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“Doctor, there is a patient in Maternity”.

It had been a good day of administrative discussions. As part of becoming the new Medical Director, I had spent the day catching up on the hospital business. We had wrapped up nicely by 5 pm. I had told my wife that I would be “home by 5:15”. She was obviously looking forward to it. 

“She is in labor, but the baby has no heartbeat”.

After the talks I decided to wander over to the Medical Ward as I had heard it was a “very busy day”. I hesitated as I thought about 5:15, but only being back in the hospital for a day, I thought I should at least show up to support our busy troops. I arrived to see a flurry of activity with our staff admitting, triaging, and treating multiple severely ill patients all at once. Our Clinical Officer was waving admission papers in his hand feeling the pull of multiple emergencies at once. A 29 year-old patient with hypoglycemia and alcohol intoxication had just pulled out his IV, and was about to seize and aspirate. He died a few hours later. 

“She is fully dilated, but having a lot of pain. The baby is not coming down”.

This story wasn’t sounding good. I looked around for a qualified delegate, but realized all hands on deck were busy. I reluctantly said goodbye to 5:15, and we went to see her together.

She was tired and pale. Her heart rate was fast, and blood pressure was low. She was tender in the middle of her abdomen, and while fully dilated, the baby was not coming. We discussed her. “Doctor, she is having strong contractions, if her uterus had ruptured, there would be no contractions”. That sounded reasonable, but something didn't make sense.

Uterine Rupture is one of the most feared complications of childbirth. It is also a leading cause of pregnancy-related death in Malawi. The most common risk factor is a previous Caesarian Section (which our patient had several years earlier).

I did an Ultrasound of the uterus. While I’m no expert at ultrasound scans, it seemed there was free blood in the abdomen. She needed a surgery.

In the Operating Theatre, her condition deteriorated. Heart rate going up, blood pressure going down; she was starting to get confused. Pulse 150. My pulse close to 150. We commenced the operation with a prayer for help. Blood gushed from the abdomen. The small rupture in her uterus had bled two liters into her abdominal cavity. An average human being has 5 liters of blood in their body. With the additional blood loss of surgery, she had lost at least 50% of her blood. We had 200 mls of blood available for transfusion (about half a pint). We started to give it. We removed the baby -- a perfect lifeless baby -- and proceeded to sew the uterus back together. Our Clinical Officer, Mikson, performed the surgery with skill far beyond his training. Jaqueline Uy, a Loma Linda University Family and Preventive Medicine Resident calmly assisted him in the procedure. I watched with admiration as the international team work to save a mother’s life.

Fortunately, we had the equipment to perform an autotransfusion of another 700 mLs of blood we could salvage from what she had lost.

The bleeding was arrested, her vital signs gradually improved. After thanking the team and ensuring she would be closely monitored all night, I started to head home a little after 8 o’clock. Her life hanging in the balance.

“5:15?”.

“I’m sorry”.

“You weren’t on call”.

Most developed countries have a maternal mortality rate of 20 maternal deaths per 100,000 live births or less. In Malawi the number is hard to know for sure, but is between 400-600. Easily 20-30 times higher than in the United States (which is far from the best in the world).

My children were energetically going to bed when I got home. “I was taking care of a mommy whose baby died”. I couldn’t help but notice how energetic and healthy they looked tonight. Jedidiah had lots of six year-old questions about how that was possible, and what we did about it. Abigail, our spunky two-year old, just got upset. “The mommy should have her baby. I want to pray for her.” She proceeded as only a sensitive angry two year-old could, “Dear Jesus, please help the Mommy that doesn’t have her baby. I don’t like that.  Amen”.

Hug your babies tonight; hug your mommies tonight. If you live in a country with good healthcare, thank God for it, and remember those who don't.