After 3 months of hard work, we finally finished most of the preparation for our clinical trial, and we finished the training yesterday. Today I was finally able to go over to Labor Ward and Postnatal Ward to round and help out.
On Labor Ward, two mothers were progressing well and expected to deliver soon, so I was not needed there. The midwife there told me that there were some post-cesar patients with bad incisions that I should see.
It was really nice to see patients again. Then again, it was bewildering to do so in this setting. I know what I would do in the US, but is the same thing appropriate here? What can they afford? What is asking for too much?
I soon noticed that it was asking too much to expect all four vital signs (blood pressure, pulse, respiratory rate and temperature) to be taken . If I need vitals, I need to pick the most vital.
For a woman with oligohydramnios (low amniotic fluid) and a severe headache for one day, I picked blood pressure (which I took myself). It was 90/60.
For a woman complaining of fever and dizziness, I picked temperature. It was 38 degrees Celsius.
I take heart rate myself, which I did on the woman with fever (it was 96) and a woman who had a blood transfusion after hemorrhage for a hemoglobin of 5, and was still quite pale (it was 100 sitting and 120 standing).
For the woman with fever, I think she had endometritis. She was already on Ampicillin, which her family had bought. So what do I do? Do I add Gentamicin? Clindamycin does not seem to be an option here. Is Amp & Gent enough? Or should I switch to Ceftriaxone, which everyone seems to get here for endometritis. But then she wastes the Ampicillin her family just bought for her.
As it turns out, the decision will be made based on what is available in the pharmacy. Tomorrow. When the In-Charge Nurse is there. Nothing can happen tonight, so I told her to continue the Amp anyway.
For the pale woman with orthostatic tachycardia - blood count isn't repeated after transfusion. I could request it, but she might have to pay for it, and do I really need it? She is asymptomatic, aside from fatigue. She is ambulating well, no shortness of breath, no chest pain. Would a blood count really make a difference? She's asymptomatic, so I wouldn't transfuse her anyway (especially given the paucity of available blood and the abundance of HIV). I sent her home.
Another woman had delivered triplets 4 days ago. They were clearly preterm - between 2.1 and 2.3 kg. She had six boys before, now she has 9 boys. To my surprise, when I went to see her, she and her mother were spoon-feeding water with glucose to the infants. I didn't know that you could spoon-feed a newborn, much less a preterm newborn. But these tiny little infants were sipping successfully from a spoon. Of course, I encouraged her to breastfeed in order to bring more milk down.
I saw several women who had had cesareans and whose wounds were infected or separated. It is truly remarkable how many of the women here have had infants die. The first woman had 3 babies, and 1 had died. The second had 6 babies, and all were alive. The third had 12 babies, but 3 had died. The fourth had just delivered her first child, but she is HIV-positive, and since mothers have no choice but to breastfeed here (and don't get HAART after delivery), it is highly likely that this child will die or develop HIV or both. The last woman had delivered 2 infants, and both were alive, but the third, which she had just delivered, had been stillborn. The woman with anemia who had a transfusion had delivered twins, but the second twin had been stillborn.
The last woman I saw was brought to my attention by her family member, who took my hand as I was leaving and asked me to see her. It was the woman with oligohydramnios and a headache. By her menstrual period, she was 37 weeks, but on ultrasound, the femur had measured 32 weeks. The fluid was low, but not specifically measured. The nurse had found her to be dilated only 1cm, and the doctor by phone had suggested either induction or cesarean. She had 2 prior normal vaginal deliveries. On my exam, I found her to be 2cm. Clearly, induction was preferable.
But how to induce? It seems that people often get Cesars here because of a lack of good options for induction. Oxytocin IV is not possible - there is no monitor for the IV drip. Misoprostol is used occasionally, but I discovered a few weeks ago that when they use it for induction, they give the woman 200 micrograms orally (or buccally, not sure). 200! This is almost 10 times the dose we use in the US, and has been clearly associated with uterine rupture and birth asphyxia. But how to correct midwives who have been doing their jobs for 10 or 20 years?
Luckily, this time I didn't have to. I decided to use the technique told to me by a highly respected Obstetrician in Kampala - dissolving a 200 microgram tablet in 500cc of water, and having the woman drink 60cc every four hours. The nurse sent the family member to buy the water and the misoprostol from the pharmacy in town, and she was back in less than 20 minutes. We dissolved the tablet, measured out 60cc, and she drank. We also had her eat some food to improve her headache.
When I went back 3 hours later, her headache was improved, she was feeling some cramping, had seen her mucus plug, and soon was ready for her next dose. The evening nurse was all prepared to give it to her, without my having to ask. I was surprised at the lack of resistance.
I told the woman I hope to come in tomorrow morning to find her holding her baby. I am keeping my fingers crossed, hoping it works, and hoping this method will be adopted by the midwives.