Inside Outside

Ebola is everywhere. Posters on walls, music playing from loudspeakers, there’s even a film with the same name being sold on the street. When walking, the local children have replaced shouting “Hello, how are you?

Ebola is everywhere. Posters on walls, music playing from loudspeakers, there’s even a film with the same name being sold on the street. When walking, the local children have replaced shouting “Hello, how are you? Give me dollar” to “Pomwee (white person), you have Ebola over there?” There’s an active campaign to try and increase the awareness and understanding of the disease, though lots of misunderstanding and rumours remain. On street corners and roundabouts there are information stalls with announcements being shouted out through a megaphone, small crowds gathered around listening intently.

There is good reason for all the activity, the epidemic continues to march through the country and is now on our doorstep. There are worrying stories coming from local villages, and patients with Ebola have managed to leave hospital to seek treatment elsewhere (including in Bo). This week brought the first confirmed case to Gondama Referral Centre (GRC), predictably it was in maternity. The lady, in late pregnancy, presented with seizures and bleeding, she died several hours after isolation. I was not on-shift that day, though news like this tends to spread round the team very quickly.

It has always been a matter of not if, but when, the epidemic will infiltrate GRC and the local community. That time appears to be now. The latent period before symptoms appear tends be around 8-10 days. It is therefore likely that in the coming couple of weeks the cases will rise, from contacts of the previous patients, and our work and lifestyle will need to change to meet the challenges this brings.

My week brought its own challenges. The unit swings between deathly quiet and busy depending on the local rumours of where Ebola cases are. The day immediately after the confirmed case barely anyone came, the following day though was the busiest I have had so far.

I was called to come, two patients had arrived together. One was a 17-year-old having a late miscarriage and bleeding heavily, the other was an 18-year-old in labour following a previous caesarean section. Getting a decent history from the patients is always a challenge, partly because most can not speak English so I depend on the nurses to translate (of variable success rate). But there is also usually a certain level of reluctance to divulge the information needed, which I can only assume is that the patient fears she will be in trouble or mocked. Initially I focussed on the 17-year-old, began resuscitating her and gave medicine to help the miscarriage to complete. I then turned to the 18-year-old.

The midwife examined her and found her to be fully dilated. Great, she can go for a normal delivery. The midwife then inserted a catheter into the bladder and all that drained was frank blood. No urine. The risk of a vaginal birth after caesarean section is that the scar can re-open, a very serious complication. I asked a bit more, had she been examined before coming to GRC? Yes, she’s been fully dilated since yesterday (not good), and was in a clinic where she was put on an oxytocin drip (even worse). I still have not figured out who and where these clinics are, but putting a woman with a caesarean scar on oxytocin (to make the contractions stronger) without proper monitoring and access to an operating theatre is inviting trouble. Leaving her fully dilated for over 24 hours and then sending her to GRC is like delivering a potential disaster cooked and ready to serve.

The 18-year-old quickly had my full attention as I began thinking through how I would repair her ruptured uterus. I examined her myself, the head was low and the pelvis had a good amount of space. I was confident that she could be delivered vaginally, if the uterus was ruptured that could be dealt with after. The midwives looked at me skeptically, but I had made my decision and I gave them a simple choice. Either I’ll deliver her, or you can do it and I’ll assist. I gently rotated the baby’s head to a better position for delivery, handed the midwife the ventouse cup and assisted her in delivering the baby boy.

He gave an almighty scream as soon as he came out, and the 18-year-old began wailing “thank you Jesus”, but the job was not done yet. There was still a uterus to check. I delivered the placenta and then slipped my hand inside the uterus to gently feel along the inner walls, focussing on where the previous caesarean would have been. Everything felt intact, no rupture. Soon after delivery she began producing normal urine again.

The shift continued with patients coming in two by two. I had two women both presenting with a prolonged time since their membranes had ruptured, but neither had begun contracting. They had both had previous children, one had delivered eight times before. I commenced both of them on oxytocin, but cautiously as the risk of rupturing a uterus increases with the number of births the woman has had before. All should have been well, but then the midwife got sick. I saw her and admitted her to the hospital, leaving me with no midwife for the night time. The nurses weren’t pleased with the women on oxytocin and implied that they should go to theatre for caesarean sections, but I stuck to my guns and explained that we needed to at least give them a chance. If they’ve delivered normally before, they should be able to do it again. Thankfully they both went on to have normal deliveries.

An ambulance pulled up around 3am with a 26-year-old inside. She had been referred from a clinic, in active labour with a history of bleeding (antepartum haemorrhage) and breech presentation. To me this sounded like I would be finding a placenta lying over the cervix (placenta praevia), causing bleeding and preventing a fetal head from going down. Once again, the history was a struggle. She had had three children before, but only one remained alive.

She had been in labour since 6pm and was now in constant pain. I gently examined her abdomen, it was hard and very tender. Rather than a vaginal examination I used the ultrasound so I could be sure where the placenta was. The ultrasound gave a confusing picture. The placenta was lying at the bottom of the womb over her cervix, but it looked as if it was folded over and not clearly fixed to the wall of the womb. I slowly moved the ultrasound probe up her tender abdomen. The fetal legs and breech were higher than I would have expected, the heart was not beating and the head was no where obvious. I moved the ultrasound probe further and further out along her abdomen, beyond the normal parameters of pregnancy. Right up, almost into her chest, I located the fetal head resting along the upper part of the mother’s liver.

Following my previous experience of performing a caesarean for a stillbirth I wanted to be sure that I was making the right decision to take her to theatre. I thought it through, the placenta looked low (could be a praevia), the uterus is hard and tender (could be an abruption), the fetus appears to be outside the womb (could be uterine rupture, the most likely option). Either way I knew she needed surgery, and so asked her if she wanted more children, she did. I explained that there was a high risk that she would need a hysterectomy but I wouldn’t know till I could see what was happening.

In theatre I stood over her ready to make a midline incision. I thought to myself, on the one hand I hope she has ruptured so that I will be justified in having started the surgery, on the other I hope she hasn’t because I will then need to fix it. With the initial incision through the skin the answer was immediately clear, blood and amniotic fluid began pouring out. She had ruptured her uterus, a catastrophic event in obstetric terms. Before I got to the uterus I found the baby floating completely free in her abdomen, it occurred to me that I had never delivered a baby from outside the uterus before. I gently delivered as I would for any other breech. The placenta had also completely detached but was still in the uterus, resting at the bottom, explaining the earlier ultrasound scan findings.

Once we had mopped up all the blood and fluid I took a careful look at the uterus. It was torn horizontally right from one side to the other, and low down. There was also a second tear down and lateral on the right. The uterus itself looked abnormal, but she was at least not bleeding. I retrieved all the parts of the uterus and held them together to restore the anatomy as best I could. Once satisfied I began stitching it back together, every now and then returning to look and make sure that the right bits were going to the right places.

By the time I had finished new patients had arrived to fill the delivery room. Another breech presentation in obstruction.

The woman whose uterus ruptured continues to make good post-operative progress. She will need to be carefully counselled on future pregnancies (had she had more living children I would have encouraged her to be sterilised during the surgery). She risks rupturing again, so will need a caesarean before labour in her next pregnancy.

I still don’t know why this patient ruptured her uterus, but I understand now that I am working partially sighted. I can ask, but may never really know what goes on outside the gates of GRC. She too could have been left on an unmonitored oxytocin drip for hours and then sent to us once things went wrong. Avoidable complications, which once the mess has happened are sent for us to clean up.