Tuesday, November 13, 2012

On maternal care . . .

This quickly written post is in response to a couple of phone calls about why there has been a sudden fall in posts related to clinical care especially complicated obstetrics which started off this blog. 

The straightforward answer is that we have quite a lot of patients. Maybe I've become a bit lazy to put them in. That's all. 

As I write this, our 6 bed acute care unit has 3 patients with some form of eclampsia, 1 patient with viral hemorrhagic fever, 1 patient with a krait bite (on ventilator) and 1 elderly lady with severe pneumonia. 

Stories about one of the 3 eclampsia patient. We shall call her NB. Pregnant for the first time, NB never had any antenatal care. She started to have convulsions sometime at dawn yesterday. As usual, she was taken by her relatives to the nearest hospital headquarters where a consultant obstetrician told them that she be taken to Ranchi. The family was poor and therefore came to NJH. 

She reached NJH by around 3 pm. She already had 15 episodes of seizures. With a GCS of 7-8 and oxygen saturation of 80%, I was quite doubtful of her surviving. To make matters worse, nobody knew her dates. Clinically, she looked about 30 weeks. Ultrasound showed 32 weeks gestational age. The cervix was unfavourable. 

The encouraging aspect was a family who was poor although willing to go the extra mile. One of the male members was off to Daltonganj after the relatives could not find a match among themselves.

Meanwhile, with the patient showing features of deterioration, we had no choice but to go ahead with the surgery. The surgery was uneventful. The baby was of course sick. Dr Johnson did quite a commendable job resuscitating the baby. The patient was on the endotracheal tube till today morning. Now both the mother and baby is doing well. 

But, last week we had a maternal death. AD, a G3P2L2 residing within city limits of our district headquarters, Daltonganj. Both the previous deliveries had occured by Cesarian section. The only problem was that the last delivery was 9 years back. Somewhere she was told that since the surgery was done quite a long time back, she should not have much problem with the present pregnancy. 

The family attempted for a home delivery. She was also given injections to increase the pain. She was taken to the nearest district hospital from where they referred her. She went to a nearby private hospital. All this travel took place in the dead of the night. 

They arrived at NJH early morning 3 AM. She was in shock and with severe anemia. The clinical decision of a rupture uterus was made quite early. One of the relatives donated one pint of blood. As she was in shock, we transfused the blood. However, to operate we needed more blood. 

The relatives were in no position to take the patient further. They sent frantic word to their relatives in town. By the time couple of potential donors arrived, it was too late. Dr Johnson was trying to resuscitate her after she collapsed once again mid-morning. Her frail body did not respond. 

The family was well off. As I talked to the husband while filling the Maternal Death Review forms, he was aghast that nobody had bothered to tell him that she should have undergone a Cesarian section. 

Sometimes I feel that I've forgotten to mention about the umpteen number of babies we lose at NJH due to delay in decision making. 

Last week, we had 3 babies who died for no reason. All of their mothers were attempting deliveries at home for more than 12 hours. Drowned in their own meconium, the babies have hardly any chance of survival.

Well, the icing of the week was 30 year old DD. A G3P2L2, who again had 2 previous Cesarian sections came to us last week with seizures. The best part was that the patient started to have seizures since 7 am and she was at NJH by 12:30 pm. Something we don't commonly see. Her blood pressure was 210/120 and she had a Glasgow Coma Scale of 8-9. We took her up for Cesarian section. And lo, we had twins. Both term . . .  Having had no antenatal check ups, it was a surprise for the family. And a relief to us that the Cesarian section went off uneventfully with the presence of so much risk factors. 

Well, the current week is going to be exciting. We already have 9 students from the MGM Medical College, Jamshedpur and 2 students from Medical College, Gaya on an exposure visit. And today evening (13th November), we have the Founder's Day dinner. Our Founder's Day is on 20th November . . . but considering that we have a local holiday on 13th, we've decided to celebrate it early. 

More on the above 2 things in my next post. 

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