20.04.2020 What to do with an uncertain age of pregnancy?

The day of the week starts off pretty generous.  My patient scheduled for her third C-section and tubal sterilization on Wednesday came in this morning at 8 am with contractions.  Thankful this didn’t happen this morning at 3 am!  The uncertainty I had in planning the operation with the question posed in the title dissipates because she has contractions and it’s the third C-section so we are off to the operating room.  I had some concerns as this was her third time to be operated and I was expecting a lot of adhesions and difficulty as some of my previous cases had shown.  To my surprise the scar was small not only on the outside but the inside showed a very orderly abdomen.  Going through the layers was almost as if she had not been operated before.  Delivery went without any complications as did the sterilization.  Unsurprisingly her previous uterine scar was very thin and with barely any pressure from my scalpel popped like a balloon spilling amniotic fluid all over my operating room nurse!  It was like a fountain.  She definitely would have been high risk for uterine rupture I thought to myself.  Her placenta had several minor placentas with a lot of amnion still attached.  I needed to do a curettage too.  Her previous operations had been done at a private clinic where she was initially planned for C-Section on April 6.  She chose to come here because one of her family members is a staff at our hospital who told her about the possibility of having the operation done here with a good quality care for mother and baby.  The nice thing about this case was it was a fantastic teaching opportunity for my resident Dr. Joselitto and our medical student.  We talked about the steps of the sterilization and the risk of uterine rupture based on the anatomy we saw intraoperatively and how a natural birth with spontaneous placenta expulsion may have resulted in these minor placentas being overseen (Intact main placenta and barely visible vessels in the amnion suggesting this! Intraoperatively easy to see because the uterine cavity was not empty and full of tiny parts of placenta with mediocre uterine contraction). 

Case #21 Baby Fanomezana with midwife Avotra 

and tubal sterilization for the mom

Note: Why did we schedule an operation for April 22 when the other clinic was prepared to do this on April 6? The date of delivery was initially May 7 (so the age of the baby today 37+4).  Her due date was corrected forward to April 10 based on a scan in the 29^th week of pregnancy that showed a larger baby.  Shocking. This scan was the basis of the pregnancy age despite the fact she had a correctly done early scan in the 9^th week!!!  Given the baby still had vernix caseosa implies it was not past the due date (the baby should be 41+10 today if we had taken the corrected due date).  It means also that had she done her C-section at the other clinic as planned two weeks ago they would have had a premature baby with all the risks and complications associated at 35+4 weeks and nothing more than a slightly higher average weight for babies that age. Sadly this happens rather often in this country.