The fatal massage

The word 'massage' brings into most of our minds scenes of serenity and comfort. Quite a lot of us are quite familiar with traditional massage systems starting from quite complicated massage processes in the Ayurveda for which Kerala is quite famous to the massage you get at the barber's saloon. 

However, in quite a few parts of the country, including ours, there is a process of massaging the uterus just as the pains of childbirth starts. And they also do that when they feel that the gestational age of the baby has gone beyond term. 

The massage ranges from very tender rubs on the gravid tummy with oil to vigorous working up of the abdomen with ones fist extending to even using planks of wood. Even today, the last patient whom I've just seen in the Labour Room has had a massage. 

But, last week, we had a patient who had got the most horrible massage one can imagine. Yes . . . a massage with a plank of wood on her tummy. I had seen quite a few during my earlier stint at NJH. 

We shall call our patient PhD. A 30 year old mother of one, who had crossed her expected date of delivery of her fourth pregnancy came to us 4 days back. Yes, of her earlier three deliveries only one had survived . . . A 7 year old girl. 

All her previous deliveries were at home. And she had taken her fourth delivery as just another chore. But, this did not go as she had thought it will. When she reached NJH, she was already in labour for 48 hours. In addition, she had got quite a lot of massages, culminating in the massage with the plank of wood. 

The process was well evident on her tummy. The angry looking skin was quite obvious. And the uterus was tense. It was like a balloon. Couple of us thought that she had ruptured. The blood tests turned out to be very bad. She was in full blown sepsis (total leucocyte count of more than 30,000) and was anemic. I was sure that she was dehydrated and therefore the hemoglobin was more low than we expected. 

And she had a hand presentation . . .

The only choice she had was to undergo an emergency Cesarian to remove the dead baby and to repair if she had ruptured. My only fear was gangrene of the intestine. We had lost a similar patient couple of years back after she had intestinal ischaemia following massaging of the abdomen. 

We somehow got hold one pint of fresh blood and she went to theatre . . .

We were relieved to find out that she was yet to rupture. But, the lower segment of the uterus was totally battered into a pulp between the endometrium and peritoneum. There was a good chance that the lower segment will not hold well when I deliver the baby. After thinking it out, we decided to put a inverted T incision on the uterus. 

We were glad that we took that decision. As soon as I put a nick on the uterus, there was a gush of putrid gas which gave us quite a tough time. The baby was badly macerated. The surgery was over in an hour. Thankfully, the patient did quite well after surgery. She should be discharged over the next couple of days.  

I've been trying to convince our local community about this totally unscientific practice. Unfortunately, nobody seems to listen. I came to know that the procedure of massaging the abdomen is so much ingrained into the local traditional healthcare of the pregnant woman. 

For PhD, the massage brought in quite a lot of troubles. Her socio-economic situation made things even worse. She was from quite a remote area. When she was brought by the government nurse in her village, none of her relatives were accompanying her. Her husband was a tuberculosis patient. I'm sure that we'll have to write off quite a lot of her bill. 

Another story of one more live saved because of the Lord working through the team at NJH. 

Please scroll down if you're interested in seeing few snaps taken of the lady and her baby. May I warn you that the snaps are very very repulsive. Be warned . . . the snaps are horrible . . .

 . . . .

 . . . . 

 . . . . 

 . . . .

 . . . .

 . . . .

 . . . .

Sr. Sushma, our Nurse Anesthetist praying hard before we start the surgery. 

The badly macerated baby

The uterine incision. You can see the vertical portion of the inverted T incision is sutured.
The lower segment was very very unhealthy and we just got the edges opposed.

Poverty . . .

Over the last 2 weeks, we had two instances where we were exposed to the stark reality of how poverty affects families, especially when it comes to healthcare. 

I shall start with the patient who I mentioned in my previous post on obstetric care. 

We shall call her Kkd. Yes, the lady who came in with a hemoglobin of 4.6 gm% and then had a hemoglobin of 2.6 gm% more than 12 hours after the delivery. I just got news from Acute Care that the relatives were able to arrange a pint of blood; almost 24 hours after she had delivered. 

Now, the whole question was about the reason why the family never brought her for delivery to the hospital. It seems that she was taken to the place where she had her antenatal check ups as well as to the nearest district hospital. She was turned away from everywhere. 

If we had got couple of pints of blood, we would have done off the Cesarian in no time. 

I believe that it was the good Lord's providence for her that she delivered normally. And then the family could arrange one pint of blood. Most probably, that is the maximum that they can arrange. 

The whole exercise of a Cesarian section with couple of pints of blood transfused would have resulted in quite a financial strain for the family. I realized it today morning when the nurses told me that they did not have money to pay for the medicines. In fact, we had admitted her without any advance. 

The relatives had been running helter-skelter to get some decent treatment for this poor lady. The fact was that almost all of their money had been spent paying for transport. 

However, while the process of getting blood was on, one of our nurses had caught bits of their conversation and found out that they were in the process of paying a huge amount to buy blood. 

In our nearest blood bank, the usual practice is to allot a pint of blood for 350 INR if the relatives are able to donate blood. However, when one cannot arrange a donor, there are processes quite unknown to most of us by which you can buy the blood from elsewhere at rates ranging from 2400 to 4000 INR. 

We somehow convinced the relatives to arrange a donor and get the pint of blood for just 350 INR. I'm happy that they heeded the advice. 

However, it was obvious that the family had run out of financial resources. 

All of us have failed them. From the very beginning. 

They had gone to a doctor in his private clinic thinking that they would get the best treatment. He/She had written quite expensive iron, multivitamin and calcium tablets. Which they brought. Instead of 30 tablets for a month, they had brought one strip (10-12 tablets) which was used for 2 months. 

They never got clear advice on what needs to be done when she goes into labour. No plan . . .

And even after she got admitted . . . unless our staff overheard the conversation about the blood, they would have spend much beyond their capacity and got the blood, which many a time is of very poor quality.

To be frank, for the poor, there is nothing much left in our country. They are the mercy of anybody and everybody. The question is whether 'the haves' of our country are listening. 

Leaving alone the subject of poverty . . . if there is 2 things which could improve maternal morbidity and mortality in this part of the country which is more of a problem for the poor and marginalised, I firmly believe that it is free availability of Iron tablets along with an awareness about the intake of these tablets and the second one - undoubtedly, UDBT.

The girls nobody want

One of the ladies who regularly attended antenatal care at NJH came in labour today morning. She was quite a complicated case. RnD was 30 years old. This was her fourth pregnancy. Only couple of months back, she had lost her only son to malignancy at the tender age of 4 years. She had 2 daughters.

During her antenatal check-ups, she used to insist that she have a normal delivery although her second delivery was through a Cesarian section. We had mentioned to her about the possibility of a Cesarian section.

When RnD arrived today morning, she had already been in labour at her home for almost 12 hours. She was dilated about 8 centimeters and a uneventful vaginal delivery appeared on the offing. However, I was a bit doubtful about the rotation of the head. I gave the option for a Cesarian section to the relatives. However, they were quite vehement about not going for a Cesarian section. I managed to convince them that the maximum we could wait was 3 hours.

Unfortunately, things did not progress as all of us wanted. She got fully dilated but there was a poor descent of the head. I had to take a call for a Cesarian section. To my surprise, the relatives were quite vociferous in opposing the surgery. Later, I found out that the baby had passed meconium . . . thick pea soup colored meconium.

I reviewed things with the relatives. They did not want anything to do with a Cesarian section. After a lot of haggling, they agreed. It was only in the middle of the haggling that it struck me that most probably the relatives knew that RnD was expecting a girl baby. I mentioned it to few of my colleagues. They also agreed.

Then after I had talked with the relatives, I came to the Labour Room and found to my dismay that the patient was arguing with the nurses for having to undergo a Cesarian. One of the nurses scooped up a blob of meconium and showed it to the lady and told that the baby was eating this stuff. She agreed.

We had the baby out in about 10 minutes. There was meconium aspiration. The theatre team did a good job at resuscitation. However, the process of labour had done the damage. A second stage Cesarian is many a time an obstetrician’s nightmare. There were tears of the lower uterine segment which extended to the pelvic region. It was very much similar to the Cesarian Ihad in the morning, but tougher.

Post surgery, I went to talk the relatives to tell about the sick baby and the difficult surgery RnD had to undergo. The family was distraught. They very well knew it was a girl. The husband confessed that they had found out that this pregnancy carried a girl fetus. I gave them the option of taking her to a higher centre to ensure that she did not develop Meconium Aspiration Syndrome. I could not believe my ears when they told that they did not mind even if the child died.

I wondered how many more Indira Gandhis, Pratibha Patils, PT Ushas, Sania Mirzas, Sainas, Kalpana Chawlas etc we need to see before we realise how precious our little girls and sisters are for each one of us.

As I sign off this post, one more story which could end up true . . .

I just had a lady in her fourth pregnancy nearing 8 months of pregnancy who has walked into Labour Room complaining of lost fetal movements. The ultrasound has confirmed a fetal death. As I announced it the family members I was quite taken aback by the shock and the disbelief that enveloped them. The grief was much more than what I usually witness. 

I suspect that the lost baby is a male. They must have known earlier. The first three children are girls.

I shall let you know tomorrow. I’ve induced labour for her . . .

3 maternal deaths . . .

 Over the last 3 days, we had 3 maternal deaths . . . 

Not much of a description . . . but I hope these are documented here.

The first one . . . Happened on Monday. We shall call her A. Brought with a breech presentation, her baby was hanging out with the head stuck inside since one whole day. She was very toxic. As we tried to take the head out, the uterus prolapsed (not inverted). The next thing we knew was that she had collapsed. None of our efforts could revive her. 

The second one . . . occurred on Tuesday early afternoon. B had delivered at a nearby PHC couple of hours back. Her referral letter showed that she had severe pre-eclampsia. But, she was gasping now. And she was in shock. We did not have any clue about what had happened. We had her intubated. But, she did not make it. Most probably, a amniotic fluid embolism. 

And the third one . . . which happened yesterday. C was admitted on Wednesday night with severe anemia (hemoglobin: 7 gm%). She had already got couple of blood transfusions elsewhere. We had induced her. The relatives arranged one pint of blood. Then she went into pre-eclampsia which we had got control of. However, the patient did not progress. The baby was going into fetal distress. We did not have a choice but to operate. 

The surgery went on well. However, she became sick soon. And then in the Acute Care, she went into a refractory Post Partum Hemorrhage. With no blood, we could only watch her die. The baby, although sick is still in NICU. 

It's terribly discouraging. But, I wonder if we could have done any better. 

The third case would have benefited if there was a blood bank at NJH. 

But, the first 2 cases. They should have come earlier. 

Another cry for better facilities and personnel in a region like ours . . .

Anybody listening ? ? ?

Marathon Cesarian sections . . . almost all MNMs

The start of the last weekend was quite hectic one. . . By standards of many big hospital, it may not be that hectic. . . But for us, it was quite a busy time. . . Not only for us, for each of the patients involved it was a close brush with death . . .  all of them mothers delivering babies. I thought I'll share each one of them. To make things easy, I've put it in a table. 

Name	Time and date of surgery	History	Final management and comments
RtD	20th july, 11:00 am	Previous LSCS, had come for ANC on 20 june, Hb: 8 gm%, never bothered to arrange blood	Boy baby, apgar 9 and 10. Had waited almost a day for the blood
SMD	20th july, 12:36 pm	Obstructed labour since previous day 8 pm	Boy baby, apgar 6 and 10. Almost a rupture
MD	20th july, 2 pm	Primi at 40+6 with labour pain since previous night. Later obtained history of leaking 4 days. Irregular fetal heart.	Girl baby apgar 8 and 10. Well off patient – did not go to Ranchi.
AF	20th July, 3:14 pm	Labour Pains since yesterday afternoon and leaking, short 136 cm, obstructed labour	Sick girl baby, apgar 1 and 4. Died later, Almost a rupture
KD	20th July, 5:24 pm	Prev LSCS  with  and Hb 8 gm%	Dead girl, Hysterectomy for placenta percreta
RnD	21st July, 2:17 am	G4P3L2D1, pedal edema 2 weeks, headache followed by seizures 2 pm, 20th july	Baby boy, apgar 6 and 10. IUGR
SrD	21st July, 3:30 am	Short primi, pedal edema > 2 weeks, was having labour pain since 12 pm on 20th July, BP 140/100. Urine alb 4+	Cervix edematous and head high, inadequate pelvis – lscs, boy baby apgar 3 and 7. Gr 3 Meconium Stained Amniotic Fluid

We lost 2 of the 7 babies. But we could have lost all the 7 as well as few of the mothers. The major challenges we faced - 

1. Availability of blood. 

2. Patients not following advice given during Antenatal Care. 

3. Ignorance of leaking per vagina as an indication for coming to hospital

4. Previous Cesarian section patients appears to be so ignorant about the fact that they need to have an institutional delivery

5. As we conversed with MD and AF's relatives, we realised that relatives have come to the conclusion that they have conceived girls. Especially, MD could have taken her easily to a higher centre. 

The weekend was thankfully not as busy as it threatened to become. . . 

However, do remember little GS, a little 6 year old girl who had come with a viper bite on her hand. Compartment syndrome has set in her hand very badly. 

I tried my best to refer the little girl, but without much response from the parents. We did a fasciotomy in the morning. Only tomorrow we shall know how much better it is going to be. . .

Then we had 4 kids who came in with accidental pesticide poisoning. 

After all the weekend rush, today was very quiet. Most probably on the occasion of a local festival . . .

And one more word of prayer for BD, who has delivered a baby at her home yesterday evening who came in with a retained placenta. On arrival, her hemoglobin was a paltry 2.4 gm%. The relatives have arranged blood just few minutes back. Shishir and Titus would be trying to do a manual removal of placenta within the next couple of hours. . . .Please pray that she will make it . . . It is almost similar to the case of SD who survived almost a identical history with a hemoglobin of 1 gm% ! ! !

Obstetric care . . . The stories continue . . .

It has been quite some time since I posted a post on obstetric care at NJH. After the empanelment of NJH into RSBY, it has been quite busy. Today morning, as I visited NICU, I was surprised to find a baby wailing and quite hungry. The reason I was surprised. Couple of days back, we had delivered this little fellow and we had hardly any hope that he would make it. The story of LD’s mother will mirror the stories that I’ve been sharing through this blog over the last 8 months.

LD’s mother as well as SD, about whom I shall share in the latter part of this post comes from Garhwa, the western most district of Jharkhand. It is one of the most impoverished regions in the entire country with stories of hunger and exploitation quite common but hidden from the rest of the world. As part of the overall backwardness of the district, the health services are also very poor. Due to some reason, almost 80% of our complicated patients especially in obstetrics come from this district.

LD was pregnant for the first time. She had couple of antenatal check ups from Daltonganj which is the district headquarters of Palamu, Garhwa’s neighbouring district. She even had an ultrasound scan sometime in the 32nd week saying that the baby has an abnormal lie. However, her family claims that she had a check-up at some place couple of weeks before where she was told that the baby has come into the normal position.

LD came to us late night on 26th March. She had started contracting sometime around the evening of 25th and her membranes had broken sometime early morning of the 26th. When she did not deliver by late morning, she was taken to the nearest health centre from where she was referred to Daltoganj. However, they came to NJH straightaway. She was told that the baby is coming legs first.

I saw the patient as soon as I had finished a Cesarian section on SD. The first thing I noticed was how small her abdomen looked. On per vaginal examination, it was obvious that the baby’s shoulder had presented and the hand was on its’ way to slip out. I had to do a Cesarian immediately.

The best part was that on Cesarian section, it was obvious that she had received umpteen number of oxytocin injections. It was already tonically contracted over the baby and there was hardly a drop of liquor. I feared the worst with a compound presentation. The head and the torso was folded over each other with the back presenting at the site of the uterine incision. I had to ultimately end up putting an inverted T incision on the uterus.

On delivery, the baby was flaccid like a rag doll. There was no pulsation of the cord. Only the heartbeat was there. I was sad . . . we were going to end up with a dead baby after a LSCS. Dr. Titus was there for the resuscitation. He went through the motions of resuscitation, thanks to the classes from Wendy of Grace Babies. After about 5 minutes, there was a whimper and then a small cry . . . By the time, I closed the skin, the baby was wailing. However, there was grunting and I had asked the relatives to take him to a higher centre.

It was good to see the baby live and healthy after such an uncertain and dangerous period. Which, could have been avoided. That’s my point. Home deliveries are such a bane to the developing world. More so in countries such as India where there is no skilled birth attendants. However, even when there is a skilled birth attendant, I’m sure that a home delivery is such a dangerous thing. Many of you may be quite aware of a growing following of people who promote home deliveries, even in the west!!! Recently, I came across people writing about this.

Well, one should realise that the most common causes of maternal mortality and death are complications like excessive bleeding, obstructed labour, infections for which nothing can be done in a home delivery. Few months back, one of my friends lost his wife in a delivery done at in a small hospital in a big city. She developed a complication for which there was nothing available in that hospital. . . not even a laryngoscope for intubation or ambu-bag to mechanically ventilate. You can imagine the predicament if it was a home delivery.

The patient, SD on whom I had done the Cesarian section before LD had arrived was more terrible. She was 140 cms tall and had a Cesarian for her first delivery. She had been having contractions since early morning of the 25th, leaking since 25th evening…she had been trying to deliver at home and ultimately came to us sometime on 26th evening when nothing much was happening. To make matters worse, she had seen one of the best obstetricians in town and in her prescription, it was clearly written that the next pregnancy would be an Elective Cesarian and one pint of blood would need to be arranged.

I was thankful that SD’s Cesarian section went off uneventful. It was quite surprising that even after so many risk factors present in this patient, the relatives were quite careless as there was no blood arranged and we took quite a long time to convince the relatives of the need of a Cesarian section.

She could have died of a rupture uterus any time.

Talking of maternal deaths, I just remembered about someone making a statement sometime that one of the most common causes of female deaths of the reproductive age group in developing countries is tuberculosis. I remembered it because we’ve a 30 year old mother of five in acute care, who has come to us with one of the most terrible Chest X-Rays I have seen recently. She can hardly lie down as she is quite breathless and has a saturation of only 70% even with oxygen in full flow… The snap below is that of her X-Ray . . . 24th March was World TB Day, which we celebrated in the district. A post on that later . . .

Unwanted girl babies . . . and the sought after male heir (2)

I was wrong about SA in the blog I wrote yesterday. SA delivered a boy and that too uneventfully at around 7 am today. Since the pregnancy was complicated the nurses had called me for the delivery. As I walked back home, I berated myself on the tendency I’ve to jump into conclusions. I was very sorry that I ended up writing about SA on my blog. I mumbled an apology to the good Lord about my evil heart.

I reached back to the office at around 8:30 am. There were a host of male relatives of SA waiting to see me and they were so profuse in thanking me for ensuring that the delivery went well without any complications. There was quite a lot of things to do and since I did not have anything much to do with SA, I became immersed in the office work and a quick review of the sick patients. It was sad to see that PD continued to be sick.

At around11:00 a m, I had a surprise with the RSBY officers from Ranchi coming in to sign the papers related to implementation of RSBY in the hospital. It was a surprise. In between the signing of the papers, I could see SA’s father peeping on and off into the office. Considering the complications SA had, I called him in and asked him what the matter was.

SA’s father wanted me to review the baby. I asked him if there was any problem which he immediately denied. I told him that I would come in a couple of minutes. SA had got admitted in the general ward the previous day. Therefore, I went there in search of SA. The nurse told me that SA’s family took a private ward in the morning.

I went to the private ward. SA and her relatives were there. The husband was beaming as he handed me a box of sweets. He told – ‘we thought that the baby was a girl’. I asked if they knew for which he gave some vague answer. Well, I put things together. I could see no other reason why they shifted out from the general ward to the private ward.

During my last stint in NJH, we had received a very sick mother about whom we could not get a diagnosis. Her only complaint was that she had attempted to abort and then her bleeding was not stopping. Dr Colin Binks, our consultant surgeon during that period started to do a curettage of the uterus. And then, he found out that there was a perforation of the uterus.

And so, the patient went in for a laparotomy. And what we found out was gruesome. Inside the peritoneal cavity was a macerated female fetus of about 30 weeks. And there was a large rent on the posterior wall of the uterus. Somewhere, they had made a diagnosis of a girl baby and had attempted to abort resulting in the gruesome end result. The mother made it after a closure of the uterine rent and a long recovery period.

Then few months, before I had taken over, there was a attempted abortion at 32 weeks – the relatives were given a diagnosis of a female fetus from some ultrasound clinic. And when the delivery happened, it turned out to be a boy – which had died during the process. Many of the staff still recollect the unforgettable expression of grief by the family – one of the senior sisters had told me that the cries of the family members still echoes in her ears.

I’ve my fair doubts if SA and her family had got into a similar predicament. But, they were lucky.

Or is it again my intuitions. I’ve been reading Sherlock Holmes and his exploits of late. . . But, here I’ve enough evidence to support my intuitions . . . Haven’t I? Before I sign off, a penny for your thoughts for PD who continues to be on the ventilator . . . Request your prayers . . .

The boy longed for . . . and the unwanted girl(s)

Yesterday, there was the news about an unfortunate incident in Afghanistan in which a woman strangled her daughter-in-law to death for giving birth to a third daughter. 

At NJH, it is quite common to be reminded about the preference for girls . . . 

3 instances . . . 

The first one, PD, the mother of four girls was brought last Friday afternoon - unconscious and frothing, almost at the edge . . .  The fact that there were 4 little girls at home waiting for their mother to come back home made our doctor on duty to try the best to save her life. PD had a blood pressure of 200/120 and Urine albumin was 4+. The baby was already dead. And there was no indication of her delivering normally for the next 12 hours. 

Dr Johnson made a decision to deliver the dead baby by surgery. She was already intubated and being mechanically ventilated. The surgery was uneventful - but PD could just not be weaned off the ventilator. Over the last 2 days, she has also gone into renal failure. . . I've discussed with the relatives that we shall keep her in the ventilator for another 24 hours. . .  Kindly pray that PD will make a miraculous recovery. 

The family had been wanting a boy - the reason for PD getting into the present state. And the dead baby was a boy. . . It is unthinkable for 4 little girls to grow up without their mom. . . 

The second one is KD. KD was in her second pregnancy. KD's last baby was born 5 years back. In spite of being only 2.5 kgs, the baby was born by an instrumental delivery. The second baby looked bigger - but then she had an ultrasound which showed that the baby was smaller. But, clinically, the baby looked big. . . 

I explained to the relatives that she could end up with a Cesarian section. The relatives were begging me to somehow ensure that KD delivers normally. We have seen quite a lot of our antenatal patients who beg us to somehow ensure a normal delivery end up with having a girl baby. 

I'm not sure whether it is my prejudice - but I've a gut feeling that most of such families are quite sure that they have a girl child. And, I'm sure that there are many an ultrasound facility to give the sex of the baby to the family. (It is illegal to divulge the sex of the baby in India as quite a lot of girl children are aborted off)

And I've seen the vice versa happening too - families agreeing for Cesarian section at the drop of a hat and even taking all possible efforts to salvage a boy baby who is born moribund sick. 

Now, I've one more lady in the labour room. SA, a primi with nephrolithiasis, severe hydronephrosis and chronic urinary tract infection - we've been advising the family from the very beginning to have her delivery at a tertiary or teaching hospital in Ranchi. The advice has fallen to deaf ears and they want to do the delivery here.  

She came to outpatient today with post dates. And her blood pressure is on the higher side. I made one more effort to convince the family to take SA to Ranchi for the delivery. I've quite sure that they've discovered that the baby is a girl . . . Maybe, I'm wrong . . .  I shall let you know when the delivery happens within the next couple of days. . . 


Well, this line was put in much later . . . What happened with SA? It was hilarious. . . 

First working day of the New Year . . .

Today was my first day after the brief vacation and oh...my....it's turning out into a major one.

To start off, as I left chapel and entered the hospital, Dr Johnson requested me to convince MD to undergo a Cesarian section. Johnson was convinced that MD was obstructed - and I was also convinced. I was thankful when Johnson went out for one more round of negotiations and returned victorious.

MD had been in labour at her home since late afternoon of the previous day. She had also recieved 6 intramuscular injections, half of which were oxytocin. She had arrived sometime after midnight, and had not progressed.

And, I was glad we operated. The outer uterine muscle fibres were starting to snap, there was petechia in the lower uterine wall, the bladder was edematous and there was a part of the lower uterine wall through which I could see the flakes in the amniotic fluid. She would have ruptured within the next one hour. The baby girl had a surprising Apgar Score of 9 and 10.

As I was starting off MD's Cesarian Section, word came that there was a Previous Cesarian without any antenatal check up who had come in with labour pains. She was also posted for surgery as soon as MD's was over.

Patients such as KD actually prevent us from readily jumping in for Cesarian Sections even when there is a faint indication for one. It was unbelievable. KD, who had a previous Cesarian 2 years back, did not even have a tetanus toxoid injection leave alone a proper antenatal check up. KD's Cesarian section was also uneventful although we had to arrange blood as her hemoglobin was only 8 gm%.

Well, I forgot about LD - who was wheeled in as we were taking a decision on MD. LD was about 32 weeks and had come in all the way from Ranka - about 60 miles away. LD was hardly conscious , had convulsions the previous day and was being managed elsewhere before they referred her to us. There was no fetal heart and the abdomen looked too big for 32 weeks.

Shishir promptly did an ultrasound and confirmed dead twins in the uterus. Then we found out that her birthcanal was almost fully dilated. But, for some unknown reason, we ended up doing a craniotomy to deliver the first twin and then the other one was pulled out breech. LD is still not fully conscious.

Then, we had two more normal deliveries, one of which was a small for gestational age baby. And another one which was an Intrauterine Death.

I'm glad we do not yet have a case of Rupture Uterus. But, we do have a elderly primi with post dates whom we've induced. I hope she delivers normally - but sometime back, the labour room nurse has informed me of couple of high diastolic blood pressure readings . . .

Well, for all those who want to know about other patients - we had two proven malaria patients today. SK aged about 19 years had been sick since Wednesday. It was quite obvious - he was shivering as he came to OPD. Then we had VS, who just came in very sick. He has been sick since January 2. He was all yellow - I tried my best to refer him - but to no avail.

Rajeev, our lab technician telephoned me VS's blood tests - Falciparum malaria positive, Total Count 21,000/ cu mm, S. Bilirubin 9 mg%, Platelets 30000 / cu mm . . . I am yet to see the full reports.

I've the ventilator ready . . . And another 12 more hours before I hand over to Dr Johnson . . .

And to top it all, two more young ladies with attempted poisioning. One had taken organophosphorus and the other permethrin shampoo . . . Both are doing well . . .

Before I sign off, an X-Ray from OPD today. There was one more good one . . . but I forgot to take a snap . . .