Keep Calm, and Carry On

One Saturday night, after a busy day, two ambulances arrived together at around 3am both from the same large hospital from another district about two hours away. The delivery room was already full so we had get each one in at a time.

One Saturday night, after a busy day, two ambulances arrived together at around 3am both from the same large hospital from another district about two hours away. The delivery room was already full so we had get each one in at a time.

The first was a 25-year-old woman in her second pregnancy, she had blood down her thighs and was contracting mildly. I gently felt her abdomen, it was soft and not painful. In a case of vaginal bleeding before birth it is always best to do an ultrasound before examining, and I’m glad that I did. The baby was alive, but the placenta was lying directly over the cervix and stretched up across the front wall of the womb. Placenta praevia major.

She had to go the theatre immediately, if left to labour she would certainly have a catastrophic haemorrhage. I consented her for an emergency caesarean, and hysterectomy if required, and sent her relatives to donate blood in anticipation.

In the operating theatre I met her placenta before the baby. It had created a wall across the area for the caesarean incision, however baby came out screaming and thankfully once the uterus contracted down she bled very little. I was soon back in the delivery room to see the next customer.

The next woman was a 30-year-old having her fourth child. She came with a note written in the same hand writing as the last one, short and to the point “No Doctor”. This lady had had a previous caesarean section. She had been in labour for over two days and both her and the baby were exhausted. The baby had opened its bowels inside her uterus (a possible sign of distress) and was having deep and long episodes of slow heart rate. The mother’s abdomen had the typical dent of a uterus about to rupture. I asked if she wanted more children - she didn’t so consented her for sterilisation at the same time.

I asked the theatre staff to quickly clean from the previous case and get ready for the next, if we wanted this baby to come out alive we needed to get things moving. I wanted to get this baby out quickly, but with a previous caesarean you never know what you will find inside from the last surgery. In the interest of speed we decided to use ketamine (similar to having a general anaesthetic) instead of a spinal. I made a deal with the midwife waiting for the baby, You come back and tell me if the baby survives before I perform the sterilisation.

On opening the abdomen I found dense adhesions (where tissues become stuck together from previous surgery), I carefully proceeded thinking that I needed to get this baby out, but I also needed to avoid damaging her bowel. The uterus was thinly stretched out, and the previous caesarean scar had already come apart just leaving a transparent film between the upper and lower parts, a window to the baby below. I gently opened above the scar, cutting upwards to try and avoid the paper-thin uterus tearing down. After two days in labour the head was now firmly fixed inside the pelvis, facing upwards. I slipped one hand under the head and began rotating it round, whilst also trying to release the vacuum that gets created in these cases.

Slowly, slowly I could feel the head moving up and round. I could also feel the uterus tearing under my hand so tried to keep movement as directed as possible, damage control. As the head began to crown through the incision, thick green stool all over it, the theatre nurse tried to help by pulling on the upper part of the uterus “Stop, stop” the tissues were so thin that any extra tension could be disastrous. The baby came out flat and floppy, and went straight round to the waiting midwife.

I cleaned up the meconium (fetal stools), blood and fluid and started taking the pieces of uterus to suture back together. I reached down into the pelvis to pick up the lower part of the uterus and instead found something horrifying. A small balloon. The uterus had torn down vertically, taking with it the top and back wall of the bladder which was now wide-open, releasing the catheter balloon. I stood looking down at the bomb site, quietly reciting under my breath a long list of profanities. Once I was composed I thought back to the text books, I know how to do this, I told myself. It’s just that I never had to do it.

I tied the bleeding sides of the uterus, then took the bladder edges and realigned the anatomy. I delicately repaired the bladder with a small needle and fine suture, then repeated it again burying the first layer. I asked the anaesthetic nurse to squeeze blue dye up the catheter tube to see if the bladder was water tight. I’m pretty sure I stopped breathing for a few minutes as I watched the bladder fill and expand with the blue fluid. I then packed clean white guaze swabs around it and waited. Still white, success!

As I repaired the uterus, the midwife came in and told me the baby was alive so I proceeded with the (very needed) sterilisation. Almost two hours after putting on the suffocating protective clothing I finally peeled it off, exhausted and soaked in sweat.

Due to the bladder injury the woman would stay catheterised for a while to allow healing, this suited me just fine I was worried that after everything she would still end-up with a fistula (constant leakage of urine from the vagina).

Once the catheter finally came out the woman came to me beaming with pride, normal urine with full control and no leaking. With the military quarantine in place for Ebola she remained in GRC for a while longer, so that when she finally went home it was about one month since surgery, and still all was good. A huge relief for us both.

Sierra Leone has a policy of free access to healthcare for pregnant women, theoretically functioning maternity units in the government hospitals providing comprehensive emergency obstetric care. Off paper and on the ground there is a very different and sad reality. Women are left in obstructed labour, basic equipment (including the doctor) missing and a lack of access to alternative services. That is what makes the MSF obstetric project at GRC so important.

Women are referred from all over a wide area, as well as those that self-refer. It is hard sometimes not to be angry when these women arrive in terrible conditions, almost always avoidable if they had only gotten the correct care earlier (or been referred sooner). It is even harder when they come with a referral letter from another hospital, where they really should get the care needed. Of course I only see one small part of the puzzle. I don’t see the midwives and doctors working in desperate conditions, stocks missing, power failures and power politics. I only see the end result, the cause is somewhere far away from the delivery room and operating theatre.

The worst cases I have seen since being here have nearly always been from the women who went to seek help, only to have to wait long periods of time before being sent on to the MSF referral centre. Most of the complications never need happen. And for each happy ending, there are so many others that don’t make it to the hospital in time, or at all.

Just for now I’m focussing on the success stories, and the women who smile when they see me and for whom I can smile back.