Thursday, October 18, 2007

This Is Africa

Everyone fears uterine rupture. In developed countries, it is seen most often in women who have had at least 1 prior cesarean or other uterine scar.
In developing countries the most common clinical scenario for uterine rupture is a woman with several prior vaginal deliveries and an unscarred uterus, and it is not a rare event. In Mbarara, they see at least 1 or 2 per week. There hadn’t been any since I arrived, and someone joked that I was a good luck charm.

Today I was in the Operating Theatre watching Dr. Mayanja and Dora repair a previously unrepaired fourth degree laceration, when one of the other interns arrived to say that there was a suspected uterine rupture who needed to come to the OR. She had been laboring since 11am yesterday (it was now 5pm), her contractions had stopped, and her abdomen was abnormally distended. She had 3 prior vaginal deliveries, and 2 living children (one died at 2 months).
There was a woman waiting in the holding area for a cesarean, but she was not the uterine rupture. It was an obstructed labor. Curiously, they did her cesarean before the uterine rupture. It was a long time before the fourth degree repair was done and the room was ready for the uterine rupture, who had by now arrived in the holding area. She was in pain, but she was not contracting, and the upper part of her abdomen was rock hard, like a skull, and there was a strange tympanic bulge on the left side. She was stable.

As we started to wheel her into the Theatre, Liz, an intern, came by to say that there was a cord prolapse on the ward, and they needed to bring her now. I said “Whose hand is in the vagina?” and Liz said “No one’s.” I wondered if it was a true cord prolapse, and if so, whether the baby was alive. Still, now we had to choose between the cord prolapse and the uterine rupture.
The cord prolapse didn’t arrive. So we moved the uterine rupture into the theatre. We overheard that the cord prolapse delivered spontaneously. The anesthetist told me to scrub. Then a midwife came in with the cord prolapse baby, who was doing poorly. He was blue, limp and gasping for air. Now the uterine rupture had to wait while the anesthetist rescusitated the baby. He tried to intubate, unsuccessfully, and left on a nasal cannula and went back to the theatre.

Dr. Mukasa came in to perform the cesarean with me. By this time, it was 7pm. When we opened, we found a seemingly intact uterus, but a huge abnormal bulge in the lower uterine segment with the bladder overlying it. I wondered if she had ruptured into the bladder.
We got the baby out, and it seemed ENORMOUS. I would have guessed 6kg, although when they weighed it, it was only 4.5kg. Not surprisingly, the baby was dead, and there was a foul odor. When we evaluated the uterus, it looked ugly. The lower segment was attenuated and necrotic-appearing. It could not be repaired, so we did a hysterectomy.

We ligated the round and uterovarian ligaments on both sides. We ligated the uterine arteries on both sides. There was some bleeding on the left. And then the power went out. Dr. Mukasa said “Get a torch, quickly!” The anesthetist shone his mobile phone (seriously), which didn’t do much. Then he used the laryngoscope light, which gave us enough light to just see exactly where we were sewing. Finally, they came with a battery-powered bright light (it looked like a bug zapper).

The anesthesiologist, who was watching us, said “Do you know what TIA is? This Is Africa.” Eventually the lights came back on, and we finished the cesarean hysterectomy. The mother was OK.

After that, I did 2 cesareans with Liz. By then we had run out of masks, so Liz tied a piece of gauze around her face. We had run out of knife handles, so we used a small clamp to grasp a surgical blade, and we cut with that. All the while, Liz kept saying, “This is Africa. We improvise.”

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