Friday, January 18, 2013

Tuesday : Part Two

Clothes drying in the sun
 Uterine rupture is one of the most feared labour complications because it frequently results in the mothers death. The midwifes call brought an abrupt end to my relaxing afternoon, and I hurried over to maternity, where I found a desperately ill young woman with the classic sign of uterine rupture : the so-called “Bandl’s Ring”.  What you see in a woman lying on her bed is that her abdomen, instead of rising up to a smooth hump then down again, has two humps instead of one, the trough between them being the “Ring” where the uterus has split apart almost into two pieces. I wanted to take a photo of it but there was no time – she had unrecordable Blood Pressure, was barely able to open her eyes and her pulse was 150 beats per minute. The baby of course was long dead.

 We started fluid resuscitation, gave her what antibiotics we had available and I inserted a catheter into her bladder – pure blood came out and nothing else. We sent relatives to see if any had compatible blood but none did and then we had to try to decide what to do. It was suggested we should send her to Bahar Dar – blood would be more readily available there – but I was in no doubt – she would be dead before she got there.  “no” I said “She is too sick to send away”  And later I found out that the hospital vehicles are still non-funtional, so we wouldn’t hahve been able to send her way even if had wanted to.

 My anaesthetist hesitated once we got her down to the Operating theatre – her pulse was 170 – he mentioned that in Ethiopia it is regarded as a particularly bad thing for someone to have died in the Operating room – better that they die with the family. Should we just send her back? Her blood pressure was still too low to measure and nothing else had appeared in her urine bag apart from blood. It was tempting – the surgery was going to be complicated and even if technically successful it seemed she may not recover – there was no blood, we coudnt get all the antibiotics we needed, her kidneys seemed to have shut down – was this perhaps one of those moments when instead of blundering on and doing heroic surgery that wouldn’t affect the outcome, it would be better to face reality and allow her to die with some sort of dignity, rather than just mutilate her and return a corpse to the family tearfully waiting in the dark outside the operating theatre? Once before I had faced a dilemma like this – it was a year ago in this same theatre when we began surgery for a ruptured uterus and found such damage to the uterus and the bladder I was urged to give up, to not even try to repair the mess. But then I reasoned there was nothing to lose by trying, so I did, and ultimately my Heath-Robinson bladder repair and ureteric reanastomosis saved her life – I was as surprised as anyone, having never before even observed let alone actually performed such surgery. It is a horribly difficult dilemma to face but I decided again that I would not give up without making some sort of attempt to save her. “OK” my anaesthetist said, “Can start” and he put her to sleep

New, still empty homes on the outskirts of Motta
Half an hour later, the operation was over. But it wasn’t the operation I had been expecting to do because on opening the abdomen to our shock – and relief – the uterus was not ruptured though it was close to doing so. The lower of the two “humps” visible externally turned out to be a swollen oedematous and badly traumatised lower segment of the uterus and  bladder, and so all I needed to do was a straightforward caesarean. I extracted the dead and putrid baby, removed the placenta and closed everything up again. Bleeding had been minimal. She woke slowly – we all felt a surge of hope and excitement – she would probably survive.  Thank goodness we hadn’t just sent her back to die!    


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