Thursday, July 8, 2010

Too Late

My phone rings, waking me up. I stare at the blurry phone – the time is 6:30am. The call is from the Labor Ward.

The midwife tells me that there is a patient who has had 1 previous cesarean delivery. She had been laboring well, and was expected to deliver vaginally. Now she is fully dilated, but the baby is not coming down. The midwives suspect she needs a cesarean, and they want me to come and assess.

I ask some questions to get more details about the urgency. How is the fetal heart rate? Is there meconium? How long has she been fully dilated? It is a struggle to get information because this midwife has a hard time understanding my American accent over the phone. It might be urgent, but maybe not.

I try to get up and out of the house quickly, but because it is early morning, and because this is Uganda and everything takes a long time, it takes longer than I would like. I ride my motorbike over to the hospital, and head to Labor Ward when I arrive. The night midwives are still there, and the point me toward the patient.

She doesn’t speak English, and I don’t have enough time to search for the chart to figure out details; the exam is more important. I listen for the fetal heart, but the mother is very uncomfortable and keeps moving. We don’t have electronic fetal monitoring here, only a fetoscope, which is a cone-shaped tool that is pressed to the mother’s abdomen, and the midwife presses her ear against the other end to hear a faint ticking sound, which is the fetal heartbeat. I can’t hear the heartbeat with the patient moving like that. I ask the midwife to help me (they are so much better at it than I am), and she finds it. I hear it, but it sounds really fast. Also, it could be the mother’s heartbeat. When the mother herself is sick or stressed, her heart rate can be high and can be mistaken for the fetus’. I make a mental note to check her pulse, but first I want to do the vaginal exam to see what is going on with the delivery.

I put gloves on and examine her. There is thick, green meconium spilling from the perineum. Meconium can be a normal sign – a full term fetus can pass meconium in labor. But it can also be a sign of trouble, and it’s hard to differentiate when it is an ominous sign. We try to differentiate the thickness of the meconium, assuming that thicker is worse, but it is still a weak predictive tool. Nonetheless, it makes all obstetricians nervous.

I palpate the presenting part. What I feel is very soft and bulging, almost like amniotic membrane. Are her membranes intact? I ask the midwife, and she agrees that it feels like membrane. But that doesn’t make sense, because meconium in in the amniotic fluid – the membranes have to be ruptured for the meconium to be visible.

I palpate further, hoping to feel a firm, hairy head beyond the membranes, but all I feel is mushiness and a strange contour. Suddenly I realize what I am feeling: the baby’s butt. The baby is breech.

I tell the midwife, and she is shocked. At the same time, she immediately realizes I am right – that is what they were feeling all along. It could also explain the slow descent of the baby, as breech infants are slower to deliver.

But what should we do now? The baby’s butt is extremely low in the woman’s pelvis. It almost feels like I could pull it out. If she were earlier in her labor, we just would have taken her for cesarean. But now the baby is close to being out. Moving her to theatre always takes at least an hour. If this baby is as stressed as it seems, it might not have an hour. Maybe I can get this baby out if I can help her push effectively.

I encourage her to push with the next contraction. I ask her to put her chin to her chest, curl around her baby, and lift her legs. She pushes better in that position. I have observed that the midwives often blame the patient for poor pushing when the presenting part doesn’t move (part of the culture here, it seems), but sometimes it isn’t the woman’s fault, it’s just the mechanics of the situation. I can see she is really pushing hard.

We try pushing through three contractions. At first it seems like we are making progress. The midwife notes that this is much more effective than before. But after 3 pushes, it is clear we are not getting anywhere. I don’t want to give up, but I don’t want to let this baby die, either. I call the cesarean.

It is not an easy call. Doing a second cesarean on a patient dooms her to a cesarean for life. And in Uganda, that means either 6 or more cesareans, or limiting her childbearing – which will damage her social standing with her husband and her husband’s family, and sometimes provides a reason for the husband to take on additional wives. Furthermore, what if she can’t get to a hospital for that third cesarean? That could be fatal. If only she could push the baby just a little further it would be out.

But I can feel that the hips are not oriented perfectly straight within her pelvis. They are tilted ever so slightly to one side, which could be what is limiting the descent. The longer I wait, the more chance that this baby will not survive.

I ask the midwife her opinion. “Doctor, that is for you to decide. I have tried and failed, and now I am asking you.” That settles it. They have tried, and I have tried. I ask them to prepare the patient.

Getting the patient to theatre always takes a while. There is no such thing as an emergency (or “crash” cesarean). It’s more like as soon as possible…..which is never very soon.

There are several reasons for this. The midwives are usually very few taking care of many patients. In order to prepare a patient for theatre, they need to have her sign the consent, they need to put in an IV, and they need to put in a urinary catheter.

In order to sign the consent, they need to find a midwife who speaks the patient’s language. With up to 5 local languages, this isn’t always easy. To put in an IV, they need to track down an IV needle, a “giving set” (what we call “IV tubing”) and a bottle of normal saline. None of these are guaranteed to be available. If they are, they are never all in the same place, usually stored in a different building. The midwives have to search several different places to see if there are any items hidden anywhere unexpected. If any item is not available, then the family member needs to be sent to town to buy it. To put in a urinary catheter, the midwives need to find that too, and if not, they need to send the family to town.

After that, the midwife needs to find the stretcher – a narrow, poorly rolling tray-on-wheels, both of whose guardrails are broken and hang limply. They drag the stretcher next to the patient, have her move onto the stretcher, and then they wheel her on the jagged, uneven concrete walkways to the theatre.

In order to cover the patient after the cesarean and to wrap the baby, the patient needs to have brought many sheets (usually large pieces of colorful cloth). If she didn’t, there are no sheets available, and this is another delay while the family buys them from town or finds a street seller who walks around the hospital selling cloth and plastic basins.

On top of all this inefficiency, the midwives are caring for many patients at once. Others may be delivering at the same time, so they need to shift their attention back and forth.

Lastly, there is little sense of urgency here. In the US, when there is a true emergency on the labor floor, every nurse, doctor, scrub tech and other staff member feels as if the action they take every single second could decide whether the baby lives or dies. People spring into action, nurses covering other patients come over to help start IVs, get medications, catheterize, whatever. Residents jump in – one consents the patient, another talks to the father of the baby, another prepares to move the stretcher, and another starts scrubbing. We know our actions will make a difference.

Here, that sense of empowerment is weak. The sense that 10 seconds can be life-or-death is not there. People see stillbirths all the time – it is thought of as nature: unpredictable, unchangeable. Although they know that their actions are important, the urgency is more of a broad feeling than a moment-to-moment tension. People sometimes do things right away, but never at a running pace. Seconds add up.

As usual, it takes about an hour to get to theatre. I find that whether or not I hover around the Labor Ward and anxiously implore people to move faster has no effect on how quickly the patient gets moved; it only makes me more anxious. I try to do other things while I am waiting, in order to distract myself and avoid frustration. But it is a difficult balance, because when I do this, I also feel a little bit like I am abandoning the patient.

When we get to theatre, we move the patient onto the operating table. That is when I remember that I didn’t check the patients pulse and compare it to the fetal heart rate I am hearing. There is a small but real chance that the heartbeat I heard could have been the mother’s, and the baby’s could be low, or the baby could even be dead. Nonetheless, would it change my current management? Not really. She has not been able to push out the breech fetus, and she has a previous scar on her abdomen, so even if the fetus was dead, I would probably have to do the cesarean anyway in order to avoid the very real risk of uterine rupture. If I were to wait for the midwife to go back to Labor Ward to get a fetoscope and bring it back, that would delay the cesarean even further. I decide to proceed.

The patient’s previous scar is a vertical scar on her abdomen. I prefer to use a low horizontal incision, called a pfannenstiel incision, because it has less postoperative pain and better wound healing. But when someone already has a previous scar, we usually use the old scar to avoid creating a T-scar on the abdomen, which would be ugly and heal poorly. I make the incision between her umbilicus and her pubic symphysis, following her old scar. When I get to the uterus, I find a cystic, bubble-like structure blocking my view to the rest of the abdomen. It is attached to the anterior lower surface of the uterus. It must be the bladder attachment – not the bladder itself (which I can see is lower down) but the filmy tissue that attaches the bladder to the peritoneum. It is hard to know when that tissue actually becomes the bladder, especially since it is completely stuck to the uterus. It bubble-like quality is also very strange; I wonder why it is bulging out like that. It could be that the pressure from the very low descended fetus is causing some compression and edema of the lower uterus and anything around it. That bubble might be part of the bladder, I can’t tell, and I can’t cut it, just to be safe.

The problem is that it is blocking the entire area I want to operate on. We usually make a horizontal incision in the lower uterine segment – a thinner, less muscular part of the uterus that heals well. But the lower uterine segment is blocked by this bubble. I have no choice but to do a classical incision – a vertical incision higher up on the uterus, through the thick muscular portion of the uterus. This tends to bleed more, take longer to repair, and have a higher risk of rupture with later deliveries, but at the moment I have no choice. I have to get this baby out, and fast.

I cut through the uterus, careful to avoid the bubble. The baby is easy to pull out. I can see that the baby is blue and not moving. This is not good, although a lot of the babies come out sedated and weak because the anesthetists here use general anesthesia (rather than spinal anesthesia, in which they are not trained) and this sedates the baby as well. They all look weak at first; it’s hard to know which ones will be ok right when I pull them out.

I hand the baby off to the midwife and start sewing. The classical incision bleeds heavy and fast. What’s more, after all this long labor, the uterus might easily be infected, and this also causes a lot of bleeding. I never think about the baby at this point. I need to focus completely on the mother, because she can bleed out in a matter of minutes. Once the bleeding is controlled, I can ask how the baby is, but not before.

It takes a while to close the uterus because of the vertical incision through thick tissue. It requires two layers. As I am finishing the second layer, I hear the anesthetist ask how the baby is.

The midwife says “Still not very good. Still no heartbeat.”

“Not very good” is a bit of an understatement – this is also known as dead.

The resuscitation skills of the midwives, while not exactly textbook, are pretty good. They do what they can. The big thing they usually miss is giving oxygen, and this is because the concentrator is usually unavailable or broken. But in this case it could truly be lifesaving. I ask the midwife whether she gave oxygen. Only then I find out that the oxygen concentrator is not in theatre. It was lent to some ward and no one knows which, and there is no oxygen for the baby. The baby might have been saved through aggressive intervention. Then again, it’s also possible that the baby has been dead since I first saw the patient. I don’t know.

I am sad for this mother. I have just done her second caesar, which dooms her to caesar forever. She will have to recover from this painful operation while grieving for her dead baby. The classical incision puts her at higher risk of complication in the next pregnancy.

If her breech presentation had been recognized earlier in labor and her cesarean performed, would the baby have survived? Probably. If I had been faster in getting to the hospital from home? Maybe. If she had been moved more efficiently from the Labor Ward to theatre? Possibly. If we had had oxygen in theatre? Hard to say – the baby was pretty bad, and might have required more aggressive intervention than we can give. Would her baby have survived if she had been pregnant and delivered in the US? Undoubtedly.


Ben said...

This was really interesting to me. Thanks for sharing the story. It's very well written.

Anonymous said...

Such a sad story, especially given how preventable this outcome would've been in the US.

Given how the baby looked at the end and the clinical scenario, the baby likely had significant anoxic brain injury, even with oxygen at the end. So if the baby had survived, this baby and family would probably be dealing with a different set of problems.

Thanks for sharing, Veronica.