Thursday, April 20, 2017

Correct technique is a must.

Lack of progress of the labor or fetal distress is kind of challenging indication for caesarean section. Fetus already in distress & not progressing the labor may need immediate delivery. 
That time I was working as a medical officer in the same peripheral unit. One patient (G2P1C1) was persistently complained of pains & put into the labor room as she is in labor. Usually before sending to labor room, these patients are given bowel enema to evacuate feces. So the patient went to toilet & then taken to the labor room.

When doing artificial rupture of membranes, it was thick meconium & soft cervix dilated upto 4cm. However fetal head was high. I informed my boss whether to augment the labor. Now she is progressing the labor with careful fetal monitoring. As I was instructed, I repeated the CTG in 2 hours. It was almost flat- low variability. Still thick meconium , very soft cervix is 5cm like but head was still high. Fetal heart rate also getting low. Mom also looks exhausted & not bearing down. I sensed something odd, but since every minute is important I  again informed my consultant immediately. He told me to prepare the patient for emergency section till he comes to assess the patient.

Prior any caesarean section, patients are catheterized. Catheter inserted. Urine filled the whole bag. Mom get a contraction & pushed the baby out within 25 minutes. !!   
Nurses, midwives & other doctor we all assumed that she may have passed urine when she went to defecate. Actually she has not. Full bladder has prevented head coming down & let her not bear down. It is natural we humans think about baby's life & get panic when we see dangerous signs like thick meconium, pathological CTGs with high head. 

If everything is good except one which is not compatible, then assess again methodically. Next time, if you come across something like this, empty the bladder (though patient may have just returned from toilet) get her bear down. Assess the cervix. You may be able to get baby out normally than doing a caesarean section.  

Tuesday, March 21, 2017

Double pathology is not that uncommon

Patients admitting to post-natal wards is not uncommon with fever. Episiotomy site infections, urinary tract infections, viral fever, endometritis, surgical site infections are common causes. Usually they are treated with common antibiotics while observing the response.  However the focus of infection is not always evident. In peripheral hospital where laboratory facilities are limited, treating such patients is quite challenging.

When I was working in such unit, I came across a patient who delivered her baby by normal vaginal delivery few days back admitted with fever for 2 days. She has done her full blood count outside with a CRP. Full blood count showed WBC something around 7 x109/l, platelets 180 x109/l & CRP more than 100. She was febrile too. But no other foci of infections. Urine also was normal. What it could be?  Endometritis? Well it could be the most likely. She was started with iv antibiotics- meropenum immediately after taking blood cultures after seen by the consultant obstetrician.

Patient continued to have fever spikes & seemed to be flushed. Even with this super antibiotic her fever did not resolved. At the 3rd day of antibiotics, full blood count was repeated. WBC- around 5 x109/l & platelets around 60 x109/l. 

Dengue haemorrhagic fever is not uncommon in this tropical region. Actually when sent for the serology, she was positive for dengue. Patient was at the verge of dengue shock state. Patient was admitted immediately for ICU care & her life was saved. 

Doing dengue NS1 antigen is much expensive & usually not affordable to the vast majority of patients who come for treatments in this kind of peripheral units. And also doing NS1 antigen may not be cost-effective. True that you have a most likely diagnosis, but still keep in your mind that something else also might be there. When the things are not going with our expectations it is wise to reconsider other possibilities. Double pathology is not that uncommon too.