OB/GYN

November 25, 2009

Ok, what would you do? A 30yo female who is pregnant with her 3rd child comes to the hospital because her water had broken. She is only 35 weeks (5 weeks early, confirmed by my ultrasound) and she has had 2 previous cesarean sections. In the US, we are able to keep babies inside for a few weeks when moms break their water early, but not in Kenya—she had to deliver today. She also really wants a tubal ligation (tubes tied) and her husband agrees (in Kenya, the husband signs the consent for the tubal). So we do her cesarean section, and two things go wrong: #1 when we open her abdomen, there is a “window” in the uterus, meaning that the uterus wall is so thin, that you can see her baby through the uterus—if she had stayed pregnant any longer, her uterus would likely have burst open, so she was very lucky to be having a cesarean early! #2 the baby looks terrible—she does not breathe on her own, and looks “floppy” and blue. She gets taken to the nursery by the pediatricians and gets oxygen and is not looking well even 30 minutes later. So, what would you do? Would you tie her tubes during the operation, since she wanted permanent contraception prior to her cesarean, with her newborn potentially not surviving? Or do you leave her tubes intact, so she can have another pregnancy if this baby dies, with the risk of a thin uterine wall that could burst, potentially killing her and her fetus in her next pregnancy?

I ended up not tying her tubes. I over-sewed her uterus in two layers, to hopefully strengthen the wall, and decided that a tubal could be done in the future if the baby did well—you can always do a tubal, but it can never be un-done. I asked Vy and Dustin, and they both would have tied her tubes, since she is at such high risk in her next pregnancy… ugh. I don’t know if it was the right decision, but I do know that having babies is the most important thing to a Kenyan woman—it is valued above almost everything. I’ve become more in tune to that way of thinking, apparently.

Just yesterday, I was scrubbed in assisting one of the obsetricians doing a myomectomy and tubuloplasty (removal of fibroids and fixing the fallopian tubes) for a 42 year-old woman who had never been able to conceive. Her husband’s other wife had 6 children, so the problem wasn’t him… when we opened her abdomen, we found that her uterus was so full of fibroids and she had two large fibroids that were completely blocking her tubes. There was nothing to be done. We tried injecting purple dye into the uterus to see if any would come through the tubes, but saw none. She and her husband had been told prior to surgery, that if things looked bad enough, we would do a hysterectomy (remove her uterus entirely) and so that’s what we did. It felt awful, since this was her last-ditch effort to have a chance to conceive, and now we would take away all hope. We worried that her husband would leave her, or treat her poorly, but we knew that she was at risk of severe bleeding or abdominal pain that would require a hysterectomy years later if we left the fibroids there, and she may not have money for another surgery in the future. So we did the hysterectomy after we both convinced ourselves it was the right thing to do. Unfortunately, as we cut the left tube to remove the uterus, we saw purple dye. Who knows if this tube was open enough for an egg to pass the whole way through? I seriously doubt it, since she’d been trying for 20 years without a child, but I think I would have felt better cutting her ureter by accident, than cutting through this tube. I’ll have the chaplain come see them today.

We delivered 3 babies in 30 minutes this morning. I came in early, since it was “staff chapel” at 8am. That was my first mistake. I saw a patient who had been admitted about 2 hours earlier, and I asked a nurse about her—they told me she was 8cm dilated and had “Grade 2 meconium” meaning the baby had its first poop inside her. But no one had monitored the baby, and I asked for some monitoring, and saw fetal distress (heart tones down to the 80s with contractions) and so checked her myself and thought she was 9cm and took her back to the delivery room and vacuumed the baby out fast! I had to cut an episiotomy without any anesthesia to make room, and the mom kicked me really hard when I did it! But once I got her baby out, I couldn’t keep the mom on the table, because she was yelling “praise Jesus!” and “I love you doctor!” and trying to hug me, while hemorrhaging all over the floor and my shoes! Sharon, one of the other OBs ran and vacuumed another baby out that was having bad heart tones and at the same time, one of my patients that I’d admitted yesterday with a really poorly controlled “seizure” disorder (I put it in quotations, because I saw her “seize” and it looked fake—unfortunately, she was being given phenytoin, phenobarbital, and carbamazepine in pregnancy for her disorder—all potentially harmful to her baby). Anyway, I could smell something foul and heard from the nurses that she was going to the bathroom all over the floor, and when I got to her, there her baby’s head was hanging out. So I delivered her, and then she had a major hemorrhage—nearly 2 liters of blood loss. No problem! Stopped that bleeding and then went and started my day! People will think I’m a sinner, since I missed staff chapel… again.

I’m hoping to make it to the vegetable stand today, to get some ingredients for Thanksgiving tomorrow! I couldn’t find Velveeta cheese, for my favorite broccoli casserole, but I’ll just have to get creative!