PREGNANCY & CHILDBIRTH: CESAREAN SECTION

 

 

PERUTH'S STORY:
An expecting mother is rushed to the hospital where she receives an emergency cesarean section.  

 

Early one morning this year, before the sun had risen, Peruth, 36, set out for the health center nearest to her home. She was in labor with her fifth child. The health center isn’t very far away. But Peruth’s home is perched on top of a steep mountain, and she had to descend a rocky footpath in the dark, as labor pains wracked her body.

She wasn’t too worried. Peruth had attended all four of her recommended prenatal visits at the health center, and all signs pointed to a normal, albeit demanding, birth. Plus, she’d had four healthy, normal pregnancies and births before. But neither she nor her nurses could have predicted that the baby would become distressed and need to be delivered via emergency C-section.

The nurses knew that she would need to be transferred to the nearby district hospital—the PIH-supported Butaro Hospital.

When she arrived, the surgical team flew into action. The operating room was prepped and a team assembled. Dr. Theophile and Dr. Emily, the anesthesiologists, joined Dr. Sierra, an obstetrician, and Dr. Illuminee, a general practitioner at Butaro who specializes in maternal health. They immediately set to the task, and within minutes, Dr. Sierra and Dr. Illuminee skillfully extracted the baby.

The baby was breathing, but barely. Dr. Emily and two midwives worked to clear the airway and stimulate breathing, and after some time, the infant regained color and vital signs. The babywould need to be watched overnight in Butaro’s Neonatal Special Care Nursery, but the team’s swift action had saved a new life.

Back on the operating table, Peruth was not faring as well. She was bleeding profusely. Her blood was not clotting. Dr. Sierra called for Dr. Robert, a Boston-based trauma surgeon, and Dr. Eric, another Rwandan general practitioner, to discuss the case. Despite receiving large amounts of blood and fluids, it became clear that in order to save her life, Peruth would need not only platelets and frozen plasma to help with clotting, but also an emergency hysterectomy. 

Despite their efforts, Peruth was still bleeding. 

The medical team called the Rwandan Blood Bank in Kigali. They would send platelets and plasma if the team could find a car to transport the products. The 2.5 hr ride from Kigali to Butaro is rocky in dry, daylight conditions. At night, it can be treacherous.  Fortunately, there happened to be a Partners In Health truck and an experienced driver in Kigali who could pick up the products and rush them to Butaro. 

If all went according to plan, Peruth would have plasma and platelets within the next three hours. 

Once they arrived, the platelets and plasma slowed and eventually stopped the bleeding. Doctors closed Peruth’s abdomen. But she was not free from peril just yet. She was in critical condition, and the anesthesia team had to take shifts monitoring her vital signs through the night.

In the morning, her condition had stabilized. After a day, her condition was stable enough for her to begin breastfeeding. After a few days, she was released with her new infant, Chirac.

 

 

Surviving was only a part of the story

Peruth is a subsistence farmer, and her husband, Theophile, drives a motorcycle taxi, paying rent weekly to be able to use an acquaintance’s motorcycle.

After they had their fourth child, they knew they could not afford more. A community health worker (CHW) had taught them about birth control and how it could help them keep their family size to four. Peruth began taking oral birth control pills, with the full support of her husband. But as sometimes happens, Peruth later received a shock: she was pregnant with her fifth child.

As she recovers from a major medical procedure, Peruth worries. They don’t have anyone to work their fields, and they worry they may have to pay someone to cultivate them. Peruth also doesn’t have anyone to fetch water for her—a twice-daily task that requires she and the children walk 30 minutes to a nearby spring, and on the return trip, straining under the weight of the yellow jerry cans they carry on their heads back up the mountain. 

When asked what her biggest challenge is each day, she says it’s dealing with their poverty. They are perpetually struggling to keep enough francs in their pockets to buy the beans, potatoes, and porridge that constitute their two daily meals.

 

Asking “what if?”

Recalling the birth, Peruth prefers brevity. She doesn’t like to think about the night when she and Chirac almost died. She does remember that as the reality of the situation began to grip her, she envisioned her death. Her family would suffer without her—she knew that well.

Theophile admits, too, that during the ordeal, he was terrified at the thought of telling their children their mother had died.

The family is grateful to PIH/IMB. Peruth doesn’t have to think long when asked what if there weren't a hospital like Butaro nearby. “I would have died,” she says frankly, in steady, rapid Kinyarwanda.

Many Rwandan women aren't so fortunate. In 2010, 340 of every 100,000 Rwandan women died in childbirth. In the U.S., that number was 21.

But things are improving. An aggressive government campaign has resulted in 71 percent of women traveling to a clinic or hospital to give birth. As a result, the maternal mortality rate has fallen. In 2000, roughly 1,051 of every 100,000 women died while giving birth—a number that has dropped threefold in ten years.

 

“Buhoro buhoro” 

The kind of care that Peruth received that day in the Butaro operating room was exceptional for poor, rural communities. But it doesn’t have to be. With continued accompaniment at all levels of a healthcare system, improvements are made “buhoro buhoro,” little by little. And sometimes, the accumulation of those small changes makes a huge difference.

Before PIH/IMB began working in Butaro, there was no hospital in the entire district, and the closest health center provided poor care. Women with complications in labor often died in a health center. Worse, some women, desperate to get to a hospital, tried to make the trip to the closest facility in Musanze by being rowed across Lake Burera in a boat. Many women died in those boats before they even got across.

We’ve come far in obstetric care at PIH/IMB, but we don’t want to stop at better than before. We won’t be satisfied until all Rwandan women like Peruth have access to the kind of quality lifesaving obstetric care that she got at Butaro Hospital that day.

Read about PIH’s work in Rwanda.
Learn more about Butaro Hospital.