Low-Risk Obstetrics

If you aren’t interested in reading about medical stuff, this would probably be as a good an update as any to skip. 

While we aren’t what you would call world travelers, this is neither mine nor Katie’s first trip to Africa. Katie went on short term trips to Cameroon and Uganda in High School, and I’ve been to Burkina Faso and Rwanda during college and medical school. In many ways, this is actually my least ‘adventurous’ experience on this beautiful continent. We’ve been here  for over a week now and so far I haven’t slept outside or in a tree branch (the roving packs of wild dogs made sleeping on the ground impractical), drunk water from an open well (yes, there were lots of ‘floaters’), or biked across the bush asking directions back to the village at nightfall. I haven’t hitchhiked or couch-surfed, and I have been eating at the Pyatt instead of hiking miles downhill to the village to buy food to cook for myself (this implies that I had to walk miles back uphill carrying my food, but the novelty of a white guy walking up a small mountain with a backpack full of potatoes was just too much, and I never had to wait long for a ride). We aren’t swimming or canoeing, nobody has tried to feed us any local delicacies, and with the running water here on the compound I will probably make it the entire trip without needing a bucket bath. With Katie here, I don’t have to spend 2 months separated from the woman I love (just so much bad planning and miscommunication leading up to my trip to Rwanda), and nobody is likely to call to tell me that her appendix ruptured and she almost died while I was on the plane. Yes, things are pretty great here in Yei, South Sudan.

The big difference is that, unlike those other trips, I’m a short term missionary doctor now, and that comes with some inherent adventures all its own. The work in the hospital is a different world entirely, and it’s impossible to compare with any of the very non-life-and-death experiences I’ve had in Africa in the past (unless you count riding through town on the back of a hired motorcycle, driven by a 14 year old that likes to weave through traffic and in and out of sidewalks).

My first week was spent on Maternity. The maternity wing consists of three rooms. The first is an antepartum room with 8 beds, where we keep women who are close to labor or being induced, or pregnant women with severe illness. This is where we treated the severely anemic woman that Katie donated blood for last week . By the 2nd hour of my 1st day I had already treated more malaria and typhoid than I have in my entire career. The CO’s and the longterm missionaries here are teaching me a ton about tropical medicine. The ‘special care’ room is on the other end of that wing; another room with 8 beds, where we keep postpartum women and newborns. There are 2 preterm incubators and they are hoping to greatly expand their NICU capacity when the funding and support is available. When I came on last week we only had one premie; a 29 week little boy who did remarkably well off of oxygen when the power went out for about 8 hours, before they got it up and running again, then emergently flew in the Australian engineer who designed the system and happened to be in another part of South Sudan on an install for another mission hospital. Over the weekend we added 33 week twins, a 32 week preterm delivery, and a 29 week baby born by C/S; we are really thankful the solar power system Is fixed up and the back-up generator is working. Please pray that the electricity and the machines needed to provide these kids with oxygen don’t fail.

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Between antepartum and special care we have the labor ward, where I spend most of my time and have most of my panic attacks. I’ve never been more thankful for how intense our OB experience is at my residency in Waco. The labor ward has 5 beds in a row, each with fetal heart monitoring equipment and several with working tocometry (measurement of uterine contractions). I would post a picture of the labor ward, but I’ve never seen it empty enough to actually take a picture. At one point on Saturday when I was on call, a woman came in unconscious with a 1st trimester bleeding emergency; she was having a miscarriage and had collapsed from the blood loss (she is doing well now and was able to go home). In the next bed there was a woman with a 3rd trimester bleeding emergency; she was in preterm labor with (previously undiagnosed) twins, and had a placenta previa (the placenta lying over the inner opening of the cervix). We had to rush her back to perform a cesarean section. A few beds over there was a woman in active labor with term twins; twin A was cephalic (head down) but twin B was breech. As we went to the OR, Dr. Perry and I prayed that she would hold off long enough for us to complete the other surgery, with plans for one of us to unscrub and rush back to the labor ward if she began to deliver (thankfully we didn’t have to). A cephalic-breech twin delivery is pretty complicated and requires a doctor, but most of the straight-forward deliveries here are done by the nurse midwives, who only call one of us if there is a complication. It’s not uncommon to manage these kinds of parallel crises with other babies being born all around you. Right now His House of Hope is doing something like 160+ deliveries a month.

A short walk from the hospital is the room for waiting mothers. It is a place to stay provided for women who are not imminent for delivery or acutely ill, but cannot safely go home prior to delivery. Two of our patients who delivered prematurely over the weekend had stayed there for a week prior, both with preterm, premature loss of fluids and a history of preterm labor. At 8 pm on Saturday night I was rounding on the sickest of our patients on the pediatric ward, when one of the OB nurses came and found me and very calmly stated, “come doctor, there is a cord prolapsed.” It was one of the women from the waiting mothers house, and the cord had prolapsed through a partially dilated cervix. This is an obstetric emergency and something I’m constantly terrified of on OB back home. We rushed back to the OR and emergently performed our 3rd C-Section of the day; baby and mother have been doing well.

 

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The Operating Theatre

The OR is a single room with an attached room for scrubbing before cases and sterilizing equipment. They have an older but functional surgical table that was donated and sent over on a shipping container. When Dr. Perry first got here, they were using an old hospital gurney; he says he had to carry a wrench to tighten the frame every few cases, because he was afraid it might collapse under the patient. At that time they were using head lamps for light and they didn’t have suction, so they just had to use lap sponges. He tells the stories and then says that’s the missionary doctor equivalent of walking to school in the snow, uphill both ways. Now in the OR we do have good lighting, anesthesia monitoring equipment, and suction. They even have electrocautery here, but use it sparingly because of short supply. The one case where we opened it, it felt like seeing an old friend.

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Scrub and Equipment Room

All of this high acuity, complex, life-saving work they are doing here is incredibly daunting. It’s hard to imagine going to a place where, as a family medicine doc, you’re the end of the line; the most senior and experienced person that they call when all else fails and they need somebody to do something to save the mother and the baby. OB never gets any less scary; your 100th or 1000th delivery (I am told) is just as scary as your 1st because things can go wrong very quickly and without warning. Coming to a place like this to stand between mothers and babies and all of those things that can go wrong must take either a huge ego, or great faith in the God who was born to a teenage G1P0 under less than ideal conditions. Pray that God would enlarge my faith and trust in Him, especially if He plans on bringing me to a place like this!

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5 thoughts on “Low-Risk Obstetrics

  1. Beautifully written, TJ! We are so inspired by the work you, Katie, and your fellow missionaries are doing over there, and we love following the kids’ adventures! We will be praying for you all!

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  2. So, some of the first part of this post I don’t ever remember you sharing about your previous adventures to Africa. Were you trying to spare me by not telling me some of those details or did you did I push them from my memories because I did not want to know. Either way, I am praying for all of you daily. Glad to know that God is using you and Katie and that you are growing in your faith as well as your skills as a doctor.

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    1. Exciting, scary and exhausting all rolled in to one. What an experience for you all. It is always so humbling to see how much is done with so little when sometimes I feel like I do so little with so much! Prayer to you all and kiss those babies…after they have their thier tub baths, of course. Tell Katie that I enjoyed her post as well.

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