High Risk OB

It all started with the usual knock on the door at 3AM. Faka, the charge nurse for the night team, is outside as I open the screen door. A dim flashlight illuminates his face as he looks up from a patient's carnet.

"A woman just came in with presentation of the umbilical cord. She's been in labor at home since yesterday. The were no fetal heart tones. She had some bleeding but it stopped."

"What time did she come in?" I interrupted.

"Just 20 minutes ago." Faka replied.

"Was it a normal vertex presentation?"

"I think so."

"Go and find out. Since the baby's already dead and the bleeding has stopped, if the fetus is head down, then she can deliver normally."

"Ok." Faka moves off into the night as the crickets, frogs and pigeons take over with the usual Chadian night sounds.

I decide to stay up until Faka comes back. I read for a while but after half and hour I assume the woman has already delivered or is doing well so I go back to sleep.

After worship, Faka gives his report to the rest of the staff.

"...and the woman still hasn't delivered and has no contractions."

I stifle my frustration and announce that we'll all go to see the patient right after the rest of the morning report.

The woman is in a dark room. The electricity is off. I go to the OR and hit the remote start for the generator. I come back to labor and delivery and find the woman in a clean room behind a blue curtain on a delivery bed with no mattress under a noisy fan.

The umbilical cord is sticking out between her legs. The abdomen is a weird shape. On closer inspection, the placenta is also half hanging out and the odor of rotting flesh wafts up into my unprotected nostrils. I examine the woman and find a hand sticking out next to the placenta and umbilical cord. This woman has three reasons to need a c-section four hours ago: placenta previa, cord prolapse and transverse presentation.

A few minutes later in the OR I have Abel douse the cord and placenta with Betadine while Samedi and I scrub. The infant's skin is already peeling off as I pull the limp form out of the abdominal incision. I leave the skin partially open to prevent infection and we clean up.

Prudence is waiting for me outside the OR.

"A woman just came in. This is her 5th pregnancy and she's been trying to deliver at home since yesterday morning. I can't exactly tell what the presenting part is."

"Ok, I'm coming." I slip off my OR shoes and into my sandals as I turn the corner and down the outdoor veranda to the maternity ward.

At first I also can't tell what part of the baby I'm feeling till my finger goes into the child's mouth.

We quickly prepare her for a c-section as well. As I open the uterus I can tell the fetus was stressed as a thick green fluid oozes out. I pull the baby out but the head is huge and her lower uterine segment thin and about to rupture due to prolonged labor. The baby is soon crying as Prudence uses the bulb suction and briskly dries and stimulates him. Meanwhile I repair the tears in the paper thin uterus and finally control the bleeding. I rinse out the abdomen well and close.

A few hours later, Prudence comes to get me again.

"This woman has been bleeding a lot." She tells me as we make the now familiar trip to labor and delivery.

On entering the room I see a woman breathing rapidly, somewhat dazed and covered with blood all over her legs and waist.

As we prepare her for surgery, the lab checks a hemoglobin: 7.8 g/dl (normal is over 14) We do a type and cross and find out unfortunately that she is O negative, one of the rarest blood types and one that can only take O negative, no other type. As I slice down the midline of her lower abdomen, the lab guys are desperately checking the blood types of all the relatives of the woman. None of the staff is O negative and we have no blood bank so we hope someone that came with her will have the same type.

As I open the abdomen I see a blotchy uterus with cracks on the surface oozing diluted red blood. After nine other deliveries the uterus just can't take much more. There are dark bruises around the edges and the fundus. As I open the lower segment a dead baby pops out followed by a large grapefruit sized blood clot. Abruptio placentae where the placenta separates too early causing massive hemorrhage between it and the uterine wall. That explains why she's oozing from everywhere: she has no platelets or clotting factors left.

Since the oozing won't stop and the uterus looks as if it's been beat up, I decide to take it out. It is rather simple to do but after it's out, despite by sutures, the wound edges just keep bleeding and bleeding. I try everything I know but nothing works. Her blood is so diluted it almost looks like pink lemonade. In desperation I ask for a packet of Celox, ignoring the large "for external use only" on the package I poor the powder over the bleeding edges in the pelvis and hold pressure with a compress. The problem is there's nothing to hold pressure to. Even with the Celox applied several times there is just too much oozing for my comfort, especially considering I have no blood to give her and she started out low. Finally, I take a large lap sponge, pack it into her pelvis and close the fascia and skin around the blue cord attached to one corner of the gauze that hangs out the skin.

As I watch her being wheeled out to the wards I'm sure it's the last time I'll see her alive. Later that evening I go to check on her. She's moaning and groaning and not really responsive. I grab 2 liters of IV fluids from the OR and let them pour in. WHen the first one is in, I change to some 10% glucose. She starts to at least make some sense. I ask her family to interpret what she's saying in her local dialect.

"She's in a lot of pain."

I order some IV pain medication and go home. At least with the pain medication, she'll die peacefully.

The next morning, she's still alive and so I have the family give her some water and porridge. Later that afternoon, the lab finally finds a family member with the right blood type and she gets one unit of blood. It's not nearly as much as she need's but it's better than nothing. The next morning, she's swollen and edematous but alert. I take her back to the OR and take out the lap sponge and reclose the abdomen under general anesthesia. Today, she is still critical but sits up with help and is taking some water and more porridge.

Maybe she'll make it after all.