Making childbirth a horror

(The snaps in this post could be repulsive to many. Viewer discretion advised)

Last week, we had one of the worst rupture uteri we've ever seen. Worst in the sense that it was quite repulsive when we got the history. 

SS, a 30 year old lady with no living issue had become pregnant the third time. As with her previous two pregnancies, she had thought that she would deliver without any problem at home. Her previous two babies were born at home but died before they attained the ages of five.

However, the progress of labour in the third pregnancy was eventful. The baby just refused to come down as the previous two had come. The family sensing that something was wrong took her to the nearby government health centre. There was no doctor or nurse at the place. 

Someone suggested a 'reliable quack'. 

The quack gave her two injection and started to applied pressure with his bare hands on her bulging tummy. He was trying to somehow push the baby out of the uterus. He had not even done a per vaginal examination. After about half an hour of applying pressure on the abdomen, she felt something give way. 

But, there was no baby. The tummy still looked swollen. The labour pain had disappeared. But she started to feel quite nauseated and sick. By this time, one of her relatives who was a Sahiya had turned up. She realised that something had gone wrong. 

It was around evening when the family reached NJH with SS. As always, the diagnosis was quite easy . . . a rupture uterus . . . 

Snaps of the surgery and how it looked . . . A grim reminder of how archaic obstetric care remains for quite a lot of our fellow citizens . . .

Tried to get a snap of the abdominal contour in a rupture uterus.
There is fullness of the suprapubic and the epigastric regions. 

The surgical team led by Dr. Shishir . . . 

The baby appears like he's sleeping . . . 

The aftermath of the violent abdominal massage . . . 

The uterine rent well sutured . . .

Twelve pregnancies . . . Experiences varied . . .

Yesterday (28th April, 2012), our youngest doctor, Dr Titus was on duty. And what a duty did he ultimately end up having. . .

I'm very sure that a post-graduate in Obstetrics in a pretty big Medical School would turn green on hearing the cases Titus ended up managing yesterday. Of course, it was with active support from the others including Nandamani.

Altogether, he ended up managing 12 pregnancies . . .

I shall try to narrate the significant ones in a later post . . . Here is the list with a brief account of the history . . 

1. AB – a primi who delivered without much problem.

2. BD – another primi, but had been trying to deliver at home. Was about 9 cm dilated at arrival with Grade 2-3 Meconium Stained Amniotic Fluid.

3. NDD – a primi, a bit towards the elderly side. Had been coming to us for antenatal check-ups. We had diagnosed Intra-uterine Growth Retardation quite early and referred her to Ranchi. The family could not afford the trip and tertiary consultation. We had to ultimately do a Cesarian for her. Mother and child are doing well. 

4. SB – another routine delivery without any complication.

5. BD – the first pre-eclampsia to come in. We induced her – but deleloped fetal distress in no time. Post Cesarian it turned out to be good decision as per operatively, the baby was sick.

6. AD – a G2P1L1 routine delivery,but with very anxious relatives who gave us a harrowing time.

7. SD – A G6P5L4D1 – Had been trying at home since early morning. Did not have any clue why she was not delivering. Ultimately decided to come to hospital. Reached NJH at around 10 in the night. We did not need an ultrasound to diagnose hydrocephalus. Of course, we confirmed with an ultrasound. Delivered after craniocentesis. Baby was dead. However, she was lucky to have got away with it as she could have ruptured her uterus. 

8. MD – A primi who came in with an IUD. She had been kept for normal delivery elsewhere. I wondered how someone could have missed the very obvious Inadequate Pelvis. Problems with not having followed protocols too as the patient has been in active labour for more than 16 hours. 

9. ND – the second pre-eclampsia of the day. However, ended up with an normal delivery after periods of uncertainty and anxiety.

10. SD1 – Someone we had induced. But ultimately ended up with an obstructed labour and a Cesarian section. Baby and mother turned out to be fine. Thank God for Partograms and Protocols. . 

11. GD – Very confusing history. But an ultrasound gave it away. It was an abdominal pregnancy – the sac had given way. The baby was about 20 weeks gestation. Shall do a detailed post on that later.

12. SoD – Maternal death. Did not deliver. Came with history of seizures. Had anuria, thrombocytopenia and was unconscious. Died within 4 hours of admission. We tried to ventilate but her heart would not yield to any medication. Again will give a detailed post later. 

This is the obstetric work alone. In addition, we had the sick babies getting admitted to NICU to be looked after, surgical and medicine patients needing extra attention. . . . The list goes on and on. Well, there was one more patient, UD who had come in with a history almost similar to SoD who's in the process of pulling through in the Acute Care Unit. That would also deserve a detailed post later. 

Well, ultimately friends, we need help. Looking forward for medicine and paediatric consultants along with nurses committed towards work in under-served areas. 

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 . . .

Blood . . . rarest commodity . . .

Some time back I had put in a terrible snap of a blood bag which relatives of one of our patients had brought from our nearest district headquarters. 

Yesterday, we had 2 patients who had come in with hemoglobin values of around 5 gm%. 

The first patient, RK was the mother of 4 children and she was pregnant at 7 months gestation. She was from quite far away. She had suddenly started to bleed early morning. By the time she reached here sometime late afternoon, she was quite pale with no fetal heartbeat audible. Her hemoglobin was around 5.8 gm%. I informed the relatives that we could not do much without at least a couple of pints of blood. 

That was when the husband informed us that the unavailability of blood in the district headquarters was the reason for her being referred to NJH. In fact, the relatives wanted to know if they could take the patient to Ranchi. I was relieved - but later realized that she was continuing to bleed and the vitals were going down. But, without blood I did not have any choice. 

In the available circumstances, doing the 135 kilometer journey through bad roads was the best choice that RK and her family had. RK's relatives were well off and it was not quite difficult for them to take a decision to move ahead. I ensured that RK had two lines going in with intravenous fluids. 

As soon as RK left, came the next one. SD, another multiparous lady with bleeding since early morning. Contrary to RK, SD's family was very poor. It had taken them quite a long time to arrange transport and other arrangements to make it to NJH. SD had another episode of bleeding earlier last month. However, it had subsided within few minutes. I told the family of my predicament of not having blood readily available. 

The family expressed their inability to go any further. The husband told me, 'Sir, please do what you can. Even if the baby dies, please save the mother.' The blood results came. Hemoglobin of 5.3 gm% and the blood group was not matching with that of any of the relatives. It was quite late into the night and the relatives informed me that they would go to arrange blood as soon as it is daylight. I told them that it is a very risky plan. If she bleeds, we've had it. 

Meanwhile, we did an ultrasound. It was a low lying posterior placenta with abruption. The baby was alive. I could only pray that she would not bleed. Soon, she was into her labour pains. I was surprised that she did not have any bleeding. Within couple of hours, the baby was on the way. She delivered a dead baby. Thankfully, she did not bleed much. 

Blood transfusion facilities are a premium in almost all parts of rural areas of third world countries. In emergency cases, we keep few blood bags where we directly bleed for donation. It is illegal - but we do it so that lives can be saved. 

The present policies of blood donation are quite archaic and it becomes quite difficult in difficult areas such as ours. And since the last few days, we had run out of blood bags . . .  We are yet to get them . . . We could have managed RK if we had at least couple of blood bags, if not given her a better chance of surviving the journey to Ranchi . . . 

Unbelievable . . . Stunned beyond words . . .

(This post is a purely of medical academic interest and contains snaps which could be offensive to many. Kindly be careful)

I had written the  previous blog about SD and PD yesterday night but could not post it as there was no internet connection.

PD's relatives brought the 2 pints of blood requested by us by early morning today and Dr Nandamani  called me to help with the surgery.

We were definite that we would be in for few surprises.

This was what we saw as we opened the abdomen. Instead of a smooth ending slope of the uterus what we got was a beveled lower segment which was quite undermined. We decided that there must be a tumour somewhere nearby and opened the uterus where we could visualize as low as possible and delivered the baby.

Then we found out that the uterus was refusing to contract and it looked more like one of those olden days' wineskins.

Dr. Nandamani then started to search for the apparent cervical fibroid which we had found out during the ultrasound. The uterus was quite large and he had to really work hard to mobilize the uterus outside. It was then we noticed where the bleeding was from. One of the ovaries looked ruptured – must have been a large ovarian cyst.

We found out the ‘tumour’ which we were looking for – but it looked quite unusual. It was then that we realized something funny. There was one more ovary on the same side. Well, it did not take long for Nandu to realize that the uterus had got twisted in its axis 180 degrees and he had opened the posterior wall rather than the anterior wall.

And as shown in the snap, the 'tumour' was the left horn of a bicornuate uterus.

We confirmed it after few more examinations. It was quite a relief to realise that we were not dealing with any malignancy.


The rest of the surgery was uneventful. However, we realised that we've just witnessed something which was quite rare.


The best part of the surgery was that although we had to remove the flaccid right horn of the bicornuate uterus, we could leave behind the left horn intact. And maybe, she may concieve. After 4 pregnancies where she ultimately lost all the babies, we pray that she would be able to concieve.


I remember a similiar case of rupture uterus during my previous stinct at NJH, where we found out that it was a bicornuate uterus and the lady concieved in the other horn after one year and delivered a baby by elective Cesarian section.