Against the Odds

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20 August 2015

Update 24 August 2015: Sharing this post on Facebook sparked a lot of healthy discussion about what was the best treatment route in this case. Following that I've added some more details to this post which will answer some of the questions raised, especially regarding caesarean sections in this context. If you have any further questions or thoughts please leave them in the comments section at the end of this post. Thank you, Benjamin.

I had just finished a ventouse delivery – a method of assisted birth where a ventouse suction cup (ventouse) is used to help deliver the baby's head – for a 16 year old girl with one of the midwives. As she was suturing the perineum I saw a tall woman with a large full term belly walk slowly into the department with a male escort.

Something about her grabbed my attention, it may have been that she looked gaunt and exhausted, or that her belly stuck out far in front of her making the lappa she wore look like a colourful big-top tent pitched sideways on her abdomen.

Either way I was curious so went over to where she was. The midwife taking the details was making a series of disapproving noises and clicking her tongue. She looked up at me and pointed to the woman, now getting onto a couch, and said “Congo.” In case I didn’t understand she clarified “Democratic Republique.”

The patient had been sent to us from a health centre across the border (a river) in Congo. I started trying to piece the story together. This was her first pregnancy and she had apparently been in labour for four days already; the membranes had also ruptured four days earlier. Now all that was draining was thick green meconium stained fluid (where the baby has passed a motion in the womb).

She had come to us by boat, car and foot at full term and in a ridiculously prolonged labour. No wonder she looked terrible.

I went on to auto-pilot, and as I continued gathering information I started placing an intravenous cannula. I was already planning our trip to the operating theatre. I started a fast running drip and asked the midwife to get some intravenous antibiotics started.

I methodically started feeling her abdomen, the baby was head down but still quite high. The reason for its extra-large appearance seemed to be because she had a very full bladder that rested at the base like an inflatable pillow.

I had already assumed that the baby was probably dead, but as I began making the ultrasound scan I found a normal heart-rate. The baby was looking directly up to the ceiling with its head bent back, which was probably the cause of the stalled labour.

Given the distended bladder and that we would almost certainly be going for a caesarean I decided to leave a catheter in her bladder, I then examined her vaginally. The cervix was only 4cm dilated, and the feeling was strange. During labour, babies can develop a swelling of the scalp called “caput”, this can be a marker for obstructed labour.

Coming from the opening of the cervix was thick wedge of caput, it was almost impossible to feel any head at all, it completely filled to opening and extended about 2cm out. I also noticed that she had not appeared to contract at all during the whole assessment.

As I examined her I started weighing up the options; do a caesarean now or a trial of labour (and then probably a caesarean anyway). The situation was not in her favour, a first time mother, four days of labour and only 4 cm, thickest caput I ever felt with a badly positioned head. And on top of it all meconium and most likely a nasty infection in the waters too. I often think what would I do if I was back home, or what would one of my colleagues do? And the answer to that is easy… section.

To get a baby out vaginally you need three things: a pelvis that lets the baby pass, a baby that can make the journey and contractions to push it through. I thought about this as I felt around the baby’s swollen scalp. It felt like there was enough space for the baby to pass, but there were no contractions (although after four days her body may well have just been too exhausted). So I decided to go for option two. Definitely the worse option for my nerves.

Along with the midwife (who has over 20 years’ experience working in the hospital) I was incredibly skeptical about my plans to try and get this baby safely out vaginally. We got the fluid and antibiotics going and then began the oxytocin drip. As she began contracting she winced with pain; there are no epidurals here. She was completely beyond tired.

I went to grab some lunch and saw my surgeon colleague; we swapped stories from our mornings. He just looked at me deadpan, “but I don’t understand why don’t you just do a caesarean?” It was a question I was asking myself too, it would in many ways be the easiest way out for me, her and the baby.

Medicine is often not black and white but a balancing of risk and benefit whilst trying to do the best for the individual who has trusted you with their care.

During my time in CAR over 17% of women needing surgery during labour were for ruptured uterus – one of the most serious and life threatening obstetric complications – all had had a previous caesarean section. Whilst we are fortunate enough to be setup to perform emergency caesarean sections, I can not guarantee that the same would be true for this women in her future pregnancies, particularly given the wider social, economic and political context.

The birthrate is very high, there is poor access to family planning and poor infrastructure. If she has a caesarean what would be her risks of complications or death in her next 6 to 10 pregnancies, assuming the time for transfer remained the same? A situation similar to this is highly unlikely in the western setting, the circumstances though would in most cases indicate a caesarean.

Indications are their to guide us, the judgement of what is best in a specific situation requires a wider consideration. This is particularly true when there remains the alternative chance for a safe vaginal delivery in a resource poor setting. The balance is not only on the risks for this pregnancy, but for the lives that continue afterwards.

That doesn’t make these decisions (often made under stressful circumstances) easy, it also doesn’t mean we can take unnecessary risks. It means seeking out the balance for each individual that comes to us, giving them the safest delivery possible whilst also demonstrating how it can be achieved.  

I had planned that I would give the woman four hours of contractions, then examine her and if there hadn’t been much change to go for a caesarean. I told the anaesthetist to expect a call at 5pm. I sat watching her contract. We have no way to constantly monitor the baby’s heartbeat here so intermittently we “listen in” It seemed to be going OK, except that she had not made any urine since the bladder had been emptied before.

I was standing next to her feeling the strength of the contractions when she began shaking. It started as a tremble, and slowly crescendoed into a full-on rigor. Her skin went quickly from cool to burning hot and sweat began pouring down her forehead. She was septic. The antibiotics had gone in only a couple of hours before, though she had made no sign of infection till now (they were given prophylactically based on the probability of four days labour).

I got the fluid running fast and all her clothes off in a hope to cool her down, paracetamol was squeezed in through the IV line. Sepsis in labour makes me very nervous, and I decided that was it. One thing too many. I’m examining her now and then we’re bailing and going for a section.

I got her quivering legs into the right position and then examined the cervix, the baby’s head had come down much lower than before, and the cervix had opened to 6cm in less than 3 hours of contractions. The swelling on the baby’s head still took up nearly the whole space in the cervix. Shit, I thought, she’s actually making progress.

I felt the disapproving eyes of my colleagues back home and thought of them saying “just get it out.” But from where I was standing it was not clear that I should just get it out. And so I settled down and said, two more hours. Then we do the caesarean.

Slowly the fever came down and we got the exhausted woman on her feet to see if a bit of walking might help. The anaesthetist (not having heard from me) popped by to see what had happened. I explained, and then added that she would probably still need a caesarean.

Despite the change in her cervix the odds were not in her favour. He looked at me, tired from a full days’ work and asked “well can we just do it now then?” I felt bad, because he would need to come back for the caesarean later.

In the end I agreed to bring the examination forward and see if there were significant changes. The head was now really low down, but still facing up to the sky - both factors that would make a caesarean more traumatic and dangerous for the mother and baby (and probably me too). I gently ran my finger around the cervixas she contracted encouraging it to go away. She was now 9cm dilated.

It seemed the tables were turning and now a vaginal delivery was looking like a reality. I told the anaesthetist it would still be a couple of hours before we would know the end of the story, but that I would probably need him present either for the eventual caesarean or help with the baby at delivery (I expected the baby would need support breathing with all the meconium, long labour and infection; factors which were in place before her arrival to our department, and would need to be prepared for regardless of the mode of delivery).

We decided to grab some food and then return. I left instructions with the new nightshift team of midwives on what to do, and to call me if there were any problems.

Whilst we were waiting for the car to get us back to the hospital a message came on the radio from the intern, “Doctor Benjamin needed in maternity”, I tried to call back on the radio to find out what was happening but all I got was snippets of conversation.

As the car took us back a thousand thoughts were racing through my head. But one more present than all the others “why didn’t I just do a caesarean this morning!” I was convinced that either mother or baby or both were in distress, or that they had lost the baby’s heartbeat and I would be left struggling to deliver a corpse.

The car came to a stop, I ran over to maternity, the woman was exactly as I had left her… “What, what happened? What’s wrong?” The midwife looked at me with a blank expression. I went over to the woman and checked the baby still had a normal heartbeat, it did. Then I examined her;fully dilated and the head wedged deep down, still looking up. Ok, I thought, it’s time we get this baby out.

By this time the intern had also turned-up, he was just calling to remind me that the woman was in the department. We got the woman pushing, she was exhausted. I anticipated a difficult delivery, but I was now more committed than ever, the baby hadn’t waited four days for a caesarean.

In an odd mix of English, French and Sango (the local dialect) I got the whole team together and delegated the jobs. Who would help with the delivery, who would be ready to give the baby immediate support and who was extra hands. As usual I spoke out loud explaining every detail of what I was doing.

I asked the midwife to explain as clearly as possible to the patient I needed her to push hard, strong and long. She looked up, her sunken eyes tired, and replied in a voice of genuine wonder “but where can I get the energy from?”

I showed the midwife how to push the cup of the ventouse far back behind all the swelling on the scalp and in the right place for a baby looking to the sky (most babies come out looking at the floor). I muttered a little prayer to myself, she’s gotten this far now we just need to finish the job.

As the contraction built-up we all started coaching her, all languages together, “push!” I put downward traction willing the head to move, to come to the world outside. With all the swelling on the head there was a high risk the cup could slip off. Slowly, slowly it moved. Sweat dribbling down my face I repeated the need for a sustained effort. The room was alive with everyone united for the same goal.

The head slipped down and began to crown, we were on the home-run. As the head entered the world it made smooth 180 degree rotation so that the baby was now in the correct position. I took a pause, the next contraction and the baby would be born, almost five days after labour began. Slowly, I lifted the head up, gently eased the body out and slipped the single loop of cord round the baby’s neck over it’s head. Silence.

I rested the pale, floppy baby girl on her mother’s abdomen. As I clamped the cord I shouted over to the anaesthetist to get ready for resuscitation. I wrapped the baby in a cloth and gave a vigorous rub, this was met with a very welcome whimper.

The anaesthetist and intern took the baby and began helping her breathe as I inspected the woman for any injury. After such a long labour I was anticipating her to bleed (a tired uterus is a major cause of haemorrhage), we quickly got drugs into her to make the womb contract and rubbed it firmly. Amazingly it behaved and I was able to suture and clean her.

The baby girl continues to be doing very well, and the mother looks like a completely different person now she has had some sleep, full of smiles. They will both stay with us for a while to have antibiotics, and so the mother can be checked for signs of obstetric fistula after the urine catheter is removed (so far all looks good).

The following day the baby girl was doing very well, and her mother looked like a completely different person now she had had some sleep, full of proud smiles. They both stayed with us for a while so the mother could have preventative obstetric fistula treatment (a risk after several days of labour). Before she went home, we performed a “dye test” to check the bladder was intact and hadn't connected to the vagina during the prolonged labour, forming a fistula. There was no sign of obstetric fistula or any other complications.

A healthy mother has now returned home with a healthy baby, no fistula and no caesarean scar to haunt the rest of her reproductive life. I would like to think that were it possible to have a discussion with her on what outcome she most wanted for her and her baby it would have been something close to this.

Sometimes I get the impression that an obstetrician is expected to provide a caesarean section servicewhich can of course be a lifesaving intervention. Though, as I often repeat, the job is to get the safest delivery, taking into account the full picture and specific context. 

Like many of the women who arrive from long distances, the delay in seeking and reaching treatment often mean that there are complications that we can not reverse. An immediate caesarean section for this woman would not change the events of the previous four days, nor would it erase the risks that the mother and baby had already been exposed to (e.g. risk of obstetric fistula or meconium aspiration).

There is an enormously wide disparity in maternal health access and quality between sub-saharan Africa and the West. Awareness of this reality makes for a sobering sense of realism in approaching medical dilemmas which in other contexts may seem clear cut.  

Days after the event the team remains on a high, more motivated than ever to learn the assessment and techniques to help the women who come to us achieve a safe delivery and a safe future.