Too Much, Too Late

“Come doctor” is the usual length of conversation when the midwives call to inform me there is a new admission. It could be anything, so I always attend promptly.

“Come doctor” is the usual length of conversation when the midwives call to inform me there is a new admission. It could be anything, so I always attend promptly. There is a popular theory on the reasons for high maternal mortality in some countries, it is considered to be the result of delays in recognising the problem and seeking or accessing care. Certainly it is true that many of the patients attending Gondama Referral Central (GRC) arrive in situations that could have been avoided if action was taken hours, or even days, earlier.

An 18 year old is lying flat on the examination couch in the labour room, her abdomen is distended with a full term pregnancy and looks like a camel (2 humps, not 1) is resting on her belly. She occasionally moans and makes a weak effort to push, she is clearly exhausted. This is her first pregnancy and she has been in labour for two days at home.

On examination the contractions are short and mild, she is fully dilated but instead of a head the baby’s breech (bottom) is presenting. A quick ultrasound scan confirms that the baby is still alive, but has extended his head all the way back as if looking directly up to his young mother. Even if she were able to deliver the breech, with the head deflexed it would likely get stuck, a nightmare complication. The patient agrees for a caesarean section, and so to the operating theatre we go.

A caesarean section at full dilatation is not the same as when performed before or earlier in labour. The uterus becomes distended and easily tears, other organs such as the bladder tend to become swollen and stretch up across the lower part of the uterus, it is with these complications in mind that I begin the operation. Indeed the bladder is distended, but easily moved away. As surgeons go, I’m shorter than average, to be able to reach under the baby’s buttocks I need the operating table all the way down, plus a box to stand on.

I reach down and gently cradle the baby’s breech in my hand and begin lifting it up and out of the incision. The mother has been pushing for so long on the baby’s bottom that one cheek is three times the size of the other with deep blue bruising and swelling.

Gently I deliver the pale floppy body, arms then head. The baby is completely still and flat.

A vigorous rub with one of the surgical swabs elicits a pathetic whimper, good, still alive. I quickly clamp and cut the cord, hand the baby to the midwife with simple words “rub, rub, rub” and soon enough a healthy, angry cry is heard from the delivery room.

I complete the caesarean and the young mother is reunited with her bruised baby boy. After such a long labour there’s a risk that she could develop an obstetric fistula (connection between bladder and vagina) from the constant pressure, so a catheter will stay in place for at least a week to rest the bladder, which gives me plenty of opportunity to make sure that she will leave with adequate contraception.

The following shift and I feel a sense of deja vu, a 17-year-old girl also in her first pregnancy has been brought in. She too has been left in labour for far too long.

Apparently the girl has been fully dilated since the morning of the day before, it is now early evening. (To put this in context, in the UK a woman would not be left fully dilated for more than three, at a maximum four, hours. Anything beyond could be argued as medical negligence as the complications to both mother and baby increase rapidly at this stage of labour.).

The girl was breathing quickly, her pulse was high and she had a fever. Unsurprising considering the length of time her body had been exposed to infection. Apparently she had been in another hospital, in a different town, waiting for a caesarean section, but there had been a power cut and when the power resumed there was no doctor so she was brought to us.

A catheter was already in her bladder, showing only a tiny amount of dark brown urine. An ultrasound showed that the baby was already dead, possibly since the day before or even longer. I examined her, the head was low down and I hoped that with good analgesia and the appropriate tools I could deliver the baby and avoid a caesarean. There was a risk that with such a long labour she could have ruptured her uterus, but clinically the picture did not fit. So we began resuscitating her with fluids and intravenous antibiotics, she also has malaria so began treating that too.

Once in theatre I examined her again, the smell was unmistakable and hideous - she was clearly badly infected already. Unfortunately the baby’s head was in an awkward position (probably part of the reason why it had not delivered in the first place), making application of forceps unsuitable. I tried to manually turn the baby so that the forceps could be placed, but the condition of the baby made this impossible (I’ll spare you the details).

I knew that the best thing for this girl was to get the baby out, ideally without a caesarean. I attached the ventouse (suction) cap to the head and pulled, it came down, turned a bit, down a bit further and then stopped. The head would not deliver. I tried the forceps again to see if the rotation would allow me to get them on, but no the blades would not lock. After several attempts of trying to deliver the baby it became clear that it simply would not fit, I only risked traumatising the vagina and the girl the more I tried.

So with a heavy heart I explained that we would proceed to a caesarean section. Prior to going to theatre I had called another obstetric colleague to get their opinion on the patient, they were on standby that if things got complicated or I found the uterus had ruptured to come in.

As with the previous patient I mentally thought through the fully dilated caesarean, technique and complications. On entering the abdomen the bladder was hugely swollen and stretched, above the bladder was lots of dilated bowel which was spilling out onto the table. But I knew there was no rush, the baby could not die again, the only thing that mattered was the teenage patient before me. I pushed the bowel back to where it belongs and moved the bladder down out of my way. As expected the uterus was distended, so I carefully chose the safest place to make my incision.

This was one of the most difficult deliveries I have ever had. The baby was too big for the patient and firmly stuck, the head refused to come back up so I tried to find the feet and deliver the other way round but that too was stuck. Again I went to the head and eventually managed to deliver the baby. The smell was awful, there was no doubt to anyone that what was inside her womb had begun to rot.

I quickly cleaned the womb and surrounding area, but there was a problem. After being fully dilated so long, with the difficult delivery and infected tissues her womb had torn downwards to the cervix. I called for help, a second surgeon would be needed. I closed the caesarean wound and as much of the tear as I could, thankfully she was not bleeding heavily.

Once my colleague arrived we carefully examined the uterus. It was terribly infected, the tissue easily falling apart as we tried to repair it. Had she not been 17 years old and childless we would have considered a hysterectomy, but we knew we had to try our best to save her womb. Once the tear was closed and we were satisfied there was no bleeding we completed the surgery and she returned to the ward.

Over the night she continued to show signs of severe infection, she gradually began to wake-up and by morning was conscious enough to talk and move around. We continued to aggressively treat the infection with antibiotics and fluid, but over the day her condition worsened. By lunchtime her body could no longer fight the infection and she slipped into a state of coma, dying shorty after.

Like many doctors in developed countries I have never experienced a maternal death, it is very rare. According to the WHO the lifetime risk of dying during childbirth in Sierra Leone is 1 in 21, in the UK it is 1 in 6, 900.

It is hard to explain the feelings that came with the event; disbelief, sadness, anger, responsibility. But also a sense of helplessness, a 17 year old girl who’s story was already written before she had arrived at GRC, through delay and indifference. I will forever remember watching her pray in front of me, and that I could not answer those prayers.