NANDINI
NANDINI
Prof. Gangadhar Sahoo, Dean
IMS & SUM Hospital & Pro. Vice Chancellor, SOADU,
Bhubaneswar
It was in the month of May in early 1980s. I was the Gynecologist in charge of the District Headquarters Hospital, Sambalpur. The specialist Dr Baidyanath Mishra was on leave. One Sunday afternoon I was just retiring after lunch. The Hospital attendant came with the call book. The medical officer on emergency duty had given a call for a case of pregnancy with convulsion , just received in the labor room.
Immediately I dressed up and started for the labor room. It was at a walkable distance. I took the history of the patient. She was NANDINI, wife of Mr. Rajaram Mishra, very well known to me. He was an employee of the Sambalpur University, staying very close to the hospital. Nandini was under the antenatal check up by a local private practitioner . It was her 1st pregnancy almost very nearer to her expected date of delivery. She had three bouts of convulsions since morning. On examination she was unconscious, snoring, bloody saliva dribbling , tongue bitten between the teeth. In front of me she had a fresh bout of convulsion which lasted around two minutes. Carefully I put the mouth gag into the mouth to avoid tongue bite. I asked the staff sister to administer one ample of diazepam ( a sedative cum anticonvulsant) intra veinously ( I.V.) and keep the I.V. line in tact with slow infusion. Her whole body was swollen, blood pressure was too high 180/120 mmHg. Pregnancy was almost full term, fetus living. The sister put the indwelling bladder catheter to collect the urine for examination and measure daily urine output which was gold standard in assessing kidney function clinically. Hardly 20 ml of concentrated urine came out . Bed side urine test showed that urine solidified on boiling suggestive of high quantity of protein was present. It was a bad sign of seriousness of the problem. Pregnancy with high blood pressure, protein in urine with convulsion pointed towards one diagnosis that's ECLAMPSIA . Eclampsia was a deadly condition. Life of both the mother and the fetus was in danger. Even in best hands and best hospitals the survival rate was very poor. I was the only specialist available in the hospital with no skilled Obstetric ANAESTHESIOLOGIST and NEONATOLOGIST. I tried to convince the attendants of the patient to refer the patient to the nearest medical college, hardly 15 km away from the hospital. But the husband and other relatives of the patient bluntly refused. They all surrendered telling that what is the God's wishes will definitely happen. It was their luck. Her husband told, "You are our living God. You treat. We have got enough confidence and faith on you." In the present condition we can’t shift the patient.” I was undone. Then all hospital admission and treatment formalities were fulfilled. Now onus was on me. I love accepting challenges and with a prayer for Nandini I accepted the challenge.
For management of ECLAMPSIA successfully our objective is to save both the lives, mother and the fetus. First we have to control the convulsion and calm down the mother without putting the fetus into risk and then timely intervention to deliver the fetus either vaginally or abdominally. At that point of time there were two established regimens for treatment of ECLAMPSIA. One which was called as Krishnamenon regimen, was practiced in medical colleges when we were post graduate students. I was familiar with that. But the disadvantage was that it was a three drug regimen, the timing and route of administration of the drugs was complicated and so skilled supervision round the clock was necessary. It was not possible in the district headquarters hospital. The second regimen was a single drug regimen, easier to monitor but it was new. I had very little experience with the second regimen. But I executed the second regimen because of its simple monitoring. The most skilled staff sister was given the charge of the patient. I personally took the charge of monitoring the case round the clock. The ANAESTHESIOLOGIST was made alert about the case. Even if he had little experience in critical Obstetric care, he agreed to manage as and when required. At that time the subject of Neonatology was not born. So the pediatrician was kept informed that at any time his service might be required. So my team was ready. We had a team meeting where we discussed our best plan of action looking to the existing set up and facilities available. Blood bank officer was also informed and requested to keep same group Blood ready after cross matching. Then our countdown started.
Taking to the core group together I had a meeting to explain the role of each one. We discussed the pros & Cons of different methods of delivery. Our priority was the lives of both the mother and fetus. In our meeting it was decided that we will go for a vaginal delivery unless otherwise indicated. By that we can avoid the risks of anesthesia, the major surgical procedure and a risk neonate. We waited for one day till convulsion stopped. Then I had a detailed examination. Everything was favorable for a vaginal birth. So I made my team ready for monitoring if I start to induce labor.
Day time is suitable for monitoring. So next day morning I started the induction of labour with low dose Oxytocin infusion. I had tuned my team to see for uterine contraction, fetal heart rate and increase the dose of infusion by 10 drops a minute every half an hour till effective contraction was established.
I had informed the ANAESTHESIOLOGIST regarding the latest developments and kept him alert for SOS call . I had also informed the pediatrician regarding the case . Since the mother was getting Diazepam as anticonvulsant , it was anticipated that the baby might be born asphyxated . So the pediatrician should be prepared to receive such a neonate and resuscitative measures should have been made available. Mother was unconscious. There were no more convulsions , blood pressure was controlled, urine output was within normal limit and albumin in urine had started coming down which is a very good sign of renal function improvement. We anticipated a difficult vaginal delivery because the mother was unconscious and unable to exert abdominal pressure. There was a chance of excess blood loss during and after delivery. For that the sister in charge had prepared the delivery trolley with a pair of Obstetric forceps which was vital for assisted vaginal birth. Blood bank was alerted to keep at least two units of blood of same group as that of the mother in the bank for emergency purpose. I decided to conduct the delivery in the OT for obvious reasons. Seeing the progress of labour I shifted the mother to OT at 4pm . All concerned were called.
At around 5pm with forceps application a healthy baby girl was delivered. The baby was a bit lethargic. So she was kept under oxygen mask, body kept warm with cover and in between tactile stimulation was given. It took nearly 3 to 5 minutes for the baby to cry . During delivery all precautionary measures were taken like active management of labor to reduce the blood loss. The forceps application was smooth. No excess or abnormal bleeding was there. Then there was strict observation of the GOLDEN HOUR . What's GOLDEN Hour? The hour following child birth, where maximum number of fatal complications occur to both the mother and the baby. Slightest inattention can cause death of one or both. So the mother and the baby were kept in the OT during this period under the direct supervision of I myself and the pediatrician.
Mother was kept under Diazepam regime, anti hypertensive and nasogastric nutrition for one week more. After one week all pipes and channels were removed. NANDINI became conscious, put her baby on her breasts, unknowingly tears of joy rolled down her cheeks. Most probably all Gods and Goddesses were watching NANDINI how she was enjoying her prime motherhood. “When a baby is born, a mother is born. " But here the mother was born along with the baby no doubt, the true motherhood was born a week later. I congratulated Nandini for achieving motherhood and Rajaram for being a father.
NO PREGNANCY IS NORMAL UNLESS A HEALTHY MOTHER AND A HEALTHY CHILD IS BORN AND DISCHARGED FROM THE HOSPITAL. The name of Nandini was written with indelible ink in my mind since she was the first High Risk case in my life, dealt successfully.
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