Mrs. X a 35 years old married for 10 years. She is a P3+0, who delivered her third child at the age of 30 years. Her first baby delivered normally and the second was a cesarean section for a fetal distress after an induced labor for poorly controlled gestational diabetes. She decided to have another child despite the maternal and fetal risks of diabetes in pregnancy, due to pressures from the husband and his family, who thought she needs to have a daughter after two sons. Her pregnancy progressed well till the 34th week , when the diabetes recurred. Her ultrasound scan showed excess of the amniotic fluid and a larger baby size, for that gestation. She was started on Inj. Insulin short acting three times a day and an intermediate acting one at night. The sugars got controlled by 3 days, without any reversal of the large baby size or the extra amniotic fluid.
At 37 weeks her water broke, and labor started. She was unwilling to have another cesarean section, due to low finances. Her labor progressed, and at a cervical dilatation of 9 cms, the fetal heart rate was low at 100 beats/min. The delivery was expediated with a forceps, applied after an episiotomy. The baby was born, and was alright. Unfortunately, the episiotomy extended, and another perineal tear was seen that tore her anal sphincter. The suturing of the episiotomy and the perineal tear was done. Within 24- 26 hours after the delivery, she found that she was leaking watery stools.
Not much could be done immediately and a decision to have the corrective surgery after 6 weeks was explained. Now even after two surgeries done to repair the anal sphincter muscles, she continues to leak watery stools, although she is able to hold the solid and semisolid ones……….
What went wrong
a) She could have avoided getting pregnant with appropriate contraception use
b) Control of gestational diabetes could have been initiated early with the previous history to prevent macrosomia and polyhydramnios
c) An elective cesarean section may have been a better delivery route , with counseling for tubal ligation in view of recurring gestational diabetes.
d) The forceps application, at 9 cms with possibly an unrotated head, could have led to the perineal tear and episiotomy extension. Checking for the correct application after confirming the pre-requisites for a forceps application is necessary to prevent maternal and fetal compromise.
e) Anal sphincter injuries are difficult to repair with good healing and suture material used as well as technique are important.
f) post-operative care after the anal sphincter repair is critical. Use of intravenous fluids, delaying passage of solid stools before healing, and judicious use of stool softeners to prevent a wound breakdown are all necessary.
Creations from the heart 