Resham Bhargava Complainant(S) v. Super Specialty Hospital And Others Opp. Party(S).

PRONOUNCED ON: 7 January 2020th ORDER PER DR. S. M. KANTIKAR, PRESIDING MEMBER The Complainant, Resham Bhargava, about 27 years of age (hereinafter referred to as the1. patient) during her first pregnancy visited Mata Chanan Hospital O.P. No. 1 at New Delhi. The O.P. No. 3 Dr. Seema Saxena, Gynaecologist examined her and advised her for regular antenatal check-up (ANC). Her periodic blood tests and ultrasound were performed and the reports were found normal. On 10.07.2016, O.P. No. 3 admitted the patient in O.P. No. 1 hospital. On the next day at 11.15 a.m. O.P. No. 3 Dr. Seema Saxena told her that due to presence of bone in delivery pathway, normal delivery was not possible and therefore she needs surgical delivery (Lower Segment Caesarean Section LSCS). It came as a mere shock to the patient, but O.P. Nos. 2 &

3 forced the patient to undergo LSCS under false impression of danger to the unborn child. Thus, unwillingly the patient herself and her husband agreed for LSCS and signed some papers under force of O.P. Nos. 2 & 3. The baby girl was delivered by LSCS. However, while shifting the patient from operation theatre to the ward, the patient experienced severe pain, weakness and blurred vision. Same was informed to O.P. No. 3 Dr. Seema Saxena, who assured that everything was normal and there was nothing to worry. After few minutes the patient was unable to breath and immediately O.P. No. 3 doctor was called who examined the patient and told her husband that such condition might be due to bleeding inside and there was need to open the abdomen again. Therefore, the husband of the complainant had signed some documents and within 15 minutes the critical patient was operated by O.P. No. 3. The operation consumed several hours, but her husband was kept in dark about the happenings. It was when the patients husband threatened to take legal action against the Opposite Parties, only then the doctor disclosed that uterus of the patient was removed and approx. 1.5 litres of blood was present in the abdomen. It was alleged that patient was operated with the help of more than 10 doctors. After the second surgery the patient was kept in ICU from 11.07.2016 to 17.07.2016. The patient paid a huge amount of Rs. 2,10,000/- towards the medical bills. The complainant / patient alleged that due to removal of the uterus, she lost her chance to give birth to a child in future and it was due to carelessness and gross negligence of the Opposite Parties. She filed a complaint against the Opposite Parties and prayed for compensation of Rs. 1,10,00,000/-. Heard the learned counsel for all the parties. Perused the material on record. 2. The dispute relates to the alleged medical negligence and the two main allegations against3. the OPs are that i) whether LSCS was performed hastily without consent and ii) whether hysterectomy was caused due to the carelessness of the opposite parties. Discussion on i) whether LSCS was performed hastily without consent:4. The patient during ANC period was under observation of O.P. Nos. 2 & 3 at O.P. No. 1 hospital. As per the initial assessment and plan the expected date of delivery was 11.07.2016. The periodic ANC follow-up with blood and Ultra Sonography (USG) investigations were normal. On careful perusal of the medical record, the final diagnosis was Primi gravida at 38 weeks + 4 days POG . Therefore,with Intrahepatic Cholestasis of pregnancy (IHCP) with mildly deranged LFT because of IHCP, the patient was admitted for . On examination the cervixthe induction of labour was uneffaced, vertex at -3, therefore, Cerviprime gel was instilled and augmentation of labour was done with Syntocinon drip but there was no improvement in bishops score. The induction of labour was not successful, therefore after informed consent LSCS, was performed. Thus, the allegation about hasty decision to perform LSCS is not sustainable. Discussion on ii) whether hysterectomy was caused due to the carelessness of the opposite5. parties: In this context, we have perused the operative notes dated 11.07.2016 (2 operation nd hysterectomy). It is reproduced as below: Notes: Dressing removed, abdomen painlted and droped. Stetch line opened. 10-15 ml of blood expressed between the skin and the rectim sheats. No definite bleeder seen. Hamoperitoneum (+++) present. Uterus atonic, flasby. Abd. Toileting done. Binarural uterin massage done. Uterotonics segutodian bolou 5 So given. Intra uterin carboprost

125 mg given. Uterus still flasby. Peruaginal examination done. Bont of fresh bleeding with clots +, Inj. Nit K inj given and TONIC / PPH withs. Pv: clots removed Internal or closed. FOR HOSPITAL ONLY Signature Consultant/Registrar MCDH/Operation Theater/Operation Notes/F-74/VER- 1/OCT-11 Uterus remained flabby inspite of the uterotonic. B lynch suture applied. Still uterus atonic and bleeding continuously. Bld. Pv +++++++. Simultaneously pt managed by the intensivist and anaesthetist for hemorrhagic shock. Decision for caesarean hysterectomy taken. Husband and family members explained clearly the lifesaving nature and need for casearian hysterectomy when all other conservative management method failed. Informed consent obtained. Caserain subtotal hysterectomy performed by the standard technique. Flasby uterus removed. Uterine cavity full of clots. Ints closed lightly. Cx, adnexae conserved. Abdominal toileting done. Detailed examination done. No active bleeding seen. Intra-abdominal drain full. Parveties examined. Small oozers ligated and coagulated. No major bleeders seen. On a bare perusal of the operative notes, it is clear that the patient developed atonic PPH after LSCS delivery. After delivery, the uterus did not contract - regain its size. The uterus remained flabby. Despite giving uterotonics and applying the sutures, the bleeding P/V was (3+). It was life saving emergency, therefore, after informed consent the subtotal hysterectomy was performed by O.P. No. 3. The patient was given transfusion of blood and its components (PRBC, FFP, Platelets) to correct the hypovolemic shock. Regarding Post-Partum Hemorrhage and atonic uterus, we have perused standard medical6. books in Obstetrics and Gynecology viz. Shaws book of Gynecology and Williams book of obstetrics. The post-partum hemorrhage (PPH) or bleeding after childbirth is a well-known. It is a dreaded and leading cause of maternal morbidity and mortality worldwide even in the best centers. The process of child birth can take such a lethal turn. Only a qualified obstetrician can understand uterine atony or failure of the uterus to contract after childbirth as the most common cause. It can lead to rapid and severe haemorrhage shock, DIC, multiple organ failure and finally death. In the instant case, as per the medical record, patient was under observation after LSCS7. delivery. Patient developed hypovolemic shock in post-operative period with sudden hypotension and emergency resuscitation was done. The patient developed atonic uterus, it was managed by a qualified obstetrician with great technical expertise. Patient had bleeding PV (3+), uterus was relaxed i.e. atonic PPH. Doctor performed vigorous manual massage. The USG revealed uterus filled with clots and haemoperitoneum (+). Based on the finding and as a last resort to stop bleeding, O.P. No. 3 performed emergency laparotomy with the help of a Surgeon Dr. J. S. Gulati. The emergency hysterectomy, as a standard treatment, was performed to save the life of the patient. The precious life of a mother and baby was saved at O.P. No. 1 hospital and on 18.07.2016, the patient was discharged in satisfactory condition. To know more about emergency postpartum hysterectomy we have gone through Williams8. book of obstetrics and medical literature and research papers on the subject. Relevant information gathered is as below: Postpartum hysterectomy refers to hysterectomy done either after vaginal delivery or caesarean delivery. It is a major operation in modern obstetric practice, being associated with a high rate of morbidity and mortality. Risk factors for emergency postpartum hysterectomy include placenta previa; placenta accreta, increta, and percreta; and uterine rupture. Postpartum hysterectomies are largely unplanned and often done on an emergent basis for obstetric haemorrhage or undiagnosed abnormal placentation. For some women, due to obstetric emergency during childbirth which results in doctors needing to perform a hysterectomy. In many cases this is because doctors are unable to stop the bleeding (haemorrhage) and in few cases it is because the womb is the site of infection (e.g. septicaemia/blood poisoning) and antibiotics are not being effective. The incidence of peripartum hysterectomy is increasing in this era not because of improperly managed third stage of labor or obstructed labor but most likely because of increasing incidence of cesarean sections. Chances of repeat cesarean sections thus increase. This ultimately increases the incidence of placenta previa and accreta. In few studies, the most common indication of Emergency Obstertic Hysterectomy (EOH) was uterine atony (25%) followed by morbidly adherent placenta (21%) and uterine rupture (17%). This reflects the situation in most developing countries where atony accounts for the majority of cases of EOH, but also shows a rising. In one study, in spite of the availability of uterotonics agents and a variety of uterus sparring surgical interventions, it was observed that 44% of women underwent emergency postpartum hysterectomy without experiencing alternative procedures. On the contrary, in the remaining 56% who underwent alternative procedures these procedures failed to stop postpartum bleeding. The extra time spent on conservative maneuvers in the setting of massive postpartum hemorrhage to avoid hysterectomy might contribute to maternal morbidity, extensive blood loss, and need for blood transfusion. In our opinion, conservative measures to spare the uterus are reasonable as long as the woman remains hemodynamically stable and is not experiencing life-threatening hemorrhage. Subtotal hysterectomy is associated with a decreased risk of visceral injuries and blood loss, short operating time and hospital stay. However, identification of the cervix can be difficult in cases in which emergency postpartum hysterectomy is performed at full cervical dilatation. Subtotal hysterectomy has also been associated with bleeding from the cervical stump of the uterus through cervical branches of the uterine artery supplying the cervix. We observed that women with abnormal placental adhesion were approximately two times more likely to undergo total than subtotal hysterectomy. Although maternal morbidity was not statistically different, maternal adverse outcomes tended to be lower after subtotal (16%) than total hysterectomy (30%). In particular, urinary tract injury was reported more frequently when total hysterectomy was performed as compared with subtotal hysterectomy. If all attempts at arresting bleeding have failed, subtotal or total hysterectomy is The decision to perform aattempted as a last resort and life-saving measure. hysterectomy, although devastating for patients, should not be delayed in cases of haemodynamic instability. The decision to escalate surgical management to hysterectomy should be made by the most senior obstetrician. Subtotal hysterectomy is indicated in cases where the bleeding source is the upper segment of the uterus. Before concluding the matter, it is advisable to go through the discharge summery of the9. hospital which clarifies the entirety and chronology of the treatment. It is reproduced as below:

Informed consent taken for LSCS. LSCS performed by standard technique. Patient stood the procedure well. Patient developed Hypovolemic shock in post-operative period with sudden hypotension and emergency resuscitation done. Bleeding P/V (3+). Uterus relaxed, atonic PPH. vigorous manual massage done. Uterotonics given. Uterus atonic. Emergency ultrasound done. Uterus filled with clots and Haemoperitoneum(+). Decision for emergency Laparotomy taken. Attendants counseled consent taken Anesthesia team on duty called, surgical consultant (Dr. J.S. Gulati) called. Perop Findings Haemoperitoneum (++) No active bleeding from uterine stitch line Generalized ooze present. Uterus atonic and flaccid. Per vaginal examination done. One litre of clots expressed. B lynch suture applied. Atonicity persistent. In view of deteriorating patient condition decision for life saving subtotal hysterectomy taken. Informed consent taken subtotal hysterectomy done. Intra peritoneal drain applied. Thorough inspection of abdomen done. Closure done. Patient stood the procedure well and shifted to ICU for intensive monitoring. Patient put on I/V Fluids, 2 units whole blood + Inj. Imipenem + 2 units PRBC + 10 units FFP + 1 unit platelet aphresis Inj. Piptaz + Inj. Metrogyl + Inj. Imipenem + moxiflox given post operatively. Patient responded favourably to treatment. Patient became haemodynamically and biochemically stable. All vital organs functions preserved. Patient shifted to labour room on 17.09.16. sepsis screening done and found to be negative. Patient discharged on 18.07.16

Therefore, considering the medical record and the relevant medical literature it is clear that, firstly the decision of Opposite Parties No. 2 & 3 was correct to perform LSCS, because the patient was primi-gravida at 38 weeks + 4 days and having developed Intrahepatic Cholestasis of pregnancy (IHCP) with mildly deranged LFT. We note, the patient was admitted for induction of labour but it was failed therefore LSCS was performed after taking the informed consent. A female baby was delivered without any complications. It was neither deviation from the standard practice nor negligence. Secondly, after delivery, the patient developed . The patient was given properatonic PPH utero-tonics and vitamin K injection but the uterus remained flabby. For correction of hypovolemic shock IV fluids, 2 units whole blood, 2 units PRBC, units FFP and 1 unit platelet aphresis were transfused. In spite of utero-tonics administration and B-Lynch brace suture being applied there was bleeding P/V (3+). Therefore, the decision of subtotal hysterectomy was taken by O.P. No. 3. The same was informed to the husband and family members of the patient as it was for saving the life of the patient. The emergency caesarean hysterectomy was performed with the help of a surgeon, Dr. J. S. Gulati. In our considered view this decision of O.P. No. 3 was correct and the emergency was handled as per standards. Honble Supreme Court in case of I (2009) CPJ 32 SC10. Martin DSouza V Mohd. Ishfaque has observed that:

49. When a patient dies or suffers some mishap, there is a tendency to blame the doctor for this. Things have gone wrong and, therefore, somebody must be punished for However, it is well known that even the best professionals, what to say of the averageit. professional, sometimes have failures. A lawyer cannot win every case in his professional career but surely he cannot be penalized for losing a case provided he appeared in it and made his submissions. (emphasis supplied) Based on the foregoing discussion, relying on the standard medical literature, it is not11. feasible to attribute negligence / deficiency in treatment given in both performing LSCS and the emergency exploratory laparotomy for subtotal hysterectomy, it is difficult to conclusively establish medical negligence / deficiency in service. The complaint fails, and is dismissed. On sympathetic and humanitarian grounds, the Registry of this Commission is directed to12. refund the fee of Rs. 5,000/- deposited by the complainant at the time of filing of the complaint, after the due verification. ...................... DR. S.M. KANTIKAR PRESIDING MEMBER ...................... DINESH SINGH MEMBER