Wednesday, February 22, 2012

One more rupture uterus and more . . .

I was on duty on Sunday and although we did not very heavy like quite a few weekend duties I was quite tired at the end of the day.

I received a call at around 4 am on Monday that there was a 2nd gravida in labour with per vaginal findings which were a bit funny for the attending nurse. She told me that she was sure that the baby would not come by normal delivery. Well, it was a brow presentation.

She had been in labour for quite a long time and I was sure that we would need to take her up for Cesarian section quite fast.

By the time, I finished doing the Cesarian, it was around 6:00 am. Something made me finish off the rounds within the hospital. Dr Johnson was on leave and with Dr. Shishir on his way to Delhi for further evaluations, we were short of hands.

But, Dr Nandamani was joining back and there was an anticipation of a heavy rush of surgical patients in Outpatient. It was good that I finished the rounds.

I rushed back home just in time for a steaming cup of coffee, when I suddenly realised that I needed to make few announcements in chapel. After chapel, someone came and told me of a new patient in the labour room.

And my, what a patient we had. KD was delivering breech and the after coming head was stuck in the pelvis. And it was stuck like that since 12 midnight. She started having labour pains since late evening and the torso of the baby delivered by midnight. This had happened in the nearest district hospital.

I could think of only one possibility. A large aftercoming head – most probably hydrocephalus. On per abdomen examination, it looked so – but there was one more funny finding. I could palpate the uterus separately. There was only one possibility – a rupture uterus. Something very rare to happen in a breech delivery. . . It was a bit difficult for us to imagine having 2 rupture uteruses to deal with within a space of 48 hours.
The hydrocephalic after coming head . . .
 I took her to the ultrasound room. Yes, it was a hydrocephalus. Meanwhile, Nandamani was in hospital. I requested him to go ahead with the craniotomy and delivery of the baby. After the delivery, he also was sure about the rupture uterus.

The unfortunate lady went straight to surgery. Meanwhile, my better half announced that there was a crowd building up in the outpatient. And there was couple of patients in labour who needed urgent attention. The first one, a primi with a height of 135 cm and a large baby. The second one, a supposedly post dated primi at 42 weeks gestation.

And, quite a lot of surgical patients for follow up as well as new patients had come to OPD. Dr Nandmani requested me to start off with the surgery for the rupture uterus, so that he could minimise the volume in the outpatient.
On opening the abdomen

The placenta lying free in the peritoneal cavity . . .

The rupture on the lateral wall of the uterus

The anterior wall . . . 
I started it off and soon I realised that it would be better for Dr. Nandamani to handle it. . . 
Dr Nandamani suturing up the rupture . . .  
 Soon, SD was also readied for surgery. It was a routine Cesarian, but did not turn out to be. SD also had polio. So, we decided to give General Anesthesia. As we pushed in the pre-anesthetic, SD arrested . . . Nandamani rushed in and resuscitated her . . . which she thankfully responded to.

Considering that she had a reaction, we took a decision not to do the case at NJH and rather refer her to Ranchi. But, the relatives were not willing. . . We got a high risk consent for the surgery. Then, Dr Titus got an idea to do a skin test for lignocaine and try to do the surgery under spinal.

To make matters worse, she reacted to the lignocaine skin test. So, we were again talking to the relatives trying to send them to Ranchi. They came with few of the local leaders and soon it was a high profile case. The relatives were adamant that they could not take her any further. . .

So, armed with another set of high risk forms and a decision taken that one of us will give the spinal – we went ahead. We thank God that the surgery was uneventful and she delivered a healthy live girl baby.

Well, in between the rupture uterus and the Cesarian section on the lady with drug reaction, we had one more Cesarian section. And this was for a lady who came to us 3 weeks back with leaking per vaginum. She was in her 28th week of gestation when she had come to us. She was admitted couple of days back with a minimal amount of labour pains.

As always we had given them the option of referral. Now she had just started her 31st week of pregnancy. While we were managing the patient with rupture uterus, word had come in that she gone into full blown labour pains.

Now, about 6 hours later, we realised that she was not progressing and the uterus was contracting against a tightly closed uterine opening. We explained to the relatives about the predicament we were in and opted to go in for a Cesarian section. The baby was just 1200 gms . . .
Sr. Wendy discussing care of the little premie with Dr. Johnson and Sr. Bharati
 Thanks to Wendy and Jerry from the Grace Babies, we’ve been encouraged to manage the baby here. The relatives, who are not that well off to afford a referral to Ranchi are happy. So far, the baby has done well. Kindly pray that both the mother and baby will be fine. As we opened a premature uterus, we realised that there was some amount of chorioamnionitis . . . and Nandamani had to come in to help me some extra bleeding . . . It was good to have him back. . . 

Meanwhile, from Tuesday till Friday, I’ll be away in Delhi . . . Pray as Nandu, Johnson, Titus and Angel manages the work. Shishir is undergoing medical evaluation in Delhi . . . We pray that everything will be alright. . .

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