Blood

The Delivery Room Door, the cleaners bucket and Mops; Theres no water to the Basin

I am sure even trauma surgeons don’t see as much human blood as we Obstetricians do. Every birth is followed by a couple of hundred mls of it, and sometimes much more, which is why, as I’ve mentioned before the commonest reason a mother dies is because of bleeding. Its why of all complications, bleeding is the one I hate the most. The death of a baby is terrible but the death of a mother is  the cruelest possible outcome of the human desire to bring new life into the world, happening as it does at the prime of a young womans life , snatching it away at the very moment when one of the greatest joys of  family life was about to be fulfilled, the birth of a baby, a new brother or sister, grandchild,   – the death of a mother creates a widower, motherless children, a huge hole that was supposed to have been filled with joy. If you ever visit India and the extraordinary Taj Mahal, reputedly the most beautiful building in the world, remember as you stand in awe that it was erected in memory of a woman who died giving birth - testimony to the impact of such an event.

In all my years of practicing medicine in New Zealand and Australia, I have never been personally involved in a situation involving a maternal death, though a small number of my patients have been close but survived – not so much because of good luck or good management on my behalf but because with the systems we have in place in the developed world, maternal death is very rare. For Australia, the latest figures are roughly one maternal death for every  12,000 births ( 8.4/100,000 births). In Ethiopia its possibly one maternal death for every 150 births, (670/100,000 births) though records are poorly kept and no-one is exactly certain what the real figure is. However a  government official visiting here a week or so back seemed surprised when, in answer to his question I said there hadn’t been any maternal deaths  so far this month! And there still haven’t been but I am writing this  today because I thought my run of luck or whatever it is was coming to a bloody end last night.



Maternal Mortality in Ethiopia : a sky scraper of death

What happened yesterday was this : firstly there is some sort of medical workers political meeting happening in Motta this week and most of the staff are at the Wubet Hotel participating in it. Absurdly, during the day maternity  is left to an experienced but – and I want to be fair – not one of the Best midwives we have, and myself, plus a gang of midwifery students, about a dozen young men and women who mostly stand around in their nice clean white coats with their hands in their pockets.. The midwifes English is poor and my Amharic is nonexistent so we have trouble understanding each other as well. However I have to say she is very sweet and hard working and yesterday, around lunch time peformed an instrumental delivery and a manual removal of a retained placenta on a woman having her third baby. I heard about it when I went back after lunch to see how things were – the woman in question wasn’t even in the ward when I had returned to my flat at about 10.30.  After lunch I was told everything was fine, but thinking about it now, I realize I am often told this.

At 4.30 I got an urgent call back to Maternity – the woman had collapsed! I was there in a couple of minutes and found the midwife trying to give the patient a syringe full of dextrose solution – maybe she thought her blood sugar was low? The crowd of students were standing round as usual, hands in pockets – “What happened?” I said “Any bleeding?” “No,” was the reply “No bleeding” and certainly you couldn’t see any blood anywhere, but then the woman and her baby were almost completely covered by  two coarse hospital blankets.  I threw them off – and beheld a lake of fresh blood and clots of blood filling up the space between her thighs – at least a liter probably nearer two, and then when I pressed my left hand into her abdomen I felt the top of the uterus way up above her  belly button, and swollen with more blood which, when I pushed down on the uterus as hard as I could, emerged in a huge torrent, another bucket of blood into the bed between her legs. She of course was in shock from all this blood loss, so we gave her fluids to get her blood pressure up, lots of fluids, blankets to keep her warm and special drugs to stop the bleeding. “Can the bed be tipped up? “ I asked “No possible” was the reply but when I pushed the bed out from the wall and went to the other end and felt round underneath I found the lever that made it possible – the idea is to have her legs elevated. And then I decided to wait to see how she would respond, though by now back home she would have been receiving a blood transfusion.  However there is no blood bank in Motta and the nearest blood bank is three hours ride away along a rough road – Bahir Dar. The other option was to try and get compatible blood from family members, something I had tried unsuccessfully to do on a previous occasion. I should have tried again but I didn’t, which was stupid, I don’t know what I was thinking, but as the bleeding seemed to have settled, and some urine appeared in her catheter and a weak  but fast pulse returned to her wrist, I incomprehensibly decided to just watch and wait. And yet she had undoubtedly lost  more than half of the blood in her body! What was I thinking?

And of course, inevitably, three hours later I got another emergency call – she was bleeding again, her blood pressure was unrecordable, she was semi conscious “Quickly come, she is critical patient” I grabbed my torch – it was about 9pm – hurried back with a sinking feeling and dread in my heart. When I got there, to my relief, things were not so bad : the bleeding was not returning, there was more urine in her catheter bag, the uterus was not refilling with blood - in fact she had eaten something and vomited. But I was snapped out of my stupor and realized we must get her some blood. She was horrendously anaemic and her pulse was 130. I rang the hospital doctor on call, Dr Yili  - I wanted to discuss getting blood – someone mentioned the  midwifery students – maybe they had a use after all! – or sending her to Bahir Dar, which would be a last resort.  Being Ethiopian, and knowing the system and the Hospital, Yili quickly sorted things out and a small crowd of extended family materialized from the dark to have their blood groups tested. I had asked for Oxygen but none was forthcoming until Yili asked for it, and about an hour later a man who I think was our patients brother smilingly gave up his forearm to a big needle and in a few minutes we had our first bag of blood. A few minutes after that it was dripping into his sisters forearm.

This morning she is still dreadfully anemic but we have no more blood to give her. Fortunately she is not bleeding any more and she will slowly recover her strength but I shall keep her in the hospital for a day or two more.

We are going to have to get better at managing post partum hemorrhage – all of us!