C-Sections at Galmi

Aug 17

What is a Galmi C-section like?

Most of the time the Nurse midwife makes the decision that the woman needs a c-section.  She has been managing the labor for many hours or else has done the initial evaluation after the patient presents.  95% of all deliveries in Niger happen at home.  Women only come to hospital if there is a problem.  Most patients present for the very first time after many days at home in labor.  Sometimes the baby has died during a very difficult time of pushing for several days.  Often it is a very long and difficult journey many times impossible, that is women never make to hospital.  The woman is carried or rides in a donkey cart for many hours or days.  There is no ambulance to go to their home/hut nor taxi service.

The majority of anesthesias are by  spinal.   Sometimes, when a spinal cannot be done ketamine is used which induces a stupor but allows the patient to continue to breathe and is sometimes inconsistent in how much actual feeling remains.  In Galmi the OR is large and well lit. There is a betadine prep and the nurse anesthetist says a prayer, usually very fervently, for the patient and the procedure.

Usually the skin incision is vertical because it is faster and more simple and allows better exposure if there are complications which do happen frequently.  Usually the uterus is incised in the lower segment transversely just like in the US.  Meconium stained fluid seems present in the majority of c-sections because they have almost universally been stressed pretty significantly.  There is a nurse present to receive the baby but she is not in a sterile gown like we do in the US.  Therefore, when the baby is handed off by the surgeon or assistant we must be careful not contaminate ourselves and so the baby is passed in the old fashioned way seen in movies: upside down held by the ankles!  Most of the surgeons try to close the uterus in one layer especially if there is going to be a tubal since they want to conserve suture.  I did all my uterus closures in two layers since that is what I know best how to do.  Tubals are common because it is very dangerous to have more than 2 csections.  Closing the abdomen with the vertical incision is easily and quickly done in one simple continuous baseball stitch layer.  This does not always give the best looking scar but it is a very effective and practical closure.

Like in the US most of the time the skin-to-skin time is about 30mins if all goes well.  But it is common for there to be serious bleeding problems because the uterus does not always quickly stop bleeding since it has often been in a state of hypertonic contraction for days and has a propensity to tear and bleed.  Patients do not automatically get pitocin.  Drugs to stop bleeding such as  hemabate and cytotec are often in short or non-existent supply. So it is common to spend 45-60 mins operating while a blood transfusion is in progress.  It is common for women to start with an Hct of 10% (or even lower!) because of malaria and malnutrition.

In addition to the OR time, just like in the US, there is the time to get to and from the hospital and go to the changing room for scrubs and plastic  apron, washing hands is done with regular soap, gown and patient assessment and patient prep and drape. After the surgery is some post op care and paperwork, changing and leaving the hospital.  So usually the call to come and return takes 2 ½-3 hours.

On Friday August 17 I did AM rounds and found that one of the babies I had admitted during Thursday’s afternoon clinic with cerebral malaria had died.  I discharged three who had made it through the night and were much better and got a second opinion on one more infant who was not getting better, being told to be patient and keep doing what we were doing: quinine for malaria, antibiotics and nutritional support. Then we had clinic.

 After AM clinic I did a C-section for a woman who presented with a previous C-section.  This was her second C-section and so was obligated to have a tubal.  Her baby unfortunately was stillborn and had been dead for several days such that there was already some decay and infection and a horrible smell.  I was in afternoon clinic which overall was light but did include a 5 year old with an Hct of 11% who I admitted for a blood transfusion and Quinine for malaria.  Later, I went on a walk-about thru the Galmi village.

Next I did another C-section in the afternoon, which was a primary c-section, that is a first one, done because this woman had had two previous stillborns.  Happily this baby was alive and well. Then after a brief time to freshen up we were guests for dinner with our friends Joe and Mame Starke.  Joe was a medical school classmate of mine and he is the main reason I chose to come to Galmi to be able to visit my good friend and assist in his ministry.  We had a wonderful time with great food and conversation and were just starting our prayer time when I was called in to do another c-section for a woman who had been in labor for many days.  Her baby was stillborn and it was difficult to control the bleeding and I was exhausted when I got home after midnight. 

I was called to the OR one more time at 3AM to come in for a repeat c-section which was just a bit over the edge of my functional capacity.  I got back to bed after 5am and got up at 7:30 to get ready for morning rounds and find out if the little 5yr old had survived the night. 

We both had!

This time in Africa has not been about me doing some great service.  The main event has been to be present in a place where Gods Spirit is working in a powerful way through the lives of the fulltime missionaries that live here with their young children and work day in day out, year after year for these suffering women and children.  I spent most of my time with Dr. Kendrick Lau.  He has been in Galmi for 12 years and is the Chief of the medical and pediatric depts.  He and his wife have 4 children under 13yrs living with them in Galmi.  He is a family physician and an expert on tropical disease.  He is the hardest working physician I have ever met.  His primary language is English but is fluent in French and Hausa.  He also studied Mandarin in his spare time.  He engages the patients in their own language and is constantly interrupted with questions about staffing, supplies, and running of the hospital while he carries the heaviest patient loads, and oh yeah, gets to orient and supervise the new guy (me) to be sure I don’t kill anyone.

I was also blessed to work alongside Dr Esther Pflaum.  She is a Swiss OB/GYN who worked in Papua New Guinea for many years and then came to Galmi because she believed it to be the neediest place on earth.  She is the chief of the maternity unit.  She is the only OB doc and overseas all of the midwives and the 2,400 hospital deliveries/year.  She also manages all of the newborn care.  She has been in Galmi for about 10 years.  Every morning she personally rounds on every patient in the maternity ward (approximately 50 women and another 30 children!) .  She speaks to the patients with great compassion and very practical wisdom and expertise, which is applicable to the context of these women and their children.  The women she has personally ministered to is in the tens of thousands and if you count all the people she has trained and the ripple of her impact it must be approaching half a million!

In clinic I also worked daily with Dr Matt Megill an internist who is an expert and chief of the HIV division which is a fulltime job and includes pedes, even newborns and pregnant women, in addition to adults of all ages.  Managing AIDs patients is very complex because every part of the body is affected and the variety and severity of infections and even cancers and other organ failure problems are all intertwined and the treatments are often different than they would be in a standard case, and this is all done while taking very complex multiple anti-viral drug regimens.  Matt has been here for about 6 years.  He is academically brilliant and able to quote the latest studies and research in the field of HIV care.  But he is also the first to directly share spiritual truths and pray himself with patients.  Matt does not do OB but does take his turn for being on call and seeing patients in the regular out patient dept.

Our time in Galmi has been a great privilege because we have worked alongside saints who may not be equal to Mother Theresa but they would be playing softball in her league!   Drs Lau, Pflaum and Megill are like David’s Mighty warriors!  They are the captains of God’s forces here on earth.  To see them in action is like being  alongside Achilles in a Brad Pitt movie!!  Wow!  It is surreal, otherworldly—literally.

I am not saying that these brothers and sister in Christ are perfect, (they might be very sanctified but I do not know them that well).  I know that God seems to delight in using flawed humans like David and Peter.  What I did witness was super-human love in action!  They were being powered by the fuel of God’s grace and burning it up at a rate just like a Jumbo 747 burns jet fuel during take off! What an honor to see them in action and be inspired to tap into Gods grace a little deeper.