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Monday
Nov022009

Inés Ramírez Pérez and the Mythical Self-Cesarean

           

Warning: Stillbirth mentioned. Graphic surgery photos.

On March 5, 2000, Inés Ramírez Pérez of Rio de Talea, Mexico, became the first woman known to have survived a self-inflicted cesarean section. When the case study detailing her son’s birth, Self-inflicted cesarean section with maternal and fetal survival, was published in the March 2004 issue of the International Journal of Gynaecology and Obstetrics, the mother of eight quickly became an international celebrity. Her story resurfaces on Internet message boards, blogs and forums several times a year and even made the pages of Tina Cassidy’s book, Birth: The Surprising History of How We Are Born, which reads, “It’s not surprising that the tales of the sixteenth century Nufer family and the contemporary Mexican woman seem almost mythical. Cesareans have always been the stuff of myth.”

The case study summarizes the series of events as relayed to them by Ramírez, then forty years old. She was admitted to the hospital after having delivered her own baby by cesarean section “due to a lack of medical care.” The authors noted that Ramírez’ previous pregnancy ended with an obstructed labor and fetal death. Finding herself in labor again and unable to give birth, Ramírez drank three small glasses of hard liquor and sliced her abdomen in the right paramedial region with a kitchen knife, cutting the uterus longitudinally. She pulled her a male infant from her uterus, who breathed immediately and cried.

The article, co-authored by Dr. Rafael Valle, an obstetrician at Northwestern University in Chicago, was met with skepticism. Dr. Honorio Galván, who was present and documented Ramírez’ case when she arrived at San Pablo Huixtepec Hospital south of Oaxaca, acknowledged the skeptics but told the press that he has heard Ramírez tell her story several times and always with the same details, which were confirmed by León Cruz, the village health assistant who was initially summoned to help Ramírez.

Four years later, Ramírez clarified many of the details of her experience to international journalists, but the story remained essentially the same.

Inés Ramírez Perez was alone in her rural cabin and felt labor begin midday. Her husband, who had assisted in six of her previous births, was drinking at a cantina. The town of Río de Talea, located in San Lorenzo Texmelúcan in the state of Oaxaca, had only one phone at the time. After twelve hours in labor and gripped with terror that this baby would suffer the same obstructed labor and death as her previous baby, Ramírez decided that she needed to bring him into the world as quickly as she could.

Ramírez told reporters, “When I was seven months pregnant with Orlando, one night the pain began. It was terrible. I couldn’t bear it. I started to panic. I knew I had to do something or this baby would die too. I knew I had to get it out somehow.”

“I had seven children before Orlando,” she says. “There was no problem with the births. But the eighth baby died. My waters broke and the midwife said I needed a caesarean but I couldn’t get to the hospital in time. I felt the baby struggling but then it stopped moving.”

Ramírez sent her eight year old son, Benito, to buy a kitchen knife at a shop half a mile away, as the knife the family used wasn’t sharp enough. After ingesting two cups of mezcal (alcohol made from the maguey plant), Ramírez held the knife by the blade instead of the handle and used her index finger and thumb to apply pressure. She made multiple passes—“poco a poco”— with the knife before pulling her baby out by his feet.

The Daily Telegraph described the measures taken by Ramírez in “desperation not to lose another child.”

Inés cut into her womb as if cutting a tortilla. “Blood came out of me like a fountain.” Pushing aside her internal organs, she rummaged around inside and pulled out her son. To her great joy, the baby cried, and appeared healthy, but Inés’s ordeal was only just beginning. As mother and baby lay on the floor, Inés cut the umbilical cord before putting her organs back in place as best as she could. “It was all a mess,” she remembers.

Ramírez told reporters, “I couldn’t stand the pain anymore,” she said. “And if my baby was going to die, then I decided I would have to die, too. But if he was going to grow up, I was going to see him grow up, and I was going to be with my child. I thought that God would save both our lives.”

While many details, including amounts and sequence of events, vary between the June 1, 2004 coverage of Ramírez’ birth experience by Lisa Adams of the Associated Press and the article by Ronald Buchanan, a Scottish freelance journalist based in Mexico City, which appeared in The Daily Telegraph on April 25, 2004, Ramírez’ story remains nearly the same.

Ramírez operated on herself for about an hour. At some point in time, either before fainting or after regaining consciousness, she wrapped a sweater around her abdomen and sent Benito out again for help. Several hours later, León Cruz and a second health worker allegedly found Ramírez alert and lying beside her live baby.

Cruz sewed up the seven inch incision with a regular needle and thread. Together, the two men lifted Ramírez and her baby, Orlando, onto a straw mat and carried them in this makeshift stretcher up a rocky path to the town’s only road. They drove in a small bus for two and a half hours to a clinic in San Lorenzo Texmelúcan, where Ramírez received basic emergency medical attention. She and Orlando were then transferred via pickup truck to San Pedro.

The Daily Telegraph reported that at during the drive, Ramírez might have been transferred into an ambulance.

The state hospital at San Pedro was another two-hour drive away down unpaved roads, on the main highway that links Oaxaca City to Puerto Escondido, a holiday resort on the Mexican coast. By this stage, her pain numbed only by the alcohol, Inés was near to collapse. “The lady doctor had phoned San Pedro and they’d sent an ambulance,” she says. “I can hardly remember the rest.”

Dr. Galván recalled his astonishment at the state of this patient presenting with self-inflicted surgical wounds. According to Galván, there was no sepsis in the wound, nor was there any internal bleeding. Everyone was amazed that Ramírez was not in shock and was remained conscious.

Galván took pictures while his colleague, Dr. Jesus Guzman, opened Ramírez up to find that her uterus had returned to its normal size, stopped bleeding and she showed no signs of infection. According to Galván, Ramírez’ life might have been spared by sitting forward in what he called the traditional Indian birthing position, which ensured that her uterus was directly under the skin made it less likely that she would cut her intestines.

The case study, Self-inflicted cesarean section with maternal and fetal survival, described Ramírez’ repair and reported that she stayed ten days in the hospital, although Galván told reporters that she stayed just one week.

Sixteen hours later she underwent exploratory laparotomy, repair of the right paramedial uterine incision, tubal ligation, and bowel exploration to rule out any injury. The abdominal cavity was irrigated profusely. The uterine and abdominal walls were closed in layers. A Penrose drain was placed on each flank and the patient was given triple antibiotic therapy. Her recovery was protracted because of an absence of bowel sounds and abdominal distention that increased by the third postoperative day. A flat plate of the abdomen demonstrated dilated intestinal loops with fluid levels and a nasogastric tube was placed. Because no relief was obtained from nasogastric suction, consultation with a surgeon was requested. On the seventh postoperative day she underwent exploratory laparotomy to rule out mechanical intestinal obstruction. No mechanical obstruction was found; an adhesion that caused the descending colon to be twisted, however, was released upon division. The patient recovered well, and was discharged from the hospital on the tenth postoperative day.

 

 

 

 

 

The discussion in the case study focuses on the unique nature of the event and the decision made by a woman allegedly “unable to deliver herself spontaneously, and with no medical help or resources” to perform a surgical birth on herself to prevent the possible reoccurrence of an emotionally traumatic stillbirth.

Authors of the case study attribute Inés Ramírez Perez’ decision to operate to the “maternal instinct for preservation of the offspring” which they assert can “under unusual circumstances, move women to perform extraordinary acts, disregarding even their own safety and life.”

In addition, the authors note that health care does not reach rural areas in many parts of the world and “when difficulties occur in the prenatal period or at delivery, pregnancy usually ends in fetal death and, occasionally, also in maternal death. This case, which would not have occurred if prenatal and delivery care had been available, should make health providers aware that the basic reproductive needs of women are not met.”

The authors further implore health providers and appropriate governmental authorities to “implement measures to avoid cases like the one presented, and be ready to make every effort to ensure that women all over the world are offered essential reproductive care.”

Sharon Storton, Licensed Marriage and Family Therapist in Campbell, California and founder of Solace for Mothers, sees parallels between the motivation behind Ramírez’ self-cesarean and women whom she has counseled in the United States.

“This woman described her motivation of wanting to allow her child a chance to grow up,” said Storton, “and her focus was clearly on the baby, with the potential cost to herself and her other children in the loss of her own life well out of her consideration.”

According to Storton, this appears to speak to an overwhelming mixture of protectiveness, grief, and terror. “I have to notice the overlaps of emotion and passion with the conversations I have had with women in this country who plan and/or carry out unassisted home births. While their techniques are not as dramatic, their fervor is no less than hers. 

“We are not as far removed from this mother’s experience as we may think.” 

 

 

 

Sources: 

Self-inflicted cesarean section with maternal and fetal survival (International Journal of Gynaecology and Obstetrics)

Woman describes self-Caesarean (Associated Press)

Inés Ramírez Pérez, la indígena de la cesárea (Associated Press article in Spanish)

‘I put the knife in and pulled it up. Once wasn’t enough. I did it again. Then I cut open my womb’ (The Daily Telegraph UK)

Orlando debe nacer (Televisa)

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Reader Comments (14)

Extraordinary. Just amazing.

November 2, 2009 | Unregistered CommenterJustine

I remember hearing this story. Just amazing what mothers will do for their children. Amazing...

November 2, 2009 | Unregistered Commentermichele

Wow. That's incredible and amazing

November 2, 2009 | Unregistered CommenterKayce

Wow. I am stunned and speechless (but not in a bad way).

November 2, 2009 | Unregistered CommenterJill

This is extraordinary. I can't imagine how I would feel if my baby would die. I don't know if I would do what this woman did to prevent a stillbirth. That is extraordinary. She was willing to do the ultimate sacrifice, give her life as long as her baby would live. I cried as I watched the video. It is so humbling.

November 2, 2009 | Unregistered CommenterPriscila

I know this is likely to come off as insensitive... but I think the clearer issue here is that she never needed a cesarean in the first place. Labours longer than 12 hours are not uncommon, and with no other symptoms of difficulty nor care (including self care) to determine whether or not her labour was indeed progressing normally, or abnormally (not to mention the fact that she apparently pulled a perfectly healthy baby out out of her that showed zero signs of distress) well... I think the bottom line here is: SHE NEVER NEEDED THIS IN THE FIRST PLACE. The spin seems to be, "See? See? We do need cesareans!" rather than, "Aren't women amazing" - but I sense there's more to it than just that.

Is this her fault? Of course not. My answer is the same as theirs: more maternal care available! More education! More access! But exploiting this woman for her ignorance is... uncomfortable. And it really feels wrong. I get this weird, uncomfortable feeling reading about her like there's a lot of racially motivated sensationalism in this.

November 2, 2009 | Unregistered CommenterHeather

Wanted to add but pressed post too fast... this is all kind of beside the point as no one seems to really know what happened. But, the sensationalism about this story in all the wrong places has always made me really, really uncomfortable.

November 2, 2009 | Unregistered CommenterHeather

Heather, I also had a question mark pop up in my brain when I read the part about the 12-hour labor. A remarkable story nonetheless.

November 2, 2009 | Unregistered CommenterSarah

Heather, yes and yes. And yes.

I've had this case study sitting on my hard drive since April after having read about it last year in Tina Cassidy's book. I felt weird posting it because I thought those were the only pictures of her... I hadn't realized that she was interviewed so many times for her story.

Since her story keeps popping up, I thought it would be nice to synthesize all of the different accounts and pictures. However, like you, it didn't strike me as a story of a woman who rescued her baby from impending peril. Maybe she did, maybe she didn't. Her story to me seems to be an example of the powerful effects of birth trauma and perhaps PTSD. Judging by the quote I got from Sharon Storton, she saw something similar.

The video goes into more discussion of how her story was co-opted to promote access to obstetric care in impoverished areas. It seems to me that her previous birth was a better example of tragic lack of access. However, she held the feelings of her previous stillbirth in her body and she might very well have felt the exact same feelings or intuitively known that she was heading for an impacted labor with her seven month old fetus.

There is so much that will never be known but I am glad that this extraordinary event eventually made the news.

November 2, 2009 | Registered CommenterJill

I agree with Jill and Heather. This sounds more like a study in psychology, not obstetrics. An amazing and scary story.

November 2, 2009 | Unregistered CommenterReality Rounds
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