Fieldset
48 hours on the frontline of maternity care

At a maternity project in the Democratic Republic of Congo, it’s non-stop emergency medicine for Lanice, a Canadian doctor on her fourth assignment with Médecins Sans Frontières / Doctors Without Borders (MSF). She blogs about life, death and learning on the frontline of medical care.

“Maternité Cas Rouge!” the radio crackled.

The door swung open with two men struggling with a rough bamboo stretcher carrying an obviously pregnant woman. The team helped the men to lift her onto the bed while asking a few questions in Swahili.

“She is from Kitchanga and she has been convulsing all night,” Este informed me as the patient was lifted onto a delivery bed.

After five months in the department, working on emergency preparation and training, it was a pleasure to watch the team spring into action.

As a hands-on doctor, it is hard for me to step back and let the local staff take over, but after five months in the department, working on emergency preparation and training, it was a pleasure to watch the team spring into action – taking the woman’s temperature, blood pressure, malaria test, glucose, and doing a quick but thorough exam.

A dreadful condition

The woman had no fever, her blood pressure was very high and her reflexes were overactive. She had a normal glucose level and malaria test, but protein in her urine. Her convulsions were a symptom of a pregnancy condition called eclampsia. If untreated, it could be fatal.

The treatment is to administer magnesium sulfate… but it is a tricky medication. It's life-saving, but too much can cause the woman can stop breathing. So, we had to provide the medication quickly but safely.

Unfortunately, we could not find the foetal heartbeat. A quick ultrasound confirmed, sadly, that the baby had already died from the stress of this dreadful condition.

The baby’s head was low in the birth canal. The safest way to continue with the delivery and help treat the eclampsia was to use a 'ventouse' - a little vacuum cup on the baby’s head, applying gentle traction. We had two excellent doctors assigned to our maternity department that day, Doctor Alain and Doctor Desiré, and they prepared the team to help with a ventouse vacuum delivery.

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Doctor Alain and Doctor Désiré reviewing the ventouse
Doctor Alain and Doctor Désiré reviewing the ventouse

“Lift her knees toward her chest to open the pelvis,” Doctor Desiré instructed the team, while Doctor Alain worked the hand pump on the ventouse to achieve the required pressure. Three contractions later, Doctor Desiré lifted out the limp and flaccid baby, to a quiet delivery room. It is always sad when delivering a lifeless baby.

Thirty minutes later, we were still waiting for the woman's placenta to detach itself from the wall of her uterus, indicating a retained placenta.

There is a little trick that can sometimes work to help detach a placenta, and I elected to try it to avoid taking her to the operating theatre. I handed Doctor Desiré a small infant feeding catheter, which he threaded through the umbilical vein towards the placenta. Meanwhile, I soaked four tablets of a medication called misoprostol in a sterile container, then sucked up the solution to have Doctor Desiré inject it down the catheter.

"Doctor Desiré" I stated, “this is what we call a "Full Meal Deal". Eclampsia, ventouse and now a retained placenta!" Only, in my fractured French, it didn’t come out that smoothly, but everyone got the picture.

Fortunately, after a 25-minute wait, the misoprostol kicked in and the placenta released itself safely and easily with no stress to the woman. She remained in our department under close observation to ensure she had no further seizures.

Renewing skills

Towards the evening, my radio burst into life with rapid-fire French: “Lanice, are you near Doctor Emmanuel?”

Marion, our Canadian nurse sounded worried, asking for our clinical team leader. 

“Yes, he's right here, just finishing a meeting,” I replied, in my slowly-improving French. “Why?”

“I think we have a case of rabies. Can he come?”

“We’ll both come!”

I was working as the international midwife in this project, but as a qualified doctor, I also took every opportunity to maintain my skills in tropical medicine.

Suddenly, the boy arched into a spasm, his body ridged, strangling out a cry.

The day was waning, long shadows stretched across the dirt road as we hurried toward the emergency department. The shadows were occasionally brightened by women in colourful African wraps, loads on their heads, babies on their backs as they made their way home.

Marion was waiting for us outside the emergency room, her brows furrowed.

“A dog bit him on the face six weeks ago and now he is in a terrible state,” she rattled the patient’s history off in French.

Behind the curtains, a young boy lay on the emergency stretcher, his father towering over him, holding his hands. Spittle drained from the boy’s mouth, his eyes wide. Suddenly, the boy arched into a spasm, his body rigid, strangling out a cry.

I had studied rabies in my tropical medicine course and knew that in a late presentation like this we could only offer supportive care to ease his symptoms. The fury of his symptoms was shattering. The slightest disturbance or even the effort to sip water launched him into horrendous spasms.

The French word for rabies is "rage": a fitting word for this horrifying disease.

Emmanuel discussed palliative care with the admitting doctor and we turned toward home, quiet in the fading light of day.

Delivery in the road

Alone in my room, preparing for bed, the radio crackled once more: “Lanice, Sage-femme!”

The voice of Patrick, our Canadian project coordinator, sounded high and fast.

“Delivery on the road!”

“On my way,” I replied, slapping my radio onto my belt as I grabbed my emergency kit and a towel.

“A delivery?” Marion, hearing the call, asked as she poked her head out from her room beside mine.

“Come!” I replied, as we both raced out into the drizzle of the rain.

Marion was the first through the gate and crouched beside a woman on the road right outside of our compound door. I tossed her a pair of gloves while I jammed my hands into my own pair. We began working in the dark with a friend of the woman shining a small phone light onto the area, just in time to see a newborn emerge onto a pile of rags the women had thrown down.

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Lanice and Canadian nurse Marion Blond with the woman and newborn baby they helped on the roadside
Lanice and Canadian nurse Marion Blond with the woman and newborn baby they helped on the roadside

“Quick, wrap him in this,” I explained, while Marion lifted the baby and I unfolded my towel to shelter the newborn.

I then reached up to grasp the placenta and ease it out of the woman. Marion dried and stimulated the newborn while I tried to massage the woman’s uterus, no easy feat as she crouched on her heels beside me.

I radioed for a car to pick us up and within minutes we were on our way to the maternity unit with a healthy mother and baby for further assessment and care.

“Wow, what a day,” I reminisced to Marion.

"Full-blown eclampsia, ventouse, retained placenta, rabies and a delivery outside our gate. We’re going to sleep well tonight!”

Obstetrics has a rhythm of its own

After such a wild day, I was hoping for a quieter time of it, so I could get caught up on our month-end reporting. Obstetrics, however, has a rhythm of its own, not to be denied.

I arrived in the department and was asked by the nurse in charge to do an ultrasound on a pregnant woman as the staff couldn’t find a foetal heartbeat and the Congolese doctors were busy.

I have learned to deliver breech babies and twins, something that a family doctor in Canada would usually only do in an emergency if an obstetrician is not available.

I prepared the woman for the exam and slid the probe over the lower abdomen. The head was low, in the right position, but the little foetal chest was still, no movement, no pulsation from a beating heart. This baby had, sadly, also died in utero.

I did the dating measurements, confirmed that the foetus was at about 26 weeks, and with the help of our Swahili-speaking maternity staff, explained what we needed to do to promote labour.

I was just finishing writing up the woman’s admission history and exam, thinking that I could sneak away to do some paperwork, when Doctor Alain stepped out from behind the heavy curtains of our delivery suite, announcing “Breech!”

Sharing skills and knowledge is one of the greatest pleasures of working with MSF.  I have worked with the team to help them prepare ahead of time for emergencies and to use oxytocin to ease labour to decrease our caesarean section rate. Meanwhile, Rehma, our excellent nursing supervisor, Doctor Alain and Doctor Desiré have all stood beside me as I have learned to deliver breech babies and twins, something that a family doctor in Canada would usually only do in an emergency if an obstetrician is not available.

This woman, in particular, was delivering her fifth pregnancy and the infant was coming down the birth canal bottom first with its legs tucked up out of the way. As the baby was not big, and it was anticipated to be a safe delivery, I was given the chance to deliver.

I tugged on the heavy plastic apron and sterile gloves while the team prepared the resuscitation table to aid the newborn. A quick check of the foetal heartbeat revealed that the heart was now racing at a high speed, an indication of trouble.

The breech was presenting quickly and within a minute the little buttocks were through the birth canal to the level of the baby’s shoulders. I tried to find the posterior arm and effect the “Bickenbach manoeuvre” – a technique used to deliver breech births – but couldn’t extract the arm, one of my ongoing struggles with a breech delivery. So, I quickly shifted to extract the upper arm using the alternative “Loveset manoeuvre”. I rotated the baby, delivered the second arm and in one fluid movement, flexed the head and somersaulted the infant up and out onto the mother’s abdomen.

Breech babies are often a bit slow to breathe, so we worked simultaneously to clamp and then cut the cord as Doctor Alain raced the infant to the warmer bed.

I, meanwhile, was stunned to find the placenta barrelling out of the birth canal literally right on the heels of the infant. The placenta had detached before the infant was born, creating a risk of foetal distress and shock. I massaged the uterus, confirming that it was firm and well-contracted, and the nurse continued with routine care of the woman.

 I then stepped over to the warming table where Doctor Alain was using the ambu bag to puff air into the newborn’s lungs.

“Come on, Baby!” he encouraged, his fractured English competing with my broken French. A cry from beneath the mask signalled a happy evolution and we continued our care until the baby was stable.

48 hours on the frontline

A half-hour later, sitting down at lunch, our project coordinator paged me again – there was a transfer of three patients being sent in from our outreach team and one of the women was bleeding from a spontaneous miscarriage.

I grabbed my bag and jumped into the jeep to meet the woman and two other patients. Before my arrival, we had had three mothers-to-be die this year – from complications and early pregnancy loss – so I felt compelled to go and meet the patient transfer and do everything possible to avoid another maternal death.

Fortunately, the woman was stable but needed additional care. There was also a little boy laying on a mattress on the floor, in a coma from cerebral malaria, as well as another woman, younger than myself but worn by a difficult life, being transferred for further care from our HIV team.

I radioed ahead to prepare our emergency team for the little boy in coma, and they were standing at the ready when we drove up. Our HIV team leader was also there to greet his patient and I took the pregnant woman and her husband to our maternity ward for further care.

By this time the afternoon had raced past, and our team of international staff was gathering for our weekly meeting.

I sank into a comfortable chair, my back warmed by the rays of setting sun, and nibbled on a handful of popcorn as I reviewed the past two days:

Eclampsia, vacuum delivery, retained placenta, rabies, precipitous delivery on the road, foetal demise, breech delivery, post-abortion complications, coma from malaria, HIV… Just another 48 hours on the front line, and l loved every minute of the work!

As I write this, I’m coming to the very end of my assignment with MSF. Soon I’ll be happy to be back home, visiting with family and friends, and dreaming of my next assignment… Doctor? Midwife? Time will tell!

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