Responsibility

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06 August 2015

We all have responsibilities in life. I know that I often take mine for granted. Sometimes I forget exactly what they are as they just become a part of life, rather than a specific duty I’m conscious of fulfilling.

This week, I became starkly aware of the responsibility I have to the local population. After several weeks in Central African Republic (CAR) I have become more comfortable with the general state of play, but comfort zones were made to be broken.

A decision for caesarean is not to be taken lightly in a country such as CAR. Whilst the operation can be immediately life saving for a baby in distress, it can also leave the women with a scar which exposes her to potentially life threatening complications in the future.

With poor, and often delayed, access to treatment this must always be part of the decision process where it is not uncommon for women to be having over 10 pregnancies in their lifetime. Achieving the balance of maternal and fetal safety is a constant challenge. Ensuring our caesarean sections are both appropriately indicated and performed timely often feels more like an art than a science.

Take for example the teenage Pygmy girl who was having her first child last week; everyone was convinced she would need a caesarean before she even got into established labour. “Small pelvis”, “too young”, “too short”. There was an incredible scepticism around my plans to allow the labour to progress… wait & see. She went on to have a normal healthy delivery.

When I arrived at work on Friday morning I came knowing that there was a women with a previous caesarean section in early labour. It was a small baby and according to the night midwife the cervix was not yet starting to open.

The patient was resting on the ward. I was due to give a training to the team on how to perform a ventouse delivery (a suction cup used to help deliver a baby, that might otherwise require a caesarean section), but decided that I would first quickly have a look at the woman.

I went to the ward, and asked her to come over to the examination couch. It was immediately clear though that all was not right. Her brow was drenched in sweat and she needed help to walk. As we approached the couch she needed to stop to sit for a moment. That’s when I knew we had a problem. I called for help and got her onto the couch.

She looked obviously unwell, and was not contracting. As I ran my hand over her abdomen I felt the baby’s head high up just under the skin below her ribcage, during the night the midwife had found it to be presenting head first. As I asked for intravenous access, I quickly placed the ultrasound scanner on her belly, the diagnosis was clear.

The baby had been expelled from her, now ruptured, uterus and was no longer alive. A ruptured uterus is often described as an “obstetric catastrophe”, it is a nightmare situation. We quickly got her prepared and taken to the operating theatre. She was losing a huge amount of blood, and her vital signs became increasingly erratic. Finding a vein to replace the lost fluid became near impossible.

I looked to the anaesthetist; he was working fast to get her asleep and to get blood for her. I scrubbed, and explained to the team we need to go fast. A bit like Forest Gump and his box of chocolates, with a ruptured uterus you never know what you’re going to get.

Just as I made my incision the power went, but there was no time to stop. “Torch” we shouted in unison and continued by the single beam till power was resumed. I began working my way though the layers of her abdomen, which were densely scarred from the previous caesarean.

Before I could see the damage to her uterus the blood and amniotic fluid began spilling out of the small space I had managed to make between the adhesions. I gently opened it up further making sure no uninvited organs were getting in the way, but it was impossible to see anything. I reached in and delivered to baby and placenta together, they were literally floating free, but there was no time to think about the sad scene.

She was haemorrhaging.

I gently lifted the uterus up from the space I had made and began inspecting the injury. The uterus had ruptured across horizontally, probably through the previous caesarean scar, but it hadn’t stopped there. Such was the force it had continued outwards and down deep into the pelvis. As I battled with the pooling blood to see where the tear might end, a stream of expletives continually fell from my mouth (at least they were in English and not French).

With each clamp I gently pulled the edges of the tear up, but still could not find the end, debating half in my head and half out loud if I should do a hysterectomy. The anatomy was so distorted that I was not even sure that I would know exactly where to cut. I knew, that like the rupture, I too was in deep shit. I felt not only far from my comfort zone, but outside my competence too.

Yes, uterine rupture is a catastrophe.

As I was about to ask for the hysterectomy set, I thought I might have finally seen the apex of the tear. Deep down, and beyond the reach of my clamp in very thin tissue. I gently let my finger feel down behind it, finally a connection. With a fine suture I carefully fed it though and tied. Surely enough as I worked my way back up the anatomy became restored and the bleeding stopped. I repaired the uterus, double checked the bladder had been spared and that she was making urine.

Throughout the operation I had been talking to myself in English, I looked to the team and apologised. They all just laughed at me, and we congratulated ourselves for making it through a nightmare operation.

The rest of the day we watched her closely. Ensuring she was making urine, her vital signs were stabilising and that the drain I had left in her abdomen was not starting to fill with blood.

The following day, I went and saw her in her bed. She still looked awful, but was alive. I started to explain what had happened, but she had only one question; the baby.

As the realisation came to her the tears streamed down her face, crying clearly gave her physical pain too. I touched her hand and just repeated how sorry I was. She then turned and asked me to sterilise her. At 21 years old, it was far from what I had expected to hear. I will discuss long-acting contraceptives and the future with her when she is a bit stronger.

Today she is walking, talking and eating. And when she saw me, for the first time she smiled. Shaking her hand I realised it was not only she who had survived that awful operation, we all had.

I am regularly called to make a decision on a caesarean, and often have managed to get a vaginal delivery instead. There are times when it is needed and times when it is not, the challenge is getting it right. None of us have a crystal ball, no-one can read the future and we all get things wrong from time to time.

As was famously told to Spiderman “with great power comes great responsibly”. Discussions of power constructs and humanitarian assistance are a bit out of the remit of this blog, but for responsibility I feel it constantly hanging over me.