64: OP#8/Malawi: day 14

Part One

This is the most difficult day to write about.  I had a 9:30 deadline for the airport bus, but before that I planned on some rounding and data collection and follow-up notes for the molar pregnancy.  I left early and saw a few patients then passed by L&D because I wanted to look at the delivery log.  The C.O. on call asked me about a woman in her first labor, pushing for about 30 minutes.  He asked about a C/S.  My exam showed more descent than one would expect after just 30 minutes--almost crowning (many unmedicated first labors push for 2 hours), so I said I thought she would be okay, but I would finish up some other business and return in half an hour.  I asked whether the baby was doing okay and was reassured that there were no problems, though I didn't personally listen to the fetal heart.  I finished rounding and returned to find that some progress had been made, but not much. After 15 minutes, there was sufficient descent to allow a vacuum delivery, which I felt justified because of uncertainty regarding the baby's status.  The delivery was quick and uncomplicted but the baby was limp at birth, in need of resuscitation.  Vigorous tactile stimulation did not help--no breathing and no movement or tone, so I took him to the warmer and prepared for bag oxygen (meaning that I'm squeezing a bag of oxygen into a face mask).  A nursing student listened for the heart beat and confirmed its presence.  After a few minutes of oxygen, first by me then more competently by a second C.O. who happened by, spontaneous respirations appeared.  But still no tone, no movement.

I had to leave, so left the baby under the care of the staff.  On the way back to my room I passed the American pediatrician and explained the situation.  She said she would call the C.O. and encourage him to proceed with the neonatal resuscitation protocol.  In this case, it would mean intravenous fluid and antibiotics and if blood tests showed anemia, then a blood transfusion, nothing complicated or new to the staff.  I don't know whether any of that happened, but a few days later the pediatrician e-mailed to say the baby had died.

[nb: all my other pictures are from Nkhoma, this one is from the net]