Jul 12, 2010

The delivery room at a district hospital in northern India was as crowded as the Palden Lhamo chapel during one of Ladakh's biggest winter festivals, the annual Spitug Gustor. It was only 10 am and it was standing room only. Dr. P, who had just gotten off the plane from Delhi that morning, waited as a woman whose bare thin calves poked out from under a bulky North Face jacket climbed up on the rusty steps to the delivery table. The jacket was a logical outfit. It was early April and nighttime temperatures inside the hospital might well sink into the 50’s.

Chime had arrived in early preterm labor at 3 am already 3 cm dilated and there was little the staff could do to slow the labor. There is only one doctor on call at night for a district hospital that serves a region one and half times the size of Denmark. In this case, the doctor, an internist with no experience in obstetrics or pediatrics was unfamiliar with the protocol for tocolytics to slow a woman's labor or prenatal steroids to help speed up fetal lung maturation. As a result, by the time Dr. P saw her, the patient was 10 cm dilated, 100% effaced, and her amniotic sac about to burst.

Which it did did as Dr. P performed her internal exam. She grimaced as the dark meconium stained fluid splashed over her pants and onto the floor. The color of the amniotic ‘liquor’ indicated possible fetal distress and were grounds for immediate delivery, she later explained. Yet she was concerned as the ultrasound from the previous night indicated a gestational age of 29 weeks and the patients’ chart suggested an even earlier date of 26 weeks.

P told Chime her baby had only a 15% chance of survival at this point and that the baby should be born as quickly as possible. I was reminded of my own precipitous labor almost 3 years earlier when I saw the terror in Chime's eyes. I, too, had found myself in a hospital in an emergency labor, with my waters broken, far earlier than I ever expected. I, too, was in labor when I was warned uncertain prospects my twins would face at 26 weeks. While I'm glad I was told the truth, I don't think there is any easy way to break this kind of news to a woman in preterm labor.

Dr. P immediately called for an IV and oxytocin, which might speed up the mother’s labor and also prevent post-partum hemorrhage, one of the most common causes of maternal death in both India and Tibet. A nurse placed the catheter, which failed to drip, until Dr. P noticed and cleared a dangerous bubble in the IV line, and then injected the syringe of synthetic oxytocin into the IV bag dangling above Chime’s head. The dose she administered---less than 1 mililiter of oxytocin per liter of IV saline----was lower than the standard US low dose oxytocin protocol that is used in over 70% of births in the US.

Yet even these protocols can be problematic. The Wall Street Journal 97/21/2006) reported that even insurance companies are trying to reduce the over-reliance on synthetic oxytocin or Pitocin in American obstetrics, as the drug is implicated in over half of all obstetric malpractice claims that involve birth trauma. These claims make obstetrics one of the most claim-ridden and costliest specialties in medicine from the perspective of insurance companies.

Chime tired after two hours of pushing ---for she been up the entire night in the throes of labor, then traveling to the hospital, never mind the panic of what must have felt like a horribly wrong time to be having this baby. But with Dr. P's encouragement and the nurses scolding, she managed at last to push her son out.

When her son was finally delivered, he was much bigger than expected at 1.6 kilos, but almost non-responsive. His color was dusky, he wasn't breathing, and had no obvious reflexes. His apgars of 2,4, and 6 at one, five, and ten minutes, reflected the concerted efforts of the hospital’s best obstetrician and pediatrician. He was transferred back to packed obstetric ward a half an hour after birth and given best treatment the Leh hospital had to offer---100% oxygen by improvised nasal canula, suctioning, and intramuscular antibiotics. Less than 24 hours later, he died of a brain bleed; his mother was discharged the same day.

Why write about this incident?

Because giving birth involves very similar and very different forms of suffering for women and infants, each and every day, depending on where they live on our crowded little planet. I honor the suffering that women in Ladakh experience who have no access to NICU's as much as I respect the difficulties that women in the US face, with some of the best medical care in the world.