Obstetrics in Africa
Unfortunately Western textbooks are not always very useful when it comes to managing childbirth in Africa. I will never forget my first (and only) hysterectomy in 1983.
The mother had presented with a prolapsed hand. There was nothing too unusual about that, except that the baby was dead, the hand had been out for two days and the mother had been taking traditional treatments – which were potent uterine stimulants.
What to do wasn’t something I could look up in a textbook. In the First World women don’t present several days into labour with a dead baby. We had to go back to basics. After that length of time uterine infection was likely and a Caesarean section was to be avoided but the cervix had clamped down on the arm and a destructive procedure was going to be difficult. We made a decision to attempt to extract the baby under a light general anaesthetic. Halothane, we knew, was a uterine relaxant. We were only a couple of years out of medical school and we didn’t realise how much we didn’t know.
I began the procedure as the anaesthetist and ended up as the surgeon. Elizabeth, my wife, began as the scrub nurse assistant and ended up as the anaesthetist. Brian, a colleague with a year’s more experience than me, began as the surgeon and ended up collapsed on the floor.
While working at Jane Furse Hospital, an ex-mission hospital in rural South Africa, I had spent a few weeks on the maternity wards so I could go on the obstetric roster. That meant doing Caesarean sections when the midwives said it was necessary. Cephalopelvic disproportion (CPD) was common in the local women. Nutrition had improved so babies were bigger than their mother’s pelvic outlets. The midwives were very experienced at making the call. The previous medical superintendent had even trained one of the theatre sisters to do most of the Caesareans herself. He would turn up just in time to incise the uterus, extract the baby and leave her to sew up afterwards.
I still maintain a Caesarean was the easiest laparotomy to do. At least you knew you were facing a pregnant uterus. With a suspected appendicitis you’re never sure until you find it. We did them under local anaesthesia with a mid-line incision through the abdominal wall which made it easier. I ended up doing over 60 procedures.
There was a tradition at Jane Furse that if you did the Caesarean you got to name the baby. We used to have a theme each month – naming children after flowers, medications or whatever. Previous doctors clearly had a sense of humour. There were children named after engine parts and a cohort of one year olds, born during the Falkland’s war a year earlier, with names like ‘Malvinas’ and ‘Belgrano’.
But back to the case; after attempts to remove the dead baby, we had to give up and operate. It was immediately apparent the uterus had ruptured. The dead baby was outside the uterus and the abdomen was full of blood. It didn’t look good.
Poor Brian, the nominal obstetrician, blamed himself and asked me to take over. Elizabeth clamped the jagged and bleeding edges of the rupture and then took over the anaesthetic. Her shouts to Brian to pull himself together had fallen on deaf ears. I quickly scrubbed and gowned up and became the surgeon.
It was a mess. In anatomy textbooks, the various organ systems are all different colours; arteries are red, veins blue, nerves black, muscles brown, the bladder yellow. In real life everything is red or turns red very quickly. It was very red.
A pool of blood kept refilling the pelvis as fast as we could suction it out. I extended the rupture to a sub-total hysterectomy and removed the uterus but left the cervix. I cobbled what remained together.
Brian’s contribution was to keep insisting I shouldn’t cut the ureters. I responded that I couldn’t see the bloody things. Eventually the poor woman stopped bleeding. She survived … and passed urine the next day.
– Paul Reeve
Paul Reeve is a general physician in Waikato Hospital. He was brought up in Hong Kong, went to medical school in London and worked in Africa and Vanuatu before moving to New Zealand.