foggy then fine

Nearly two am and I can hear my thirteen year old talking to her older sister on Skype.At least it is the weekend.They have been together during the week, watching romantic films and going to dance exercise classes, while their mother is having treatment and I have been too busy to stop for a meal.

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I woke up to a foggy morning and drove in for the operating list.







There were two in labour ward exhausted from irregular but persistent contractions. Between cases arranged for an epidural and oxytocin infusion for each, and did a ward round. Told that all our residents are away on exam leave next week. I will have to do all their clerical work as well as manage labour ward and clinic, starting after eight days and nights already on call. I'm not sure if I can cope, not so much psychologically but logistically. Ok, psychologically too.
No surgical complications, finished on time for once so home briefly for lunch and talk with my mother who comes over and does housework every couple of days. We have come so far since my childhood yet here we are again, just me and my mother, in a tiny oasis of time, all of our mutual history telescoped into a few minutes of sunshine and tea stolen from the working day. She has ironed my shirts and put away the dry dishes. We discuss the news of the day and the progress of the children, now moving into the world so fast, and suddenly I am in clinic counting down the appointments until the end of the week.

I run up to the labour ward for a delivery which is quick but followed by more than a litre of blood loss.It settles then back to clinic. The other patient in labour seems to be making no progress . I feel pessimistic but allow labour to continue. The clinic also goes on. I see a woman who bled over three litres with her last baby nearly four years ago.She has had difficulty dealing with her reactions to the birth and her nearness to death but is pregnant again. I used nearly every treatment to stop her bleeding, finally succeeding by inserting a balloon device inside the uterus. She still has misgivings but cannot turn back.
The resident calls during the last consultation of the day. That other patient now has a worrying foetal trace and has not progressed in the last few hours. I concede and suggest we organize a Caesarian delivery while I finish in the rooms.I am disappointed as my daughter will have returned and will be on her own at home.I had hoped to prepare a meal. I call her and suggest she heat up a meal I had saved.
As I leave the room a midwife calls to say the trace is now normal and the patient would like to try a little longer. I agree but decide to stay and do some paperwork, checking results and calling patients. Nothing happens so I call my daughter and say I will join her for the meal. As I insert the car key in the ignition, my phone rings. The foetal heartbeat has worsened. I hurry to the labour room without time to call my daughter.

The cervix is fully dilated so the baby is delivered by vacuum cup, fortunately in vigorous good condition but there is bleeding. I massage the uterine fundus to help it contract and pull gently on the cord which immediately detaches from the placenta -  still stuck inside the uterus and preventing the uterine contraction which is required to stop the bleeding. Blood pours freely from the vagina. The patient is given nitrous oxide gas as I reach in to remove the placenta. It will not come easily. A major portion is firmly attached to the lower segment of the uterus. It needs to be removed as the bleeding is not slowing down and yet the lower segment contains few muscle fibres and so will not contract well therefore potentially adding to the bleeding problem. By this stage the gas and blood loss have resulted in loss of consciousness so I reach inside the uterus and detach the placenta piece by tiny piece, removing my hand at intervals to try to pull out the whole placenta. It refuses to come out in one piece. Looking down, my arm has disappeared into the vagina to half way up my forearm which is coated with still clotting blood. At times my patient groans and she momentarily wakes up in the middle of the procedure. The bleeding continues. The laboratory is cross-matching blood as quickly as possible. We are running in fluid through the drip.
Eventually the last of the placenta has been removed but this leaves a seemingly huge floppy area with unconstricted blood flow. She has been given oxytocin, ergometrine and rectal misoprostol without much effect. I bimanually compress the flaccid posterior lower uterine segment which does seem to somewhat reduce the flow. I ask for an intra uterine balloon device and, while keeping my arm inside the pelvis to maintain pressure, survey the surrounds for blood loss. There are two kidney dishes full of blood, each holding at least a litre, and quite a lot of blood soaked into into packs and bedding. Then the midwife looks under the bed to find a spreading pool of blood and clots, probably another litre or more. If  much more blood is lost the bleeding will become even worse from lack of clotting factors and the possible development of disseminated intravascular coagulation, from which there might be no return.

The husband leaves the room looking paler than his wife.
In total there is probably well over three litres of blood loss and more collecting above my hand in the vagina when the balloon catheter arrives. As usual it has a thick instruction booklet so we look at a diagram to ensure it is properly set up then I guide it into the uterine cavity. Five hundred ml of fluid is gradually inserted into the balloon. I can feel the apparatus slowly pushing against the tissues, firmly in the end, and remove my hand from the pelvis with trepidation.The bleeding has stopped.

Blood arrives and transfusion commenced. The husband returns and looks at the baby with his wife who is now awake with only a hazy memory of events. I write notes and drive home in a post adrenaline daze wondering what my reputedly self-obsessed teenage daughter has made of my absence. I can smell cooked food as I enter but I am disheartened to see that there is none left in the container.Then I look up to see my daughter smiling .The table is set for two and dinner is served with a freshly made pot of tea.

 She asks me how my day has been and shows me the clothes she bought in the city.
 Later she talks to her sister on Skype.