They said she had come in because of retained placenta after childbirth at home. She lay on the delivery table, umbilical cord clamped and dangling, bleeding a small but constant trickle, like a faucet that leaks even after the tap has been turned off. But that isn’t what drew my attention. It was the desperate way she was breathing – her chest heaving, nostrils flaring, sucking fast and shallow breaths – it was her restless movement on the delivery table, writhing as though she was trying to escape an ill-defined pain – but most of all it was her eyes, wide and glassy eyes shot through with fear like a trapped animal, bright, unfocused. Her body trembled. I tried to find her pulse but it was fast and weak, barely a faint hummingbird flutter in her wrist. Her blood pressure was too low to measure. Cardiovascular collapse. Her abdomen was tender and rigid and distended like an overinflated beachball. I knew in an instant that she was dying.
The nurses tried to resuscitate her with IV fluids but had only been able to place one tiny IV in her inner elbow. Even wide open, the IV dripped maddeningly slowly. Edwin managed to place an IV in her neck, but her restless movements immediately dislodged it. I made a mental list of possible causes – uterine rupture, DIC with spontaneous intraabdominal bleeding, less likely placenta accreta or amniotic fluid embolism or simple hypovolemia from bleeding. It did not seem that a retained placenta alone could cause her critical state. The hardest part to explain was her bloated abdomen, hard as a rock, exquisitely tender to touch. I couldn’t find the contracted knot of her uterus that usually is palpable at the level of the belly button after delivery – I couldn’t feel her uterus at all. The moaning mother turned her head to the side and heaved. I grabbed a trash can but her convulsive vomiting overshot the bucket entirely, spewing foul brown vomit with feces across the room.
She has to go the hospital, I announced. Now. One nurse was still trying to place a second IV and another nurse was unsuccessfully trying to extract the patient’s retained placenta. They seemed surprised – the patient had just arrived, they had just started working, and retained placentas are common enough, not a reason for emergency referral. But they did not argue. I don’t know if it was the patient’s state or my own unusual agitation that convinced them. In my heart I feared that the OB surgeons at Bonga Hospital would not be able to help her anyway. As the Land Cruiser pulled away from the clinic, I did not feel rage or even strong grief at her plight. Just helplessness and quiet sadness.
That night, I dreamed over and over again about her death and I woke up in the darkness crying. The next morning we got the report – her placenta had been removed manually in Bonga Hospital and she was fine. I was stunned and confused and embarrassed. It was just a simple retained placenta after all? My clinical judgment was so off base? I misdiagnosed her symptoms and referred her to a surgeon when really I should have just taken out the stuck placenta and everything would have been fine. I had been so wrong. I tried to put aside my pride and focus on the fact that she was ok. But, there was new doubt and caution in my heart.
Days later, we got a more complete report. “Complicated manual extraction of intra-peritoneal placenta.” That was it! Placentas should never be “intra-peritoneal,” which means outside of the uterus and in the general abdominal cavity. A thousand questions sprang to mind. How did they get their hands into the abdominal cavity? Did they operate? How did the placenta end up in the abdominal cavity to begin with? Uterine rupture? It must have been uterine rupture… But my intellectual confusion was mixed with sheer relief. I wasn’t crazy. I didn’t overreact. An “intra-peritoneal placenta,” regardless of how it got there or how it was removed, could have caused her symptoms of abdominal distention and shock. And it would have eventually caused death. Of course she has other problems now – anemia and a draining vesiculo-uterine fistula. But fortunately the patchy Ethiopian health system worked in her favor, and she is alive.
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