Friday, December 9, 2011


This Orthodox Christian Priest often visits the Hospital and is highly regarded by all
Its easy to write stories about my successes and about the things that turn out well, but I have to tell you , not everything does. In the interests of balance and a more accurate perspective in relation to my work here I should tell you about some of the bad decisions Ive made, and the one the night before last was a horror.

I was woken about 1.30 and asked to come to maternity because a woman had arrived in labour with twins, and the first one was coming bottom first  (breech presentation) and one foot was already out. And indeed that was what I found, when I got there. In fact she was a woman I had seen about a month earlier, when we estimated she was around 30 weeks pregnant, and noted both babies were breech. I gave her some steroids then – two injections dramatically improve a babies chances of survival if born early - and indeed, as is common with twins here she was in premature labour. I used the ultrasound  machine to check on twin 2 – I saw one head above the other and concluded Twin 2 was also still in the breech position. However, at that time both babies seemed well and the labour had been progressing well, and ,given they were about 6 weeks early, they were small and ought to come out easily, probably in the next hour or two so I didn’t  see any reason to deliver them by caesarean section. In the back of my mind I also thought it would probably not be a good idea to do a cesarean on  premature babies that might not be mature enough to survive anyway.

Well, as expected before long the mother felt the urge to start pushing her first baby out, and soon both legs popped out, and then the bottom appeared. With her next push we expected to see the babies abdomen and for the arms to come but they didn’t – they seemed stuck so I felt around to see why – and almost immediately realized twin one was about to die, and there was nothing I could do about it. Such a  sickening and horrible feeling is almost impossible to imagine, but it filled my guts as  I realized that what I could feel near the shoulders of twin one was not twin ones head but the head of twin two, and it was never  going to be possible to get twin ones head past it.  Twin two had not been in the breech position at all but was actually in the usual position that babies are in when they are born, with its head down, and I had  failed to recognize it. The head that was uppermost on the scan was actually twin ones and as it descended, it forced twin twos head before it and into the pelvis, and now they were all stuck there, so-called “Locked Twins”- look at the number “69” and think of twin One as the 9 with the circular part being the head and the tail being the body and legs - and twin Two as the 6 – if you pull down on the tail of the 9 you might be able to imagine how the circular head of the 6 might get pushed down by the head of the 9 if it cant squeeze past…and as the enormity of my blunder descended on me like a cliff toppling onto me, twin one died!

Meanwhile the poor mother was consumed by an overpowering and irresistible urge to push the rest of her baby out and kept squeezing and pushing twin two down and trapping twin one even tighter and I was momentarily paralysed with indecision, not having ever faced this situation before or even heard a story from someone else who had and not knowing what the hell I should be doing. It takes an hour to organize a caesarean and I had previously had the debate with myself about doing one and decided it was a bad idea – so how could I get Twin 2 out?  “I think destructive delivery is better” said one of the midwives and I quickly searched the instrument collection for something to use – a large knife, some powerful scissors – could I decapitate Twin 1 so Twin 2 could come out past it? Or would I have to decompress Twin 2’s head – empty its skull of contents – at least I had done that a few times before - so Twin 1 could be delivered? “Oh my God” I kept thinking to myself “this is the worst horror-“. The mother crying out, a dead baby hanging by its neck, another one trapped inside….At times like this you regret  and curse every little thing you ever did that got you into this mess, you regret ever coming here, ever doing obstetrics, ever doing medicine, you regret not being an accountant or a school teacher or a librarian or anything that lets you sleep all night and not have to be involved with life and death and have people thinking you know what the bloody hell you’re supposed to be doing, and looking at you with fear and confusion on their faces, people who trusted you and thought you would help them and now here I am in this horrendous disaster and its all my fault….”shit shit shit” is what I kept saying to myself, my mind spinning wildly.

And then suddenly I realized what I should do – Twin 2 was still alive- there was no way I could kill it and decompress its skull - we should do a Caesarean and try to get it out before it too was dead. I woke up the theatre staff and the anaesthetic nurse, urging them to be as fast as possible, and they responded well but it still took nearly an hour . I opened the uterus quickly and grabbed twin ones head and pulled her out – she was long dead, but Twin two followed and she was alive and remarkably vigorous, requiring  virtually no resuscitation at all. She was warmly wrapped and taken back to the family and her husband waiting in the cold air outside maternity, a large group of people I had to walk past on my way to theatre, feeling like a mass murderer – hopefully they would be kinder to me now. But once the operation was over and I went back to maternity, I discovered the baby weighed only 1.5kg meaning she would be lucky to survive – she was too small and too premature.
In Theatre
And so, at the end of it all, she had the caesarean I didn’t want her to have but it was unavoidable, and she lost the twins she had been unhappy to discover she was carrying when I first met her and did the scan a month before. If I had been a bit cleverer and realized twin 2 was not a breech, we would still have had to do the caesarean, but it wouldn’t have been preceeded by all that horror and pain and misery for the mother, and panic in the family and hospital staff including me – albeit momentarily. And after the caesarean Twin one may also have succumbed to her prematurity and low birth weight as did Twin 2 eventually,  but at least she would have had a chance which I regret she was denied because of my blunder. It was a miserable way for a baby to die and a horror for her mother – but fortunately she is young and tough and I expect will return in a year or two to try again.  Certainly by doing the caesarean this time she avoided the likely natural outcome of locked twins for the mother, which is death, so it hasn’t been all negative. We have given her the chance to eventually end up with an obstetric history something like that of so many of the women we see here –  after perhaps 7 pregnancies, 2 stillbirths and 1 infant death : 4 live and healthy children. And I daresay they give thanks to God for them.

No comments:

Post a Comment