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Field Blog: Obstetrics in Sierra Leone
August 29, 2013
Sierra Leone 2012 © Lynsey Addario/VII
Today while making morning rounds I stepped on a rooster’s foot. That NEVER happened back home! The screen door hadn’t closed properly when someone came in or went out and the rooster decided he had as much right to be there as anybody. He let out a horrible squawk when I stepped on his claw and then batted his wings angrily at me and started pecking my foot. It was a little unexpected and I may have overreacted just a little but it gave all of the postpartum patients a good laugh. I’m not sure if I should be embarrassed or proud for how far I jumped but I managed to laugh along.
I survived my first 24 hours on call but am just amazed at the types of cases I saw. In an ordinary year of practice you might see a few of these types of cases every year or two but over here it’s a daily occurrence, largely because it’s a referral center for cases just like these. The maternal mortality this past month was about 3% so for every 100 women who presented in labor only 97 would go home. That factors out to 3000 for everyone 100,000 women compared to around 16 per 100,000 in the United States.
I saw a woman yesterday who had been in labor for six days, was diagnosed two days ago as having too big a baby to deliver vaginally, but it took almost 48 hours for her to make the trip from the southern part of the country over rough roads full of potholes. She was exhausted, semi-delirious, running high fevers, and barely conscious. The baby had had a bowel movement and that was draining from the mother but the baby was still alive. It was a true emergency but there is no general anesthesia here so we did the Cesarean under ketamine, an injectable anesthetic that allows the patient to keep breathing on her own. We got the baby out and it still had a heartbeat but its chances of surviving aren’t great. Mom’s uterus initially refused to contract down to control the bleeding but eventually responded and we didn’t have to remove it. But the mom is still running high fevers and has very low urine output, lost a lot of blood and doesn’t have any available blood donors (family members are asked to donate blood if a patient needs blood) and is O negative, a rare type of blood here in Africa. Rh negative patients are few and far between and therefore it’s hard to find matching blood. They make great donors because their blood can be given to patients with most other blood types but they make lousy recipients because they are incompatible with almost all blood types except their own. Her hemoglobin count this morning was 3.1. Yours and mine is usually 12 or 13 or more so she’s operating on about a quarter of what we would consider normal. In her favor is that she’s probably chronically anemic and may be better able to tolerate the anemia. Also in her favor is that there are no insurance companies over here and there is no limit on how long I can keep her in the hospital. If it takes two or three weeks or more in the hospital to help her recover then that’s how long she’ll stay.
And that was only the first of seven cases including a ruptured tubal pregnancy with over a liter of blood in her belly even though she was walking around and denying pain in her abdomen. The only reason she came in was because she was having some discomfort in her shoulder, probably because she had a belly full of blood. There was a complete placenta previa who came in bleeding heavily at eight months. Fortunately she had family with her so we were able to give her two units of blood during and after the surgery. [Placenta previa occurs when a baby's placenta partially or totally covers the mother's cervix. Placenta previa can cause severe bleeding before or during delivery.] All of the cases were like these which is to be expected in a place where the normal labors are referred out. Still, it was a little overwhelming to be confronted with all these complications just one right after the other. (I also found that I felt right back in my element. I had been afraid that not having worked for the past nine months might make me rusty but it’s kind of like riding a bike. It comes back quickly.)
Sierra Leone lost most of its doctors during its protracted civil war. Most of them left for greener pastures and there’s a massive shortage of trained professionals and most of the new doctors that are trained end up leaving the country as well, knowing that they can do better elsewhere. In response to that the government has set up a program to train Community Health Officers (CHO) to fill the gap. These are young men and women who are trained in some of the technical aspects of surgery and management of complicated patients without a large knowledge foundation. I did two Cesareans with a CHO named Amado yesterday and let him do most of the work. He’s very capable and tells me that he would like to go back and become a doctor but for the time being is glad to be employed doing what he is doing. He is in the second class of this project and says that most of his colleagues who have graduated have already found good employment in outlying areas where they are badly needed.
Only four out of five children survive to their fifth birthday in Sierra Leone. That statistic is just astonishing to me but I think it explains the passive reaction of the mother when I tell her that her baby has died. There is no show of emotion, just a resolute stare. I don’t think they grieve any less but they certainly express it differently. I’m told that if a woman has many children it is easier to accept but if she is a first time mother or has no or very few children it is much harder on her.
I think that’s about it for me now. Just writing this stuff down seems to kind of help get rid of some of the pressure you feel in the presence of it all. I have so much more I want to talk about but It’s been over 30+ hours since I slept and I can feel myself fading. I wouldn’t exchange this experience for anything, the heat and the sadness notwithstanding.