January 27th
So before you all think that I am already getting remiss in my blog updates, we have had a period with no internet connection. It seems that Ethiopia telecom is just like the trains in the UK and the slightest inclement weather takes the lines downs (or something of that sort anyway). I was told it was the dry season (which should last until end of April i.e. long after I am back in the UK- thus I came with no clothing for wet weather. No doubt someone in some meteorogical department will say that it is due to global warming but we had 2-days of intermittent torrential rain- there is no doubt that these 2-days left me relieved that I am not here in the wet season. One return trip from my bungalow left me soak to the skin (in spite of a plastic apron to make me both look like a local using whatever is to hand and theoretically to offer some degree of rain protection), thankfully "scrubs' & Crocs (which are standard wear for work here) dry out very quickly.
So back to life on labour ward in Gimbi. Monday presented me with my biggest challenge yet- this is meant in both a literal and a metaphorical sense. Late in the afternoon, a woman was transferred from the Government hospital in Assossa which is 5hours drive (300km) further west almost on the Sudanese border. A brief letter presented the facts that they had tried to delivery her by caesarean section (reason for caesarean not given) under general anaesthetic and that she had had a cardiac arrest but been resuscitated and they had abandoned the planned operation and transferred her to us. What the letter didn't say (but perhaps they felt it unnecessary as it was immediately apparent on looking at her) was that she weighed 150kg. This is the sort of weight that in the UK creates comment but we do deliver women who are very overweight relatively often but here where the women of all ages are all incredibly lean and have no body fat at all (there is the occasional wealthy person who might be reaching a BMI at the upper limit of normal) this woman was massively obese. Being this overweight is a health issue in the UK in spite of having special equipment (hoists and a bariatric operating table) and extremely experienced anaesthetist who will see the woman and careful plan the anaesthetic to try to make it as safe as possible. So you can imagine the issues involved in caring for a woman of this size here, the only good news was that looking at her it seemed unlikely that she had had a genuine cardiac arrest as she was well in herself. The reason that they were going to deliver her was because she was in very early labour having previously had a caesarean section and they suspected she was carrying a large baby. I agreed with their suspicions about the size of the baby but of course the accuracy of clinical examination in this situation can be poor (the faithful scan machine was not able to add any information in a woman this big). So I bad a dilemma- should I let her labour and wait to do an emergency caesarean or just get on and do it now whilst there was no apparent urgency? On balance I decide to go for the latter option on the basis that it would be safer for her- the risks of the whole situation were explained to her and her family (or at least something was said).
In this situation it is the anaesthetic that is the issue not really the surgery (which is just more difficult) and so this was a serious challenge for Abate the nurse-anaesthetist. He tried a spinal anaesthetic but the needle wasn't long enough to reach her spine (we have special long needles in the UK) and so he was forced to give her a general anaesthetic. Obesity makes this particularly dangerous as it is difficult to get the tube into their airway that is required to allow them to breath (they have fat, swelling and relatively shorter necks due to their body shape) and this is something that you only get one attempt at. Thankfully he managed to get the tube in place first time although her oxygen levels did fall to an alarmingly low level very briefly (which we suspect is what happened in Assossa resulting in them panicking and abandoning the operation).
So I was able to do the caesarean and delivery a large 4.5kg (9lb9oz) baby who has the body fat distribution of a laughing Buddha. This is a very large baby for here where the average birth-weight is about 3kg (6lb6oz) and the appearances all suggest that the mother had diabetes in pregnancy which would be in keeping with her weight. The operation was uneventful other than having to finish the skin with local anaesthetic as she was waking up and in the circumstances giving more general anaesthetic was not an option.
Thankfully 35hours on she is doing remarkably well and is mobilising better than an equivalent woman would back home. Her baby has a few feeding issues (unusually she is refusing to breast feed which only the very wealthy do here as formula milk cost $16 a tin).
I couldn't help but ask the midwife to ask her what she ate as on the basis of the diet I am eating here it is difficult to maintain weight never mind gain to any degree. The midwife asked her, she responded in a serious way and the midwife smiled and translated "she says she eats nothing doctor"!
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