14.04.2020 Record surgery day!

The day began as scheduled with the two C-section patients we had planned during the Easter weekend.  The two procedures were a great teaching experience for me.  Dr. Joselitto performed the first case with was a re-C-section.  He did a great job.  We had some very difficult adhesions between Uterus and abdominal rectus muscle to get through which made the case a bit challenging.  The delivery went well and after I completed my first tubal ligation here, he finished up the case.  The next C-section was easier in comparison as the patient had not had any previous abdominal surgeries.  Again Dr. Joselitto did the procedure with me taking on the teaching responsibility. For the tubal sterilization part I took over again before handing the case back to him.  I was very proud of his work and feel happy that I was able to teach him some of my skills especially including intracutaneous suture but more importantly to carefully go through the abdominal layers in such as way that the wound healing will be better and allowing for potential further procedures not full of adhesions and difficulties.  This is something on which very little emphasis is placed here.

Case #17 and Case #18 Two C-sections and two tubal ligations for the mommies back to back.  Both of them weighing around 3400g so quite big for babies here where the normal term weight is 2500g!

As the afternoon continued in ultrasound I soon found reason for our next case: Abdominal bleeding with either a ruptured corpus luteum cyst or an ectopic pregnancy for a mother of 6.  The pregnancy hormone beta-HCG was taken and sent to the lab in town, time to diagnosis at least a few hours.  Right after this I saw a patient in her 23^rd week of pregnancy with what looked like a duodenal stenosis, this causes the chest cavity to fill with fluid and squeezes the heart.  Sadly nothing to be done about this here.  We referred her to our chaplains. (I found out a few days later she had had a still birth at another hospital.)  

Ultrasound scan showing a fluid accumulation in the thorax (round black area)

Meanwhile my patient with abdominal bleed was deteriorating.  Decision was made to operate.  I just found out we got that one bag of O Rhesus positive blood from our patient over the Easter weekend which is the same group our patient would need, that is good to know. Phone calls to the university hospital in Antananarivo as well as the military hospital confirmed there is no laparoscopic surgery available on Madagascar, the only option is to do it open.  I have never done that procedure before but we were extremely lucky today to have a French fully-trained Malagasy gynecologist here today applying for the permanent open position we have been trying to fill since prior to my arrival. We asked if he could help spontaneously and thankfully he could.  As we were preparing for that surgery I continued my work in the ultrasound and was doing a check up on Antoinette, a patient (IG), we had just admitted to labor and delivery with contractions and possible IUGR (intrauterine growth restriction).  Her CTG had been showing some pathologies and as I am performing my scan I see a fetal bradycardia not recovering!  I immediately call for help to have an i.v. put in and administer drugs to get the babies heart rate back up and prep for emergency surgery.  Our guest gynecologist, Dr. Eli, who happened to be standing in front of the surgery suite at the time immediately scrubs in with me and Dr. Joselitto.  The two perform the surgery together, allowing me to take a step back and feel not only relief as the baby is quickly delivered but satisfaction that the new team of completely locals has done this case without the help of the visiting staff of volunteers.  That really made me happy for the future of the obstetric department of this little hospital here.  

Baby Agate with IUGR born at 17:15 with an 8/9/9 APGAR

After finishing up this case we bring in our patient with the abdominal bleed.  She is in quite some pain.  Dr. Eli opens the abdomen using the same cut as for a C-section and slowly works his way down to the lower pelvic area with me assisting him.  We cut through some adhesions, remove a lot of blood from the lower Douglas cavity and search the Fallopian tubes and Ovaries for the source of bleeding.  We soon find the culprit, a ruptured corpus luteum cyst of the left ovary with quite some bleeding out of many small and one big vessel.  A suture solves the problem and we are quickly finished with the procedure.  A record total of 4 operations in one day for a tiny hospital with only about 300 deliveries a year!  How blessed we were today.  I guess Dr. Eli didn’t expect having to perform as part of his application process but we were all very thankful to have him here today!  As for me, it was my first opportunity to see this surgical case operated open and not laparoscopically and am therefore very thankful for this opportunity 😊