Two Near Misses in One Week

Here at Mulanje Mission Hospital it is Thursday afternoon on May 1, 2008, a public holiday in Malawi. I am resting a bit after a busy day on call. We have had two “near misses” here at the hospital this week. In obstetrical terms a near miss is a maternal death that did not happen. Malawi has a very high maternal death ratio, something like 844 per 100,000 live births. Many organizations, institutions, and individuals are working to reduce the maternal death ratio in Malawi. Studying each and every case of a death and a “near miss” of a death helps to analyze causes and seek solutions.

Tuesday morning about 9:00 AM relatives pushed a young woman in a wheel chair into our labor ward. She was as pale as a ghost, and she is a black Malawian. There was no blood pressure recordable and she had bled profusely on the way to the hospital. She was brought from her village on a bush ambulance, which is a metal stretcher attached to two bicycle wheels. She had started a spontaneous miscarriage sometime during the night before.

The one nurse and I tried to gain venous access so we could pour in intravenous fluids to try to get a blood pressure. Her heart, thankfully, was beating. Finally, we were successful. I rushed to the laboratory with a sample of her blood hoping to find a unit of blood. She had O positive blood. There was no O blood in the blood bank. Her husband was ready to give his blood for his wife. The testing showed that he was O also. But the blood test for hepatitis B was positive on the husband, meaning we should not use his blood. We were stuck. I told the lab tech I thought she might die without a blood transfusion.

Then the lab technician told me there were two small units of O blood for children, with about 100 cc in each unit. I said we would be happy to have that 200 cc of blood. So, after crossmatching, we rushed the blood back to the labor ward. By that time her blood pressure was 80/40. The small transfusion helped to stabilize her. Her blood pressure was 100/80. An evacuation of the retained miscarriage was done easily. This morning, two days later, she looks like the healthy 18 year old person she was before this obstetrical disaster struck. I was very happy to discharge her this morning with good information about her family planning options, which are free at our hospital and all our village health posts.

This morning, a Labor Day holiday, I arrived at 6:30 AM, full of egg and toast, ready for work. The nurses looked at me on labor ward and asked if I was “on call”. Yes, I am on call. “There’s a woman over there who convulsed upon arrival, is bleeding heavily, and we cannot hear the baby’s heartbeat.” I went over and looked at her. Then I quickly went and got the small, portable ultrasound machine to have a look at her pregnancy. She had a placenta previa, with the placenta in front of the baby. The baby’s heart beat looked to be less than 60 beats per minute. Normal for a baby would be 120 – 160 beats per minute.

I told the nurses we have to hurry to try to save the baby and the mother. The lab tech was sent for quickly from home. The operating room was mobilitzed. The anesthetist was quickly called from home. We quickly loaded her onto a trolley and rolled her to the operating room. Washing off the belly, applying alcohol and iodine, making a quick incision after the intravenous anesthesia, delivering the 3.7 kg baby girl, and then hearing the baby start to cry was one of those obstetrical experiences we do not forget. This mother had “A” positive blood and there was some “A” blood already in the blood bank. The rest of her cesarean section was not difficult. She looks fine this afternoon and the baby looks fine as well.

At the patient’s bedside, I was able to ask some more questions about what happened to this woman. Her husband was there and told me she started bleeding slightly at 7PM the night before, and then bleeding heavily at midnight. He works for a tea estate and called for the estate ambulance after midnight. At 5 AM the ambulance began to bring her to our hospital. I asked why it took four to five hours for the ambulance to start. He replied there was paperwork and administration involved. This delay in arriving for care is often a cause of maternal death. Fortunately, it was not too late for this woman or her baby this morning.

One of the big challenges for Malawi and other developing countries is community mobilization and awareness to get everyone involved in promoting maternal health. Delayed transportation and difficult transportation are huge factors in maternal morbidity and mortality. There is still a lot of work to do in this area. I am thankful that I can be a part of this effort.

Grace and peace to all of you on Labor Day in Malawi,

Dr. Sue Makin
PCUSA Mission Co-worker
Malawi, Africa

Mulanje Mission Hospital
Mulanje, Malawi