Cesar No Power

I arrive on the Labor Ward one day and there is a lady I recognize. She is light-skinned for a Ugandan, and she is tiny; she looks like she’s 12 years old, minus the hugely pregnant belly and the developed breasts. I remember that I had promised to do her cesar.

She hands me her card, and I remember more detail. I had seen her a month or two ago, and confirmed her gestational age. She had three deliveries before, and two were cesareans. Only one of the children is still alive. Because of the two cesareans, she needs another one in this pregnancy. I had scheduled her to come back at full term.

By my calculation, she is between 38 and 39 weeks. Typically, we do elective cesareans at 39 weeks, but given the haziness of the dating here, the difficulty that most patients have reaching the hospital, and the likelihood of disaster if she goes into labor at home, better to do it when we can. Unfortunately, we can’t do it today. It’s Tuesday, and the power has been off since Sunday. The power was cut off because the hospital couldn’t pay the power bill, and we don’t know when it will come back. I tell the midwives to admit her, and we will wait until we can do the cesar.

I plan to meet with the hospital administrator. I call him to see if he is around.
“How are you?” I say. (It’s a required exchange at the beginning of a call, even before you know who you are talking to. The universal answer is “fine.”)
“Not very well,” he says, “The power has been cut for nonpayment. The situation is very bad.”
I sympathize. He tells me that they are worried about the vaccines that need refrigeration, and was hoping to ask the various study centers in the hospital (there are 2 others, and all have generators) if the hospital can store some materials with them. I assure him that we will make some room for the hospital vaccines. I ask him to take an inventory of what he needs, and I will look for space.

I meet with the head of our lab, and he makes space in our fridge. Later as I am on Labor Ward again, I get a call that the hospital administrator has come to the clinic looking for me. I rush back, and he tells me that the most urgent thing right now is the blood for transfusion. I tell him we are happy to store it. The head of the hospital lab brings over 2 coolers filled with packs of blood, and they all fit. We also find room in the pharmacy fridge for hospital vaccines.

We discuss the power issue, and it is not sounding good. The hospital has a generator, but there is no fuel for it because of the money problem. And the generator would not last long even if there was fuel. I tell him that I have a cesar patient who is stable, but who will need the cesar urgently if she goes into labor, and she is too poor to refer. He is very concerned, and tells me that if I need, he will find some way to get fuel for the generator. I thank him and assure him that we are ok for now.

The next day, there is power in the morning, by some miracle. It seems that the hospital was able to obtain some money to pay half the bill, and the power company agreed to give the hospital power for 24 hours while the money came through.

I am passing through the Antenatal Ward, and I see my cesar patient. I wave and she smiles and waves back. She looks well, and I will come and check on her in a few minutes. I spend 10 minutes on Peds Ward seeing the child with kidney problems, and then I pass back through Antenatal Ward. Suddenly, the patient looks terrible. She is very pale, sweating, moaning, keeping her eyes closed and only minimally responding to me. The other women on the ward are starting to close around her. What is going on?? Is she rupturing her uterus?

One woman tells me that the patient is having contractions, but another woman insists it is chest pain. The patient doesn’t speak English, and only opens her eyes when I force her to respond to me. She looks terrible. Her pulse seems a little high, but not remarkably so. I palpate her uterus, but it doesn’t seem tender, which you would expect if she were rupturing the uterine scar. She seems to moan in 2-3 minute intervals. Seems like labor. I call a midwife over, and ask her to resuscitate. If she is going into labor, we need to do the cesar NOW. The nurse goes to get IV fluid, and I dash over to theatre to get them to do the cesar, since we have power. They need 1 hour to prepare and sterilize everything. An hour is about as urgent as it gets here, so I agree.

Ten minutes later, the power goes out. NOOO! I must do the cesar. I can use a head lamp if necessary, but I have to do it. I race to the administrator’s office. He greets me warmly and tells me that things are still not good. I explain the situation and he is very concerned. He tells me that he has obtained some fuel for the generator since we spoke, and he asks how much time I need. I have a headlamp, so I can use that for the easy parts of the surgery, but it would be good to have adequate lighting for the harder parts – getting in, getting the baby out, and closing the uterus. I tell him I need an hour at most. “That is fine. Let us help this poor patient,” he says.

We decide that I will call the person in charge of the generator immediately before we need it, in order to have it switched on. I dash over to theatre to tell them to prepare the OR. I have heard rumors from the midwives that there might be no sterile instruments or no sterile drapes. When I arrive, the theatre nurse says that there are instruments, and that she will look for drapes.

I race back to the Labor Ward, where the midwife tells me that the anesthetist has just arrived, and has said that we can’t do the surgery for lack of drapes. He recommended referral. I don’t understand – it seemed like the theatre nurse could find some.

I race back to theatre to try to find the anesthetist. He is not there, and neither is the theatre nurse, but I fine the theatre tech, a young man. He says the instruments are sterile, but that just before the sterilizing machine for the drapes was to be turned on, the power went out. There are no sterile drapes or gauze.

For crying out loud. Is this for real? Am I going to have to send away a poor, contracting, possibly rupturing patient because there are no freaking sterile drapes? I have an anesthetist, I have a headlamp, I am a surgeon, I have instruments, I have everything. Drapes?

I rack my brain to think of ways to adapt. I grill the theatre tech about whether there might be sterile drapes hidden anywhere. He opens all of the sterile drums and they are empty. Do I really need drapes? Can I do it without the drapes? But that would mean no gown – that’s really dangerous for me. Also, no gauze to wipe with. How could I see anything through the blood?

Ugh. Think, think, think. There has to be a way. The overriding theme in residency was “Make it Happen.” No matter what the task was, you had to get it done. It took a lot of effort, with uncooperative and surly ancillary staff, satanic ER attendings, and sometimes less than ideal availability of resources. If you didn’t push hard, you would never get adequate care for your patients. Here, the people are a lot nicer and more cooperative, but there are no resources.

Finally, I am at a loss. I can’t believe it, but I might have to admit failure. That feeling comes back to me – the one I had when I allowed them to refer the bleeding placenta previa. A pit in my stomach full of guilt, rage, sorrow, horror, injustice.

I trudge back to Labor Ward, hoping for some kind of inspiration or deus ex machina. When I approach the patient, I notice immediately that she looks much better. Her eyes are open, she is calm, not sweaty, and appears to be in no pain. She has a bottle of IV fluid hanging. I ask how she feels, and she says the pain has gone aside from some slight backache. Using her neighbor as a translator, I tell her that if she is in labor, we need to refer her to St. Anthony, because she will need a cesar. “She says she has no money, and the pain is gone. She will stay.”

I am surprised to find she is so much better, but I also know that IV fluid can do that. I tell the patient that she should not eat this afternoon, in case the power comes back and we can do the cesar. The neighbor translates “She says she has not eaten or had any drink in two days. She is very hungry.” I almost laugh out loud. No wonder she was so dehydrated. She must have starved herself in anticipation of the cesar, even though we told her there was no power. When a pregnant woman is very dehydrated, a hormone is released that mimics oxytocin – the hormone that causes contractions. This can cause a very believable false labor, but usually the patient’s cervix does not open. That’s probably what happened.

I tell her not to eat until 6pm, just in case. If we haven’t done the cesar by then, she can eat, but she should fast after midnight. Power comes back at 4, but the theatre staff has already gone, so I let her eat and we decide to do it tomorrow. She wants her tubes tied, and her husband has finally arrived, so I have the midwife help me consent them for the cesarean and tubal ligation. Even though this will only be their second living child, they both feel strongly that she should not have any more cesars.

The next day, I plan to do the cesar at 9am, which is the earliest I can agree to get anyone to arrive. At 9am, I can’t find anyone. I keep hearing the theatre staff is around, but they are not in theatre. The night midwives have not yet been relieved by the day shift. It takes until 10am to get everything together. I am holding my breath, hoping the power won’t go out before we get to do the cesar. I confirm that there are instruments and drapes. I will use my headlamp if I need to, but I will do this cesar.

When I see the patient, I see that she is contracting for real. It doesn’t stop with IV fluid. She cries out in pain with every contraction. We move her to the OR, and we reaffirm the tubal ligation. The cesar is tough. She has a prior vertical skin incision, which I hate, but I use it because it’s better to use the old scar. There are many adhesions everywhere. My assistant is a very inexperienced and overconfident Ugandan medical student, who has never done an OB rotation before and cannot do an adequate pelvic exam, but frequently professes to know what he is doing. (This is atypical from my experiencee – in Mbarara, I was very impressed with the knowledge and competence of the medical students. Their exams were extremely challenging, and they were expected to know information on a resident level, and to work independently, for better or worse.)

When I get to the uterus, it is largely covered by the bladder and scarring. I can’t differentiate bladder from adhesion, and I need to move the bladder away so I can incise the uterus. The medical student keeps pointing at the scarred mess and insisting it’s bladder. He doesn’t seem to appreciate the significance of that being bladder (ie. you can’t cut it), nor does he consider that it might be more complicated than he thinks if I am not sure. At first, I ignore him, then I chastise him. There are few things more dangerous than an overconfident medical student.

I identify the bladder, and am able to dissect some of it off. Eventually, the uterus opens up, and I am forced to enlarge the opening and deliver the baby. It’s tough, but the baby comes out and is fine. Now I have the problem of closing the uterus when the bladder is nearby. The overconfident medical student keeps pointing out bleeding areas and wanting to clamp them. Unfortunately, they are on the bladder, and can’t be clamped willy-nilly. I keep trying to explain that to him, and I ask him to hold the uterus or assist me (as he is supposed to) but he keeps dropping what he should be holding to point out bleeding that I already know about and insist on clamping the bladder. I want to smack him. I let my voice get just annoyed enough to shut him up. It works for about 15 seconds.

I close the uterus, and do the tubal ligation. I have to physically restrain the medical student from poking the engorged blood vessels around the tube with idiotic abandon. “I wasn’t poking,” he says. I consider throwing him out of the OR, but I need someone to retract, and he is wearing the only other gown.

I finish the cesarean, but the blood loss has been high. She looks pale, and I ask the anesthetist to give her a lot of IV fluid (they usually give way too little). Her heart rate and blood pressure are ok. I will check on her later to see if she needs a transfusion.

In the evening, she seems to be doing well. Still pale, but I will check the level in the morning. Power in the hospital is still on, and this lady is lucky it came back when it did.