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.