Wednesday, November 2, 2011

The True Knot

As I had mentioned in one of my earlier posts, it has been quite busy although on another side we were quite busy celebrating the Golden Jubilee.

We had a very sad story of PD - who came with one of the most terriblest obstructed labours with an alive baby. We have seen many an obstructed labour where the baby is dead and it is easy to take a decision to do a craniotomy and deliver the fetus.

PD's case was quite different. It was quite apparent that she had recieved intramuscular oxytocin injections. The fetal head was quite firmly wedged into the pelvic outlet. In addition, she was subjected to multiple per vaginal examinations as well as attempts to somehow deliver the baby normally, because of which there was enormous edema of the vulva and the vaginal wall.

Initially, we could not hear the Fetal Heart. Later, after ultrasound, we could localise the fetal heart quite well and it was going quite strong. And we made a decision to operate to deliver the baby. I decided to take it out as breech since the head was quite deep stuck into the pelvis.

The surgery turned out to be a nightmare. The head was really wedged into the pelvis. And to top it all, there was a true knot in the umblical cord which was almost tight. I wonder how the baby had stayed alive all this time.

The baby came out quite sick and I was wondering if I had made a right decision to do a Cesarian section on the mother. I was quite tired after the preparations for the Golden Jubilee. Dr Nandamani had done a good job resuscitating the baby.

Unfortunately, he was becoming sick after he reached the nursery and I was definite that it would be quite a big ask on us to manage him. We tried our best to refer to Ranchi, but to no avail. The family was quite poor.

I wonder what the problem was  - but my weary grey cells have not been able to think much. The baby is still alive - but he has got hypoxic ischemic encephalopathy. In addition, he has got a positive sun-set sign in his eyes. Most probably, he had a intracranial hemarrhage following trauma of having got his head wedged and later disimpacted during the process of delivery.

The question is on the rationale of doing Cesarian section when there has been quite a lot of trauma on the fetus. But, here, PD was in labour for only 6 hours before she reached NJH. What could have been avoided are the intramuscular pitocin injections which she recieved from the traditional midwife in her village.

However, she is lucky to have an intact uterus. Few of my patients have not been very lucky. At least I appreciate that her relatives realised there was some problem within 6 hours of the process of labour.

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