Sunday, September 11, 2011

Story of a maternal death

KD, aged 19 years, married for about a year came into labour room at around 5:30 pm yesterday. It was a bit sorry to see her in such a state. She was fully bloated up, looking quite dehydrated and exhausted. KD was at term and she had been in labour since the day before. Admitted in one of the hospitals at Daltonganj she was referred couple of hours back with a diagnosis of obstructed labour. Her relatives were told that we would be able to pull the baby out with special instruments which we had in NJH. They must have been referring to the forceps or the vacuum extractor which we had.
I was called in to see KD. There was no question of getting a live baby per vaginally. The head was stuck firmly in the vaginal opening. Along with the caput which had formed, there was edema of the scalp which had worsened the situation. I was in a dilemma. The baby was alive. I went to talk to the bystanders. They wanted something to be done. But, the story they told me made me all the more confused.
KD had been diagnosed to have severe anemia for quite some time. Her hemoglobin was 4 gm% four days back following which she was brought to a doctor in Daltonganj. KD was from the border region of Jharkhand and Bihar. The family was quite poor and one of her uncles in Daltonganj volunteered to help her with her delivery in Daltonganj.
Nobody was willing to take her with a hemoglobin of 4 gm%. One of the places however took her with the condition that the family provided 6 units of blood. The uncle arranged the 6 units of blood which was transfused over 2 days. Meanwhile she had gone into labour.
When she reached us she was already completed more than 24 hours of active labour. After discussion with the relatives which included her uncle, we decided to take her for Cesarian Section. They had one pint of blood with them.

Her hemoglobin before surgery was 9.6 gm% and with one pint blood, it was worth the risk. However, considering her previous hemoglobin of 4 gm%, I took a very high risk from the patient including chances of uterine atony as well as vesicovaginal fistula. I gave them a very guarded prognosis for both mother and baby.

The pre-operative phase was uneventful. Once I opened the abdomen, I realized that I was in for trouble. The intestines were all edematous and there was quite a lot of fluid in the abdominal cavity. The bladder was edematous and there was edema on the anterior uterine wall and the space between the peritoneum and the lower segment of the uterus was also filled with fluid. As is routine, I incised the peritoneum over the lower segment and pushed it down along with the bladder. When I opened the uterus I knew that this was going to be a struggle. The baby had passed meconium and was totally caked in it. The inside of the uterus was stinking.

After somehow extracting the baby who had poor Apgar scores (3 at 1’ and 6 at 5’), I cleaned the uterus. However, it was refusing to contract. After about 3 ampules of carboprostin it contracted. I had also started to suture the uterus back. However, I noticed that she was bleeding from the edges of her wound. I could tell that the patient was going into Disseminated Intravascular Coagulation. The bleeding somehow stopped in between. So, I started to close the incision. Meanwhile, I realized that the uterus has again started to relax and her blood pressure was not recordable. She had gone into uterine atony. More injections of carboprostin went in after which the uterus contracted again.

We shifted her to the acute care unit and put her on the ventilator and started dopamine. She was bleeding again from the uterus when we noticed that the uterus had relaxed yet again. When we gave the carboprostin injection again, the blood she lost was enormous. We needed more blood. The relatives had donated quite a lot and they just could not find more donors.

Meanwhile, Dr Johnson had done quite a good work with the baby. He was crying and was doing fairly good.

However, by now we knew that we were losing KD. She was not responding to dopamine nor adrenaline. Most probably, she had gone into a septicemic shock and compounded with the obstructed labour and the state of anemia which she was in and the DIC, she had gone into a state of non-response to whatever intervention we were trying out.

I declared her dead at 10:30 in the night. I was quite confused on whether I had taken the best decision for KD. During the discussions with the relatives earlier in the evening, one of them had suggested that I kill the baby and somehow pull him out.

Later, as I reminisced about how things went about – maybe I should have waited for the baby to die, then do a craniotomy and pull the dead fetus out. But, she still could have gone into uterine atony.

But, all of this could have been prevented – had she got a regular antenatal check up and got a good hemoglobin whereby at least one of the high risk factors could have been got away with. However, the obstructed labour had made things worse.

The baby has been left behind by the family for us to care for till he is well enough to be taken home. I hope they will come back for the baby.

I just wished that things had turned out well for both the mother and the baby. But, that remained a dream for the family and us.

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