Dr. Banka Soujanya on High-risk Pregnancy, Patients’ Well-being Post-delivery and More! (Part-3)

Dr. Banka Soujanya: During my 1st year of practice after completing my PG. There is a case of placenta accreta, she's a known case of a previous Cesarean. She was conceived, and in the second pregnancy, the placenta was attached to the previous scar. It was a low-lying placenta; we call this placenta previa. So she had on-and-off complaints of bleeding. It is called placenta previa, a complication that involves bleeding, spotting, so we have to admit her for 2 months in the hospital. Imagine her situation being in a hospital bed, completely for bed rest, monitoring her because any time bleeding can happen, which is like a time bomb. 

In our labor room, she's like a time bomb. Anytime the bleeding can happen, we have to take her to the OT(Operation Theatre). So luckily she carried for 36 weeks. Then we started delivery, electively keeping in mind that we might need to remove her uterus if the bleeding doesn't stop. So it's like teamwork where we have two surgeons, not one obstetrician, but two obstetricians and a critical support team, ICU team, where we will be dealing with excess hemorrhage when the blood transfusion is needed immediately. Not only the blood, the plasma, the platelets, but everything should be ready at hand. We have kept almost 4 units of blood and 4 units of FFPs, and everything in our blood bank is ready, and a pediatrician, because the baby is 36 weeks. Any resuscitation needed? The pediatrician is ready over there. Luckily, the operation was done. 

Imagine the uterus is covering the placenta. We don't have anywhere to give the incision to deliver the baby, and even if we need to give an incision, we need to deliver the baby within a short time frame. Suppose any blood loss happens during the process. In that case, it affects the baby, and if we cannot deliver the baby in time, there might be a risk of losing the baby, and the mother may not have a next chance to carry another pregnancy because we may need to remove her uterus to address complications. 

It's a very challenging case. When we opened the uterus, we needed to deliver the baby immediately within a span of 1 or 2 seconds then we handed over the baby, and our next task was to control the bleeding. However, we followed the protocols in a stepwise manner for the devascularization approach. Using clamps and other methods but unfortunately, we couldn't, and we have to go ahead with a caesarean hysterectomy. 

We removed her uterus, which was done within 15 minutes, but usually, hysterectomy surgeries can take about 45 minutes. It’s challenging as the entire procedure must be done within a short time frame where one gynecologist worked from one side while another gynecologist worked from the other side, and finally, we managed to remove it.

The biggest challenge during pregnancy is the increased vascularity, particularly for the uterus, which becomes very edematous and fragile. So it is crucial to perform the clamping, tying, and suturing in time. Ideally, the delivery should be done within 15 minutes, and additionally, it's important to coordinate with anesthetists and to support the blood transfusions and also all the resuscitation methods. Luckily, everything went well and the mother is happy. We can see the baby's pictures on WhatsApp status, which feels like a blessing for us. 

The lady has shared all the babies' pictures. In her 1st pregnancy, she welcomed a baby boy, and in her second pregnancy, she had a baby girl. The mother is doing well because we were able to retain her ovaries. Which means she doesn't have any menopausal signs at this time. However, she may feel emotionally low because she no longer has a uterus and therefore is not experiencing monthly bleeding. This is the only emotional support we will need to provide her. She has accepted this situation as her primary desire was to have two children by her side.

It's worth noting that her husband was a soldier, serving in our army, which made her treatment feel like a contribution to the nation. They're like family now for me.

Dr. Banka Soujanya: My counselling starts at the table itself. After delivering the baby, I maintain a conversation with the patients when they are still on the table, to help them feel more comfortable. Once the baby is delivered, i will share the good news about the baby's health and reveal the baby's gender. Following this, my counselling for the post-operative care starts. After everything is done, I make sure to show my face to the patient and communicate with them. I say, "The delivery went smoothly, with no complications on our end. Overall, it was a very successful operation, and the efforts on your part were commendable.

Once the anesthesia effect wears off and you are feeling stable, our hospital team will assist you to get up and ambulate, like walking. Early ambulation is crucial to prevent most of the complications. We aim to help you start ambulating or walking immediately 6 or 8 hours after the procedure."

While some might not feel comfortable initially, at least after 12 hours, it is important that you at least sit up and walk in the hospital itself. If they lie completely on the bed for a prolonged period, there are chances of blood clotting, and there are chances of thrombus and embolism. So ambulation is our top priority.

Second thing is wound care; It is important which apply regardless of whether you had a normal or cesarean delivery. In case of normal delivery, there is typically a small incision at the vaginal area called Episiotomy. We guide them on how to take care of the wound properly, while those who underwent C-section, we explain how to manage dressings and necessary care. Additionally, nutrition plays a important role in recovery. A good diet helps them recover fast, and mostly a high-protein diet will help to heal the wound. An iron-rich diet helps to restore the blood loss that has occurred.

The third important aspect to consider is hydration. It is essential to maintain 3 litres of fluids in your body, so that it will significantly improve breastfeeding. The fourth point is the necessity of a fibre-rich diet, because after surgery, patients experience symptoms of constipation as a result of the iron supplements, antibiotics, and reduced mobility. So, including a high fiber diet is a mandatory thing. 

The fifth important thing involves bonding with the baby. Generally, patients often think, "I'm in pain and I can't get up or I can't walk, and I can't feed my baby." But the first important thing to relieve pain is to start walking for some time. Additionally, breastfeeding the baby will also help to relieve the pain. So these are the two things that we advise daily in our rounds. 

The next day, post-operative, we discuss these considerations with the patient, including wound care, diet, fluid intake, breastfeeding, and emotional support. As far as possible, I make a it a point to maintain physical contact such as by gently touching or tapping their shoulder to instill confidence so patient feels encouraged or motivated to share any concerns with me, even if it is a small thing, as patient might feel, "if I share with Madam, she might feel silly". Remember that what may appear silly to you might not be so for a doctor; you have to share every aspect that is troubling you. 

Lastly, don't endure post-operative pain without seeking help. Obviously, you'll be suffering with pain; don't hesitate to ask for pain relief. However, we will be prescribing the painkillers, but if pain remains intolerable, we can add another medication so that you'll feel comfortable. These are the standard practices we usually do postoperatively.