Tearing through the night (Part III)

- Written by Dr M.

Tearing through the night (Part I)
Tearing through the night (Part II)

After much manipulation and struggling, when Dr M managed to pull down the cervix, he saw a full thickness tear on the left lateral cervical wall, along the whole of the vaginal part of cervix, about 5 -  6 cm in length. He had never seen a cervical tear before in his life. Definitely not a full thickness one like what he was seeing. He now wonders for a while how he can repair the tear in his current situation. The cervix is no more continuous, no more cylindrical. Tear is too small a word to describe the magnitude of the injury. Rupture can come close, perhaps. Dr M demonstrates the tear to the nurse and explains to her that repairs of such injuries should ideally be done in the OT, with anesthesia, good light, proper retraction and most importantly, by an obstetrician. He then tries to just pack the vaginal vault, and wait for hemostasis, but the patient continues to bleed profusely. She must have bled at least a liter of blood by then. She looks pale, shivering, pulse 90 and thready, but BP is stable at 110.

Second pint of RL is dripping through the small blue scalp vein now. The nurse becomes presyncopal looking at all the blood and sits down on the floor. This is the second time she has become dizzy that night, as the patient continues to drench many a dupatta with blood. The nurse once again asks anxiously, the same question that she has asked multiple times that night: "Sir, you will be able to stop this, right?” Dr M's answer to that has now changed from a strong and confident 'yes' to a small, hopeful 'yes'.

He requests the nurse to call the senior in-charge, it is 12am. After repeated pushing of the redial button, the senior answers the call, and Dr M explains the situation and says that he can attempt to close the cervix but he may not be successful and without proper retraction it would be very difficult. Dr M gets the green signal. But then, he already knew he would, which is why he had called the senior at this hour. Who would not allow a repair at this stage, when the patient is actively bleeding to the extent of going into shock, at midnight, and at a place from where transportation to a higher center was impossible? Dr M just required this permission so that he was in the clear if anything went wrong, and he got it. Perfect timing, he thinks. Dr M is now relieved.

Dr M jokingly asks for a gown. He is amazed when they actually bring one. He changes his gloves, of course the gloves are also being reused after 'autoclaving'. As he puts on the gown, the lights go out. A single tube light at the patient's head end starts to ionize the gas inside it. This still means it is dark at the working end of the patient. Dr M always carries a torch in his pocket; it has other uses as well. This was not the first time the torch had come in to save the day. Few months back it had helped in a taxi delivery at his parent hospital. Dr M uses the needle holder to remove the No 0 chromic catgut, holding the round bodied 3/8th circle needle. He rubs the 40cms of the thread with isopropanol based solution and keeps it aside. The peon holds the torch, the nurse holds the Sim’s and AV retractor, the assistant holds the sponge holder and volsellum attached to the torn ends of the distal most cervix, the mother-in-law holds one of the patient's leg onto her chest while the other leg is held by the patient herself.

Dr M still isn't able to visualize the apex of the tear as the retraction is insufficient, he can barely see the tear at all. He adjusts the retractors again and asks the nurse to hold still and give fundal pressure to cause descent of cervix; it works to some extent. He takes the sponge holder in his hand and gives the first bite to the anterior end of the tear, exchanges the sponge holder for the volsellum and finishes off the first suture with three throws. As he starts to readjust the retractors and forceps, the assistant pulls on to the volsellum too hard and unknowingly takes a part of cervix along with her. New bleeding point. Luckily this is easily visualized and closed with a single interrupted suture. Dr M continues to toil, trying very hard not to shout at the nurse. How does one not learn how retractors are to be held, he wonders. After the second suture, Dr M's right hand starts to ache. He had fractured one of his metacarpals in a boxing match few days back, remembering that match brings back good memories. After the 5th suture at the distal most part, there is no more active bleeding. It is 1:00am now. The patient hasn't passed urine and her bladder feels empty on bimanual exam. He orders a pint of NS after the RL and then leaves, saying "We will wait for 15mins to confirm hemostasis".

As he waits in the gown sans the gloves, he chats with his colleagues about the events that ensued. They make him realize that he has forgotten about the infant, and that feeding hasn’t been initiated. They wonder for how long the infant can survive without the first feed. The mother is hypovolemic and in too much pain to begin feeding. There is nothing he can do at the moment. Dr M looks down at his brown leather shoes, there are blood stains over them. All his attire is in shades of brown that night. Auburn colored pants, dark brown belt and buff brown shirt. He is regretting not clearing his shoes from the path of blood.

He goes back to check on the bleeding, there is none. To be safe he wants to pack it with tampons. Tampons this time are recovered from the floor. They are previously used ones, and have been soaked in phenol and then Betadiene. Phenol came into the picture when the nurse confused phenol for Betadiene and poured some over them instead of Betadiene. Dr M is forced to use those phenol drenched tampons anyways, since he has nothing else to pack the vault with.

Dr M is reminded about the Pepsi he had bought by the peon. He goes to the refrigerator located in the dispensary and has half of it. 20 minutes later the tampons are removed and they are soaked in blood. So they start exploring again. Dr M decides to take few more stitches even though the patient begs him not to. Every time retractors are placed she winces in agony. Two relatives are now required to hold her down. Dr M picks up the catgut, it has dried up and there is no more solution left to wet it. With great difficulty he maneuvers it through the tissues in spite of the great deal of friction. He applies two more sutures and that’s as far as he can go. He knows for a fact that a 100% hemostasis will require going up to the apex, something that is out of the question in his situation. So he stops. There is still some minimal bleeding for which there is nothing he can do except pack the vault again, with used tampons and cotton ie. He allows moving the patient out of the labor room and prompts her to initiate feeding, and starts a pint of DNS as well. The infant takes up feeds well. Dr M removes the gown which he was told will be reused in the future. He doesn’t ask how it would be washed or sterilized, he knows the answer. As everyone retires to their beds, Dr M goes back to his cell phone, searches for causes and prevention of cervical tears. He wants to know if he went wrong somewhere. Turns out there was nothing much he could have done to prevent the tear, except maybe he could have been harsher to the nurse and assistant for their fundal pressure practice. Another breath of relief and then Dr M too retreats to his bed at 3:30am.

In the morning, his alarm will ring at 6:10am but he is up a few minutes before that. Soon he goes and checks on the patient. Subjectively she is fine and so is the infant. He can't examine her without the nurse present. She is sleeping, so he goes off to stroll in the farms nearby, looks at the sunrise and thinks to himself "This is a day that follows a night of no losses, no regrets. It was a great night, perhaps the best till date".

When the nurse wakes up, they go to examine the patient. The packing is soaked in blood but that is it, no active bleeding at all, and the most satisfying part is that she has passed good amounts of urine. The infant too has passed both urine and stools by now and OPV is administered. Dr M writes puerperal orders and generous analgesics and antibiotics to cover all the infections he can think of. He waits for the senior doctor to arrive and give him the thumbs up to leave. He gets done with one bottle of Pepsi and opens the other. At around 8 am, another patient in labor comes in. Gravida 4 this time, with contractions every 5minutes. Within half an hour she is done delivering, very uneventfully that too. Very vanilla. Good for the patient, as there isn’t a single unused piece of equipment left at the centre. Between then and 10am, two other patients come in with vague complaints, then turn out to be UPT postive. Coincidence? Whenever Dr M thinks about coincidence, the words of Dr Sheldon Cooper flash before him: "Coincidence is for those who don't understand the law of large numbers".