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Obstetrics in Sierra Leone: Bottoms Up
October 15, 2013
Fifty-eight-year-old Doctors Without Borders/Médecins Sans Frontières (MSF) OBGYN Stephen Torres previously worked with Native Americans in the Indian Health Service for three years after completing his training, then spent the next 22 years in private practice in the state of Arkansas. He retired from private practice in 2012 and hopes to spend the coming years working with MSF in areas of need.
Stephen's first mission with MSF was at the Gondama Referral Center in Bo, Sierra Leone. This is a referral hospital for pregnancy complications and for pediatrics. Sierra Leone has one of the highest maternal death rates in Africa.
MSF has played a large role in reducing those numbers but access to health care for pregnant women and children continues to be a problem.
This blog is being published retrospectively. Read more from Stephen's blog here.
The day started off busy and stayed that way. My first patient was a 22-year-old woman who had had four pregnancies, delivered three babies, and all had died before the age of two. She had delivered this baby at home over 36 hours before. The baby was doing well but she had not delivered the placenta and had started hemorrhaging.
She had to walk an hour and a half to the nearest clinic to get an ambulance to take her to the hospital. When she arrived she was only semi-conscious, covered in blood, and her hemoglobin was only 3.1. I think I’ve mentioned that a low normal hemoglobin for women in the US is at least 12 or 13 so she was dangerously low. We approached her family to donate blood but they all refused and I finally came to understand that they are Jehovah’s Witnesses, who believe that receiving blood products will keep you out of heaven, even though the patient was not.
Fortunately the patient was amenable to receiving blood over the objections of her family (and they were pretty angry at us, convinced that we were condemning her to eternity in hell) and we were able to find blood to give her. I took her to the OT and after a really difficult 45 minutes was able to get the placenta out but during the entire time she continued to lose blood. Her hemoglobin after the procedure, even after the transfusion, was 3.0 and we didn’t have any more blood to give her. We’ll keep looking for blood but in the meantime she’ll need to stay in the hospital until her blood counts have improved. She needs help just to get up to go to the bathroom and now her family is angry at her and refuse to assist her. I can’t help but wonder what life is going to be like for her when she goes home, still ostracized by her family.
That got the day off to a rousing start. It seemed like the door into labor and delivery never closed after that. I’ve started to become desensitized to dead fetuses, it’s so common here. The baby is already dead in easily one out of five of the patients we see. During a typical month in the US you might see an occasional fetal death but it isn’t common, at least not where I practiced, and most of these babies died before labor started. In contrast almost all of the fetuses that die here occur during labor. It is understandable that in a referral center such as this that there would be a higher rate of complications since any woman who wasn’t complicated would have delivered somewhere else. But I’m beginning to understand why the mothers don’t react with grief they way they do back home. I think they go into the pregnancy understanding that the chances of having a bad outcome are not low so their expectations aren’t high.
Last night after midnight I had a patient come in with severe polyhydramnios–way too much fluid around the baby. As a result she went into labor early and delivered a malformed baby, stillborn. It only weighed 850 grams, about 2 pounds, so even if it had been alive there would have been no attempt to keep it alive. The policy here is no resuscitation on babies weighing less than 1000 grams. That’s what most babies weight at about 28 weeks along in the pregnancy, 12 weeks early. The hospital doesn’t have the resources to keep these babies alive. There are no ventilators, they don’t have the nursing staff they would need, and there is no other place to refer these babies to. When these babies are born alive they are wrapped in blankets and given to the mother to hold until the baby dies. Shortly after she delivered another patient delivered a baby that weighed only 750 grams but that baby is somehow still alive. Perhaps it was further along and just stunted in growth so maybe its lungs are more developed than most 750 gram babies but the likelihood of it living more than a day or two isn’t very high.
I got to bed around 2:00 AM and slept for a couple of hours but then got an urgent phone call from labor and delivery. I still have trouble understanding the nurses sometimes and this was one of those instances so I just got over to labor and delivery as quickly as I could and found a patient who had just arrived by ambulance, pushing, with the baby’s buttocks halfway delivered. This was her first baby and based on the size of the babies buttocks, it wasn’t a small kid. There wasn’t time to get her back for a Caesarean so I got my hat, mask, eyeshields, apron, gown, and double gloves on in record time and prepared for a breech delivery. I felt pretty calm thinking optimistically, “What could go wrong?” Well, everything apparently.
The baby delivered up to its hips pretty easily. Mom pushed again and the baby delivered the umbilical cord. That’s when the clock starts ticking in my head. From that point on the baby’s umbilical cord is being compressed between the baby’s skull and the mom’s pelvic bones, effectively cutting off the delivery of oxygen to the baby. We had mom keep pushing but the baby didn’t budge. I remember Dr. Quirk, a maternal-fetal specialist and the man I learned the most from during my residency, saying of breech deliveries vaginally: “Keep your hands off until the baby has delivered up to the scapulas (basically just below the shoulders).” I kept that in mind and tried to avoid trying to help the mom by pulling on the baby until another minute passed and the baby, who had been kicking, started going limp. I could feel the pulse in the umbilical cord and it was very slow. I put some traction on the baby’s hips while having the mom pull her knees as close to her chest as possible to try and give the baby more room but the baby was stuck.
I’ve heard horror stories about babies that deliver up to the head and then get stuck but that’s one of those things you always think will never happen to you. But here it was happening. Out of options, I did the only thing I could do and reached up into the mother and found that both arms were trapped above the babies head. Picture someone with their arms over their head getting ready to dive into water and you’ll understand how the baby got stuck. The two arms combined with the head just couldn’t get through the mom’s pelvic bones. I was able to get one finger past the mom’s pelvic bones and hooked around the baby’s right arm near the elbow and tried to pull the arm down, bending it at the elbow but it wouldn’t move. I really don’t know how much time had passed by then. It may have only been a couple of minutes but it seemed like an eternity. Not really giving it much thought but knowing that if something didn’t happen quickly to improve the situation the baby would die, I pulled as hard as I could on that arm. I felt a pop, am pretty sure I broke its arm, but it finally moved and I was able to get it down past the head into the vagina. The other arm came more easily since some of the pressure had been released with the removal of the right arm and after that the baby’s head came out easily. But the baby was as limp as a rag and I could no longer feel a pulse in the umbilical cord.
We moved the baby over to the resuscitation table and started resuscitating the baby. I used the bag and mask to force air into the baby’s lungs while the nurse started chest compressions. Nothing. We rolled the baby to the side and massaged its back, slapped its feet, and then continued bagging and compressing. Still nothing. The mother was wailing, watching us, helpless. And then the baby gasped. It wasn’t much and it didn’t last long but it was enough to give us hope and we kept working, all the while watching the baby’s dusky blue color start to lighten and then turn into a mottled pale and then finally a pinkish color. When the baby opened its eyes and started crying everyone in the room just looked at the person next to them, eyes wide in something like disbelief. I think when you’re used to seeing babies die watching one come back from the dead is especially miraculous. The mother started crying and chanting something, the nurses regained their brusque attitudes, and within a minute or two the baby was screaming its lungs out.
It could’ve gone either way. I hope that I don’t someday have to tell a story like that but with a different ending. I’ve looked back over everything that happened and I just don’t see what could have been done differently. Perhaps if she had come in sooner we would have taken her for a Caesarean but around here a breech presentation isn’t necessarily an indication for a C-section. I alerted the pediatrician to keep an eye on the baby’s right arm but even if it’s broken, and I suspect it is, that seems like a reasonable price to pay.
I was so hyped up on adrenaline after that that I never went back to sleep. I’m on call again tonight but wanted to wait until the electricity comes back on at 11:00 AM (20 minutes ago) and the fan starts working again to try to get some sleep. I’ve been here three weeks now and that’s a little hard to believe. In some ways it feels like I just got here but in other ways it feels like I’ve been here a long, long time.