Saturday, December 31, 2011

A Sad Day

Once I had passed the halfway mark on my 2200nm solo sailing trip to Tubuai earlier this year and everything had progressed smoothly to that point, numbers of people congratulated me as if I had already arrived and suggested from there on it would be a piece of cake, plain sailing, all downhill, no sweat….But of course then the wind went round to the wrong quarter, and strengthened, and the seas developed into something quite wild and so the last week turned out to be the toughest week I had  ever endured sailing.

Something similar seems to be happening here, as my last week begins, and the event I had been dreading since arrival, the thing I am here above all to try and prevent - maternal death - finally happened. To be honest at times Ive felt lucky that it hadn’t already happened - Ive felt like a lone and inexperienced goal keeper leaping this way and that to keep out  a furious barrage of  attacks, but that it was only a matter of time before one would get through. Never-the-less as the last week approached I started to hope that maybe on my watch, none would – but that all changed yesterday: a mother died ; her name was Erteban, she was only 23.

I wrote early in my stay here about Etewa who arrived looking dead, with a dead baby stuck in a “Brow” presentation. We performed a so called “destructive delivery” on that baby, using an instrument to penetrate its skull so that its contents would be expelled and the head collapse making vaginal delivery possible. Erteban arrived looking as dead as Etewa did, with no recordable Blood Pressure, semi conscious, dehydrated and the  babies head stuck in the birth canal. It was dead. We found out that she already had a healthy toddler and this was her second pregnancy, that she hadn’t had any antenatal care and had been in labour at home and had been trying to push the baby out for six hours . Then her pains all stopped but by then it was midnight. In the morning they carried her for four hours to a road and caught a bus to Motta and she arrived just after lunch. As is typical here, she had on a horrendously filthy dress, her arms and legs looked as if they hadn’t seen water for months, her feet were dry and cracked with souls that were as thick and hard as a layer of bark on a tree, and she could barely lift her head up. One valuable but ominous sign that  Ive learned to recognize, is that in someone who has previously had one or more babies , if contractions stop after thay have been in strong labour for a long time, and now the baby is dead, it probably means the uterus has ruptured. And when that happens there is a massive internal bleeding. It seemed very likely that this was what had happened. So, whereas for Etewa major abdominal surgery was avoided by the destructive delivery, Erteban was going to need it, even though she was in shock and desperately ill. Without surgery she would soon die from ongoing internal bleeding,  and infection carried into the abdominal cavity by the baby expelled ther from the birth canal.-but the operation by itself could kill her – but it was her only hope.

We took her to theater and it took an hour and a half to deliver the dead baby – quite a large baby for a small Ethiopian woman – and to repair  a huge tear in the side of the uterus. We guessed she had lost close to two litres of blood. At the end of the procedure it was still not possible to record her blood pressure, her pulse was racing at about 150 beats per  minute, her breathing was still fast and shallow but there was urine in her catheter, the only reassuring sign. We tested all six of her accompanying family members to find someone with compatible blood, but were unsuccessful, and she was too unwell for transfer to Bahar Dar where there is a blood bank.. We were doing all we possibly could, which was not very much.

I couldn’t imagine how she would even survive the night, but she did. In the morning she was still desperately unwell, but blood pressure could be recorded, she spoke a few words, and her temperature was normal. On the other hand her pulse remained close to 150 and her breathing was very fast. She struggled on all day as we watched for some sign of improvement but it took hours for our one daily set of limited blood tests to come back, and the X-Ray machine has now been unfixed for eight months, so it was impossible to see if she had heart failure or pneumonia – so I treated her for both. In fact nothing we did seemed to make much difference and her condition worsened with a rising temperature, increasing restless ness and then unconsciousness. Infection was setting in. Late on the second day, when it was clear she would not survive the night, her grieving brothers and husband decided they would like to take her home. Tears ran silently down their faces as we removed the catheter and the IV lines that had given her the fluids and antibiotics and other medicine that had prolonged her survival to that moment, but now there was no denying it, it was too late for her. Hopefully she would survive the road trip and being carried in the middle of the cold night along that four hour track to her village, where the rest of the family could comfort her for however many hours remained. It was moving to see how much they all loved and cared for her, and how dignified and how true was their conduct. It seemed worse to me that these poor ragged farmers who already had almost nothing should have even their young mothers and babies taken from them. Strangely I felt more numb than sad, and I thought about everything I had done and  wondered if there was something I could have done differently. In fact numerous things suggested themselves to me, and there are some things I would do differently next time, though I am not certain the outcome would have been different . However I do know that if they had made that four hour trek to the road at the beginning of her labour rather than at the end, it would have been: but how were they to know?  Mother nature can sometimes be a very cruel midwife.

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