Tragedy . . . And a Paradox

Before you can start of imagine what could be the tragedy – yes, another maternal death.

SD, aged 22 years and married for the last 3 years was brought to our labour room in the wee hours yesterday with history of leaking and seizures since midnight. She was unconscious and threw another episode of fits in the labour room. She had already been to one of the private hospitals in Daltonganj. We were not sure of what all medications she got there – but she was told that something can be done only in NJH.

According to dates, she had one month more to go before being full term. I noticed that she was contracting quite violently. Looked like she received an intramuscular pitocin, which is quite common management in many places in India. And the uterus also was looking elongated and very much suggestive of an obstructed labour too.

The pervaginal examination confirmed my worst fears. She was in fact terribly obstructed. However the baby was alive. I wanted to see if the baby had passed meconium – but I could not go anywhere beyond the edematous scalp which was firmly wedged in the pelvis. There were no signs of any fetal distress.

Considering that SD had eclampsia and an obstructed labour, I talked to the relatives about the pros and cons involved in the surgery. Ultimately – telling them that there is a remote possibility that we could lose SD as well as the baby in the process. All done including the informed consent, I set out for the surgery – the first one in an ultimately busy day which saw 2 more cesarian sections.

The initial part of the surgery was uneventful including the delivery of the baby although the liquer was thick with meconium. The baby had a good Apgar score. The trouble started from then onwards. The uterus was refusing to contract. No amount of Prostodin and Pitocin would do the trick.  Ultimately, it contracted.

I somehow closed the incision and came out only to find out that the uterus has once more gone into a state of relaxation. SD was losing blood in enormous amounts. The relatives were running from pillar to post for blood.

By late morning, we realized that we were losing her. We removed her off the ventilator at around 1:30 in the afternoon.

As she was taken off the ventilator, a group of SD’s husband’s friends had turned up to donate blood. They became somewhat agitated. They started shouting at me – telling that I did the surgery without the necessary facilities. I calmly explained to that that all options had been well explained. When I showed them the consent forms – they dispersed without making any more fuss.

Since the meeting on maternal death monitoring, we have been quite prompt in sending the necessary reports to the district level. I had to call SD’s father to find out more details before I fill in the report. One of the details we had to fill in was about the occurrence of any danger signs.

I was shocked to find out that SD had swelling of the body since the last 20 days and has not been feeling very well since then. Nobody had taken it quite seriously. Then came the biggest shock. It was a dramatic moment. I asked SD’s father, if the local Sahiya (ASHA) or the ANM knew about her pregnancy and if she had not told her about the danger signs. It turned out that SD was the Sahiya for the village.

The incident spoke volumes about Maternal health care in the district. I could not initially believe my ears. The lady who was responsible for quite a lot of the maternal health care in her village could not diagnose a danger sign in herself and did not take any effort to present herself to a doctor.

We have miles to go before we can claim any sort of success in the area of maternal and child healthcare. It is unfortunate that SD had gone into atonic post-partum hemorrhage. I do not think that anything could have been done even in the best of centres. However, if an early diagnosis was made of her pre-eclampsia and her obstructed labour at a later stage, SD may have survived.

This is the second time within a period of two months that we were having a maternal death due to uterine atony. Maybe, I should be taking the option of opening a blood bank seriously. There are enormous stipulations to be met before I can even think of a blood bank. I recently heard from one of our sister units how and much more troublesome it is to maintain rigorous stipulations required for a blood bank. However, the paradox is that we have licensed blood banks which supply substandard blood and get away with it.

Story of a maternal death

KD, aged 19 years, married for about a year came into labour room at around 5:30 pm yesterday. It was a bit sorry to see her in such a state. She was fully bloated up, looking quite dehydrated and exhausted. KD was at term and she had been in labour since the day before. Admitted in one of the hospitals at Daltonganj she was referred couple of hours back with a diagnosis of obstructed labour. Her relatives were told that we would be able to pull the baby out with special instruments which we had in NJH. They must have been referring to the forceps or the vacuum extractor which we had.

I was called in to see KD. There was no question of getting a live baby per vaginally. The head was stuck firmly in the vaginal opening. Along with the caput which had formed, there was edema of the scalp which had worsened the situation. I was in a dilemma. The baby was alive. I went to talk to the bystanders. They wanted something to be done. But, the story they told me made me all the more confused.

 

KD had been diagnosed to have severe anemia for quite some time. Her hemoglobin was 4 gm% four days back following which she was brought to a doctor in Daltonganj. KD was from the border region of Jharkhand and Bihar. The family was quite poor and one of her uncles in Daltonganj volunteered to help her with her delivery in Daltonganj.

 

Nobody was willing to take her with a hemoglobin of 4 gm%. One of the places however took her with the condition that the family provided 6 units of blood. The uncle arranged the 6 units of blood which was transfused over 2 days. Meanwhile she had gone into labour.

 

When she reached us she was already completed more than 24 hours of active labour. After discussion with the relatives which included her uncle, we decided to take her for Cesarian Section. They had one pint of blood with them.

Her hemoglobin before surgery was 9.6 gm% and with one pint blood, it was worth the risk. However, considering her previous hemoglobin of 4 gm%, I took a very high risk from the patient including chances of uterine atony as well as vesicovaginal fistula. I gave them a very guarded prognosis for both mother and baby.

The pre-operative phase was uneventful. Once I opened the abdomen, I realized that I was in for trouble. The intestines were all edematous and there was quite a lot of fluid in the abdominal cavity. The bladder was edematous and there was edema on the anterior uterine wall and the space between the peritoneum and the lower segment of the uterus was also filled with fluid. As is routine, I incised the peritoneum over the lower segment and pushed it down along with the bladder. When I opened the uterus I knew that this was going to be a struggle. The baby had passed meconium and was totally caked in it. The inside of the uterus was stinking.

After somehow extracting the baby who had poor Apgar scores (3 at 1’ and 6 at 5’), I cleaned the uterus. However, it was refusing to contract. After about 3 ampules of carboprostin it contracted. I had also started to suture the uterus back. However, I noticed that she was bleeding from the edges of her wound. I could tell that the patient was going into Disseminated Intravascular Coagulation. The bleeding somehow stopped in between. So, I started to close the incision. Meanwhile, I realized that the uterus has again started to relax and her blood pressure was not recordable. She had gone into uterine atony. More injections of carboprostin went in after which the uterus contracted again.

We shifted her to the acute care unit and put her on the ventilator and started dopamine. She was bleeding again from the uterus when we noticed that the uterus had relaxed yet again. When we gave the carboprostin injection again, the blood she lost was enormous. We needed more blood. The relatives had donated quite a lot and they just could not find more donors.

Meanwhile, Dr Johnson had done quite a good work with the baby. He was crying and was doing fairly good.

However, by now we knew that we were losing KD. She was not responding to dopamine nor adrenaline. Most probably, she had gone into a septicemic shock and compounded with the obstructed labour and the state of anemia which she was in and the DIC, she had gone into a state of non-response to whatever intervention we were trying out.

I declared her dead at 10:30 in the night. I was quite confused on whether I had taken the best decision for KD. During the discussions with the relatives earlier in the evening, one of them had suggested that I kill the baby and somehow pull him out.

Later, as I reminisced about how things went about – maybe I should have waited for the baby to die, then do a craniotomy and pull the dead fetus out. But, she still could have gone into uterine atony.

But, all of this could have been prevented – had she got a regular antenatal check up and got a good hemoglobin whereby at least one of the high risk factors could have been got away with. However, the obstructed labour had made things worse.

The baby has been left behind by the family for us to care for till he is well enough to be taken home. I hope they will come back for the baby.

I just wished that things had turned out well for both the mother and the baby. But, that remained a dream for the family and us.