Shades of Grey....

In actuality it was shades of bright red.  She was “6 months” pregnant and bleeding from her vagina.  This was her 7th pregnancy, but first time to the hospital for a delivery.   She had delivered all of her other pregnancies at home.  

I used to hate it in residency when someone would come in with “no prenatal care” with an urgent issue.  It just meant more work to figure out what was going on with mom and baby.  

Then I became one of those “no prenatal care” patients in New Jersey.  And thus Zane was brought into this world.  

Back to our bleeding pregnant woman.  She had no prenatal care.  Today she was working in the field and started bleeding briskly.  So she walked to the hospital, bleeding and all.  No one had been home except for her.  She didn’t wait for her mother.  She didn’t wait for her husband.  No one from home even knew she came.  (This in itself is a big no no here.  You should get the permission from your husband before coming to the hospital).  But she came anyways.  

The bleeding seemed to slow down some.  

I did an ultrasound.  Partial placenta previa.  The placenta was covering part of the opening of the cervix, blocking the baby.  I measured the baby and he measured 28 weeks.  This estimated him to be 1.28 Kg (less than 3 pounds).  I give her a shot of dexamethasone in case the baby might live (this is supposed to help develop the lungs).

There were several things to consider.  

Mother is bleeding.  To save her, I need to get the baby and placenta out quickly so that the bleeding stops.  

Baby is very tiny.  Will he live?  This would help determine my mode of delivery.

In the US the age of viability is 24 weeks.  Though this is a little grey area.  Babies that live at 24 weeks are miracles also, even with all of the fancy american help.  

This is NOT America.  We DO NOT have NICU or much means to help premature babies.  

I do a speculum exam.  She has several large clots that block our view of the cervix.  I very carefully move the clots, but still can’t see the cervix very well.  Is it possible to deliver this baby vaginally?   I do a digital exam (normally you don’t do with previa for fear of hemorrhage) and discover that she’s 4 cm dilated.  She continues to bleed a little.  

Okay...we need to do a c-section to stop the bleeding.  I walk her to the operating room and put her on a gurney.  

There’s another patient who’s already in the operating room, so she’ll have to wait.  

I consider my options again.  I dislike indecision.  Normally, you look at the facts and make an educated decision based on them.  Stick with it.  The facts aren’t going to change.  You can’t change the fact that this baby is so premature.    

I know this baby is not going to live.  He’s too small.  If he were in the states it would be an easy decision.  C-section right away.  Stop the mom’s bleeding and wisk the baby up to NICU.  But here, the smallest baby I’ve had live is 1500 grams.  Not 1200 grams.  He’s just too small.  

Why do I NOT want to do a c-section?  Because women don’t come to the hospital for labor.  The next labor would risk mom’s life if she stays too long at home when there is a problem.  So I avoid c-sections like the plague here.  From my history taking, 98% of women have lost babies here...term fetal deaths, neonates secondary to the delivery, or a child.  That’s not including all of the babies that are lost to miscarriages or preterm births.  That’s a reality.  People are “used” to it.  It doesn’t get easier, but it’s the harsh reality.  

I talk to her about possible vaginal extraction of the baby because he is too small to live.  She accepts.  She does not want a c-section.  How can she have a c-section when her mother or husband aren’t even here?  (In other hospitals people die during “uncomplicated” c-sections).  However, even a vaginal extraction is dangerous with the location of the placenta due to the risk of bleeding. 

I ask her if she wants more children in case a c-section is necessary due to bleeding.  It depends on God she says.  “Well, if He gave you the decision today, what would you say?,” I was trying to ask her if she wanted a tubal ligation.

She does want more children.  She has 5 girls and no boys.  She just wants a boy and then she will be done.  

Her bleeding mostly stops, but the risk of bleeding is too great, so we bring her into the operating room when it becomes available.

She gets spinal anesthesia.  I ask my dad for help.  I do another vaginal exam and find that she is 5cm dilated.  Maybe we should give her oxytoxin to progress her labor?  Also a big no no on a woman who is bleeding.  Or maybe we should just do a c-section to stop the bleeding faster.   

We decide on trying vaginally with possible destructive delivery.  But this would mean that the baby would not come out alive.  He wouldn’t live anyways.  This baby is too small.  I know he’s too small.  There is no question.  Right?  I’m not liking my indecisiveness.  I even say that out loud.  

We say a prayer and begin.  

I decide that feet first would be easier to deliver the baby, so we manipulate the baby around.  With a hand in the vagina, I find a small area that is not covered by placenta and break her water.  More blood comes out.  She’s still only 5 cm’s dilated.  I grab onto one of the baby’s legs and pull out a foot.  I look at how tiny it is.  If I just pull harder, the baby should come out, but his head would get stuck.  The baby pulls his leg back.  He’s fighting me. 

Grey areas are difficult.  At least this one is for me.  

Do I risk the mom’s life the next year to try to save a baby that is too small to live?  

It seems to me that Africa usually has less shades of grey and more black and white.  I’m not talking about skin color.  Though we do stick out like sore thumbs.  The death and suffering is very intense here.  Everyone knows it personally.  Because of all of the suffering, you either fully live...or you die.  Survival.  There doesn’t seem to be much in between here.  It’s more black and white.  

But this is not black and white.  

I grab the little foot again.  But I just can’t do it.   

So my dad and I do a c-section, deliver the tiny baby, and stop the bleeding placenta.  

He’s little.  Too little.  He actually weighs 1400 grams (about 3 pounds), a little more than I estimated. 

Is he too little?  

No, don’t get attached.  I did the c-section to stop her bleeding.  Really.  You can rationalize a lot of decisions in medicine.  It wasn’t to save the baby.  It wasn’t because I couldn’t do the destruction.    Really...I think.

 Lyol helped wrap him up snugly

He’s not going to make it.  

But is he?  

Maybe he’s one of God’s next miracles here?

Olen suctions him out, cleans him off and ties his cord.  He’s crying (the baby, not Olen).    

Janna is our pediatric queen, so we have her come over and put in a neonatal NG tube for feeding.  Seraphin even got an IV for iv antibiotics in his tiny little arm.  We arrange our special incubator, a cardboard box.  I brought the baby home to get some blankets and a little hat that my friend Bekah sent me.  I tucked some warm water bottles in Olen’s socks (not too dirty since we never use socks here) to keep this cutie patutie comfie and warm (it’s not hot season and does get “cold” during the night).  

We can give milk, give antibiotics, keep him warm and dry, and pray.  Please help us pray that this cute little miracle continues to live.  He is 3 days old today.  He has a special place in my heart already even though I know it’s taking a risk.  Mom’s milk has come in well now and the baby actually latched on her breast well this afternoon.