Women often arrive to the department in all sorts of ways. Some walk in, get on the bed and just have a baby. Other’s are transferred from community health centres with complications, and some come through the emergency department.
I was seeing a patient who had had an abortion when the midwife came over to inform me of an emergency transfer; a woman whose waters had broken but the amniotic fluid was pouring out from her back-passage instead of the vagina.
It took me a moment to absorb this bluntly put piece of information.
The midwife then added “it must be fistula”.
While it’s true that we unfortunately see women here with obstetric fistula from previous complications of labour, I have never heard of a woman breaking her waters through her rectum. I was suspicious.
The woman arrived shortly after on a stretcher, she was lying there looking quite unwell and moaning. We got her into the delivery room, and tried to establish what might be happening.
This was her fourth baby, she had been leaking clear fluid for a day and having occasional contractions. The cervix was closed. I decided to pass a speculum so we could get a clearer view of if there was amniotic fluid draining. On opening the speculum it was clear that the vagina was dry, but then a sudden gush of clear fluid poured from her back-passage. It was like someone had just turned a tap on full flow. I removed the speculum and watched as the fluid continued to pour out, it looked just like clear amniotic fluid, but there was nothing to suggest this woman suffered from any kind of fistula. It was actually profuse clear diarrhoea.
I immediately asked for IV lines and fast fluid to be begun, I have never seen cholera but it is entirely possible in this region. It is also highly contagious.
The MSF team in Bangassou live, eat and work together. Of course, sometimes it can feel suffocating, but it also means that we have strong bonds and can rely on each other.
Deciding if this woman lying inside maternity had cholera was of vital importance for many reasons beyond her own health.
As I haven’t direct experience of the disease I got on the radio… soon almost all the doctors and nurses were present. Some had experience in Congo and other areas where cholera is endemic, each taking a look at the sample I had kept for them. The infectious disease doctor and I began discussing alternative diagnoses. In the end it was concluded that she probably didn’t have cholera, but we sent the sample to the lab for testing and microscopy. We also live with the very helpful laboratory doctor, who confirmed it was negative.
During this time we put in place infection control measures for anyone entering the area where the patient lay. Even without cholera she was clearly dehydrated and having a serious diarrhoeal disease. We went back over the history of her illness, and then quietly from the back of the room the local midwife, who had been watching the whole thing, said just one word: “rougeole”.
Since I arrived in Bangassou there has been a measles outbreak in the surrounding areas. MSF is responding to the epidemic, a vaccination team is in the project to begin an emergency campaign, however we are continuing to see increasing numbers of cases.
The woman had no fever, no little white spots in her mouth. But her eyes were red, there were some raised spots on her face and neck (there is no red rash on black skin, instead a bumpy, raised rash usually develops) and she had an occasional dry cough.
Now we had a new problem.
Measles is not a disease we often see in Europe, and over the years of routine vaccination there can be an element of complacency to it. It is however an illness to be respected. Easily spread, and with risk of serious and life threatening complications, the suspicion alone should not be taken lightly.
I spoke with my colleague who covers the medical ward (where there are isolation rooms), I wanted to transfer her. The maternity unit can be quite crowded, women usually labour, deliver and rest in shared rooms with the new born babies too. The last thing I wanted was a measles outbreak inside maternity and neonatology.
Either way everyone was nervous; measles in maternity or a full-term pregnant woman in the medical ward. But in the end we agreed to move her and disinfect everywhere she had been.
Each morning we have a large medical meeting, I was met the following day by a very unhappy-looking matron from the medical ward. The woman with measles was contracting and at 7am was 5cm dilated. They wanted her out of the department. I sat and thought for a while.
She was in the infectious stage of the disease with colourless rash and fever just beginning. Labour and delivery during measles also came with its own complications, particularly bleeding, and the there was the question of what to do with the baby who might or might not be infected.
I balanced the odds in my head and explained that I would prefer to deliver her inside the medical ward, away from the other pregnant women (as it was we were having a busy morning with twins and breech deliveries). I personally would come and deliver the baby.
I had previously been involved in the management of pregnant women during the West African Ebola epidemic, and whilst measles is a far cry from Ebola some principles remain the same.
I quickly put together a 'maternity box' which we would use for the deliveries inside Ebola treatment centres and prepared all the drugs I might need in case of haemorrhage. A blanket to wrap the baby in and lots of absorbable pads. My colleague (friend and housemate) who is a nurse came to join me and a local nurse for the delivery and to receive the baby.
The woman was exhausted, between the measles and having been in labour overnight. When we arrived she was 8cm dilated and thankfully the amniotic membranes were intact, I wanted to keep them intact till as late as possible to try and protect the baby from infection. We got the room prepared and all the drugs and fluids ready.
She was soon fully dilated, but sleeping between the contractions that had reduced to just one every 10 or 15 minutes. We urged and encouraged her to keep going. The medical doctor next door was trying to round on her patients with medical student and nurses, and kept being disturbed by this rowdy team who would burst into “PUSH!!!”
The baby delivered in the amniotic sac, which burst just after the head was out. The screaming little boy went over to my waiting colleague who dried him off. We immediately gave the drugs to contract the uterus and delivered the placenta, thankfully no bleeding followed.
The baby was taken to a prepared isolation room where he could be nursed till the mother was no longer infectious. Despite their reservations the medical ward staff were all very proud of their special patient who had given birth in the isolation area.
Both mother and baby recovered well and were eventually discharged home together.
Since then we have had five cases of pregnant women with measles, including a twin delivery. Each time we are faced with the same difficult decisions of balancing obstetric, medical and infection control needs.
Measles in pregnancy can cause miscarriage, preterm delivery and stillbirth. There is also a risk of serious neonatal infection and complications for the mother including haemorrhage and pneumonia. That is why being part of a team (medical and non-medical) that collaborates and remains flexible to new and challenging scenarios is so important. It is what makes me so pleased to work with colleagues, national and international, who come together with a common goal - the best we can do in less than best circumstances.
The very last baby I delivered before finishing my posting in Bangassou was to another woman with full-blown measles. She had a burning high fever, colourless bumpy rash all over her body, awful vomiting and looked anorexic.
The labour was also not following a normal course and we had to begin contemplating the possibility of a caesarean section. With some gentle encouragement we managed to get the labour to complete normally, another screaming boy who went off to be isolated.
The following day (my last in Bangassou), I saw the mother who now looked like a different person altogether, much healthier. She asked for my name, and now as I leave this project I wonder what will be in store for the little Benjamin that stays behind.
At least I know that come what may, he and his family have a team behind them working hard to give care with dignity and to reduce the burden of disease that hangs over their community.