Joshua was safely delivered from Sylvia’s belly instead of her uterus one year ago. Biénne Huisman meets mother and baby, and hears from some of the healthcare professionals involved in the remarkable outcome.
Sylvia Nodela’s eyes fill with tears as her son bounces in her arms, happily chirping. It’s a grey winter morning as we gather at a maternity clinic in Gugulethu. Exactly one year prior to our interview, Joshua’s birth defied formidable survival odds for both mother and baby – and yet here they are, both in excellent health.
At nine-months pregnant, Nodela received devastating news. She reaches for tissue paper to wipe her cheeks as she recalls the heart-stopping moments on July 30 2024, following an ultrasound at Cape Town’s Mowbray Maternity Hospital.
“I was told that they see the child, that they see the womb and that they see the placenta. But they said the baby is not inside the womb, that he’s outside the womb,” she says.
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The 37-year-old continues: “So they said they would have to do an operation the next day. I was told that there is a possibility we’re not going to survive. They said this operation is very huge.”
In Cape Town’s medical circles, some experts comment on Nodela’s “miracle baby”, describing Joshua’s safe delivery as a remarkable public healthcare outcome and testimony to the city’s public obstetrics referral system.
Thanks to quick healthcare escalation and careful surgery by a multi-disciplinary team at Groote Schuur Hospital, affiliated to the University of Cape Town (UCT), Nodela gave birth to a healthy baby who had grown to full term inside her pelvic cavity, outside her uterus.
“It’s a great feeling. It’s a good story worth telling,” says Professor Mushi Matjila, who heads the Department of Obstetrics and Gynaecology at UCT.
Advanced abdominal pregnancy occurs in about 1 in 10 000 to 30 000 pregnancies, and the condition poses a significant risk to mum and baby, Matjila says. In fact, early diagnosis in high-income countries usually results in termination. This is due to the “minimal likelihood of delivering a healthy baby and the risk of maternal complications,” he says.
Published data on incidence and outcomes particularly in low- and middle-income countries are scarce, mostly derived from isolated case-reports. Matjila says that it is not unusual for the diagnosis to be missed in low- and middle-income countries due to resource constraints.
Beating the odds
Indeed, from moments after his conception, Joshua’s journey beat the odds. In this case, the zygote (a fertilised egg, smaller than a pinhead) rolled the wrong way in the fallopian tube and ended up in the belly instead of the uterus. For the pregnancy to survive in the abdomen, the fertilised egg had to attach to a vital blood supply, which rarely happens. Yet in this instance, it implanted in the external iliac artery in the left pelvic sidewall, the main blood supply to the leg, which nurtured the embryo to full term.
A foetus outside the womb is at risk of getting hurt due to a lack of protection, Matjila explains. “There is a lack of fluid around the baby, because there isn’t a uterus so although the baby is in a sac, it does not grow as well as it should. Most of these babies are what we call growth restricted. And [the foetus] may get compression effects because there isn’t enough cushioning to protect them against shocks,” he says.
Experienced nurse raises the alarm
During her pregnancy, Nodela says she had two ultrasounds at the Gugulethu Maternity Obstetric Unit (MOU), but the rare complication wasn’t picked up. It was only during a third visit that experienced Sister Olga Venfolo first raised the alarm relating to the position of the baby. Venfolo qualified as a nurse at the Glen Grey Provincial Hospital in Lady Frere in the Eastern Cape in 1991, specialising in advanced midwifery at UCT in 2002.
Speaking to Spotlight at the clinic in Gugulethu, Venfolo recalls: “I picked up that it was a breech. Normally by the last weeks of pregnancy, babies flip so their head points down toward the birth canal. In a breech position, the baby’s feet are pointing down instead of the head. I did not pick up that he was outside the uterus.”
Venfolo referred Nodela to Mowbray Maternity Hospital and here, five days later, on July 30, an ultrasound identified an advanced abdominal pregnancy. This prompted an emergency referral by ambulance to Groote Schuur Hospital, where Nodela was observed overnight as a surgical team was assembled.
This type of rapid referral – from Gugulethu MOU to Mowbray Maternity to Groote Schuur – doesn’t always occur in South Africa’s public healthcare system.
Specialists placed on standby
Gynaecological Oncologist Dr Sedick Camroodien was one of the specialists notified to be on standby. Speaking to Spotlight inside his office at his private practise at Melomed Gatesville in Athlone, Camroodien glows as he reflects on the case. At the time of Joshua’s delivery, he was a senior fellow in gynaecological oncology at Groote Schuur; the subspecialty he completed after specialising in obstetrics and gynaecology in 2021.
Saying that he reviewed his clinical notes before our interview, Camroodien recalls: “Obviously when we hear advanced abdominal pregnancy, all the alarm bells go off.”
He says besides the obstetric surgeon team; himself, a colorectal surgeon and a urologist were asked to be on standby. “The reason being that we just didn’t know where the placenta had attached. It could have grown into the bladder, it could have grown into the bowel, it could have grown into the liver.”
In advanced abdominal pregnancy, removing the placenta is a demanding and tense procedure. Burrowed into an organ or large blood vessel, separating it poses a high risk of catastrophic maternal bleeding.
Camroodien explains: “So once they opened the patient up, they delivered the baby. Getting the baby out was fine, they ruptured the sack and delivered him. But then I got called because the placenta had actually grown into the pelvic side, which is my subspecialty.”
He adds: “So it’s fascinating in her case, actually the placenta got its blood supply from that region. And that’s what allowed the pregnancy to actually continue and flourish. It was attached to that strong blood supply. The placenta was going past the external iliac artery and vein, growing into the area below that which is called the obturator basin. There are a lot of veins and stuff, and if there’s bleeding there, it’s really difficult to stop. So I mean, if any complications happened there, the patient could bleed and she could lose a limb.”
Camroodien admits to breaking a sweat as he entered the theatre that day: “Trust me, I was praying walking into theatre. I think the one thing that stands out for me as a gynae oncologist – I mean after sixteen years of studying to sub-specialise – is that the pelvis will always humble you. Every case you come across is sacred and special. But in this case, thankfully I could get the placenta out within two hours. I mean, from start to finish, with no major blood loss. I was very happy.”
A ‘miracle baby’
After the procedure, Nodela was transferred to ICU for one night. Four days later, both her and Joshua were discharged from the hospital.
“He’s my miracle baby, I tell anyone who would listen,” she says. “I was very lucky. And they explained nicely the procedure, how they would do it.”
Nodela lives in Philippi and worked as a cleaner before falling pregnant with her third child. She has two daughters aged 18 and 20.
It is not the first remarkable birth at Groote Schuur. More than 20 years ago, the hospital made headlines around the world for the safe birth of Nhlahla. She was also part of an advanced abdominal pregnancy. Gynaecological oncologist Dr Bruce Howard safely delivered her from behind her mother’s liver. In fact, Camroodien says that Howard had been one of his mentors during his studies.
Risks to mum and baby
Matjila, who is also Chair of the National Health Research Committee, co-authored a study published in May this year, which tracked the outcomes of 17 cases of mothers admitted to Groote Schuur with advanced abdominal pregnancies from 2010 to 2023. Fourteen of the 17 cases were missed on initial ultrasound. Twelve of 18 babies – there were one set of twins – were born alive, though two of them died in hospital. Two of the 17 mothers died, with blood loss being the most frequent maternal complication.
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‘Organisation is everything’
Reflecting on Nodela’s case, Matjila says Cape Town’s public healthcare referral system – which filters pregnancies to allocate top resources to high-risk cases – is largely to thank for mum and baby’s survival. In place from around the 1970s, the triage system allows for most births to be managed at clinics or MOUs run by midwives. Complications are referred to Mowbray Maternity or Somerset Hospital, with extremely high-risk cases referred to well-resourced Groote Schuur’s emergency wards.
“The organisation of the healthcare system is everything,” says Matjila. “Let alone other countries in Sub-Saharan Africa, this system is an example to certain provinces in South Africa. Essentially allocating resources – ultrasounds, the availability of blood and blood products, and more – to mothers who really need it.”
At Gugulethu MOU, 3.6 babies are born daily, on average over the past three years (live, still, and premature births included). At Mowbray Maternity Hospital the figure is 27.1; and at Groote Schuur Hospital 7.1. This is according to spokesperson for Western Cape Health and Wellness, Samantha Lee-Jacobs.
As our interview draws to a close at Gugulethu MOU, Nodela picks up Joshua in his fleece-lined little jacket. In her one hand she is carrying a shopping bag of Huggies nappies. Venfolo rises to resume her work. Retired two years ago, she continues at the clinic as a locum, examining up to 18 mothers a day, from 07:00. “The way I love my work,” she says. “And the younger nurses here, they say that I am their inspiration.”
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