The midwives have a few patients they would like me to review, and one of them, they say, “has a retained placenta.” After a delivery, the placenta should detach within about 30 minutes. On occasion, it does not, and this can lead to infection and excessive bleeding. In the hospital, we actually reach in and pull the placenta out manually, and if that doesn’t work, then we do a D&C. But when women deliver at home and this happens, they have to come to a health center, but often in countries like this, they die at home.
The midwife points out the patient. She does not look like she recently delivered a full term infant. She is skinny as a rail, wearing a tight, fashionable ankle-length skirt with a cute fitted top and I can see no bulge on her abdomen. There are 2 male family members accompanying the patient.
“They are saying that the fetus came out, but the placenta didn’t come. They say she was three months pregnant.”
Now the picture is a little clearer. She had a miscarriage, not a delivery. That would explain the lack of a visible bulge. But something doesn’t make sense.
“If she was three months pregnant, they shouldn’t have seen much of a fetus. How do they know the fetus came out?”
At three months, the products of conception usually look like a big mush after a miscarriage. The midwife agrees that this is strange, and re-interviews them.
“They are saying they saw it,” she says.
“How big was it?” I say. Maybe she thought she was three months, but she was really in second trimester. In second trimester, you do see a fetus separate from the placenta, and can identify each. The midwife translates.
“They don’t know how big it was, but they say they saw it and the placenta is still inside.”
OK, whatever. I go to examine the patient. Her face shows a mix of fear and something else. Sadness? Apprehension? But the women are often intimidated when they come to the hospital. Luckily, she speaks English. I ask her about the bleeding, which sounds like it was quite heavy.
I notice there is blood on the bottom of her feet. In residency, one of my attendings taught me the blood-on-the-bottom-of-the-feet sign. Women often come and say bleeding was “heavy,” but many women have never seen truly heavy bleeding, and think that a normal period is “heavy.” But when you see blood on the bottom of their feet, that’s when you know it was a serious hemorrhage.
I want to look for her chart, so I ask for her name. The two men tell me her given name. We ask for her family name. They look at each other confusedly, then, stuttering, give us a family name. Why is this so difficult? The midwives ask their relationship to her. One is the husband. Why would a husband not know his wife's name?
I go back to the patient to try to elicit the story from her, because I am guessing that she will be a better historian than the men, who are probably just freaked out. She doesn’t fully answer my questions, though. I am trying to ask when the bleeding started in relation to the pain, when the bleeding became excessively heavy, and when it became lighter. Her answers are vague non-answers. This is weird, because typically women are acutely aware of the onset of pain and bleeding in these situations.
The medical student and the nurse are trying to help me elicit the information. I know I need to get the ultrasound to see what is inside her uterus, but it would be helpful to have a history first. Then, suddenly, she tells us the truth.
“A woman came to the house. She removed it. But the bleeding was there.”
“Who was the woman?” I ask.
“A nurse,” she says.
“When did she come?”
“When did the bleeding start?”
“You have been bleeding since then?”
Now I understand why the husband’s story didn’t make any sense, why the girl was being vague, and why she has that look on her face. I want to reassure her that it’s ok, that I don’t care, and that she doesn’t have to fear what she has just told me. I don’t want to be totally open about it in front of the midwife (just in case), but I know I should say something.
“It is ok. I am glad you told me the truth. You don’t have to worry. We are going to help you, and it will be fine.”
Her expression doesn’t change much, but she nods. Illegal abortions are done by all kinds of random people. Some are medically trained, some are completely non-medical, and some are people who work in hospitals and maybe have observed a D&C and so they think they know what they are doing. They stick instruments, sharp sticks, cassava stems or whatever they can find into the cervix. They don’t know the anatomy of the pelvis, and have no idea what to actually do and what not to do. Women can end up with life-threatening infections, or hemorrhage, and often have a perforated uterus – a puncture in the uterine wall from an instrument or stick jammed in with force. A small perforation might be inconsequential, but these are rarely small, and rarely sterile. Bowel can be injured if the stick goes too far. The more advanced the pregnancy, the thinner the uterine wall, and the higher likelihood and danger of a perforation.
It’s hard to know why this girl is bleeding so much. It could be that the procedure was incomplete, but it also could be that she has a perforation. I check her vital signs. Her blood pressure and temperature are normal, and her pulse is on the higher side of normal, which is ok since she is probably terrified and has been bleeding. She doesn’t seem to be septic. Her abdomen is not particularly tender. I do a pelvic exam, and find blood clots and an open cervix with more blood inside. She will probably need a D&C, but I need to make sure first that she doesn’t have a perforation.
As I am listening to her heart with a stethoscope, I hear the medical student asking her something. I take the stethoscope off and ask what he said.
“She says she is married, so I asked her why did she do this if she is married.”
“We don’t ask that,” I say, tersely. He picks up on my tone, and complies.
Later, I explain to him – with the midwife listening – why I cut him off. I tell him that women are desperate, and many will risk their lives to have an abortion. Once they come in having had one, there is no point in asking why, or making her feel bad. We are here to treat and help. I see the midwife nodding next to me. The medical student understands what I am saying, and agrees. I tell them that abortion is legal in the US, and women who are considering it can openly discuss it with a doctor, and receive counseling. Sometimes they choose to do it, sometimes they choose not to. But the abortion rate is much lower in the US, and it’s not a coincidence.
“That is good, the women can discuss” says the midwife. “And also women in your country are allowed to choose family planning?”
That too – American women don’t need their husband’s permission to use contraception. (There is no rule in Uganda that women need their husbands permission, but it is a cultural norm – so much so that a woman requesting contraception is nearly always asked what her husband wants. A woman who wants a tubal ligation is prompted to have her husband sign the consent form, but it doesn’t seem to matter if she signs. I always insist that she sign.)
I bring the ultrasound from the clinic. I see that her uterus is hugely filled with clotted blood, but there is no fluid in the abdomen or pelvis, and the uterus looks intact. A perforation seems unlikely.
So now she needs a D&C, but there is a problem: no power. Without hospital power, we can’t do the D&C. Another alternative is Misoprostol, the wonder drug. It’s the same drug that is used for induction, and it is also great for postpartum hemorrhage and as an alternative to D&C. She doesn’t seem infected, so we have time for the Misoprostol to work.
I haven’t been using Miso as a D&C alternative, because the patients have to buy it, and they are wildly overcharged. The medicine itself should cost pennies, but at one pharmacy, they pay USh 10,000 ($5) per pill. For this indication, I would need 3-4 pills, which is a huge amount of money for most patients here. I recently found out that there is another pharmacy that charges only USh 3000 ($1.50). This is more reasonable, although still many times the actual cost. In this situation, we have no choice because we can’t do the D&C. This patient is lucky that she is here with male family members. Men usually have the money, and can go and buy the medicine. When women come with other women as attendants (more typical), they usually have little or no money.
We send the men to the pharmacy. When I return to Labor Ward, the medical student is putting the pills in vaginally. Misoprostol is a versatile drug – the same pill can be taken orally (swallowed), buccally (sucked on until it dissolves), dissolved in water for drinking, vaginally or rectally. In this situation, I would have preferred that she take it buccally, since she is bleeding vaginally and this can make the pills come out. But what is done is done, so hopefully it will work out fine.
The next day, the patient is dressed in another cute outfit – she has style that would fly in New York. She looks calmer and relieved. She had some increased bleeding overnight after the pills were inserted, but now it has completely stopped and there is no pain. I bring over the ultrasound, and see that the uterus is now empty.
I ask the midwife to send her home, and she handles the paperwork for me while I dash to see other patients. Before I go, I tell the patient where to go for family planning and problems “like this” in the future, just in case. I hope she doesn’t need another abortion, but if she does, I hope she listens to me and chooses a safer place.