KATRA SATYANARAYANA vs LAKSHMI NURSING HOME

THIS appeal has been filed by the unsuccessful complainants in O.P. No. 293/1996 on the file of District Forum, Guntur.

THE first complainant is the husband of late Rajani Kumari and complainants 2 and 3 are his minor children. When Rajani Kumari was expecting her second baby, she approached opposite party No. 1 and consulted third opposite party, who is the Gynaecologist. She was a patient of third opposite party from 26.9.1995 to 21.11.1995 when she died in the first opposite party nursing home. Her first delivery was by caesarean section in another hospital in 1990. When she approached the third opposite party, she showed all the reports of her first delivery. She was admitted in the opposite party nursing home when pains started on 20.1 1.1995. However, no tests were conducted like blood, sugar, urine etc. nor RH typing was done. When she was admitted at 12.00 noon on 20.11.1995, as per the case sheet, her B.P. was 140/90 which came down on 130/90 and there was mild meconium stained liquor and the opposite parties did not make any preparation for caesarean section in case of emergency, such as, blood grouping, cross matching, RH typing etc., and keeping the necessary blood ready. It is alleged that at that stage Syntocinon was given with 40 drops per minute and not 20 drops as mentioned in the case sheet. This high rate of Syntocinon led to rupture of the uterus and previously operated scar also got damaged which led to profuse blood loss. This all happened due to the negligence of third opposite party. At 3.30 p.m. the baby was delivered but bleeding was not controlled inspite of methergine injections, but no attempt was made to investigate the bleeding and clotting time. Only at 4.40 p.m. the blood was sent for grouping, typing and cross-matching. By 4.45 p.m. B.P. was not recoverable. Though her condition was bad, till 5.00 p.m. relatives were not informed only then they informed the relatives that ''A'' negative blood was required. Since it was not available ''A'' positive blood was given to the patient. In spite of repeated requests by the family to consult some other doctor, it was not done, nor was the patient investigated for renal failure. No record of urine output was maintained. Ryles tube was passed and 200 ml. of coffee coloured fluid noticed and ultimately she went into shock from which she never recovered. The opposite parties filed a joint version and denied all the allegations. Their contention was that Rajani Kumari came as out-patient for the first time on 26.9.1995 and after that she never turned up for check up. She finally came on 20.11.1995 when labour pains started. All the necessary tests like urine-albumin, blood grouping typing etc. were done when she visited the first time. She had undergone caesarean operation for her previous delivery 5 years ago. On admission on 20.11.1995 she was given routine treatment with antibiotics, 5% dextrose with 2.5 units of syntocynon with 20 drops per minute which is half the usual dose. Opposite parties 2 and 3 were constantly monitoring the pulse rate, B.P., foetal heart rate and progress of labour. A healthy baby was born at 3.30 p.m. by normal delivery. Presence of mild meconium stained liquor was not a very serious thing and it would never affect the mother in any case. Placenta expelled automatically within 10 minutes after delivery and methergine injection was given at 3.15 p.m. Suddenly profuse bleeding started and even another dose of methergine followed by Prostadin injection at 4.00 p.m. could not control it. By 4.30 p.m. the patient went into shock, the pulse became thready and B.P. fell. At that stage all required drugs were given and measures taken to control the bleeding and a second time, blood grouping was done as a measure of abundant care. As ''A'' negative blood was not available and seeing that the condition of the patient was deteriorating one bottle of ''A'' positive blood from her maternal uncle was given which shows the care taken by the doctors. Subsequently 6 units of ''A'' negative blood was also transfused. Inspite of all this, the patient could not be revived. The complainants complained huge amounts which is not justified since there was no negligence and also because complainant No. 1 has married a second time.

The District Forum on a consideration of the material and evidence on record came to the conclusion that there was no deficiency in service since the opposite parties acted in the manner generally acceptable to medical profession and thus dismissed the complaint. Hence the appeal.

WE have carefully gone through the material filed in the appeal as well as before the District Forum. There is no dispute that late Rajani Kumari had her first delivery by caesarean section in another hospital and that she consulted the third respondent for the first time on 26.9.1995 and showed her first delivery records. There is also no dispute that she was admitted in the first respondent hospital on 20.11.1995 with labour pains and delivered her second baby by 3.30 p.m. and the baby was healthy. Basically there is no dispute that syntocinon at the early stage and methergine after the delivery were given and that there was profuse bleeding after the delivery. When the blood grouping was tested and it was found to be ''A'' negative and when ''A'' negative blood was not available 2 units of ''A'' positive blood was given to the patient followed by 6 units of ''A'' negative blood along with Dopamine drip etc. to revive her condition and in spite of that the patient did not recover. The dispute is basically on three grounds, (1) while the appellants allege that the patient had been under the treatment of respondent No. 3 from 26.9.1995 till 20.11.1995 according to the respondents, she never visited them in between. Secondly that urine, blood and other necessary tests were not conducted by the respondents prior to the delivery and that they were not ready for performing caesarean section if the need arose. Thirdly over-dose of Syntocinon was given and when ''A'' negative blood was not available, ''A'' positive blood was given which resulted in the death of the patient.

WE have carefully gone through the records and find that Smt. Rajani Kumari had consulted respondent No. 3/opposite party No. 3 on 21.10.1995 after 26.9.1995 and before delivery, as per Ex. A6, hence the contention of the respondents/opposite parties that the patient did not visit her after 26.9.1995 is not true. Moreover, in the prescription dated 21.10.1995 while particulars like weight 52 kgs. LCB 5 years etc. are mentioned, there is no mention of her expected date of delivery or blood group like ''A'' negative which is a vital information. If really the tests were done on her first visit, this fact would have also reflected in the prescription. Moreover there are no instructions written on the prescription such as come for weekly or fortnightly check-up. Most probably they found the patient to be a normal case but since the first delivery was by caesarean section as a precaution they ought to have advised properly since chances of second delivery by caesarean section could not be ruled out. Therefore, going through Ex. A1, case sheet, we find the blood was drawn and sent for grouping, typing and cross-matching only at 4.45 p.m. after the baby was delivered at 3.30 p.m. and the bleeding did not stop in spite of cleaning the vagina after expelling the placenta. By that time it was already too late and when ''A'' negative blood which is very rare was not available, therefore, as per the case sheet, two bottles of ''A'' positive blood was given at 7.30 p.m. ultimately at 10.30 p.m. ''A'' negative blood was started followed by 6 units, one at 11.00 p.m. and another at 11.30 p.m. According to the respondents this shows that they took utmost care and showed diligence in giving ''A'' positive blood from a close relative of the deceased when ''A'' negative blood was not available and this argument was accepted by the District Forum. However, we do not find any literature or medical opinion supporting transfusion of ''A'' positive blood when ''A'' negative blood is not available. WE find that the respondents did not take precaution even when the patient was admittedly at 12.00 noon to keep and procure the necessary blood after grouping, typing and cross-matching. As per D.C. Dutta, Text Book of Obstetrics, Chapter 22, Special Cases under Pregnancy with Previous History of Caesarean Section under ''Effects of Pregnancy and Labour'' it is stated as follows : "Previous history of Caesarean section does not appreciably alter the course of pregnancy and labour. However, the following complications are likely to increase :(1) Abortion, (2) Premature labour; (3) Normal pregnancy ailments; (4) Operative interference and incidental morbidity; (5) Retained placenta and postpartum haemorrhage."

Therefore, if first delivery is by caesarean section at the time of second delivery the doctor has to be careful about probability of retained placenta and postpartum haemorrhage.

UNDER ''Effects on the Scar'' it is further noted that "there is increased risk of scar rupture. Whereas the lower segment scar usually ruptures during labour, that of classical or hysterotomy scar ruptures during late pregnancy and labour. The incidence of scar rupture is about 1-2% in the former and about 5-10 times more in the latter".

IN the present case as per the records due to LCS there was a lower segment scar where the chances of its rupture during labour was there. Therefore, it was imperative that respondent No. 3 should have considered the option of delivery by caesarean section as one of the alternatives in case there was emergency, which was not done. On page 334 under ''Evidence of Impending Rupture During Labour (Scar Dehiscence) under ''Prognosis'' it is stated as follows : "Previous history of classical Caesarean Section or hysterotomy makes the woman vulnerable to unpredictable rupture of the uterus. This may occur either during pregnancy or during labour and when it does, the maternal mortality is to the extent of 5% and the perinatal mortality to 75%."

Again on page 631 one of the reasons for acute renal failure are transfusion of mismatched blood. From the records, we do not find whether this aspect was kept in mind when ''A'' positive blood was given instead of ''A'' negative. There is no record of urine output or indications of renal failure. IN fact it appears that this aspect was not even checked and it is incorrect to say that if ''A'' negative blood is not available ''A'' positive blood can be given. IN the Text Book of Current Medical Diagnosis and Treatment 36th Edition by Lawrence M. Tierney, Jr. Stephen J. McPhee and Maxine A. Papadakis under Blood Transfusions, Red Blood Cell Transfusions : it is stated as follows : "Red blood Cell transfusions are given to raise the hematocrit levels in patients with anemia or to replace losses after acute bleeding episodes."

It is further stated under Compatibility Testing "Before transfusion the recipient''s and the donor''s blood are cross-matched to avoid hemolytic transfusion reactions. Although many antigen systems are present on red blood cells, only the ABO and Rh systems are specifically tested prior to all transfusions". While in emergencies ''A'' or ''B'' positive or ''O'' positive blood can be given to ''AB'' positive person. It is nowhere stated that Rh+ve blood can be given to Rh-ve person. On the other hand in emergencies O-ve blood can be given since ''O'' group is universal donor and it was second delivery. "The other important antigen routinely tested for is the D antigen of the Rh system. Approximately 15% of the population lack this antigen." Under Hemolytic Transfusion Reactions, it is further stated : "The most common antigens involved in such reactions are Duffy, Kidd, Kell and C and E loci of the Rh system". Under Symptoms and Signs it is further stated : "IN severe cases disseminated intravascular coagulation or acute renal failure from tubular necrosis can occur, or both may occur". Traces of meconium stained liquor may not be such a serious thing but that is another indication for elective caesarean section. We, therefore, do not agree with the order of the District Forum. We find that there was lack of diligence on the part of respondent Nos. 2 and 3 in not being prepared for caesarean section in case of emergency and also on the part of all the respondents for not acquiring the requisite ''A'' negative blood and keeping it ready in case of emergency since the first delivery was by caesarean section and in the second case a normal delivery was attempted, there could be haemorrhage at any stage specially postpartum haemorrhage and not keeping ''A'' negative blood ready shows lack of diligence. In Clinical Obstetrics on page 496 it is stated as follows : "Intelligent attention is required to spot the early signs of commencing rupture and in making a decision whether to terminate labour by caesarean section or allow the patient to continue in labour. The operating theatre must always be ready for emergency section, as also compatible blood for transfusion. There are many who hold the view that oxytocin drip should not be employed in patients with a caesarean section scar as the danger of the rupture of the scar is great."

Therefore, in the present case the respondents were not ready for caesarean section if necessary nor they requisitioned ''A'' negative blood. On the other hand oxytocin drip was given which might have aggravated the problem and ruptured the scar.

NOW the question that arises is what should be the compensation ? It is true that the appellant No. 1 has remarried but appellant 2 was just a 5 year old baby and appellant No. 3 lost his mother at the time of birth itself and they are deprived of the affection of their mother. The deceased was a graduate and was also an insurance agent. Therefore, we are of the view that compensation of Rs. 3,00,000/- with interest at 12% p.a. from the date of complaint till the date of payment will meet the ends of justice. The amount so awarded will be shared equally by the appellants and the shares of the minor children will be kept in fixed deposit in a Nationalised Bank till they attain the majority. In the result, the appeal is allowed with costs of Rs. 2,000/- and order of the District Forum is set aside. Time for payment six weeks. Appeal allowed.