Saturday, October 29, 2011

Tearing through the night (Part II)

Tearing through the night (Part I)

The new nurse panics and requests Dr M for a referral or to at least call the senior in-charge. Both are politely denied. Another dose of Nifedipine goes in, and the increase in duration and frequency of contractions is reassuring. Dr M at this point consults his colleagues. But he has already decided to accelerate the events of labor. He thinks about artificially rupturing the membranes but then decides against it and is fixed on only stripping them for now. He starts creating a partograph of the data he has gathered. Graph makes it obvious that the labor is progressing normally, but what bothers Dr M is that it will take another 2-3 hours at this rate. By 9:45pm, the cervix is fully dilated. Dr M now approaches the relatives, explains the high risk and the chances of poor prognosis to them, and that referral is required urgently. Of course, he knows very well that they will not agree to it, now that she is so close to delivering, no matter how near the referral centre is or how the grave the patient can become. The same was presented in writing and without hesitation they signed the high risk/poor prognosis write up. A grin appears on Dr M's face, it grows in size as he turns away from the relatives and walks towards the patient. Dr M is now getting all the action he hoped for at the start of the night.

Dr M swabs the perineum, albeit not liberally on account of limited betadiene that is left, introduces two fingers and gleefully strips the membranes off the lower uterine segment.

Back at his table, Dr M is approached by the peon who offers him food from his own house. By the time Dr M realized it was time for food, everything around had closed down, so he had been prepared to fight the MMC that would eventually come to trouble him. But of course Dr M couldn't turn down such an offer, so he agreed to eat with the peon. They were joined by the nurse and another assistant. During dinner conversations it became known that the assistant was asked to come over by the nurse as she had been present in a number of deliveries at the centre. Dr M didn't mind. He was open to any help he could get, but none that would interfere with his autonomy.

After dinner, Dr M goes out to get others and himself a bottle of Pepsi. The general store is a 5 min walk, but has closed down by then. The shopkeeper is there however, and recognizes Dr M. Turns out he had come in the late afternoon that same day with his son who may or may not have swallowed a coin, to the centre. He opens the shop; Dr M buys two bottles of Pepsi, a liter each. As Dr M walks towards the health center, he is greeted by many who invite him into their homes. It is an auspicious night, a night of celebrations. That is another reason why Dr M wants to hasten the delivery, besides him being bored of repeated observations of course. The fetus could be born on this auspicious night if his efforts are successful. Not that he cares when it is born. Yes, Dr M referred to fetuses as 'it'.

Back at the centre, he can't find anyone. He grabs his stethoscope and rushes to the labor room. Stripping has worked. Labor pains have accelerated, membranes have ruptured and liquor is clear. She is getting contractions every 2 minutes lasting half to a full minute. Prior PV exams had confirmed vertex presentation in occipitolateral postition. On PV now, head is well flexed and internal rotation has occurred. Her contractions and efforts to bear down forcibly are disproportionate to the outlet provided by the perineum, as a result of which caput is evident over the occiput even before crowning. The assistant starts applying fundal pressure. Dr M instructs her to stop, but she continues anyway. The mother was getting exhausted and crowning wasn't occurring. She had already taken many a hit from the peon and assistant. Dr M, though violent by nature himself, contributed nothing to that. On the contrary, he asks them to stop hitting her. They slowed down. Dr M at this point expresses his concern that an episiotomy will be required. The nurse remarks that they aren't ready for it and that nobody has ever performed an episiotomy over there. So the labor continues in the same way and forcible crowning is achieved after which the neonate is delivered.

No cord cutting scissors or cord clamp is available. With a suture cutting scissors, the cord is cut and ligated with two ties. A female neonate is delivered at 10:30pm weighing 2.6kg with caput and acrocyanosis. APGAR at 1 and 5 mins were 10. Placenta was delivered 15 minutes later and it was evident that a segment of it was retained. Dr M inserts his hand inside the uterus and removes the retained placenta, and whatever clots he can discern. Bleeding still doesn’t stop.

He orders 4 misoprostol tabs and gives them orally to the patient. There are no other oxytocics available. Half an hour later, the bleeding still continues. Dr M once again introduces his hand to inspect for clots or placenta, none found. The uterus is well contracted and hard to feel on PA exam. Dr M now starts swabbing the vaginal walls to inspect for tears. Swabbing is done with cotton, as gauze is not available; this leads to strands of cotton fibers being stuck everywhere, on the vaginal vault, on the instruments, on the gloves, all mixed with blood. It is difficult to work in the bloody mess, but Dr M manages somehow.

Vaginal walls seemed intact after inspection. Only plausible option now was the cervix. What worries Dr M is the possibility of coagulopathy. There is nothing he can do for that and from what he has heard, the referral unit doesn't send help after 10pm, another thing that he had been informed of and had ignored earlier. When Dr M asks for speculums and retractors, the staff looks at him as if he had spoken in an alien language. He instructs them to get all the instruments they have along with a veinflow, RL and Foley's. They return with two instrument trays, a scalp vein, DNS and nothing instead of a Foley’s. Apparently those are all the obstetric instruments they have. Dr M searches for an RL and startsa pint. He inserts a Sim’s and an AV wall retractor and can now see the cervix. He tries to teach the nurse and assistant how to hold them, and fails. With great difficulty the cervix is held with a sponge holding forceps and a single volsellum. There is no other atraumatic instrument available. Small tears are found on the anterior and posterior cervical walls. On swabbing them, none bleed actively. Dr M starts walking around the cervix with the sponge holder and is shocked to his core with what he finds over there.

Tearing through the night (Part III)


  1. this one's the best part.

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