Fresh Stillbirth

I still remember the first patient I ever had to tell that her baby had died. It is an experience and an emotion that I don’t think anyone ever forgets. There have been many women and families since the first one, though in a multitude of different situations. Here in Kenya it is a daily experience and on a busy day it is more than once per day. The statistics are very difficult to come by and most likely underreported, since many women who have a stillbirth do not seek care or are not seen in a health care center where they will be “counted.” The best information I could find from 2009 WHO data (https://www.quandl.com/c/health/stillbirth-rate-by-country) quotes the United States stillbirth rate as 3 per 1000 births, whereas Kenya’s stillbirth rate is 22 per 1000 (which looks good compared to Pakistan’s rate of 47 per 1000).

The term we use here if the stillbirth is delivered & there are signs that it has been dead for a while is a macerated stillbirth (MSB). If it has died recently, usually in the course of labor, it is called a fresh stillbirth (FSB). When a woman comes into the hospital they are initially seen by the nurse and clinical officer (CO), who take their history, vitals, and check the fetal heart rate with the fetoscope. If they cannot find the heart rate, they bring the patient to the room where we have an electronic fetal monitor and ultrasound, where they will most likely see the midwife or I.  Usually I have to explain that we do not know why this has happened, but that it will most likely not happen again- that they hope for their next baby to survive. Often I have to explain that they are very sick with high blood pressure or preeclampsia and that is why their baby has died. It is harder to explain to the chronic hypertensive patient that when she was seen in the rural clinic 2 weeks ago and her blood pressure was high they should have sent her here or that if she had not waited until the 42^nd week of her pregnancy we might have been able to save her baby.

But the fresh stillbirths are the worst. I already wrote about my first Monday working here, but it has taken me much longer to write about my second Monday. It has been hard to find the words to explain what happened and how it felt. Just as we were finishing our sign out to the night team, a young patient who had already lost her first pregnancy came in late in her labor with the baby in breech presentation. Our team discussed the pros and cons of doing a breech vaginal delivery or cesarean delivery, but there was no theatre available and she quickly began to push. We performed a breech vaginal delivery that went very smoothly. I was assisting the midwife who is far more experienced in breech vaginal deliveries. I was eager to learn and happy to be improving my skills to help the next patient I see, when I may not have the midwife to help me. I was also happy to be helping the patient avoid a cesarean section, an intervention far more dangerous here than in the US. Although we are lucky to have safe cesarean deliveries in our facility, the future with a scarred uterus here is much less predictable than in the United States. In her next pregnancy she may not be close enough to a hospital to have a safe delivery. If she chooses to have a trial of labor, she will not have continuous fetal monitoring to catch a uterine rupture before it kills her or her baby. Although I do not have any statistics, uterine rupture is much more common and deadly here, where blood products are hard to come by. Just this past week there was a maternal mortality from a ruptured uterus in a woman with 5 small children at home. 

The breech delivery went easily, but following the delivery she had a large gush of blood and the placenta delivered too quickly thereafter- a placental abruption. We quickly clamped & cut the cord & began resuscitating the baby. Neonatal resuscitation is done entirely by the obstetrics team- the nurses, registrars, midwifes, and physicians. There is no NICU team- we can only alert the newborn unit (NBU) if we are bringing them a baby after we have fully resuscitated it. After the usual efforts did not work and the baby continued to be limp and not breathing, we had to move it to the other labor room, the only room with an infant “warmer.” I put warmer in quotes because it is an old warmer in which the warming bulbs broke years ago. We began CPR because we could hear a slow heartbeat. I performed chest compressions while the intern gave positive pressure ventilation with an ambu bag for 30 minutes. Intermittently we would hear a heartbeat but never any breathing and on our last check there was no heart rate either. I was devastated. I wrapped the baby in the most lovely soft, white cable knit blanket the family had brought for her. I wrapped her the way I would wrap a live baby, so the mom could see just her small, beautiful face. I brought the baby to her mother and had to explain what had happened. It is hardest when you feel guilty about what has happened, when you feel that there must have been something you could have done to prevent this terrible outcome. She was all alone at that point and was trying to be strong, holding back tears, reluctant to reach out to hold her baby girl. The midwife and I stayed with her, told her it was ok to cry, told her it was not her fault when she asked what she could have done differently. Her husband came in and they prayed over the baby. He asked again why this had happened and told us he was so sad because this was the second baby they had lost.

As she drove me home in the dark that night, the midwife explained that when she first came to work here the nurses would admonish her for doing what we did that night. That they would tell her to completely wrap the baby so the mother could not see it, to take it away quickly, to not “upset” the mother more by encouraging her to grieve. She explained that the perspective is that they are trying not to let the woman be traumatized by something that happens so frequently. That if they “move on” from this experience quickly it will be better off for everyone. I was struck by the difference from my experience and learning in the US. We are encouraged to grieve with the mother, to allow her to spend as much time as she wishes with her baby, to take pictures and keepsakes that she can have to remember the baby she was only able to hold for a short time.

The next day the midwife and I saw the mother walking in the hall before I had the chance to seek her out to check on her. She took my hand and held it in both of hers and just looked at me and smiled sadly. I asked how she was and she just nodded, smiling softly and said she was going home soon. I didn’t have much to say either, but it didn’t matter because I think in that moment we were both finding our peace with what had happened.

Earlier this week I was triaging women with fetal monitoring and ultrasounds when I was called by my intern that there was a fresh stillbirth. The baby was lying on one of the makeshift baby beds in the labor rooms- really an old hospital crib with one side dropped down. I talked to the nurse to find out what had happened. She said she was very busy taking care of 6 patients actively in labor, one of whom she had recently delivered. She hadn’t checked the fetal heart rate in 2 hours when the patient, a 17 year old girl, began pushing and quickly delivered a fresh stillbirth. The nurse had tried to resuscitate the baby but it didn’t work. As I found out, earlier on there had been some question of the fetal heart rate being low by fetoscope, but it had never been rechecked by electronic fetal monitoring. As the nurse was cleaning up the patient after her delivery and I was wrapping the baby in her brown animal print blanket, the patient’s family asked me what had happened. I explained that I didn’t know but that the baby had not survived through the labor, and offered for them to hold her but they did not want to. Once the mother was cleaned, I brought the baby over her but she only spoke Kiswahili. I offered the baby to her to hold as I said one of the most common things I say all day long here: “Pole, mama” which means “I’m sorry.” She did not want to hold the baby but sobbed inconsolably.   

Needless to say, I was happy to accept an offer to get away this past weekend. We drove 5 hours along bumpy dirt roads and bigger paved roads with drivers (including ours) constantly passing each other such that most of the time when I looked out the front window I would see oncoming traffic in both lanes. Suffice it to say, I kept my eyes glued to my side window to see the interesting sights- mostly lush, green trees, grazing cows, sheep and goats, and women sitting on the roadside selling their produce. We spent the weekend at Lake Naivasha, a beautiful lake with incredible wildlife. The town is known for its flowers which are shipped all over the world, but which has unfortunately caused the lake to be polluted with pesticides. But the real reason no one swims in it is because of the dangerous (but beautiful) hippos! We took a bike safari and went hiking in nearby Hell's Gate National Park. Below are some of my favorite pictures.