Wednesday, January 6, 2010

One More

A midwife pulls me aside to ask me to see a patient who has just arrived.

"She has come for a D&C. She took the family planning injection twice, but she was probably pregnant when she took it, because now she is bleeding and they have told her she is pregnant. I am looking at her and she may be too far along for a D&C."

I look at the woman too. She looks pregnant, which probably means she is in her second trimester. I bring the ultrasound to figure out what is going on.

She speaks only Lugazi, which none of the people in this area speak - it is more common in Mbale, which is an hour away. Her husband is hovering at the window looking worried, and the midwives tell him to come inside to be with her and help translate.

I scan the woman. She has had 9 prior children - this is her tenth. She is 17 weeks pregnant, with a normal, live fetus. She has what looks like a complete placenta previa. Her bleeding stopped last night, and it was never very heavy, just persistent for several days. They had thought (hoped) that the family planning injection had caused a miscarriage and that was causing the bleeding, but this was not the case.

When I explain to the husband that the baby is alive and well, he looks stricken. I try to explain it as good news, but it's obvious that it's not. I try to encourage him to translate for his wife and he tries, but the more he processes the information, the less he communicates to her. He looks like he is going to throw up or cry. He says some things that I don't follow. The midwife explains, "She has suffered a lot with this bleeding and they are worried about her." He seems genuinely concerned about her, and very upset.

A medical student from Mbarara is on rotation for 3 weeks, and he helps me. When I say something in English, he repeats what I said (in English) for the husband. Sometimes he rephrases. When I ask the husband questions about the woman - does she want more children, does she understand why she is bleeding - the medical student "rephrases" but asking the husband his preference/opinion/understanding. How many children do you want? The husband says that he wanted 6 or 7 children, but they kept coming more. That's helpful, but what does she want? I am all for male involvement, but not at the expense of the involvement of the woman.

Finally, I specify that I want to know HER preferences and HER understanding. A midwife who can speak a little Lugazi tries to ask her. How many children do you want? The woman starts listing all of her current children. No, how many children do you want? She lists her children again. The midwife can't get her to state her preference (which I have found to be remarkably common here). Finally, the husband says "We had agreed. That is why we went for family planning. We didn't want more."

Still, I can't do anything about this one. In the US I could, but here it's illegal, and with her gestational age and her complete placenta previa, it would be dangerous.
I start to explain the plan for her pregnancy - she will come to see me in my clinic every month, I will check the placenta to see if it improves, and if it doesn't she will need a cesarean at term. Either way, she MUST deliver in the hospital. The midwives and medical student help me to emphasize this point.

The husband only half hears us. He still looks devastated. "But can't you take out the bleeding?" I am confused, until the midwife says "He means take out the pregnancy, but he doesn't want to say it."

I am sympathetic. They are dirt poor, and they already have 9 children to take care of. But I know I can't do anything. The midwives and medical student chastise him, lecturing him that we can't "kill the pregnancy" when it is this far along. This is true (in Uganda), but I feel his pain and I don't want them to scold him more for hoping it. Those who proclaim their total opposition to elective abortion should live in this degree of poverty before they make their sanctimonious judgement.

I review the pregnancy plan again with him. I ask him if his wife has understood, because I realize that most of our conversation has now been conducted without translating for her. The husband says "I have understood." The medical student says "He has understood and that is enough because he is her husband." I say, "She is the patient and she needs to understand." What if she starts to bleed again and he isn't around? (Not to mention the ethics of patient autonomy.)

I have him translate word-for-word my explanation of the placenta previa and the plan for the pregnancy. It is obvious that she had not understood until now. She also doesn't seem to want the pregnancy, although she is less explicit and more stoic than her husband. She asks similar questions - about whether I can stop the bleeding, and what to do if it happens again. Finally, when I feel like they have both grasped everything, I sit to write my note.

Later, outside the Labor Ward, I run into the husband again. I take his hand and apologize that I can't help him more. He thanks me, and he asks again if I can't take away the pregnancy. "We have 9 already - it is so many mouths to feed, so many bodies need clothes, so many school fees to pay. It is too much." He looks so sad.

I apologize again, and explain that it would be unsafe. It occurs to me that in their desperation, they might try to go somewhere for an illegal abortion. If it is unsafe for me to do a D&E, it would be fatal to get one illegally. The placenta previa would bleed rapidly, the fetal size would require larger dilation, and she would be unlikely to be able to get a sterile procedure or a blood transfusion if she needed one.

I don't tell him what I suspect, but I explain to him what would happen if I tried. "She could bleed to death. What is important now is her life." He echoes me, "Her life." I continue, "If we tried to remove the pregnancy now, she could die, and she would leave your 9 children without a mother. She should come and see me in this clinic, and I will help her in the pregnancy and the delivery. She should be very careful." He asks me to point out the clinic building and I do, repeating the date I have scheduled her for follow up in 4 weeks. He still looks upset, but he takes my hand. "I will take your recommendation, doctor."

I hope so.

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