Friday, February 12, 2010

Everything You're Not Supposed To Do

I stop by labor ward to see a patient who needs a D&C, and a midwife asks me to review a different patient. She is 16 years old, having her first baby, and according to the midwife, has been stuck at 6cm.

I look at the chart. The last note was at 7pm last night,and she was 4cm. It is now 11:30am, and there is no documentation of 6cm. I ask the midwife - she says the patient was examined this morning, but not by her and she doesn't know when. She is sure that whoever examined her said she was 6 cm.

According to her last period, she is about 34 weeks pregnant. At 34 weeks, the baby is preterm, but usually survives unless there is another problem like infection. Even here, a 34-week baby has a very good chance of survival.

Her belly looks at least 34 weeks, if not full term. Rupturing her membranes might help speed up her labor (and avoid medication, which is difficult to use here because you don't have a pump and no one really watches). However, if the baby is preterm, having the water broken for a long time before delivery could predispose toward infection, and preterm infants are much more at risk. A 34-week fetus should be ok, but you don't want to take chances. Then again, a cesarean here is highly morbid - most people get infected and require antibiotics, transfusions are hard to get even when lifesaving, and the potential for complications in the next pregnancy is very, very high. And she might have 8 or 10 pregnancies ahead of her. This girl is 16 - I don't want to doom her to all of that if she can have a vaginal delivery today. And who knows - gestational age is quite unreliable here and the baby might be full term after all.

I examine her, and find that she is, in fact, 6cm dilated and her membranes are bulging. As I am considering whether or not to break the water, the tense bag ruptures suddenly. I jump back to avoid being doused with amniotic fluid. The fluid is a mild green color - meconium, although light, which is ok. It can sometimes be a sign of stress, but can also be present during labor or when the baby is full term. I feel the head, and it is quite low. She will likely deliver vaginally.

As I am writing the note, I hear her start to groan with discomfort from contractions. This often happens after rupture of membranes - the contractions pick up in frequency and intensity. The midwives agree that she will likely deliver soon.

I go to theatre for the D&C, and then I get some more research work done. Around 4pm, my work has slowed down, so I decide to check on her and a few other patients.

When I arrive on Labor Ward, the evening shift midwife is sitting at the nurses' desk, writing. I greet her and ask about the 16-year-old patient. "She has delivered." I am glad to hear that. I knew they would have called me if she had needed a cesar, but still it is nice to hear when things go well.

I look up her name in the delivery book and see that she delivered at 2:30pm - about 3 hours after I ruptured her membranes. Pretty good. "She pushed for almost 30 minutes," says the midwife, disapprovingly. This seems fine to me. Women at home push for 1-2 hours, even 3 if they had an epidural. But then I notice the Apgar scores are 3 and 4. The Apgar score, invented by Virgina Apgar, an anesthesiologist, is a method of grading the baby at delivery, and is thought to be predictive of future outcome in term infants. The score is determined through clinical evaluation of the infant at 1 minute and 5 minutes (and sometimes 10 minutes) after delivery. A perfect score is 10 and 10, although most infants score 9 and 9.

Apgar scores of 3 and 4 are terrible. The midwife tells me, "They worked on that baby. He is over there." I don't know if that means he's dead or alive. I go over to the baby, who is in the bassinet under the heating lamp. He is small, and not moving. His face is pale. I uncover his head and hands - they are blue. Is he dead? I listen to his heart - the heartbeat there, but it is below 100 (a baby's heartbeat should be high, around 120-150).

I know the midwives tried to rescusitate. I have been present when they are rescusitating, and the are quite skilled. They have taught me a few things. Usually they have little to work with, but just yesterday we had some visitors from Kampala who fixed the oxygen concentrator and the suction machine. The midwives also usually inject some saline with glucose into the umbilical cord during resuscitation.

Nonetheless, I try again. How can I not? I bring the baby over to the oxygen concentrator, which I can see was recently used, probably on him. There is a bulb suction there, a nasal cannula for the oxygen, and 3 Ambu-Bags for pumping air into the baby's lungs. I can pretty much guarantee that none of these things are clean, much less sterile, but they are all I have. The hospital has run out of money, and so can't buy soap or bleach at the moment. I weight my options, and use what I have.

I know oxygen doesn't attach well to the Ambu-Bag, so I try the nasal cannula first. It is for an adult, so it is too big for him, but I put it in his nostrils anyway. I look around for a breathing mask, but there isn't one. His heart rate seems to pick up. I measure it, and it is 108. Still low, but improving.

I need to pump the air into his lungs. I can't get the oxygen tube to attach to the part of the bag I think it should, but I see another attachment where it might fit. Will this actually get oxygen through the mask? Unclear, but I try. When I test it, I feel some air coming through. I start bagging the baby. He is still blue, except for his face, which is pale.

I keep my stethoscope on his chest listening to his heart while I pump. No change. I keep going, but it doesn't help. After a while, I try the oxygen nasal cannula again.

After a good 30 minutes of alternating between pump and cannula, plus doing some chest compressions, nothing changes. The midwife who had spoken to me earlier is still sitting at the desk. She knows it is hopeless. I bring the baby back into the bassinet.

An old woman arrives, and she manages to tell me that she is the grandmother. "The baby is not good," I say. "Not good," she repeats. "It is not going to live. Does the mother want to hold him?" She doesn't understand.

When I was a medical student, I saw a baby born with a lethal anomaly. Her face was terribly deformed - only the baby's mouth looked normal. The parents held her immediately after delivery. They took turns holding her lovingly until she died.

I don't know what the culture is here. I don't know if everyone would feel the same way or not. I decide to go ask the mother. She is only 16, and this may haunt her for the rest of her life. Would she want to have seen her baby while he was alive? Would she want to know that she showed him love before he died?

I walk with the grandmother to the Postpartum Ward. The girl is there, and she won't make eye contact. She stares out the window, looking upset or angry. The grandmother (her mother) encourages her to talk to the "mzungu" but she won't. I need a translator.

I walk through the ward, but there is no nurse there, and the medical students have left. I find one patient getting some sort of IV fluid. Her husband speaks English and she speaks even better English.

In medical school, we are taught the ethics of using a translator. Never use a family member - they could be biased. Never ever use another patient - it is a breach of confidentiality. The best is to use a professional translator, either in person or by phone. Otherwise, you can use a staff member who speaks the language, but they must maintain patient confidentiality. When patients would come in speaking Arabic, Bengali, French or even languages like Quechua, Wolof and Mandingo, we could call a phone translation service and they would link us with a professional translator over the phone. (Sometimes for Wolof and Mandingo, you had to schedule the translator in advance, which really doesn't work when you need to do an emegency cesarean).

Here, most of the time, there is a nurse or staff member around who speaks the language. Most of the patients speak Japadhola, Ateso, Swahili and/or Luganda. But sometimes, you get someone who speaks Lugizu or some other language, and often other patients are used to translate. Confidentiality, what?

I stand there thinking about whether this is ok. But what choice to I have? The grandmother says something to the English-speaking patient, and the patient translates:
"She is saying her daughter has delivered a baby, and now the baby is dying."
"I know," I say. "The baby is dying now, and I want to know if she wants to hold him. Come and speak to her for me."

She takes her IV bag with her and we walk over to the girl, who is still staring out the window, looking upset and angry. She tries to speak to the girl, but the girl won't answer. I try to explain about the baby, and ask what she wants to do. The grandmother speaks. The translating patient replies. Finally, the girl says something brief.
The translating patient says "They are waiting for someone now."
"Who?" I ask.
"That I don't know," she says.

Just then, about 10 people stream in though the door. I don't know if they are family, or what. There are 2 men, and another woman with a baby on her back, and some more women who stay in the background. One of the men sits on the bed next to the grandmother. He is the girl's husband.

I say to the husband "Do you speak English?" He nods. "The baby is not well. He is going to die. We have tried everything, but he has refused to breathe. I want to know if your wife wants to hold him now before he dies." He looks at me, then stares at the ground. He looks angry, although I can't really tell. He says nothing. No one says anything. The translating patient looks as confused as me.

Thinking that I no longer need translation, the translating patient leaves. But has the husband understood me? And should I be talking in front of all these people? Who are these people? And why won't the patient talk to me? The grandmother seems responsive, but she won't answer this question.

In the gathered crowd I spot E, a patient I know. She has twins at full term, and she is waiting to go into active labor. She speaks very good English. Since confidentiality is already out the window, I summon her to translate. She speaks more confidently to the family. The husband says little, but the grandmother speaks. E doesn't always translate immediately, sometimes responding first. But she gets what I am trying to say, so I let her.

She turns to me "The relatives are saying they want her to go home now, but she doesn't want to go. The midwives have told her she should stay tonight and go tomorrow, but the family doesn't want."

The girl says something brief. "You see? She doesn't want." says E.

I realize that while my primary concern is the baby, this is their most pressing issue, so I address it first. "She should stay," I say. "The problem with the baby could mean a problem for the mother, too, like infection. She needs to stay to be observed tonight."

There is more discussion. The grandmother pipes up, as well as the husband. Even the woman with the baby on her back says some things. E tells me they are still saying they want to take her home. She tries to convince them to let her stay. The girl insists she wants to stay.

"Now they are saying that they take the baby's body tonight, and then tomorrow they will come and collect her. She can sleep here tonight."

"Well, the baby is still alive, but he is dying. That is why I want to know if they want to see him, or if I should bring him here so she can hold him."

This is confusing, and E explains to them until they understand that the baby is sick but not dead yet, and will likely die.

"They are asking if you can do everything you can to save the baby, give him medicine." says E.

"I have tried everything. And the midwives have tried everything. We have given him oxygen and tried to force breathing but he has refused to breathe. We have tried for two hours." E translates this. It takes a few repetitions to sink in.

"Does she want to hold him now?" I ask. E translates. The husband says no, and the grandmother says no.

"They are saying no," says E.

"What does she want?" I ask. E asks her several times. Finally she speaks.

"She doesn't want," says E. Then the husband pipes, up and the grandmother says something seemingly in agreement. She points to me and then herself and then the door.

"They want to go and see the baby again with you." E says.

I thank E for her help and take the husband, the other man, the grandmother, and the lady with the baby on her back over to Labor Ward. I show them the baby, and explain how he is not breathing and his heartbeat is slow. I lift his arms and he has no muscle tone. (At this point, even if he does live, he is probably severely brain damaged from lack of oxygen. I can't even figure out how he is alive without breathing for 2 hours).

"You try to help him," says the husband.

"I have tried and tried," I say. "He does not want to breathe."

"You try again," he says.

I pick up the baby - who is limp and lifeless - and bring him to the rescusitation table. I show them the oxygen. I attach the oxygen to the Ambu-Bag, and try to pump air into him. I listen to the heartbeat - no difference. I bag for a while, then look for breathing. I show them that there is no breathing. Occasionally, the baby makes large gasps, sometimes waiting several seconds before releasing. These are terminal breaths - adults make them too, while dying. They are infrequent and slightly scary.

I switch to the nasal cannula, which is still too big for the baby. I put it in his nose, but it just seems mean because it stretches his nostrils to the sides. I try that for a while, and show them that he is still blue and not breathing. I try putting it in his mouth, where at least it stays. Nothing. I let the father listen to the heartbeat with my stethoscope, and explain that it is too slow.

I switch back and forth between cannula and Ambu-Bag, until it just becomes pointless. I tell the father "You can stay here with him. I will bring you a chair to sit. Do you want to hold him?"

At first he refuses, so we stand there watching the baby with the cannula in his nose, not breathing, not changing, still blue. Then I try again. I offer to let him sit, and he doesn't refuse. I bring him a stool to sit on, and he sits with the baby and watches him. The grandmother had given up at some point during the rescusitation and left.

My rescusitation efforts were pathetic. I don't know much about it. Even if I had learned more in residency, there is not much here we can do. We can't intubate the baby, the oxygen barely works. I feel badly that I saw the mother in labor and that the outcome was bad. But thinking over my actions, I can't think of what would have been different. The heart rate was fine, and the rupture of membranes did help her deliver. Maybe this baby was infected before delivery, and therefore weak. It might explain why she delivered preterm. The baby isn't so small that it seems less that 34 weeks. In fact, it looks like a small term infant. I suppose the good side is that she didn't get a cesarean for a baby who died. It's possible that a cesarean would have saved the baby. It's also possible that it wouldn't have. But at the time that I saw her, she had no indication for it. Still, it doesn't feel good.

Thinking about the crappy rescusitation, the discussion with the devastated teenage mother translated through other patients and in front of 10 people who may or may not have been related to the patient, my lack of ability to get her to make eye contact with her or explain anything gently, I think of how everything is the opposite of what you are supposed to do. You are supposed to give people privacy, compassion, confidentiality and dignity. I wish I could say that I persisted and gave this patient the closure, but I didn't. This girl will go home, and the loss of this baby will haunt her forever. Many women here lose at least one or two children if not more - so many that it is often shocking. Birth asphyxia, malaria, pneumonia, diarrhea, malnutrition. It would make us feel better to think that they are less affected by the loss because it is so common. But I saw that girl's face, and I have seen the faces of women recounting their obstetric history to me, telling me about infants or children who died. They are devastated, but they receive no validation, no support and no compassion.


Lady B said...

V, reading your story I think you gave this woman compassion, and the family - even if you didn't feel it at the time. Shockingly you probably gave them more attention than they would otherwise have had.

Anonymous said...

very touching report. writing such things should be with awareness of wetserncentric and eurocentric terms i think. it is not easy to reflect upon that all the time. but it is good to remember it again and again i guess. and judging is worth nothing in my view. the one says u did a good job. a person from another angle criticises the same thing.the one says dealing with a dead child needs four eyes talks and support the other says that it is one of natures faces and with time it will become less horrible...