Saturday, December 26, 2009

Christmas Previa

I am sitting at home this evening when I am called in by Sister Patricia, one of the Labor Ward midwives, to see a woman with antepartum hemorrhage. I take a bodaboda into the hospital, pick up the ultrasound at our clinic, and head over to Labor Ward.

I can’t find Sister Patricia, and another midwife helps me figure out that she has taken a baby to the OR for rescusitation. Another woman, who tells me she is an OR nurse, helped me figure out which patient was the one bleeding.

As we are preparing the ultrasound, Sister Patricia and the anesthetist arrive in Labor Ward. I greet the anesthetist and ask about the baby. He tells me “We have failed,” meaning the baby died. I ask Sister Patricia the details. The baby was full term, but had a long second stage of labor (pushing), and a lot of caput. It sounds like birth asphyxia. I think of the mother, who is still lying on the delivery bed, exposed, legs wide open, with the umbilical cord still hanging out, waiting for the placenta to delivery. She doesn’t know yet.

I scan the woman that Sister Patricia called me about. Right away, I see a very clear placenta previa. It is completely covering the cervical os, and is well below the baby’s head. She needs a cesarean or else both she and the baby could bleed to death.

I don’t see any blood, but she is wearing several kangas around her waist. I ask if she is bleeding actively. The anesthetist and OR nurse are translating for me, but they speak only minimal Japadhola. It sounds, though, like she is still bleeding actively.

They know, as I do, that she needs a cesarean. They seem resistant, insisting that she will be sent to St. Anthony. I tell Sister Patricia that the woman needs a cesarean. She tells me that we can’t do it because there is no anesthetist and no OR nurse. I look around and realize that the anesthetist has disappeared – he has gone off duty, and the anesthetist who was supposed to be on hasn’t arrived.

“Why didn’t he come?” I ask

“Probably because of Christmas,” says Sister Patricia.

The patient will be referred to St. Anthony. St. Anthony is a private hospital in Tororo. It is not far, but it requires payment, unlike Tororo District Hospital, which is a government hospital and therefore care is free.

“What if she can’t pay?” I ask.

No one answers my question, because there is no answer. I ask several times, but I never get an answer.

“The last one who was sent to St. Anthony with antepartum hemorrhage came back 24 hours, still bleeding,” I say. I know this because it was the now-off-duty anesthetist who had told me.

Here I am, a trained specialist in Obstetrics and Gynecology, available to do a lifesaving cesarean, and I can’t do it because one person went off duty and the other one didn’t show up.

I don’t know what to do. I try to insist, but what can I say? I write a note in the patient’s Antenatal book, emphasizing the previa and the need for urgent cesarean. I tell the patient’s husband, through a translator, that if the people at St. Anthony refuse to do a cesarean tonight, they should come back tomorrow morning and I will do it (and hopefully there will be an anesthetist and an OR nurse).

I think about Christmas, and the story that people are celebrating, and I wonder what would have happened if Mary had had a placenta previa. She would have bled to death in a barn because someone didn’t show up for work.

Tuesday, December 22, 2009

Furrowed Brow

A fellow Einstein resident used to point out with amusement that when someone would say something inane or incomprehensible, I (apparently) would make an expression of confusion consisting of a furrowed brow. Yesterday was the day of the continuously furrowed brow.


I arrive on labor ward yesterday.

MIDWIFE: Hello Doctor! Maybe you can come and review this patient. She has cervical prolapse. We were going to refer her to St. Anthony.

We start walking toward Antenatal Ward.

ME: Cervical prolapse? I can see her. But why is she on Antenatal Ward? Is she pregnant?

MIDWIFE: 32 weeks.

MY INNER THOUGHTS: Cervical prolapse in pregnancy? Can that exist? Is this one of those Only-In-Africa things? How am I going to manage this? Who can I email for advice? Oy.

At the midwives’ table, I meet a medical student, who says he is a fourth year student. Medical students here do clinical rotations twice – once in third year and again in fifth year. In my experience, they are generally much stronger than American medical students because so much is demanded of them. So he should know something about Ob/Gyn.

The patient is sitting on a bench. She is sent to her bed for me to examine. The nurse brings gloves.

I look at her external genitalia, which are normal. I don’t see a prolapsing cervix.

ME (to the student): Where is the cervix?

MEDICAL STUDENT: It is inside. Examine and you will feel it.

ME: Inside where? Inside the vagina?


ME: (Furrowed brow)

ME: Then how is it prolapsed?

MEDICAL STUDENT: (Silent confusion)

ME: What was her presenting complaint?

MEDICAL STUDENT: She came in with APH [Antepartum Hemorrhage]

ME: She was bleeding?


ME: Did you do a speculum exam first?


ME: So she was bleeding and you put your fingers inside?


ME: (Furrowed brow)

ME: When did the bleeding start?

MEDICAL STUDENT: 5 days ago, when she arrived.

ME: She’s been here 5 days, bleeding?


ME: (Furrowed brow)

ME: Is she still bleeding?

(Discussion in Japadhola)

MEDICAL STUDENT: No, but the water.

ME: Water? What water?

MEDICAL STUDENT: The water was still coming, but now it’s not.

ME: When did the water start coming?

MEDICAL STUDENT: Before the blood. The same day.

ME: So she’s been leaking water for 5 days?


ME: And you put your fingers inside?


ME: (Furrowed brow)

me: She has water leaking. What does that make you think of?

MEDICAL STUDENT: (Silent confusion)

MIDWIFE (shouting from outside curtain): Ruptured membranes!

ME: Exactly, ruptured membranes. So examining her could cause infection, or could cause her to bleed if she has placenta previa. Ok, I can’t do an exam. I need to do a speculum exam.

MEDICAL STUDENT: There are no speculums.

ME: What do you mean, there are none?

MIDWIFE: They are not sterile.

ME: Ok, let’s put them in the autoclave.

MIDWIFE: We cannot use the autoclave.

ME: When did it break?

MIDWIFE: It is not broken. We cannot use it.

ME: Why not?

MIDWIFE: There is someone sleeping in that room.

ME: There’s someone sleeping in the autoclave room so we can’t sterilize speculums?


ME: (Furrowed brow).

ME: Who is sleeping in there?

MIDWIFE: Someone.

ME: Who?

MIDWIFE: Someone.

ME: (Furrowed brow)

MIDWIFE: So we cannot use it. So we have no speculums.

ME: (Continued furrowed brow)

MIDWIFE: We can get one from theatre.

ME: Ok, do that.

MIDWIFE: Or maybe we bring her to theatre.

ME: Ok, that’s fine. We’ll examine her there. I’ll go get the ultrasound.

The nurse in-charge arrives.

ME: Hello Sister. I have a question. When will we fix the autoclave?

IN-CHARGE: It is not broken.

MIDWIFE: No, but he is sleeping in there.

ME: Who?

IN-CHARGE: Someone is sleeping in there, so we cannot use it.

ME: Who is sleeping in there?

IN-CHARGE: Well, the cleaner.

MIDWIFE: And he is smelly, so we cannot use the room.

ME: The cleaner is smelly?

MIDWIFE: Yes. (waving hand in front of nose).

ME: (Furrowed brow)

ME: And he is sleeping in the room where we sterilize instruments?


ME: (Very furrowed brow).

ME: We need speculums. He needs to sleep somewhere else.

IN-CHARGE: I will tell him to move tomorrow.

On arrival in the OR with our ultrasound, I see a kidney basin with sterilizing fluid, half a vaginal retractor, and a ring forceps.

ME: What is that?

MEDICAL STUDENT: That is a speculum.

ME: That’s not a speculum, that’s half a vaginal retractor. Do we have a speculum? Or the other half?

MEDICAL STUDENT: No, we don’t have.

ME: (Furrowed brow)

I try to start the ultrasound.

ME: Is there gel?

MEDICAL STUDENT: Yes, there is gel.

15 minutes later, the medical student and OR tech have searched everywhere.

MEDICAL STUDENT: There is no gel.

ME: No gel.

MEDICAL STUDENT: Well, there is gel, but the anesthetist has locked it in the cabinet.

ME: They lock up the gel?


ME: So we don't have gel, and we don't have a speculum.

MEDICAL STUDENT: No, we don't have.

ME: So why did we come to theatre?

MEDICAL STUDENT: (Silent confusion)

ME: (Furrowed brow)

Friday, December 18, 2009

Luwo Neko

When you scratch the surface, you realize that the mortality of birth is everywhere.

Driving from Kampala to Tororo, I was speaking with a doctor who was sharing the ride with me. She told me that she lost her first born in utero. She had been 30 weeks and developed severe pre-eclampsia. The obstetrician tried to delay delivery for the sake of the baby, and the next morning, there was no heartbeat.

She tells me that the woman in the bed next to her had the same problem - pre-eclampsia at 30 weeks. After the first loss, he took her immediately to the OR for a cesarean. He delievered the preterm infant successfully, but the baby died soon afterward.

Then she tells me of a friend she saw in the obituaries recently. The friend had developed eclampsia at 26 weeks - she had a seizure at home and was brought to the hospital. After she arrived, her condition improved, but her pressures were still high. Knowing that her baby would not survive (the earliest possible survival in Uganda is 28 weeks), the doctors tried to induce her labor in order to spare her a cesarean for a non-viable infant. The first day, the induction failed. The second day, the induction failed. The third day, the induction failed. On the fourth day, she finally went into labor, but when she became fully dilated, she had another seizure. The baby was delivered, and she seized again. Below her, the doctors found a huge pool of blood. She had developed DIC (disseminated intravascular coagulopathy), which meant that was unable to clot her blood, and she died.

I remark to the doctor that in the US, where we have made pregnancy much safer, few people realize how common these complications are, and how dangerous pregnancy can be without access to medical care. She says "In Uganda, after you deliver a baby, we say 'Luwo neko' which means 'You have survived the battle between life and death.'"