A RARE LABOUR-ROOM EMERGENCY

A Rare Labour room Emergency

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Labour room is the most important work arena of a Gynaecologist.Labour pain is the hardest form of pain a lady is destined to suffer.In this era of ‘painless labour’ many in our country still do not opt for that.Of course the pain duration is much lessened with safe medicines.

Loud hues and cries,angry and even abusive words,big or subdued sobs,attacks with hands and feet..what all actions from ladies in labour we face there!!The lady who enters the labour room smiling and calm,sheds all her inhibitions and gradually adopts a different behavioural pattern when the pain threshold is lost. Of course she is in happy tears and smiles of gratitude once she perceives her baby’s soft sweet cry.

With all these din and bustle how I loved my labour rooms!!The floor always bore stinky stains of blood and other body fluids though cleaned instantly.A Gynaecologist can be successful only if she likes the labourroom atmosphere.Watching expressions of the new moms and their bystanders on seeing the newborns used to enchant me immensely.

99% ladies are happy and easily forget the pain part of the great event once they and their newborns are marked safe. I have to mention that a few of them are taken up for Caesarean deliveries as a safety precaution.Very few nurture the memories of pain and refuse to conceive a second time.Please note that the second and subsequent ones are less and less troublesome,a painless labour can be opted also.

Labour room is a place where sudden and startling complications can ensue for any healthy lady.A Gynaecologist has to be available 24/7 and is to have the expertise and presence of mind to handle such unpredictable situations successfully.

Bleeding during and after deliveries is the common major problem we face.It can happen all of a sudden on any lady and we have to anticipate and be prepared to face same.Availability of enough blood/blood components/other paraphernalia is to be confirmed regularly.The most difficult part is to convince the bystanders about the unexpected complications.They often consider the healthcare providers as culprits.Fortunately this part was nice for me as my patient folks always understood the situation and supported me with prayers.

My meeting with Mrs C yesterday in a wedding ceremony prompted this storyline.2decades back she saw me for her first pregnancy.This 23 yr old beautiful,smart,blooming and energetic patient-friend entered my labour room one fine morning with mild pains and joyful expectations.There was no need for tender touches and consolations as she was nice to say she would suffer any pain for her baby,and she kept her word.She let out her healthy bundle of joy into my hands soon.Every newborn made me happy as though it was a first baby through my hands.

It was a rather busy labour room that day with 5,6 more deliveries ahead and fresh cases keeping on entering.Entrusting the expulsion of Mrs C’s placenta with my experienced assistant I got busy with the next patient in the adjacent cot.

My assistant called me in panic to see Mrs C.The placenta had separated 30minutes after delivery only(long but acceptable interval) but the uterus had turned upside down,the uppermost part (fundus) of the uterus could be seen big outside with very profuse bleeding and Mrs C was going in for a ‘shock’.Her BP came very low,pulse was very rapid,the body was cold and sweaty,she vomited and was semiconscious…ACUTE INVERSION OF THE UTERUS had happened..the rarest of rare incident.

I had seen only one case in the labour room of Calicut Medical College and I remembered how panicky our HOD,Professor T,was then.The patient ,who had her 7th delivery,did not survive.She was in shock and she bled to death.Yes,Acute Inversion can cause death within a very short time if not interfered very promptly with all the supportive measures sufficient and handy.The only case I had witnessed was in 1973 and the case of Mrs C was in 1997…we were better equipped.

I tried my level best to hide my tension.I tried to keep back the uterus in position while hasty preparations were being made for a surgery.My attempt was a failure as a tight band had already formed around and above the big protruding part of the uterus.

The General Surgeon was summoned who said he knew very minimal about such a case.I asked him,a person who could use a surgical scalpel very effectively as per instructions,to be with me.A briefing about the grave situation was done to the bystanders.

On the table Mrs C lay virtually lifeless and extremely pale. My Anaesthesiologist asked me to concentrate on the surgery without seeing the very bad numbers on the monitor.

Nothing was there in the tummy in place for the uterus.It had inverted fully and gone down.No time to lose,memorising the textbook description of Haultain’s manoeuvre I made an incision in the midline at the back of the tight ring that had formed on top of the inverted uterus and gradually pulled it up to the normal position and stitched up the cut part.With unit after unit of blood and other measures already on,Mrs C’s condition improved dramatically and she was discharged home after a week.She had two Caesarean deliveries later and the uterus never showed any signs of the past insult on it.

This can happen to any patient in the labour room.Causes cited are weak and thin uterus after repeated deliveries or abortions,placenta implanted at the topmost part of uterus (fundus),wrong and impatient way of pulling the umbilical cord to deliver the placenta,and NO SPECIFIC REASON.Mrs C’s case fitted into the last category.

I explained to her well about Acute Invertion of uterus and how she happened to be my first patient with that problem.Later whenever we met she rushed to me to know if I had another similar case.Till date she is very proud that she was my sole case of inversion!!