It’s wound day today... Another reason that the decision to perform a caesarean is difficult in these environments.
I think mainly about the risk of uterine rupture in a future pregnancy, and the high risk of mortality associated with this, when deciding on a caesarean. However, the morbidity from wound infections is extraordinary.
This was a common finding in my last MSF project in Sierra Leone, also.
It’s not so much that people are doing anything wrong. Operating theatres are sterile, especially here in Jahun. The team is very strict with that and they are definitely not shy in telling me what to do. If I do anything vaguely out of protocol, I get questioned. (This is great and shows the confidence the team has in theatre. It shows they are in charge of their domain, and as an international staff member, I am visiting their unit. This makes me very happy.)
When the infection takes, it is terrible. It’s like nothing you ever see back in the UK."
The problem is that patients will have often been in labour for a long time before they reach us, so damaged tissue inside the womb may have become necrotic (died off) and infected. This makes wound hygiene difficult.
So, despite antibiotics and as good wound hygiene as possible, the fact that we have operated and made a communication between the patient’s skin, sterile abdominal contents and necrotic infected tissue within their womb, means that infection is there. And, when it takes, it is terrible.
It’s like nothing you ever see back in the UK.
"Awaiting the next pregnancy"
So, today is wound day and I have taken a 17-year-old to theatre to clean out and pack her wound which is open into her abdomen.
My fingers can touch her womb when I uncover the wound. It is still infected, so she’ll need more antibiotics and then we will repeat this tomorrow and the day after that until it’s clean enough for us to close it again. (The procedure will fail if the tissue is still infected, and then she will be back to square one.)
This young girl has no baby with her to at least make this whole saga less horrendous.
I keep my fingers crossed for the next day or two, hoping that this can be the end of this story for this woman."
So, she is with us in hospital, surrounded by new mothers and other recently pregnant women whose babies have also died, waiting for what will end up being weeks for her wound to be cleaned and re-closed.
Then she will go home, back to her village, with no baby and dense scar tissue around her womb, awaiting her next pregnancy.
Ready to celebrate
I have reviewed another wound that is also infected, but this one is only a few centimetres wide.
So this patient we will leave on the ward with antibiotics and dressings, see if we can get her wound cleaner before taking another look to see if we need to operate or if it will close by secondary intention (that is, from the bottom upwards).
We will give her nutritional support. She is so tiny. Here, in Jahun, there is a 60 percent malnutrition rate, so we need to think about food supplements, vitamins and iron to help patients' wounds heal.
And now I am waiting to close another wound. On the radio, in the background, Stormzy is being “blinded by grace” while we wait for the patient.
This patient's wound is clean now. It’s not a big surgery, but it’s super important to do it well, clean it well, debride it down to find fresh tissue to approximate (bring together), close the layers, and then skin. Then, finally, I keep my fingers crossed for the next day or two, hoping that this can be the end of this story for this woman.
Now, 25 days after giving birth, she at least has her baby who is waiting for her on the post-natal ward – ready to go home, to be greeted and celebrated by an expectant village.