This week is going to be a hard one to top, I think. It was one of those weeks that it’s easier to look back upon than to live through. It was one complicated patient after another, all of them very sick, and more surgical emergencies than I would see in a couple of years back home.
It all started on Sunday when I got a call from one of the national staff midwives. She was evaluating a patient who had come in with abdominal pain after being in labor at home for over 24 hours. She was exhausted from pushing for over four hours before one of her family finally brought her to the hospital. The fetus was dead. On exam the head was high out of the pelvis. She was exquisitely tender over the upper part of her left abdomen and her blood counts were low, low, low. An ultrasound confirmed that her uterus had likely ruptured and that her abdomen was full of fluid, almost certainly blood.
We notified the operating room (OR) and the anesthetist while I explained to her through an interpreter that her uterus appeared to have ruptured while she was in labor. I explained to her that there was a strong possibility that we would have to remove the uterus and that meant she would no longer be able to have children.
Not surprisingly, of the two children she had already given birth to, the first had been born by C-section while the second had been born vaginally. The biggest risk factor around here for a uterine rupture is a previous C-section. The certainty that she had ruptured her uterus went up to close to 100%. She gave us consent to proceed to the operation and we moved her to the OR.
Upon opening her abdomen and entering the peritoneum, the thin film of tissue that holds the bowels inside the abdominal cavity, there was a great deal of dark blood. The uterus had indeed ruptured and the fetus was floating in the mother’s abdomen in a pool of the blood. The placenta had partially separated and the uterus had contracted down partially, preventing a possibly catastrophic blood loss for the mother.
After removing the fetus and the placenta and removing as much blood as possible it was pretty obvious that there was no way to save the uterus. The rupture had started at the old C-section scar but had extended along the left side of the uterus almost all the way to the fundus, the top of the uterus. The muscle had retracted making it impossible to reapproximate the muscle edges for closure. Even if I had been able to close it was at a high risk to rupture again in a future pregnancy and when that happened she might not be as lucky as she was tonight. An enormous volume of blood flows through the uterus and it wouldn’t take long to bleed to death.
The hysterectomy itself went smoothly and postoperatively she was a great patient. She was up and walking the next morning and went home four days after her surgery. I told her again after the surgery that she was no longer able to get pregnant just to make sure she understood. She understood and said she was grateful for the two children that she had.
Stephen wrote this post in March 2015