Monday, December 19, 2011

The 2nd Maternal Death. . . Many lessons to learn

Carefully read this report of the maternal death, the second one of the previous post on ND. There are a lot of lessons to be learnt especially something which I've been emphasizing in my blog.

RD, a 25 year pregnant lady almost at term had multiple episodes of seizures since Friday night. She went to the nearest health centre which was not a government run health centre - a mission hospital about 135 kms away from our place. I'm not sure of the circumstances of her going straightaway to this mission hospital where there is not much facility for any secondary care - but similiar to us do a lot of secondary care especially in obstetric and malaria treatment.

RD was unconscious by the time she reached the above mentioned mission hospital. And it was Saturday morning.

I recieved a call from one of the main nurses of this place saying that they have referred RD. I was quite busy and told her not to refer as we were having a tough time and I was leaving on vacation. But, it seems that RD had already left. I informed the labour room that such a patient is coming and I should be informed as soon as the patient comes.

I was doing all the last minute clearing up of office work and I totally forgot that this patient would be coming in. I was on leave and it seems that Dr Nandamani had told that he be told of every patient who comes in.

After I entrained, I happened to call up Nandu who told me that a very sick eclampsia patient had come in sometime in the afternoon and he had referred her. I told him that was fine and told him that I had asked the nurses to call me as the patient came in. But, then, they saw me rushing to and fro finishing my work before rushing to catch the train.

Next day, as I called up Nandu, he seemed quite disraught. After he had the shock of having lost ND, he had to deal with RD too. It seems that he was quite busy with other patients and RD did not leave NJH for quite some time. By the time her family arranged everything to take her to Ranchi it was late afternoon.

As they travelled to Ranchi, they were stopped by policemen on the way saying that the route was quite dangerous and they would not allow travel. With quite a lot of social unrest going on, this was a common occurance in this part of India. Many a time, travel before 5 in the morning and after 6 in the evening is not without risk.

RD came back to NJH. She was still unconscious and was putting out frothy pink sputum from the mouth. Similiar to SDe on whom we spent quite a lot of our energies, RD was also quite sick. Nandu hooked her onto the ventilator, but she was too sick for attempt of any sort of intervention. RD died by midnight.

Recently, there was some bit of discussion on one of the social networks about the cause of maternal mortality. I've always maintained that health education and social changes are only possible once we have a robust system of healthcare put in place.

Most of the places where the MMR is high has a very poor public healthcare system. 3rd world regions like Sri Lanka and few states within our own country boasts of high standards of maternal and child health indices only after they've had basic necessities of primary and secondary healthcare and to some extent tertiary healthcare put into place before all the other social engineering measures including changes of health seeking behaviour was attempted. (In some places, it was done alongside)

In the region (block level) where we serve, we had run a 3 year programme on reducing maternal and infant mortality. One of the major emphasis that we had given was on taking the patient to the nearest healthcare centre on earliest signs of complications. But, if you had noticed - in most of the maternal deaths and the maternal near misses which I've documented in this blog, almost 70% of them had taken the expectant mother to a government health centre - subcentres, primary health centres and even district hospitals. And there were glaring deficiencies.

Before I finish this post, I need to tell about ED. The story is pathetic. I did a Cesarian on ED on Friday afternoon (16th Dec) for the indication of hand prolapse and obstructed labour. The baby was alive on delivery but died soon after.

ED's pains had started sometime on Thursday morning. It was her 4th pregnancy - the family had 3 girls and social norm demanded that she has a boy. The traditional birth attendant who saw ED had diagnosed the complication as soon as she had done a pervaginal examination. And she had told the family to take her very soon to a hospital . . . Which they did . . . The nearest Primary Health Centre . . . who also diagnosed her complication and had referred her to the District Hospital.

ED remained in the district hospital from Thursday evening till Friday morning when she was told that nothing more can be done there and to take her NJH. Which also they did . . .

But it was too late. The baby was moribund . . .with only the heart beating. The lungs were all clogged with thick meconium. We intubated the baby and tried to suck it out. But, it was too late. . .

ED's family and RD's family did the right things, took decisions at the right moment. But, the healthcare system failedt them. For RD it was more than that.


I'm not out on a blame game. What I want to emphasize is that we would not make much progress on all our umpteen health related goals without giving utmost priority to our healthcare system. No amount of health education or attempts at changing social beliefs are going to change health more than serious attempts at ensuring that the three tiers of public healthcare are in place to at least some extent.

Per operatively, it was a difficult case. She narrowly missed a uterine rupture. The bladder was all edematous and there were multiple hemorrhages on the lower segment which was dangerously thinned out. Some part of the lower segment had dehisced out and was like mincemeat. The baby was very badly impacted in the inlet.

After all that had happened with ED, the biggest disappointment for ED's family was that the dead baby was a boy. They wished they had brought her straightaway to NJH. But, they have not realised that it could have been worser. ED still runs the chance of developing a vesico-vaginal fistula.

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