Friday, November 13, 2009


Since my last post, things got worse. After I saw the woman with preeclampsia, the Medical Officer for Maternity Ward saw her, and disagreed with me. He told the nurses that the baby was too small and would die, and because the woman had not yet had a seizure, she should not be delivered.
For the non-obstetricians out there, this is crazy talk. At 31 weeks, the infant does have a chance at survival, albeit lower in Uganda than in the US. And regardless, the mother is at high risk of death. Waiting for her to seize is not an option - once she seizes, her survival is unlikely here.
The Medical Officer had ordered two antihypertensives for her, and no magnesium.

I am stunned when I hear this. The nurses have no choice but to follow his orders. I start to doubt myself - maybe I don't understand a low resource setting, maybe priorities are different here, maybe I'm wrong. I go and speak with several of the Ugandan Medical Officers in our study, all of whom agree with me. They are shocked and horrified at the doctor's management plan, and are just as certain as I was that this woman will die soon if we don't do something. But what to do? The Medical Officer had made his decision, and there is no one left in the hospital to overrule him at that hour.

I sleep poorly, thinking of the woman. The next morning, I am relieved to find her alive. She still reports headache, scotomata, epigastric pain, and a total lack of fetal movement. I brought the ultrasound with me to see if the baby was alive - to my relief, it was, and with even less amniotic fluid now. I try to comfort her and her family, but they are very concerned about her headache and the obvious swelling in her feet, hands and face. Rightly so.

The other woman - the one with the ruptured membranes that I was inducing with misoprostol - is still pregnant, too. She had a lot of pain with the medication, but had not delivered. I examine her, and her cervix is still closed. What to do? This could take many doses, and the misoprostol is too expensive. She and her family are begging me for an alternative. I know I can do a D&E easily, but with what instruments?

I pull a nurse aside and ask her to take me the the Operating Theatre to look at the instruments. To my excellent luck, I run into Dr. W, an excellent family physician from Kampala who also works in Tororo, and whom I know and trust. I tell him about the woman with preeclampsia, and halfway through my story, he is already exclaiming that she must be delivered Now Now. He announces that I have his support, that the hospital knows and supports me, and that this patient will die if I don't deliver her. He tells the anesthetist that we must do this cesar right away.

The nurse helps me organize and consent the patient, who also wants a tubal ligation (she had 6 children already). The cesar is challenging. The lack of instruments is not a surprise - I had seen it in Mbarara, and as long as I have something that clamps, something that cuts, and something that ties, I am fine. I am a little confused by the sutures - some things have different names, one suture seems like it will be Vicryl but isn't, it is hard to find the right size suture for anything - but I deal with it. There is, of course, no stool for me to stand on, and the bed can't go any lower. As soon as I open the uterus, I find placenta where I don't expect it, trying to come out before baby. I have a very hard time getting the baby out - she hadn't been laboring, the head is floating, the scrub tech has no idea how to give fundal pressure, and the placenta is in the way. It takes so long that I use profanity once, but only once. And then I get the baby out. He is pale, small and has a weak cry, and I pass him off to the nurse. Looking at the placenta, I realize it looks about 50% abrupted. Later, I go to see him, and he is doing ok. He is pale but warm under the lights, and I encourage the midwives and the family to do kangaroo care.

After that cesar, I have to do the D&E. I look at the instruments in the OR that were prepared for me. They are as follows:

Half of a speculum
2 Regular-sized ring forceps
1 Small ring forceps
1 Curved allis clamp
4 Dilators - all the same (small) size, labeled "6"
1 Tiny sharp curette (about the size of an endometrial biopsy pipelle)
1 IUD hook (what for, I don't know)

I have no tenaculum, no real speculum, no suction, no MVA, no large curette, no large forceps, and no ultrasound.
The dilators go into the cervix easily (being all the same size, I only need 1), but I still can't even get my pinky finger into the os. By no small miracle, I manage to get the procedure done. It takes over an hour, the allis clamp shreds her anterior cervix and I think I grossed out the nurse, but I manage to do it safely and completely. Go go gadget family planning training.

Two mothers and one baby safe and healthy. In one day, I have gone from frustration and despair to exhilaration and relief. And I am sure there is much more to come.


danengber said...


danengber said...

plus, this is an amazing story.