Quite
a weekend…. I’d arrived late Wednesday night, spent the day Thursday organizing
and distributing the meds and supplies I’d brought with me. Friday I met with
the medical staff and with our SIM Liberia Director. Saturday morning I took over as the on-call
physician at ELWA Hospital, covering our 50 bed facility for the weekend. One
of my local colleagues helped me with rounds on Saturday. And then, about 11:30 AM, it all started….
Amelia
(not her real name) is a 32 year old mother of 3 who had not been to ELWA
before. She came from 25 minutes down the road—the rural area between Monrovia
and the airport. She told us she’d never had a day of formal education. She was
9 months pregnant, and had severe abdominal pain starting around 10:00 in the
morning. There were no fetal heart tones, and she had significant vaginal
bleeding. The abdomen was so tender that it was difficult to really get a good
exam. I talked with Amelia, her sister,
and an Aunt who had helped get her to the hospital. I told them she’d need an
urgent operation, as it looked like the placenta had separated from the uterus
and we needed to get the baby out and get the bleeding controlled, though it
looked like the baby had already died in her abdomen.
After
the surgical team made their preparations, I scrubbed in and got ready to start
the case. I’d been hoping for an easy first weekend—maybe a c-section or two,
but let them be healthy ones with good babies. Not this time. As we entered the
abdomen, we encountered copious clots and blood—I reached my hand in through
the incision and explored, and realized this was not an abruption, but a
uterine rupture—the baby had been expelled through a tear in the lower uterine
segment, along with the placenta. We extracted the stillborn baby and the
placenta and brought the uterus into view—there was a stellate rupture
extending in 3 different directions. With some skillful help from Gideon, the
assistant, we pieced the uterus back together and repaired it in 2 layers.
After a transfusion, Amelia’s BP stabilized and she was able to go on the
postpartum ward.
Sunday
morning I was awakened at 5:30 by a call from the ER—a pregnant woman had come
in, short of breath, with O2 saturation of 57%. When I arrived, she looked like
she might give up the ghost at any moment. Her heart was massively enlarged, she
was in pulmonary edema, and she was full term. I silently prayed for her as we
gave her oxygen, lasix, hydralazine, and IV digoxin. Miraculously, she
gradually stabilized, and later in the day delivered a full term baby girl who
unfortunately appeared to have brain damage from her prolonged hypoxia.
Add
to that a couple other challenges—a vacuum extraction on a woman whose baby had
apgars of 5, 5, and 7; and a c-section on a patient attempting a trial of labor
after prior cesarean.
All
these women survived, and two of the four had good neonatal outcomes. If these
women had been pregnant just 18 to 22 months ago, during the worst Ebola
epidemic the world has ever seen, it’s quite likely that all 4 of them would
have died or had even more complicated deliveries, due to the closure of most
health facilities here. Timely, skilled maternity care is a lifeline in a place
like Liberia—a very fragile lifeline. One of our priorities is to extend that
lifeline to as many women as possible, as well as training local midwives and
physicians in quality emergency obstetric care. I’m so grateful to practice as
part of teams, both here in Liberia and in Worcester, that make women’s health
and maternity care such a priority!
