After completing my MD Anesthesiology in October 2012, I joined a tertiary government hospital located in Kathmandu, Nepal. The hospital conducts approximately 18,000 deliveries are every year along with 5,000 caesarean sections. There were only 6 anaesthesiologists, including me, covering the 24 hours. There are lots of important case studies I can think of but I would like to share one particular unforgettable case that occurred in my presence.
The day was like any other, running smoothly before we heard the emergency call. Two of our juniors responded immediately, rushing to the ward where the emergency call was made. We followed them and on reaching the floor saw that all of the team members were actively doing cardiopulmonary resuscitation (CPR). The patient was 30 years old, parturient, with diagnosis of gravida 2, para 1 at 40 weeks of gestation being processed for normal delivery. To facilitate the delivery, the amniotic membrane was ruptured artificially and she collapsed.
Despite the effective CPR, there were no signs of life so the decision was made to perform a perimortem cesarean section. Two teams were created; one team prepared for emergency caesarean section while the other went to counsel the patient’s family, detailing the current scenario and the management plans. As soon as the patient’s family signed the informed written consent, surgeons began the procedure and delivered the baby. Throughout the procedure, CPR was continued.
It seemed like magic to see the patient return to spontaneous breathing, though it was not adequate along with normal cardiac activity. With a majestic smile and some support, she was immediately moved to the intensive care unit (ICU) and put on mechanical ventilation with ionotropic support. Unfortunately vaginal bleeding was noted less than 30 minutes of her shift to the ICU. The bleeding was profuse thus altering her vital parameters and immediate resuscitation had to be commenced but she again collapsed. CPR was restarted, but sadly in vain, and we finally had to declare her deceased.
The most probable cause in that scenario was a severe haemorrhage due to disseminated intravascular coagulation (DIC) or amniotic fluid embolism, but the cause remains unproven as the patient’s family denied the autopsy.
The patient was healthy and her vitals were within normal range, and she had no documented risk during her antenatal check-up but we still lost her in this unexpected way. The incident highlights the importance of the close monitoring. Not only that, staff of every level should be made to understand even the most unlikely complications that could arise. Early recognition and immediate resuscitation is the key to save each parturient, thus close monitoring and investigation should be standard practice.
The main objective in sharing this story is to highlight that prevention can often be more important than the cure. As normal vitals and a healthy looking patient can deceive us, detailed knowledge and close monitoring is the key to recognize and tackle the problems early - helping to save not just one, but two lives at the same time.
-- Sangeeta Shrestha, Consultant Anesthesiologist, Nepal
Sangeeta Shrestha was one of 32 SAFE Obstetrics course participants in Nepal this year. The three day courses, funded by the Laerdal Foundation, focus on small group teaching with content based on clinical conditions that currently cause 80% of maternal deaths. To learn more please click here