Monday was declared a National Day of Reflection by the President of Sierra Leone, Ernest Bai Koroma, the population were requested to stay at home and consider the implications of the ongoing Ebola epidemic. For myself and the staff of GRC however it was business as usual.
I began my 24 hour shift optimistic that the patients would stay at home and I could relax a bit, chat to my colleagues, even read a book. The day was going as planned, not too many inpatients (there has been a decline in numbers due to the perceived fear of catching Ebola in a healthcare centre) and just one pre-eclamptic lady I was trying to induce into labour, the fetus had died before arrival.
After lunch I got comfortable and then the phone rang “Doctor. Patient. Come”. On the bed in the delivery room was a woman making the deep vigorous noises of someone with the uncontrollable urges to push a baby out. I went over, she had had two children before, both normal deliveries. This time she had been in labour for over one day and pushing since the morning. In another clinic she had already been given oxytocin to try and make the contractions stronger.The uterus had the tell-tale sign of a dip in the middle (pre-rupture) and the catheter had only a small dribble of blood inside it. No urine. The baby’s heart rate dropped slowly down with each contraction making a difficult ascent back to normal during the break in-between the forceful pushes of its mother. The baby was stuck, in the wrong position and too high to attempt a vaginal delivery. All the hall marks of obstructed labour were there, and uterine rupture was a real risk.
In the operating theatre the caesarean went relatively smoothly. The baby came out flat, but with a heartbeat present. As I was closing the final layers of her abdomen the hospital director stuck her head round the door. “Do you need me to call a second gynaecologist?” I had no idea what she was talking about. Apparently two new patients had arrived, one in a bad condition.
I left the theatre nurse to put the final stitches into the skin and made way next door to the delivery room. If you have ever been in a witness to a road traffic accident you may have experienced that moment when everything slows down, just for a few seconds, and you absorb the scene in front of you. I had that moment in the delivery room when faced with the pandemonium before me.
The two women were in the delivery room, the first to grab my attention was a 20 year old having her third child. Her last delivery had been by caesarean section. She was making a lot of noise. Screaming and wailing, but to my ears it was the sound of progress. I then saw the woman in the bed next to her. A 19 year old who had delivered the first of her twins at home in the morning, she was now here with the second twin’s purple arm hanging out between her legs. She was not screaming, just lying flat making an occasional grunting noise.
I went to the quiet one first. She acknowledged my presence, eyes wide open and a look of terror on her face. I turned to the nurse to find out what were the vitals - no blood pressure doctor, heart rate 150, breathing 45 per minute. Haemoglobin 4 (extremely low). Around me the nurses and midwives were fluttering in disorganisation, I took a deep breath. Order and control was needed.You, take the IV fluid and squeeze it into her as hard as you can. You, get oxygen now and put it on the highest flow. You, get a second IV line in and then take a manual blood pressure. You, get antibiotics. You, go the the patient in the other bed and don’t leave her, whatever is happening here you stay with her. I asked the hospital director to run to the blood bank and beg for whatever they had. I got all the personal protective gear on (with the ongoing Ebola epidemic extreme care must be taken with all patient contact) and felt her abdomen. It was tight and tense, a deep ridge in the middle where the uterus doubled in on itself. A quick scan showed a dead, trapped twin. The baby was lying in an awkward position making vaginal delivery impossible. The head buried into the left corner, neck and body wrapped in an almost perfect circle with the legs right at the top of the uterus. And of course one arm hanging outside.
I had two options for getting the baby out, one was to try and reach inside and bring the legs down and then deliver the baby breech first, the other was to do a caesarean. However before I could decide what to do the woman became unconscious. Her pulse suddenly dropped from racing at 150, to a slow 60. Still no blood pressure even with two lines and fluid being forced down them as fast as possible. Her breathing was now nothing but an occasional gasp. She was dying in front of us. I stood there feeling both responsible and helpless.
A unit of blood arrived, so we started transfusing her and put up a third line. Her condition was beyond critical. I stood with four national staff and started talking out loud announcing my thought process to anyone willing to listen. “Airway: it’s open and clear. Breathing: she’s breathing but slowly and we’ve got oxygen going. Circulation: pulse is slow, no blood pressure, fluid going in, blood going in, no urine coming out. Uterus displaced (pushing the uterus to the side helps circulation). Antibiotics given (I suspected septic shock on top of everything else). Fetus still in. What are we missing? No, okay lets start from the top again.”I decided that whilst we were resuscitating her to see if I could get the baby out, she was unconscious, not stable enough for theatre but may be if I could remove the baby it would help with infection and also make resuscitation easier. I put long, gynae gloves on and reached past the prolapsed arm. The baby was tightly fixed inside, I got my hand round the head and chest and found the other arm. I kept going, but the feet were all the way up past the tight constriction ring and beyond my reach.
Again, I recited my monologue, asking the national staff if there was anything else they could think was missing. Though I’ve looked after women that have subsequently died, I have yet to see a woman’s heart stop beating on my watch. I turned to the hospital director who was still in the room, “She’s going to die” I whispered. I was out of ideas. I began preparing mentally and practically for the oncoming cardiac arrest.
The fourth time I went through the systems we finally got a blood pressure. 60/40. Bad, but better than nothing. Slowly but surely her pulse began rising, the breathing became stronger and the blood pressure started to come-up. Our efforts were kicking in, not a second too soon.
The midwife I had sent to the other patient started shouting “Doctor come here please”. I did not want to leave the 19 year old so I shouted back “What’s wrong?” The noisy 20 year old had made it to full dilatation, soon after she had begun pushing the midwife had applied a suction cup to try and speed the delivery up, but it hadn’t worked and the baby was still in the same place. A failed instrumental delivery is considered to be an obstetric emergency, especially in a woman who had a previous caesarean. But so is a teenager trying to die. I told the team to keep doing what they were doing and then pulled off my protective clothing only to replace it with a new set and attend the patient next door. I examined her; the baby was alive, head still quite high, but deliverable.
Unfortunately the baby was looking upwards (making delivery more difficult). I desperately needed the operating theatre to stay free so that once stable I could get the 19 year old in. This baby needed to come vaginally. I re-applied the suction cup far back on the baby’s head. With the contraction I told the patient “Too-pey, TOO-PEY!” (push in Mende, the local dialect). At first nothing moved, but slowly I felt the head coming down and rotating to look downwards. As the head crowned it was clear this was going to be a big baby. I gently eased the head and body out, baby crying I gave him to the midwife and made my way back to the 19 year old.Her eyes were open and her breathing normal, unbelievably she was already talking to the midwife. I had already sent all her relatives to donate blood in anticipation so we gave her another unit and prepared her for the operating theatre.
As I stood over her large abdomen I felt nervous. A caesarean for a baby lying transversely across is not easy. I decided to make a large midline incision, I wanted all the space I could get. Once I began it became clear, her uterus was ruptured. Litres of blood were pooled either side of the uterus, the thin translucent outermost layer of tissue had not torn creating a huge haematoma (blood clot) to spread across the front of the womb, completely obliterating the usual place for a caesarean section. I opened up the clot and continued as if normal, delivering the baby feet first. The rupture itself was small, but had ripped through the arteries to the uterus on one side, which in late pregnancy carry about a half litre of blood every minute. Once the uterus was repaired and all the blood washed out I closed. Her haemoglobin was now 2.4, desperately low. Again, I begged for blood and got another unit.
I sat outside the theatre writing my notes and reflecting on the situation. As I began giving the ward nurses instructions on the post-operative plan I heard shouting coming from the theatre “Dr Benjamin!!”. I ran round, she was bleeding from everywhere. Not blood really, just a watery pink. Her uterus was relaxed and the blood was pumping out from her vagina. The skin edges of the wound were pouring down the sides of her skin. After losing so much blood, receiving large amounts of fluid, and probably with severe infection, her body had no clotting factors left. Leaving the watery blood free to flow. We gave drugs to contract the uterus, tilted her head down, I got the theatre nurse to press on the bleeding wound and I pressed my fists deep into her abdomen to compress the aorta (a major blood vessel) and reduce blood flow to the uterus. I did not want to open her again but knew it was a possibility. I got someone to call a second gynaecologist, pressing the aorta I could buy time till he got in. If we were operating, this time I wanted company.
Together we looked over her and balanced the possibilities, she could be bleeding internally after the surgery, it could be that there was no clotting, and also her uterus was relaxed causing vaginal bleeding. In the end we open the stitches and looked inside. The same watery blood was there, but no active bleeding. The surgery was clean, and dry. A huge relief. The other gynaecologist wanted to perform a hysterectomy, I was unconvinced. With no clotting we risked causing more bleeding by operating again, but if we left the uterus in she could carry on bleeding vaginally. We looked at each other across the operating table, the girl’s open abdomen before us. Impossible decisions in extreme circumstances. I was the first to concede, and so we proceeded with the hysterectomy.
Once closed for the second time, we somehow managed to get another unit of blood for her and then into a bed on the ward. Blood is more precious than gold in GRC, the lab technician came to complain, but soon realised the drastic situation we were in. Through the night her blood pressure remained low or unrecordable. I kept pushing the fluid. Hour by hour we checked for a change. As the sun began to rise so did her blood pressure, at 7am something very special happened. Urine. I have never been so pleased to see a catheter tube fill with pee. Everything was starting to go in right direction, I left in the morning physically exhausted and emotionally drained but sure that we had turned the corner to recovery.
I remember clearly waking up, it was early afternoon and once I got orientated to my surroundings I began running over the last 24 hours in my mind. I texted my colleague who was now covering the 24 hours on-call. It was 3pm and I had one question only. “How is she?”
It is estimated that one in every twenty-one women will die during childbirth is Sierra Leone. Each one is a tragic story of poverty, children without mothers and a reflection of socio-political attitudes, priorities and understanding. It is nothing short of a protracted emergency, in both humanitarian and epidemiological terms. At 2.50pm, a 19 year old girl became another sad statistic.