Monday, June 11, 2012

Complication part 3

Not long back.......may be One and a half years back I conducted a very straight forward vaginal delivery of a lady at around midnight.She had a previous caesarean section.It was a baby boy after a daughter.The couple was really happy.The family was complete and it was a vaginal delivery after previous caesarean section.I congratulated them and they thanked me.I left the lady to catch my sleep.After may be 2 hours I got a call from Dr Sweta,Our registrar on call.The patient was bleeding heavily and the medicines for stopping PPH ( post partum bleeding) were not working on her.I rushed to the hospital.She was bleeding in fact.Uterus was well contracted on abdominal examination.So had the scar of caesarean given way?I did an internal check up and found the scar to be intact.The lower segment and the portion below previous scar felt very floppy with a fibrous ring where previous scar was.This floppy lower segment wasn't contracting.I did bimanual compression which didn't work.Syntocinon,ergometrine,carboprost.........all in vain.Tried to put a Foley's  Cather inside the uterus.Tried to put roller gauze.Nothing worked.the floppy lower segment continued to bleed.Patient's husband and her family who were rejoicing in the room were called and informed of this sudden unexpected complication.My team had ordered for blood products.I got the Lady shifted to the OT.Dr Priya immediately intubated her anticipating her to collapse.By then I had taken consent from her husband to operate on her to stop the bleeding.I did an internal iliac artery ligation.It seemed that the bleeding was decreasing in amount and I decided not to perform a hysterectomy ( removal of uterus).Got her shifted to the ICU. It seemed like early DIC was setting in.
Mumtaz mahal who died of PPH
It was difficult for me to perform the surgery,keep the patient's family informed and keep their morale up as well.I was tired,stressed and sleepy.In between the patient's husband wished to me to comment if shifting her to Max saket was a good idea as it is a bigger hospital.I told him that I think I can manage her equally safely in Max Gurgaon provided he had the faith and trust and also that I would never let my personal ego come in between his wife's life and proper care.He agreed to stay with me.(Later on he did confess that he was under tremendous pressure from his family members to get her shifted to Max Saket under some older Gynaecologist,but he went ahead with his gut feeling).  After 2 hours of sleep I went and assessed her.Still her dressing was getting wet.Her Haemoglobin had again fallen down though her clotting profile was improving.There wasn't any active vaginal bleeding but I wasn't sure whether she had stopped to bleed or was still bleeding inside.I had done my best and only measure which I could have taken was to remove her uterus.I wasn't sure whether that was necessary or not.I involved another Gynaecologist to give her opinion as personally I believe when under so much stress one's judgment can be blunted.Even that Gynaecologist wasn't sure whether this patient needed observation for some more time or a hysterectomy.A falling Hb wasn't letting me relax and yes I was afraid that I might loose the patient if frank DIC sets in.Ultimately I decided to remove her uterus and within 24 hours she was taken second time in the OT ,this time for removal of the uterus.I swear I was mentally and physically tired.Felt like had had not slept for days altogether.Every hour i was talking to the patient's husband.I requested Dr Shalabh  to sit in the OT waiting lounge,just in case I felt too tired and drained to come and help me for the hysterectomy.(The reason I have mentioned this fact is to tell you how drained and  vulnerable a doctor feels in such situations.No one wants to loose one's patient.Normally I don't need a Surgeon to support me for my surgeries,but yes here I needed that mental support).Surgery went well.......her bleeding stopped.She recovered from her early DIC.A strong lady herself she didn't end up in post traumatic stress.........I did.It took me a while to forget that bloody night.In this blog itself I have mentioned this incident before.......It was scary.I am thankful to the whole family who showed trust in me,stayed at Max Gurgaon and gave me the opportunity to take care of her.

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