DRC: Cas Rouge! Red Case!

02 August 2018

Lanice is a family doctor from Canada. She is currently on her fourth assignment with Médecins Sans Frontières / Doctors Without Borders (MSF), working at a maternity project in the Democratic Republic of Congo (DRC). In this blog, she shares how her team raced to save a newborn during a dramatic delivery.

“Can you examine this woman for me? Something feels strange,” one of the nurses called me over.

It was the end of a Saturday half-day and I’d been working for two months as the midwife supervisor in Mweso, Democratic Republic of Congo.

I quickly cleaned my hands as the nurse outlined her history:

“This is her 12th delivery at term, all normal vaginal births. Seven are alive, four died but not as newborns. No caesareans. Last birth was two years ago.”

I palpated the woman’s abdomen, confirming that the baby felt a normal size and position. I pulled on a sterile glove and reached in to check the opening of the cervix. The head was high, the cervix not fully open… and I felt something abnormal, my fingers stroking a slippery little circular tube, beating against my fingertips.

“Cas Rouge!” I called out.

“Procedont du cordon! Red Case! Cord Prolapse!”

The cord

When a woman has delivered many babies, the uterus remains more relaxed, more floppy. It increases the risk that the baby’s head won’t jam tight against the birth canal, allowing the umbilical cord to slip below the head. Then, as the baby descends head-first down the passage, the cord can get squished, cutting off vital oxygen and nutrients… resulting in compromise or even the death of the baby.

We took off! Out the door of the maternity suite and down the outside hallway – both of us riding in tandem, kneeling on the stretcher."

The team sprang into action while I remained in position, my hand pushing up hard against the baby’s head, relieving pressure off the umbilical cord.

Tresor, the national staff supervisor called on the radio for the surgeon, operating room, and the laboratory to quickly prepare for a caesarean section. The rest of the team pulled the gurney into position, allowing us to roll the woman onto the stretcher and into the hands and knees position, head down, which encouraged the baby to slide a little further up into the uterus and reduced pressure against the cord.

Racing to the operating room

Once the woman was kneeling on the stretcher, I maintained continuous pressure as I scrambled behind her onto the stretcher.

I had discovered the hard way that if I ran alongside a stretcher, the operating room door was too narrow to allow me to pass through the door beside it. So, I knew the only way I could keep continuous pressure against the baby’s head, preventing loss of blood flow through the umbilical cord, was to jump up onto the stretcher and kneel behind the patient.

With the side rails of the gurney locked into position, we took off! Out the door of the maternity suite and down the outside hallway, with staff and patients around me suppressing giggles at the funny “muzungu”, or white person, as we rattled along – both of us riding in tandem, kneeling on the stretcher.

I could feel the umbilical cord beating against my fingers, reassuring me that the baby was alive. But the pulse less than 110 was a warning sign…"

Once in the operating room, the patient was quickly rolled onto her side. The anaesthetic nurse inserted the spinal anaesthetic and prepped the woman for surgery, all the while I maintained pressure with my hand turning numb from pushing firmly against the baby’s head.

An MSF surgical team in DRC prepare to operate. Photo: Gwenn Dubourthoumieu

An MSF surgical team in DRC prepare to operate. Photo: Gwenn Dubourthoumieu

The circulating nurse covered my head, tied a mask on over my mouth and set a paper drape on the floor for me to kneel upon as the team finished sterilising and draping the woman’s abdomen for the incision.

I crouched beside the operating room table, enshrouded by the surgical drapes, noting that in the stillness before surgery that I could feel the umbilical cord beating against my fingers, reassuring me that the baby was alive. But the pulse less than 110 was a warning sign…

The maternity nurse was meanwhile preparing our infant warmer and bed for an emergency resuscitation, anticipating the need to assist the newborn with the first minute of breathing after the stress from the prolapsed umbilical cord.

As I huddled beneath the surgical drapes, pushing upward against the baby’s head, I felt a movement against my hand… the surgeon’s own hand brushing past my fingers as he reached down to cup the baby’s head and lift it up and out of the pelvis.

With the release of pressure, I dove out from beneath the drape as the baby was brought limp and silent to the warmer.

Breaking the silence

I and Philemon, the maternity nurse, quickly dried and stimulated the baby then placed his head in the “sniffing position” to open his airway… but the baby still wasn’t breathing.

We immediately began to breathe for the baby with a mask and ambubag – a small balloon that we use to help the newborns breathe if they arrive too stunned to take their first breath.

“No chest rise,” Philemon spoke softly in French.

I quickly adjusted the mask and opened the baby’s airway by lifting his jaw into the mask as I attempted to gently squeeze air into his lungs.

He broke the silence of the operating room with the most beautiful sound in the world… a lusty cry!"

It was only seconds that had ticked by, but aware how long the baby was taking to get a good breath of air, I was now sweating and anxious. Without an immediate chest rise, the baby boy wouldn’t make it…

“Guedel!” I called out, grasping the small tube that I needed to insert into the baby’s mouth to open his airway.

I slipped in the tube, replaced the mask and puffed gently. The baby’s chest began to rise and fall as I counted in French: “One, two breathe. One, two, breathe.”

Philemon listened with the stethoscope and indicated that the heart rate was rising. Within a minute the baby boy was making gasping efforts and, by the second minute of assisting his breathing, he broke the silence of the operating room with the most beautiful sound in the world… a lusty cry!

Lanice with the woman and her newborn baby. Photo Lanice Jones/MSF

Lanice with the woman and her newborn baby. Photo Lanice Jones/MSF

As we continued to monitor the baby and provide routine care, I looked around the operating room, noting that the ambience was light and easy now that the newborn had recovered and the mother was doing well.

“That was a sight to behold,” commented Doctor Juan Diaz, an MSF surgeon, as he began to remove the drapes. His eyes crinkling, laughter bubbling from beneath his surgical mask.

“I heard the call for surgery and ran into the room… smack into the butt of a midwife kneeling on the gurney!”

I giggled along with the team, thinking to myself: “Note to self. Next time build a wider operating room door!”

 

 

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