I began my day like all others, sitting down with the gynae who had just completed the previous 24 hours, sipping a black coffee and going over the previous shift’s admissions. It’s a sort of handover, debrief and case discussion rolled into one. Sharing the joys, and inevitable frustrations of managing complex cases with only basic resources.
There was one patient of special concern: A 37-year-old admitted early the previous afternoon, this was her fifth pregnancy however all four births had been stillborn. She had arrived feeling unwell, headaches, visual disturbances and central abdominal pain. Her blood pressure was 240/160 (the highest I have ever known) and her urine showed maximum amounts of protein; there was no denying this woman had severe pre-eclampsia.
The baby was still alive, but she was very premature at 30 weeks gestation. During the shift the gynae had struggled to gradually bring the blood pressure under relative control. The lady was now already on three drugs (including powerful intravenous medication) and still the pressures were creeping up into a range high enough to cause a stroke. Magnesium had been started to reduce the risk of eclamptic seizures, and steroids given to help prepare the baby’s lungs for an early arrival. Medication to try and get labour started had also been cautiously given.
We all agreed that this pregnancy would need to end, the only definitive treatment for pre-eclampsia.Though we also knew that this baby was so precious to the woman and that we needed to find a way to give them both the best chances. Despite several doses of medication to encourage labour the woman felt nothing happening. The baby’s heart rate was fine, but still the blood pressure was a struggle and the woman continued to have symptoms from the disease.
I could see the dismay and confusion on the woman’s face. The baby is alive, why are they making it come so early? I sat next to her and with help of a national staff explained gently to her how much we all wanted her to have a baby to take home. If the pregnancy was left to continue the baby would almost certainly die before birth, if she was left untreated then she herself could have major complications including death (and so the baby would also die). Delivering the baby now was early, and due to the pre-eclampsia it may be quite an unwell baby at that, it was true there was a high likelihood that the baby would not survive, but there was at least a small chance. She nodded sadly, resigning herself to whatever would be.
Again, the case was discussed. Time was passing by and no sign of labour beginning. The BP still a battle and coming up to 24 hours since magnesium was started. As a group we agreed, if by 2pm there was still no change to deliver by caesarean. At Gondama Referral Centre (GRC), though there are paediatricians, we do not have them present at deliveries. A neonatal nurse would be called by the midwife only if a problem arose. But we decided that this woman needed to see and know that we were true to our words. I went and spoke to the paediatrician and explained the case, and the woman’s poor obstetric history. They would come to receive the baby if able.
At 2pm there was no change and the BP still fighting to get higher, but there was a new problem. The midwife could not find the baby’s heartbeat. Shit, not now. I quickly performed an ultrasound scan; the heart was beating, but very slowly and we did not know for how long. If we were getting this baby out alive it had to be now.
Everyone was called, “We have to go now, fast, fast, fast” (GRC is not usually a fast paced place). The anaesthetic nurse appeared, and I quickly explained the issues, if you can get a spinal in fast that would be best (spinal anaesthetic also reduces blood pressure). He was on it. I called the paediatrician (who also happens to be housemate); she was coming… and bringing a team.
In the theatre I was scrubbing, I did not want to give this woman her fifth stillbirth. The second the spinal was in we cleaned the skin, checked the anaesthetic block was working and went for it. Quickly the unexpecting uterus was before us. I carefully cut through the thick tissues of the premature womb, avoiding breaking the amniotic membranes. Gently I peeled the membranes off the inner walls, lifted the delicate head to the bulging sac now presenting through the incision.
Premature baby’s are easily traumatised, so delivering the baby still inside the sac provides a naturally protective cushion. It ruptured as the delivery completed. I took the cord- clamp clamp cut. As gently as possible I passed the pale, floppy baby to the waiting nurse who then relayed it to our waiting neonatal team. I was pretty sure the baby was dead on arrival. I saw no signs of life in the few seconds I had. The caesarean was completed without complication. In the theatre we were in near silence, waiting to hear if any cry came from next door.
A baby girl, weighing 1.13Kg, fighting even harder than we did to stay alive. One day at a time, but for now she is doing surprisingly well in the neonatal unit. Amazingly the next morning the mother was already on her feet so she could go and begin caring for her daughter. Her blood pressure immediately became easier to control, but she will need to stay and be observed as the postnatal period is not always clear sailing. I have explained that in the next pregnancy she can take a medication (a routine part of antenatal care in the UK) to help prevent, or minimise, the same complications from happening again.
Everyday in GRC there are sad stories, both obstetric and paediatric. But for this woman together we all united to try and give her (and I guess ourselves) the one thing she needed: a happy ending.
The story is far from over, the baby is small and premature, and born in Sierra Leone (which according to UNICEF has the highest under-five mortality rate globally). At least for now we can look into her eyes with a knowing smile, we tried.
These photos were taken on the baby’s one week birthday! Mum has also now been successfully discharged.
Update 27/08/2014: Mum and baby are doing well.
Update 12/09/2014: Baby discharged!