Hiding the horror

I’m sure that the sad story of SS is quite fresh in your minds. However, you’ll be stunned when you hear the story of RD who came to us few days back.

RD arrived sometime in the midnight. As is the protocol, the nurse on duty took the history which looked quite innocuous. RD, a primi was quite regular with her antenatal care check ups at NJH. The last time she came to NJH, she was already 5 days past her Expected Date of Delivery. 

The doctor in outpatient had asked for admission so that we could induce her. The family left with a promise to come back the next day. They did not turn up the next day, but arrived at midnight of this particular day which was about five days after her last visit to outpatient department.

According to the family, RD had started to have contractions from 6 pm – about 6 hours before she arrived at midnight. On per-vaginal examination, she was already 8-9 cms dilated. A perfect progress if not a fast progress of labour. The plan was put up for a re-assessment at around 3 am in the morning. There was only one thing which worried the team. The head was a bit higher than usual and a small caput had formed.

At around 2 am, the doctor on duty received a call to attend to another emergency. After that was settled, he decided to take a look at RD before it turned 3. Per abdomen, the head was still palpable. A repeat pervaginal examination showed that the head was still quite high and the caput had increased in size. During this pervaginal examination, there was a foul smell coming out from her vagina. The staff asked the patient once again about any leaking which started earlier.

The patient had been quite positive that there was no leaking. However, a new relative who had just come blurted out that she had been leaking for 3 days.

The family was conveyed the decision to take her up for Cesarian. And of course, the high chance of having a sick baby and septicemia in the mother.

Per-operative, the uterus appeared quite edematous and the liquer was stained with meconium. The baby was quite sick. Something was amiss.

The doctor closed the uterus and as is the usual protocol checked the posterior wall of the uterus. And what he got was the shock of his life. There was a hole in the posterior wall. Below is the snap of the posterior wall.

The patient was wide awake to talk. The team told her what has happened. The doctor told them that he suspected that she had been subject to abdominal massage and longer period in labour.

The story she told us unbelievable. After she returned from outpatient 5 days back, RD had gone gone to a quack who gave her some injections to increase pain. Nothing happened for the first two days. On the third day, she was again given injections and a massage of the uterus was done. She started to have contractions on the fourth day. When the contractions were quite good for about 6 hours, the quack did more vigorous massage with the intention to push the baby out. But, nothing happened.

One of the relatives realized that it may be better to go to hospital.

They had concealed the original history.

RD is lucky. The baby had very bad birth asphyxia and meconium aspiration. It was a baby boy. They have rushed the baby to a tertiary centre in Ranchi.

We pray that RD would recover without any problems. She was in florid sepsis when blood tests were done. And also remember the baby in your prayers. 

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 . . .

Cont'd - Dangerous Obstetrics

Yesterday, we had quite a crowd in our Labour Room. Over the last 5-6 months, we've had a fall in our Labour Room statistics. We presume that the fall has been due to the opening of multiple nursing homes and hospitals in the small towns from where patients usually came to NJH. Most of these hospitals are manned by nurses or junior doctors, but has names of consultants from the nearby cities on their rolls. 

Of course, we still continue to have our share of eclampsia and rupture uteri. Yes, I've sort of stopping writing about them for some time. You can read the following posts which I had put up some time back about our high risk obstetric patients. 

1. Dangerous obstetrics. 

2. Maternal health care . . . quo vadis.

3. Obstetric Care stories . . . cont'd

4. Weekend diaries

5. Best posts on RCH

We continue to have such patients regularly, although I've not written about them of late.

However, I was quite surprised by yesterday's rush. We had 6 labour patients coming in of which we ended up managing 5 of them. 

The first to arrive was SabD, a 32 year old G6P5L3D2 who had a Cesarian section to deliver her last child. She was in labour and had been trying to deliver at home. By God's grace, she had progressed to quite an extent. But her hemoglobin was only 8 gm%. Considering the prolonged labour, I offered to do an emergency Cesarian section if blood was arranged. The family went to arrive blood. However, the lady progressed well and delivered vaginally by late morning. 

We were glad, but the family was downcast. The reason - - the baby was a girl and the family already had 3 girls, and no boy. They were expecting a male baby. I counselled them to do off a tubectomy, but the family nor the patient would have nothing of it. 

The second patient was PrD, a 20 year old who was pregnant the third time. She had lost one baby earlier due to premature delivery and one was spontaneously aborted in the 2nd trimester. 

To our horror, PrD was leaking for more than 2 days. She was being managed elsewhere, was told that everything is fine and was discharged. Soon after discharge, she started to have fever. The family thought of a second opinion. PrD had a hemoglobin of 9 gm% and she was in full blown sepsis - -  a total count of 40,000/cu mm. She was only 136 cms tall and on per vaginal examination, there was hardly any space along the pelvic outlet. We had to do a Cesarian. 

Per operatively, on opening the uterus, the entire endometrium and the baby was stinking. It was hard to believe that the baby was still alive. So far, the mother and the baby have done well. 

The third patient was SanD, a 23 year old primi who had an uneventful labour and delivered normally. 

The fourth patient was AnwD, a 20 year old G2P1D1, who had a previous LSCS, but no live issues. She had been trying to deliver at home since evening and had ended up with a rupture uterus. The rupture was quite a bad one and very uncharacteristic of previous Cesarian ruptures which usually occur only along the suture line. 

Below is the snap of the rupture after the suturing was done. Since she has no issues, we have not done tubectomy. We pray that she will conceive and deliver a healthy baby later. 

The fifth patient was RekD, a 25 year old, G2P1L1 with previous Cesarian section who came in with labour pains as we were doing surgery on PrD. According to her dates, she was only of 32 weeks gestation. The baby looked quite small and I thought of suppressing her labour. However, the pains just increased. We had told the relatives of the non-availability of specialist facilities should she deliver. 

She did not respond to any of our treatment, but, almost after 6 hours of good pains, she was not progressing. There was a danger of going into rupture uterus. The doctor on duty thought of screening her by ultrasound and found that the baby was in fact term. Yes, the baby appeared to have low birth weight. 

Off went RekD for Cesarian and she delivered a Low Birth Weight baby. RekD had a hemoglobin of only 7.8 gm%. She is yet to receive a blood transfusion.

There was one more patient - the sixth one who did not stay on with us. IikD, a 26 year old wife of a army jawan. The poor lady was leaking since the last 2 days. They were trying for a normal delivery at home. She was G3P2L2 with the first delivery done by Cesarian and the second one a home delivery !!!. Her husband wanted an assurance that we would ensure that she has a normal vaginal delivery. 

I told him that that assurance cannot be given. The family went off in a huff with the jawan shouting all obscenities about the staff and the hospital. It was sad to see that an army jawan just not understand my reasoning and wanted to rather have his way without looking at the possible adverse outcomes. 

Now, all except one patient were very very high risk obstetric patients. 

In fact the 5 of the ladies who delivered yesterday, had lost a total of 4 babies earlier (5 if you include the present rupture uterus too).

5 families . . . 14 pregnancies . . . 5 dead babies . . . one more could have died if we had not intervened on time (PrD).

As I mentioned in one of my previous posts, the status of obstetric care in the region is so bad that we've not still got into the process of looking at neonatal outcomes. 

I'm proud that we've been entrusted by the UNICEF with the responsibility of supervising obstetric care in the district. 

However, to do justice to this responsibility, I need more help. One of the major challenges we have is the unavailability of an obstetrician and pediatrician. And there is always the dangling sword of the Clinical Establishment Act and non-understanding officers who could stop us managing such patients in the near future. 

Please spread word about the urgent need for consultants in the specialities of Obstetrics, Pediatrics and Anesthesia without which quite a number of hospitals such as ours would not be able to be the sort of blessing we are now to many a families. 

Living on the edge

It's sometime that I've written about the high risk obstetric patients that we continue to have at NJH. Of course, winter is considered to be off-season for obstetric care. 

The first one was TB. TB was into her fourth pregnancy. Her first 2 deliveries were at home. The third one was a Cesarian section done 5 years back. She had no clue on why the surgery was done. 

She came in with labour pains since about 12 hours. They were trying to deliver her at home when someone thought that something was amiss. On arrival, we were quite convinced that she had ruptured the uterus. 

On opening, there was something funny. The rupture was not along the previous suture line. The rupture had happened along the lateral aspect of the body of the uterus.

There can be only one diagnosis. The gravid uterus was massaged and thus the rupture happened. On finishing the surgery we asked the relatives whether some sort of massage was done. They were quite surprised that we found that out without their telling it to us. 

TB's 3 children are lucky to have their mother alive. 

The next patient, whose story I am going to narrate is not yet out of danger. SD, a young mother of a one year child came around the 8th month of her pregnancy. The problem was she was bleeding. 

We could tell that clinically, her hemoglobin did not look beyond 3 gm%. She had a complete placenta praevia. It was horrifying to note that she had spotting on and off and her relatives never thought that the condition could be life-threatening. 

More on SD in my next post . . . 

Urrgghh . . . UDBT

From today, we start a unique experiment with regard to first calls in NJH. It's just Dr. Shishir and me for taking first calls for the next one week. The arrangement is that we are going to do alternatively 12 hours of first call . . . The reason being that both of us in the wrong side of 35 seems to do better with periods of 12 hour rest. 

May sound a bit hilarious, but I thought that the harsh early winter and our poor respiratory systems would benefit from such a system of taking calls. 

Leave that alone . . . I wanted to talk about UDBT again. Oh . . . how I wish that this was legal? 

The story was that we had a lady with a rupture uterus today afternoon, KD, who had a hemoglobin of 7 gm%. She was hemodynamically stable. We got assurance from the relatives that they would arrange for blood from Daltonganj as soon as possible. 

The relatives were quite a few and therefore we thought that we would get the blood soon and we decided to take her up for surgery. Dr. Shishir did the surgery and the post-operative period was uneventful. However, the promised pints of blood never came. 

As soon as KD's surgery was over, we had another lady with a rupture uterus, SD, who also a very similar history. 

The team on duty was busy managing SD. It was only late evening that we realized that KD's blood never reached. Then, our nurses started asking them about what was happening about the pints of blood. Then to our chagrin, we found out that KD's relatives have not even gone to Daltonganj for getting blood. We had given them a request at 2:30 pm and while this was going on, it was past 8 pm. 

I came to know that there was a problem at around 10 pm, when the Acute Care nurse called me saying that there was fellow shouting and threatening everybody. 

I reached the Acute Care to find out a burly middle aged man in a agitated state. He wanted to know who ran the hospital and who the doctor was. He said to me that he will ensure that we drew blood. He then threatened to file a case against me for obstructing blood donation in the hospital. 

He went on ranting. I thought it was a matter of time before he hit me. I thought I'll give him a chance to slap me. Maybe, this was the moment I would get to bring up UDBT into the headlines of the country's media. 

That was when the whiff of country liquor clouded my senses. The fellow was drunk. The sniffles of winter had kept the smell of alcohol in his breath away from me. 

I remarked to a onlooker on how a drunk can be allowed into the hospital. The mention of the word 'drunk' had him make a hasty retreat. 

However, I'm still in a quandary. I've a rupture uterus lady with 7 gm% hemoglobin operated upon without a chance of getting even a pint of blood in the next 12 hours. I can only pray that she'll make it through the night. 

After the drunk relative was gone, I called another relative who was thankfully sober and explained about the problem. He apologized for allowing the drunk fellow come in. But, it was too late into the night. The dipping temperatures and the possibility of being looted ensured that no vehicle owner was ready to ply till early morning. 

Before I end, the common history of SD and KD. 

Both of them had delivered by Cesarian sections before. Their families were attempting home deliveries since yesterday night. In fact, KD's relatives told me that her abdomen was been regularly massaged since the last 2 days and it was so surprising that the baby did not deliver normally. 

I told KD's relatives that I find it surprising that KD is alive. 

Please pray that the relatives will get blood by early morning. 

And also a wish that UDBT would soon be legal for hospitals such as ours . . .

The Precious Baby

Today Shahana Khatun got discharged. SK was a high risk pregnancy under our care.

SK and her husband, Mr. Khudoos Ansari were married 5 years back. They had got married against the wishes of Mr. Ansari’s parents. The major reason – Shahana was an orphan and had no-one to take care of her.

SK had first come to us in 2010. She was having non-stop seizures towards the fag end of her pregnancy. We had to ventilate her and there was no progress of her labour after we had induced her. As a last option we had offered to operate on her to remove the dead baby – something we don’t do often.

By God’s grace, Shahana did well after surgery and got discharged in about a week’s time. Unfortunately, the neglect of the family to Shahana and her husband continued.

The second time Shahana became pregnant was sometime towards the latter half of 2011. Mr. Khudoos was away in Chennai. He had made up plans to come towards the last weeks of the pregnancy. Unfortunately, Shahana went into labour a bit earlier. The in-laws did not seem it cost-effective to take her to hospital. They tried a home delivery. In fact, during her first pregnancy, it was only two days since Shahana came with her husband from Chennai that she went into eclampsia.

The end result – Shahana’s uterus ruptured and she ended up with a dead baby. Thankfully, she was brought in time before she developed further complications.

We had advised the couple to wait for couple of years before a pregnancy. However, they started coming for ante-natal care from the beginning of 2013. We tried our best to refer them to a higher centre.

The family was poor and there was no way they could even think of a journey to Ranchi for safe confinement.

After getting all the necessary consent, we made a decision to do elective surgery on her at 37 weeks. Towards the middle, she was admitted twice for pre-term labour. Ultimately, she came for elective surgery last week.

By God’s grace, the surgery was quite uneventful and the family was blessed with a baby boy. 

We thank the Lord that we could successfully manage SK's high risk pregnancy. 

2 Rupture Uteri . . . and one live baby

About 10 days back, we had 2 rupture uteri. I had  written about it in an earlier post. 

SktD and NmnD . . . the patients. SktD's baby was not lucky as NmnD's baby. 

Couple of days back, I got the consent to publish the snaps of NmnD and her baby. 

By the grace of God, NmnD and her baby are doing fine. SktD was discharged couple of days back. 

Both of them benefited from the Maternity Charity Fund supported by one well-wisher. 

The snaps . . .

That is how NmnD's baby looked soon after delivery. The baby was in a face presentation.
I hope you remember UD whose baby also had a similar presentation

NmnD and her baby just before discharge . . . 

The Short Lady

Today early morning, we had a lady who came with a neglected previous Cesarian. She was brought in quite late. SwrD had started to contract sometime late evening yesterday. They lived quite away from a place where a Cesarian section could be done. It was midnight by the time she reached a place in our nearest town. Being Dussehra, there was no doctor there. They reached NJH today dawn (15th October, 2013).

SwrD, about 25 years old was 125 cm tall. It was quite obvious that the labour was obstructed. Her haemoglobin was only 8 gm%. Titus send off the relatives to get blood. He also got consent to operate without blood. It may look very foolish but that was the only option considering that she was fully dilated, the baby was stuck and very much alive.

The problems started after he opened up the uterus. Till the delivery of the baby, there were no obvious problems. However, as soon as Titus started to suture the uterine opening, he realised that there was a problem. There was torrential bleeding from below the uterine incision. That was when he realised that the previous Cesarian scar was quite low and it had given way.

With a hemoglobin of 8 gm%, it was only a matter of minutes before she got drained of her blood. We acted quite fast. I realised that the prolonged labour had made the proximal part of the uterine opening quite friable. We somehow got her sutured up and achieved hemostasis. However, there were very much evident signs of shock.

We were blessed to have the relatives come quite fast from Daltonganj with one pint of blood. We had asked for two. 

By God's grace, she responded well to whatever we offered her. It's midnight now as I write this. She has been shifted to the general ward from acute care. 

This is a typical case where a UDBT would have helped the patient and given a peace of mind for the doctors involved in her treatment. If the relatives were not that forthcoming, only a UDBT would have saved her. I later found out that the relatives had someone known within the blood bank . . . and that was the reason they got a blood bag fast. They had also taken someone to donate.

I understand that the government is considering to legalise UDBT. Hospitals like us would definitely benefit . . .

Fear and Frustration

As I heard the story of SD, it was the sad face of PD which came before me. And her moans of pain and distress. 

PD had a history very similar to SD. 

After having tried to deliver normally at her home, PD came to us couple of days back. The diagnosis was almost the same as SD. 

Rupture Uterus with septicemia and severe anemia. She was on the verge of going in a circulatory collapse. Few years back, we would have taken her in. Maybe one of our staff themselves would have donated her blood. And we would have taken her in for a laparotomy. And she would have made it. 

Now, things have changed. A sort of fear has come after recent happenings in one of our sister institutions. 

The next best thing we could ask was for them to arrange for blood. 

It was nearing dawn when PD was wheeled in. Everything was explained. As always, the first choice was for them to take her to a higher centre in Ranchi. They preferred that we manage her. 

PD pulled through till the blood came. But, we were in for a surprise. We had asked for 3 pints of blood. 

The relatives came with one pint. The doctor on duty did not need to look much into the pint of blood to decide that it was diluted blood. We sent it for hemoglobin. It was a measly 3.6 gms. 

On further inquiry, we found out that they had paid 3500 for the blood, ten times of what it took to get blood from the government blood bank. It was obvious . . . the blood bank in the district hospital did not have the required blood group. And they could not give them a donor. 

So, someone had fixed them up with an agent who arranged the pint of blood. 

It was nearing evening when I went to talk with PD's relatives. I told of the predicament. Meanwhile, some more relatives of PD had arrived. 

Thankfully, they were ready to take PD to a higher centre. 

There is not much reason to believe that she would not have survived the journey to Ranchi. But, she could have ended up as a maternal death too. I don't know.  

However, we could have served her well had we had the freedom to draw blood here, transfuse her and do the surgery. I'm sure that the family would end up selling quite a lot of their possessions to fund her expenses. 

Yes, we would have broken the law and ran the risk of ending up in prison. 

I wish we had an additional clause in the laws of blood banking in India, where hospitals which are beyond a certain distance from a blood bank which could guarantee the supply of blood 24X7 be allowed to draw fresh blood and use it in emergencies. 

Could someone advocate for this? And we could do well with quite of few supporters of this amendment in the law. 

Rupture Uteri . . . and the luckiest of them

Over the last 1 week, we’ve had 4 patients with rupture uterus.

Two of them were previous Cesarian sections who tried to deliver normally elsewhere. One of them continues to be very sick. Today we found out that she has developed a vesicovaginal fistula too.

However, the luckiest of the lot seems to be Kanti Devi, a 28 year old lady who had a twin pregnancy after 2 previous successful pregnancies, both of whom needed Cesarian sections.

Now, for the present twin pregnancy which she was not aware about (as she did not have any sort of antenatal care), she started to have pains since about 3 pm on Friday afternoon. 

The kept her for some time at home after which by around 8 pm, they took her to a nearby private clinic.

At the private clinic, she delivered a baby by normal vaginal delivery. However, after that the people in the private clinic waited as they most probably diagnosed a second baby.

They waited for almost couple of hours after which they realised that something was amiss.

The relatives brought her to NJH with a diagnosis of undelivered second twin.

Dr. Shishir, who was on duty did not need to ponder much to diagnose a rupture uterus. 

The surgery was uneventful.

I’m sure that this would be a very rare presentation of a rupture uterus - a patient with 2 previous Cesarian sections who in her third pregnancy conceives twins. She delivers a live baby by normal vaginal delivery and then ruptures her uterus and loses the second baby. 

And here is Kanti Devi with the surviving twin . . . 

The snap has been taken after obtaining consent from the family including the patient. 

Waiting . .. ...

(This post was written on Monday, the 29th July, 2013)

As we wait for rains . . . I’ve been waiting for something else since today early morning.

When I arrived for work today early morning, Titus had news for me about a rupture uterus which has been refusing to go to a higher centre after she arrived her at around 5 am today morning.

This is the second rupture uterus over the last 24 hours.

Dr. Shishir did the first one on Sunday evening.

MD had come sometime early morning on Sunday (28th July). MD had been in labour since 4 am on Saturday (27th July). This was her 3^rd pregnancy. By around 10 am on Saturday, the family realised that there was some problem. She was shifted to the nearby PHC.

The doctor at the PHC was smart enough to realise that there was some complication and she was shifted to the nearby district hospital. At the district hospital, it took some time before the family was told that she appears to have a rupture uterus.

It was late evening. The family was told that the best place for them would be a private hospital in the adjacent district. However, no vehicle was ready to take them to the adjacent district.

They were told that it would be dangerous to be in the district hospital. Therefore, they took refuge in a private hospital for the night.

Very early in the morning, they set out to the Daltonganj. The private hospital they were referred to refused to have anything to do with the patient. It was much beyond their skills. They promptly referred the lady to NJH.

They reached NJH by around 8 am on Sunday. The problem was that she had very high counts and her haemoglobin was just above 7 gm%. It was unthinkable to do anything without blood. We sent the relatives to the nearest blood bank in Daltonganj for 3 pints of blood.

The relatives returned by around 3 pm. Dr. Shishir operated. It was quite tough. She was in severe sepsis and appeared to be going to severe Acute Respiratory Distress Syndrome. She has pulled through the night. 

As I write this (Monday night), MD continues to be on oxygen.

The next maternal near miss, the one I mentioned at the beginning of this post, arrived today morning. RD, had a Cesarian section for her previous delivery. Similar to many of our previous rupture uterus following a Cesarian section, the family was ignorant of the fact that she needed an institutional delivery.

She was better off than MD. Her haemoglobin was 9 gm%. Still considering the time she was in labour and the long period of dehydration, we were definite that there was hemoconcentration.

RD had arrived at 5 am today. It was 5 pm by the time the relatives could arrange blood from Daltonganj. The surgery was uneventful. However, her uterus was quite damaged to conceive another baby.

To top the 2 rupture uterus, we had a severe eclampsia sometime around mid-morning. We kept her for normal delivery as she appears to progress well. However, we realised towards the beginning of her second stage of labour that there was a malrotation and she may not deliver normal.

We ended up doing a Cesarian section for her. As it was a second stage Cesarian section, there was lot of problems. The uterus was in atony for quite some time after delivery of the baby. And she lost quite a lot of blood.

Again, we needed blood. We tried to send the relatives to Daltonganj for blood. But, it was too much of an ask. We have to ensure that she does not bleed more during the night.

The availability of blood is quite a crucial aspect in the smooth running of a centre like ours.

Last year, we’ve had about 1500 deliveries. And with quite a large proportion of them accounting for high risk obstetrics, if we need to develop further, we urgently need to think about setting up of a blood bank.

And not to mention the very high chance that all three of them could have ended up as maternal deaths if NJH was not around. 

However, the big question remains about committed personnel who would be willing to come all the way to a remote location such as ours . . . and continue the good work and look at possibilities of new avenues of quality care. 

Tale of 2 Anaemic Patients

Yesterday was my first Sunday first call duty of the year 2013.

Early morning, I was informed of a very complicated patient in the labour room. LD, a 26 year old lady has been in labour since Saturday early morning. She has been running from hospital to hospital trying to get some help. The problem was that she had a hemoglobin of 6 gm% and nobody was willing to take her. To make matters complicated she had been given injection pitocin elsewhere. She had a pregnancy couple of years back. The baby had died just after childbirth after she had attempted a home delivery.

She was O positive. Dr. Johnson tried to arrange some staff to donate when she reached late night on Saturday. Unfortunately, we do not have many staff with O positive blood group. There was only one option. Either the patient had to be referred or we had to do the surgery with a consent to do without blood which was not a easy choice. The family having had visited quite a few  hospitals before entering NJH had already spent quite a lot of money on her ‘treatment’. So, the question of going to Ranchi was totally out of question.

However, we decided to wait for blood to come.

It came . . . by around 11 am on Sunday morning. It had been a full 33 hours since she had been in labour. And she was into obstructed labour.

I opened and found the worst I had feared. The uterus had ruptured. The baby was alive but quite sick. The endometrium and placenta was grossly stained with meconium. The baby died by evening. LD lost quite a lot of blood. She is on the ventilator and fighting for her life.

As we were doing LD’s Cesarian section, rather laparotomy, in came SeD.

Frighteningly, SeD also had a history similar to LD.

SeD was brought by her parents. Her father, a wizened old man who had quite a lot of creases on his face was a sorry figure.

The history . . . SeD had also been in labour since the previous day. The family had been to many hospitals. She was also told that her hemoglobin is 6 gm%. And her baby was in an abnormal position. The nurses could not get the fetal heart. I was in a hurry.

I told them to push SeD into the ultrasound. I had a cursory glance at the fetus. The heartbeat was going strong and was a footling breech. No other choice than to do a Cesarian section.

I did not think twice. She was B positive. I send word to 2 of our staff requesting to donate blood. SeD was having very strong uterine contractions. I did not want SeD to end up with the same outcome as LD. Ebez George, our Project Officer and Dr. Basil, our Dentist were were happy to donate.

We did the Cesarian in no time. To my surprise, SeD had a twin pregnancy. Mother and babies are doing well. I had missed that in my ultrasound screening.

I wondered why we did not have a staff with O positive blood who could help LD and her baby. They would have done better. The baby would have been alive.

But, a terrible thing happened later. I went to see SeD’s father. He had narrated to me SeD’s sad story. SeD had also delivered 2 years back, but the baby had died soon after her home birth. When SeD got into her present pregnancy, SeD’s husband took her and left at her parent’s home and told them not to send her back if she did not have a live baby this time.

I was congratulating myself as I saw SeD’s father standing at a distance and was happy that I had good news.

I could only watch with horror the pain that SeD’s father’s voice echoed when he came to know that his daughter had delivered twin girl babies. The creases on his face becoming deeper as he pondered aloud, ‘Doctor saab, I wonder if SeD’s husband would come to take her back with the 2 girl babies’.

Please pray that LD would recover well and SeD’s husband feels proud to be the father of 2 daughters.

3 adverse maternal events . . .

Today, I'm on first call after quite a long long time. Necessitated as we are just 3 of us running the hospital from Friday last. Many a time, I wonder about how long I shall shout about adverse maternal events in this part of the country. And every time, I get an answer about what to do . . . Yes, continue to shout about it till something happens. 

We had 3 mothers today . . . all of them had gone through adverse events. Of the three mothers, one was already dead by the time she reached us. The second one was . . .  from a medical point of view . . . a gone case . . . it would need a miracle for her to live. The third one came to us on time . . . she should live. 

Their stories . . . 

The first patient, AA, was a known case of pregnancy induced hypertension. She was supposedly under treatment. However, I did not see any records. Therefore, not sure. She had started to have convulsions today early morning. They had taken her to some hospital in the nearby district headquarters. From where they were asked to go to NJH. It was too late for her. She was dead by the time she arrived. 

The second patient, BB, a primi mother had been having contractions since the last 3 days. When she did not deliver by today morning, they took her to a hospital nearby where she delivered a macerated baby. But, then her abdomen started to distend. She was given a letter to go to Ranchi. 

Her relatives brought her to us. The family was too poor. And her blood group was O Negative. She was putting out blood from her bladder. And then to our horror, found out that she was leaking urine. And on putting a nasogastric tube, there was pus coming out. Most probably, she had undergone abdominal massage when she was trying to deliver at home. 

My provisional diagnosis - Rupture uterus with bladder involvement and intestinal necrosis following abdominal massage. 

Thanks to a new fund we created following a donation from a well wisher in Australia, we paid for her travel to Ranchi. I can only pray that she survives. 

The last patient, CC. Into her 2nd pregnancy, she had a cord prolapse. And her baby was dead for almost 2 days. There was pus pouring out from the uterus. The last thing I wanted to do was a surgery to deliver a dead baby which was stuck in the uterus. But, that is what the doctor who first saw her elsewhere wanted us to do. 

I was not sure about how friable was the uterus. She was in full blown septicemia.

We took a decision to try to do a craniotomy and keep her ready for laparotomy if the uterus ruptures in the process. It's a difficult thing to do a craniotomy and I always pray that I do not end up doing one. 

As we were explaining to the relatives about all possible complications, the fortunate lady suddenly started to have contractions. And she miraculously delivered normally. It was a relief. 

It was very unfortunate . . . for the first two ladies . . . 

Next week, it is International Women's Day on the 8th. 

I pray that we would continue to make a difference in the lives of women in our surrounding communities especially when it comes to managing their pregnancies . . .