Wednesday, August 10, 2011

Maternal Near Miss...

UD a mother of three girls was quite an experienced expecting mother. In addition to the 3 daughters she had, she had delivered 2 boys who had died soon after birth. In addition, her second daughter was born by a cesarian section. And, the rest of the deliveries had been conducted at home. Her eldest daughter, the first born was 15 years old. She had lost both her babies in the last 2 deliveries. So, she was a G6P5L3D2.

UD came on the at around 1:30 am yesterday. She had been having pains since early morning the previous day. As all her previous deliveries, UD had thought that it would go about without much problems. However, since afternoon, she got a feeling that this is not going to be a uneventful delivery.

UD's husband is away in Delhi working in a factory. He is yet to arrive. He has supposedly got into a train from Delhi. UD's brother told me that he should be here by late night or tomorrow morning.

By the time, UD's relatives arranged for a vehicle and took her to the nearest health centre it was 4 in the evening. There was a doctor at the PHC who told them that she looked really anemic that it would not be safe for them to deliver there. They rushed to the nearest town, about 70 kms away. By the time they reached it was around 8 pm. They initially took her to a private hospital. She had some relatives who worked there. They talked with the doctor - who told them that they'd better take her to the District Hospital. However, no doctor examined her.

They arrived at the District Hospital at around 9:00 pm. She was taken in to the emergency. Couple of paramedics (compounder) examined her. They supposedly had a discussion with a doctor who told them to bring her to NJH. Once again, it seemed that the doctor never saw the patient.

On arrival at NJH, Johnson saw the patient first and he suspected a rupture uterus. He called me first. Since Dr Nandamani (surgeon) was around, I suggested that he be called as we are never sure about what all would be involved in a rupture uterus. In addition, I needed to leave for Ranchi at 5 in the morning. Dr Nandamani also came to conclusion that UD had a rupture uterus.

She was posted for surgery. Her hemoglobin was 11 gm% - which could have only been because of a dehydrated patient. Dr Nandamani had the shock of his life when he opened the abdomen. The uterus was open with the baby in the peritoneal cavity. In addition, the bulb of the Foley's catheter (urinary catheter) was also in the peritoneal cavity. He thought that someone had inadvertently put the catheter into the vagina rather than the urethra. However, it was only after some time he realised that the bladder had ruptured and the catheter was sticking out of the rent in the bladder.

The repair took almost 3 hours. By the time, it was all over, it was around 6:30 pm. She needed 2 pints of blood.

One aspect which was very much noted during the narration of the whole line of events by the patient's brother was that there were 2 places where a decision was taken without a clinician examining the patient. I pray that this is not true or that the bystander somehow missed seeing the doctor come and examine the patient. In addition, in spite of the patient having visited 3 healthcare providers, nobody had thought about putting an i.v canula or at least measuring her blood pressure.

It is unthinkable that such a high risk pregnant patient had to travel 100 kilometers visiting 4 healthcare facilities before she got to be properly examined by a doctor and any sort of treatment started.

UD's male family members does agricultural work in their own fields of about 4 hectares. Since the last 2 years because there were no rains, many of the menfolk including UD's husband had migrated to cities like Delhi to earn a living. This year, the rains have just started and they should be involved in agricultural work - but, now, they are all busy caring for UD. UD brother sounded very apprehensive about the coming year as they have not been able to start the agricultural work.

Considering the extent of surgery which was done, they would end up with quite a heafty bill. I was told that UD earns about 5000 IR per month. I'm sure that UD's treatment costs would not be less than Rs. 15,000. Elsewhere, it would have been twice this cost. We don't need much evidence to prove that healthcare costs pulls quite a lot of families into penury.

UD has done well so far. Kindly pray that she will make a fast recovery.

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