Oxytocin is a medicine that can be used to induce labour before a delivery and to contract the uterus for preventing blood loss after it. Yet, gynaecologists say, had the oxytocin not worked, the doctors would have noticed the continued bleeding immediately, and used other methods to prevent further blood loss. “And, it is not that oxytocin is always needed, many deliveries happen without it. Human physiology is such that the uterus contracts even on its own,” says Dr Maruti Sinha, former head of gynaecology at one of Delhi’s biggest maternity hospitals, Kasturba Hospital. “Assuming the drugs were spurious and the doctors would have noticed and managed them, there could have been other factors at play too,” she adds.
Hypertension and preeclampsia can trigger organ failure
Dr Nutan Agarwal, former professor at the All- India Institute of Medical Sciences (AIIMS), says hypertension during pregnancy (commonly known as preeclampsia) is another common cause for such organ failure. “Women need regular check-ups throughout their pregnancy to monitor whether they have high blood pressure (BP). Such pregnancies are high risk and have to be handled well. The change in their condition can be sudden — they can be normal one minute and their BP might shoot up the next. If you do not deliver on time in such a case, it can lead to heart failure and failure of other organs, such as the kidneys.” High BP during a C-section damages the kidneys by reducing blood flow and causing severe inflammation. These stressors can lead to Acute Kidney Injury (AKI) through restricted blood vessels, oxygen starvation, and heavy blood loss.
Excessive bleeding during or before surgery raises the risk
Dr Sinha says while she did not know the history of each patient, the deaths likely happened because of excessive bleeding, which can happen if C-section is not performed properly. “With the rise in the number of C-section deliveries, there has been a corresponding increase in placenta accreta — a condition where the placenta attaches too deeply to the uterine wall and does not come out easily after delivery. A skilled surgeon is needed to take the placenta out properly. Otherwise, it can lead to massive bleeding. Sometimes doctors have to perform hysterectomy (removal of uterus) even in women who have only had one child to save them from bleeding out,” she says.
Bleeding before the pregnant woman reaches a hospital can also be a big risk factor. “If they have already lost a lot of blood and there is another 500 ml to 800 ml loss during the C-section, new mothers can go into a shock.” The sudden blood loss and circulatory shock can, in turn, result in organs such as the kidney shutting down.
Sepsis, haemorrhage and delayed hospitalisation
Aside from surgical complications, the most common reasons why women might end up losing excessive blood, and end up in circulatory shock, are haemorrhage and hypertension. Women can end up with kidney damage and multi-organ failure because of sepsis (blood infection), as was seen in the cases of maternal deaths in Rajasthan as well. “Acute kidney failure is usually caused by either haemorrhage before or after the delivery, preeclampsia or hypertension during pregnancy, and sepsis. These can be managed if the patient reaches a hospital with adequate infrastructure on time. But in most cases, they arrive very late, often after bleeding for a long duration, so by the time they reach the hospital, their organs start shutting down,” says Dr Anjali Dabral, retired gynaecologist from Safdarjung hospital, Delhi’s other high volume maternity centre.
Anaemia and hygiene lapses increase infection risk
She adds that kidney failure can also happen if the woman has pre-existing chronic kidney disease. Dr Sheeba Marwah, associate professor at Safdarjung Hospital, says, “Sepsis may occur because good hygiene practices were not followed during the C-section but they are more likely because of prolonged leaking of the amniotic fluid, multiple checks during a long labour and ungloved checks. The risk also goes up when a woman is anaemic — and 80 per cent of pregnant women who come to us are. Anaemia limits the body’s ability to carry oxygen properly — and in its absence the body cannot fight off infections well.”
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Need for regular antenatal care and qualified emergency support
Dr Agarwal adds that there is a need to ensure that women receive regular antenatal check-ups, get their C-section done by qualified doctors and the hospital have a proper transfer facility in case a woman needs to be moved to a higher centre because of an emergency. “While the trend is changing, many still come to the hospital only at the time of delivery. So, we do not know whether they have any pre-existing conditions or whether they are likely to get any complications,” she says.
Dr Marwah adds that government centres like hers receive the most complicated cases and at the last moment, meaning the number of deaths is likely to be high at such centres. “While the number of maternal deaths has reduced significantly over the years, they continue to be a regular problem,” she says.
Drug under spotlight
Oxytocin is used to induce labour before a delivery and to contract the uterus for preventing blood loss after it. Many of the women who died or developed complications in Rajasthan saw excessive blood loss.
Rajasthan is one of the states with less than the average national Maternal Mortality Rate. The national average has come down to 88 per lakh live births, inching closer to the sustainable development goal of 70. Rajasthan has an MMR of 87. While states such as Maharashtra (36), Tamil Nadu (38), and Andhra Pradesh (47) have a much lower MMR, there are several states with a much higher mortality number such as Madhya Pradesh (159), Chhattisgarh (141), and Uttar Pradesh (141), according to the latest available Sample Registration Survey data.
Delivery by caesarean section has been on the rise in the country — increasing to 27.2% from 21.5% as per the recently released NFHS-6 data — going up to as high as 40.5% in urban areas.