This blog post contains graphic descriptions of obstetric surgery which you may find upsetting.
It’s kind of hard to believe that four weeks have already passed since I left Fort Smith. The days just kind of run together into one long period of time.
The weekends are the biggest break in the routine. Instead of going in to the hospital at 8:00 am or 8:30 am we get up a little later and usually don’t head into the hospital until 9:00 am, or a little later. There’s a more relaxed feeling around the compound. It’s still business as usual but in a more relaxed way.
We make rounds, evaluate the new patients that have come in during the night and tend to the day’s work but once that’s finished we can head back to the compound with instructions to call us if anything comes.Then we can read a book, watch a movie, or even take a nap if it was a busy night. Weekends are a chance to sort of recharge before the next busy week.
This was a busy week at the hospital. Every night there are at least three or four admissions for malaria. I haven’t seen a case of malaria that was as bad as the woman I told you about, the one with cerebral malaria, but we see lots of patients whose blood counts are so low that it’s a wonder they can even walk. One or two units of blood, usually donated by relatives if we can coerce them, is usually enough to bring them back to an acceptable range. Over here an “acceptable range” is a hemoglobin of 6.0. At home, a hemoglobin of 6.0 would warrant an emergency phone call from the lab that the patient is dangerously anemic. Context is everything.
The most interesting case I saw this week was a woman who walked in looking like the picture of health. She was a little on the heavy side, unusual around here, but not obese by any stretch of the imagination. She was having some vague abdominal pain.
We did a pregnancy test which was positive so we proceeded to an ultrasound that was anything but normal. It showed a uterus that looked like a balloon that was partially deflated. There was an empty space full of fluid where the baby should have been.
The abdomen was full of the same kind of fluid, full of ultrasound “echoes”, irregularities that suggested blood or pus. The right side of her abdomen was unremarkable but on the left side the ultrasound showed a huge collection of fluid and, attached to the top of the uterus, a lot of tissue that looked like placenta would on ultrasound.
Following it even further out led to a 13 week fetus just floating in this fluid collection. By this time I suspected pretty strongly that the fluid was blood and that she had a ruptured tubal pregnancy. It’s unusual to see a tubal pregnancy last until 13 weeks though and even more unusual to see a patient just walking around with what seemed to be minimal discomfort.
I explained to her that she needed to go to surgery and explained what we expected to find, that it was likely she would lose at least one of her Fallopian tubes. She had four living children, so I asked her if she wanted to have her tubes tied but all of her children were girls and she still wanted a boy, so she said no.
Her hemoglobin was on the low side, although not frighteningly low. She had a family member with her who agreed to donate blood so we sent him to the blood bank. We headed to the operating room (OR) and after a spinal block we opened her abdomen.
Even though I expected to find blood, it was still a relief when we got inside the abdomen and found a big collection of it. But it wasn’t a tubal pregnancy that had ruptured. It was something I’ve read about but never seen before; a pregnancy that had ruptured through the top part of the uterus.
I pulled a clot of blood containing the placenta through the hole in the top of her uterus and had it all the way out before I realized that it also contained a fully formed 13 week fetus. The tube itself on that side looked perfectly normal as did the tube on the opposite side. The site of the uterine rupture was bleeding profusely, adding bright red blood to the dark blood and clots that had already accumulated in the pelvis.
The entire area was edematous and swollen, like wet tissue paper. I placed sutures through the tissue but they would just tear through. Eventually we got the bleeding under control, but it took a lot of sutures, and I was worried that she might continue to ooze from all the suture sites.
In the end I put a drain in her abdomen and externalized it through her abdominal wall so we could keep track of any continued blood loss. (I’m happy to report that the drain only put out about 30 ml of blood, two tablespoons, over the next 24 hours and we were able to remove it).
After that it was just a matter of removing all the blood and clots that had accumulated in her abdomen, about a liter in all. She’s done well since her surgery, but her biggest risk isn’t during the immediate postoperative period.
The time she’s going to be at the greatest risk is if she gets pregnant again. The area we repaired is now going to be permanently weak and at a significantly higher risk of rupturing during a future pregnancy. This woman will need a Cesarean before she goes into labor in the future, a fact she’s been made aware of, assuming she makes it that far in her pregnancy.
I asked her if she had any kind of procedure that might have predisposed her to the uterine rupture. I was thinking perhaps she’d had an attempted abortion; someone might have punctured the top of her uterus while trying to abort the pregnancy and the pregnancy had ruptured through the weakened area. She said had not and I think she was telling the truth. I guess it’s just another example of Murphy’s law: if something can go wrong, it will.
I also had a 19-year-old patient come in with her first pregnancy, a set of undiagnosed twins. Twins seem to be diagnosed at delivery more often than not here since most patients have virtually no prenatal care. She presented with a prolapsed cord and two feet hanging in the cervix. She was only dilated four centimeters and the pulse in the cord was only 50 beats per minute.
This was another one of those middle of the night cases. She had traveled in from her home, at least a 30 minute journey, after the cord prolapsed. After she arrived the staff called me. By the time I got to the hospital another 10 minutes had passed and then I had to call the anesthetist in and move the patient to the OR, another 15 minute wait. All in all, probably more than an hour had passed since she had prolapsed the cord and the baby’s heart rate indicated the baby was probably not going to do well.
I really struggled with this one. On the one hand it felt like we should do everything we could to give the presenting baby every chance, but on the other hand it seemed pretty obvious that the baby had already been compromised past the point where it could have a good outcome.
A Cesarean was one option. The second option was to do nothing, to let the baby die while in the uterus, deliver it vaginally, and then deliver the second baby vaginally. I ended up going ahead with the Cesarean just because the staff in labor and delivery had done everything they could do to optimize the baby’s chances.
They had replaced the cord in the vagina, had filled her bladder to elevate the baby, were giving her oxygen to try to help the baby, and even had her in Trendelenberg (head down at about a 30 degree angle) to try to elevate the baby off of the cord.
Sadly, the baby only lived a little over a day. It had just gone too long without oxygen. Had it lived, it would have been seriously impaired. The second baby came out screaming, as expected, but probably would have been healthy no matter which choice I’d made. And now this first time mother has a scar on her uterus that puts her at an increased risk in future pregnancies. Still, the scar is the good kind, the kind that puts her at the least risk.
I don’t think there was a right choice here, just a better choice and a less good choice. I chose the less good choice. Still, I expect that if I were faced with the same situation I’d probably make the same choice again. I think.
Yesterday afternoon a patient came in after being in labor for 48 hours at home. She’d been pushing for over 12 hours. She was running a high fever and the baby was dead. It’s head was visible when she pushed but it was mostly “caput”, the swelling of the top of the baby’s head (the French call it “chignon” which I had always thought only referred to that Grace Kelly bun that women wear on the top of their head).
The midwife I’m working with, Sally (originally from Australia but now living in Atlanta) tried delivering it with the vacuum extractor but the baby’s head was too large. I tried to place the forceps but the head was too large so, for exactly the second time in my career (the first was in Sierra Leone), I had to do a destructive delivery, making a stab incision with a scalpel through the soft spot in the baby’s skull in order to drain some of the brain matter and decompress the baby’s head making it small enough to pull out.
It’s a gruesome procedure and it was made worse by the awful smell of this mother’s infection. There’s a part of you that just disengages from the reality of what’s happening, thank goodness. We were able to get the baby out though, saving the mother an operation through an infected abdomen and pelvis. The baby had obviously been dead for several days which I guess made it easier to come to terms with.
I don’t think five years ago I could’ve imagined doing things like this. The most horrifying thing is not that I’m relatively comfortable doing it now, but the fact that there are places in the world where it’s necessary.
When I think of hospitals I think of porcelain sinks with disinfectant hand soap, glistening surfaces, private or semi-private rooms with individual bathrooms, and pristine operating rooms.
Over here there are communal rooms that hold 20 or 30 people, blood on the floors until housekeeping comes with the mop, “corridors” where pregnant women sleep on straw mats because they didn’t meet admission criteria, and huge open dirt spaces outside where family members sleep on cardboard at night. It’s pretty amazing what we can accomplish given the limitations that are impossible to avoid.
I’m a little past the halfway point now. If it weren’t for the 24/7 call, I think I wouldn’t mind staying longer. But I’m planning on a long, uninterrupted sleep when I get home.