Maybe, we should have send her home . . .

Couple of days back, we had a very sick pregnant lady being wheeled in.

As DD was wheeled in, we were quite sure that we were dealing with a very sick patient. She had been in labour for more than 4 days. It was very obvious that she had been through a tough time. She was in a terrible shape; all bloated up; the birth canal was so edematous. The baby was obviously dead. The head was so high up and appeared to be stuck. The abdomen had a very abnormal contour which is quite commonly seen with those who sustained a rupture uterus.

There was a high chance that the bowel and the bladder were all ischaemic because of the abdominal massage she had over the last 4 days. There was only a 4-5 centimeter diameter of the birth canal. Even if we tried a craniotomy, there was high chance of severe birth canal injuries. There was also a chance of a rupture uterus.

She was also in severe sepsis.

There was only one thing that we could think about . . . to operate and remove the dead baby. The family were very very poor. They had not even a single rupee to take. They had been to couple of other places. The travel from their home to the various centres and lastly to NJH had taken up all the money they had.

Considering the chance of a rupture uterus and bowel injury, we decided to operate. On hindsight, the decision was a ill thought one. The uterus was not ruptured. But, the lower segment was like mincemeat. Putrefaction had set on the baby. On opening the uterus, there was a gush of pus and foul smelling gases.

The bladder was distended and edematous. So was the bowel. There was no necrosis or ischemia . . . but it was obviously unhealthy to look at.

I somehow closed the uterus and came out of surgery.

She did well for the first 24 hours. Then, her condition just deteriorated. She was running high grade fever round the clock. We had to hook her to the ventilator. There was foul smelling material coming out of the uterus. Her urine output was fine, but it was getting bloody and brownish. Her creatinine is about 6.

Today evening, she is all puffed up.

The costs of the treatment has been on the house. However, we will not be able to give her high end antibiotics like Piperacillin-Tazobactum. We helped the family arrange one pint of blood. We’re quite sure that we would not get any payment for this patient. The family had a RSBY card. We’ve blocked her under the scheme.

Please remember DD in your prayers . . .  

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. 

Safe in His Arms

This is the post I promised about SD, the second patient mentioned in the previous post. 

SD had come with bleeding per vagina as she finished 7 months of her second pregnancy. Her first child was just 1 year old. On arrival, she was in shock. She looked white. Hemoglobin came as 4 gm%. We were sure that it should be lower than that as she was quite dehydrated after being to multiple places over a period of more than 12 hours since her symptoms developed. 

She was too sick to even go for an ultrasound. She responded well to intravenous fluids. With a hemoglobin of 4 gm%, we were sure that she needed blood. We sent her relatives off to get blood. She could die any moment. The lady had come at around 10:00 am. 

We were worried as no blood came even after 12 hours. It was good to find one relative return with one pint of blood in the midnight. We had asked for three pints. We had to transfuse that pint of blood. 

She somehow pulled through. And the night was uneventful. We saw a new relative the next day. It was her father. He told us that her husband's family was too poor to bother. That was when we realized that nothing much was done towards bringing the three pints of blood. 

Meanwhile, we had an ultrasound which showed a complete placenta praevia. The baby was dead. 

A repeat blood test showed her hemoglobin as 2.5 gm% and she was in sepsis. A lowered hemoglobin after a blood transfusion . . . either she was so dehydrated on admission or the blood bag contained diluted blood. 

The father returned late evening. We were glad to see 3 pints of blood in his hand. One pint was on immediately and she was posted for Cesarian Section. However, the joy was short-lived. One staff noticed that the pints looked quite watery. The next two pints were sent for their hemoglobins . . . You can see the results . . . 

It was horrible . . .  Time was running out. One bag's hemoglobin was 5.2 gm% and the other 5.6 gm%. 

Then, we realised that SD had not bled after her admission here. We thought about thinking a way out without doing a surgery. As usual we contacted Dr. Hilda Yenuberi, consultant obstetrician at Christian Hospital Chattarpur, one of our sister units. She suggested that we try a normal delivery if she has dilated to some extent. This was only because we did not have quality blood and time was running out. 

A gentle per vaginal examination showed that she was not bleeding even on touch and her cervix had dilated to 6 cms. With prayerful hands, we induced her. 

The induction was uneventful. She delivered just after midnight. There was not much bleeding. However, we gave all the pints of blood that the family brought for whatever good it could do to her. 

They had gone again to get 2 more pints of blood. But, she had turned worse by morning. She was running high grade fever with chills and rigor. Repeat blood investigations showed that her hemoglobin continued to remain below 3 and there was evidence of sepsis. 

We changed to higher antibiotics. It was a miracle that she responded. Meanwhile, her father came with 2 more pints of blood. The quality was the same . .. ... water (most probably Normal Saline) mixed with blood. 

By today, she looked alright. We did not do any more blood tests. 

We thank the Lord that SD is alive. In spite of all the risks . . . Undiagnosed placenta praevia . . . no antenatal care . . . hemoglobin of 2.5 gm% . . . husband not bothered . . . difficult procedure to get blood . . . adulterated blood . . . and a vaginal delivery with placenta praevia . . . a centre (NJH) with no obstetrician/anesthetist . . .

I should say that her 1 year old child is so blessed to have her alive . . . I hope her next pregnancy is less eventful. 

Now, looking at interventions which could have eased the processes we and her family went through, if there is one intervention which could have made life easy, it would have been a UDBT (unbanked direct blood transfusion) at NJH.  

I would encourage your comments on this . . .

2 Rupture Uteri . . . and one live baby

About 10 days back, we had 2 rupture uteri. I had  written about it in an earlier post. 

SktD and NmnD . . . the patients. SktD's baby was not lucky as NmnD's baby. 

Couple of days back, I got the consent to publish the snaps of NmnD and her baby. 

By the grace of God, NmnD and her baby are doing fine. SktD was discharged couple of days back. 

Both of them benefited from the Maternity Charity Fund supported by one well-wisher. 

The snaps . . .

That is how NmnD's baby looked soon after delivery. The baby was in a face presentation.
I hope you remember UD whose baby also had a similar presentation

NmnD and her baby just before discharge . . . 

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. 

Dangerous obstetrics . . .

Over the last 3 days, we had 3 obstetric patients – each of the patients presenting some facet of reasons maternal mortality and morbidity continue to ravage third world countries, including India, who sees itself as an emerging superpower.

JK, 25 years old, married for 4 years and into her 3 pregnancy had been coming to us for regular antenatal check ups.JK had two major issues. On her first visit, which was at around 28 weeks, she had a haemoglobin of 5 gm% and she had severe kyphoscoliosis. We had taken a decision not to take her case at NJH – the question was about doing a Cesarian section with such a low hemoglobin as well as ending up with a child with severe growth retardation.

Nevertheless, she came for couple of more visits. And the final one, she came with mild labour pains. She continued to remain anemic and we referred her off to Ranchi on Sunday last.


It was a busy Monday and suddenly we had a commotion in the labour room. JK had come back – she was pouring out blood. There was no time to hear what had happened. We were wondering what to do, but we needed to act fast. One of the relatives told us that she had couple of blood transfusions at Daltonganj.

Daltonganj? ? ? What was she doing in Daltonganj? We had referred her to Ranchi. Well, this was not the time for questions. Someone shoved a sealed packet of blood to me . . . ‘We had arranged 3 pints. Only 2 pints of blood has gone. The doctors at Daltonganj had told that something can be done only at NJH . . .that is why we rushed’, panted one guy, whom we later realised was JK’s brother. . .

I checked the Fetal Heart . . . for 5 seconds. Must be around 80-100/min. The bladder was full . . . Then, she told that she felt like straining . . . There was only one diagnosis I could think off. . . The baby was on its way and the placenta had seperated . . . I decided to do a per vaginal examination. I was right. The vagina was fully dilated . . . But the head was a bit high up . . . Then, I realised that I had an advantage. The head felt a bit smaller for the quite spacious pelvic outlet.

We decided to put in a vacuum for pulling out the baby. . . And to the glory of God, it worked. The baby was of course sick . . . The placenta came out along with the baby. . . She had lost quite an amount of blood. I realised that the baby had also lost blood. . . The baby’s hemoglobin came as 10 gm% – whereas it should have been around 15-20 gm%. And the mother’s was 8 gm% after we transfused one pint blood today.

It was nightmarish . . . We could have lost both the mother and the baby . . .

As soon as JK’s drama was over, came in an eclampsia patient, MD. Unlike many of our Eclampsia patients, this one was of a different genre. The patient with only home based antenatal care had started to have seizures since 6 in the morning. The quack who was doing the antenatal care was summoned. He gave some treatment and his prescription is given below . . .

There were 3 more episodes of seizures from morning till mid-afternoon. After the last episode she became unconscious. And that was sometime around 12:00 pm and then the family took a decision to take her to NJH. By the time a vehicle was arranged, it was 2:00 pm. She was brought in at around 5 pm yesterday. On investigations, it was evident that she already showed low platelet counts and increased liver enzymes. She was already going into HELLP Syndrome. We asked the relatives to take her to Ranchi which they refused.

We asked them to arrange blood. But she was worsening. As usual – with a death on the table consent, we took her in for Cesarian section. The baby was caked in meconium, weighed a measly 2 kilograms – required quite a good resuscitation attempt. She could be easily weaned out of the ventilator. However, her blood pressure remains high . . . Please pray that she would make a recovery. Meanwhile, her platelets had come down to 45,ooo today morning. We sent the relatives for few pints of platelet rich plasma. . .

The last one was the most terrible one . . . At least we can console ourselves that the previous one was managed by a quack and therefore the 'near maternal miss'. Let's look at the 3rd one . . .

The lady, RD, who was G3P2L2 had presented dramatically with bleeding per vaginum at 36 weeks in emergency. Both her previous deliveries had happened by Cesarian section. She was on regular ante-natal check ups elsewhere. She had couple of ultrasound scans. Both of them were normal. Below are scanned copies of almost all antenatal check ups she had.


I have tried my best to remove any evidence about the concerned doctor/ultrasonologist who saw her before she turned up in emergency here. 

Well, we repeated the ultrasound and what did we have - a placenta praevia. The paradox was that she had films printed of one of the outside ultrasound scans and it clearly showed placenta praevia, whereas the report did not mention anything about it.

Worse was the blood report. There were 3 reports from the same place within a period of 14 days all of them showing varying values. You can make your own inferences. The scanned copies are shown below. The names of the ‘shops’ have been scratched out for posterity’s sake.

3 patients – each of them showcasing myriad shortcomings in our healthcare system . . . The sad part is that almost all of these shortcomings pertain to the basics . . .

JK’s case brought into the fore the following issues -

- Need for well run secondary care centres (if possible tertiary care centres) at district level.

- Need for Blood Bank facilities. One may need to relax few of the present regulations for licensing so that blood will be freely available.

What did MD have to tell us?

- Most of our populations live in remote regions without any basic facility of healthcare. They are dependent on the quacks for their regular medical care. Operationalising sub-centres and training ASHA workers and ANMs is a major challenge. 

- Transport remains one of the major challenges in almost all our rural areas. Many of our states have circumvented this issue by 109 Ambulance. In Jharkhand, we have something called the ‘Mamta Vahan’. I’m absolutely certain that we need to look beyond the ‘Mamta Vahan’.

And the last one RD?

- You cannot blame RD for the quandary she is in. The healthcare community let her down.

- 2 ultrasounds and a Grade 3-4 Placenta Praevia missed.
- Varying reports of hemoglobin from a single laboratory in a space of 14 days.
- No mention of RD being a high risk patient in any of the prescription charts.

As I had told in one of my previous blogs, the quality of healthcare is a major issue in almost the whole of the country. Each day, it is not uncommon to see diagnoses being missed, unnecessary investigations being done and lack of technical knowledge in paramedical services mainly laboratory and radio-diagnosis. Hope you remember one ASHA worker who failed to recognise her own complicated pregnancy and paid with her life.

Well, sorry for the quite long post. Before I sign off, just a passing reference to a law that is coming into force. The Clinical Establishment Act. More of that in my next post. Already in force in Assam and Orissa, it could sound the death-knell for hospitals such as NJH. . . 

Tale of 2 pregnancies . . .

I had 2 ladies in the labour room yesterday (Sunday, the 12th February, 2012).

The first one was SD. . .  In fact, it was a bit funny. Dr Titus was on co-call with me. And I was just commenting about how long it had been since we had a patient with eclampsia. SD came in sometime around 2 pm. She has been in labor for quite a long time. . . In fact, almost 36 hours. She had initially tried to deliver at home. After which she was in the district hospital for almost a day before she decided to go to a nearby private hospital today early morning. By afternoon, as the relatives saw that nothing much was happening, they decided to bring her to NJH.

We saw SD walking in through emergency. In fact, we realized that she had a urinary catheter. And was it blood tinged? Yes, it was. . . We really scratched our grey cells on why this patient was kept in labor for quite a long time. We found out  - - more than an hour later.

After a detailed examination, we decided to keep her for normal delivery for another 2 hours. The baby seemed fine although the liquer was a bit meconium stained. She was about 8 cms dilated which prompted us to keep her for normal delivery. As the nurses were ordering the medicines, one of the relatives asked her if she could use some of the medicines which was purchased in the previous hospital. The nurse asked them to bring the lot . . . and along with the normal medicines used in the course of labor, there were half a dozen ampules of magnesium sulphate.

The nurse immediately informed Titus. We asked the history once again. Well, the lady had 2 episodes of seizures sometime during the time she was trying to deliver at home. They did not realise that the history was important. Somehow, it was almost couple of hours after she was admitted. And, we did a repeat per vaginal examination. Nothing much had changed. 

SD was posted for a Cesarian section. The baby was a bit sick, but after a good resuscitation, he's done well. SD was also sick during the post-operative period. However, overnight she has made a good recovery. 

The second one who we'll call RD . . .  It was RD's first baby. RD had been in labor since the last 3 days and she had been leaking since almost 36 hours. RD was trying for a home delivery with the help of a retired nurse. The interesting aspect was that RD had another 3 more weeks to go before her due date. On a detailed history, the pain with she started did not look like normal labor pains. I thought that it looked more like a urinary tract infection. But, she was put on intramuscular oxytocin injections - to speeden up the process. And there was no looking back. 

To complicate matters, she had started to leak. But, she did not take it seriously and did not report it to any of her relatives. The delivery having been planned at home - most probably, there was not much of a seriousness in the whole affair. However, sometime around Sunday afternoon, the relatives started to become concerned - which is when they brought her to NJH. 

With RD having been leaking since 36 hours, I had to explain to the bystanders about the possible complications of chorioamnionitis and a prolonged labour. They looked quite well off for our usual clientele and therefore, I gave them the option of taking to a higher center. They initially refused and allowed us to manage her. I was not much in favor of going in straightaway for a Cesarian section. 

She was about 3 cms dilated with full effacement. I explained to they relatives about us taking the risk of trying for a normal delivery. I decided to give it a try as long as there was no sign of a fetal distress. I was surprised that RD progressed textbook fashion. But then, she suddenly stopped contracting at full dilatation. I had to do a vacuum extraction of the baby. 

The mother and the baby are doing well. 

Both SD and RD could have ended up with severe complications endangering the lives of both mothers and babies. They are blessed to have had happy endings. We praise the Lord for the same. . . 

As I had mentioned in many of my posts, the solutions are not very difficult. SD need not have run from one hospital to the next, trying for a good management. RD should have been investigated for urinary tract infection, before a decision was taken to induce her. . .  And how was the induction done . . .Intramuscular Pitocin . . . It continues to be a scourge in maternal healthcare all over the country. And RD was quite unaware of the dangers involved when she started to leak . . . And the worst of all - especially when a patient comes from another healthcare provider - the lack of a proper referral letter . . . SD and RD could have been provided referral letters by their previous respective care providers . . . 

All these are not rocket science . . . We've been shooting off rockets with satellites into space, manufacturing supercomputers and contributing heavily into the information technology field and more interestingly developing into a medical tourist destination . . . But, what a paradox - when it comes to providing safe delivery facilities for our sisters and mothers, we come up a cropper . . . 

Obstructed Labour . . .

Just wanted to post couple of photographs and couple of thoughts related to a Near Maternal Miss we had today morning. . . 

As you are all aware, obstructed labor is one of the major causes of maternal mortality. If I'm not mistaken, obstructed labor is either the fourth or the fifth most common cause of maternal mortality. Of course, the most dangerous presentation of obstruction is a rupture uterus.

I would be sinning if I do not admit the fact, it was couple of eclampsia patients and one rupture uterus which actually started this blog moving. . . 

Many of the babies in an badly obstructed labor do not make it. And we had a very bad one today morning. The only thing we had in our favor was that the uterus was still intact and the baby was alive. 

SD was in labor since yesterday evening. She started her pains at sometime around 6 pm in the evening. And from 8 pm, she was in the district hospital. She was started on a drip with some medicine - the family was not sure on what it was. . .  All through the night, she was contracting . . . Unfortunately, nobody did a pervaginal examination on her till today morning, sometime around 6:30 am, and she was asked to come to NJH. . . 

I'm impressed. We've had terrible cases where patients were kept in the lurch in healthcare institutions, both public and private. Here, SD was referred within 10 hours of her admission although she could have been monitored a bit more better as well as had antenatal check up. 

Well, that is the reason, she did not end up with a rupture uterus. 

I was in the middle of a Cesarian section at around mid-morning when the news about SD's reaching NJH reached my ears. Dr Johnson saw her first and immediately posted her for Cesarian. . . The baby was wedged tight in her pelvic outlet. . .  He was worried if I'll have difficulty getting the baby pulled out from the abdomen . . . 

And, oh my! It was the worst obstructed labor that I had ever seen. . . The uterus looked quite funny from the outside - was suggestive of bladder edema and dilated bowel loops. I decided to open the abdomen through a midline vertical and oh boy! Was I not overjoyed? The snap below tells the story . . . 

The finger is on the upper part of the incision and shows the bladder. The second snap shows the place I put the stay suture before I opened the uterus. . .In my career of 10 years, that was the highest stay suture I've ever put . . . .

Of course, the baby was sick . . . However, my colleagues including the new kid on the block, Dr Titus ensured that the baby was breathing well . . . It was then that we noticed that the baby had a head little larger than usual. . . A head circumference of 40 cms for a 3.5 kilogram baby is definitely on the higher side. . . We've given an option to the relatives to take the baby to Ranchi for evaluation . . . Surprisingly, there is no caput or cephalhematoma . . . 

One more aspect about the whole incident was the time taken by the patient to reach NJH from the place where she was being managed earlier. . . A decision was taken to refer her to a higher center was taken at around 6:30 am . . . however, she reached us only by 9:30. The place she came from is only 30 kms away . . . Inadequate transport facilities, bad roads etc contribute. . . 

We got the baby out at 11:12 am . . . We could have done it faster had the theater been free. . . When the patient arrived, another Cesarian was on and I was sure that the Cesarian on SD be done on General Anesthesia. And I was thankful to the Lord that we did it on GA as the surgery took more time than normal as well we needed more muscle relaxation . . . 

We still need to go a long way . . . And the most easiest aspect of this journey is that the interventions, such as protocols, identification of danger signs etc that we need to implement are simple and inexpensive . . . 

Unbelievable . . . Stunned beyond words . . .

(This post is a purely of medical academic interest and contains snaps which could be offensive to many. Kindly be careful)

I had written the  previous blog about SD and PD yesterday night but could not post it as there was no internet connection.

PD's relatives brought the 2 pints of blood requested by us by early morning today and Dr Nandamani  called me to help with the surgery.

We were definite that we would be in for few surprises.

This was what we saw as we opened the abdomen. Instead of a smooth ending slope of the uterus what we got was a beveled lower segment which was quite undermined. We decided that there must be a tumour somewhere nearby and opened the uterus where we could visualize as low as possible and delivered the baby.

Then we found out that the uterus was refusing to contract and it looked more like one of those olden days' wineskins.

Dr. Nandamani then started to search for the apparent cervical fibroid which we had found out during the ultrasound. The uterus was quite large and he had to really work hard to mobilize the uterus outside. It was then we noticed where the bleeding was from. One of the ovaries looked ruptured – must have been a large ovarian cyst.

We found out the ‘tumour’ which we were looking for – but it looked quite unusual. It was then that we realized something funny. There was one more ovary on the same side. Well, it did not take long for Nandu to realize that the uterus had got twisted in its axis 180 degrees and he had opened the posterior wall rather than the anterior wall.

And as shown in the snap, the 'tumour' was the left horn of a bicornuate uterus.

We confirmed it after few more examinations. It was quite a relief to realise that we were not dealing with any malignancy.


The rest of the surgery was uneventful. However, we realised that we've just witnessed something which was quite rare.


The best part of the surgery was that although we had to remove the flaccid right horn of the bicornuate uterus, we could leave behind the left horn intact. And maybe, she may concieve. After 4 pregnancies where she ultimately lost all the babies, we pray that she would be able to concieve.


I remember a similiar case of rupture uterus during my previous stinct at NJH, where we found out that it was a bicornuate uterus and the lady concieved in the other horn after one year and delivered a baby by elective Cesarian section.

CLOSE CALL FOR ANOTHER BABY AND A NEAR MATERNAL MISS (maybe)

SD has had a very uneventful life so far. Life has been quite a mixed bag of joys and sorrows – more of sorrows like quite a lot of her friends in the rural hinterlands of the country.

Married about 6 years back, this was her 3^rd pregnancy. Unfortunately, none of her previous 2 children were alive. The first one had died at the age of 4 years after a bout of fever. And the second one which was born in a hospital died 3 days after he was born.

The present pregnancy was precious to her. However, neither she nor any of her family members deemed it fit to have a regular antenatal check up. Her labour pains had started very early today morning. SD’s first child, a girl was born at home – there had been no problems.  The second child was born in the hospital – thanks to the Janani Suraksha Yojana – she ensured a hospital delivery so that she would get the financial incentive. For a poor family 1400 rupees was quite a large amount.

However, she lost her second child, a son – much treasured in Indian homes, within duration of 3 days. He was sick on the night of the 3^rd day after birth. The family stayed close to the nearby town and decided that they would go to a doctor as soon as it was daylight. But the child was dead by dawn. It was a tragedy.

The financial incentive that the family received looked quite insignificant in the light of the dead baby. Meanwhile within the next 2 months, the elder one, the daughter had fallen sick. The doctors in the district hospital diagnosed cerebral malaria. They treated her for about 1 week, at the end of which she was also dead.

The family was overjoyed when SD became pregnant for a 3^rd time. However, they had quite decided that the delivery would be a family affair at home rather than a physician/nurse assisted one.

The labour pains came quite strongly. SD had taken the help of one of her relatives who knew something about childbirth. Nothing much had happened by afternoon. The relative who came to help out was smart enough to realize that something was wrong.

She took the lead along with the rest of the family to mobilize SD to NJH. Going to the district hospital was not an easy choice considering the ‘bad result’ that the family had with both their other children. In spite of very bad roads from Daltonganj to NJH – the family somehow got hold of a vehicle to bring them here.

I happened to see SD as she came into labour room. She did look to be in distress. On examination, it was obvious that it was not a vertex presentation. And the uterus was in a constant state of spasm. Ultrasound confirmed that the baby was lying transverse. She was straightaway rolled into theatre after the necessary formalities. I had not asked much of the history.

On opening the abdomen, I realized that I was in for trouble. The uterus was shaped like a inverted pot with a long neck. It was obvious that the lower segment was hardly stretched and the baby was fully in the uterine body. I was not sure whether the lower segment will expand enough to deliver the baby. I opened a bit high closed to the uterine body.

To my horror, the bag of membranes was black in colour. It was meconium and the baby was caked in it. I already told someone to call Dr Nandamani to help with the resuscitation of the baby. The presentation of the baby in a tonic uterus made the extraction of the baby quite difficult. Somehow, I delivered the baby.

Dr Nandamani was quite fast to come to theatre and he did quite a good job with the resuscitation. As I started stitching the uterus, the nurse anesthetist was already talking with the patient on any other relevant history. It seemed that the kind relative had given her intravenous fluids and couple of injections to increase her pain.

The baby was lucky to have made it.

Quite a number of lessons I learnt from this patient. The importance of ensuring that a patient has a pleasant experience during an interaction with a healthcare provider is quite key to her trusting hospitals and doctors at a later stage. Communication regarding identifying danger signs in babies is quite important at the time of discharge of mothers after delivery. Cash transfers such as JSY motivates patients for institutional deliveries, but as I wrote earlier, we need to ensure that their experience is quite pleasant. Of course, there are more lessons I would need to learn from such patients.