Written by Matthew Prior, a UK-based doctor specialising in obstetrics and gynaecology. He recently visited Liberia in his role as a health ambassador for Save the Children.
I walked into theatre. A girl was lying flat out on the operating table, her eyes fixated on the ceiling. I wasn’t certain if she was still alive, there were no monitors beeping, in fact there were no monitors at all.
The theatre looked like a battlefield – blood was everywhere, soaking the drapes and trickling onto the floor. Her abdomen was open as the surgeon was fighting to save her life after her womb ruptured during labour.
I saw her take a breath. It suddenly dawned on me: she was awake.
Anna was twenty years old and this was her second pregnancy. What was happening was quite predictable after her last pregnancy.
During her first labour, her baby’s head wouldn’t pass through her pelvis and became obstructed. After two days in labour, she was transferred to hospital to have a caesarean section. But the damage was already done.
While her baby’s head was stuck, it cut off her blood supply in the surrounding area, resulting in an ‘obstetric fistula’ – which meant she became incontinent. Were it not for the vital surgery carried out by an international charity, Anna may have been ostracised by her family and village because of this condition.
The scar on her womb from the first caesarean was a weak area. Despite warnings, she attempted this second birth in her village.
There could be many reasons for this; she had too little money to pay for transport, had another child to care for, or had been reassured by the untrained traditional birth attendant whose livelihood was reliant on Anna’s homebirth.
Once again her labour was obstructed. Eventually the scar could take no more and ruptured and now she was fighting for her life.
After her womb had ruptured, the baby was born into her abdomen. It couldn’t survive and sadly died before she got to hospital.
Fighting to survive
Struggling with unimaginable internal bleeding, she needed a highly skilled team to give her the best chance of survival.
This situation rarely happens in the UK because all women with a previous caesarean section are advised to give birth in hospital and their labour is carefully monitored.
If it does happen, it’s a major emergency involving an array of senior doctors, obstetricians, experts in blood transfusion and anaesthetists to rush the patient to theatre and put her to sleep for major surgery.
But Anna only had an epidural-like anaesthetic and a student nurse, still learning basic medicine, was injecting something into her arm.
I asked what it was – ketamine, a horse tranquiliser. I’d be pretty concerned if I saw this in the UK, but it actually made a lot of sense.
There was only limited equipment to monitor her blood pressure and nothing to control her breathing, not to mention the shortage of skills and experience. Ketamine is much safer in these circumstances.
Anna’s pulse was racing fast as her heart pumped to get oxygen around her body. Along with the massive amount spilled on the floor, some results were back from the lab showing that she needed a blood transfusion.
Calling the blood bank wasn’t an option as there wasn’t one. Blood needed to be donated by family members, which is commonplace in Africa. I was hoping someone outside was arranging this quickly.
A world apart
At first glance I was horrified – horrified by the fact Anna was in this situation in the first place, the short supply of well-trained health professionals and the basic equipment available. Overall I thought it was sub-standard care that would be considered negligent at home in the UK.
But then I could see the courage, determination and compassion shown by the team. With what they had available they were doing their best. Without their commitment and struggle, Anna would die for certain. They gave her their all.
Once everything was under control the surgeon handed over to his assistant to finish up.
I asked him what he thought her chances of living were. He humbly replied, “We don’t have much, but we do our best.”
Unfortunately I don’t know how Anna’s story ends, but cases like this are commonplace in Liberia.
Women have a 1 in 24 chance of death during childbirth, most die from excessive bleeding. However things are beginning to change, structures are being put in place to prevent and deal with emergencies and healthcare facilities are well supplied.
I think we need to reflect on how fortunate we are in the UK and continue to fight the case for international aid.