The ruptured uterus dilemma

In most parts of civilised India, a ruptured uterus is unheard of. It's something that is to be read about in text books or to be enthralled by as senior professors tell stories of the occasional patient they have seen with this problem. However, in places like Bihar, it is sadly an all too common occurrence. For however far medical and obstetric care have progressed in the rest of the country, here childbirth remains an extremely risky proposition for both the baby and the mother. (For those not associated with the medical profession, a uterus can rupture in pregnancy when there is prolonged labour or the uterus has been weakened by previous Caesarian sections). In the short time I have spent here, the stories of tragedy during the delivery process have been too many to recount. The worst part of every story without fail is that doctors and quacks all around seem to wait till just past the point of no return before referring the patient to us, by which time even our most strenuous and aggressive efforts prove to be in vain. And the icing on the cake of course, is that the blame and the ire of relatives and even mobs falls on us, rather than the various places they had come from, whose improper treatment had led to the problem in the first place.

From these respects, the story I recount today has a happy ending. It occurred on a day when all my other colleagues were on leave and at about 11 pm at night (the time when patients who have been referred from other places usually reach here), 3 patients came at the same time to the Emergency. As doctors often do when busy, I mentally classified them based on their diagnosis - snake bite, OP poisoning and oh no! Ruptured uterus! The patient was a lady who had not yet reached term but had had two previous Caesarians with one baby dying shortly after birth. She had been in labour for a day and had been undergoing treatment at a local clinic where the doctor had been attempting a normal delivery. However, she suddenly started to pour out blood and had been immediately transferred to our hospital.

The moment I saw her, white as a sheet and lying in a pool of blood on the stretcher, I knew there was very little time. As the sisters (who are an outstanding yet unsung group of people in our hospitals) readied her for the operation, I took the consent and sent the relatives off to try and get some blood. We were in the operation theatre in about 10 minutes (again an outstanding feat given that the OT staff need to come from their homes!) and the baby was out shortly after. To my surprise and delight, he was alive although rather sick and needing to be sent to the neonatal ICU. The reason for the bleeding was soon clear. The uterus had been adherant to the bladder and had ruptured it as well. After closing up the uterus and bladder, I was about to begin the ligation of the Fallopian tubes to prevent future pregnancies and ruptures, when my floor nurse told me the relatives had refused the tubectomy. They wanted another baby!! After 2 Caesarians and a rupture!! I went out to try and convince the relatives, telling them clearly that another baby may kill the mother. But as I have found so many times, a woman's life is not considered important enough to make plans based on her welfare. Risking her life for the sake of another baby made perfect sense in the eyes of the family. I knew that in her heart of hearts, my patient herself was keen for the tubectomy, but she flatly refused to go against the wishes of her family, once she knew they were not agreeable.

And so, for me, the joy of saving the child and the mother was dampened a little. I felt sad that the woman's life had so little value for her own family. I felt angry that crucial decisions about her own body could be made by others and she did not even have a say. I even felt a little guilty that I did not have the courage to go ahead with the tubectomy on medical grounds against the express wishes of the family. It is a situation I find myself in ever so often nowadays. Perched on the horns of an ethical dilemma, not knowing what to do. And always fearing that I have finally made the wrong decision!!