A case of uterine rupture from the rugged hills of Bajura.
Sitting on a patch of grass outside our inpatient ward, Jogeni looked frail and pale. The intense surgery meant it would take another week to heal. Picking blades of grass, she worried about her future. “Is it that I cannot have a baby again? I want a son, because I have one daughter already,” she thought.
Three-weeks ago, Jogeni had felt differently. Making tea in the cold winter morning, she first felt the familiar pangs of labor. Pouring tea into the steel cups, she wondered if this time it would be a boy or a girl. As the pangs spread around her abdomen, she and her husband walked along the dirt path to the clinic; she had delivered Gita, their first child, there.
Inside the clinic, the Auxiliary Nurse Midwife positioned Jogeni on the delivery table. An injection was given to catalyze labor, and they waited for the water to break. Twenty-four hours had passed, there were still no signs of delivery. Uncertain, the nurse asked Jogeni’s husband to take her to Possible’s hub in rural Nepal — Bayalpata Hospital.
Two men on each side carried Jogeni down the rugged hills on a bamboo stretcher. After a two-hour walk, they finally reached the black-topped road, and at last put her into a jeep to our hospital. Lying inside, Jogeni felt her sharp contractions diminish — the baby wasn’t moving.
The clock struck 4:30 pm; it was a Sunday, typically the busiest day of the week. Dr. Santosh, our Deputy Medical Director, was entering patient updates for the day in our Electronic Health Record (EHR) when a nurse from the Emergency Department rushed in.
“There’s a patient who needs immediate attention,” she said.
Jogeni’s vitals — the heart and respiration rate — were exceedingly higher than normal. Unlike ordinary pregnancies, Jogeni had a tender womb and a bulge in her abdomen. Dr. Santosh was certain this was a case of uterine rupture, a rare occurrence even in developing countries.
Within ten minutes the surgical room was prepped. The clinicians scrubbed, the equipment sterilized, and the blood bank informed. It was important to counsel Jogeni’s family; there was a slim chance of the baby surviving and there were risks involved with her own surgery.
Our team administered two anesthesia shots; a quick incision showed the baby’s head outside the uterus wall and in the abdomen. The fetus was a baby girl, but it had been more than twelve hours since she had breathed her last.
A number of factors had played part to this tragic conclusion — a prolonged labor with a baby that’s too big for the mother’s pelvis, excessive use of labor inducing agents at the health clinic, and a tumultuous journey to the hospital.
Had she been from our catchment area the story would have been otherwise. Possible’s cadre of Community Health Workers carry out an active surveillance for pregnant mothers; tracking them not just through their pregnancy, but also through two years after child birth. The Community Health Program includes counselling, birth planning, lab tests, vaccinations for babies and even referral of high risk pregnancies to our hospital hub, delivering comprehensive healthcare at their doorstep.
In the past year, we ensured that 78% of women in our catchment area gave birth in a healthcare facility with a trained clinician.
Inside the operating theater, decisions needed to be made quickly. Every minute was crucial to save her life. “I consulted the patient’s family and went ahead with tubal ligation, a surgical procedure for tying up of the fallopian tubes” said the doctor. Jogeni would not survive if she were to become pregnant again. The poor antenatal care in the health clinics where Jogeni lives, lack of adequate infrastructure and the difficulties of travel would make it unlikely that she has constant follow-up during pregnancy. And after a C-section, the scars are most likely to give easily under the stress of contractions.
Two hours later the team in the operation theater heaved a sigh of relief. It was a success. Said Dr Santosh, “That was the moment I felt I had saved a life. Why do I choose to work so far from home, from my friends? It’s moments like these, that make it worthwhile.”
Jogeni’s husband, a sinewy man in his mid-twenties sitting next to her outside the inpatient ward stayed silent for a while. “It was shocking,” he said, staring into space. “First I get to know the uterus had ruptured, then the baby had died, and then I get to know that we cannot have another child.” As is the trend in remote Nepal, husbands often remarry to procreate a son so that they can carry on the family heir. “But when it came to saving her life I could not think twice.”
