Arm

02 March 2016

I hear the radio crackle, but it’s hard to understand. The local midwives are calling Cecile, the experienced expat midwife. She is on first call, and I am backup call. I can tell that Cecile can’t really understand what they are saying either. A few minutes later, I hear her say “I couldn’t understand you, so I came in. I am here.”

Cecile is so good, I know she has it covered. I don’t need to worry; if she needs me, she’ll call. 

A few minutes later, my phone rings. Cecile says, “There is a woman here, she has a hand in the vagina. The fetus is dead.” That’s all I need to hear. I’m on my way. I bang on the door of the anesthetist, Eileen, and tell her we need to go in. She leaps out of bed and, like The Flash, she’s waiting for the car before I can even get there.

When I arrive, I see the team gathered around the woman, who is partially sitting up. She looks exhausted. The arm of a full term fetus is dangling out of her vagina. It has been that way since yesterday—it’s hard to know exactly when, but probably since about noon. It is now around 2am.

When the arm is coming out first, this means that usually, the fetus is in transverse presentation, where the body is lying across the mother’s abdomen, instead of the head or the butt or feet coming first. In this position, there is no way to deliver the fetus vaginally—it absolutely cannot come out that way. However, it is such a shame to do a C-section for a dead fetus. We want to avoid it as much as possible, especially in this setting where C-sections are much more morbid, and it is hard for women to get obstetrical care and C-sections in future pregnancies.

Cecile and I discuss what to do. If the cervix is dilated enough, we could ask Eileen to give her something to relax the uterus so that we could reach inside and try to turn the fetus. It’s difficult, but since we don’t have to worry about the well-being of the fetus, it would be worth a try to avoid surgery.

Cecile and I both perform a vaginal exam, and come to the same conclusion. The cervix is completely clamped around the arm, maybe only 3 to 4 cms dilated. It would be impossible to push the arm up, much less reach in enough to turn this fetus. Unfortunately, we have no choice but to do a C-section. We make eye contact, and we both realize it.  This woman has had seven children before, but unfortunately this one will be the hardest.

She has already signed the consent form, but I always prefer to review the risks again with the patient, because I can’t be sure that it was actually discussed with her. The interpreter helps me.

“Tell her that the position of the fetus is very bad, and we need to do a C-section in order to remove it.”

The interpreter relays this, and the woman says something back.

“She says she already knows, and has agreed. She is very tired.”

I can imagine. She has had a fetal arm hanging out of her vagina for 14 hours now. Still, I am worried about her bleeding and I want to make sure she understands the risk. This has been drilled into me since my training years—I can’t let go of informed consent.

“Just tell her I want her to understand the risks of the surgery.”

He repeats this, and she listens with a bored/irritated look on her face. I review the risks of bleeding and infection. When I get to the risk of pain, she speaks and he says: “She says you can bring the pain. She can handle it.”

Can she ever. This woman is tough. She walked barefoot from her house to the health center, about two hours, with this arm in her vagina, in the South Sudan heat. Then she waited at the peripheral health center for an unknown number of hours, still contracting, arm still in vagina. Then we don’t know how she got from the peripheral health center to MSF—ostensibly by vehicle over terrible roads, violating curfew, still contracting, arm still in vagina.

She agrees to the C-section, and we get her to the operating theatre. It’s hard to sit her up for the spinal anesthesia with the arm there, so Eileen does it with the patient on her side, but this ends up not working, so the patient finally does tolerate sitting up, despite the arm.

The C-section goes quickly because the patient is so, so thin. When I open the uterus, I reach down and first pull the arm up out of the vagina and out of the abdominal incision. It’s fairly disgusting—I hear a crack and am pretty sure I fracture something in the process. The presenting part of the fetus—lowest in the pelvis - is the right shoulder. The head of the fetus is pressed toward the patient’s left pelvis. It’s a very difficult presentation to deliver, even by C-section.

With the arm out, it’s hard to get anything else out of the incision. I try to manipulate the head to get it out. It feels humongous, and doesn’t move very easily. I have my surgical assistant push the uterine fundus, but it doesn’t help much. I try to put the arm back in to get the head instead, but I can’t get it back in. I try to feel for the other arm to see if I can move the fetal position, but I can’t. I struggle for what feels like ages.  I am lucky that I don’t have to worry about the fetus.  Finally, somehow, I am able to bring the head out.

I can see immediately that the face of the fetus looks like it had Down Syndrome. I recall that the rupture of membranes and malpresentation (like a transverse lie) can occur more often with Down Syndrome. We clamp the cord and pass the fetus off to the staff. I close the uterus and finish the C-section as quickly as possible. I close her incision with subcuticular sutures and try to make it as beautiful as possible so that she has almost no scar. I don’t want her to have any reminder of this experience.

After the C-section, we bring her to the ward. Her husband and other family members are there, looking very worried. I reassure them that the surgery went well and that she is fine. We discuss briefly that she will be able to have more children(!), and that she would be able to deliver vaginally. I recommend that she wait two years before becoming pregnant again so that she can heal.

I want to discuss family planning with the husband, because the wife often needs (or wants) the husband’s permission. I am worried that he won’t be here the next day when I come back. But it is also 4:30am and I don’t really want to get into a long discussion about contraceptive options right now. The husband seems to have a hundred questions (which is sweet, it indicates concern), and I answer some of them and then confirm with the interpreter that he will be around the next day. I promise to come back and discuss further with him in the morning.

Postoperatively, the patient does well. She has very little pain, and her incision looks very good. She looks very comfortable in the bed, wrapped in a fleece blanket despite the hundred plus degree weather. Her husband stays attentively at her bedside every day, always looking very concerned. She is incredibly stoic, and bears no sign of the trauma she survived.

On Postoperative Day 4, the family planning lady places a contraceptive implant in the woman’s left arm. When I go to see her, she has a Band-Aid over the insertion site. I ask her how she is feeling and she wonders if her fatigue is from the implant (it’s not). She complains of constipation, and I tell her through the interpreter that it’s normal after a C-section, and I start her on some lactulose to help her move her bowels. I tell her that I think she will be able to go home tomorrow.

She points to the contraceptive implant and asks if that is the family planning that I had referred to after the C-section. I tell her that it is. She says, satisfied, “Then I have the thing you were telling me about, and with the medicine you are giving me, I will feel better, so tomorrow I can go home.” It’s a sweet moment, and the interpreter, the patient and I all smile together.

We don’t talk about the arm that was hanging out of her, or the baby she lost. She will go on with her life and the seven children she already has. I don’t know how she processes this loss, how she thinks about it or accepts it, if she does. I don’t know if she wakes up at night remembering that she had to walk for hours with the arm of her child hanging from her, not knowing when or if she would get help, not knowing if she herself would live or die. I have done what I can, and provided some kindness, but in this case, I can tell that it is not my place to pry any further.