I have just finished my fourth week of work in Togo. So far everything is going well and I am enjoying
the work here. On a typical day, I get
to the hospital around 7:15am to round on my patients. I do newborn exams here (usually done by a
pediatrician in the US) so now I have babies as patients too! I really love being able to play with the
newborns every morning. After rounding,
I head to clinic or the OR if we have a Gyn surgery scheduled.
We have clinic on Monday, Tuesday, Thursday and Friday. Some days it is OB clinic and some days it is
GYN clinic. We see a majority of our
patients in the morning then I do Ob/Gyn ultrasounds at 1pm. We see a few new clinic patients in the
afternoon, but mostly it is a time for patients we saw in the morning to come
back for lab/imaging results that were ordered earlier that day and to discuss
treatment planning based on those results.
Many of our patients live hours away and often have to wait in line for a
few days before they can be seen so we try to get everything done for them in
one day.
There is another American midwife here who has been running
the OB side of things by herself for the past couple of years. She is amazing and we alternate days that we
cover labor and delivery. We average
about 1-2 deliveries a day. Twins are
very common here and I have delivered a set of twins every week since I have
been here.
There is also a visiting Ob/Gyn here from Arizona right now. He is here for six weeks and we have been
doing a bunch of surgeries together.
There are a lot of women with pelvic organ prolapse here (bladder/uterus
falling out), but we have been doing hysterectomies for a wide variety of
reasons. I’ll leave operating in Togo
for another post…it is quite different to say the least…and I wanted to start
off by sharing a patient story.
The women here are incredibly resilient and strong. I am continually amazed at how much they can
endure. They hardly make a peep when
they are in labor (there are no epidurals here) and the day after surgery I
often find them sitting up and ready to get out of bed. The
woman in the story below is no exception.
She greeted us every morning she was in the hospital with a smile and
never had a single complaint even though she had reason to have many.
Obstructed Labor #1:
One evening I was at the hospital finishing up a delivery
when we received a patient from a local Togolese hospital. I happened to be covering the first part of
the visiting Ob/Gyn’s call, but luckily he arrived at the same time as the new patient. The patient was in labor and we were told
that she had been pushing for 8 hours.
She was transferred to us because the other hospital didn’t know why the
baby hadn’t been born yet. This was the
patient’s eighth baby and her previous seven babies had been born without
any problems.
Red flags were flying up all over the place. Eight hours of pushing is way too long. She should have had a cesarean section hours
ago and someone who has had seven normal, uncomplicated deliveries should have no
problem with baby number eight. We did an
ultrasound first to look for the fetal heartbeat. The heart was no longer pumping. The baby had passed.
We then did a quick scan of the rest of the baby’s body and
saw that his head was very abnormal. It
was filled with fluid and very big. It
had worked its way into an oval shape in attempt to get out, but it just
wouldn’t fit. We decided to take our
patient to the OR and deliver the baby there where we had better lighting and
better tools.
This situation was a first for me, and initially I wrestled
with what to do. (In the US, this baby’s
head deformity would have been identified and addressed long before his mom
went into labor.) I knew the tools we usually use to help deliver "stuck" babies wouldn't work in this case and I didn’t want to do a
cesarean section and put the mom through a major surgery to deliver a baby that
had already passed. We decided the best
thing to do was to drain the fluid from inside the baby’s head and then deliver the
baby normally. This was clearly the best option, but I really struggled with it. What we had to do was so
morbid. I knew the baby had already passed, but we had to make a hole in his skull in
order to drain the fluid.
We were very relieved once the baby was finally
delivered. Since the mom had been in
labor for so long and her uterus had been working so hard, we were worried that
she may hemorrhage after the baby was delivered. Thankfully, she did not. We let out a sigh of
relief thinking the hard part was over.
We then went to inspect the mom more closely to make sure
she did not have any tears. The first
thing we saw was the Foley bulb as clear as day. Not good.
(A Foley catheter is a type of tube that is placed in the bladder to
drain urine. If you can see the Foley
bulb, it generally means there is a hole in the bladder.)
We quickly double checked to make sure the Foley was in the right place.
It was. There was no mistaking the fact
that the patient had a huge hole in her bladder. We couldn’t even see the end of it. She also had a large tear in her cervix that
went up into her uterus. We couldn’t see
the end of that either.
We made the decision to make an abdominal incision to see
how extensive the bladder and uterine damage was. Once we opened her abdomen, we saw that her
bladder had essentially been shredded and the tear in her cervix extended well
into her uterus. Thankfully we were able
to sew everything back together, but we knew this patient was still at great
risk for developing complications during the recovery period. Have the ureters been damaged? Is this going to heal
properly? What if our repairs break down
and she develops a fistula? (If she doesn’t heal well she could start leaking urine
into her abdomen or vagina.) In the US,
I would have called in a urologist, a doctor who specializes in the bladder, to
help with her repair. In Togo, I’m the
urologist.
The next morning on rounds we were nervous to go see our new
patient. Was there going to be urine in
her Foley? Would it be filled with
blood? Was she going to be infected? I think
we were both holding our breath, but when we got to her bed she was sitting up
smiling at us with her feet hanging off the side of the bed. We both looked at each other as if to ask,
“Is this our patient?”
She stayed in the hospital for about a week and did not develop
any complications while hospitalized. We left her Foley in for two weeks to
give her bladder time to heal then did special imaging to confirm that urine
was not leaking from her bladder. It was
not! We took out the Foley and told her
to come back immediately if she starts leaking urine. I am praying she will continue to heal
appropriately.
Please pray that the
Lord would give me wisdom as many patients here have conditions I am not used
to seeing in the US. Please also pray
that the Lord would guide my hands and decision making during tough surgical cases.
Grandma giving her new granddaughter a bath. This is a very common sight on our postpartum ward.
Life in Togo.
Big termite mounds are all over the place. This one was taller than me!
