One little life…

I read this harrowing account of a VBAC gone wrong some time ago. I hadn't posted on it until now as I wanted to be sure it was a true story and not an urban legend. But I have recently read the full account on Madmomma's blog and she says she's in touch with the poor mom who underwent this tragedy so I am posting it here for those of you who haven't as yet come across this outrageous incident.

You know, when you are pregnant, you read all the baby books anyone's ever written, talk to every woman you've ever known who's ever had a baby…And yet ultimately, you know you know nothing and you put yourself in the hands of your doctor, professionally qualified, experienced and, hopefully, with your best interests at heart. Any of us who've had a complication during pregnancy would remember the feelings of panic and the reassurance you feel when your doctor seems to be competent and advises you calmly and yet sympathetically on your options. What do you say when a doctor, whose negligence seems to have caused you to lose your baby, advises you to take up 'Japa and tapa' and says you can always have another one? Does that replace the baby you have lost? Do you ever forget how old the baby would have been and stop crying for the 'it might have beens'? Especially when you realize it was a matter of minutes, and sheer medical negligence, do you ever stop regretting and not counting the 'what-if's?

I wept unashamedly the first time I read this story, in my office. I don't have the strength to read it again. But I'm putting it in here to hopefully forewarn any expectant young mother about the risks and the kind of things to watch out for. As for Rashmi, my heart goes out to her and I hope she somehow finds the strength to cope with this. God help her.

Rashmi's story

My name is Rashmi B.T. I am 35 years old, married to an air force officer, Vivek, and have a four year old son, Dhruv, delivered by emergency Caeserean section in 2004. On March 4th, 2009, my life was changed unalterably. I lost a baby that I had carried inside me, completely healthy, for a full 41 weeks.

I understand that doctors are human, that mistakes happen. However, I have come to believe that what happened to me could have been prevented if the doctor and the hospital had provided the most basic level of care and expertise. What's worse, they refuse to take steps to prevent someone else going through the same nightmare, simply because they want to protect themselves from the possibility of litigation – something I am not interested in unless it is the only way to force them to change their protocols.

The Beginning

In June 2008, Vivek and I learnt that we were expecting our second child. The pregnancy was uneventful. I was healthy and fit. Every prenatal visit and test showed that the baby was healthy and developing well. During my 35th week, I decided to consult Dr. Latha Venkataraman at The Nest, Wockhardt's Bannerghatta Road maternity facility to see me through the rest of my pregnancy.

Despite the fact that I had already undergone a C-section, she urged me to opt for a V-BAC (Vaginal Birth After Cesarean Section) or in layman's terms, a normal delivery. She brushed aside my concerns, telling me that a second C-section would be six times more risky and assuring me that a V-BAC would be less risky and almost pain-free.

My due date was estimated as 26 Feb 2009. I visited Dr. Latha on 28 Feb. She wrote on my record: "delivery will be attended by Dr. Latha/Dr. Prabha." Since I had neither met, heard of, nor been examined by Dr. Prabha before, I was concerned. Dr. Latha explained that Dr. Prabha Ramakrishna is another consultant at Wockhardt, and that it was a hospital requirement for her to write both their names down as possible attending doctors for my labor/delivery. However, she assured me that it was just a formality, and that she would be the one to attend to me when I went into labor.

On 3 March, I visited Dr. Latha again. Since I was so far past my due date, I requested that a scan be done to check on the baby. When I called her to read out the results of the report, she did not want to know anything other than the liquor content, though I specifically asked her if there was any other information she would require from the scan. She told me I could either wait for labor to start or choose a day to come in and have my labor induced.

The Nightmare Begins
I went into labor at 2am on 4 March, and got admitted to the hospital at 5.15am. By 7.45 am, I was experiencing contractions less than a minute apart. Dr. Latha came and did a quick examination. I was shifted to the labor ward at 8am where I remained until 1.50p.m., under the sole care of nurse Savitha. Dr. Latha was not present at all.

A junior doctor, Dr. Shirley, was available intermittently. She spent most of the time on her cell phone, talking to her husband. She was keen to see him before he left on an 11-day vacation. A Dr. Chetna substituted for her while when she went to see her husband off. There was no other doctor present. Dr. Prabha was called each time the fetal heart rate fell (this happened a couple of times). She was seeing outpatients and attending two other deliveries simultaneously, so she was only able to come to the labor ward to see me four times, for less than 5 minutes each time.

At 10am, I was given Syntocinon, a drug used to enhance labor; the dosage was increased at 10.45am. At 12.30, there was vaginal bleeding, and the nurse phoned Dr. Prabha, who advised her to "keep a watch". The bleeding reduced, but I began to feel pain of increasing intensity during contractions. Dr. Shirley reappeared at 1.00 p.m., examined me vaginally and announced that I was almost fully dilated and would deliver by 1.30pm. I complained several times of excruciating pain but was told that it was normal. At 1.30pm, Dr. Prabha came in and was told by Dr. Shirley that I was fully dilated and would deliver any minute. Despite that, Dr. Prabha breezed off to visit another patient in the OPD.

I felt no urge whatsoever to push, yet was asked to do so. The stirrup on the delivery table kept breaking off – I was told that this is a recurring problem that "needed attention". At 1.50 pm, the fetal heart rate dropped to 80 beats per minute. Dr. Prabha was called again. She checked the fetal heart rate on the CTG, explained that this was normal when the baby was passing through the birth canal, and asked me to hold my breath and push hard. I felt no sensation in my cervical area, but felt intense pain tearing my stomach apart. I felt like my baby had rolled into my stomach and could see its body pushing up against my ribcage. I was screaming, pointing at my stomach, and telling them that my stomach was hurting, and there was no urge to push. But she told me to "push, push harder". I then heard Dr. Prabha saying "Get the OT ready". She told my husband that she was going to attempt to deliver by forceps – if that was unsuccessful, she'd have to do a Caesarian.

The OT wasn't on standby, wasn't ready. I was numb with pain. They wanted me to get up and move to the operation table. I couldn't move. They eventually slid something under my back and I pushed myself on to the OT table, as there was no transfer stretcher available. I complained of severe shoulder and chest pain. No one paid me any attention; everyone was busy preparing the OT, and the anesthetist was attempting to top up my epidural. The fetal heart rate was never monitored in the OT. Dr. Prabha unsuccessfully attempted a forceps delivery at 2.20 p.m., and then cut me open. I heard a deafening sucking sound, after which I must have passed out.
Later, I learnt that my uterus had ruptured along the scar of my previous Caeserian section. My baby was found floating in my abdomen. He had no heartbeat and he wasn't breathing. He had been deprived of oxygen for a long time – 43 minutes. They "resuscitated" my son and put him on a ventilator.

When I opened my eyes I saw Dr. Latha leave, followed by Dr. Prabha. Dr. Shirley was suturing me while laughing and talking with another nurse. I felt reassured that my baby was okay, even though I had neither seen nor heard him.
"Don't Worry, You Can Conceive Again"
At 3.30pm, a nurse struggled to take my BP reading; the BP apparatus wasn't working and had to be replaced. Dr. Latha met Vivek at the NICU and told him that the baby was doing fine and had to be kept under observation. She also told him that my scar had ruptured, but said that I was okay. At 4.30 pm, my husband repeatedly begged the nurses to give me pain relief. I was then shifted to the ward.

At 9.30 pm the neonatologist told Vivek that the baby had been deprived of oxygen for over 40 minutes, possibly resulting in "some extent" of brain damage. This was the first inkling we had that something had gone wrong.

The next morning, I was given a sponge bath at 6am. I then lay unattended until 2.30 p.m., when Dr. Prabha, Dr. Latha, and Dr. Prakash (the neonatologist) saw me for the first time after the operation. Dr. Latha unceremoniously ripped the dressing off my wound without using any gel or spirit, and pronounced the wound clean.

We were told that our baby would be kept under observation for another 24 hours. Later that night Dr. Latha came in at 9.50pm. Her only words to me: "Don't worry, you can conceive again. Your uterus is intact."
"Do Japa and Tapa To Get Better"
None of the consultants saw me on 6 March. That night, my milk came in, and my breasts became swollen and painful. I asked in vain for assistance. After repeatedly begging for help, I sent Dr. Latha a text message at noon on 7 March. At 4pm, a nurse told me that the doctor had instructed them to use a breast pump to relieve my pain – however, since the hospital didn't have one, I would have to go and buy one.

Dr. Latha finally visited me at 7.30 pm. She confessed that she was unaware that there had been a 43 minute delay in performing my C-section. She also admitted that instructions delivered over the phone could never substitute for personal supervision. She said, and again I quote, "Do some pranayama, japa, and tapa to help you get better."

Throughout my stay, nurses didn't know what medication I had been prescribed. They kept asking me what medication I was to be given. They had to be repeatedly reminded to give me medication.

For the next 13 days, Arnav was in the NICU on a ventilator. Throughout that time, he was completely reliant on ventilator support, his eyes were dilated and non-responsive to light, and there was no sign of movement. After a week, the neonatologist asked me to express milk and said they would feed the baby with a pipe inserted from his nose to the stomach. I did this for the next six days.

On 16 March, we decided to let Arnav go. We requested that he be removed from life support.

"We Would Do Exactly The Same For The Next Patient Who Walks In"
Vivek and I wanted to learn what had gone wrong with such a healthy pregnancy. Basic reading indicated that scar rupture is a well-known risk when you attempt to deliver vaginally after a first C-section, and must therefore be monitored very closely by a doctor if attempted at all. We met with the hospital administration and the doctors. All we wanted was an explanation. To hear the words, "I made an error in judgment". Instead, we were met with a wall of defensiveness. Dr. Latha said that despite knowing the outcome, she would take exactly the same steps with the next patient who walked through her door.

I decided to get a second opinion. And then a third, and a fourth, and a fifth. Three of Bangalore's best-known gynaecologists (and other doctors too) categorically stated that given my age (35), the estimated weight of the baby (> 4 kilos), and the duration of gestation (>40 weeks), a vaginal birth should never have been attempted, and scar rupture was a logical, obvious outcome.

All reading I have done has backed this up. Even a layperson's book like "What to expect when you are expecting" (pages 363-364) says that abdominal pain during a V-BAC indicates a scar rupture and outlines the procedure for safe delivery of the baby. Given that I was complaining of excruciating abdominal pain, shoulder pain and chest pain, the doctor should have known my scar was rupturing. I should never have been asked to push; it exacerbated the rupture. Nor should I have been given a drug that intensified my contractions. By Dr. Prabha's own admission, she did not know about the rupture until she opened me up.

Several doctors have also told us that keeping Arnav on the ventilator for 13 days was an exercise in futility from the first. At no point were we told that he would never survive if taken off the ventilator – had we known that, we would never have subjected him, or ourselves to two weeks of anguish. All we were told was that he "might be" brain damaged to "some extent" but they couldn't predict how bad it would be.

A Brick Wall of Defensiveness; Discrepancies Galore

When I attempted to engage with the hospital to ask them to change their protocol of treatment based on an unbiased review conducted with the inputs of external gynecologists, I was met with a brick wall of defensiveness. They refused to conduct a fair, transparent investigation, claiming that their internal investigation showed that they had done everything right and that losing the baby was "my destiny". Dr. Latha went so far as to say that since I am educated, I should have been better informed about the procedure.

I don't want to sue them for money. I just want them to change their policies and protocols so that this doesn't happen to someone else. I have been hitting a brick wall for two months, and feel that the only way to make them pay attention is to tell my story to people.

There are many discrepancies and attempts to cover up the hospital's inefficiency (to name a few: baby's weight recorded as 3Kg despite the fact that he was never weighed; post-facto note of fetal heart rate as 180bpm despite the fact that the heart rate was never monitored in the OT; discharge summary says "live term baby extracted" even though Arnav had no heartbeat or respiration at birth; half-hour discrepancy between CTG trace and labor room clock). I asked questions to which I was given ludicrous answers (Eg: Our pediatrician is very experienced, so he can guess the weight of any baby just by looking at it).

We were charged approximately Rs. 2,20,000 by Wockhardt. Of this, we found over Rs. 7000 billed for things that had never been done (spinal anesthetic, an extra day of room rent, food not consumed). We subsequently found more extraneous charges, amongst them an amount billed for tests that were performed on 18 March, two days after Arnav's death.

My Story Has Just Begun…
My uterus is still healing. My back still hurts from the trauma. And my heart aches for Arnav, the baby I will never hold.

More than that, I am filled with the fear that this will happen again. After all, Dr. Latha says she would "do exactly the same again" even though she knows the outcome. And the hospital agrees that she – and they – did everything right.

Wockhardt delivers approximately 80 babies each month. With BP machines that don't work, a delivery room stirrup that's falling off and that has "needed to be fixed for a while", nurses who don't know what medication they are supposed to administer, and one (yes ONE) OT dedicated to emergency deliveries. That OT wasn't ready when I needed it. What guarantee do you have that it will be ready when you need it? Sure, they claim to have nine other OTs in the hospital – but if they are all as woefully unprepared as the one I was in, my story could be yours.

I want them to change their policies, and I won't give up until they do.

Thank you for reading.

Wockhardt's side of the story

1. Reputations take a lifetime to build, is it right to destroy them without understanding true facts and make a hospital and its doctors look inhuman? The true facts of Ms Rashmi BT's case
   

   Ms. Rashmi B.T. was under the care of a senior gynaecologist in Bangalore for her second pregnancy. She had a breech presentation (where the legs of the baby present itself first instead of the head during the time of delivery) in the earlier pregnancy which required a C-Section. She made a conscious decision to shift under Dr. Latha Venkatram's care at Wockhardt Hospitals, Bangalore in the 35th week of her pregnancy largely because she was aware that Vaginal Birth after Caesarian Section (VBAC) was an option and wanted to select that option for her second delivery. She had collected information that Dr. Latha Venkatram was one of the senior gynecologists in the city who offered this option to her patients. From the OPD records filed by Dr Latha Venkatram it is evident that Rashmi was counseled and given ample information about the procedure and the risks associated with it and she took an informed choice to select this procedure.
   Vaginal Birth after Caesarian Section (VBAC) is the term used when a woman gives birth vaginally, having had a caesarian delivery in the past. Worldwide VBAC, if possible, is being recommended and preferred over repeat C-Sections as its advantages substantially outweigh the disadvantages. According to the Royal College of Obstetricians and Gynaecologists patient information guideline 2008 "Birth after previous Caesarian Section", overall three out of four women with an uncomplicated pregnancy would give birth vaginally following one caesarian section delivery. The short-term and long term complications inherent in a C-Section make it preferable that a woman is offered the choice of a VBAC. The American College of Obstetricians and Gynecologists and have set a goal of 37% VBAC deliveries by 2010
   Repeat Caesarian sections are associated with:
   o A possibly more difficult operation
   o Longer recovery period
   o Possibility of injury to bladder or bowel
   o Possibility of blood clots developing in legs and pulmonary thrombosis
   o Breathing problems for the baby. Higher in C-Section than in VBAC
   o Serious risks increase with every Caesarian delivery
   o Higher chance of infection
   o Future complications for the mother who has had repeated opening of the abdomen
   o Higher costs
   VBAC has a shorter stay in the hospital, faster recovery as well as lower cost for the patient. There is a risk of uterine rupture but this risk is approximately 0.5%. In spite of this risk the benefits of VBAC far outweigh the risks. As in all medical procedures there is no way to predict which patient would fall under the 0.5% risk of uterine rupture or any way by which this rupture can be prevented. A VBAC delivery is more demanding of the gynaecologist, as it takes 6-8 hours as compared to a C-Section, which in a planned fashion would be over in less than 40-45 minutes. Also the mother and child need close monitoring it is estimated that one will have to do as many as 200+ unnecessary C-Sections to prevent the occurrence of 1 uterine rupture. In most cases a uterine rupture is not fatal. However in the best interest of Ms Rashmi, Latha Venkatram gave her both the choices and Ms Rashmi chose to opt for the VBAC option.
   

   Ms. Rashmi B.T. was a fit candidate for a VBAC. She had a breech presentation in the earlier pregnancy which required a C-Section. A breech presentation in the earlier pregnancy which necessitated a C-Section is in fact an indication to offer a VBAC to the patient in the subsequent pregnancies. An age of 35 is not a contraindication to a VBAC. The fact that she was 5 days past her due date was also not a contraindication to a VBAC because less than 5% of patients deliver on their due date.
   During her antenatal visits to Dr. Latha Venkatram, Ms Rashmi B.T. was explained in detail about the pros and cons of VBAC and she agreed to undergo the procedure. The OPD case records have these notations. She was also clearly informed by Dr. Latha Venkatraman that she works along with Dr. Prabha Ramakrishna as a team and either of them would be present during her delivery. Doctors particularly in the area of obstetrics frequently prefer to work as a team since many times an emergency may hold one of them which would make it possible for the other team member to attend to the delivery as the date and time of delivery cannot be predicted. In a VBAC considering that a consultant needs to be around for most of the labor period it is prudent that a team takes care of the patient. Both Consultants of the team Dr. Latha Venkatram and Dr. Prabha Ramakrishna are Fellows and Members of the Royal College of Obstetricians UK.
   

   Ms Rashmi B.T was admitted to the hospital early morning on the 4th of March 2009 in spontaneous labour. She was connected to monitors for a close monitoring of both maternal and fetal parameters. She was visited by Dr. Latha Venkatram soon after admission. An experienced nurse and a fully qualified gynaecology registrar were monitoring her constantly. The Consultant Dr. Prabha Ramakrishna was also available on the same floor and repeatedly examined her. She was kept informed about the progress of the labour.
   The labour progressed normally until 1.50 p.m when a sudden decrease in the fetal heart rate was noted (fetal bradycardia). The tracings before 1.50 p.m were normal. The moment fetal bradycardia occurred, the consultant Dr. Prabha Ramakrishna who was on the same floor was called in by the gynecology registrar. When Dr. Prabha Ramkrishna examined Ms Rashmi, the baby's head position was a little high. She was asked to push to see if the baby's head would come to +2 position in which case she could do a forceps in the labor room itself and deliver the child. When the baby's head did not descend as required she asked for the patient to be shifted to the Operating room. After this Ms.Rashmi was not asked to bear down any further.
   

   Shift to the OT was rapid since the dedicated Operation Theatre for Caesarian sections is situated within the labour room complex and this theatre is not used for any other procedure. Within 7-8 mins the patient was in the theatre. The anesthetist had a choice of going in for an emergency general anesthesia which has inherent risks for a pregnant woman or to go in for epidural anesthesia. Since the patient was already receiving pain medication (epidural analgesia) it was decided that for the safety of the mother increasing this analgesia to achieve anesthesia was the preferred option. In the OT the fetal heart rate was recorded as 180 b.p.m on the Doppler. On the OT table an examination was done and it was found that the head had receded and a forceps delivery was not attempted. An immediate emergency C-section was then performed.
   The anesthetists, Neo-Natologists and the surgical nursing team had assembled in the theatre within a few minutes of the emergency being declared. The hospital has full- time anesthetists, Neo-Natologists and a surgical nursing team working round the clock to attend to all kinds of medical emergencies.
   At the time of birth the baby did not have a heart beat or respiration. Resuscitation was started and the heart beat started about half a minute later. The child was immediately shifted to the Neonatal ICU and put on the ventilator. The baby's weight at birth has been recorded in the NICU as about 3 Kg. The only reason an exact weight could not be taken in the NICU was that the child was already attached to various lifesaving equipments and the neonatologist had to make the closest estimate. However it must be noted here that a birth weight of 4 KG is not a contraindication for a VBAC.
   

   In the neonatal ICU the clinical team met the family on a daily basis and kept them informed about the status of the baby and the prognosis. The poor prognosis was explained to the parents on the 2nd day itself. An opinion from an external eminent neonatologist was also sought who concurred with the poor prognosis. All decisions regarding further care were made only after extensive discussions with the parents of the baby. Dr.Prakash Vemgal our Neo-Natologist is not only highly experienced but has also gone through some of the highest training in Neo- Natology in high patient volume and reputed international centres.
   The doctors and the management (including senior management personnel) of the Wockhardt Hospitals group spent long hours with the parents understanding and trying to address their concerns. As is the normal practice in such a case a complete internal review was done. The family sent to us a detailed list of areas they wanted us to look into during our investigation. We did go into each of these areas and sent them a detailed reply addressing most of these issues including taking the opinion of two leading and senior external gynecologists of the city who do substantial VBAC work. It is unfortunate to note that inspite of providing her all clarifications Ms Rashmi has been projecting an extremely poor image of Dr. Latha Venkatram and the hospital.
   Our internal review involved discussions with our own team of gynaecologists, meetings with two external gynaecologists who practice VBAC and the entire clinical care team. Our findings after this detailed internal review are summarized below.
   a. Ms Rashmi BT was a fit candidate for a VBAC. She would have been offered this procedure as a first choice by any gynecologist or hospital which practices advanced obstetrics anywhere in the world. Her age or the week of pregnancy were not contraindications to go in for a VBAC.
   b. She had made a conscious and informed decision about going in for a VBAC. She had changed her senior gynecologist whom she was consulting until the 35th week of her pregnancy primarily because that gynaecologist was not in a position to offer VBAC.
   c. The OPD case notes of which she was given the duplicate copy recorded that she was willing for VBAC and she was informed about all risks of her decision.
   d. Both the mother and the child had been monitored carefully right through the labour
   e. All medications used for progressing labor were prescribed agents and safe for use in VBAC
   f. She did have a uterine rupture which in VBAC carries a risk of 0.5%. This rupture could in no way be predicted or prevented. In spite of the rupture the gynecology team was able to save the uterus for future child bearing.
   g. The Operation theatre was ready at the time it was required.
   h. All the staff were present in the Operation Theatre within a few minutes of the emergency being declared
   i. While the baby was in the NICU Dr.Prakash Vemgal the head of Neo-Natology met up with the parents at regular intervals and kept the family clearly informed about the status and prognosis. All major decisions were taken only after discussion with the parents.
   j. Senior management of the organization met up with the family on multiple occasions to understand and address their concerns
   A minute by minute account of her story as is being spread through the various emails circulated by various people who were neither physically present during her admission to the hospital nor were involved in her care process exhibits to us a determined effort to harm the reputation of the gynecologist and the hospital without having any understanding of the clinical facts of the case.
   Is medicine now going to be judged through the lens of only opinions running across chain mails or through the untiring efforts of institutions and doctors which toil endlessly to save lives but remain spectators to their actions being judged by emotive outbursts?
   We do understand the pain and suffering of Ms Rashmi BT. As a hospital every life is precious to us but we are also are in the world of medicine where unfortunate rare complications can be counteracted but every procedure cannot be made risk free. There are many lives which we save each day when all has been given up and each such case teaches us that to pursue medicine is to pursue the limits of the unknown but does that mean that we become victims of public misinformation
   We have taken all necessary care and followed every medical protocol that any reputed institution across the globe would have followed. However it is unfortunate that even though Ms Rashmi has not been a victim of any medical negligence she has chosen by this random spread of irrational mails to use a redressal system that is purposely harming the reputation of Dr Latha Venkatram, Dr.Prabha Ramakrisha and our institution.
   

   The case can be subjected to analysis by any competent authority.

I am not a medical authority but I can see some discrepancies in the hospital's story right way. For one thing, a 4 kg baby is big in any geography especially India where women are much smaller built. So it should have rung alarm bells in the doctor's mind, given a previous CSec.

Moreover, how can the hospital wash its hands off saying the mother was fully infomed? Did the doctor tell her what could be a potential outcome while Rashmi was in labour? We all know things change in, literally, a heartbeat in medical situations. What the doctor may have told Rashmi earlier would be negated given the dynamic situation in the labour room, so it really is up to the doctor to take a competent medical decision, backed by experience and training, rather than to say the patient was educated and informed and to pin the blame on the patient.