Pippa is an obstetrics and gynaecology consultant from the UK. She is currently on assignment with Médecins Sans Frontières / Doctors Without Borders (MSF) in Jahun, part of northern Nigeria’s Jigawa state – working on a maternity project in an area where a high number of women and children die during childbirth. You can read her previous blog post here.
There are times, after a complicated delivery, when you don’t silently exhale in relief. It’s all too common in these settings.
In Jigawa, the decision to operate is complex.
We talk about women in terms of their pregnancy history: the number of times pregnant, deliveries and how many children are alive. It’s common to have 10 pregnancies, eight deliveries and four alive children or “12, 10, 6” or “6, 6, 2”.
Most women here are pregnant or breastfeeding for all of their fertile life and almost all will have had a number of children die. We know that at least 20 per cent of babies born here will not make their fifth birthday (UNICEF).
Making difficult decisions
In Jigawa, only about 10 per cent of women will give birth in a healthcare facility. So, doing a caesarean section is a big deal.
The operation can leave women with a vulnerable uterus, at risk of uterine rupture that could potentially cause to them to quickly become seriously unwell or even die. And, whereas at home in the UK no matter what you are doing you are rarely more than an hour away from caesarean section, in areas such as Jigawa, life-saving surgery is often hours if not days away.
On the ultrasound scan, I could see a significant amount of blood in her womb."
All of these issues combined makes my decision to undertake a caesarean difficult and mostly for maternal benefit – to save the mother’s life and not necessarily the baby.
Maternal mortality is obviously a devastating event, but the effects it has on the wider families and community, and even nationally, are harrowing. Studies show that in these areas, the children of mothers that die are 15 times more likely to die themselves than those of surviving mothers.
So yes, it’s difficult to decide to operate.
If you do go ahead, you want everything to be perfect but it is so often not. And, when it’s not, you soul-search and reflect on all the steps of your management and wonder if you could have done anything to change the outcome.
“I could see a significant amount of blood in her womb”
Amina came in with an abruption, meaning the placenta had come away from the womb before the baby was born.
On the ultrasound scan, I could see a significant amount of blood in her womb. But, she was stable, no longer bleeding and the baby was still alive. Amina had had two babies before, so usually should give birth quickly. I tried to hurry up the delivery with medication.
There is a hush, the ambient noises and bleeps of machines become more prominent as people focus on the task in hand… resuscitating the newborn."
After a couple of hours, her labour wasn’t progressing quickly. She was still not too unwell, but her blood count had dropped slightly suggesting some on-going bleeding.
So, I made the decision to deliver by caesarean section, which we did.
The operation was routine and during surgery at least a litre of blood was found in the womb, which we removed. Amina was well. No more on-going bleeding; she was no longer at risk; surgery technically was easy.
The baby’s heartbeat was normal before delivery, but I had seen the murky, ominous meconium (a newborn’s first bowel movement) before we had gone into theatre. A sign of a baby in distress. So, at delivery we were careful to assess for meconium with resuscitation.
And here I am, holding my breath again, but this time there is no silent exhale. The room does the same thing, as it does anywhere in the world when things get medically serious.
There is a hush, the ambient noises and bleeps of machines become more prominent as people focus on the task in hand… resuscitating the newborn.
Should I have done it sooner? Would things have been different?"
And still no cry, five minutes now. I am operating on my patient but asking the team what is going on with the baby. What’s the heart rate? Any chest wall movement?
The heart rate is low, 10 minutes now... and the baby is gasping, it’s a little boy!
I know as we transfer the little boy to the neonatal unit that he is unlikely to leave hospital. He is floppy and gasping for air, trying to deal with the lack of oxygen from the abruption, the meconium on his lungs and the difficulty of the resuscitation.
And the room is quiet.
Amina’s little boy
Amina is delighted to have a boy but she doesn’t know yet how sick he is. The rest of the team do and we are sombre. The anaesthetist explains to Amina that the baby needs support.
And I wrestle with MSF obstetrics again. Mother’s life is paramount, but the baby looks bad. This is not what I want and Amina now has a caesarean scar on her womb.
Should I have done it sooner? Would things have been different? Had the baby already been distressed before they arrived in hospital? Should I have not done it at all?
That would be a certain story for the baby and would have different risks for Amina now, but not long-term risks for future pregnancies.
I am in the reflective process. I cycle around my decision-making wondering if I could have changed the outcome, knowing if we were back in the UK that the little boy would do well… Then I have to move on as the next patient arrives and another decision is made.
I go to see the baby later. It is, in my mind, still looking gloomy…
Home now, the next day. I am in the kitchen at the MSF base. The neonatologist is eating lunch:
“Your baby – abruption/meconium aspiration – looking much better. I was surprised, much better.”
So, we will see, maybe Amina’s little boy will be discharged from hospital – maybe – then he will face the fresh insults of being a child under five years old in this setting.
Will he be strong enough for that?