Anatomy of a Post-Partum Eclampsia

I just returned from work. It has been a heavy day . . .  2 rupture uteruses, 1 previous Cesarian and a Eclampsia with Chickenpox . . . Enough to learn complicated obstetrics . . . And then we had a maternal death . . . Humanly, there was hardly any chance of her surviving. 

MD1 had come in yesterday, Sunday sometime around late afternoon. We were not expected more eclampsias and rupture uteruses and the recent heavy day that we had of complicated obstetrics . . .

The history has been unbelievable . . .  Before that snaps of the slips of papers her relatives had with them . . . It was very difficult to find out who gave the first 2 slips . . . The next 2 slips have the names clearly written. . .  Please go through them. The history is given after the photographs . . .

Inj Calmpose, most probably received after she had her first dose of seizures . . .

Febrinil is Paracetamol . . . I'm not sure where she got it . . .

This is from the district hospital, from where she was referred. However, there is no name/address or any time or date . . . So, we cannot say whose this is . . .

This is the discharge summary from the hospital where she delivered . . .

Now, for the history . . . 

MD1 had a very uneventful pregnancy except for the last week, when she had some amount of headache and swelling of the legs . . . She had regular Ante-Natal check ups at the local Anganwadi. However, nothing much went wrong. She started labour pains last Friday evening. . .  The Sahiya (ASHA worker) took her to the local Community Health Centre . . . 

As you can see from the last snap, she delivered at 3:20 AM on Saturday, the 9th of June. According to the relatives, the Sahiya made them take a discharge against medical advice at around 10:00 AM the same day. Everything went fine till around 4:00 pm when she suddenly had multiple episodes of seizures. 

The local villagers told the family that most probably an evil spirit has attacked the women in her weak post-partum state. A witch doctor (ojha) was promptly called and ceremonies were held for around 5 hours. She continued to have multiple episodes of seizures. And she was unconscious soon after. 

When no relief was forthcoming, one of the relatives suggested that she be taken to the place where she delivered. She was immediately referred from there to the district hospital. If the 3rd snap is hers, that is what she recieved . . . No Magsulf, no blood pressure taken, no nifidipine . . . But, intravenous fluids, Injection Taxim and Inj Pantoprazole. 

By around afternoon of Sunday, the 10th of July, the relatives were asked to her to us . . .When she reached us, she had a Glasgow Coma Scale of 3, a saturation of 60% and blood colored urine. There was nothing much . . . However, the relatives requested us to do something. 

She was put on the ventilator. Soon after, the blood pressure started to crash. She was on dopamine . . . I wondered later whether dobutamine would be a better option . . . However, I did not have to worry much. She had a cardiac arrest from which she could not be resuscitated . . .  It was sad . . . You can get all the causes of poor maternal care from the MD1's story . . . 

After MD1 came, we had 2 rupture uterus. The first one gave us a wrong history . . . She came early in the morning. . . We thought of giving her a trial . . . but our doctors were quick enough to diagnose a probable rupture uterus by around 8 am. . The baby was a bit sick. . . Later, we came to know that the labor pains were more prolonged than actually told. . . 

As soon as finished the surgery, we had one previous Cesarian Section who came in early labour . . . As we rolled her in, came one more severely obstructed labour . . . We had to wait till the former's surgery was over. . . By then, she had ruptured . . . 

As soon as we finished suturing up the Rupture Uterus came in MD2, with Severe Eclampsia and Chicken-pox . . . I just finished the surgery . . . She is on the ventilator . . . We pray that she'll make it. . . 

As I mentioned earlier, when we have unfortunate occurances like rupture uteruses and eclampsias happening, we expect things to improve as time passes . . . The sad part is that does not seem happening. I hope it worries us . . .

Koel Karo . . . Snaps of a past struggle . . .

About an year back, EHA started a Community Health and Development Project in Khunti district of Jharkhand state by the name 'Injot' which means light in the Sadri language. Couple of days back, I got the opportunity to visit the region.

The region was significant because of the 'Koel Karo movement' against the construction of a dam which I understood would have displaced a population of almost 200,000. You can read a recent article about this project in the latest edition of our in-house magazine Safar in Page Nos. 5.In addition, it had also historical importance in struggle for a separate Jharkhand state.

I understand the movement against the dam, led under the aegis of the 'Koel Karo Jan Sangathan' is the only struggle in India which has been successful in preventing such a dam from coming up. 

Well, the snaps from the visit . . .
 

The first thing that you notice is the absolute dryness of the region.The villages wait eagerly for the monsoon rains . . .

Well dug for security personnel within the forest who came to protect the construction of the dam.

Remains of the buildings constructed to house the security personnel (above and below)

Unripe jamuns waiting to ripe . . . They ripe once monsoon sets in . . .

The long walk towards the proposed dam site . . . Note the huge stone which has been split through to make way towards the site . . . Must have been quite an effort put in . . .

The dam site . . .

The walls of the dam were supposed to have been built at a height of about 50 metres from the top of this hill . . .

Picturesque view of the Karo river . . .

Another view . . .

The road built to transport things to the other side . . .

Memorial built in Tapkara village to remember 5 martyrs who were killed in a protest demanding seperate Jharkhand state in 1946 . . .

Memorial built to remember those who were killed during police firing on Feb 2, 2012.

I felt sad after the visit . . . A region rich in tradition and history. It was obvious that the whole region continue to remain impoverished and backward.

As we visited the market after the visit, I happened to talk to few of the locals . . . They are sad that the government has ignored them. There was hardly any development. 'It looks as if the government wants to punish us for preventing the construction of the dam'. Echoes of similar sentiments are heard from the villages around NJH . . . 

Even though there has been reports of the government having shelved the project, there have been no confirmatory official notes . . . The damage has already been done . . . People continue to live in a state of an unsure future for their land, culture and children . . .

I wish our country know about the struggles of such regions . . . There have been similar millions of countrymen who were unsuccessful in their struggle from being displaced . . .The oppression brought about on such people groups who do not have a voice fuels the country towards the so called term we call 'development' . . .  The stories continue today.

Prayer Bulletin, NJH . . .8 June

1. We thank for the life of Sr. Martha Tigga, who went to be with the Lord yesterday. Sr. Martha served NJH for almost 30 years before she retired last year. Kindly remember her family in your prayers. 

2. We request your prayers for rains. The heat has been quite bad here with temperatures reaching as high as 50 degree celsius. 

3. Maternal health care is at crossroads here. The load of work in the hospital is on the constant rise. Meanwhile, the number of complicated cases are also on the rise - which stretches the resources even further. We thank the Lord for the successes we've had. There has been an increased number of deaths . . .and it is very disheartening to see . . .

4. We thank the Lord for the Skin Graft Mesher. 

5. Kindly pray as we prepare for the Annual Reporting meetings during the last week of June. 

6. Bandhs (General Strikes) continue to play havoc with normal life and the smooth functioning of the hospital. We feel sad when patients suffer. Kindly pray that people will realize the futility of such bandhs. 

7. Please continue to pray for the needs of the hospital. 2 Generators of 100 KV and 30 KV each are needed at the earliest. We need about 1,000,000 INR for the same. 

8. Schools for the children of the campus would be re-opening soon. A new school bus would be a welcome addition. (1,200,000 INR).

9. Please continue to pray for the admissions for the Nursing School. The response from the local community has been very subdued as the minimum qualifications have been raised from 10th standard to 12th standard. 

10. We continue to require a Pediatrician and a Medicine Consultant. 

11. We thank the Lord for Dr Sam David and Mrs Sarah David from EHA Central Office, Chennai who spent time with us for the last 4 days. 

12. I would be in Ranchi over the next 2 days traveling in the newly started Community Health Project in Khunti district of Jharkhand. Kindly pray for safety as well as wisdom as we meet the various stakeholders. 

12.

Maternal health care . . . Quo vadis . . .

 Last Wednesday, I was quite content that I would be able to sail through the day without being very busy. Wednesdays are usually quite light at NJH - the major reason being that it is market day in Satbarwa. Most of the local crowd would not be free enough to come to the hospital and there would be fewer vehicles available to bring in the patients as most of them would be eying the market crowds . . .

I was wrong. . .  And to top it, I had 4 maternal near misses of which already one is a maternal death, one is on the verge of a possible maternal death, one is out of danger and there is no blood available for the fourth one . . .

I would not go into details - but just a glimpse into each patient. We shall call them A, B, C and D - just to protect identities.

Patient A: A previous Cesarian, had been having pain since yesterday night. As she came in, we had a very alert Titus who ensured that the baby was delivered within forty minutes of the patient entering the hospital. It was impending rupture and the baby was quite sick.

Patient B: A very interesting case. Came with a history of seizures in a hospital at the nearby town. Urine albumin was 3+ and there was gross hematuria. We gave the option to go on to Ranchi. The baby was alive. We took her for Cesarian. The surgery was uneventful - but the mother became sick soon after. Went into respiratory failure and suffered a cardiac arrest and died. The baby although sick was doing well.

Patient C: If Aamir Khan knows about this, he could make SMJ Part 2 against the doctor community. But, then he'll have to pull few of the policy makers also. Patient C, a mother of 2 had been having labour pains since Monday afternoon. She was trying for a home delivery. Nothing happened till Tuesday morning, following which she was taken to the local Primary Health Centre. They were told that nothing much could be done and she was taken to a private practitioner who kept her till the evening. By around 4 pm yesterday, the relatives were told to take her to the district hospital. She was given one unit of blood . . .kept overnight. One more unit of blood was transfused today morning. By afternoon, she was told that she had some major problem.

She reached us by around 4 pm. The abdomen looked as it had ruptured.She was toxic. 

There was nothing much we could do. The fact that she was mother to 2 girls made us take a decision to try to save her. Two of our staff donated blood. 

Per-operatively, we knew that it was going to be tough. The blood was very dilute and the whole abdomen was stinking. On opening the uterus, there was a gush of toxic gases - it was like a little volcano bursting. One of the nurses went searching for eucalyptus oil which we keep for such occasions. 

She was stable after surgery. However, we decided to keep her on the ventilator. 

Although she made it till the next day, she suffered severe hypotension followed by cardiac arrest sometime during the afternoon. She was dead . . . most probably multiorgan failure secondary to severe sepsis.

Patient D: She came in as we finished operating on Patient D. A previous Cesarian section done at Garhwa couple of years back, the patient had been trying for a home delivery since early morning. It was almost quite late in the evening. She was visibly pale. And we needed blood. Clinically it looked rupture uterus. 

Blood  came sometime past midnight. Again Nandamani had to be called in. It was a very bad rupture uterus. She has done fairly well so far. 

So, on a unusually busy Wednesday we had 2 Dead Babies, 2 Dead Mothers - one of whose babies was alive although sick. The other 2 mothers could have also died. The 2 babies born alive were also born with low Apgar Scores. . . 

Well, to nail the facts once more - 

Patient A: Mother alive, Baby sick - Impending Rupture

Patient B: Mother dead, Baby sick - Eclampsia

Patient C: Mother dead, Baby dead - Impending Rupture

Patient D: Mother alive, Baby dead - Rupture Uterus

All the 4 patients came within an interval of 10 hours. All mismanaged elsewhere . . .

I wonder how long will this 'tamasha' will go on before sanity dawns on the policy makers and the government . . .

Monkey story . . .

I happened to come across a monkey family on one of my routine village visits. I decided to photograph them. I clicked a lot of photographs. It turned to be pretty good. And I even found out a story to go with the photographs. I hope you enjoy the photos and the storyline. Would be quite enjoyable for kids.

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That is Papa monkey and Mama monkey waiting for the tuition teacher to come for their child – Baby monkey. Today is his first day of clases.

Baby monkey is very naughty and is learning all the wrong techniques of climbing trees. That's the reason, Teacher monkey was employed to give special lessons in tree climbing.

The parent monkeys wait as Baby monkey continues with his antics.

Papa monkey is getting inpatient. “Have we got the right monkey as the  teacher?” he says to Mama monkey. “I hope his degree certificate is not a fake,”
he continues.

Mama monkey also cannot hide her impatience. She looks to the sky to have an idea about the time. “I hope he has not lost his way,” she replies.
 

Mama monkey gets hold of Baby monkey and manages to quieten him down for some time before the teacher comes – if he ever comes.
 

Mama monkey keeps a watch on the traffic on the road to ensure that the  Teacher monkey doesn't get lost. Meanwhile, Baby monkey entertains thoughts of the Teacher monkey not coming today. He thinks of the various other options available to him. He could go to raid the mangoes along with his friends or  maybe try to sneak into one of the neighborhood kitchens. He thinks, “Wow, I wish the teacher doesn't come.”

Mama says, “Hey, son. I think I can see your teacher coming”. Baby monkey thinks, “Oh, no! All my plans for the afternoon are washed out.”

Mama monkey thanks the heavens, while baby monkey contemplates the grim one hour of training that awaits him.
 

“I hope I'm at the right address,” the Teacher monkey wonders.

 

 
 “Now, go fast. Don't keep your teacher waiting,” Mama monkey urges Baby  monkey to go down fast. “Yes, mama, I'm going down fast,” Baby monkey replies as he prepares to climb down.

 The Teacher monkey waits for his new pupil with trepidation. “The new  generation kids are a difficult lot to teach. I wonder how this one is going to be,” he thinks. He'll have to make the lessons interesting.

“Good afternoon, sir. Here I come.” The Baby monkey slowly gets down the tree as everybody watches.

The training starts . . . The Baby monkey finds the initial steps quite boring . . .

However, later he starts giving attention . . . 

He learns complicated steps . . . 

Well, all this training has helped him to succeed and go up in his life . . . 

HOPE YOU ENJOYED IT. PLEASE SHARE . . .