Emergency tubectomies??

EMERGENCY TUBECTOMIES???

        Recently, while reflecting on my experiences in mission hospitals, one thing that made me pause, smile to myself and shake my head was having done emergency tubectomies.  One may wonder why it was such an unusual thing. To understand that, one needs to know that tubectomies themselves are procedures that the family puts a lot of thought into before deciding to make the woman under go it.  Another thing that one needs to understand is what constitutes as an ‘emergency’.  I would call a procedure an emergency if the procedure is done after routine working hours and definitely if the procedure is done  after the surgeon has gone to bed for the night. So, is emergency tubectomies (not LSCS+TL) done anywhere in the world? I would not think so. But I can remember at least two occasions where I had to perform tubectomy in the middle of the night while I worked in Uthraula between 1998-2003.

       The first was on a woman who had undergone 6 deliveries before. And all of them were in the house with just the relatives’ support. But on this the 7^th pregnancy she had problems during her labor. Labor was taking too long. And so she was brought to the hospital late at night. As she had been seen in 2 places before arriving in the hospital it was difficult for me to make an assessment clearly. So, I wanted to do a ‘trial forceps’- it is when we take the woman into the operation theater and under spinal anesthesia apply forceps to deliver the baby. If forceps is successful it is a good thing but in the event that the forceps was not successful then the woman is already under anesthesia and so she can be delivered by LSCS.

      But from my experience with working in Utraula, I knew that if I told the woman and the husband that I will try forceps and if not successful then do a LSCS, what would usually happen is that they will not give consent for LSCS. Uneducated people think in absolutes. If there is a way to deliver vaginally why do an LSCS? So, the usual course of action when I post a woman for ‘trial forceps’ is to get consent for LSCS. And in the OT, forceps is applied and if it was successful the relatives are more than grateful that a smaller and cheaper procedure was done which allowed them to return to their house within 3 days. So, when I informed the family about the need for LSCS they also wanted a tubectomy done as they were just fed up with the troubles they had just been through for a pregnancy which they did not really want.

       In the OT the forceps delivery went on smoothly and I would have just had to send the mother and baby back to the ward and go back to bed. But, there was this woman who was under anesthesia for a 7^th delivery. If I discharged her the next day there was likelihood that she will be pregnant again in 2 years’ time and may attempt a termination and die while attempting it or may die during delivering the next time. So, I walked out of the OT and talked to the family. Since, they had already given consent for tubectomy with LSCS would they consider having the tubectomy even though she had delivered vaginally? And yes they were!!

That was how I did my first EMERGENCY TUBECTOMY.

The lessons I would like to pass on especially to young doctors-

1. In remote areas where a woman is in labor for a long time and has been treated in 2-3 places before they arrive in the hospital, it is always advisable to try vaginal delivery. It is not a sign of your ignorance if you are not able to say after examining the woman if she can be delivered vaginally or not. The whole scenario changes after anesthesia has been given. And why is it advisable to deliver vaginally? You reduce the risk of wound infection and peritonitis. And also financially it is cheaper for the family- the procedure charge is less and the hospital stay is less.

2. How you communicate to the family depends on knowing what they are capable of comprehending.

3. Have a uniform protocol but be also willing to change when the need arises- individualizing the care.

4. Always be willing to think outside the box.