Thursday, June 30, 2011

Retained Twin

On my most recent trip to Tororo, I am asked by the midwives to see a patient for “retained second twin.” This means that the patient delivered the first twin (usually at home, on her own) but the second twin did not come out for a long time, prompting her to present to the hospital. In this case, the patient presents with a note from the traditional birth attendant, who sent her in.

The patient delivered about 18 hours ago. She looks calm, and not in pain. There is a single umbilical cord coming down between her legs. The midwives can’t determine the position of the fetus. I palpate the abdomen, and I don’t feel a head in her pelvis, but I can’t tell much of anything. I do a vaginal exam, and find that while the membranes are bulging out into the vagina, tense with amniotic fluid, the presenting fetal part is high up in the uterus, and I cannot palpate it, no matter how high I reach, although the cervix is fully dilated. It is very hard to reach around the bulging membranes. The midwife tells me that there was no fetal heartbeat, but miraculously (normally I am quite unskilled at using the fetoscope), I seem to find one. The midwife agrees.

I bring the ultrasound, and find that the midwives and I were correct – the head is not coming first. It is a difficult scan because the infant’s body is bunched down in the lower abdomen, but as I follow the axis of the spine, it seems that the fetus’ pelvis is lowest in the woman’s uterus. The fetal head appears to be at the uterine fundus, so it is most likely breech.

If the fetus is breech (meaning either feet or pelvis coming first), I can try to deliver vaginally. But if the fetus is transverse (meaning torso, arm or shoulder coming first), there is no way to deliver without performing a version.

If I had been present at the delivery of the first twin, this would be easier. Usually, the second twin is still high up in the uterus, and I can actually reach an entire hand in and turn the fetus to either cephalic (head down) or breech, and then deliver. (It helps if the patient has an epidural, of course). But since the woman has now labored for 18 hours since delivering the first twin, the second twin is stuck in position, and I cannot rotate it successfully, despite my efforts.

I would really like to avoid a cesarean in this woman. This is her fifth delivery – she has four living children other than Twin A. She clearly has a proven pelvis, and it is not clear whether Twin B will even survive at this point. Cesareans are much more morbid here than in the US, and I don’t want to put her through one for a non-viable fetus.

However, I can also see on the ultrasound that this fetus’ heart is beating strongly. This kid is alive. So I have to decide – do I try for a vaginal delivery now, or go straight for cesarean?

The midwives and I both feel that she has a good chance at delivering vaginally. She has pushed 5 babies out, so her pelvis is good, and her only problem seems to be the lack of powerful contractions. We decide that we will hang a slow infusion of oxytocin to get her contractions back, and then I will slowly break the bag of water and see if I can deliver the child breech. I am not 100% sure that he is breech, but I am taking a gamble in the hope of sparing the mother a surgery.

Before I do so, though, I want to make sure that theatre is prepared in case I need an urgent cesarean. If I get a cord prolapse, we won’t be able to wait the usual hour (or more) to get the patient to theatre before the fetus is compromised.

They start the infusion, and I take care of some other patients. When I return, she is grunting heavily and telling the midwives she wants to push. I examine her, and the bag is bulging even more tensely in her vagina. The presenting part is still not palpable. I take a needle and puncture a tiny hole in the bag. As water leaks slowly out and the bag becomes less tense, I am able to palpate what is inside. And what I feel is…..cord.


I just lost my gamble. Now what? Will we ever get her to theatre on time? If the baby is breech, should I just try to do a quick extraction instead of taking the risk of theatre?

I palpate the cord. It has pulsation, meaning the baby is still alive. Since the fluid is leaking out only very slowly, it is still buoyed by the fluid in the membranes. I palpate further and feel something as narrow as cord, but much more firm. I follow it up..….fingers.


Transverse presentation. Now I have really lost the gamble. I have already called out to the midwives to prepare for theatre. One is bringing over the stretcher – I am impressed as this is unusually fast. I tell them not to bother having her sign consent, just bring her. (That never happens.)

I dash over to notify the theatre staff, and they start preparing. First, they are out of suture. I look in the suture closet and find only silk and a little nylon. AARGH. Both of those are non-absorbable (permanent) and I loathe using them. What happened to the vicryl and chromic that used to be here?

The theatre nurse informs me that they have been out of stock of most sutures for 2 weeks, and the district has not yet approved the purchase of more. Facepalm. Luckily, the anesthetist has just a little vicryl and catugut stored away in a locked cabinet for just this reason.

A tray is already being prepared with a c-section kit ready to be unwrapped. When I was living here, I had bought sterilizing cloths so that instruments could be packed in sets, and sterilized in advance of surgery (so that we wouldn’t have to wait an hour to sterilize instruments right before the surgery). I am pleased to see that the system has continued.

When I left the labor ward, the midwife was moving the patient onto the stretcher. But where are they now? I feel the minutes ticking by. It always takes forever to move the patient, and is one of the most frustrating things that, no matter what I do, never seems to change. I pace and keep poking my head outside the theatre door, staring anxiously. Just when I am about to run back to the labor ward, the patient appears in the prep area. They had stopped to consent her, hence the delay. Fine, whatever. They tell me that the patient asked very clearly for a tubal ligation. I reconfirm with her and document it.

Kevin, a female anesthetist who has training in spinal anesthesia, appears and asks me if she can do a spinal. In the US, we would do general anesthesia in this situation because we have no time to spare in a cord prolapse – the child could be dead in minutes. But I know that spinal anesthesia is much safer for the mother, and given all the other delays we still have to get through in preparing theatre, I don’t think that putting in the spinal is going to make a difference, so I agree.

Kevin is a rusher – I like that. Things tend to go at a slow pace here, even emergencies. But when Kevin realizes she needs a different needle for the spinal, she runs to the supply room, and runs back. The spinal is in very quickly.

I have invited Katie and Hannah two young American possible pre-meds to observe the c-section. They are quietly observing in a corner. I hope they don’t pass out, but I’ve given them instructions on what to do if they feel woozy. I’ve also warned them that there’s a good chance this baby will die.

We are finally ready after what seemed like much too long. The spinal anesthesia works beautifully. I get in quickly, but once I open the uterus, the first trouble starts. The position is terrible, and I realize I should have made a vertical incision on the uterus. The fetus is folded over itself and squeezed into the lower uterus, and the back is facing me, with the shoulder at the incision. Mentally, I kick myself, because I should have put together my ultrasound findings (spine up) with palpating the hand in the vagina (transverse presentation) to know I needed a vertical incision.

It is impossible to grab anything. I try to bring the feet out, but can’t. I try to bring the head out, but can’t I try to turn the fetus, but can’t. I try to push the arm up from the vagina to flip the baby, but it doesn’t help. Finally, I extend the uterine incision on one side. It’s still difficult, and I repeat my maneuvers. Finally, as I am trying to move the head, I see testicles pop out of the incision, and realize that the pelvis is out. I have to scold the scrub nurse not to yank on the infant’s body as I am delivering – this is the worst thing you can do, because it causes a reflex in the baby that can cause the head to get stuck. I can now gently sweep the legs out, and carefully ease out the body and the head.

The baby is blue, limp…..dead. I try to palpate rapidly for a pulse in the neck or the cord, but feel nothing. I quickly clamp the cord and pass the baby to the midwife. Sometimes, babies who look like this are assumed to be dead, so I give clear commands to resuscitate immediately. I turn back to the mother, but continue to keep one ear on the resuscitation.

The midwives generally do a good job resuscitating, but the one thing they are often complacent about is oxygen. The oxygen concentrator is often not working, or doesn’t have the right connecting tubes, so people tend to give up and not waste time trying to use it.
But I know this kid needs oxygen if he’s going to live, so I keep calling out to use the oxygen.

Katie and Hannah are watching anxiously, itching to help. I tell them to try to hook up the oxygen while the midwife works on the baby, so they jump in. The oxygen can’t connect to the bag/mask, but there is a small nasal catheter that can be placed down the baby’s nose to give oxygen. I tell them to leave the oxygen catheter in and keep bagging if there are no spontaneous breaths. The heart rate improves to almost normal, but still no spontaneous breathing.

Meanwhile, I am suturing a bloody field. My extension of the incision and my aggressive attempts to deliver the fetus have damaged the left uterine artery, which is shooting blood. The uterine artery is not far from the ureter, which connects the kidney to the bladder. It is very easy to damage the ureter, and potentially catastrophic if it happens. I clamp the artery carefully, and then am able to dissect it away from the surrounding tissue and tie it off so it stops bleeding. All the while, I am calling out orders for the resuscitation without actually being able to see how the infant is doing. It’s hard to focus – one of the knots I tie is is useless because I am distracted while tying, and I have to retie. Finally, I control the bleeding. I start to wonder if I operated on this woman and bled her out only to deliver a dead baby, and I kick myself again.

Katie and Hannah are communicating to me how the baby looks so I don’t have to take my eyes off the field. The color is improving, but it is not clear if the infant is breathing. Kevin and the midwife insist that the breathing is fine, while Katie and Hannah say that there are only infrequent gasps. It’s hard for me to tell, but at least the heart rate is staying up. I tell them to keep the oxygen on and count the respirations per minute. There is no clock in the room, so one of them has to count seconds while the other counts respirations. Now that the bleeding is controlled, I can try to get through the rest of the surgery quickly, and then check out the infant. But my first priority always has to be the woman.

It is time to tie the tubes. I generally try to confirm once more before I cut them, and especially in cases where the baby is not doing well. I have the midwife ask the patient in Japadhola, and there is some confusion. First she says yes, then no. They ask her again, and she says not to cut them, because “her husband will quarrel with her.” I have them ask again. She repeats that she has not discussed it with her husband, so I should not cut them. Everyone is disappointed – this woman has been through so much, and is having her sixth child. If only the men came to the births, the women would all get contraception. I leave the tubes alone, and close the abdomen.

I have to argue with the theatre staff again about the skin closure. All of the doctors at TDH use silk (permanent) suture, in which they drive a huge needle straight through the skin on both sides, and pinch the skin together tightly. The silk suture has to be removed (painfully) after 7 days. Often the incision gets infected, and leaves a giant scar with a keloid. The staff (who are not the ones I have operated with in the past) has never seen a subcuticular suture, which is what I do. I take a tiny suture, and I sew just beneath the skin edge, bringing the skin together gently. When I am finished, you can’t see the suture, only a very thin line. The suture absorbs over a few weeks and does not need to be removed. They don’t get infected the way that the other closure does.

The staff is concerned that the suture I am using is too small, but when they see my closure, they stop questioning it. The midwives have seen how nicely my incisions heal, and they love it.

The patient has lost a lot of blood, but seems OK. I check out the infant. He is no longer blue, just pale. His heart rate is normal, and he is finally breathing spontaneously. His muscle tone is weak, and he does not cry. His arm (the one that was in the vagina) is very swollen, but not broken. I try to stimulate him by rubbing his back or flicking the bottom of his foot. At first, he doesn’t respond, but finally he gives a weak objection, and I am pleased. It’s at least some reaction.

I write my operative note while the patient is being moved off the table. When I come back to the infant, he looks even better. His skin is turning light brown, and his whine when stimulated is getting louder, almost a cry. His hand squeezes Katie’s finger, and we are pleased. Now, his biggest problem is warmth. I write for him to be placed in the warmer, and when the mother is ready, kangaroo care.

Hannah and Katie are pretty stunned. We go out for lunch (it’s 3pm, we are all starved) and reflect. I sincerely believe that if they had not been there to assist with the resuscitation, the baby would have died, and I tell them as much. “You saved the baby,” I say, and it’s true. I joke that this might be the first day of their medical careers. Katie announces that she just might go to medical school to go into Ob/Gyn. I try not to beam too much, but I am proud.

The next morning, we all go to see our patients. I am worried that the infant might have died overnight; he was still weak. Will Katie and Hannah be too upset if he died? At least I have dealt with this before and am emotionally prepared, but the first time is really hard. But no, the nurse tells us both twins are alive.

We find the mother lying in bed, but she beams when we arrive. I greet her and her mother, who is holding the infants. They both look great. The first twin, Opio*, is happily sleeping. The second twin, Odongo, is slightly bigger, and looks great. His tone is a little weaker than Opio’s, but much improved. His arm is still swollen but less red, and when I move it and try to unflex his hand, he cries out with angry objection. I am happy to see that forceful cry.

The woman looks great. Despite her blood loss, she looks happy and bright. I remove her bandage, and the incision is beautiful (if I do say so myself). We ask if she wants a photo with her babies, and she does.

The Odongo is on the left, Opio is on the right. The patient, so smiley, immediately puts on a serious face for the photo, as is the custom here. She laughs when we show her the photo. She tells me that I can share her photo, because she is so happy we saved her.

I remind the patient that we did not cut her tubes. “But I signed to cut them,” she says. Sighhhhh. I remind her that she told us not to cut them during the surgery. “Yes,” she says “because I had not informed my husband.”

The nurse lectures her about family planning, and she does not want more children, but is vague about her plans for contraception. She agrees to come back in 2 months for family planning, and I warn her that she could get pregnant after 1 month. The husband is at the window, so we bring him into the discussion. He speaks English.

I tell him what happened at the delivery. He doesn’t realize that the infant nearly died, so I tell him that the situation was very dangerous for both the woman and the second twin, and that the next pregnancy could be complicated as well.

“I was thinking about this yesterday,” he says. “I think that we have enough and we should stop, because my wife was in danger and I don’t want that again.”

We explain that we could not cut her tubes, and we encourage him to make sure she comes back for family planning. Bringing the husband in is essential in getting women to accept contraception here, and it’s unfortunate that most do not come. If he had been around yesterday, we could have cut her tubes. Luckily, we are all in agreement now. We shake hands all around.

Over the next week, I continue to visit the woman every day. Katie comes with me to see the patient every day. I am very impressed with Katie’s passion – I wish more medical students would show this level of commitment. I strongly believe that we should follow up on our patients and take responsibility for them, especially as a surgeon. Seeing patients after you operate on them means that you see the consequences of your actions, and that you don’t put the patient aside once the skin is closed. It also means that you see the pain, the healing, the struggle and the reality.

Many patients are anxious to go home, and often start to ask for discharge when they are healthy enough to get out of bed, but she doesn’t. Her milk is slow to come in, but finally comes in on the third day. But she is emaciated to begin with, her infants are small and the delivery was stressful. I am in no rush to send her home. It turns out that the patient speaks more English than she had initially indicated, and we can communicate a little. I tell her that I want her to eat lots of food, including meat and beans (protein malnutrition is a huge problem here), and that I want her to become “fat” so she can produce plenty of milk. She laughs gleefully when I say that.

I tell her she can stay as long as she wants to rest. I don’t want her chasing after 4 more children and digging in the fields and carrying water anytime soon. I ask her when she wants to go, and she says “Saturday?” That will be around 10 days after delivery. Hey, why not?

Odongo’s arm improves slowly. The swelling decreases, and he cries less and less when it is moved. I palpate carefully, and I don’t feel a bone injury. I have him examined by one of our study’s medical officers who is very knowledgable about Pediatrics, and he agrees that the injury is only soft tissue, and is improving well.

Every day, the patient shakes my hand warmly and proudly displays her babies. Through the nurse, the patient tells me how happy she is. The nurse says “When she goes to bathe, she runs quickly quickly and comes back because she doesn’t want anyone else to touch them. She loves them so much!” She is gazing lovingly at them as this is translated. It is hard to fathom that Odongo was so close to death. With a slightly different twist of fate, all of this love would have been profound grief.

*In Tororo, surnames of children do not match those of the parents. They often relate to the circumstances at birth (eg. born in the morning, or born in the time of the rain, etc.) A first twin is always given the surname Opio (boy) or Apio (girl), and a second twin is Adongo (girl) or Odongo (boy). The first name is not assigned until a chicken is cooked to celebrate the birth.