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Medical fraternity divided over alleged unethical sterilizations at Kurunegala
Medical circles are abuzz with numerous stories doing the rounds of surreptitious and unethical sterilizations of mothers during Caesarean-sections (C-sections).
While some Consultant Obstetricians & Gynaecologists (commonly called VOGs) said that such sterilizations could be performed by a skilled doctor, there was an outcry from others – both seniors and juniors – in this field that such action would not be possible without “someone” in the operating theatre (OT) noticing what was happening.
In the eye of the storm is tubal ligation (Ligation & Resection of the Tubes – LRT). This is a surgical procedure for sterilization in which a woman’s fallopian tubes are ‘ligated’ (tied up) and ‘resected’ (cut).
Usually, ‘fertilization’ – which later results in the birth of a baby – occurs when sperm from a male partner travelling through the female partner’s vagina, cervix and womb (uterus), meets in a fallopian tube, the female partner’s egg (ovum) released from an ovary. A woman has two ovaries and two fallopian tubes. The fallopian tubes are linked to the top corners of the triangular womb.
“It would be a near-impossibility for the others on the team not to notice, question and report the matter to their superiors,” was the view of a number of VOGs, who declined to be named for fear of a massive mud-slinging campaign on social media.
They voiced serious concern that the efficient state hospital system was having its very foundations shaken by such allegations which they said seemed “totally fabricated and baseless”.
This was while others said that though LRT may take some time and it is unlikely that ligation may have been done, the fallopian tubes could be held or clamped during a C-section.
“What is suspected is that the fallopian tubes may have been clamped and held for some time. This damage may prevent future conception,” a VOG said, referring to reports that when one nurse had asked the Kurunegala Hospital doctor in question during a procedure, why clamps were used, the alleged answer had been that the clamping was to control bleeding.
All those that the Sunday Times spoke to, however, were adamant that an impartial, prompt and thorough investigation, based on “evidence” and “science” is a “must” to distinguish fact from fiction.
The Council of the Sri Lanka College of Obstetricians and Gynaecologists (SLCOG), it is learnt, is due to meet today (June 2) to discuss this issue with regard to the Kurunegala doctor. The SLCOG has offered technical expertise to the Health Ministry.
When contacted, the President of the Sri Lanka Medical Council (SLMC), Prof. Harendra de Silva said that if the Health Ministry after investigation of the conduct of this doctor finds him guilty and informs the SLMC, it will follow procedure. It will study the ministry file, seek evidence from people if necessary under a preliminary inquiry held by the Preliminary Procedure Committee (PPC) and submit its findings to the SLMC’s Professional Conduct Committee (PCC).
“The PCC would then hold a formal inquiry, at the conclusion of which if the doctor is deemed guilty, a decision would be taken to erase his name off the register for a variable period of time,” said Prof. de Silva.
The Kurunegala doctor, Senior House Officer (SHO) Seigu Siyabdeen Mohammed Shafi (42) who had also worked at the Dambulla Hospital, has been taken into custody by the police for allegedly acquiring a large number of assets through suspicious means.
The Kurunegala Hospital Director, Dr. A.M.S. Weerabandara, told the Sunday Times last week that an inquiry was being held by the hospital whether there had been misconduct on the part of a Medical Officer when performing C-sections. He said they were due to submit a report to the Health Ministry.
This was while Kurunegala Hospital staff unions refused to give any information to a Health Ministry team appointed to investigate the issue.
Meanwhile, one VOG was very specific about the complaints generating from some of the mothers who had undergone C-sections at the hands of the Kurunegala doctor.
Taking up the complaints, this VOG told the Sunday Times that what needs to be investigated is whether these women were ‘sub-fertile’ after the Kurunegala doctor performed C-sections on them.
Referring to sub-fertility, this VOG said that usually after the first child (whether such childbirth has been a normal delivery or through C-section), a woman may have problems conceiving again. “This is called ‘secondary sub-fertility’ and could vary from 10-15% among such women,” the VOG said, pointing out that a woman is deemed sub-fertile if she has had ‘unprotected coitus’ (not using any method of contraception) for one year, while also not breastfeeding.
“The Kurunegala doctor had reported for duty in his latest stint at the Kurunegala Provincial General Hospital on February 26, 2017 and, therefore, in mothers who delivered after that it is too early to say whether they are sub-fertile or not because they may still be breastfeeding their babies,” the VOG said.
The VOG suggested that the Kurunegala Hospital authorities should only entertain complaints from “really sub-fertile women” and not those with non-specific complaints. Of the 300-odd complaints, 90% are not related to sub-fertility. Those are all non-significant complaints such as back-ache, impaired vision, abdominal pain and leg oedema (swelling).
“If sub-fertility is established, then follow-up investigations should be carried out whether it is due to a cause on the part of her male partner or herself. If it is a problem with the woman, it needs to be checked whether it is due to an ovulation problem; an infection in the pelvis which can damage her fallopian tubes; or whether damage to the tubes has been caused intentionally,” said the VOG.
Taking up other allegations of the Kurunegala doctor surreptitiously crushing the fallopian tubes, the VOG was insistent that it could not be done without his assistant seeing it. During a pregnancy, a mother’s fallopian tubes are “friable” (crumbly) and such crushing could set off bleeding.
The VOG said that damage to the ureters and bladder may be caused when bleeding control is difficult during an emergency C-section and this is a known complication.
Next, the Sunday Times asked many VOGs: Who is in the OT when a mother undergoes a C-section?
The team (please see graphic) will include:
- The operating doctor [in the Kurunegala case it was a Senior House Officer (SHO)]
- An anaesthetist
- An assistant to the operating doctor who is an intern or resident house officer
- A scrub nurse
- One or two running nurses
- Two or 3 attendants
- The midwife and the Paediatric SHO would be in an adjacent room
There is, of course, the patient or the mother who would be undergoing the C-section. She would usually not be under ‘general anaesthesia’ or GA (a sleep-like state or complete unconsciousness brought on by a combination of medications and where no pain is felt).
However, she would be only under ‘spinal anaesthesia’ (where local anaesthetics and painkillers are injected into the spinal fluid) or an ‘epidural’ (where the drugs are sent into the epidural space), it is learnt.
When asked who is authorized to perform C-sections and when necessary tubal ligations, doctors said that it could be by a trained Senior House Officer (SHO) but under the supervision of the VOG (who is required to be “physically present in the hospital” and specifically “not in the quarters”). These trained SHOs would also be allowed to carry out normal deliveries including forceps and vacuum deliveries if the VOG is happy and satisfied with his/her performance.
The exceptions, where an SHO cannot perform procedures include C-sections after the first surgery (second C-section onwards), any instances when the baby’s condition is not normal, the baby’s position is not normal, the mother has complications in the form of high blood pressure or heart disease, where the mother has womb abnormalities or placental abnormalities etc. The VOG performs all difficult and high-risk surgeries.
These conditions apply to all state hospitals. The Kurunegala Hospital is a Provincial General Hospital.
The bottom-to-top order is – intern house officer (with provisional SLMC registration); post-intern Resident House Officer; Senior House Officer (with full SLMC registration); and Consultants/Specialists.
In Teaching Hospitals, meanwhile, there is the intermediate cadre of Registrars and Senior Registrars who are known as post-graduate trainees on the pathway to specializing in a particular field of medicine.
A skilled SHO could do many C-sections because the VOG simply cannot attend to all, considering the large number of deliveries in state hospitals and also due to the fact that there is no intermediate cadre to perform this work, except in a Teaching Hospital, many doctors told the Sunday Times.
A senior VOG, of the old school, explained that due to the large number of C-sections done, especially in the night, a VOG may allow a trained and trusted SHO to perform C-sections unsupervised.
Referring to the role of the SHO in Obs & Gyn, other doctors said that usually he/she has anything between 5-10 years of experience and is well-trained.
| Tubal ligation & consent | |
| When a woman’s fallopian tubes are ligated (tied up) and resected (cut), it prevents an egg fusing with the sperm of her male partner. It is only if there is fusion that an embryo is formed, gradually growing into a foetus and finally a baby. Tubal ligation can be performed during a C-section or as an elective procedure (in non-pregnant women). It is a permanent method of sterilization and birth control. Under this procedure, one tube is made into a loop and clamped and then the top part of the loop is snipped off and stitched. The same is done to the other tube after that. How is tubal ligation Explaining that the two fallopian tubes from the right and left ovaries are attached to the top-corners of the triangular-shaped womb, many doctors say that to perform a ligation the tubes have to be taken up. Each tube is then looped and clamped with an arterial forcep while another forcep is placed under, before a stitch is put in and the top part of the loop is cut-off. This takes a few minutes, explain the doctors, adding that whenever the doctor carrying out the procedure needs the forceps or a scissor it is the scrub nurse who hands it to him/her. The scrub nurse keeps a strict count of what instruments are being used, they add. How consent is obtained for tubal ligation? Both the patient and her husband have to sign the document giving their consent for tubal ligation, after having an extensive discussion with the House Officer and the Midwife. Usually tubal ligation is advised when:
Even if a couple has signed for tubal ligation, once the C-section has been done, usually the mother would once again be asked aloud in the OT whether she consents to it – getting verbal consent. If the doctor sees an issue with the newborn, such as the baby not crying after delivery, having a congenital problem, he/she would make an on-the-spot decision to delay tubal ligation for a while, informing the mother that it would done at a later date.
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| What is a C-section? | |
| A Caesarean section – also known as a C-section or Caesarean delivery – is when a baby is delivered through surgery. This is often necessitated when a vaginal (normal) delivery could put the baby or mother at risk. Explaining that a C-section entails cutting through the walls of the abdomen and the uterus (womb) to take the foetus out, doctors say that once the womb is opened up, the first action is to deliver the baby. After that the need is to deliver the placenta (a structure that has provided oxygen and nutrients to the growing baby, while removing waste products from the baby’s blood. It is attached to the womb wall and the baby’s umbilical cord arises from it.) “We have to clean the inside of the womb with a towel to ensure that parts of the placenta and membrane are not retained in the womb when we close up,” a doctor says, going onto explain that thereafter a special tool called the green armytage hemostatic forceps is used to hold together the ends of the cut lips of the womb. It’s a very “bloody” working field, it is learnt. Then the doctor would place one stitch at the end of the womb’s open area to anchor down that area and start stitching from the other end of the open area. Once one layer is secured, another set of sutures would be put in place. The operating doctor is also expected to inspect both ovaries and both fallopian tubes on either side, before the abdomen is finally closed. Thereafter, the abdominal wall would be stitched together with three layers of stitches.
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