Misoprostol & Moses

“She would really benefit from some Misoprostol” I said to the nurse in theatre, “could you go and ask matron for it”.  It had not been a straightforward Caesarean section; the baby’s size (which suggested she was almost ready to start school) and my efforts in delivering her had caused a sizeable tear to the woman’s womb (probably more the latter to be frank, but it’s always easier to hold the defenceless baby responsible for the doctors’ inadequacies). Despite repairing the damage, she had continued to bleed as a result of her uterus not contracting strongly enough (the most common reason for bleeding after childbirth); envisage a floppy rubber glove when you’re hoping for something more akin to the firm boxing variety.  Misoprostol is a medicine with many uses (more on this later), one of which is to help reduce excessive bleeding following child birth and would have been very useful in this type of situation when we were heading towards a 1.5 litre blood loss.  On his return, the nurse was unfortunately empty handed and came with the news that Misoprostol was not available. “Are you sure?” ‘Yes, it’s not there’. Although not ideal, we made do with a different medication and after some compression and patience we turned a corner. Thankfully the lady recovered well although I reflected whether we should have intervened sooner in her labour. When I had reviewed her earlier in the day, I had been told by the midwife on shift that her labour had started spontaneously overnight and by mid-morning she was 8cm, although this had possibly been the case at her last two examinations. However, reasonable progress in my mind, especially as it was her first baby. The midwife on duty had suggested a Caesarean section at this point due to her assessment of the size of the baby but I thought it had been reasonable to give some more time. We had talked about giving medication to make her contractions stronger but on balance I felt this wasn’t the limiting factor.  Nevertheless, several hours later with no further progress and signs that labour was becoming obstructed, I came to the same conclusion as the midwife that a Caesarean section was needed. 

When I went back to the ward to see her later in the evening, I was pleased to hear from the night midwife that all was well. Yet I was a little surprised when she said to me ‘yes, I knew she would need a Caesarean section, so I started her induction of labour last night so you could do her operation if you needed to in the day time.’ 

“Oh” I said, “no one told me that she had been induced (or had documented anything!) What did you use to induce her?” 

 ‘Misoprostol- we have several packets in the cupboard.” 

A human factors coach would have enough material analysing our collective communication pitfalls to provide hours of teaching.  At least mum and baby remain well. 

Together with communication, prioritisation remains central in any clinical role; both are therefore often a component of medical interviews. Certain days here can feel like a prioritisation and problem-solving task on steroids. 

It may start simply enough:

You are asked to see 3 women who are in the delivery room. One of the patients has had significant painless vaginal bleeding. She is at the end of her 5th pregnancy. Her haemoglobin (blood count) has been checked and is 7 grams per decilitre (about half of normal). The second lady is in labour in her first pregnancy and has been referred due to concerns about her progress. The third lady is another referral case who has delivered her baby at a peripheral health unit but the placenta is stuck, thankfully she is not bleeding.  At the same time there are 6 patients to discharge and you are informed that a member of the hospital board is waiting for you in outpatients. 

You assess the woman who is bleeding and after scanning and examining her you establish the placenta is completely covering the entrance to the birth canal and the only option will be to offer a Caesarean section. She is stable but continues to bleed. You assess the second lady in labour, and whilst reflecting on the difficult case a few days previously, still want to give her the benefit of another couple of hours before deciding if an operation is required. A catheter, medication and some gentle coaxing enable the third lady to deliver her placenta without going to theatre.  After communicating the above plans, you try and complete some discharges enroute to see the hospital board member. A brief meeting ensues where you try to remain calm at his convictions on the importance of exploring funding options to develop a proper mortuary whilst you think maybe keeping the current patients in the hospital alive and possibly looking at how to ensure staff salaries can be paid consistently should be higher up on the priority list. You leave pleased that you managed a level of self-restraint and stupidly have a moment when you feel in control and have a plan. 

This feeling lasts about 7 minutes. 

You are then informed that neither of the two staff members who have the keys to the theatre (which is locked) and access to prepare the sterilized instruments and equipment needed to do a caesarean section have turned up at work (in part due to delays in payment of salaries). 10 attempted phone calls and sending someone on a motor bike to the staff members’ homes do not retrieve either the keys or the individuals. Incidentally the same staff members are also needed to assist at any operation. 

A blood transfusion is organised by the relatives for the lady who is bleeding. You reassess the second lady in labour; not good news. There are more overt signs that her labour is becoming obstructed- she needs a Caesarean too. Although frustrated, a plan B is needed. You conclude that as you cannot provide what they need, they should be transferred to another facility. Although this will damage the reputation of the hospital and the suggestion is met with resistance initially, a collective agreement develops that this is what must be done in the context of staffing limitations and practical constraints. 

The satisfaction from the clarity of a new plan is even shorter lived.  

The new national ambulance service designed to facilitate referrals is called. You are informed that there is a national fuel shortage and the ambulance for your district can not be used. The driver for the hospital’s own vehicle is called. He says the vehicle is not roadworthy and currently in pieces at the garage.

Put simply, at that moment you have two women that need an operation but you do not have access to the staff or equipment you need, or the means to transfer. Not knowing what role you can serve, you revert to the pervasive comfort that comes from 'phoning home'. The call to your parents unsurprisingly doesn’t provide any miraculous solutions (as a retired teacher and accountant their medical knowledge is limited) but their ears are greatly appreciated. 

One hour later, one of the theatre team is found. However, by this time it is 7pm and the nurse in-charge of the pharmacy, who also keeps the stock of sutures, has gone home and does not return.  (Why sutures are kept in the pharmacy seems nonsensical but I am informed it is for security). A total of 8 sutures are found in the theatre cupboard. The scalpel blade is the wrong size for the holder and it is held in an artery clamp instead. The theatre is prepared and 2 Caesareans sections are completed. 2 babies are born alive and 2 mums are alive.

A sense of satisfaction battles with exhaustion and frustration to become the overriding emotion. It need not be this difficult. 

However, in amongst the chaos, challenges and apathy, two small interactions perhaps signal hope for the survival of honesty and compassion. 

We buy 6 eggs every few days from Hawa (pictured at the top of the page with her sister and 4 month old niece) at a cost of 1500 Leones per egg. Instead of keeping the change of 500 Leones (less than 5p) from the 10,000 Leone note we give her each time (which we repeatedly try to say is fine with us), we have noticed that she surreptitiously but very deliberately puts an extra egg in our black plastic bag on every third visit, just to make sure all is fair and even.  

When we take refuge for a drink at Victor’s bar, a man in his 40’s called Moses (pictured below) is often present. Moses has had learning difficulties since birth and either is found sitting quietly watching the world go by or occasionally ruminating loudly that everything is ‘Fine, Fine, Fine!’ (I wish I had his optimism). People often buy him a drink or share food with him. Despite a level of stigma that persists in relation to disability, the fact that he not only survives but to some extent thrives and remains in reasonable health is testament to the individuals that choose to show him warmth and generosity. 

Maybe there is hope.