Tuesday, November 15, 2011

Close Call . . . And a poor Healthcare system

We had a very difficult antenatal case to deal with over the weekend. It was KB's first pregnancy and when she gave her history, it was a bit difficult to believe it. I had to ask the family over and over again whether what I was hearing was true.

The poor lady had been in labour for the last 5 days before she reached NJH. Her labour pains had started the Monday of the previous week. Initially, it was very mild pains. She went to the nearby Ranka Primary Health Centre where she was admitted till evening. She went back home the same evening as the family felt that nothing much was happening. She continued to have pains overnight and she was again taken to the PHC on Tuesday morning. She was there for the whole morning and when nothing happened, she returned home.

On Wednesday morning, as told at the Ranka PHC, the family took KB to the Garhwa district hospital. The family was told by afternoon that she cannot be managed there and therefore needs to go further. The family had already spent quite a lot of their finances by then. They went back home so that they can plan as well as arrange some more finances.

Overnight, she felt that she could not feel the fetal heart anymore. They family thought that now that the baby was presumably dead, they could do the deliver at the Ranka PHC and took her there on Thursday morning. The staff at Ranka told her that she needs to go to a higher centre. Since, they already had been told to go ahead to a higher centre at the Garhwa district hospital, they decided to take her to Daltonganj, the adjacent district headquarters.

KB was in the Daltonganj district hospital over the day and by morning when nothing much was happening, they decided to bring her to NJH. KB arrived sometime in the late in the morning last Friday. I was on call.

On examination, KB was quite toxic. The baby was of course dead. The cervix was about 8 cms dilated and there was marked Cephalopelvic disproportion. As always is the case here, she was quite pale. Her hemoglobin was 8 gm%, but I suspect that she was quite dehydrated after all the trouble she had been having over the last 5 days. But, more worrying was that her total counts was about 25000 with about 90% neutrophilia.

With the patient being in septicemia and her having been in obstructed labour for quite a long time, all the possible complications raced through my mind. The easiest option was to refer her to Ranchi which I did. But they were in no mood to go citing lack of finances. After taking a high risk consent and a discussion with my other colleagues, I decided to take her in.

This time, I decided to get at least couple of pints ready before I intervene, so that I do not end up in a situation last week when the uterus went into atony and I did not have blood.. None of the relatives' blood group matched. Unfortunately, her cervial dilatation stayed at 8 cm till around late evening. I started weighing the option of doing a craniotomy. I hate the procedure, as mentioned in my previous blog. The relatives went off to Daltonganj to get blood.

I started to get worried about the possibility of a rupture uterus as the uterus had been contracting against a non-dilating cervix. I did not have any other choice other than to pray. Sometime in the night, the relatives informed me that they may not get blood until morning.

We took a decision to act. With no blood available, it was dangerous. However, one of the nurses offered to donate blood if there is a dire need. With everything made ready for craniotomy, I positioned her to find that she had dilated fully.

The baby was delivered without any problem. We had taken all the precautions - however, it was a blessing that we did not have any of the problems that we had anticipated. The baby and the membranes were stinking. However, she responded well to antibiotics and was discharged today.

However, I had no inkling that we were going to have more challenges over the night.

No comments:

Post a Comment