OB Week...

My second week as medical director at Chiri Health Center provided an unplanned orientation into obstetrics in Ethiopia. Our health center is a government health center that is supported and run by an NGO (Lalmba). Like most health centers, we do not advertise ourselves as a birthing center simply because we do not have the capacity or staffing to deliver many babies. But we will care for any patient that comes into our clinic, and in a typical week we deliver between 2-3 babies. This week, I would later discover, would not prove to be a typical week.

Monday- One miscarriage, and two healthy deliveries before noon. Four hours into our work week and we’ve already met our normal baby quota…maybe we won’t have any more deliveries this week….? As we were closing the clinic that afternoon two additional expecting mothers arrived. One was sent home, the second was ready to deliver. The midwife Desalegn examined her and was immediately concerned. She had been in labor for 2 days, and Desalegn was worried about problems with the placenta or a small uterine rupture. His experience definitely trumped mine, so we all piled into our Toyota Landcruiser—mother, family, nurses and myself—and we drove her about 40 minutes down the road to a bigger town called Bonga where they have a small hospital with 2 health officers (nurses with extra training) and the surgical capacity to do C-sections.

Tuesday- In the early evening another laboring mother arrived at our clinic with vaginal bleeding, and we worried that she too would need a C-section (for the medical people–we thought she may have had a placenta previa). So we sent her to Bonga. On arrival, the nurse who accompanied her discovered that the woman from the previous night did indeed require the C-section we anticipated. Unfortunately she had complications during the surgery. They were not able to control her bleeding and she did not survive.

Wednesday- I learned of this disturbing piece of news on Wednesday morning, and hoped that the worst was behind us. Soon after, I noticed a large crowd as a man, woman, and their 3 month-old infant were rushed into our inpatient ward. I hurried down with our health officer Bezu. The infant was unconscious and had a large amount of swelling in the back of his head. Apparently, his father was taking him on horseback to our clinic for vaccines. The noise of an automobile jarred the horse, and both father and son fell head first. His mother and father looked at me with tears in their eyes, and hoped for a miracle. We tried giving anti-seizure meds in case the impact had precipitated a seizure. We knew this effort was futile, but it was all we could offer them. The baby likely fractured his skull and was bleeding into his brain. His breathing was labored. Without emergent neurosurgery, his prognosis was grim. I felt helpless. He died within an hour.

I tried to express the profound sorrow that I felt for the family and staggered out of the inpatient unit, hoping to get some air and a few minutes to process this tragedy, only to discover that a laboring woman had arrived and was being ushered into our labor and delivery room. The midwife Solomon examined her. During the exam, his face contorted in a not-so-positive manner. I knew something was wrong…I said “cord?” hoping this wouldn’t be the case. “No,” he said. “Breech.” He then proceeded to show me the foot nearly hanging out…a footling breech…even worse, I thought. The problem here is that the cervix does not have time to completely dilate, making it hard for the largest part of the body, the head, to deliver. Solomon starting delivering the baby – first the legs, then body, then arms. As anticipated, the head became stuck. He tried many maneuvers to help flex the baby’s head and get it out. My heart raced as the minutes ticked away. After about 7 minutes, I asked him how much time we had left to get this baby out before it is too late. He told me bluntly, “She is already dead.” Three minutes later (a full 10 minutes since the rest of the body delivered), Solomon finally delivered the head. The baby had no color, tone, or other signs of life. I quickly clamped and cut the cord. Solomon brought the baby to the table and checked for a pulse. Miraculously, he felt one. For the next 45 minutes, Solomon, Desalegn, and I worked to resuscitate this baby. We used a bag to give breaths since the baby was not breathing on her own. Solomon even performed mouth-to-mouth. We gave chest compressions, epinephrine. Slowly, the baby regained its color, and began grunting. The grunts turned to more regular breathing. We placed her on oxygen. Her temperature was 94.1 degrees (very low), but without access to baby warmers like back home, we improvised. One of the other expats has a space warmer for their 2-year-old. After a night with this heater (and her mom’s body warmth), the baby’s temperature was up to 98 degrees (normal!)…and she began breastfeeding!

Thursday- As I drove to Addis Ababa on a med run to re-supply our pharmacy, I tried to process the past three days. Here, many of the lines that we take for granted in the states seem so much more blurred—lines between good and bad, lifesaving and harmful, promising and ill-fated don’t always exist. The paved road that I was traveling on to Addis will soon stretch all the way to our small town, bringing sorely needed medications and supplies and easier access to Bonga hospital… but also more cars and dangerous traffic. The man with his small child was traveling to our health center because he learned of the value of vaccines and disease prevention only to lose his son in a terrible accident. So many times our efforts here seem futile, like we are destined to fail, but then there is something (even if it is ever so small) that we are able to do… and we save a life… and those lines don’t matter any more.