Just another day...

About the only scheduling 'rule' we have here is 'prepare for it to be changed'. Here was our Tuesday morning...

First, we had a patient on the ward who had been admitted for an elective caesarean section because she had had two previous caesareans. However, she started to labour painlessly overnight, and by the time she reported to the nurses that she was feeling contractions she was nearly ready to start pushing. To the surprise of our nurses I did not rush her to theatre for surgery, but when she had pushed for more than an hour without delivery, I instead took my resident through a gentle forceps delivery (our vaccum pump wasn't working). The patient is amazed and delighted in the aftermath.

Then we had a lady come in with bleeding at 33 weeks who very rapidly delivered a little boy - he has delighted the nursery staff by how well he is doing.

Immediately after handing that baby off to nursery the nurses called us to see the new admission - a lady in advanced labour with a breech presentation. My intern was delighted when I let her conduct the delivery, restricting myself to giving instructions and occasionally readujsting her hands.

Hanging on...

One of the the difficult decisions we often have to make here, is the best mode of delivery for babies that have to be delivered prematurely either because they are sick or their mother is sick. In the UK that was rarely such a difficult choice. Our good neonatal intensive care units mean that most babies more that 28 weeks gestation would survive, and that means even if you started off inducing a mother, if the fetal heart was abnormal we would generally do a caesarean section in the confidence that we had a good chance of a living baby. That, however, is not the case here. Since I have come to Africa not a single baby less than 32 weeks of age that I have delivered by caeasrean section for fetal reasons has survived. I have had some live that I have delivered for maternal reasons (e.g. bleeding placenta praevia), but not even one if it was the baby who was sick.

So when this lady came with severe pre-eclampsia at 28 weeks gestation I explained to the mother that she needed delivery and I thought we should induce labour. I also explained that in my experience, either babies were strong enough to survive labour at this age (in which case they often have done very well), or else they weren't strong enough, and in that situation I have always seen them die within a few days if I did a caesarean section. We agreed therefore, that we would not operate even if the baby seemed to be sick during labour, and we decided it would be best not even to listen to the baby's heart during labour - because it would be aweful for her and for us if we heart a bad heart rate and didn't do anything about it. Then we spent some time praying together, and started the induction.

During the next 24 hours we started labour, and when she got near the end we call the paediatrician, explaining that we weren't sure how the baby was, but could she please be there to receive it. A little boy was born, a bit flat at first, but he responded very well to resuscitation and was taken to nursery where he is slowly growing strong and healthy. His mother has learned to feed him through the tube from his nose to his stomach, and carries him 'kangaroo' style with great patience.

Baby Sharon

This is the mother who had the ECV a few weeks ago - she was induced and had a very straightforward delivery. Last Friday we had two more successful ECVs. Two of my interns were with me and I had them do one each. They were rather pleased with themselves to feel the head where it belonged after their efforts.

Her story...

Today I am grieving for an 18 year old girl who has now been with us for nearly 2 months. She agreed for me to tell her story when she was still well, and now she is in great need of your prayers…

This story began 4 years ago when a 14 year old girl from the north of Kenya was married off to an older man. He got her pregnant immediately, and at age 15 she went into labour with their first child. As you would expect, she went into obstructed labour, and after several days her husband finally agreed to take her to the local hospital. The baby was already dead, and the doctor there did a caesarean section to deliver it. After the delivery she ended up with a vesicovaginal fistula and a rectovaginal fistula (a connection between the bladder and vagina and one between the rectum and vagina – leaving her permanently leaking urine and stool).

Two years ago she attended hospital and they attempted to repair her fistulae. The RVF was repaired successfully, but the VVF repair failed after she went home. She has continued to have urinary incontinence, and though she no longer had stool coming through the vagina, she was troubled by increasingly severe watery diarrhoea which became impossible to control consistently. During those years her husband divorced her and her family kicked her out. She ended up in Nairobi living with her brother's family, but he got fed up with her because of the smell and refused to feed her.

This January she ended up with a severe bout of pneumonia and was brought again to Kijabe, and on admission it was discovered that her loving husband had left her with another gift besides incontinence - HIV. So she was admitted and treated for pneumonia with good response. Her CD4 count (repeated now 3 times) has consistently been >500 (this means her immune system is not very compromised yet) so she has not been started on anti-HIV medicines.

After getting better from the pneumonia I was asked to review her fistula. I was pretty worried about her malnutrition and anaemia, and wanted her to be fed up before we operated on her, so when her brother refused to take her back we kept her in hospital to feed her up before surgery. Well, we did take her to theatre for her fistula repair, (which went quite nicely) but post-operatively we were troubled to find that no urine was coming through the catheter, though she still had urine coming through the vagina and this terrible watery stool. I assumed that the repair must have failed – but when we tested the site by putting dye in the bladder – the fistula repair was still intact. So then came my next panic – had I somehow damaged her ureters (the tubes draining the kidneys)? – but when we did ultrasound scans there was no evidence of that.

Well I won’t bore you with all the details, but suffice it to say that she has been very perplexing, but I think we are finally seeing the light. Here is a summary of her problems:

1) Watery diarrhoea and leaking through the anus, begun after her obstructed labour. Our infectious disease team decided after careful investigation that her diarrhoea was not related to an infective process.
2) Chronic renal failure (exacerbated by dehydration), and moderate bilateral hydronephrosis with cortical thinning (i.e. the kidneys are not working well, and probably haven’t been for quite some time)
3) Recurrent episodes of sepsis (infection affecting the whole body) – but not attributable to her opportunistic infections due to the HIV as her CD4 count is still high.
4) Leaking urine through the vagina – despite a successful repair of the fistula through the bladder and vagina.

Eventually we improved her kidney function enough to do a dye test to try and identify where her ureters went, and our results showed something I had never seen before – dilated ureters filled with air, and dye in her rectum.

Last week she was doing pretty well, and so we took advantage of the presence of a visiting urologist and borrowed some portable imaging equipment from our orthopaedic colleagues. We did a cystoscopy and identified both ureters – and saw no urine at all coming from either of them. We passed small tubes into the ureters and they both came to a dead stop 8 cm away from the bladder – and when we injected dye and took pictures that provided confirmation of complete obstruction of both ureteters 8 cm from the bladder (too high up for it to have been caused by my surgery, the urologist reassured me).

Right now we think she has one ureter that is communicating with the bowel (thus causing her diarrhoea) and one that is communicating with the uterus (which might explain why we didn’t see urine coming through the cervix during the fistula operation – we had her tilted very far back and the urine was apparently flowing from the uterus through the fallopian tubes and into the abdomen – on ultrasound scan during the post-op work up we did find free fluid behind the uterus which had not been there pre-operatively). This trauma almost certainly occurred at the time of her original delivery - I wonder what they were doing at her caesarean section.

We were hoping to open her abdomen this week and repair the ureters, but several day after the cystoscopy she got another episode of severe infection – and this time she doesn’t seem able to fight it. Her pneumonia is back with a vengeance and she is barely conscious, responding only by flickering her eyes when we speak to her. This morning she began coughing up blood, and our medical colleagues are afraid that she may well have TB. Clearly a major abdominal operation is not an option for this week, and I am becoming increasingly afraid that she will not survive to discharge.

All of us on the ward have become very fond of this young woman – during her months of feeding up she became friends with many of the nurses, and used to help the cleaners with their work just to help pass the time. As she has been deteriorating we are all anxious and grieving, though glad that at least she is here where there are people who treat her with kindness. And she has appreciated the love that she has been shown.

During all of her struggles here I have been praying with her almost every day, and our chaplains and nurses have been meeting with her to encourage her. And as she listened to talk on the ward and took heart from our concern and prayers for her, she decided that she too wanted to become a follower of Jesus. She has clung to Jesus during the weeks of hope leading up to the surgery, and the crushing disappointment as she realized she was still leaking, then the hope again as we told her that we may have finally figured out what is wrong, and then her realization that she is getting sicker and sicker. And now, when she can hardly respond, she has a stream of visitors who come to sit with her, tell her stories about Jesus and pray with her – and I hope and pray that while she can hear and understand, she knows that she is not alone.

ECV

My final task before going home this evening was to turn a naughty baby from breech to head down. This particular technique (called 'external cephalic version' or ECV) is recommended in the UK in order to decrease the risks of a breech delivery for the baby without subjected the mother to the risks of a caesarean section. I have found it particularly satisfying to do here in Africa because it seems to work so much better (smaller babies and mothers who have had lots of kids before...). Unfortunately, it seems not to be practiced much in Kenya - and the first time Sara and I suggested an ECV our nurses were fairly horrified.

Now, however, they have seen that it does work most of the time, and this afternoon I had a group of enthusiastic student nurses come to watch Martha (our new resident - who had never seen an ECV before and was terribly eager to be involved) and me turn the baby. Our very tolerant patient agreed to the audience because she thought it would be a good thing for more people in Kenya to become familiar with the concept of ECV. She was highly satisfied at the end of the procedure when we could show her the fetal head down at the bottom where it belongs.

More often than not it's fun to be an obstetrician.

Organized chaos

Today was one of those satisfying days - very busy, but controllable, and good outcomes for all of our patients. Between 8AM and 6PM we had 11 deliveries (and not a caesarean in the lot), 1 eclamptic fit and 8 operations. Irritatingly the surgery that took the longest was the diagnostic laparoscopy - because it took longer to find a scope and light lead that worked and matched each other than any other single operation.

Martha has now joined our team - she is a Kenyan registrar in obstetrics and gynaecology at Kenyatta National Hospital (the major teaching hospital in Nairobi) and she has chosen to do an elective placement with us for the next six months. She is pleasant and competent, and as she worked here as an intern she is known and liked by the staff here, which is a great bonus. We're trying to increase her operative experience - today I supervised her in a myomectomy (removing fibroids from the uterus) and a hysterectomy (removing the uterus itself) - enjoyable for both of us I think.

Then I came home in the pouring rain and have just come back from walking Luthien after it let up - and so I think maybe I'll go to bed!

Who's the guy?

Recently a good friend from the UK commented, ‘Some folk have said, "Who is this guy Sharon is marrying? She has said a lot about the place they got engaged but hardly a word about the man himself in her letters or on the blog"!!!.......’ So here is an attempt to rectify that deficiency without getting embarrassingly sentimental in the process.

Let me see, I first met David in May 1999. I was in my second year of medical school and was attending a conference organized by the Christian Medical Fellowship for medics with an interest in ministering to Muslims. One of the speakers at the conference was a very intelligent senior house officer who caught my eye. One afternoon we both joined a walk through the countryside around Hemel Hamstead, and soon found ourselves deep in conversation.

David was actually a friend of a couple I had known since childhood, and through them had been brought into this ministry in London. He reminded me a lot of my father – a quick mind and great attention to detail, a willingness to take my ideas and opinions seriously (even seriously enough to disagree with), and a distinct lack of attention to time (but far greater musical talent – David’s the only person I know who has the option of being a concert organist if he ever gets fed up with medicine.)

Over the years we bumped into each other a lot through CMF and Islamic events, eventually becoming good friends. He went on to train in Public Health – working first in London and then in Birmingham, and I finished medical school in Leeds and then started my OB/Gyn training. In 2007 David started working for MedAir in Eastern Congo (out of all the places in the world that MedAir works, they sent him to the same town as my sister and brother-in-law, and he got to know them quite well through the work there). Meanwhile I continued to work in Britain and prepared for my own adventure in Ethiopia. Our communication dwindled away during this time, and I assumed I had heard the last of him. But clearly God had different ideas.

In January 2009, David heard about the concerns we had regarding my father’s health and the possible diagnosis of cancer. His mother had died several years earlier of cancer, so he was able to really empathize with how worried I must be, and he began calling me every week to see how I was doing and encourage me. This continued even after dad’s illness was over, and I came to look forward to these conversations, particularly during some of the challenges I faced in Ethiopia. Then when my plans to train at the Fistula Hospital in Addis Ababa fell through, he was able to arrange for me to come to Bunia for the fistula camp with Christina de Wind. We saw each other quite frequently during those three weeks, and after years of friendship the timing was right for the relationship to change.

These years in Africa have been good for both of us – God has taken each of us through some very difficult times, increasing our faith and trust in Him. He has also shown us how our friendship and affection can support and encourage one another.

I'm rather looking forward to the adventure of being married to David - though we both will have some adjusting to do. In many ways our backgrounds are very different – I was raised in Kenya as the child of American missionaries. In my immediate family I have 1 brother and 2 sisters – now all with spouses and children of their own. My extended family numbers nearly 70, all told – though we cannot get together as often as we would wish. David is an only child, raised in Manchester with a much smaller extended family. Until moving to Congo his international experience had been confined to short trips – though he has travelled widely through Europe, Africa, Asia and the Americas. He finds the chaos of my huge family a little overwhelming – but has come to enjoy my parents and siblings, and they are very fond of him.

But suffice it to say that I am still coming to grips with the privilege of receiving the love and affection of this man, and I am looking forward to seeing how God leads and directs us as we grow in love for one another, living and working side-by-side. (There, I warned you that I was likely to slip into sentimentality – I do apologize.)