Fieldset
ER mode: My last patient in Nigeria

Pippa is an obstetrics and gynaecology consultant, recently returned from assignment with Médecins Sans Frontières / Doctors Without Borders (MSF) in Jahun, part of northern Nigeria’s Jigawa state – an area where high numbers of women and children die during childbirth. 

I make a point of trying to remember my last patient. 

This is a shorter assignment than my previous ones with MSF. So, with that I don’t get into a zone when the complexities and shocking cases that come through become less extreme and more of a daily occurrence.  

Sierra Leone

I remember my last patient in Sierra Leone – a 14-year-old who arrived with sepsis due to tissue that was left in her womb following an unsafe abortion. Her teacher had got her pregnant.

Too young to have a baby, unmarried and with the baby being a product of rape, she did what many desperate pregnant women do, which is to seek an unsafe abortion. 

In this case, it was a twig in the cervix by the traditional healer outside her school. So, she was sick, very sick, and without treatment she may have died. However, we took the damaged tissue away and she got better, so a happy ending to a particularly horrendous story.  

It was one story of many that come through MSF’s services, and my last patient in Sierra Leone.  

Abortion is an emotive things, but there are also facts about it.

If governments criminalise abortion and legislate against it, it does not change the amount of terminations that occur – it merely increases the number of unsafe ones that occur.

Unsafe abortion contributes to 8% of global maternal mortality. In a conflicting discourse, but in fact, safe abortion services save lives.  

Uterine rupture

Back to my last patient here in Jahun. Her story, I guess, starts ten days previously with a venture into the culinary delights of “Jahun Paradise”, where we bought some super tasty smoked brochettes from the market. 

They were excellent going down, but seem to be making themselves felt 10 days later in the form of abdominal cramps and low grade fevers… but today the nausea has set in.  

This is fine and manageable, and to be expected, but after 10 days I am feeling a bit low, physically, from it. Unexpectedly, I almost fainted at the smell of an infection and stumbled over after a caesarean – which is obviously high-risk in an operating theatre.

Anyway, so I’m busy finishing a procedure when I get an emergency call from the team in pre-delivery. We have a uterine rupture – when the uterus tears open.

The doctor is compressing her aorta. This is what you do when things are serious.

Our team had been inducing a lady who had already suffered a massive abruption, meaning the placenta had detached before the baby was born. She arrived with less than half the normal blood volume. Her baby had died some time ago, and she was not actively bleeding, so we gave her a blood transfusion to get her into a safer position and started the delivery process. 
Somehow, during delivery, she has had a uterine rupture. Now, this is a complication we try and avoid.  

This is one patient of about 50 with exactly the same case history that we have looked after over the last few weeks, and all those patients delivered and were largely healthy. But, unfortunately, this lady had a uterine rupture AND is actively bleeding.

“ER mode”

I run over to the delivery room and assess her. I see the amount of blood around and I am hugely aware she is moments from losing the ability to clot her blood. (This happens with massive haemorrhages, a kind of medical "Catch 22" you bleed and then your blood looses the ability to clot and therefore loses the ability to stop you bleeding so you bleed more: not ideal.)

So, we make a plan for a laparotomy (an incision into her abdomen for major surgery). She has already delivered the stillborn and the doctor has examined her, diagnosing anterior uterine rupture.

And now we are in proper ER mode…

The doctor is compressing her aorta. This is what you do when things are serious. A kind of last-ditch attempt to stem the blood flow from the womb by stopping the blood flow to the entire lower half of the body with a fist on the abdomen, compressing the main blood supply from the aorta.  

There is a lot of blood about. The lady has passed out because of blood loss . The midwives are running around organising masses more so we can give her more blood as soon as possible. 

And crash, doors open, doctor still with his hand firmly compressing the patient’s aorta and another midwife squeezes through the fluids… and we are in theatre.  

And me? I run back to theatre: make sure they are ready, ask my most experienced OT nurse to help me and get the team prepped for what is going to be pretty hectic surgery.  

And then the brochettes are still there. I feel a cramp, which is a slightly awkward situation to be in. Then I remember… Japan, the other obstetrics and gynaecology specialist is back at the MSF base. If there is ever a time I need a hand it is definitely now, so I call her and she’s on her way in. 

Breathe.

And crash, doors open, doctor still with his hand firmly compressing the patient’s aorta and another midwife squeezes through the fluids… and we are in theatre.  

Anaesthetist doing his thing, OT nurses scrubbing at her abdomen around the hand of the doctor compressing her aorta (or, more accurately, keeping her alive). And I am there, scrubbed, with plastic apron on. Goggles. Gloves. Scrub gown. Itching for the anaesthetic to be sorted, with scalpel in hand… and phew, Japan is now opposite me. 

And boom. The starter gun is sounded when the anaesthetist says "go".

It's abdomen open and through the layers. The darkness below the peritoneum – the abdominal membrane – is as expected, indicating massive haemorrhage. Usually abdominal fluid is clear. 

And boom. The starter gun is sounded when the anaesthetist says "go".

And bang, through the peritoneum. Our suction to remove the blood is pathetic, like sucking on a straw to get the tide to come in. 

I reach in and grab the womb through the incision on her abdomen. It’s me and Japan, grabbing instruments and clamping tissues a bit indiscriminately. First anchoring the tissue and then clasping the spurting arterial bleeds.

Japan and I work away… and the tear is finally secured with clamps. It goes deep down towards the bladder. 

Stitches now. We find the angles of the tear and secure them. We are safe now, well, safe-ish. 

Haemoglobin of two

The blood is not clotting, so we stitch the tear closed, place another layer of sutures over the tear and then slow down a bit. The major bleeding from the tear is secured. 

Now we wait...

We give it time and compression and hope the head end (the anaesthetist and the blood) can catch up with us. We have done what we can for now. Now she needs her blood to be able to clot, which will only happen with blood transfusion.  

We sit with her womb between our hands, applying pressure on the wound to stem the oozing from everywhere with the occasional stich. But we both know it’s the blood she needs now.  

One unit of blood, two units, the third on its way. We are getting there, but the body takes time to catch up.

Her haemoglobin (red blood cell count) is two. The minimum for a normal pregnant woman is 10.5. However, in Jahun, where severe malnutrition is endemic, we could say she probably walks around quite happily with a haemoglobin of eight or nine. 

Two is less than a quarter of the blood she needs to carry oxygen to her vital organs.  A dangerously low level of haemoglobin, I am surprised that she is still alive.   

So, one unit, two units, the third on its way. We are getting there, but the body takes time to catch up.  

But time is the thing, and we are hoping her womb stays contracted and that we can close her up. We talk about putting packs in that we could remove after a few days.  

And then, as is the way here in “Jahun Paradise”, the phone goes… 

A new case. Abruption. Bleeding. Live baby. We need to open another theatre.

It’s midnight now, so we scrabble around and call in the team from their beds to open the second theatre. All the time, drip, drip, drip, the blood goes in and still oozes out of our patient’s wound.

And so there it is, my last patient. I nip the other operating theatre next door and do what is now a fairly routine procedure. You know, only one litre of blood in her womb. The baby comes out crying and it takes a few minutes to close up.

Meanwhile, Japan is next door closing up our lady whose blood is now clotting (awesome) and on her way to recovery.

Oh, and there it is. The brochette speaks to me again and the nausea builds up.

Japan saves me by staying to do the next case… 
 

Top image shows a scene from the maternity ward in Jahun, taken in 2017.