Monday, October 10, 2011

First Night at Work

Women in labour can be carried many miles on homebuilt stretchers like this
I couldn’t really understand what the midwife who called me at was saying – mobile phone transmission seems quite distorted sometimes and also doing their best to speak my language is often only partly successful but it was obvious I should get dressed and go in to maternity, which I did, by torch light
When women first arrive they are assessed in an open room that has two more of those clapped out beds in it and even more dirt on the floor because it is right by the front entrance to the unit. I have learned already that if  there is a cluster of old women and men gathered about the entrance to the unit, it usually means trouble within. A further clue as you approach will be an empty jerry built stretcher made of a couple of stout  branches - the men will have carried the woman in distress to the hospital on it, sometimes from many kilometers away, many hours  tough walking along rocky tracks and roads, often with no footwear and almost all dressed in worn out dirty rags.

Waiting outside after bringing a mother on a stretcher, barefooted
And there they were. Inside, a woman was groaning and rolling about on the plastic mattress, the midwife and a relative were with her, and it was obvious she had been in labour for a very long time and was exhausted almost to the point of collapse, with sunken cheeks and her dry lips stuck to her teeth. The real problem was obvious almost immediately – all she had managed to deliver after all those agonising hours, maybe even a day or perhaps two of labour, was the right arm of her baby, hanging between her legs, purple and swollen. The baby had been trying to come down sideways and now its shoulder was rammed down into the pelvis and its head pushed across to one side. The baby was dead and the mother would die as well before too much longer without help. This was something I had never seen before: this scenario just would never happen in a modern country because care would be available right from the beginning of the labour. The abnormal presentation would be recognized and the baby delivered promptly by caesarean section  in perfect condition and both would go home in 5 days probably never really appreciating the fate that had awaited them without modern technology. In fact, if the caesarean scar was a bit crooked or developed a superficial infection as they are want to do – but easily treated with tablets – someone may even have complained!

I had read about the so called “destructive delivery” where to save the mothers life in pre-modern times, a baby stuck like this would be decapitated or dismembered to get it out. Historical obstetric text books had gruesome diagrams and drawings of the techniques and instruments used, but I had never seen them in real life. This womans situation however was of the worst possible kind, and attempting a “destructive delivery” would be more likely to kill her than achieve the desired outcome, especially in inexperienced hands.  Fortunately there was an alternative: caesarean section; but even that is a high risk solution in this environment. The risks are great enough in performing abdominal surgery on a desperately ill woman anywhere, but at a place where there is no blood bank, no anaesthetic  monitoring equipment – not even an ECG machine – and limited surgical equipment – the dangers are obvious. Furthermore, a caesarean will create a serious risk of death from uterine rupture in any subsequent pregnancies, especially if she labours miles away from help. In fact attempting such surgery under these conditions would not be acceptable or even permitted in a modern  country.  But nevertheless it was her safest option, indeed her only option. The family was called and discussions took place between them and the midwife about what needed to be done, and I saw them all rummaging through their ragged filthy clothes and handing equally filthy money over – there are charges for all obstetric services – but after a while, voices seemed to be raised and nothing was being done for the mother – “whats the problem? “ I asked. “They wont pay” I was told “They cant afford” So how much did they have I asked “40 Birr “ was the reply – about $3 between them – and they needed another $8 (130 birr) but it was easy to believe, looking at them, that they had nothing else.

The argument continued a few more minutes but no more cash was forthcoming – so I interrupted “lets get her to theatre and I will settle their account myself in the morning”  I had hesitated because I didn’t want to undermine the midwife or the way the system worked – but on the other hand I thought $8  was nothing to me  – two coffees are sometimes more and we order them without a seconds thought. The woman was dying……

So I did my first Caesar in Africa, and delivered a dead baby from a nearly dead mother. We managed to disimpact the baby from the pelvis without causing any further damage and the operation was uneventful.  The urine draining from her bladder before the operation looked like pure blood, such was the trauma the bladder had undergone during the labour. Hopefully that damage will repair itself but only time will tell : if not, before too long a hole will develop and she will dribble urine  and be constantly wet and smelly.   The baby was dropped into a big old cardboard box and forgotten about till I went to find it and later, it was incinerated with all the other hospital waste.
Am I wearing her pants or has she got my top?
 It had been a confronting and emotional experience for me, and stressful, but everyone in the hospital was tremendously helpful and supportive. I stumbled back through the tunnel of grass now wet with heavy dew and crept back into bed at about 5 am. I just felt glad that at least the mother would survive. Or so I hoped.

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