At last! Some obstetric action!
During the morning ward round today a lady came into maternity from home, haemorrhaging in labour. The baby’s arm prolapsed when the membranes were ruptured and the baby’s shoulders were leading the way, impossible to deliver normally. Scan revealed a marginal placenta praevia, probably responsible for the position of the baby and certainly the reason for the bleeding.
The baby’s heart rate was rapid and it seemed that the cord might be compressed or entangled although a slow heart rate in this circumstance is more ominous. After the scan I insisted the patient be turned into knee chest position to take the pressure off the cord. She was then taken to a procedure room for catheterisation and intravenous infusion which seemed to take so long and all that time she was lying flat on her back. Not at all good for the baby. Transfer to the theatre was in knee chest position – a strange barang custom!
In the theatre I found a wedge to tilt the patient towards the left side to relieve pressure on the inferior vena cava and preserve her blood pressure and placental perfusion. The table does not tilt and the wedge seemed not to be standard procedure. A spinal anaesthetic was established – the safest method for the mother in this country, indeed in most places this is so – but this was done with the patient sitting upright and once again I’m fearful for the baby with the pressure directed downward on the pelvis. Spinal can be done with the patient in lateral position but it seemed the wrong time to suggest it, the safest thing to do right now for all concerned is the procedure that everyone is used to. At last I’m hoping to see Dr Chhaya operate but no. Once again she insists that I am the surgeon.
Midline incision, transverse on the uterus, while Dr Chhaya is insisting on a classical caesarean scar because she will have a tubal ligation. I soon discover that the uterus is clamped down tightly on the fetus and although the arm has delivered through the scar, the rest of the fetus cannot be accessed. Converting to a midline scar, the delivery is completed without further delay, feet first, and the baby girl cried out immediately. I don’t know about the others, but I was so immensely relieved to see and hear the baby so well. Of course the good outcome means that all the palaver about the position of the patient during transfer, anaesthesia and surgery is rather irrelevant now. A bad outcome would have been the time to emphasise the need for good procedures and speedier action but of course we don’t want bad outcomes simply for the opportunity to teach. Nevertheless it will be the teaching topic for next week.
We are all happy because of the outcome and I am especially glad to have been involved more directly in obstetric care. It’s all because of the mothers and babies that VSO is placing me here, and with the purpose of helping improve the capacity for good practice and good outcomes. These doctors are very experienced at dealing with emergencies but there are things we can all learn from each other. I have learned to do a midline uterine incision on a labouring woman when operating under spinal if tubal ligation will be done because the uterus is not relaxed and they have no means of relaxing it here. I hope to encourage a better understanding of when to rupture and when not to rupture the membranes in labour; the value of the knee chest position for transfer in cases with prolapsed cord, arm, or fetal distress thought due to cord complication at the pelvic brim; and the use of lateral lilt whenever the patient is supine as well as the lateral position for spinal anaesthesia.
It all seems like barang ideas – the foreigner again – but we are having a laugh about my foreign ways and getting to trust and respect each other as the days pass.
So now for the afternoon operation…
Removal of a breast for cancer with a 10cm lump. Definitely time for Dr Chhaya to show me what she can do.