abdomen started to distend. She was given a letter to go to Ranchi. 

Her relatives brought her to us. The family was too poor. And her blood group was O Negative. She was putting out blood from her bladder. And then to our horror, found out that she was leaking urine. And on putting a nasogastric tube, there was pus coming out. Most probably, she had undergone abdominal massage when she was trying to deliver at home. 

My provisional diagnosis - Rupture uterus with bladder involvement and intestinal necrosis following abdominal massage. 

Thanks to a new fund we created following a donation from a well wisher in Australia, we paid for her travel to Ranchi. I can only pray that she survives. 

The last patient, CC. Into her 2nd pregnancy, she had a cord prolapse. And her baby was dead for almost 2 days. There was pus pouring out from the uterus. The last thing I wanted to do was a surgery to deliver a dead baby which was stuck in the uterus. But, that is what the doctor who first saw her elsewhere wanted us to do. 

I was not sure about how friable was the uterus. She was in full blown septicemia.

We took a decision to try to do a craniotomy and keep her ready for laparotomy if the uterus ruptures in the process. It's a difficult thing to do a craniotomy and I always pray that I do not end up doing one. 

As we were explaining to the relatives about all possible complications, the fortunate lady suddenly started to have contractions. And she miraculously delivered normally. It was a relief. 

It was very unfortunate . . . for the first two ladies . . . 

Next week, it is International Women's Day on the 8th. 

I pray that we would continue to make a difference in the lives of women in our surrounding communities especially when it comes to managing their pregnancies . . . 

TALES OF 3 PREGNANCIES . . . LIVES OF MISERY AND SUFFERING . . .

Over the last 3 days, we’ve had 3 pregnancies – in almost all of them the mother could have died . . . But, they were all lucky and as always, there are lessons to learn – almost all of them with simple solutions.

3 days back, we had a lady with rupture uterus. SD1, aged about 25 years, was in her 4^th pregnancy. And she had just one live child – a girl aged 6 years.

Her first child was born at home and had died after couple of days – this was 8 years ago. The verbal autopsy was indicative of birth asphyxia.

Second child was born at home – and she was the only child who was alive.

The third child was born at a private clinic, but the child was dead by the time they reached the health centre.

The pains started from the night. 4 am she went to a private clinic in Japla who referred her to the nearest district hospital where she was kept for about 2 hours before she was sent to NJH.

On arrival, our duty doctor, Dr Shishir was sure that the uterus had definitely ruptured and it could be a surgeon’s nightmare. He suspected bladder rupture too.

The surgery was uneventful. SD1 is making a slow recovery.

The saddest part was that SD1 took quite a lot of time going from one centre to the other because of poor roads and transportation.

Then, there was SD2, 32 years old who came with her 8^th pregnancy. Her first 4 children were alive. Then she had 3 deliveries where the baby’s head got stuck – and all of them died during birth.

However, they had taken a decision to do a hospital delivery for the next one. They somehow got hold of an ultrasound which confirmed that the present baby was also quite a large one. It was quite surprising that they came straight to NJH without stopping anywhere.

After they reached NJH, for some reason, SD2 had a very bad episode of antepartum hemorrhage. And to post her for Cesarian Section became all the more needed.

The third one happened today. 24 year MD, who had delivered about 3 years at NJH came with a obstructed labour. The family had been trying to deliver her at home since early morning. She was not from very far – maybe about 20 kms away.

MD’s first pregnancy was also obstructed, the baby had died in utero and we had to do a craniotomy to deliver the dead baby. Maybe, the family thought that the first baby would have somehow widened the birth canal – and therefore, the second delivery should not be a major issue.

When MD reached NJH, she was already in a very sorry state. The baby had passed meconium in utero and the heart rate was dipping. I was sure that I could not assure the relatives that this baby would also make it. However, the relatives opted for surgery.

I was glad that we could deliver a healthy baby by Cesarian section, although she had aspirated some meconium.

Later, I found out that all the three ladies had received intramuscular oxytocin injections at some point of time during their labour. 

3 ladies - totaling 14 pregnancies . . . Of the 14, only 6 yielded live babies . . . And as I told earlier, all the 3 ladies could have died delivering their last babies . . . 

Well, considering the trauma all these 3 ladies had undergone during their lifetime, I wonder what you would make of the story of the young man about whom I plan to write within the next couple of days . . . 

Maternal near misses continued . . .

My last duty was a bit stressful. I had to do 3 Cesarian sections back to back. And to make things quite difficult there were the 3 malaria patients in the ACU and the terribly burnt patient which Nandamani kindly agreed to manage.

The first one was SD who came in at around 10:00 pm with a hand prolapse per vagina. I somehow hoped to do an internal version. However, she being a primi – it was quite a tough ask. And when I examined her, it was obvious that I would not be able to do the internal version. The uterus was in a state of tonic contraction without any moment of relaxation.

Per operatively, I was glad that I did not try the internal version. The lower segment was on the verge of a rupture. Later I found out that she had recieved intramuscular pitocin injections from her village.

However, what I wanted to bring to your attention was the fact that SD had been diagnosed to have breech presentation on arrival in the Leslieganj PHC and she had a referral letter dated the same day at 5:00 pm. But, the relatives decided to stay on whatever the consequence is. There was a high risk consent absolving the PHC doctor of any complication if she did not go ahead to a higher centre.

The hand prolapsed occurred on the way. The baby was freshly dead. Maybe, we would have got a live baby if she had turned up early.

The second one was AD, who came in sometime late morning. It was AD’s first pregnancy and she lived adjacent to the District Hospital at Daltonganj. Interestingly, till the day of admission her family never thought about taking her to the District Hospital for an Ante-Natal Check Up.

On the day of her admission to NJH last Monday, sometime in the early hours of the morning, AD threw a fit out of the blue. There were no warning signs. No swelling up of the body or no blackouts. Taken straight to the neighbouring district hospital, she was referred to NJH. Unfortunately, on arrival at NJH, AD was quite groggy and had 5 episodes of seizures.

The problem was that according to her dates, she was just in the middle of 32 weeks of gestation. Her blood pressure was 160/100, and Urine Albumin was 2+. As always is the case, we explained the limitations we had in terms of not having an obstetrician, a paediatrician, anesthetist, medicine consultant, ventilator, blood bank…everything I could think of. Armed with a high risk consent, I told them that I shall try for a normal delivery – without any sort of guarantee for the mother/child.

Over the next two hours, her blood pressure had become controlled and I was sort of confident of somehow getting the steroids to act on the baby’s lung tissue by waiting for 24 hours before we acted. I also induced her with Misoprostol.

As evening progressed, with the malaria patients and hand prolapsed, my thoughts were on how AD is doing. In between the surgery for SD who came in with the hand prolapsed, the nurse in the Labour Room informed me that there was a rise in AD’s blood pressure and her Urine Albumin is 4+. I knew that I had to act.

I posted her for Cesarian section immediately after SD’s surgery. AD delivered a healthy boy more of a Small for Gestation Age baby rather than premature weighing about 2 kgs. The mother and baby have done well so far.

It was quite a paradox that within a week of my post about non-availability of proper medical facilities, here was a patient who totally ignored getting herself at least one ante-natal check up and ended up with a complication and another one who ignored an advice to go to a higher centre.