Thursday, September 22, 2011

Rupture Uterus and Broken Dreams

BD was 22 years old and was married 3 years. Her last 2 pregnancies had ended up as first trimester abortions. So, when she got pregnant for the 3rd time, she was quite careful. Her family was poor. Therefore, she could not afford to go to any of the major doctors in town. Her local Anganwadi and the nearby Primary Health Centre provided the basic antenatal care including iron tablets and the tetanus injection.

BD went into labour on the 18th evening at around 7:00 pm. There was no way she could reach the nearby PHC as it was quite dark. Her family arranged for a vehicle to take her to the PHC in the morning. There was no doctor in the PHC the whole day. A nurse who was in the centre was on and off examining her contractions. By evening, the family was quite frustrated that nothing much had happened. Therefore, they decided to take her back home and have a home delivery. Unfortunately, nothing happened overnight.

BD was back at the PHC on 20th morning where the nurse informed the family that they should think about taking the family to the district hospital at Daltonganj. They reached the district hospital at Daltonganj by around 10:00 am where they were told that she was quite serious and that she can only be managed at NJH.

When BD reached NJH, we were having a quite hectic day in OPD and the theatre. There were quite a number of elective surgeries posted, Dr Nandamani was sick, Dr Johnson was away and I was looking after OPD as well as doubling as the anesthetist in the theatre as couple of patients for elective surgery was elderly.

Drs Angel and Shishir saw BD and a diagnosis of rupture uterus was not difficult. After explaining the risks to the family, we decided to operate as soon as one pint of blood was available. All the relatives who accompanied BD had their blood tested – unfortunately, either each of them did not have a match and when they had a match, the donor hemoglobin was not enough to donate. So, off the relatives went to arrange blood.

By the time, a pint of blood was available it was quite late in the night. Dr Shishir who was on duty operated. It was a mess inside the abdomen. It was quite a long time since the uterus had ruptured and the uterus was quite gangrenous. Shishir realized that the uterus has to be sacrificed if the patient needs to survive.

It was a tough decision for the family to take. Neverthless, they gave the consent and Shishir went ahead with the partial hysterectomy.

It has been 36 hours since the surgery. BD continues to remain sick. She would need more blood as well as stronger antibiotics. I sincerely pray that BD somehow survives.

Her family is quite ignorant about what is happening. I have mixed feelings about BD’s future. In a society which is so obsessed with having a male progeny, her status within the family is going to nose-dive. Most probably, her husband – although very concerned as of now – would most probably marry a second time.

But, issues such as PHCs being manned by staff who have no basic idea about the physiological process of pregnancy and normal delivery and especially in identifying danger signs in a mother in labour needs to be seriously looked into.

After MD, it was quite a long time since we had a rupture uterus and I was feeling happy that the incidence of rupture uterus was on the low - but the experience with BD has made me realise that there is always a possibility of us seeing more of similiar cases in the future. But, BD's story was the saddest story I had encountered of rupture uteruses I've come across.

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