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A hard week

This week has been hard. The following is an excerpt from my journal of our time here from yesterday. It was hard to live and probably hard to read, not to mention sprinkled with medical terminology. This is the reality some weeks, I guess.

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The baby born a few days back with birth asphyxia who I suspected was seizing died overnight. I found the mother and told her "I'm sorry." I cried with her and didn't know what else to do. I'm not sure what went wrong with that baby or what I might have done to help.

Hours later, I answered the Maternity Ward phone and was told about 2 transfers from the smaller hospital down the road: one bleeding placenta previa at 28 wks, and one 34 week breech primigravida with hydrocephalus [big head] dilated to 8 cm. It was hard to decide which to be more worried about. When the ambulance arrived carrying both of them, it was easier to see - the breech primigravida writhed on her stretcher with contractions. Once we wheeled her inside I checked her cervix. Just as I'd worried, she was fully dilated and definitely breech. We drew blood and scrambled to figure out if we had time to take her to the OR for emergent C-section It quickly became clear that we didn't - crossing her legs was little help to resist the primal urge to push. After weighing our options, we told her to push and prayed for the best. The butt came quickly, and then the legs in frank breech position. I twisted the body back and forth and it came easily. The shoulders delivered, and then it was time for the head. I pulled. Nothing happened. Dan coached me to pull straight upward, so I did. Nothing. I pulled harder. He tried pulling. I placed my hand inside and tried to tug the head out. I put a finger in the baby's mouth, and felt the baby sucking my finger. This only made my pulling more urgent. I pulled and regrasped and pulled some more. Finally Dan went to find Mr. Khondowe to attempt decompression of the baby's head. Horrified by this thought, my pulling became more urgent and finally, with a finger in the baby's mouth, the head delivered. The baby was limp and small, and the head did not look so big. I checked the baby - a girl. No breathing, no pulses, no more sucking. I cleared the airway, bagged the baby, did chest compressions, did everything I could think of. There was no pulse, no breathing. Nothing. The baby died. One midwife said, "Too bad."

Yesterday I was asked to help with IV access on a severely dehydrated 10 month old boy in the pediatrics ward. Ray the CRNA said there were no veins, so I placed an IO access in the tibia. It worked fairly well, swelling up the leg but delivering fluids as intended. By afternoon the tenting visible in his skin was improving. The next morning, though - today - the tenting looked worse again. This was perplexing since the IO had done its job and allowed an IV to be placed. I turned up the rate this morning when I visited him and hoped things would start to go the other direction again.

After rounds, a 19 year old primigravida at 40w2d appeared in Maternity complaining that her membranes had ruptured a week ago but she wasn't contracting. The ultrasound looked good, the NST looked good, and she wasn't contracting. I placed 50mcg Cytotec to start the labor, and checked back four hours later. Her cervix had dilated to 6cm and she was contracting hard. A spot check of fetal heart tones (FHTs) showed a good baseline in the 140s. I left her alone and came back shortly thereafter to find her dilated to 8cm. Not even 30 minutes later she couldn't hold back pushing. She was almost completely dilated, just an anterior lip of cervix left, so I decided to let her start. The heart rate was still 140-150 and stayed there throughout her pushing. She pushed and pushed, moving the head very little despite excellent effort. At 45 minutes pushing, Dan appeared and wondered if she would be able to do it. We decided to give her 30 more minutes pushing and if things were still not progressing we would take her to the OR. Shortly after this the FHT baseline climbed to about 170. There were a few decels to 90-100, but most went down to 120 only. We shuddered as we heard the wailing of women outside in the Pediatrics Ward. Someone told us the news: the dehydrated baby, the one I had tried to resuscitate the day before, had died. The wailing continued.

The 30 minutes out mark came, but the OR was full - the eye surgeons were doing a complicated eye case and using the CRNA. As this was being worked out, the pt was moving the head down more and more. FHT stayed the same and recovered well between contractions. Finally when we were going to call in the backup OR team, Dan reassessed and because of how close the head was, decided that we could deliver vaginally with an episiotomy and vacuum. I cut a midline episiotomy and the head advanced even further. Several more pushes and the head still didn't come out all the way, so we applied the vacuum. I pulled once and the head advanced to the eyes. We pulled and she pushed and finally the whole head was out. The anterior shoulder came with difficulty, requiring suprapubic pressure and downward traction that we didn't hardly have room for, as she labored sitting upright in a regular bed. Dan got the anterior shoulder and I took over, delivering the posterior shoulder and then the body with great effort. Finally the baby came out. The little boy was not breathing or moving, but I clamped the cord and handed him off, expecting to hear a cry momentarily. I massaged the uterus and delivered the placenta, but still no cry. I repaired the episiotomy as I saw Dan intubate and bag, and then start chest compressions on the baby. I prayed and sutured. Finally she was repaired and the bleeding slowed. I came over to the warmer and saw the baby there, not breathing, not moving, no pulse. Cool to the touch. I began bagging and doing compressions, but it was already 30 minutes out. Nothing more to do but weigh him, and show the mother. She stared at him with blank eyes, but did not hold him. She covered his face with the towel and I took him away.

I don't know what went wrong.

Posted by vagabundos 11:11 Archived in Zambia

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