Emergency C-section

So we get a lot of emergency c-sections here at Soroti Regional Referral Hospital. The most common indication is for fetal distress, as diagnosed by fetal heart rate auscultated with either a fetoscope or a stethoscope. And when fetal distress is diagnosed, there is a complex chain of events that follows. Allow me to illustrate with just one example.

We get called for an emergency c-section for fetal distress. We go to the labour suite to prep the patient. We call the attendants of the patient over, and give them a list of things they have to go buy at a nearby pharmacy – urinary catheter, 8 bottles of normal saline, and 20 IU of pitocin. No we do not have those things here on the Obstetrics ward. We then go outside to get the trolley for patient transport. It is not there. We ask one of the sisters to go find it. We start an IV on the patient, and once the cannula is in, we look all over the ward for some strapping to secure the cannula – there is none. So we send another attendant to go buy some strapping, and the patient holds her own IV line in place while awaiting the arrival of the strapping. Finally, the trolley arrives. We put the patient’s cavera onto the trolley, and ask the patient to transfer herself over. The attendants then roll the patient from Ward 4 (Maternity) to theatre (OR), all the way on the opposite end of the hospital. There is no direct paved path, so they have to cut diagonally across half the hospital, and cut diagonally back across the other half of the hospital. The pavement has potholes all along it, making for a very bumpy ride for the labouring mother and her distressed fetus. The journey that usually takes around 3 minutes at a leisurely stroll over the grass lawn takes the patient and her attendants around 10 minutes to complete. Finally, we get to theatre. We ask the patient to transfer herself from the ward trolley over to the theatre trolley. Hopefully, by this time, the attendant who was sent to buy the normal saline has also arrived, and we start running the fluids. Oops, the blood has clotted off this line. We try to find a syringe to flush the line, but the supplies closet is locked, and only the anesthetist has the key. We call the anesthetist on duty – the day-shift anesthetists have just left, and then night-shift anesthetist came for a split second, and then split. The number written on the duty sheet is no longer in use. We call another anesthetist asking for the on-call anesthetist’s number. Meanwhile, one of us runs back to the ward to get a syringe. When the syringe arrives, the line is flushed, and the normal saline starts flowing. We finally get ahold of the on-call anesthetist, and he is on his way.

While we await the arrival of the anesthetist, the theatre staff scrubs the theatre with Jik bleach and water. When we go to change into scrubs for theatre, we realize that they are not there. One of the theatre staff goes over to the other theatre to get some. Meanwhile, we iron our cloth scrub caps and face masks in order to “sterilize” them. Suddenly, the power goes off, and everything goes dark (it is now past dusk). We write a note requesting the presence of the superintendant in charge of the generator, and tell the attendant to go run the note over to the superintendant’s home. Meanwhile, we get our torches ready, preparing for the possibility of operating under torchlight (we found 2 torches). The linens arrive, and we change into scrubs, and put on our theatre boots. We don our theatre aprons (they make me feel more like a butcher than a surgeon, as the front is usually always stained with blood, especially towards the end of the day, after multiple caesars and before the nightly cleaning). Suddenly, the lights come back on. The superintendant has finally arrived and started the generator. We check to make sure that the patient has received 1L of fluids, and then roll her into theatre. One of us dons some gloves and places the urinary catheter (no lubricants are used, since we have none). The anesthetist arrives and prepares to give the patient spinal anesthesia. He changes into theatre garb, “scrubs”, dons some sterile gloves, and heads into the theatre. Now we scrub – by scrubbing, I mean basically wash our hands with sterile soap, and then use possibly unsterile water from a can (since with no power, we usually have no water either) to wash the soap suds off. We then grab our reusable cloth sterile gowns, and use the lower edge to dry our hands and arms off. We don the gowns, and put on our sterile gloves (there are only size 8 gloves today; sometimes we are lucky and have size 7.5 gloves – back home, I wear size 6.5 Micros on the bottom with size 6 Esteems on top). We head into theatre, dragging out mayo tray with our instruments in with us.

The anesthetist is placing the patient in position for spinal anesthesia. “Sit up straight! Bend your head down! Come on, sit up straight! Now bend your head down!” He loses patience with her and pushes her head down roughly with the backs of his sterile-gloved hands. “Sit up straight! Straight!! Come on!” He inserts the needle into her back with no local anesthesia given beforehand. She jumps at the pain. “Don’t move!” he yells at her. He tries again, she jumps again. “Stop moving! What’s wrong with you? We try to help you. You don’t cooperate!! The more you move, the more I’m going to have to stick you. So don’t move!” He tries again. He finally gets CSF flow. He injects the anesthetic. “Move down, down! Lie down! Hurry up!!” The patient scoots down. We take the sponge forceps, and use our sterile cotton wool soaked in iodine solution (we have iodine today; yesterday we didn’t, so we simply cleaned the patient with normal saline) to sterilize the patient’s skin surface. We put the reusable cloth drape over the patient, wipe the iodine/normal saline dry with a piece of gauze, use the toothed forceps to pinch the patient’s skin to check for adequate onset of anesthesia. No pain response. Scalpel! Cut! No wait. The midwife who was supposed to catch the baby and resuscitate it has been called back to the ward since they were shorthanded. We send another attendant to run and fetch the midwife.
“You run. Speed. Speed.” The midwife arrives. We start the caesarian. Time elapsed since fetal distress was diagnosed – usually anywhere from one to three hours, though it may be significantly longer than that. Sometimes if it’s really chaotic on the wards, and there is a more urgent emergency such as APH, PPH, or ruptured ectopic, the emergency CS gets put on hold (saving mothers is more important than saving fetuses, because the government and all major politicians are involved in preventing maternal mortality, so when we lose a mother, the hospital gets into a lot more trouble and gets a lot more unwanted attention).

When we finish the surgery, we find another “emergency” c-section awaiting us. This is a transfer from a health centre 3. They have spent an hour on the road to get to us, and have been waiting for about 20 minutes outside the theatre. I take out a piece of paper, and write down the things they need to buy. I hand the paper to one of the attendants. “You go buy these things. Run. Speed. Speed!” He dashes out. I look for a cannula to start a line. It is not there. I walk back to the ward to get one. I don’t have to run, because the normal saline will not arrive before I do.