The patient was unremarkable for Kenya.
This was not her first pregnancy. Or was it? Honestly, it all starts to blur together. Patient after patient, never speaking to any of them directly, only using interpretors, the turnover more rapid than triage at Good Slam Hospital.
She had partial previa - where the placenta overlies the cervix. She had vaginal bleeding when she presented at 25 weeks and a few days. Her hemoglobin was 5.3. We decided not to give dexamethsone (steroids) to enhance fetal lung maturity because the fetus was small and the limits of viability here are really around 26 weeks.
The limits of viability....this is when we expect that a fetus can theorectically survive outside the uterus. But we don't typically intubate neonates here - longterm outcomes are bad and I suspect social and financial issues are at work. In a place where death and dying is common and language barriers abound, it is not difficult to begin overlooking the privelege of personalized care.
This patient was hospitalized for several days, receiving blood transfusions and on bedrest - in hopes that she would maintain her pregnancy to viability. On Thursday of last week she received steroids for the fetus. Then on Saturday, I was on call. At 0200, the call came that I had been dreading.
She has bled again. Maybe it is just a small clot? The baby is looking well. Okay, let's watch for one hour.
One hour later - she is still bleeding.
Reluctantly, I know I must get out of bed and call a C section to end this pregnancy or she will continue to bleed. I am thinking about this 26 week fetus, wondering if it has any chance.
I begin the C section. The pediatrician is waiting to assess the baby and resusitate. I can see the placenta bulging underneath the uterine wall, exactly where I want to cut. I point it out to the intern. She is not interested in learning at 3am. Oh well. I make my incision in the uterus and with just a little pressure, the placenta and fetus expels into my hand. It appears that a partial or total abruption has also occurred.
**Sigh**
I feel completely defeated as a look at a baby that fits into one hand and weighs maybe one pound. Very small- appearing for even a 26 weeks, with a thin and collapsed umbilical cord. Great. Probably bled out while she was being prepped and waiting. The events of the previous week has just crashed down on me: two maternal deaths, several IUFDs, one quad dying, a term baby with birth asphixia.....the list goes on in my head and the frustration mainfests in the sentence that I speak, "Never mind. It's too small."
As I reach to cut the cord, four tiny extremities extended and flexed. Two eyes opened and an amazingly vigorous cry came from the small body in my hand.
It was a total - "Are you talking about me?!" moment. So, I gave the baby to the nurse and off to Peds she went.
I felt like an ass. You ever been told off by a one pound baby? That's what I felt like. In a time that I was passing (clinical) judgement and surfing the sea of frustration - life was trying to happen.
There are many days here in Kenya when seredipity seems to govern the universe - I often don't know what it wrong with the patients who are sick, the ones who die OR the ones who get better! It's a little challenging for the Type A control freak! It is good to smart, good to be surgically competent, but here it is more vital to just be blessed.
Back to baby with an attitude: she weighed 640 grams and she lived for ~ 4 days. We do the best we can, with what we have and leave the rest is up to God. In that moment, she was a reminder that focusing only on the impossibilities of this place may rob us of the miracles that are happening: DIC patients who survive, three remaining quads now on feeds and eclamptics who go home alive with live babies.
"He humbled you, causing you to hunger and then feeding you with manna, which neither you nor your ancestors had known, to teach you that man does not live on bread alone but on every word that comes from the mouth of the LORD." Deut 8:3 NIV
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