This blog post contains graphic descriptions of obstetric surgery which you may find upsetting.
I mentioned a 17-year-old patient a few weeks ago who had labored at home for two days and then pushed for over 12 hours. She, like most of the patients we see, had not had any prenatal care. It’s fairly common to deliver at home so the fact that she labored there was not unusual.
Her family became concerned when her labor lasted for so long, though, and when she could not push the baby out in spite of pushing for 12 hours her father spoke to someone in the military who arranged for her to be transported in a military vehicle from her home in Pan-Tit to Nyamlel. From there her father was able to hire an ambulance to take her the rest of the way into Aweil. Altogether the trip took about five hours. She left home in the early morning but didn’t arrive at the Aweil hospital until after 1 pm.
She was running a high fever when she came in and the baby had died. We had to do a destructive delivery to get the baby out without resorting to a C-section. She is still in the hospital with a problem unlike anything I’ve ever seen.
Before you read any further you should probably know that there are going to be some graphic descriptions that might not sit well with the squeamish.
When she presented to the hospital the day of her delivery her labia were swollen to about five times normal size, engorged with blood. The pressure of the baby’s head in her vagina had effectively made it difficult for the blood to continue to circulate and the tissues had just become more and more full of venous blood. The effect was like putting a rubber band tight around your finger.
She ran a high fever for the first few days after her delivery. We placed her on broad spectrum antibiotics to cover mainly for uterine infection although the antibiotics provided coverage for just about everything else as well. Because the baby’s head had pushed on her urethra for so long it had become so edematous [swollen] that she was unable to empty her bladder so we placed a urinary catheter. We tried to remove the catheter a few days after her admission but she then had uncontrollable urination so we replaced it, planning to begin clamping the catheter tube to give her bladder muscle time to regain its strength. It was a long, slow process. She continued to spike temperatures in spite of the antibiotics.
When she began complaining of vaginal pain and odor we took her to the exam room to investigate. What we found was unlike anything I’ve ever seen. The entire surface of her vulva and vagina all the way to the cervix was composed of dead, necrotic tissue. Inside it was sloughing off in huge pieces, black and malodorous, so noxious to smell that I had to breathe through my mouth.
She was at a high risk to develop a fistula between her bladder and her vagina or her vagina and her rectum. I was glad she had the catheter in her bladder. That would help minimize her risks. It was pretty obvious that she wasn’t going to heal on her own so I scheduled a trip to the operating room (OR) figuring that I could examine her better under anesthesia. She could barely tolerate being examined because of the pain of the inflamed tissues. She was already on the correct antibiotics so I asked that she not have anything to eat or drink after midnight and scheduled her in the OR the next morning.
The next morning in the OR the tissues looked even worse than they did when I examined her before. The tissues were black and brown, breaking down into almost a liquid type of skin. Beneath the dead skin, once it was removed, were pockets of pus and infection. I spent a while debriding the dead tissue, using scissors to cut away tissue that was dead, trying to get down to healthy bleeding tissue without entering the bowel or bladder or any major blood vessels. Every surface of the vagina was involved, a testimony to how long that baby’s head had put pressure on those sensitive tissues.
After finally getting to relatively healthy tissue I scrubbed the tissues with a dilute solution of iodine and sterile water, trying to remove any of the dead material that remained. And last of all I soaked a large surgical sponge, about the size of dish towel but much more porous, in that iodine solution, squeezed out most of the liquid, and packed it into the vagina so that it was in contact with all of the surfaces of the vagina. The plan was for it to slowly dry out and stick to the remaining dead tissue at the surface of the vagina. When I pulled it out in 2 days it should remove more dead tissue along with it.
Two days later she was back in the OR. I removed the packing and inspected her vagina. It still didn’t look great but compared to the first trip to the OR it was a remarkable improvement. There were still a few infected areas that needed debriding, still a few hidden pockets of pus but there was definite improvement. That was a huge encouragement since I was pretty much just making up the treatment plan as I went. There are some basic principles of treating infection that are the same no matter what the body part.
On her third trip to the OR she continued to show improvement in the tissues. Most of the dead tissue has been removed and now it’s just a matter of giving the healthy new tissue time to grow in. She’ll need to form a whole new layer of epithelium as she heals, the layer of skin inside the vagina that was destroyed by her traumatic birth. I’ll need to keep the packing in the vagina so that the raw tissue areas don’t attach to each other and effectively close the vagina. I suspect that’s what happened to the woman I mentioned a few weeks ago who came in with a vagina that only admitted a small finger and who had a fistula between her urethra and her bladder.
So I’m pretty thrilled that she’s doing as well as she is. I expect she’ll be staying in the hospital for a few more weeks, probably until after I leave, so I won’t get to see her healing through all the way to the end but I think she’s on the right path and that’s tremendously satisfying. I just hope she waits a while before she even considers another baby (I’m going to push for a birth control implant) and I’ll tell her that she really needs to be in the hospital for the birth of her next child. This is one woman I wouldn’t hesitate to take to the OR for a C-section.
I know it’s hard to read about, much less hard to see but I mention her because I think she demonstrates some of the challenges of taking care of women in parts of the world like this. I can’t imagine something like this happening back home and even if, by chance, it did I can’t imagine ever seeing patients like this back home with the regularity that I see them here. The things we take for granted are luxuries that most people here never have the opportunity to experience.