It's a dangerous thing......

I would like to preface this post by saying that if you are not medically inclined it might be a little too boring.  And gross.  Sorry.  You were warned.

Last night I was working during the evening.  When I got to work we had zero OB patients….the first time I’d ever seen the ward empty.  I was hanging around, just in case something came in.  Kadiatu was having a bit of a rough time and at about 6 I went up to the house to change my clothes after she’d peed on me.  Again.  I was just about to jump in the shower when I got a call that they needed the ambulance to go out.  I grabbed Kadiatu and we ran down to the hospital.  Fortunately the rest of the hospital was quiet so my friend agreed to watch her for me while I went out. 

We were going to an area that isn’t served by any health center. It’s kind of in the middle of nowhere and neither of the closest health districts will claim responsibility for it.  For some reason (impassable roads?) we couldn’t go directly to them but were going to meet them at an arranged meeting place and pick up the woman.  The ambulance driver told me it was going to be 2 hours one way.  Oh dear. 

The road was pretty bad the whole way, oftentimes barely resembling a road.  We ended up reaching in about an hour and 15 minutes and the woman was just sitting on a bench (the driver told me he said it was going to take longer so I would be pleasantly surprised when we got there sooner.  Nice call. Very un-Sierra Leonean!)  She was weak but was able to walk. The story we got was that she’d been in labor since the night before. She wasn’t bleeding and hadn’t urinated or had a bowel movement in a long time.  It was her first baby. 

When I first started going on the ambulance I would always want to do some exam. Do a vaginal exam, listen to fetal hearts, etc.  I’ve come to learn though, that usually what we need to do is just get to the hospital quickly. If the woman’s not bleeding, really weak/unconscious and/or seizing, I usually just scoop and run.  That’s what we did with this lady.

After going back over the wonderful road again (can’t even imagine doing it when I’m in labor!) we reached the hospital.  (This is where I may be a little too graphic for some of you so….sorry).  We took her into the labor ward to get her checked out. Her blood pressure was fine, the baby was full term.  I listened with the Doppler but didn’t hear any fetal heart tones.  Honestly, I would have been shocked if I had.  When I did the vaginal exam the baby’s head was almost crowning.  When I stopped to look at the woman, I noticed that she wasn’t contracting very much.  If she’d been in labor for that long, her contractions should have been coming hard and fast.  I decided to start an oxytocin drip to see if we could strengthen her contractions. I also attempted to insert a foley catheter to drain the urine since they said she hadn’t urinated in a while.  The only foley I could find was huge, but I decided to try.  It was difficult because the head was so far down. I pushed and pushed but got no urine, just started to get some blood.   Huh.  Well, I left it and decided to let her try for awhile and then use the vacuum to try to get the baby out.  Since this was her first pregnancy I wanted to avoid a c-section for a baby that wasn’t alive. 

That’s where I was when the cavalry showed up.  I love having a cavalry here!  In addition to the two doctors we have here who are pretty much on call 24/7, right now we also have a Sierra Leonean doc who’d doing a surgery residency and a doctor hanging out with us for 7 weeks.  Anyway, they came in and one of them immediately mentioned an odor.  Huh.  I hadn’t really noticed.  I felt bad, but honestly there are so many smells in this country that are unfamiliar to me…I don’t always notice the bad ones from the really bad ones.  Opps.  Anyway, I told them what was up.  I couldn’t find any fetal heart tones but asked if we should use the ultrasound to try and confirm.  They confirmed that indeed, the baby was already gone.  Next we looked at getting this baby out.

They tried to use the vacuum but agreed with me, that her contractions just weren’t coming very strong. There was also the problem of the full bladder. We tried using two other catheters but couldn’t get any urine to come out.  They could feel the bladder and it was really distended. It could have been what slowed down some of the progression in the first place.  We also started to suspect a ruptured uterus.  Although her hemoglobin was fine, something just didn’t seem right.  When her uterus was contracting, it was firm at the top, but not at the bottom.  But was that just because her firm bladder masked the firmness of the belly, or was it indeed soft?  In America they tell us that one of the ways you know that a woman has ruptured her uterus, is that she is writhing around in pain.  Not so much here. It’s very difficult to tell.  You can try to use the ultrasound, but it can be difficult to see.  We decided that since we were no questioning a ruptured uterus and couldn’t seem to get the baby out with the vacuum anyway, we would head to the OR for a C-section. 

OB can be such a fun place to work…when everything goes like it should. But cases like this, where we already knew the baby was gone….no fun.  Also, because of the smell we were suspecting that the baby had been gone for awhile and had started to decompose. 

The first thing they had to do after opening her up was to drain her bladder. They couldn’t even get to the uterus, it was so full.  They ended up using a large bore IV catheter to put a hole in the bladder to drain it.  She probably put out about a liter of urine.  After that was getting the baby out.  One of the docs told me I needed longer gloves to help them.  Wait, what?  Because the head was so far down, I needed to go under the sterile field and help push the head up through the vagina to help the doc break the suction and be able to pull the baby out.  When my time came I got down on my hands and knees and started to push.  I wasn’t confident in what I was doing because I’d never done it before and the doc who had his hand at the other end started saying, “Push. Push, Emily.  Emily Push!!”  It was on the tip of my tongue to comment that it sounded like he was trying to get me to deliver…but didn’t think it was the time.  Thank you social filter.

The baby came out and it had definitely been gone for awhile.  I took it into the other room, cleaned him up a bit and went back into the OR.  When I came back in the room they were looking at a badly ruptured uterus.  At this point I usually leave but since it was a pretty rough surgery I stuck around in case they needed me to go grab stuff. 

They finished the surgery without any major complications and took her back to the ward. I headed up to bed.  When I got there the next morning and asked the nurse how she did overnight I was pretty surprised to hear that she wasn’t doing well. I kind of assumed that she was going to be doing fine. Apparently they had called one of the doctors down at five thirty when the nurse couldn’t find a blood pressure or feel a pulse.  They did everything they could for her which included giving her a mask for oxygen.  That’s pretty much it. Her hemoglobin that morning was fine, but she just wasn’t doing well.  The doctors came by a little bit later to do rounds and we sat around trying to think of anything else we could do. We suspected that she was in septic shock.  The baby had been gone inside of her for so long that the infection had spread to her bloodstream, making her incredibly sick.  We gave her some more antibiotics and hoped for the best.  None of us were very optimistic.  At 10:04 this morning I was turning her to get her cleaned up a little bit and she stopped breathing.  That was it.  She was gone. 

Of course the doctor from America and I were going over the things we could have done if we were home but it really only served to make us frustrated at the lack of resources here.  Her first baby…and it killed her.  With one in eight women dying in childbirth, Sierra Leone has one of the highest maternal mortality rates in the world.  The hospital where I work does an incredible job in saving so many lives….but it still hurts when there are ones we can’t.