Once more into the breech dear friends - An emergency delivery in Nigeria

03 July 2018

Pippa is an obstetrics and gynaecology consultant from the UK. She is currently on assignment with Médecins Sans Frontières / Doctors Without Borders (MSF) in Jahun, northern Nigeria – returning after a break of five years. In this, her second blog, Pippa shares her experience of settling back in, as well as an emergency operation to save a mother's life.

We arrive at the project late in the afternoon. The rains are coming but have not quite landed which means it is hot, hot, hot (highs of 42 degrees Celsius).

I am not sure at what temperature your blood boils but I think we are almost there.

Welcome to paradise

The team here have had a busy day: two operating theatres open performing life-saving surgeries all day.

My colleague, who has been to the project before, is set to work straight away to take over from the obstetrician who has been run ragged over the last few days and needs a well-earned rest. So, she jumps up into a jeep to go to the hospital and tackle a night shift. 

I breathe a (secret) huge sigh of relief that I get to sleep tonight.

I expect my gentle introduction back into MSF obstetrics. However, once on the ward I am told there is an emergency"

I will have a tour around the hospital tomorrow and meet the hugely important team before being set to work. For now, we have a tour of the compound, some supper, meet the team here and find our rooms – complete luxury: air conditioning and WiFi. MSF and connectivity have clearly changed in the last five years!

The compound is great, while the project itself is affectionately known by everyone as “Paradise”, which is good to know and definitely a relief as I know the stresses that are in store over the next few weeks.

“You’ll be busy,” I must have heard fifty times already. A kind of medical understatement.

Back to work briefings

In the morning, my colleague comes back from the hospital. She’s a Japanese obstetrician who first came to this project two years ago for a month.

We have a chat about her night. She was busy at the hospital but did manage to get some rest, so I feel less guilty now.

The pre-delivery room at Jahun's maternity unit. Photo: Maro Verli/MSF

The pre-delivery room at Jahun's maternity unit. Photo: Maro Verli/MSF

Our conversations staccato as we get used to each other’s language. I remember this now and remind myself to curb my use of British slang and concentrate on becoming slightly more “RP” (“Received Pronunciation”, considered a standard form of English).

We have a briefing of the dos and don’ts in the compound and a security session updating us on the kidnappings, suicide bombings and robberies that have gone on, as well as the context of the project in terms of tribal, religious and cultural tensions.

Then more admin bits and it’s off to the hospital. 

The fistula centre

MSF runs a maternity hospital here along with an obstetric fistula centre.

The centre treats this rare, but terrible childbirth complication that leaves (generally) young mothers with continued incontinence of urine or faeces, following a difficult or obstructed labour. Here, their fistula injuries are repaired, which for these women, is a life-changing operation. 

We pop our head into the centre and a group of young girls stare back at me. It is makes an impression. 

A young fistula patient at a physiotherapy session in Jahun. Photo: Maro Verli/MSF

A young fistula patient at a physiotherapy session. Photo: Maro Verli/MSF

I have experience of obstetric fistula, having attended some repair camps in Uganda where it now more often an "old" condition, as patients tend to be women who have been suffering with it for years.

But here, in Jahun, it's not the same. These are all children, with underdeveloped pelvises. Young marriage is the culture here and, as our local medical team leader explains, “girls will see their first period in the house of their husband”.

As we finish for the morning, we pop our heads into theatre. My colleague there explains that they are preparing to deliver a baby from a mother who has previously had a successful fistula repair. As fistula surgery is complex, this new delivery needs to be a caesarean section to prevent damage to the repair and the fistula returning.

The woman is not yet in labour and this is not an emergency. I plan to come back this afternoon and help deliver her baby when she is ready for theatre.

An afternoon emergency

I come back for the afternoon and expect my gentle introduction back into MSF obstetrics. However, once on the ward I am told there is an emergency.

The patient is in obstructed labour.  She has had six children before. Four were delivered naturally and two were by caesarean section. They tell me she delivered the four babies at home. This tells me a lot… she would not come to hospital unless there was a problem.

The first thing I see is a dangerous sign in obstetrics: an hourglass shape on her abdomen that signals an obstruction and impending uterine rupture"

She has been in labour for two days, but we have no idea, really, how long she has been obstructed for. I am acutely aware of the pressure that must be being placed on the existing caesarean scars on her womb. She also has an infection.

Initial treatment has already been started by our doctors. They have done a great job diagnosing an obstructed labour, giving the woman fluids and potentially life-saving antibiotics, as well as preparing her for theatre.

The baby is still alive as I start to make my own assessment.

I uncover her abdomen and that’s it… she must go to theatre, now. The first thing I see is a dangerous sign in obstetrics: an hourglass shape on her abdomen that signals an obstruction and impending uterine rupture – a condition with a high mortality rate.

She needs to be delivered now. We transfer her to theatre.

The operation

The team in theatre is a well-oiled machine. They have seen everything; every condition you can imagine as international staff like me come and go.

I explain that the patient needs anaesthetic and that I will complete my assessment in theatre to make sure there is no other way we can avoid surgery… But there isn’t, and so we start the caesarean. 

She’s so thin. I remember this now, skin and then immediate sheath. No cutting through fat tissue as we have to at home. Then I reach the unexpectedly dense scar tissue on her uterus from her previous surgery.

In order to avoid damaging her bladder, I have to make my incision high on the uterus. I realise this is going to complicate the delivery, but bladder damage has a high risk of fistula formation and I am doing what I can to avoid this.

Pippa finally delivers the baby following the dangerous obstructed labour Photo: Pippa Letchworth

Pippa delivers a baby in Jahun. Photo: MSF

Careful dissection to find a space on the womb to deliver the baby and I am away from her bladder.

Next, incise the uterus. Things have to be efficient now.

The baby needs to be delivered quickly as the afterbirth will detach and the baby will not receive vital oxygen. 

The silence that is waiting for a baby to cry is always profound. Seconds can feel like hours"

The baby’s head is far down into the mother's pelvis. My small hands have no space to cup its head and gently deliver it through the incision, as we would normally. 

My mind goes through my drill now. Difficult delivery: I ask for medication to help ease the process and an assistant to push up from down below to help dis-impact the head of the baby.

The woman has been obstructed for a significant amount of time and there is still no space to cup the baby’s head, so I reach for its foot. To my relief, it’s easily accessible. Then the other foot, too.

I gently deliver the feet out of the incision and go on to deliver the baby bottom first.

It’s great. The baby comes out with a few other manoeuvres… and then silence. 

The silence that is waiting for a baby to cry is always profound. Seconds can feel like hours. It doesn’t matter what country you are in and how much resource or experience you have, everyone in the room holds their breath. They might hide it so it’s imperceptible, but we all do it.

I dry the baby quickly with a swab and check its pulse... and then he cries. The room silently exhales.

We have a healthy baby boy.  

And I am back.

I remember being an MSF obstetrician again. My first delivery in the project required me to use skills I have drilled for, taught and feel comfortable with, but have only used a limited number of times previously in my career.

Less than 24 hours after landing in the project and I am back into this role. With the nervous anticipation of the cases that lie ahead... I am back. 

 

 

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