Waiting (for the baby) to Exhale

I stood there scrubbing my palms in a circular fashion, the bar soap gripped tightly in-between.  Each stroke was cautiously undertaken, as I was unsure of my technique.  The instructions taped on the wall informed me of my next move: first the palms, then the backside of the hand, then the fingers.  Had it not been for these instructions on the wall, I surely would have attempted to emulate what I had seen on tv.  Dr. Peter Benton from ER meets East Africa...or at least that's how it played out in my head.

My surgical career began that day with a few short words: "So, you'll assist me on the c/s?"  Rajiv, a 2nd generation Kenyan with a surely-Indian background, had been my mentor for the past two days.  He was the perfect go-between for myself and the brash, quizzing consultant.  Rajiv thought quickly and his answers came with, quite seemingly, no effort at all.  His willingness to indulge my curiosity was the reason I stayed near his side.  I knew nothing about Obstetrics, and prior to this week, was terrified of Gynecology.  Watching one vaginal delivery cured me of my fear, however.  I wondered why it had been built up so in my mind.

With my arms bent and palms facing my chest, I backed out of the scrub room, and into the theater.  The daunting task of donning sterile gloves with semi-dry hands ensued.  I fumbled through the entire process, both times failing to realize that sterile gloves are handed.  This was not the case for any other latex glove I had worn.  Had it not been for Malia's guidance, I might never have made it to the table.  Rajiv noticed I wasn't wearing my surgical cap (where did mine go to?), and quickly gestured to an assistant to fetch one.  I made him explain the instructions to me twice, fearing that somehow this baby wouldn't come out in one piece if my forceps weren't arranged just so.

"The key to it is not freaking out," Rotich, the other intern, murmured into my ear.  Easy for you to say.

Eye contact was made, a slight "So, we begin" from Rajiv, and we're off.  Outer skin, muscles, fascia all stand no chance against the surgical steel.  Despite their tenderness to the blade, each layer is carefully breached.  Pools of blood form in the pockets made by the incision--I was warned that suction is not routinely used in c-sections in Kitale District Hospital--and my initial shock at the sight was quickly spurned: "Be more aggressive with the gauze, and help him blunt dissect," Rotich said over my shoulder.  Hearing the words "blunt dissect" in an African accent was nothing new for me: Dr. Paul at school loved this technique.  You should check out his book if you get a chance.

The procedure ticked on, until the uterus was reached and the last incision made.  The c-section gained exigency when intrauterine fetal distress had been noted by the examining physician earlier in the maternity ward.  This is all done by fetoscopes, not doptone like in the states.  The baby was also lying transverse in the mother's belly, making the procedure much tougher than a routine c-section.  Once the uterine wall was crossed, the pace of Rajiv's movements hastened: once cut, the uterus begins to contract, making extraction of the baby much more difficult as time progresses.  He struggled to get a hold on the child's head.  His frustration, and my anxiety mounted with every passing second.  "Press downward on her uterus," he commanded."  I did.  "With all your weight.  Don't hold back."  The change in his tone alerted me that this had crossed over into a dangerous situation for both mother and child.  There I stood, pressing my hand into and downward on her belly, all my weight on top of this woman.  Still no grip, still no child.  This continued for an eternity, so it seemed, until one final push from me and a secured grip from Rajiv brought the baby out into the chilled air of the operating room.

I had been informed that the clamping and cutting of the cord was my chief responsibility once the baby was out, and it was to be done closer to the mother than the baby, to allow for injection of resuscitating medication for reviving of the child.  When the baby appeared, I saw why.  The cord was wrapped around his neck twice.  No time for freaking out, I thought.  I clamped and cut quickly, then returned my attention back to the mother.  She was bleeding quite excessively from the forceful tearing of her uterus and abdominal wall.  Rajiv began suturing, I, blotting.  This went on for nearly 4 minutes without any noise from the table across the room, where a team had assembled to revive the child.  I periodically locked eyes with Malia, who sat peering over their shoulders trying to view the baby.  Just as I began to think that this, my first surgical procedure, was going to end in fetal demise, the cry came.

"That is a good outcome for us," Rajiv said, noting my wayward gaze, "but we must focus on this woman, for she is our responsibility."