Letting Your Pessaries Fall Where They May

Sydney with the OB nurse (who got hit with the flying pessary)

You know the phrase, “let your chips fall where they may?” Getting into a rhythm here in Togo has taken a few weeks, but we are beginning to see some of the dust settle. Especially the first week, though, felt like an interesting dance to try to figure out new systems and expectations and workload and balancing kids and new househelp and new jobs. After several particularly busy days wherein I felt like I was expected to be doing surgery, running labor and delivery, rounding, and seeing patients in GYN clinic and supervising OB clinic, all at the same time, I was very tired. The day before, I had left 9 patients waiting to see me and simply put them off until today. And today, as I was trying to get wrapped up, several OB patients were complicated and I needed to stop and see them. It was already beginning to get dark, and I knew that my husband wasn’t likely home yet because he was playing soccer that afternoon, and I knew we were having company over for dinner, in 30 minutes…. So I was stressed. An OB patient with history of incompetent cervix now with twins had a shortened cervix. She probably needed a cerclage or pessary to reduce her risk of preterm delivery (OB's reading this, I know there is no evidence in twins.)

I barely had time to discuss it with her, and quickly found a pessary that would probably fit. This particular kind folded, and to put it in place supporting the cervix, one usually uses gel. So I did. And then I folded it. And in my hurry to place it, the thing slipped right out of my grasp, flipped up in the air and flew across the room and hit the poor GYN clinic nurse on the shoulder. She didn’t bat an eye, but bent over and picked it up to go out and clean it. I just stood there with my glove on, pondering how incredibly funny it was to have flying pessaries, and how thinking of that was going to help keep my stress level down as I finished out the final patients and headed home for a busy evening. Things will get better, we’ll settle into a routine, but until then, a few more flying pessaries to lighten the mood may be in order. And we’ll just let them fall where they may.

Let’s back up a couple of days. When we arrived in Togo, there were a couple of visiting retired OB/GYNs who were taking care of essential clinical care and being on call, so I was able to concentrate on unpacking and organizing life. I took over on Thursday, rounded with the departing OBs and reviewed their patient lists and treatment plans. I was on call, which means I admit patients, am first call for labor and delivery, and can go home for night but need to be available for 24 hrs. It wasn’t super busy, but there always seems to be a question about something around 5:30am that inevitably wakes me and little Zack for the day. Friday I was somewhat tired, but went in for a C section I had put off for the morning, as it wasn’t urgent. It was routine. Second baby. Second C section.

But… I struggled getting through tough fascia. I struggled getting the baby out through an unforgiving scar. And then her uterus wouldn’t contract. Refused. As in, it NEVER felt firm. I did what I’ve been taught to do- gave IV Pitocin, gave IV methergine, gave rectal misoprostol, gave more IV Pitocin, gave IM methergine, slapped and massaged and hit and pleaded with that uterus to contract and get firm. She was a young patient, unlike the momma we had done a C-hyst on for her 9^th pregnancy having just given birth to triplets almost at their due date. THAT made sense. If I was a uterus and had carried 9 pregnancies, two of which were triplet pregnancies, I would probably refuse to contract too. I’d be done too. And a hysterectomy after C section in a momma like that is only done when necessary, but it is an easy decision when they bleed. For young patients without many children, this is a VERY hard decision to make.

So I refused to give up on this uterus. I had already sewn the uterine incision in two layers, but there was blood oozing from the suture lines, from the inside of the uterus which wasn’t contracting (normally this clamps off blood vessels), and I knew that there was likely a huge amount of blood underneath the surgical drape because the cervix is open. I tried a B-lynch suture around the top of the uterus to force it to be smaller. I scrubbed out of the sterile field and packed the inside of her uterus with three foley balloons to make a “uterine sandwich” with the B-lynch suture holding it clamped down from the outside and pressure from inflated balloons on the inside.
I noted that there wasn’t as much blood in-between her legs as I had feared. Weird. I scrubbed back in. I oversewed a bleeding area to try to stop oozing. I was tired. So I decided to put the uterus back in the abdomen (I know this is creepy to non-medical folks, but we can easily pull the top of the uterus and the tubes and ovaries out of the abdomen during a C section). I tried really hard. Remember that tough fascia. Yeah. Still tough. I actually ended up cutting the skin and fascial incision open wider to put the uterus back in! It had already been big enough for the baby to come out, and then the uterus right after, but now I couldn’t get the uterus to go back in without cutting my incision wider!?! And she continued to ooze. It was odd. With how boggy her uterus felt, she didn’t have a ton of blood between her legs nor was blood pouring out of the incision site. But a non-contracting uterus almost always requires action, so I needed to make a decision of whether to do a hysterectomy to save her life. Surely she would just continue to bleed until there was no blood left. After all, 500mL of blood is going to the uterus at the end of pregnancy every minute.

You know those visiting OB’s? I knew they were still around for another hour before their vehicle left to take them back to the capital for their flight back to the US. I called one of them in. I just felt that as long as they were there as a resource, I should get their second opinion. One graciously came and scrubbed in. We took a long look, evaluating the amount of blood lost, evaluating the still soft and very large uterus. She finally said, “well, let’s use Surgicel and close her.” You might have to take her back to the OR later, but her vitals are fine, she isn’t bleeding that much even though her uterus is not contracting down, and she might do well!” So I used the gray mesh called Surgicel that helps small oozing vessels to coagulate, and I closed the fascia and skin.

Even though I was post-call, I couldn’t get her off of my mind. I told the on call family doctor (Dan) to keep a close eye on her. I worked until evening, then headed home to the family after working a full day and being on call at night and then working a full day. I hadn’t even finished eating the last bites of dinner when Dan walked by the house on his way in, saying that her blood pressure was very low now and he was going in to check on her. I knew what that meant. She had lost enough blood now that her uterus needed to be taken out. I kissed my husband and kids goodbye, swallowed a few more bites of dessert, and changed back into scrubs. I was sad, but I was convinced that she either would die or I’d take her uterus out.

But, I met Dan walking out of the hospital. He said that she didn’t clinically look bad, the ultrasound didn’t show free fluid, and her repeated blood pressures were not as low. He thought she was stable. I wanted to be sure, so I went in and repeated the ultrasound and pushed on her belly. Indeed, she didn’t look like she was bleeding to death. So I went back home in time to put the kids in bed, hoping I wasn’t just delaying the inevitable until the middle of the night. 

In the maternity ward with a happy ending

Sure enough, I got a call from Dan at 2:30am. Even though I wasn’t technically on call that night, I’m still the one they look to if there is a serious problem as I have the most OB experience of the doctors here. But it wasn’t about her. It was a new patient who had been emergently transferred here because she had a hand presentation- instead of the head coming out first, the hand had delivered and the baby had died in the labor process already. She was only 34 weeks. Dan asked my advice, and I recommended trying to avoid C section for a dead baby unless the mom is unstable or had had previous C sections and it seemed dangerous. It’s not difficult to deliver by C section- just deliver as you would a breech presentation, I told him. I went back to sleep. At 4:30am, I was awakened again.

**************************Notice- this next part is extra medical, so if you don't care to read it, just skip to the "One Quiet Night" picture.****************************************

This time, it was to do a hysterectomy, but NOT on the patient I had been so worried about. No, it was for this new patient. They had put a foley catheter in her bladder in preparation for delivery, and it had returned as straight up blood. Concerned about uterine rupture, Dan had called the general surgeon back up to do a C section for probable uterine rupture, as he did not want to wake me. But when they opened her abdomen and had taken down the adhesions, the whole bottom portion of the uterus was ballooned out and dark red, as if the placenta had invaded through the anterior uterine wall and was now in the bladder. Indeed, the foley catheter balloon could be felt at the top of this red mass.

Most bizarre pregnant uterus 

I had never seen this before. Placenta percreta? That means the placenta would not come out easily; she would need a hysterectomy, and even then, the placenta was likely invading the bladder so how would we repair that? I decided to start with the known part. I split the uterus front to back. Sure enough, there was anterior placenta and baby feet. As soon as I ruptured the amniotic sac, the big purple mass which looked like the invading placenta simply collapsed. And we saw the baby’s head where I thought the bladder was. I tried pulling the baby out by its feet, but the muscular part of the uterus was contracting too much (opposite problem as previously).


So I continued to cut down anteriorly until I had completely transected the anterior part of the uterus and it was now filleted open in right and left halves. To my surprise, the placenta easily came out. And then the baby did. Now we just had two halves of a uterus to finish removing. It was easy enough to detach the remaining posterior cervix from the vagina. We left the ovaries, and clamped along each side of the broad ligaments until we got underneath the cervix. With that, the two halves of the uterus were removed. I tried to find some remnant of anterior vaginal wall to sew the posterior wall to in order to close the opening, but it wasn’t clear. The remaining large purple part still had a foley catheter which was palpable, so that was the bladder. Its surface felt extra thick, so I decided to take part of that tissue in my bites in order to close the vaginal opening to make a cuff. Nothing was bleeding, so we took one last look at her abdomen and then closed her fascia and skin.

I left around 7am, scratching my head and wondering what in the world I had just seen… uterine rupture which happened a while ago? A pregnancy that grew within the old cesarean section scar and slowly opened it?… bizarre. And I was incredibly thankful that Zack hadn’t woken up yet wanting to eat. Not 10 minutes after I walked through the door, he started whimpering to eat, and I took him and cuddled with him and he nursed. And I thought. Wow, I just did a hysterectomy, but it wasn’t on the patient I thought it would be on. Wow, God did a miracle and the first mom is doing well. Wow, I’m tired. Wow, I hope things slow down. I was on call the next day, Sunday, again, but it was as if I had played the “One Quiet Night” card in the game of Pandemic. After regular rounding and seeing that both post-op patients were doing well, there were no further surgeries or emergencies. Eerie.

The next week started out busy again with surgeries, and by Tuesday, there were flying pessaries. That’s why I was stressed. A short-termer pace is unsustainable long-term, especially with a family and young kids. We’ll let the pessaries fall where they may, but only after we make adjustments, decrease expectations to a reasonable level, and try to ensure that these kind of weeks are the exceptions and not the rule. May God give us wisdom, the needed “One Quiet Night”, and a few more comedic moments to help us laugh, even if it’s a pessary flipping end-over-end across the exam table.