Fieldset
Just another night

I remember my busiest weekend in private practice. It started on a Friday at noon and stretched on until early Monday morning. One patient after another came in either in labor or with some complication that made it necessary to induce labor.

I remember my busiest weekend in private practice. It started on a Friday at noon and stretched on until early Monday morning. One patient after another came in either in labor or with some complication that made it necessary to induce labor. At the end of the weekend I had delivered 15 patients, more than double what we considered a busy weekend. The majority of those deliveries were uncomplicated normal deliveries.

In the last 24 hours alone I had 16 deliveries, Seven by C-section, nine vaginally, and only two of those deliveries were uncomplicated. I had three true emergencies. One was a transfer from Kenema, a woman who had delivered two babies previously, neither of which had been born alive. She had been in labor for over 24 hours.

When she arrived the baby’s heartbeat was only 80 beats per minute, well below the healthy range. The nurses, seeing that she had no living children, went into overdrive to get her to the OT for a C-section and we had the baby out in less than 10 minutes but the baby couldn’t be resuscitated. Sometime between the time she left Kenema, where they had a recorded a normal heart rate for the baby, the baby had gotten into trouble. It’s only a two hour drive but for this baby they were a critical two hours.

I had to break the news to the husband and family who had come with her and it was heartbreaking. They all sobbed, grieving openly, and the nurses cried along with them. When I had to tell the patient that the baby had not survived she was stoic and expressionless, in stark contrast to her family. I know that it was a facade, a coping mechanism, but somehow that makes it even more sad.

The day was full of patients like that. A patient came in convulsing with high blood pressures and her baby was also dead. We had to induce her labor while controlling her seizures and managing her blood pressures. A 17-year-old patient whose clinic records identified her as HIV+ stated adamantly that she did not have HIV. When we retested her she refused to believe the results. Needless to say she hadn’t been taking her antiviral medications during pregnancy, increasing her baby’s risks of acquiring the disease. When we encouraged her to take the meds for the sake of the baby she reluctantly agreed but it’s clear that she won’t continue to take them after the baby is born. The best we can hope for is that she will continue the baby’s regimen in the coming weeks.

A 15-year-old came in in labor seven weeks early and the baby was in the wrong position, feet down. She was already seven centimeters dilated so we had to rush her back for another emergency C-section. The fear is that her water will break and the cord will prolapse or the baby will deliver up to the neck but then become trapped as the cervix contracts back down. During the C-section that’s exactly what happened in the incision I made in the uterus. Because of the baby’s position and prematurity the portion of the uterus that is usually wide enough to deliver the baby was instead very narrow. It was wide enough to deliver the baby’s body up to its head but as the uterus contracted the baby’s head became trapped. The only option was to make another incision on the uterus to release the baby’s head.

That’s all well and good for the baby whose head delivered easily after the additional incision, but the 15-year-old mother now has a scar through the thickest part of her uterus that will dramatically increase her risk of a uterine rupture in future pregnancies. I will warn her that she should have a scheduled C-section before she goes in to labor in the future but with the health care system the way it is here there is no guarantee that she will even have that option. That scar makes any pregnancy in her future a potentially life-threatening condition for her.

It was a revolving door in labor and delivery. I would be changing clothes from a C-section when the nurses would say another two patients had arrived. Or I would be finishing the paperwork on a routine delivery and would hear a siren heading up the drive. For the entire 24 hours there was rarely more than 15 minutes when I wasn’t moving from one patient to the next.

On the bright side the day flew by. When I looked at the clock and saw that it was almost midnight I couldn’t believe it. I had noticed it was getting dark so it wasn’t a complete surprise but the previous 16 hours were just a blur. I keep a log in my pocket so I can write down the essentials on each patient; it makes it easier to do the handover to the doctor who comes on call the next day. By midnight I had admitted 10 patients, half of whom had delivered naturally and half by C-section. If you’ve done the math you know that means that six more patients came in during the night and two of them delivered by C-section.

At exactly 4:43 a.m. (I know this because I was writing a note and had just written down the time) an ambulance pulled into the drive. A 35-year-old woman came in by stretcher. She didn’t appear to be in much pain, just looked anxious and a little frightened. Her husband was following behind her. I didn’t actually notice the patient bleeding but I noticed that the husband was leaving bloody footprints behind him. Then I saw the line of blood that followed the stretcher and my adrenaline kicked in. The ultrasound was in the unit so I slathered gel all over the patient’s belly to determine the status of the baby. There was a heartbeat but it was slow, only about 60 beats per minute. And one quick look at the placenta confirmed that it was abrupting, separating prematurely from the lining of the uterus. I wasn’t optimistic that the baby could be saved but it had to be delivered emergently just to get the bleeding to stop. A quick look at the mother’s conjunctivae, the pink lining under the eyeballs, showed them to be almost white. She had lost a lot of blood.

Her blood pressure was very high, 220/120, and she was spilling large amounts of protein in her urine so we knew she was preeclamptic. That explained the abruption, a condition that is much more common in hypertensive disorders. She was 35 years old and had three living children and in the process of getting her consent for the operation I asked her if she wanted her tubes tied. Through a translator she answered that she did but we would have to ask her husband. When we asked him he didn’t hesitate. “No.” And that was the end of that. I pegged him as the type of man who views his wife as his property and had no real consideration for her wellbeing. But she wouldn’t have a tubal ligation without his consent so the discussion ended there.

We were able to get her husband and another family member to go to the blood bank to be screened for blood. We try to get everybody who is with a patient to donate blood since we are usually low on blood products. This patient was going to need several units. Fortunately she had a common blood type.

We got her back to the OT and after the ketamine anesthesia made the incision and quickly got down to the uterus. Her uterus was discolored, black and blue like a giant bruise, from all the blood that had dissected through the muscle wall after the placenta began separating. I made the incision in the uterus and was met by at least a liter of blood clots and blood. I got the baby out quickly and handed it off to the pediatrician I had called and he rushed out of the room to start trying to resuscitate the baby, who did not look good. When I turned around the placenta was floating out of the uterus on another wave of blood and clots. It was running off the table onto the floor, making huge puddles everywhere. The anesthetist was having trouble getting a blood pressure and her pulse was in the 150s. Two units of blood arrived at about that moment and he hung both units and began running them through both IV lines.

We administered drugs to force her uterus to clamp down but they weren’t effective. I massaged the uterus until it my hand was cramping but it still stayed floppy like a big balloon while blood poured out of it. I closed the incision, hoping to control some of the blood loss, and continued to massage the uterus, convincing myself that I felt a little tone coming back into it. That must have gone on for just a minute or two although it seemed like much longer but finally I had to admit that we weren’t gaining any ground and she was losing a lot of blood.

“We need to do a hysterectomy,” I told the anesthetist, a devout Muslim. He looked shocked and said, “But the husband said he didn’t want her to have a tubal ligation.” He knew that the ability to have more children would be gone if we removed her uterus. I knew I couldn’t leave the OT so I asked one of the nurses to go explain to the husband what was happening, that she might die if we didn’t get the bleeding under control and the only way we had left to accomplish that was to remove the uterus. She was gone for about five minutes but when she came back she had a signed consent form.

And then the uterus began to contract. What had been a floppy balloon was now a semi-floppy muscle mass. I continued to massage it and it became downright hard. It seemed pretty miraculous but we were all thrilled at our good fortune. We watched her for another 10 minutes but the uterus stayed firm so finally we closed and moved her back to the recovery area. She had received two units of blood and her hemoglobin was still low at 5.0 but not critically low. Her conjunctivae had some pinkish hue again.

Another patient came in. She’d had two previous C-sections and was in labor. She was only about five-feet-tall and had a huge abdomen. We got her ready for surgery while the OT was cleaned and had an uneventful C-section. We were wheeling her out of the OT when the nurse who was taking care of the lady who had almost had a hysterectomy came running up breathlessly. “Doctor, please come assess,” was all she said. I followed her and my heart sank when I saw the patient in a bed full of blood. I pulled on my long gloves and checked her uterus, not an easy thing to do in someone who is fresh out of surgery. It was as floppy as it had been in the OT.

We opened up her IV fluid, sent out another request for blood as quickly as possible. I saw her husband standing nearby and asked a nurse to come with me to translate. He looked frightened. I suppose anybody would be when seeing a loved one surrounded by that much blood. I asked the nurse to tell him that I had hoped we could save her uterus but that we couldn’t afford to wait, that she was losing too much blood and we needed to stop it now. As she began to translate into Mende, the language the patient spoke, he answered me in english, “I understand. Please save her.” His eyes were moist. I felt like a fool for having so easily characterized him as just a man who saw his wife as property. It’s easy to make everything black and white for convenience when human behavior is infinitely more nuanced.

We got her back to the OT at 6:30 a.m. Maybe it’s just my good fortune but it’s always seemed to me in obstetrics that when you reach that point where you really can’t afford to have another distraction everything just seems to pause. From 6:30 a.m. until 8:00 a.m., the amount of time it took to do the hysterectomy and stabilize the patient, not another patient showed up on labor and delivery. During the previous 24 hours there had not been a 15 minute gap when someone wasn’t coming in or a patient who was already there wasn’t developing a critical condition. For that hour-and-a-half I didn’t have to focus on anything but what I was doing in the OT. The operation went well. She had lots of oozing from various sites but she continued to form blood clots so I knew she wasn’t in full-blown DIC. I left a drain in her abdomen just in case she had bleeding afterwards.

I spoke to the husband after the surgery and he was gracious and thankful. I’m off today since I was on call yesterday but called the hospital earlier to see how the patient was doing. The nurse told me the drain was only putting out small amounts of blood. The husband had called family members to come donate blood and the blood bank received seven units total. Most of them will be used for other patients but my patient received three more units and was now stable with a good blood pressure. Her husband has not left her bedside since the surgery.

8 a.m. arrived and I finished writing my postop orders. My replacement walked in and saw every bed full after we had discharged 15 patients the day before. “Don’t ask,” I said, but then I proceeded to gleefully give her more details than she probably really wanted. Afterwards I made the car ride back to town, back to the house. I walked past the kitchen and straight to my bedroom where I fell into bed fully clothed. When I woke up four hours later I was still in the same position. No electricity. No fan. Drenched with sweat but feeling very rested.

And I think I’ll sleep well tonight too.