Rupture

It is evening and I am at the base, where all the expats live. I have found that 6-7pm is my Power Shower Hour, when the day is still warm enough that you feel hot and want a shower, and the water is still a little warm from the heat of the sun. I have just showered and dressed when Emilie the Hospital Manager shouts to me, “Veronica, come with us right now!”

It doesn’t occur to me that this is serious, even though while I was dressing, I distinctly heard gunshots from a semiautomatic weapon. “Come with us now!” she shouts. Oh shit, this is for real. I dash off with the group to the safe room, which is protected against gunshots and shrapnel. It is hot and dusty, and people jokingly moan about being there, but really, everyone appreciates the safety. The Logs establish everyone’s location and confirm that everyone is somewhere safe. We stay in the safe room for a little while, not particularly worried, until we are told it is safe to go out. The suspect has been apprehended. It’s not clear what happened, but we hear that someone was shot in the leg.  It turns out to be the least stressful part of my night.

I go to bed around 11pm. The generator is turned off at midnight here, and that’s when the fan goes off and the tukuls get very hot. My phone rings; it’s one of the expat midwives. She is seeing a patient and she suspects uterine rupture. I need to go in, and I need to bring Val, the anesthesiologist, and the OT (Operating Theatre) manager with me. The patient will probably need surgery. I realize my fan is still working; it is just before midnight. I know that when I get back, the power will long since be off, and my tukul will be a sauna. I will also probably be too tired to care.

When I get to the hospital, the patient is prepared for the OT, and just waiting for me to evaluate her. She is 3cm dilated – which is very early in labor – and yet her contractions have stopped. The fetal head is so high up in the pelvis that the midwife’s fingers can barely touch it – a bad sign. She has been having vaginal bleeding, and the fetus is already dead. She has a history of four previous deliveries, one of which sounded like a fetal demise – the baby had been “removed with a hook” by the traditional birth attendant (TBA).

When I examine the patient, I can feel the baby’s limbs so close to the skin. I look with the ultrasound, and I don’t see any uterus around the baby. I also see liquid blood around the baby. It is very indicative of uterine rupture.

Uterine rupture is a catastrophic complication in which the force of the contractions is too strong for the uterine muscle, and the tissue literally bursts open. It looks as if the uterus has exploded. The infant is released into the abdominal cavity, and the placenta usually is too, which means that the fetus dies within minutes. The bleeding can be so severe that the woman herself can die before reaching help, so the fact that this woman is alive at all is a positive sign. I have seen uterine rupture twice before, and in both cases, the woman was already laboring in the hospital in the US, and the c-section was initiated (“decision-to-incision time”) within 5 minutes of recognition of the rupture. In both cases, the baby and the mother lived, although I also heard about cases in which the baby died. I have never personally seen a case where a uterus ruptured and the woman then had to travel an hour or more to reach the hospital. (This woman was brought in by the International Rescue Committee (IRC) that runs an ambulance-like service in South Sudan.) It has now probably been several hours since this woman’s uterus ruptured.

We take her to the OT. She has been fully informed that we will probably have to remove her uterus, that she will probably not be able to have more children, and that this baby is already dead. She shows no emotion on her face, but to me, her eyes look wide and nervous.

Val puts her under general anesthesia, which means that she is completely asleep and intubated for the procedure. This is appropriate when the surgery is likely to be extremely complicated. I do a vertical incision on her abdomen rather than a horizontal incision. The vertical incision allows me more room to see, remove and repair what I need to. You never know what you are going to find in these situations.

Normally, I would open the layers of her abdomen and then reach the peritoneum, which is clear and thin, like saran wrap. I would open that thin layer easily, and see her huge uterus quietly waiting for me. That is not the case here. As soon as I get through the peritoneum, there is dark liquid blood, and the baby’s head is floating in her abdomen, outside the uterus. I pull out the baby – it is clearly dead, and feels huge. I remove the placenta, part of which is still in the uterus, and pull the uterus up so I can see it. There is a massive gaping hole in the lower uterine segment – the part of the uterus that normally thins out with contractions. It would be too difficult to repair, and she would be at high risk of another uterine rupture. I clearly need to remove the uterus.

This is easier said than done. A hysterectomy in a non-pregnant patient is a delicate affair. The normal uterus can be smaller than a fist, and visualized easily. But pregnancy makes the uterus humongous and swollen, and all the anatomy is distorted. Furthermore, the patient is usually bleeding profusely, making visualization difficult.
I need to stay calm, move fast, and get this done. The patient is losing blood rapidly, and won’t stop until I get her uterus out. But I also need to make sure I don’t do any lasting damage to her bladder, bowel or ureters. I look for the ureters where I expect them to be, but I can’t see anything. The area near her cervix is a mess of swollen, ragged tissue and blood. I control the bleeding with clamps, and start where I can see.

I rapidly detatch her fallopian tubes and ovaries from the uterus on both sides. She needs to keep her ovaries for normal hormonal function. (She doesn’t need the tubes, but they are quite attached to the ovaries and it’s faster not to separate them.) Once I am done with that, I can see a little bit more on the sides of her uterus. I clamp and cut her round ligaments – which hold the uterus in place.

As I am operating, her bleeding has improved significantly, but not stopped. At the site where the uterus ruptured, multiple blood vessels are still open, and I have clamped the ones I can see. Every so often, I need to wipe away collected blood. Until I get her uterus out, she won’t completely stop bleeding. Val, as the anesthetist, is in charge of keeping track of her blood loss and volume status. She occasionally peers over the curtain to see how my operative field looks.

“So, it would be nice if at some point she could stop bleeding,” Val says, hesitantly. The comment is almost funny, under the circumstances.

“Working on it!” I respond.

The most challenging thing is identification. I am used to being able to identify all the parts of the uterus and nearby structures at once, but in this case I can’t. As I go about dissecting what I can identify, I reevaluate and more becomes clear. Now I need to move her bladder away from her uterus, so that I avoid her ureters. The ureters bring urine from the kidneys to the bladder, and cutting them is catastrophic. I don’t have the ability to repair them, so I cannot make that mistake. But they are so close to the cervix, and so hard to see.

I ask Val to give indigo carmine, a blue dye that is injected into the bloodstream, processed by the kidneys and turns the urine blue. It will then turn the ureters blue, and make them easy to see. But there is no urine in her bag. Has she lost so much blood that she is not making urine? Oh shit.

We reevaluate. I realize that her bladder has become enlarged, and is not draining anything. It is pushing its way into my surgical field, which is both annoying and dangerous. However, the fact that it’s full means that she is making urine, which is a good physiological sign for her (when people lose too much blood, they stop making urine). We try to flush the catheter, hoping that it will start draining, but it doesn’t work. I decide to drain the bladder by puncturing it with a tiny needle and pulling the urine into a large syringe, but this is much too slow and she is bleeding. We are at least able to establish that her urine is, in fact, blue.

I decide to just continue with the surgery as carefully as possible, because replacing the catheter will be too difficult and time-consuming, and I need to get her uterus out. At least with her bladder distended, I can see where it is and avoid it. I push it down and block it with a retractor.

But where are her ureters? The ureters are the most dangerous part, because they are hard to identify, and are close to the cervix, especially in pregnancy when everything is swollen and enlarged. I need to identify her ureters, but I also need to get her uterus out so that she doesn’t die of hemorrhage. Eventually, I just decide to clamp and cut what I can see – removing her uterus, but leaving her cervix (and hopefully her ureters) in place. As I am clamping the fear that I am cutting her ureters gives me heart palpitations. But if I stand around for another hour searching for her ureters, she’ll bleed to death and she won’t need her ureters anyway. The enemy of good is better, I remind myself. OK, here we go. After a few clamps and cuts, her globular, mushy, exploded uterus is freed from her body and moved out of the surgical field.

I suture the cervical stump closed, and eliminate all bleeding. We pour sterile saline into the abdomen to clean out any leftover blood and to look for unidentified bleeding. I review her ovaries and tubes – they look intact and they are not bleeding. I can’t find her ureters, but with the uterus out I can see her pelvis more easily, and see that the likely location of the ureters is much deeper than where I made my cuts, and that pushing the bladder down probably moved them far away. That gives me partial relief. I’d feel better if I could actually see them. But the enemy of good is better. We close her abdomen.

In the end, she has lost 3 liters of blood. In the US, she would have received at least 4-6 units of blood in return, if not more, plus a lot of fluid. Here, she got 1 unit of blood (which was donated by her husband, who luckily was a match for her), 8 liters of fluid, and 2 liters of colloid. I am grateful for Val, who is a calm and capable anesthesiologist. Having someone so skilled keeping my patient alive makes my job as the surgeon so much easier.

We bring the patient to the recovery room, and Val sits with her while I go to clear off an ICU bed for her and speak with her family. Her husband is there, as well as three female caretakers. I shake the husband’s hand and tell him that by donating blood, he saved his wife’s life. I ask the three female caretakers to go and get tested for donation, but I receive a confusing reply. They are not close family, just caretakers, and so they don’t want to go. That seems strange to me, but the nurses have tried multiple times to talk to them during the surgery and they kept refusing. I tell the husband that he must go to the village at dawn to bring other family members to get tested for donation. His wife lost a lot of blood, and she will probably need more. We don’t have any blood in the hospital to give her.

I also explain the uterine rupture, and the hysterectomy. I tell them that she cannot have any more children. “As long as she is alive,” they say.

I go back to the recovery room and relieve Val, who goes to clean up the OT anesthesia area. The patient is very sleepy from the general anesthesia, so I just watch her vital signs. After a while, Val comes back in, and we both sit and wait for the patient to wake up. We discuss how scared we were.

“You are amazing. I can’t believe how calm you were.” I say to Val.

“Me? I was terrified. I thought you looked so calm,” she says, and we laugh at our mutual terror and our ability to hide it.

Suddenly, noiselessly, the patient is awake. Her large eyes are wide open, and staring at us.
“Well, hello!” Val says, in surprise. After trying to wake her so many times, she is finally awake.

“Arem?” I say, asking if she has pain.

The patient says something very quietly in Dinka. We call the OT assistant to come and translate. The patient repeats her sentence, but so quietly that he can’t hear her. She has to repeat it twice. Finally, she speaks louder, and he translates.

“She is saying ‘I was dying, and my children were going to be alone, but now I am alive.’”

Val and I, who hid our fear so well, look at each other with tears in our eyes.

We roll the stretcher to the ward. It is 5am, but suddenly the entire ward is awake, curious about our most recent patient. In order to move her to the bed, we need to move her family off the bed, then line the stretcher up. The stretcher is two feet higher than the bed, and, unlike back home, neither one can change height. We hoist her up, over and down using the sheet she is lying on. It’s not exactly gentle, but it works.

“What do you think her hemoglobin is?” asks Val.

It’s hard to say. She lost so much blood. We agree that she lost at least 3 liters, and a pregnant woman should only have 5-6 liters in her body. We only had one unit to transfuse her, which means that most of the blood in her body is going to be composed of fluid, not red blood cells. I look at her conjunctivae – the area inside the lower eyelid – that becomes very pale when someone is anemic. I take her heart rate – it’s elevated, but not terribly so.

“4.0,” I guess. Val rolls her eyes.

“I don’t know, I think lower,” she says. She could easily be right – my prediction is hopeful. She could easily be as low as 2.0. And if she is, what are we going to do? There’s no blood.

The nurse brings over the Hemocue machine, which checks hemoglobin level immediately. He pricks her finger, but her hands are so rough from the lifetime of hard labor that she has done (digging, planting, reaping, carrying water, pounding grain) that he can hardly get one drop out. He has to prick her three times before he finds a place that will bleed. The machine beeps with its result, and reads “4.0”

Val and I laugh and slap hands at this wonderful result. I imagine that all the onlookers in the ward have no idea what we’re happy about. It would also be hard to explain to anyone back home. By any standards, a hemoglobin of 4.0 is a life-threatening level. But when you’ve bled someone of at least 3/5 of their blood volume and you have nothing left to give them, it’s a damn miracle.

Val and I leave the hospital after 5am. We are completely wiped. Not only have we been up all night, but the intense focus required to operate on this extremely ill patient is profoundly draining.

Over the next few days, the patient does surprisingly well. She reports feeling weak, but she is able to sit up in bed and walk around remarkably quickly, and her pain seems well controlled. On her second postoperative day, she asks us if we removed her uterus. The translator and I look at each other nervously, because we have already explained to her twice that her uterus was removed, and that she will no longer be able to bear children. Is she in denial? Did she not understand it?

I re-explain the situation at length, including the uterine rupture, the hemorrhage, the need to remove her uterus, and the implications for fertility. I hope she is able to absorb this information, and I await the translation of her response.

“She understands,” the translator says. “She remembers that you told her this before, but she just wanted to confirm. She has two boys, and they are enough.”

“Tell her to focus on the two children she has, and to provide for them and make sure they get an education,” I say. Two educated sons will go far in this new country of South Sudan, which is so hungry for progress.

The patient responds.

“She will take good care of them,” the translator says, and the patient shakes my hand and smiles just the tiniest bit.

 

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Yin A Mat Po? (Are You Happy?)

The woman came to us with no living children. She had been pregnant twice before, but both pregnancies resulted in stillbirths. In the first pregnancy, she had labored for days, and the baby died during labor, but delivered vaginally. In the second pregnancy, she had pushed and pushed, but the baby did not deliver. A c-section was done, but the baby died anyway.

I cannot imagine what that must feel like. In the US, a stillbirth at term is a huge event. Privacy is paramount. A subtle sign is placed on the patient’s door so that the staff knows not to enter unnecessarily. A sympathetic nurse is chosen, one who will comfort the patient. Aggressive pain control is offered, because pain can only make grief worse. And the woman carries that loss with her for the rest of her life.

In South Sudan, it is unusual for a woman not to have lost at least one child. They die in childbirth, or they die later of malnutrition, malaria, infection, unexplained illness. I have seen women who have delivered 7 children, only to have 3 of them die, or delivered 4 children but having only 1 living child. When a woman arrives, the first question asked is “How many children have you had?” The second question is, “How many are alive?”

It may be a part of life here, but it would be hard to argue that these women suffer less. I truly cannot speak for them, nor know what they feel, whether they have different expectations or a more effective way of processing grief than we do. But in my opinion, grief is grief, and whether you acknowledge it or bury it, it is there and always will be. It is only how you process it that differs.

I have noticed that there is a lot of psychosomatic illness here. One would expect that, given how tough these women are, you wouldn’t have a lot of non-urgent medical problems; that people would only come in to the hospital for really serious things. But in only 2 weeks here, I have seen 4 or 5 cases of “hysteria” – in which women completely collapse and are unresponsive even to severe pain (rubbing the sternum, pinching, etc), and when they awake, there is always a convoluted backstory involving family drama, traumatic experiences and sadness.

Other women have “total body dolor” (a term I learned in the Bronx) – generalized body pain with no apparent source and no real description. Often, they will fully admit that they are having major emotional upheavals for one reason or another, and they will agree that the pain is probably related to the emotions. This is an astounding degree of self-awareness that I wouldn’t have expected. Often I give them Tylenol or Ibuprofen and, depending on the severity of emotions, a mild sedative, and let them rest in the hospital for a day or so for TLC (tender loving care). Everybody needs a damn break sometimes.

So I think that the deaths of their infants do affect these women in one way or another. They are extremely stoic. I have never seen a woman who lost her baby (and I have already seen many) react with tears, or even a facial expression indicating sadness. It is really mind-blowing, because I would probably be inconsolable, and loudly emotional. But there is an incredible cultural factor at work here, I guess, and emotions don’t seem to be expressed on the face.

We examine the woman with two previous losses, and decide that her pelvis is terrible and no baby will fit through it alive. She should have a c-section. Although it means that she will be having her second c-section and will now require c-sections for any future deliveries, it also means she might finally have a living child.

Intaoperatively, I am glad I decided to do the c-section. Her pelvis is tiny, like many of the women here, and I have a hard time even getting my hand in there to lift out the baby’s head. The baby cries right away; it is a girl. I clamp the cord twice, and hand it over to the waiting nurse. The baby is cleaned off, examined and wrapped in a towel. Katie, the Australian midwife, brings the baby to the mother’s face so that she can see her while we are finishing the c-section. The mother makes no expression, but tears roll down her face when she sees her healthy baby.

As the surgery ends and we take down the drapes, I try my few Dinka words on the woman.

“Yin a pwal?” I ask. (Are you OK?)

She nods once. No expression.

“Meth a pwal?” (Is the baby OK?)

She nods once. No expression.

I ask the nurse to ask her if she is happy.

“Yin a mat po?” he translates.

She answers.

“She is happy,” says the translator. She still has no expression.

I take her at her word. It is sometimes a challenge for me to have so little emotional response from patients. I realize that I am accustomed to my own culture, and even Ugandan culture, which I have more experience with – both have a lot of reflexive smiling. When you make eye contact with a person, the first instinct is to smile.

I find it harder to connect here, where people make eye contact, but not a single muscle in their face twitches, and they feel no obligation to acknowledge the connection. I try to wrap my mind around it; what does it mean? How does it evolve? The South Sudanese staff that I work with has been very warm and friendly, with smiles and handshakes. Sometimes strangers respond to eye contact with smiles, but infrequently. Smiling is clearly not a cultural expectation. But most surprising of all is a patient you have just operated on, to whom you have given a very happy, very desired outcome. They have no obligation to smile, but it is hard for me to understand how anyone could suppress a smile at a time like that. I have come to learn not to expect it, and not to worry about it, but it is fascinating.

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Sepsis

It is Tuesday, my first day on the job in Aweil. The outgoing obgyn is still here, and she is handling the hospital work today while I get my briefings from various people. Katie, the midwife who arrived with me, and I are getting a briefing with the Head of Mission: an abbreviated version of 200 years of Sudanese history. As the briefing wraps up, we get a message from the radio operator that maternity is looking for us.

When we arrive in the Operating Theatre (OT), the patient is under anesthesia, and the outgoing obgyn (whom I am replacing) is attempting to deliver her vaginally. She is 18 years old. It is a full term pregnancy, and the baby is already dead. She has been in labor for 4 days. Since it didn’t come out during labor, we can assume it will be difficult to get out now.

We try the Kiwi vacuum. I like the Kiwi for normal deliveries, because it is easy to use, and doesn’t put too much pressure on the head; if you use too much force, it just pops off. It’s like a safety check. If that happens a few times, it’s time to do a c-section. But in this case, there is no such thing as too much force; the baby is already dead. And the Kiwi keeps popping off.

Next we try to use the forceps, which are metal graspers that are placed on either side of the baby’s head to guide it down. But the head is so wedged into the pelvis, we can’t get them on at all, despite multiple attempts by both of us.

Next we try the stronger vacuum, which has a large silicone suction cup and an external manual suction mechanism. It seems to have more force than the Kiwi. We pull and pull and pull. Slow progress is made. The other obgyn pulls on the suction cup while I hold the patient’s pelvis back to stop her from falling off the table. She is using all her strength. Finally, we deliver the dead fetus.

Because the patient has been in labor so long, there is a risk that she will have tissue necrosis and form an obstetric fistula. From below, her uterus is abnormally displaced upward in her abdomen, near her umbilicus. This is probably because most of the fetus was sitting in her vagina, not in her uterus or cervix, and the lower tissue is stretched out. We examine with a speculum, and the cervix looks relatively normal, although large and floppy. She is not bleeding. We are finished.

The anesthetist comments that the patient was already septic when she came in. This means that she had already developed a uterine infection from prolonged labor that had then spread into her blood stream, and had caused physiologic changes like low blood pressure and high heart rate as a sign of overwhelming infection. The anesthetist had to give the patient dopamine to improve her blood pressure during the procedure. She is not out of the woods yet; she will need strong antibiotics, good care, and a lot of luck.

We send her to the ward, and repeatedly check on her throughout the day. She is stabilizing. She has a fever, but we are giving her antibiotics and Tylenol. She is weak, but able to talk and her family is taking good care of her.

The next day, she looks, so-so. We are treating her infection and giving her IV fluid, but most notably, her oxygen saturation is low at 91% (it should be 95% or higher). In combination with the low blood pressure and tachycardia (high heart rate), I am worried that she is decompensating. We put her on continuous supplemental oxygen. I ask for input from the anesthetist, and she gives me a vial of dopamine and a bag of normal saline, and explains how to give it. The idea is to artificially increase the patient’s blood pressure in order to maintain her organ function until her status improves. The patient’s nurse dutifully counts out the number of drops per minute, to carefully monitor the dopamine dose. Her blood pressure improves soon after starting dopamine. After lunch, we plan to reevaluate and possibly lower the dose gradually.

That afternoon, she looks worse. Her abdomen is swollen and she is complaining of abdominal pain. She is breathing fast and looks uncomfortable. Her oxygen saturation is getting worse. It is very likely that the sepsis is causing pulmonary dysfunction, called Acute Respiratory Distress Syndrome, or ARDS. Her blood pressure is OK on the dopamine, but when we lower the dose, the BP drops quickly.

The anesthetist stops by as I am examining her, and we agree that her bowels probably aren’t functioning well as a result of the infection, and she needs a nasogastric (NG) tube. This tube gets inserted in the nose, goes down the esophagus and into the stomach. It allows us to decompress the stomach and bowels from above, since they are not emptying from below. The nurse races to get an NG tube, and we insert it successfully on the second attempt. We get a little fluid back. I am concerned about her condition and want another opinion, so I call the Hospital Manager, who arrives immediately.

The Hospital Manager (HM) finds a large syringe and is able to aspirate a lot of ugly fluid out of the NG tube. This visibly decompresses her stomach, although doesn’t change her breathing, heart rate or blood pressure. At this point, the dopamine has run out and we need to decide whether to restart it. I am concerned about leaving her overnight with dopamine and no supervision of the nursing staff. The HM, the anesthetist and I discuss the dopamine. The HM points out that the use of dopamine is not sustainable; we don’t have an ICU setting and it is a powerful and dangerous drug that, although sometimes lifesaving, is probably out of our range of care options. It is fine for the acute setting, such as intraoperative resuscitation, but this patient is more than 24 hours out of surgery and we don’t have the ability to provide the intensive care necessary for dopamine. We agree that the patient needs aggressive IV fluid hydration, oxygen and monitoring.

On Wednesday evening, I am in the hospital to do another surgery, and I stop by and look at the patient. She has decompensated. She is unconscious. Her vital signs are still bad. Her oxygen saturation is 83%. For some reason, the oxygen machine has been turned off. I turn it on, and her saturation improves to 90%. There is confusion as to who turned it off and why. Her nurse is frustrated because other staff members came by and turned it off. We speak to everyone we can, and let them know that it should not be turned off.

She is not febrile, but she is now suffering the effects of sepsis. She probably has multiple organ dysfunction, but we don’t have the lab tests needed to find out. Her lungs sound wet. Her blood pressure has improved after fluid hydration, but I realize that her sepsis must have allowed the fluid in her bloodstream to seep out of her blood vessels and into the “third spaces” of the body – in her case, the lungs. I start giving furosemide, a diuretic. We also change her position to have her sit straight up so that her lungs aren’t completely drowning in fluid. After multiple doses of furosemide, she puts out a lot of urine, and her oxygen saturation improves a lot. A few hours later, her lungs are more dry, although her saturation is not perfect – she still has ARDS.

I can’t wake her up. Even after improving her oxygen saturation, giving some concentrated glucose and suctioning her NG tube, she is unconscious. It doesn’t look good. Her blood pressure is very inconsistent. It varies within minutes from very low to normal to borderline elevated. I can’t think of anything else to do. I ask the anesthetist and the HM, but they don’t have any additional suggestions. There is only so much you can do in this setting.

Throughout the next day, I check on her repeatedly, and she looks worse and worse. Her heart rate shoots up to 150s, and her breathing is extremely rapid and she gasps for air with each short breath, even though the saturation on supplemental oxygen is good.

I realize that she is probably going to die. I start preparing her family for this. I tell them, through a Dinka-speaking nurse, that we are doing everything we can, but she is probably going to die. They understand. Her father says “It is in God’s hands now.” Her mother and father both sit on her bed, each holding one of her hands, watching her carefully. They have been so dedicated throughout. When we asked them to hold on to the syringe for the NG tube, they wrapped it up carefully and hid it in the corner under a blanket so it wouldn’t get lost. They help us check her urine, or her oxygen saturation, or adjust her tubes. They are lovingly stoic.

It is only in this moment that I start to process the injustice of this. She is 18 years old. She was having her first baby. That is what is killing her.

It is hard to watch her like this. Although she is unconscious, she looks so uncomfortable. Her breathing is so effortful, so tortured. Her fever spikes again and I change her antibiotics. Now that her lungs are dry, I give a little IV fluid. I have nothing else. Every time I come to her bedside, I check her vital signs, her oxygen saturation, and then I shake my head and walk away. I don’t know what else to do. Eventually, I stop checking the vitals, and just gaze at her from the head of the bed. She is dying, and there is nothing I can do.

That night, I am in the OR late until 2am. I check on her afterward. She is still alive, still heaving. Her family doesn’t even seem to sleep. They sit on her bed, holding her hand and watching her die painfully.

The next morning, I am told that she died at 4am. She and her family were gone from the ward by morning.

In South Sudan, women have a lot of children, and little access to care. Women mostly deliver at home, and when things go sour, they are very far from the nearest health center. A recent survey of a remote area nearby revealed that the nearest health center to that population was six hours away. So, when the baby doesn’t come out, the women just wait and suffer. They wait for days, because to get up and find help would be excruciating, and probably would not be very helpful anyway. That’s how four days go by, and a baby dies inside a vagina. By the time they reach someone that can actually help them, they are so sick that sometimes they are beyond help. We try anyway, and often, miraculously, they make it. Those are the ones that would die if we were not here. Then there are the ones that still die, too many of them, who would not have died if they had given birth in the countries that we come from.

Posted in Doctor, obstetrics, South Sudan | Tagged , , , | 30 Comments

Head Entrapment

Katie, the Australian midwife, wakes me up at 4:30 am.

“There is a mum with 5 previous births. She’s a breech, and they’ve called me saying she’s been pushing for an hour and hasn’t delivered.”

I am woozy. I sit up, and think. I’ve done several breech (butt or feet first) deliveries at home, even though they are unusual. But I learned the most about breech delivery from the midwives that I worked with in Uganda, who do them all the time. The most important thing in a breech delivery is patience. They take much longer to descend and delivery than cephalic (head first) infant. So maybe this one is just slow to descend. A woman with 5 previous deliveries is a good candidate for a breech delivery. She obviously has an adequate pelvis, and has experience pushing. But the midwives here are less experienced, so I know that we should go in and assess, at the very least to support them.

Katie and I get ready within a couple of minutes and shuffle out to the front of the base compound, where we wake the driver and get a ride to the hospital. We have just gotten out of the MSF car and are entering the hospital when the radio crackles. It’s hard to understand, but it sounds like “The head has come, but it has not delivered.”

The head has come? That doesn’t make sense. In a breech delivery, it’s the body that should come first. I assume that they probably got the presentation wrong, and it was cephalic all along, but now it’s a shoulder dystocia. Shoulder dystocia is very dangerous, because the head is out, but the body is not, and the cord is usually squashed alongside the body. The infant can die quickly, or be injured in the process of pulling it out. We sprint to the Maternity Ward.

When we reach the ward, we find the patient sprawled on a delivery bed, and the body of the infant hanging out of her vagina, face down. The head is still inside. The South Sudanese midwife is trying to remove the head. It’s even worse than I thought.

Head entrapment is one of the scariest things we can encounter. The infant has delivered breech, but either the cervix was not fully dilated, or the head is too big, and the head cannot come out. Katie and I race to the bedside and throw gloves on. She tries first to deliver the head, but she can’t. I try. It’s quite a big head, and it’s quite stuck. The trick with breech delivery is to flex the head, because an extended head is harder to deliver. In order to flex the head, you have to find the baby’s face, and put pressure on the cheeks or on the mouth/chin in order to flex the head. But I can’t find the baby’s face. I feel around but it’s very difficult. Is that an ear? Is that the cord? Based on the body position, the face should be downward, and there is a lot of room posteriorly, but I don’t feel it. I feel around while trying to get it out. I am able to get my hand all the way around the baby’s head to the top, but it still won’t come out.

I ask for forceps. Katie has to run all the way to the Operating Theatre (OT) to get them. Meanwhile I keep trying. I also notice that the body is extremely limp, and I can’t palpate a pulse in the cord. Is this kid already dead? I don’t know, but I have to assume not. Katie arrives, and I try to place the forceps. I can place them on one side, but not the other. The anterior part is very, very tight.

It’s at this point that I start cursing. Cursing helps me in emergencies; it’s a way for me to express how hard something is, but also to maintain focus. Motherfucker, this is hard.

Katie takes over. I look at my arms, and realize they are covered in blood. I also look at the baby, and know that it is dead. I ask the nurses, and they confirm that it is dead. I tell Katie to slow down, and be careful with blood exposure, because the emergency is over. We need to get the baby out, but there is no chance of saving it, so we can slow down.

I wash the blood off my arms while Katie tries to get the head out. The mother is splayed on this delivery bed, thrashed and exhausted by our efforts to remove this baby’s head from her vagina. Katie has a good idea of flipping the mother onto her hands and knees. While she is doing that, I put on gynecological gloves, which go all the way past the elbows, to avoid getting blood all over me again. I also put on plastic clogs, and make Katie change out of her sneakers. The woman was on her hands and knees, but now she is prone on the bed, making no effort to hold herself up. That is no position for delivery. We force her back onto her hands and knees, and Katie keeps pulling. We are both worried that we will decapitate the kid, and we are both thinking that we will need to go to OT for a destructive delivery to get this head out. There is a special instrument there that allows us to remove the head of a dead fetus. Ugh.

As I am putting on the gynecological gloves, Katie suddenly pops the head out. Blood spurts out behind the head, splattering both of us. Despite our plastic aprons, our shirts are bloodstained, and Katie has blood on her forehead. I send her to wash, and take over delivering the placenta.

After the placenta comes out, the woman has a minor hemorrhage, but we massage quickly and the uterus firms up. We have moved her onto her back, and clean her up and let her relax. The infant weights 3.56 kg. Not very big for the US, but very big for South Sudan. Katie offers to let the woman hold her baby, and she accepts. She cradles the baby as if it were alive, her face stoic. Her husband is next to her, comforting her.

We are both a little stunned. What the fuck. That was so ridiculously traumatizing, that now we are a little punchy. We fully appreciate how sad the situation is, and how disappointed we are to not have saved the baby, but these emotions are too powerful for right now. Instead, we have to laugh at absurdity. We laugh at the blood spatters on our shirts that look like we’ve been shot. The maternity staff is shellshocked too. The midwife thanks us for having come so quickly. “Not quickly enough. The baby died,” I say. But he says “No, you came very, very quickly.”

On our way back to base in the car, I ask Katie how she finally got the head out. “I have no idea,” she says, and we burst into laughter.

I had read about head entrapment in textbooks, and talked about it extensively in the hypothetical, but I had never seen it, in part because we rarely do breech delivery in the US. And now I have seen firsthand why we don’t. If anyone was ever a good candidate for breech delivery, it was that woman. She had a proven pelvis and spontaneous labor and a baby that was big but not extremely so. And yet, she had the worst possible outcome. A traumatizing, horrifying complication in which her baby died between her legs, with its head inside her vagina. South Sudanese women are so stoic; it’s hard to be certain what they are feeling, whether good or bad. This woman held her dead baby silently, but she held it tightly, and for a long time. There is no doubt that she has been emotionally scarred by this delivery. I hope I never see a head entrapment again.

Posted in Doctor, obstetrics, South Sudan | 24 Comments

Precious Blood

The woman was sent from the Ministry of Health (MOH) section of the hospital. MSF operates the Maternity Ward, the Pediatric wards and the therapeutic feeding center. The rest of the hospital is under the direction of the MOH. We are not sure why she was sent, but there is a written request to check hemoglobin. The midwife has checked it, and it is extremely low at 4.4 g/dL. If I had a hemoglobin this low, I would probably be dead, but people here are generally so anemic that they are physiologically more adjusted to it, and can tolerate very low levels. Nonetheless, she is symptomatic. She is visibly tachypneic (fast breathing), tachycardic (high heart rate) and she looks weak and miserable.

There is some confusion about what to do with her. She is quite sick, but we only manage pregnant women. If she is not pregnant, then the MOH should manage her. We learn that they had already given her one unit of blood – her original hemoglobin on arrival was 2.9 g/dL. Good grief. But why did they send her to us then? She arrived with a piece of paper, ostensibly a referral, but it is in Arabic.

We decide to do a pregnancy test, and if it is negative, we will send her back. It comes back positive. We put her in a bed, and the maternity manager (who is a midwife) examines her while I see other patients. She asks me to come and look at her ultrasound. She shows me the uterus, and it looks empty. She moves the ultrasound probe to the right, and suddenly a very clear pregnancy appears – outside the uterus. The patient has an ectopic pregnancy. That may or may not explain the anemia. If the ectopic ruptured and she bled into her abdomen, that would make her very anemic, but we don’t see any free fluid in her abdomen, and she doesn’t have any abdominal pain. She did have abdominal pain 2 days ago, she tells us. Strange.

Now we have a problem. She needs surgery to remove her ectopic pregnancy, but she is so anemic that we are not sure she can tolerate the surgery. She needs blood before we can operate, but there are two problems. First, if we transfuse her, will she just bleed what we give her into her abdomen? And second, is there any blood for her in the blood bank?

We contact the blood bank. There is a very tiny amount (a pediatric unit) in her blood type, and there is one unit available of O-positive, which she is also able to receive, and one unit of another type that she cannot receive. That leaves us with a problem: we can use the O-positive blood, but that blood is very valuable because it can be given to most blood types (except for people who are Rh-negative). If we give it to her, then the next person who comes in with a life-or-death need for blood will die. She is definitely sick and needs the blood, but exactly how much does she need the blood? Is it possible that she will tolerate the surgery without the unit? She might not lose all that much in the surgery. And she is young, so her heart is strong. Would another person need this unit more than she does?

This is never a problem we need to think about in the US. If someone needs blood, they get blood. Blood is a precious resource, but it is an available resource. An additional problem in South Sudan is that there are some cultural beliefs about giving blood that make blood donation almost impossible. On occasion, we have been able to convince people to donate for their gravely ill family members, but no one donates blood for strangers, and even for family it is a challenge. Many anemic pregnant women have languished weakly on the wards for lack of a family member willing (or able) to donate.

We explain to the woman’s family that she needs surgery, and blood. They immediately agree to the surgery – “anything that is needed to save her life,” says her husband. We send him and her mother to the blood bank to see if they are candidates for donation. They are not.

We discuss the issue with the hospital manager. Should we give her this precious O-positive unit? And if we do, what is the best timing to have the strongest effect? Two hours before surgery? Immediately before surgery? Intraoperatively?

We hash out the issues. The hospital manager makes a good point. She tells us not to worry about hypothetical patients. This patient needs this blood, so she should get it. They will go and try to rustle up donations somewhere, and try to get her to bring in more family members for her, but we should give it to her, because she is here now and she needs it. “If another patient comes in and dies, well, that’s how it goes here,” the Hospital Manager says. She’s right. We can’t deny a real, sick patient blood in favor of a hypothetical sicker patient.

When we get back to the patient, we learn that her brother arrived, and was sent to the blood bank for evaluation. She can receive his type, which is very lucky. He has donate 450cc of blood. I shake his hand, and tell him that he has saved his sister’s life.

We decide to hang the blood in the Operating Theatre (OT), just before the surgery. That way, if her ectopic ruptures before I get to it, she won’t have time to lose too much of the transfused blood.

When I open her abdomen, I find about 800cc of old liquid blood in her abdomen. It seems she had ruptured that ectopic, probably back when she had the pain, and we just hadn’t seen the fluid on ultrasound for some reason. I suction the blood, and pull out her right tube, which is thickened with the abnormally placed pregnancy. The wall of the tube has exploded on one side, with some clot around it. That is the rupture.

I remove the tube. She doesn’t lose much new blood in the process. I look at her left tube – it doesn’t look great, a little scarred, a little dilated. She probably had some kind of infection that caused pelvic inflammatory disease, leading to tubal scarring and trapping this pregnancy in her right tube. I leave both ovaries and her left tube in place, and hope for her sake that she is able to get pregnant. (She has three children, but told me she wanted more).

We request a postoperative hemoglobin, and we are told that it is 6.0 g/dL. We rejoice, knowing that we left her with more blood than she started with.

Posted in Doctor, obstetrics, South Sudan | 8 Comments