The baby died after the uterus ruptured. Or maybe the baby died first, setting off the cascade of events leading to the uterine rupture. It's difficult to know the exact story. The patient, E., went to the first hospital after she started having abdominal pain and vaginal bleeding. She wasn’t sure if the abdominal pain was normal labor-related or a worrisome sign, since this was her first baby. She had not felt her baby move for a week.

E. was referred to KCMC for the vaginal bleeding and concerns about placental abruption (but without a referral form we can’t tell if they ever heard fetal heart tones).

What is known is that on admission to KCMC, a lack of fetal heart beats led the staff to do an ultrasound which showed a murky picture with possible placenta previa and placental abruption, but definitely no fetal heart beat. An emergency c-section was called, but first some blood had to be found from the blood bank (because of 2 days of vaginal bleeding). Since a hemoglobin level could take 24 hours for the lab to process, E’s anemia was diagnosed clinically.

During c-section, the chief resident (Zuhura) surprisingly found a ruptured uterus, a dead baby of a healthy size (about 7 pounds) floating in the abdomen along with its placenta, and about 1 liter of blood. She called Jeff to assist, but she handled the emergency well, and E’s vital signs were stabilized. The tough question for Jeff was whether to stitch the uterus back together, or remove the uterus by hysterectomy. E. is a young lady on her 1st pregnancy, and since she could not be asked her thoughts while under general anesthesia, Jeff decided to err on the side of fertility and keep the uterus in place.

E. is doing well today, with her fever resolving and in less pain. By now she knows that her baby has died, although we don’t know when or for what reason.

E’s story is one reason that the residents have instituted a Stillbirth Audit with our help. We plan to collect data on babies who died before admission, during labor or immediately after delivery. We plan to do it within 24 hours of the event, so that the history is fresh in the minds of providers. The entire obstetric staff is behind this initiative, because evaluating the problem is the first step in creating long-lasting and effective interventions to solve the problem.

It is a start.

Sumera