MATERNAL HEALTH/MORTALITY -- THE FACTS BEHIND THE FIGURES

Photo shown for presentation purposes only.

First of all, I must make it clear that, I do not intend to embarrass anybody by my writing, neither do I intend to make people uncomfortable, but the facts one day must come out.

As health workers, sometimes I doubt if some of us must be labeled hell workers and not health workers.  We prefer protocol to protection and emergency.  I have always thought and practice that, we must start the life-saving process before protocol.

Madame C L, 31 years old, came to our facility because she heard we practice emergency obstetrics and gynaecology. She had a previous intra-uterine fetal death which ended up in a caesarian section in a hospital in a neighboring region. This time she had developed Gestational Hypertension (PIH), and at 34 weeks she was breech.

We managed her and then booked her for elective caesarian section at 39 weeks on 8 April, 2011. She came on admission with labour pains on the 7 April, 2011. After examination she was prepared and taken to theatre for emergency caesarian section. The mother had spinal anaesthesia and the significant findings were: live female baby with excellent APGAR scores and multiple uterine fibroids.

The surgery was uneventful so the patient was taken to the recovery ward.   In all, there were six surgical cases with diverse diagnosis respectively. Less than an hour later, the midwife rushed to inform me that the patient was bleeding and the abdomen had distended.

Agression

The response to this call was aggressive. I must say that for any haemorrhaging patient to survive, time is the greatest factor that has to be considered. It is important to respond immediately whenever one is called to see a bleeding patient. For Post Partum Haemorrhage (PPH) in particular, death is just a few minutes away, so one has to race against minutes and not hours.

We implored our protocol for managing PPH, but the bleeding would not stop. We went ahead to give directly intrauterine syntometrine (oxytocine /ergometrine) but the uterus would not contract and the bleeding would not stop. We therefore took an urgent decision to do hysterectomy, while blood was being organized for the patient. For the sake of time and life, we had to do a quick subtotal hysterectomy. The patient had actually lost so much blood and then she had a cardiac arrest while surgery was on-going.  Resuscitation with Adrenaline and cardiac massage was done and then cardiac activity started again. We transfuse her five units of grouped and crossed matched whole blood.

We were fortunate to have about 8 units of blood in our small bank. By the end of the fast surgery Disseminated Intra-vascular Coagulopathy (DIC) had set in. The bleeding would not stop and oozing was coming from every part.

Precision

At a point the collection of blood was such that I thought there might be some form of rapture within the epigastrium.  I wanted to pack the pelvic but then if what I was thinking was true it would not be possible.

Cooperation

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At this point in time, we called Dr. Emmanuel Srufenyo of Ridge Hospital for help and advice.  It is important to state here that, under such critical conditions; help must be sought from colleagues who would not start playing politics, blame-game and intellectual showmanship but would be down to earth and ready to help save life. I must say that, Dr. Srufenyo is one person our communication line was opened to throughout and was simply more than helpful. He did not think that there might be bleeding from the epigastrium so we went ahead to pack the abdomen firmly.  He suggested transexamic acid but it was not available.  We packed the abdomen firmly with gauze towels and then closed up.  The patient recovered well from anaesthesia. By midnight the husband (who was cooperating) had brought in 10 units of requested fresh frozen plasma (+FFP) from the National Blood Centre at Korle-Bu Teaching Hospital (KBTH).

All this while, Dr. Srofenyo kept calling to find out about the patient and discussing management. By morning of 8 April, 2011, the patient was communicating and up in bed. She even asked if she could have a cup of water or tea as the rest. Urine output has been adequate throughout. In the afternoon, she became restless and had some respiratory distress. The abdomen was distended but percussion was tympanitic. She immediately confessed to drinking almost a full bottle of 1.5 litres of Voltic water. We passed a naso-gastric tube and drained one litre of fluid. The pressure on the diaphragm eased and the patient became better (respiration was satisfactory).

Her blood pressure began rising very high. It got to the highest of 190/140 mmHg. She had been on nifedipine tabs. However, at that time we needed to quickly prevent a fit, so we started IM magnesuim sulphate 4g – 4-6 hourly for the first 24 hours.

To control the blood pressure, we were torn between using hydralazine and sublingual nifedipine. Hydralazine, though good, is a massive peripheral vasolidator and if the nurses do not monitor well, whiles  I see some other patients, the patients blood pressure would crashed to zero and all our efforts would be in vain. Sublingual nifedipine in this case is a calcium channel blocker and would quickly reduce the blood pressure.

Nevertheless, I called Dr. Srofenyo for his opinion, in answering he agreed with me on the problem of inadequate monitors (only 1 in theatre) and nursing management so we are better off using sublingual nifedipine (take note that, this was in the thick of the night). We wanted, at this time to add gentamycin and metronidazole to the ceftriaxone she was already receiving, but Dr. Srofenyo phoned in and thought, that though her urine output was adequate and we could give gentamycin, we could not be sure of its safety in this critical case so we drop it. The patient therefore went on metronidazole in addition to the ceftriaxone.

Recovery

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The following day 8 April, 2011, the patient’s general condition had improved, she was conscious and alert, with the naso-gastric tube in-situ.  Her blood pressure was 140/80mmHg and respiratory rate was satisfactory, urine output had remained adequate. She even wanted to eat and that, she was hungry.  Her condition was explained to her. At 4:00pm, I was called from the office to the ward to review the patient. She complained of some degree of breathlessness (“me humi nsume”).   She had crackles in the chest so we began IV Furasemide (Laxis). She might have some fluid overload from the resuscitative therapy. The next problem was whether we should titrate the next dose of Furasemide or not. I sent a text to my good friend Dr. Srofenyo to call me. In the interim, we got Dr. Patrick Frimpong of La General Hospital and discussed.  He felt that, we should start IV Furasemide 40mg in 500ml of normal saline.  There and then Dr. Srofenyo phoned in and suggested that due to inadequacy of nursing strength and monitoring we should rather give bolus of the same dosage 6 hourly.  In all these, the patient’s condition had improved the crackles had reduced and she was breathing normally and beaming with smiles.

On the 9 April, 2011 at 7:30am she was conscious and alert, answered questions appropriately, but her abdomen was fully distended and tympanitic to percussion with some degree of respiratory difficulty.  Wound dressing was clean and dry. Urgent hemoglobin was 10.0g/dl, platelets 117 and white blood cells 14.2.  She was prepared for theatre where the packs were then removed, her blood was clotting.  A flatus tube was passed which removed large volumes of gas.  Her abdomen went flat, pressure on the diaphragm was released and she got better (breathing and smiling).

By evening she was already ambulating.  Around 2:00 am on 10 April, 2011 I was called by both the anesthetist and the midwife that, the patient who, hither to, was talking with her mates had begun gasping.

How I managed to drive from Achimota in Accra to Dodowa within a few minutes I do not know.  We found out that her chest was heavy with crackles and she had a cough.  As to whether the instruction to give Furasemide 40mg 4-6 hourly was truly given is something different.  So we gave Furasemide 80mg stat, in a couple of minutes she produced a large volume of urine and the breathlessness subsided, she got better.

At this time we felt that the patient must go to Intensive Care Unit (ICU) where she would be put on the ventilator and have equipment monitoring.

This was where the greatest of all the problems started.  All attempts to call the National ambulance failed.  Not that the call did not go through, it went perfectly well, but nobody picked it.  I then called Dr. Srofenyo who picked it and started making contacts in KBTH.

Out of frustration and pain in my heart (transport) I called the Regional Director of Health Services, Prof. Irene Agyepong.  At that hour of the time Prof. Irene Agyepong responded to the first call and contributed as to whether the patient should go to ICU of KBTH or Ridge Hospital.  The regional director promised to call back after some contacts.  Prof. Irene Agyepong got us an ambulance through Dr. Zakariah (National Director of Ambulance Service).  The Ambulance arrived eventually and the Operators insisted we made pre- arrangement before going to KBTH.  I told them we had done that so we set off with the patient on oxygen.  This intervention was really God sent.  What a big relief.  Relief that the mother and woman we were fighting to save would live.

Repulsive System

Signage pointing to Obstetrics and Gynaecology Department

When we were about to leave I spoke to a senior specialist in KBTH and told her about the case, and that we needed the ICU of KBTH.  I called this doctor because I felt we were once neighbors and had worked together before.  She initially said we should send the case to the Physicians.  I insisted that, what the patient needed now, before anything else, was an ICU and ventilation.  I also insisted that it was an OBGY case and that she need not gynaecological care now and that there was an urgent need for an ICU.  She directed me to take the case to the maternity block for them to receive and then decide to send to them at the ICU.

We eventually, got to KBTH through a heavy down pour in the Dangme West. Let me make it clear that, the patient needed an ICU and not OBGY care, however,  the protocol is that, before she gets to ICU in KBTH a consultant OBGY had to certify or do a write up before she is accepted.

In all these, the patient was on oxygen.  The first name that came to mind was Prof. Richard Adanu, thinking that he was still in KBTH.  I called him because I knew he was one person who has extremely keen interest in reducing maternal mortality and also that  we had work together on the same floor as senior and junior residents and he was my outstanding lecturer in maternal (motherhood) issues in postgraduate school.

Prof. Adanu quickly linked me up to two doctors. Prof. Adanu did help us tremendously.  I contacted one of them who said he was at a funeral at Sogakope, and that we should go and asked the outgoing team on duty to receive the case on their behalf.

The other doctor was preparing for sermon so he asked that the senior resident on duty sort us out.  We got to the maternity block and things changed.  I rushed to the labour ward to inform the resident on duty about this case.  The general attitude and response was not a hasty one until my anaesthetist sent a medical student (my cousin) to collect a stilet from theatre to help intubate the patient in the ambulance because she was then gasping.  In all we spent almost one hour in front of the maternity block making contacts here and there until we were told finally that the ventilator at the ICU was faulty so we should look elsewhere, maybe 37 Military Hospital.  We therefore set off for 37 Millitary Hospital.  The ambulance drivers displayed all the maneuvering skills and brought honour to Dr. Zakariah’s service.

At 37 Millitary Hospital, I first rushed to the gynaecological ward and met one of the young doctors I knew (Major in the army).   Frankly speaking he had to follow laid down protocol also, but he was extremely fast, running on his feet.  I called a doctor anaesthetist friend who was at church he made contacts on phone and help started coming our way. In facts, he left church immediately and headed to the ICU to receive us.  At this time, a nurse anaesthetist passing by saw our predicament and she rushed in to help.  She helped my anaesthetist and they intubated the patient in the ambulance and they kept bagging her.  The ambulance then run out of oxygen, so I rushed to the obstetrics emergency and the one on duty was one of those nurses I spent my time to teach in Maamobi Polyclinic, she quickly gave me the small oxygen cylinder they had.  I grabbed it like it was a light briefcase.  I got to the ambulance when the patient’s oxygen saturation had dropped to 32.  I left Mr. Christian Gbekor (my anaesthetist) and Miss Afua Asante (my most dynamic young midwife) to continue with the resuscitation and run (I mean run) to the ICU.  My intension was to scream hell out there, but there and then I saw them bring a bed out and when I asked they said it was for the Dodowa patient.

Front of 37 Military Hospital

I run back to the ambulance and all of us together wheeled the patient with the oxygen cylinder to the ICU.  Having already intubated the patient in the ambulance it was easy for them.  The patient was put on the ventilator and then the oxygen saturation began to rise before our naked eyes.  The machine read 30,40,50……87, after a few minute the patient responded to her name by opening her eyes and closing them and then she responded to verbal command to raise her both hands.  Her blood pressure was around 132/80mmHg.

In facts, I felt like shouting HALELUUUUUUUUUUYA.

The morning of 11 April, 2011 we called the ICU and were told that she was very fine.  They also said, she had been put on manitol because she had cerebral oedema.

The heroes of this Salvation Army were:

• Dr. Kennedy Brightson (Maternal Health Expert and Medical Superintendent )
• Dr. Emmanuel Srofenyo (Ridge Hospital)
• Christian Gbekor (Nurse Anaesthetist)
• Afua Asante (Midwife)
• Prof. Richard Adanu (School of Public Health, University of Ghana Legon)
• Miss Arthur – (Nurse Anaesthetist)
• Dr. Obed Allotey-Babington (Anaesthetist)
• Prof. Irene Akua Agyepong (Regional Director of Health Services)
• Dr. Zakariah (National Ambulance Director)

But the supreme commander still remains GOD.

- story by DR. Kennedy T C Brightson, Head of Maternal Health/Medical Superintendent