Monday, April 4, 2011

#36 Rupture

Sabbath afternoon.  It’s a time of relaxation, getting out in nature, refocusing our mission here, resting at the house, maybe going to the river.  It’s usually NOT a time to think about the hospital.  The hospital only bothers us for emergencies.  

Today we had plans to go on an outing.  One can get cabin fever here on the compound.  Olen and I rarely go anywhere lately, though we did go to the market once this week.  It’s really to hot to do anything.  

Gary and Wendy were late picking us up in their vehicle.  Gary has lived in Africa too long and now he’s on African time.  

Just as Wendy and Gary arrived, Seraphin, one of the nurses from the hospital, came to  tell me there was a patient in labor who was fully dilated, but her contractions had finished.  

I went to assess her quickly before we all left.  I was pretty sure this meant that I wouldn’t be going though.  

The patient had just arrived.  

“Her water has been broken since yesterday, “ Seraphin said, “And she has no contractions.”

“Yeah, how long has the head been here?” I said after I checked her.  She was fully dilated and +2 station.  

“She doesn’t know.”

“Someone had to be helping her at her house.  Ask the mother how long the head has been here.”

After several translations, “The head has been like that for 1 day,” he said in French.  

This was her third delivery and the first 2 babies had died.

I did an ultrasound and the baby was still alive.  With my abdominal exam, however, the uterus felt malformed.  I suspected uterine rupture.  Unfortunately I have had 2 already here.  Here in Tchad they don’t follow the normal rules of the textbook.  In the textbook...Pain, loss of station, fetal distress, etc.  This is the third patient who hasn’t had a lot of pain (that I could tell), I don’t think her station had been further along before, and I don’t know if she had fetal distress.  Her abdomen just didn’t feel right.  

The family agreed to the c-section, and I told them she may end up with a hysterectomy.    I called Samedi and Simeon from home to help me, and told Olen and the gang to head on without me.  

Luckily I had brought my keys to the OR with me, so I opened "the bloc" (OR) to get things started while I waited for Simeon and Samedi to arrive.  

The team arrived and I decided I was going to put in the foley with sterile technique.  I’m tired of postop urine infections and complications.  No one puts in a foley with sterile technique here.  I would show them now!  

I could NOT get the foley in.  The head was too low and wedged in place.  So much for my sterile foley insertion.  I would have Seraphine or Simeon put the foley in after we had the baby out.  

After the spinal, I made a vertical incision, and my fears were confirmed.  Rupture #3 for me in my first 3 months!  I pulled the term baby out breech because we entered the peritoneum so high to avoid the bladder.  I wished for Olen to be here to help revive the baby and passed the baby off to Seraphin.  

“Suction out the lungs and then breath for him, “ I struggled to say in French.  I feared for the baby’s life, but decided not to break scrub this time as I’ve done in the past to help.  The mom’s uterus was torn quite badly.  

We assess the uterus and I was quite ready to do a hysterectomy after Honorine’s story.    There was no way to get the laparotomy kit for the other tools to help with the hysterectomy because Simeon (our anesthesia nurse) was now helping to resuscitate the baby.  So I wrapped both hands around the base of the uterus to block off the blood flow and waited.  It was probably a good thing to do anyways to gather our bearings.  

Baby wasn’t breathing, but had a strong heart beat.  Seraphine continued breathing for him.  

Meanwhile I reassessed and the rupture was all in the inferior part of the uterus.  It seemed like it was repairable.  God knew what he was doing when I couldn’t get the foley in, because the tear was all the way down right next to the bladder.  With a full bladder, it made it easier to see what was bladder and what was uterus.  

After a long and extensive repair job on the uterus, I thought it looked pretty decent.  We irrigated like crazy because meconium had been dispersed throughout the abdomen with the ruptured uterus.  We finally closed her up.  The baby was still alive after 1 1/2 hours, but was not in good shape.  

I had the family come into the exterior room in the block to be with the baby.  It was trying to take breaths on it’s own, but was just to weak.  He lived for another 30 minutes.  

Mother is now doing considerably well after the operation, non-sterile foley and all.  

Later that night I would end up doing a hysterectomy after (but during) another cesarean section for uterine atony.  The crazy obstetrical complications here are never ending.  Her baby lived though and both are doing well.  

Again, please continue to pray for God's wisdom and guidance as we give medical care for the people in Tchad.

Danae Netteburg

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