Saturday, June 9, 2012

complication -Part 2

I was the registrar on call at my UK hospital.There was this third time pregnant Lady in the antenatal ward who was escorted by the midwife to the labour room.She had a bad CTG suggestive of foetal distress.I offered her an instrumental delivery as she was already fully dilated.She declined.She wished to have a caesarean instead.No amount of convincing worked.So here she was under GA and baby was out in no time.....healthy baby girl.I started closing the uterus.Even with easiest of pace it never takes me more than 20  minutes to complete a caesarean section and here I was still closing the first layer of uterus and 1st layer was still Little wet with blood.There was a small ooze which I was not able to stop.The protocol in UK is to call the consultant if expected blood loss has already been more than 1000 mls in a caesarean.It was much less than that but a bleed like this should have been controlled by couple of figure of eight stitches I reasoned to myself.No harm in calling the on call consultant.I tried to reserve my call for help for dire emergencies,so consultants used to beat their super prompt arrival on such occasions.When my consultant arrived in not more than 10 minutes ,he was surprised to see me call him for such a small ooze.And he was relieved as well that it won't take him much time to fix it and he can go back home and sleep peacefully.Almost 2 hours past by and still the bleeder was bleeding.The uterus had started to become atonic.Her blood pressure was going low.I could see the sweat drops glistening on my bosses forehead.He asked me to call the senior most consultant and when he didn't pick the phone at 3 am in the night,he asked me to call the second senior most consultant.The senior consultant arrived but by that time the uterus was boggy,patient was in DIC(disseminated Intravascular coagulation) and was bleeding from all over.I don't know how but superior and inferior mesentric arteries were also bleeding.
Her BP showed a measly 15 mmHG.My heart sank.I imagined this case to get a mention in the forthcoming edition of 'why mothers die'?
Then the senior most consultant talked to the patients husband and decided to proceed for caesarean hysterectomy.By this time she had already receive approx 35units of PRBC apart from other blood products.She was still bleeding.I remembered such a case which had happened in a famous corporate hospital of Delhi where a politician's wife operated by renowned gynaecologists of India(Mumbai) had ended in DIC and then the vascular surgeon had saved her.So,I suggested to call the vascular surgeon and my boss agreed.That lady was slowly taken care off.In between I performed 2 instrumental delivery as well :-) while my bosses kept on struggling.It was the longest caesarean I have ever been washed for......9 hours.The patient survived.My name didn't become a part of confedential in inquiry,but it was a close save.I was shaken for 12 hours as I had to come back for another night on call and didn't have the luxury to destress my self.
The patient had post traumatic stress disorder for some time.But was discharged on day 5th of the caesarean with a healthy baby but minus her uterus.For a week I kept on explaining everyone ,consultants,midwives and colleagues that it wasn't my fault.It wasn't actually no ones.In hind sight a consultant told me why didn't you give her an option of forceps under general anaesthesia rather than a caesarean.
Anyways after a week,I was asked to present this case in front of the department and was declared 'not guilty'.

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