18 May 2023

"Bonjour, Doctor, we have a woman here who has been waiting for her repeat cesarean section, and now she’s having contractions. She wanted to know at 4 am why we weren’t already calling the doctor at the first sign of low back pain because she’s been waiting here for her cesarean and she isn’t supposed to labor!"

This G4P3 (that means fourth pregnancy and three previous deliveries) only had one living baby. Her first had been a normal delivery but the baby had died in the process. Her second delivery had been a cesarean in another hospital and that baby also had died before it was born. Her third delivery had been a cesarean in our hospital and was her only living child, so her plan was another c section at our hospital. She had been staying outside under our very basic shelters next to maternity which were built for this purpose—for moms who need to stay at the hospital for awhile before delivery, either because of a current complicated pregnancy or complicated obstetric history. She was eager to have another live baby, even if it meant a third operation, no chance of trying for normal labor again, and a limit on how many babies she could have in her reproductive lifetime. "I just want a couple of live babies!" After two stillbirths, living and healthy became her priority over having a large number of kids. As Abouna—the nurse who operates with us as he has been doing with Danae for years—and I started the operation, working through each of the abdominal layers to get to the baby, I was thankful that this mom is going to be content with just one more pregnancy. I started to question if she should really even get pregnant again after this. Scar tissue had glued everything together inside her abdomen. I was thankful this was a c section right at the beginning of labor, and she hadn’t tried to go through labor normally, waiting until the baby was stressed to go to the OR. There was no way we were getting this baby out quickly without doing a lot of damage to mom. However, since this baby wasn’t in distress, we were able to slowly and carefully separate planes of tissue safely, finding a place to reach the uterus above the bladder, with the bladder then finally peeling down to where we wouldn’t damage it by cutting into the uterus to take out the baby. Still, it seemed like a relatively narrow window between all the scars to the sides and above. I finally cut into the uterus and we pulled out a large, immediately-yelling, very much alive baby girl. We handed her off to be dried and resuscitated if needed—though we could tell by her cries she needed no extra care beyond being dried off and kept warm. Later we found out she weighed about 8.5 lbs. We finally stopped all of the mom’s internal oozing from the scars that we had detached in sorting out different layers, and we got her abdomen closed. Watching the mom later with her baby on the postpartum ward, it’s clear that this is a baby who is well-loved and cherished by her mother and family, and definitely needs to be exclusively breastfed and avoid parasite water!

Another repeat patient I met on maternity last week is another perfect example for why a hospital like ours has to have places for mothers to stay and wait out the weeks before delivery right here at the hospital. This mom had an even more dramatic obstetric history. G7P1321. This doesn’t mean she’s delivered 1,321 babies. It means that out of 7 pregnancies, she delivered only one time at 9 months (but the seven include the current pregnancy, which thankfully had also made it to 8.5-9 months already). The rest of her pregnancies had ended in the first or second trimester and her only living baby had only made it to nine months with the help of a cerclage. Basically, after losing so many babies she had come to our hospital in the first third of her pregnancy and had had a non-absorbable suture placed to tie her cervix—the opening of her uterus—closed. When she got to term and the baby was big enough to deliver and survive without complications of being premature, then the suture was snipped and the opening of the uterus was allowed to let the baby out as soon as she was ready to spontaneously go into labor. This time she had gone a few days past the date that we had written for her to take out her cerclage, but thankfully she hadn’t gone into labor yet. I easily snipped the cerclage and told her she would now wait near labor and delivery to see if labor would start. Later that evening she delivered a normal-sized, healthy, term baby! 2/7 living to non-living. But 2/2 alive with cerclages! I think she’s convinced that this is the way to go with the rest of her pregnancies, and it’s worth spending a couple of months in the hospital to have another live baby!