Case series on uterine rupture depicting the atypical presentations in the labour room

Uterine rupture is the complete division of all the three layers of uterus. Most uterine ruptures occur during labor in pregnant women, most commonly seen in previously scarred myometrium. Consequences of uterine rupture depend on the time between diagnosis of uterine rupture and intervention, and can be as grave as fetal and maternal death. Vigilance and avid action by the obstetrician can lead to better outcomes. Case 1 represented a 28-year-old moderately anemic G4P2L2A1 having previous 2 LSCS at POG 39 weeks 1 day presented in COVID emergency in active labour and was found to have a uterine scar rupture (5 cm rent) extending towards bladder wall with shoulder presenting on rent. A live female baby with thick meconium staining was delivered and uterine repair along with bilateral tubectomy was performed. Case 2 represented a 21-year-old primigravida with breech presentation at a gestation of 34 weeks 6 days with preterm labour pains who had been referred to our centre. Decision for LSCS was taken and on entering the abdomen rupture uterus with an inverted T-shaped rent in the upper segment extending up to the fundus was seen. A stillborn male fetus was delivered through the rent, followed by successful uterine repair. In spite of massive blood loss, the mother had survived. Case 3 represented a 30-year-old grand multipara at a gestation of 38 weeks 3 days with ultrasound documented fetal demise with fetal hydrocephalus and holoprosencephaly with labour pains was taken up for laparotomy due to suspicion of uterine rupture based on examination findings. Intra-operatively, baby was found lying in the peritoneal cavity with an unsalvageable uterus with a rupture in lower uterine segment and left lateral wall extending upto round ligament above and cervix below. A stillborn male fetus was delivered and peripartum subtotal hysterectomy with left salpingoophorectomy and right salpingectomy was done with a good maternal outcome. The above series suggest that the signs and symptoms of uterine rupture are usually variable and nonspecific, hence posing a challenge for the diagnosis. Early diagnosis and timely intervention by the obstetrician, can help us to improve the fetal and maternal outcome drastically.

Maternal and neonatal outcome in COVID-19 pregnancy: an ongoing review of first wave in a tertiary care center in North India

Background: This study analyzed the clinical outcomes in the obstetric patients with COVID-19 and their neonates in first wave of COVID-19 pandemic in North India, 2020.Methods: This prospective study was conducted between 10 May 2020 to 31 December 2020 on 83 obstetric patients with COVID-19 and their 52 neonates.Results: 36.14% obstetric patients presented with COVID-19 like symptoms with most common symptom as fever in 60% and cough in 53.33%. 4.81% patients were admitted in HDU and 1/83 (1.20%) patient who required ICU had mortality due post-operative complications. 20.48% had pre-existing medical diseases. Amongst (78) antenatal patients, 21.79% had pregnancy related hypertensive disorders, 12.82% had deranged liver function tests without hypertension and 8.97% had gestational diabetes mellitus. More probability of pre-term labour pains 2.4 (95% CI, 1.37-4.18) and IUFD 2.18 (1.13-4.20) were observed in symptomatic patients as compared to asymptomatic patients. Neonates born to COVID-19 symptomatic mothers had 1.81 (95% CI, 0.73-4.49) times the risk of being symptomatic, 1.37 (95% CI, 0.54-3.41) times the risk of getting admitted to NICU and 1.57 (95% CI, 0.48-5.09) times the risk of getting infected by SARS-CoV-2 and increased morbidity in neonates. 8% neonates had perinatal and 1.5% had horizontal transmission of SARS-CoV-2.Conclusions: First wave of COVID-19 pandemic did not cause significant adverse outcome in pregnant patients and mother-newborn dyads in our tertiary care centre when active and intensive management of mothers and newborns were done but still there is possibility of severe morbidity and mortality due to COVID-19.

Successful External Cephalic Version in Early Labour: A Case Report and Literature Review

Presentation: A 35 year old woman, gravida 7 para 7, all vaginal deliveries, presented with labour pains at 39 weeks’ gestation with intact membranes. Cardiotocograph (CTG) was reassuring. Diagnosis: Breech presentation was confirmed by an ultrasound. Treatment: The patient was offered options of External Cephalic Version (ECV) versus (vs) Lower Segment Caesarean Section (LSCS). She opted for ECV which was successful, followed by controlled artificial rupture of membranes. She delivered a healthy baby girl vaginally and was discharged home on day 1 postpartum. Conclusion: Although intrapartum ECV is not recommended routinely, there is a place for its judicious use in selective cases. The prerequisites include an experienced obstetrician, reassuring CTG, previous vaginal delivery, no obstetric indication for performing LSCS, adequate amniotic fluid volume with intact membranes, early labour, and informed maternal consent. We recommend keeping theatre on standby while performing ECV in case an obstetric complication arises.

Community Based Study of Awareness of Maternity Dangers Amongst Rural, Tribal Preconception and Pregnant Women

Background: Every pregnant woman faces risk of complications which can cause severe illness or even death of mother and /or baby. Creating awareness about maternity dangers is crucial for safe birth, safe future of mother and baby. Although it remains unclear how awareness translates into appropriate actions, chances of better outcome are there. Objectives: Community based study was carried out to know about rural, tribal preconception and pregnant women’s awareness and perceptions of maternity dangers. Material and Methods: After approval of institute’s ethics committee, study was conducted in tribal communities of 100 villages of hilly forestry region, where mother child services were initiated after creating health facility in one village. Randomly minimum 20 and 10 preconception, pregnant women each, from every village, total 2400 preconception, 1040 pregnant women of 15 to 45 years age were interviewed by research assistant with help of pretested tool. Results: Of 2400 Preconception women interviewed, 801 (33.4%) were aware of labour events, 298 (37.2%) mucoid discharge, 291 (36.3%) little bleeding, 212 (26.5%) labour pains. When asked about source of information, 300 (37.5%) said doctors, 291 (36.3%) Accredited Social Health Activists (ASHAs) and 210 (26.2%) nurse. Of 2400 preconception women, 1015 (42.29%) did talk of some maternity dangers, 403 (39.7%) said swelling over face and feet, 271 (26.7%) giddiness, 184 (18.13%) excessive vomiting and 157 (15.47%) bleeding, leaking with some overlap. Of 1040 pregnant women, 910 (87.5%) were aware of labour events and 870 (83.7%) some maternity dangers, 474 (54.5%) preterm pains, 118 (13.5%) leaking, 97 (11.1%) epigastric pain, 73 (8.4%) headache, 67 (7.7%) vaginal bleeding and 41 (4.7%) loss of fetal movements with some overlap. Conclusion: Only one third preconception and little more pregnant women had some awareness of maternity dangers, but it was scatchy.

Non-pharmacological interventions of pain management used during labour; an exploratory descriptive qualitative study of puerperal women in Adidome Government Hospital of the Volta Region, Ghana

Background Women have experienced labour pain over the years as various attempts have been made to effectively manage this pain. There is paucity of literature on the experiences and perceptions about labour pain management with the contemporary Ghanaian health system. This study explored the perspective of puerperal women on the use of non-pharmacological labour pain management at Adidome Government Hospital. Methods The study adopted an exploratory descriptive qualitative approach as data was collected through individual interviews. Informed consent was obtained from all participants who were purposely sampled until data saturation was reached on the 17th participant. Interviews were audio recorded and transcribed immediately. Thematic analysis was engaged in three interrelated stages, namely data reduction, data display, and data conclusion to analyse the transcript and field notes. Results were presented with supporting quotes from the transcripts. Results The women described labour pain as very severe, severe and moderate as the pain lasted more than 12 h. The various strategies adopted in managing labour pains included shouting and walking around, crying and screaming and staying calm and snapping the fingers. Other pain management strategies adopted during labour included women engaged in deep breathing exercises, chatting with other people and relatives, diversion therapy, reassurance, taking a shower, assuming side lying positions, and receiving intravenous therapy. The presence of the husband of a labouring woman during labour improved pain bearing ability. Conclusion It is important that midwives institute pragmatic protocols in the labour ward that ensure a relaxing atmosphere for women in labour, respond to the sensitivity and specificity of labouring women needs and when possible significant others (e.g., husband) of the labouring women could be allowed to visit. Labour wards should be made sound proof to allow women the ability to express themselves satisfactorily during labour without fear of being heard outside.

Health workers’ perspectives on informed consent for caesarean section in Southern Malawi

Objective Informed consent is a prerequisite for caesarean section, the commonest surgical procedure in low- and middle-income settings, but not always acquired to an appropriate extent. Exploring perceptions of health care workers may aid in improving clinical practice around informed consent. We aim to explore health workers’ beliefs and experiences related to principles and practice of informed consent. Methods Qualitative study conducted between January and June 2018 in a rural 150-bed mission hospital in Southern Malawi. Clinical observations, semi-structured interviews and a focus group discussion were used to collect data. Participants were 22 clinical officers, nurse-midwives and midwifery students involved in maternity care. Data were analysed to identify themes and construct an analytical framework. Results Definition and purpose of informed consent revolved around providing information, respecting women’s autonomy and achieving legal protection. Due to fear of blame and litigation, health workers preferred written consent. Written consent requires active participation by the consenting individual and was perceived to transfer liability to that person. A woman’s refusal to provide written informed consent may pose a dilemma for the health worker between doing good and respecting autonomy. To prevent such refusal, health workers said to only partially disclose surgical risks in order to minimize women's anxiety. Commonly perceived barriers to obtain a fully informed consent were labour pains, language barriers, women’s lack of education and their dependency on others to make decisions. Conclusions Health workers are familiar with the principles around informed consent and aware of its advantages, but fear of blame and litigation, partial disclosure of risks and barriers to communication hamper the process of obtaining informed consent. Findings can be used to develop interventions to improve the informed consent process.

Fetus papyraceus: a rare case report

Fetus papyraceus occurs in multiple pregnancy, more common in monochorionic twin as compared to dichorionic twin. We report a case of 30-year-old gravida two para one living one, previous caesarean section, booked and immunized at private hospital was admitted with labour pains and underwent emergency caesarean section and on examination of placenta found an incidental finding of fetus papyraceus.