Climb to Catheterise

A retained placenta can be an Obstetric nightmare.

Many women in rural Nepal in the early 70s, hesitated to have their babies in the hospital. There were many reasons for this. Firstly they were on alien turf among strangers. Secondly it was more expensive than a home delivery. I discovered a third reason quite late into my stay in Nepal.

We had a hospital dinner for which the staff and their families had been invited. One of the drivers Sathya was like a family member. He drove the kids up and down to school and looked after Rekha and Anish like his own.  He was as loyal as you make them. During the dinner I noticed that Sathya’s wife was missing. I asked him if she was unwell and he replied sheepishly that they had just had a baby a couple of days ago and the placenta had not fallen off yet.

I nearly choked on my food. Whaaat , I said . What are you talking about , Sathya ?  I asked incredulously. That was the night I found out another old Nepali custom.

Many  Nepali mothers who delivered at home, did not cut the cord after the baby was born for cultural reasons . The baby and the placenta remained attached and the placenta was kept in a mud container alongside the infant, till the cord shriveled and dropped off with the dry placenta. Only when the placenta and cord fell off was the woman considered Cleansed . Only then could she move out of the house.

This tradition had a flip side. The incidence of neonatal tetanus and cord sepsis was low in Nepal, because no unsterile instruments were ever used to cut the cord. This was the third reason many Nepali women hesitated to have their deliveries in hospitals. In the Hospital, we cut the cord and threw the placenta out in a bucket,, without so much as a please.

When they delivered at home, many of them would have a prolonged 3rd stage of labour with a retained placenta. Normally the placenta is expelled within 30 minutes of delivering the baby.  In retention of the placenta this time is prolonged and often requires manual removal, ideally under anaesthesia.

The most common cause for retention of the placenta is a full bladder. The bladder, the uterus and the rectum lie in front of each other linked by slings holding them in place. Dysfunction of one of the these organs disturbs the normal function of the others.

In the busyness of dilating her cervix and delivering the baby the mother forgets to void her bladder.  A full bladder in turn causes  retention of the placenta. This is potentially dangerous because it increases the chances of postpartum haemorrhage and infection from all the manipulations that are tried, often unsuccessfully, to deliver the placenta manually.

I used to be called for a house visit, when a lady had a retained placenta in the villages near by. The first few times when they told me that the house was just here , I believed them and walked miles to reach the patient.  Subsequently I got smart and I knew that their Just here was anything but that.  Just here could be several million steps on a pedometer I did not possess.

The first time I set off with the ward boys, the paramedics and the patients relatives, we drove to the nearest point on the road and then took to walking down a mud path which seemed to go on forever. Finally we reached a three storied house set in a wooded cluster. The ground floor housed the animals that the family owned. The goats, the cows and the dogs lay around, perfectly at peace with the kids who played a short distance away . The family lived on the first floor and the grain was stored in the second floor.

To get to the first floor one had to use the wooden ladder that leaned on the side. Did I just say leaned  ? No correct that to, we had to climb up a wooden ladder that was screwed in vertically at ninety degrees to the building. I was in a sari which is not the best attire to climb anything.  Kicking off my slippers, I nonchalantly tucked my saree between my legs and held on to the ladder and climbed as far as I could, with my eyes  shut tight. If I closed my eyes I could shut out the perpendicular ladder which brushed against my nose with every rung I climbed.

When I threatened to slip and fall all the way down,  two of the ward boys pushed me up apologetically from my behind and two male relatives standing on the floor above, at the top of the ladder, took hold of my arms and pulled up and I landed unceremoniously with a thud onto the mud floor.

I was totally unprepared for the stench that hit me as I surfaced to take stock of my surroundings. I had landed myself in a dark and dank room that smelt foul. It smelt of stale blood, stale urine and stale human excreta.  Gagging I got up . My eyes had accommodated to the poor light by then and in the far corner I saw a low bed which seemed to have someone sleeping on it.  Gingerly, I inched closer and I got the shock of my life.

Lying on it was a lady , stark naked , covered with a sheet of flies flying over her. She was lying propped up against the head of the bed and she was swatting the flies around her listlessly with a vacant stare. She looked tired and dehydrated. Between her legs in a pool of clotted blood, lay something long and twisted that looked like an umbilical cord that had stopped pulsating hours ago. There was a dirty cloth ball tied to the cord . They must have tried to pull at the cord using the cloth ball.  There was no sign or cry of any baby in the room.

The ward boys had climbed up and reached the room by then.  They positioned her flat on the bed and brought her near the edge of the bed. On examination , her vitals appeared normal . Her bladder seemed distended and needed to be catherised.  Forgetting  the unsterile conditions we faced, I put on a pair of gloves and catheterised her, letting the urine collect into a plastic bag the ward boy held out.

No sooner had we done that, I saw her wince as if she was having a contraction.   I pushed the contracted uterus gently  away from her suprapubic region with my left hand and wound the fingers of my right hand around the cord  to give it a gentle tug. To my utter and unmitigated relief,  it came out freely, bringing the culprit placenta with it , followed by a surge of blood that squirted everywhere.

We sponged her down with some cotton, got her dressed and padded , bundled her up in blankets and put her in a cloth sling stretcher, tied like the ones the proverbial storks brought babies in.  They lowered the sling stretcher down  carefully,  navigated  by a crowd of spectators who had gathered below. When  she had reached the ground floor safely,  I slid  and  slithered  down the perpendicular ladder and landed on the same behind, that had been pushed up the perpendicular wooden staircase, barely an hour earlier.  Dusting myself I got up with the giggles, which helped ease a tense and embarrassing situation all around.

Somewhere in the weary entourage that headed back, I heard a baby cry. One of the ward boys was carrying the baby who on examination had appeared to be fine and none the worse for wear.  Mother and Baby were in safe hands and were on their way to the Anandaban Leprosy Hospital. We walked back to the Landrover, settled her in and drove to the hospital where the staff were waiting for us.

The Nursing team took complete charge. They wheeled her away,  mopped and sponged the patient, started a drip , added the antibiotics , checked the cord, cleaned the baby and settled the exhausted mother and child in a warm bed and clean sheets with a hot meal. The Staff at Anandaban were wonderful. They stepped in when needed and followed their instinct and training, rising admirably to the occasion. We would have been utterly lost without them.

I was cross eyed when I reached home. Shedding everything outside the bathroom, I had the longest bath ever, rubbing off layers of grime and dirt before I crashed out, wondering what Dr. Paranjothy or Dr. Kunders or Dr. Prabha, for that matter, would have had to say about my first encounter with a retained placenta in Nepal ?

Sam had an amused expression when I recounted all that had happened. And this is the lady who lived in high heels, hated using the stairs and went from one floor to another in a lift, wherever and whenever possible, he said with a quiet laugh.



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