Nyaya Health

At Bayalpata Hospital, we face clinical questions that our so harsh, so uncomfortable, that they challenge our very humanity as healthcare providers.  The clinical challenge in this morbidity and mortality review is precisely one such instance: What is the appropriate management when a pregnant woman comes in from a village eight hours away with a dead fetus in her belly?  No woman should be placed in this scenario, yet they are.  We as a healthcare team do the best we can in managing these cases.  Sometimes we make the best choice in an awful scenario.  In this instance, we did not follow the best practices, and that misstep placed an already devastated woman at high risk.

Further clinical details are provided in the link below our mortality review.  Briefly, a pregnant woman presented to the Bayalpata Hospital after traveling eight hours during the monsoon season. She described that she had not felt fetal movements for four weeks.  She was found, using ultrasound, by our clinical team to have a dead fetus in her uterus.  The classical training that our team had received was to discharge the patient to allow for follow-up with natural passage of the fetal material.  We did this in this instance.  This, however, is not the appropriate standard of care, which would be induction of labor to remove the dead fetus and observation in the hospital so as to protect against blood clotting disorders and severe bacterial infections, both of which are life-threatening.  We have no way of contacting the patient at this point, and can only hope that this will be a “near-miss”, and that she passes the dead fetus naturally without further clinical consequence.

We have reviewed the case with our team, including the special consultation of Dr. Astrid Christofferson-Deb, MD, who is currently working as an obstetrician in Kenya. Our team in Achham has discussed her recommendations, and resolved to change our practices to provide induction of labor and admission to inpatient monitoring for patients with intrauterine fetal demise.

CLICK HERE FOR FULL TEXT OF THE MORTALITY REVIEW

Note: this report is a part of our “Comprehensive Morbidity and Mortality Review” initiative aimed at cataloguing and reflecting on the underlying causal pathways in cases of excess morbidity or mortality. This work is supported in part by a grant from the Lovejoy Foundation at Children’s Hospital Boston, Massachussetts, USA.