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. 

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. 

A big 'Thank You'

This post is to express our gratitude to a wonderful couple who makes life at NJH quite lively and facilitates neonatal care which has ensured quite a number of babies to live every year. 

Yes . . . you guessed right. It's Wendy and Gerry . . . the team from Grace Babies .. .. ..

Over the last 4 years, they have turned around a very docile neonatal unit to quite a busy place. About 400 babies were cared for last year. The training sessions continued this year too. Snaps from their visit. 

Of course, the gifts of baby blankets, caps and mufflers have made the place a lot colorful and the babies quite cosy. 

Well, the training sessions went a step ahead this year. Wendy trained nurses from 15 Catholic dispensaries, most of them in quite rural locales on neonatal resuscitation. 

So, the impact is going to be more widely felt . . . 

Best Posts on RCH

I mentioned in my previous post that, over the last month, I had been searching for the best story in Maternal and Child Healthcare over the last financial year to write up a Human Interest Story for our Annual Report 2012-13. 

Around the same time, one of my friends suggested that I should make a list of the best incidents/posts in my blog worth reading in the realm of Reproductive and Child Health and sort of tabulate them. 

So, here is my selection. The period covered is April 2012 - March 2013. 

1. This is the story of a miracle we had in the hospital. 40 year old MD, a grand multipara had come to us with antepartum hemorrhage. With a hemoglobin of 4 gm% and no blood, only God could intervene. We thank the Lord that He intervened. MD lives to be a blessing to her family. 

2. The curse of anemia in pregnancy is something we've not taken seriously. Unavailability of blood and reluctance of relatives to donate blood deteriorate the scene. One of our biggest killers in the labour room is undiagnosed anemia. 

3. Many of our patients come in and die within minutes. This patient died within 15 minutes of admission. An obvious rupture uterus with severe anemia, there was nothing much for us to do. However, around the same time, someone had asked about tabulating the causes of maternal deaths during 2011 and 2012. 

4. However, there are others who take a long time to develop complications and then die. Most of the time, it's quite painful. And then you start wondered if you should have intervened this much in a situation where finances, specialist care and time are a premium. 

5. A narration of 3 adverse maternal events, all on the same day. And a worse spate of events on a fateful day in August . . . 3 maternal deaths . . . yes, one . . . two and . . . three.  

6. We knew this lady who was brought dead. She had become quite sick during her first delivery. Although she had her regular antenatals elsewhere for her present pregnancy, she was admitted about 2 weeks back with a very bad urinary tract infection. It was a shock to see her rolled into emergency with no sign of life. It looked like a case of post-partum eclampsia.

7. Many a time we become so busy to even note down about our patients. No time to even pause and think about the horror that many of the pregnant women go through. Some of them are so young to be even pregnant . . . leave alone have a rupture uterus. 

8. We have been actively managing severe eclampsia patients . .. ... going to the extent of elective mechanical ventilation. This appears to be yielding quite good results. A description of 2 such cases. 

9. A primi rupture uterus is not something which is common. However, last year we had an unfortunate lady with the condition . . . thanks to her lazy and ignorant family. 

10. Quite a lot of maternal near misses occur due to neglect. Poor infrastructure like bad roads complicate things. A typical case study. And ignorance makes things all the more worse. It is sad when healthcare fails people by not explaining potential risks. 

11. And worst, when patients are mismanaged by the medical fraternity on whom they have put their utmost trust. We also have instances where civil unrest in the form of general strikes result in maternal deaths. And to top it all there is corruption . .. .. blood bags with low hemoglobin values. And there appears to be no hope when they have no money to spend for their womenfolk in labour. 

12. Many people think that Magnesium Sulphate is a magic drug. However, our experience says that you need to have basic skills of stabilising a patient's airway and circulation if you want to manage your eclampsia patients well. And not to forget good skills in neonatal resuscitation if you want a healthy baby. 

13. Many healthcare professionals have requested us to share photographs especially of rupture uterus. This post (with snaps of the surgery) is about a rupture uterus where the baby turned out to be alive although sick. However, she did well in our Neonatal Intensive Care Unit. And there was one more lady who had a rupture uterus, but was blessed to have a live baby.

14. To showcase the seriousness of the obstetric cases we take up, I had put a post with a typical list of Cesarian cases and later the costs we had to write off. Thanks to this post, we have a well wisher from Australia who's helped us with more than a 200,000 INR to subside high risk obstetric care.

15. And last but not the least, the experience that a clinician or a midwife can get at NJH is amazing. 

We've slowly realised that we need consultants in obstetrics and pediatrics to share our burden. Please pass on this exhaustive post with links to those who may be interested. And of course, pray for us . . .  

Neonatal Care . . . Grace Babies

Similar to last year, Gerry and Wendy Cowles were at NJH, helping us out with Neonatal care for about a week. We are thankful for the time, they've spent with us. And of course, I had a great drive bringing them from Champa.

Teaching neonatal resuscitation

Classes .  . .

More hands on classes .  . . 

The beneficiaries . . . These beautiful sweaters have been knitted by churches in New Zealand.
Gerry and Wendy facilitate their distribution in hospitals such as ours.

Attentive staff . . . 

Another beneficiary . . . the winter cloths are from the same place as the above snap. 

For those interested to make financial contribution towards their ministry in the US, to to www.interserveusa.org, click on donate, then click donate online and under Category, scroll down to Project and type in Grace Babies 469973. 

Last maternal death of 2012

The sad part was that she was one of our regular antenatal patients and she had delivered her first baby also with us. Interestingly, her first pregnancy was also complicated. She had enteric fever, later viral hemorrhagic fever and ultimately had a premature birth. 

However, for her second pregnancy, she her her regular check ups elsewhere. However, she came with a very bad urinary tract infection with false labour pains more than 2 weeks back. We had to admit her and manage her aggressively to control the infection and the pain. 

She was well controlled and later took a discharge saying that she can continue her treatment in her town. 

She had an institutional delivery at a Primary Health Centre (PHC) on the morning of 31st December. Within half an hour, she had an episode of seizures which was managed at the PHC. She was at the PHC till around 2:30 pm, when the family was told that she appears to become sick. 

We do not know the details. But, she was brought dead at around 4 pm at NJH . . .

The relatives were in a hurry to take the body home. So, I did not get the details.

I've informed the same to the concerned people. However, I'm not sure if there would be any sort of follow-up on this matter . . . 

It was a like a message for us . . . Maternal and child health continues to be a major concern of the region which we serve. It was a bit unbelievable, but year 2013 also started off with a case of maternal near miss for us which I would narrate later. We have a long way to go. I'm sure that year 2013 is also not going to be any different. We would continue to deal with extreme obstetric care. My biggest wish for 2013 is that we would be able to involve ourselves in child survival a bit more than what we are doing now. 

Wish you all choicest blessings for 2013 .. .. ..

Rupture Uterus . . . Double escape

The other day, we had one visitor comment that there was so much happening at NJH more than what was being put up in the blog. Of course, it's become so busy that I have lost count of the amazing miracles that we witness each day. The other day I read somewhere that once you start counting your blessing, you'll loose count. Therefore, I ain't complaining. 

And all praise to my team of clinicians Drs Nandamani, Ango, Titus, Johnson, Shishir and Kumudh who silently labour on without a whimper. The support received from the nursing staff especially the theatre team is amazing. 

Just as I was getting out for a proposed half day leave today, Mr. Selvin, one of our nurses came in with a patient's chart who he thought would require some amount of charity. 

I was stunned on seeing the chart. 

It was of a case of a rupture uterus with a alive baby.

The story . . . It was not even one year since Mr. Gopal Yadav and his wife, Mrs Kavita Devi from Tarhasi village which is about 40 miles from NJH, lost their newborn baby. Mrs. Kavita had undergone a Cesarian section at a private clinic. They are not sure of the indication. The only thing they knew was that the baby was so sick that the obstetrician referred the baby to Ranchi. 

Mr. Gopal did not have enough money and spent almost a day making arrangements. They somehow reached Ranchi the next day, but the baby was dead by the time they reached. 

Nobody told them they should wait for some time before trying for a baby. Mrs. Kavita Devi was soon pregnant a second time and she went into labour sometime early morning of 6th July, 2012. 

The family took her to the same obstetrician who did the Cesarian on her the first time. She was given some injections. However, by around 10 am, she was told that there appears to be some problem and the uterus seemed to have ruptured. 

Someone advised them to rush to NJH as soon as possible.

They reached NJH Emergency at 12:50 pm on 6th July. It did not need much of an examination to suspect a Rupture Uterus. Dr Nandamani was quite fast. The baby was delivered by 1:40 pm. The uterus had ruptured with a hematoma of the right broad ligament extending to the urinary bladder. 

The baby had an Apgar of 2 and 4 at 1 and 5 minutes. The resuscitation was quite good. God's amazing grace and the excellent care at the new NICU ensured that the baby recovered fast. 

The family could not afford the full bill. Thanks to the Grace Babies Charity, we would write off the baby's bill. We wish we have some sort of Charity fund from which we could write off maternity care expenses. 

There have been more unfortunate cases where women end up living terrible lives because of poor obstetric care or lack of care of any sort. However, for Gopal Yadav and his wife, they have been blessed because of NJH. We are thankful that we are called to be a blessing through the service given at NJH. 

(The names and the photographs were put after taking permission from the patient and her family)

Neonatal Care at NJH . . . cont'd

After the initiation of regular service of the NICU after Wendy and Jerry's last visit to NJH, we've had a steady stream of neonatal admissions all through the last month.

Dr Johnson has been kept really busy. We've already set into motion plans to upgrade facilities fast. Over the last month (March 2012) we had 40 admissions - which is quite a good number by our standards. 

Today, we've 4 babies - all of them who were quite sick or was sick at some point of time - - 

1. PD's baby - 1500 gms born at 34 weeks gestation. Doing well. 

2. KD's baby - Severe meconium aspiration. Uncertain history. Grade 3 Meconium with staining of uterus with meconium. Initially poor maintenance of saturation. Offered referral to Ranchi. Did not accept. Has improved quite well. 

3. SD's baby - Preterm, delivered by Cesarian section yesterday. Grade 3 Meconium stained amniotic fluid. Uncertain history. Poor maintenance of saturation. Offered referral to Ranchi. Did not accept. Continues to have episodes of apnea and poor saturation. 

4. LD's baby - I had mentioned about LD in one of my previous posts. Has made a remarkable recovery. Should be discharged soon. 

5. RM's baby - Birth weight of 4.5 kgs. Was kept for observation. Would be moving out soon. 

In addition, we've a mother at 35 weeks who's just come in with findings suggestive of intrauterine growth retardation, severe oligohydramnios and leaking since 18 hours. We've offered a referral to Ranchi considering into fact that they appear quite well off. But, they have not taken . . . She would be delivering soon . . . which means, one more admission. 

Well, it has been a privilege for us that Wendy and Jerry facilitated the production of a video for the Neonatal Unit at NJH.

Well for those who would like to help us out, our immediate requirements are as follows - 

1. Infant cots: 6 nos

2. Infant warmers: 6 nos

3. Phototherapy units: 6 nos

4. Pulse-oximeter for infants: 10 nos

5. Infusion pumps: 6 nos

6. Infant ventilator: 2 nos

Neonatal Care . . .

Neonatal care has always been a challenge. However, we’ve been able to save quite a bit of little lives over the years. You can find quite a lot of stories on my blog. The post I can remember fast is that of KD's baby.

Jerry and Wendy

Now, a major influence in neonatal care in NJH along with many other EHA Units has been Mrs Wendy and Mr Jerry, a lovely couple from Maine, US. They have facilitated the setting up of the neonatal unit at NJH.  The construction of the unit had happened couple of years back and we also had the supportive equipment including warmers, incubators etc. Unfortunately, we found it quite difficult to operationalize the set-up because of the shortage of committed staff and the necessary administrative will-power. However, I was quite encouraged when Mrs Wendy decided to push through with the starting of the unit during her present visit to NJH.

And, she also was kind enough to give us an extended period of stay at NJH to facilitate opening of the unit. We are blessed and are thankful.

We’ve already have few very sick as well as small babies coming in. The tiniest one is about 26 weeks by gestational age born to a lady with abruptio placenta and placenta praevia. He’s just 700 gms and has made it so far.

I understand that Grace Babies, the movement through which Jerry and Wendy has been helping hospitals like us is a registered American charity with facilities for Tax Deductible Donations.

Of course, as we had been praying for quite a long time for a pediatrician, we have also been planning to upgrade the neonatal care unit with more equipment. For a start, we have realised that we need couple more each of baby warmers as well as phototherapy units.   In faith, we look towards a time when we will have a paediatrician coming in to be part of our team. . .  Meanwhile, we thank the Lord for the commitment Wendy and Jerry has shown towards the care of poor Indian babies many of whom would have died if not for their support.

And please remember the 750 gm hero in your prayers . . .