(Disclaimer: This story is both upsetting and has one gross part. I will put a warning before the gross part.)
P., one of the medical officers I work with in the research clinic, tells me breathlessly that he was asked to review a patient in labor ward and is really afraid she might die. He has recommended transfer to St. Anthony, the private hospital nearby.
I know that transfer to St. Anthony can mean being turned away if the patient can’t pay, and if this patient is in such bad shape, she really could die if that happens. And besides, how can a critically ill patient travel to another hospital on her own?
I dash over to labor ward to assess the situation myself. The patient is only 15 years old. She was 9 months pregnant, and delivered her baby at home last night, sometime after midnight. It is now 9am, and the placenta is still in place.
A retained placenta occurs when the placenta – or a part of it – does not detach from the uterus. This can happen for a number of reasons, but the bottom line is that it can cause the patient to bleed heavily, and/or get a severe infection, and can easily cause death if not treated.
Everyone tells me the same story – that the patient is too combative and won’t allow the placenta to be removed. They tell me that they had 6 people tried to hold her so that someone could remove it, but she was too strong. Now, everyone has given up and is letting her lie in the bed, ostensibly until this transfer occurs at some point.
I know that this placenta needs to come out. One good thing is that P. correctly ordered for oxytocin to be given – in the hope that this would increase uterine contraction and expel the placenta.
I walk over to the patient and immediately notice the distinctly fecal stench. It’s hard to know if this is a result of having delivered and not cleaned up yet, or something more abnormal. I try to talk to the patient, but she is sound asleep. I am informed that she was given Valium in an attempt to calm her down and remove the placenta, but she still fought. I can see bloody cloths lying on the floor around the patient, and blood on the floor. It looks pretty bad.
I wake her up and try to get her in a position where I can try to do an exam, but she is hard to move. She finally turns on her back, but the minute I try to bend her legs, she resists and turns on her side. I enlist her grandmother and a medical student to try to help her into position. The medical student tells the patient not to resist, that we are trying to help her.
In residency, we would often get combative patients coming in delivering. Sometimes they were on drugs – and that often makes them extremely agitated and remarkably strong – but sometimes even sober, sane patient would go nuts from the pain and the fear. You had to learn to move fast, and do what was needed to have a safe delivery, even while the patient was kicking and thrashing.
This is no different. I know that she is at risk of dying if I don’t remove that placenta. The patient resists, and is very, very strong, but I push back. I reach in, grab the placenta, and within 10 seconds, I am able to pull it out completely. While she fights me, I press on her uterus to make sure it is firm, contracting and not bleeding. It is fine.
The patient lies down and goes back to her Valium sleep. The medical student looks vaguely stunned, but relieved. While I was pulling out the placenta, I noticed that the patient had a vaginal laceration that would need repair, but I know that she will not let us repair it right now.
The midwives are still worried about whether the patient needed transfusion, because she is so pale. But her hemoglobin is 6 – extremely low in the US, but in Uganda anemia is more common, and it would not be a level that requires transfusion. Her blood pressure and heart rate are normal – indicating that she is tolerating the anemia well, and should not need a transfusion.
Over the weekend, the patient does not seem to get out of bed. I see both her mother and her grandmother at her bedside. She speaks some rare dialect that makes it difficult for even most of the midwives to talk to her, although the medical student seemed to be able to communicate with her in Luganda.
The patient came in on a Friday, and the first time we can get her to the OR to repair her laceration is Monday. I know that the 3 days of healing will make the repair difficult.
I have the medical student obtain the informed consent from the patient and the mother because he is able to speak to them. Before we bring the patient to the OR, he tells me what he has learned about the situation, and what he tells me leaves me flabbergasted.
The father of the baby is the patient’s brother. He raped her while strangling and beating her. He had raped her in the past, and before her, he had been raping her sister. Their mother does not care that he rapes his sisters. The brother himself has two wives and five children. Now, since the delivery, he has run away and cannot be arrested because they can’t find him. (It is unclear whether they would arrest him even if he were there.) The patient confided this to the medical student, and while she was talking, the mother stayed quiet. The grandmother also told him the same story. The grandmother seems bothered by the situation, but powerless against the mother and the brother.
Good grief. This poor kid. No wonder she has stayed in her bed for three days – she is probably traumatized and severely depressed. At home, there would be a major support intervention for something like this. There would be social workers and psychiatrists, in-hospital security measures for the patient, extensive counseling, and of course, the police would be called. I have no idea what can be done here, but probably not much.
Before I can worry about that, I need to repair her laceration. It looked pretty big, but I am hoping it is just through the vaginal muscle. The anesthetist sedates the patient, and we examine her. What we find is horrifying.
*****GROSS PART STARTS HERE*****
The laceration goes through the thin vaginal wall lining, the vaginal muscle, the capsule to the rectal muscles, the rectal muscles themselves, and the rectal lining. It is the worst laceration you can have in a vaginal delivery, and needs careful stitching in order to avoid an obstetric fistula in the future.
In addition, she has had 3 days of healing, so a while layer of granulation (healing) tissue has formed over the lacerated surfaces. If I were to stitch those surfaces together as is, they would not heal closed, and the wound would fall open again. The granulation tissue is pretty revolting, with some green tissue that looks unhealthy. There are flies that were surrounding the patient on postnatal ward, and they have followed the patient to the OR. Now that she is asleep, they are landing everywhere, including inside. It is one of the most disgusting things I have ever seen.
The anesthetist fends off the flies for me by thrusting splashes of alcohol at them. It actually works.
In order to close the wound properly, I have to shear off the white and green healing tissue. I do this with a scalpel and a pair of crappy forceps. It is difficult and slow-going. Healthy tissue bleeds, and so once I remove this tissue, I am glad to see that the tissue underneath has started to bleed, but it makes everything harder to see. I have to be especially careful around the rectum, because I don’t want to remove too much tissue, or there will be nothing to sew, and that would be horrible.
Finally, I have removed enough tissue. I stitch her up, layer by layer. This poor girl has got enough problems – I want to at least give her back a functional vagina and rectum.
During the repair, the power goes out – of course. The anesthetist holds up an electric lantern, and I continue stitching. Finally, I finish. I am pleased to see that the stitches look beautiful (yes, we gynecologists sometimes say that in reference to a vagina), and she will hopefully heal up like new. That is, if she can get away from her brother.
*****END OF GROSS PART*****
Everyone in the OR is horrified by the situation. The medical student and anesthetist keep lamenting that the brother can’t be arrested. I am glad that this is their reaction – sympathy for the girl, anger toward the brother. But then after the case, the two OR nurses say things like “Why did she let it happen?” and “Why didn’t she run away?”
Finally, I say, “Where should she run to? To live on the street? So someone else can rape her?” They acknowledge my point.
The next day on the ward, the patient is lying in bed again. I can’t get anyone to translate for me, so I don’t find out very much.
The day after that, I stop by again. The mother and grandmother are there, and all three are eating lunch. I go to find a translator. This time, I find the medical student, and a very sympathetic midwife, S, whom I like and respect a lot. I need to figure out what we can do to protect the girl and how to rectify her awful social situation. I bring them to speak with the patient.
When we get to the bedside, only the grandmother is there, and the food is gone. The midwife tells me that yesterday, the mother was beating the girl.
“Beating? What do you mean beating?” I ask, alarmed.
“She was beating her, she was hitting her. She was hitting her where you stitched. I had to pull the mother away and I threw her out of here.”
What. The. %@$!&#. What? WHAT??
I thought the story was bad before, but now I am just dumbfounded. Why on earth would anyone, much less the mother, hit a girl IN THE VAGINA after she has just DELIVERED A BABY and TORN THROUGH HER RECTUM and then been STITCHED UP. Much less a young girl who has been brutally raped by her own brother and nearly died of hemorrhage after delivering his baby. Why?
The midwife tells me that the mother blames the girl for being involved with the brother, for “tempting” him. The mother is angry with her and was trying to hurt her. Now the girl is saying that she wants to go home, but she has nowhere to go, no money to clothe the baby or take care of herself.
I am confused because I just saw the mother here, eating lunch with them. Apparently, I am told, the mother is no longer staying with the patient, but is still bringing food to the hospital. Only the grandmother is staying, because of what happened yesterday.
There are so many things to address here. The trauma, the depression. The girl’s feelings about her baby, the product of this incest/rape. Does this girl even know what rape is? Does she understand that she is a victim, that she is not at fault? I have no idea. Then there are the practical aspects. Where is she going to live when she leaves the hospital? How will she care for the baby? What if the brother comes after her again? What if he does it soon – he will tear open her stitches and probably give her a fistula.
I realize that I need to have this conversation with her, but it’s so hard given the language barrier. She obviously trusts the medical student, so I have him and the nurse translating.
“Tell her that what happened is not her fault,” I say. “Ask her if she knows what rape is.”
He does, and then says, “She is just narrating to me what happened. I don’t think she understands.”
I have him explain the concept of rape. I repeat that it is not her fault. I tell her that we are here to help her. I ask if she understands what happened since she came to the hospital. When the patient replies to this, both the medical student and the nurse can’t help laughing.
They translate for me: “She is giving her perspective. She is saying that she came here, and she was bleeding and she was having pain, and you took her somewhere and gave her an injection that caused her to die. Now she is here, and the pain is better.”
It is both endearing and a little overwhelming to realize how little she understands – and how this probably reflects what many patients here understand. Some of the things I do must seem so crazy and foreign to them. No wonder they still go to traditional birth attendants and take herbal concoctions – they seem just as crazy and improbable.
We explain in simplified detail the retained placenta, and the laceration. When we tell her that she almost bled to death, and that’s why I had to hurt her to pull out the placenta, she looks me in the eye for the first time.
In English, she says “Thank you.”
I am taken aback, but pleased. I take her hand. We explain the rest of the situation.
We ask her feelings about the baby. She says she feels good about the baby. She is breastfeeding him and caring for him.
We ask where she will live. She tells us that she will stay with her grandmother. Her mother had separated from her father a long time ago and remarried another man. When the brother started raping the girl, the mother didn’t believe her. When she ended up pregnant, the mother blamed her, and so the girl moved in with her grandmother. But the grandmother is elderly and doesn’t have much money.
I ask if the brother lives far. She says he lives near the grandmother.
Great, just great.
We ask if she is in danger of being raped by her brother again.
“No,” she tells us, “I will stay away from him.”
“How will you stay away from him? What if he forces you again?”
The medical student shakes his head before translating her response. “She is saying that if he tries to force her, she will raise an alarm and people will come and help. She is young, she doesn’t understand, she is not thinking about it.”
Sigh. Now what? The midwife, the medical student and I discuss different options. There are no shelters, no safe houses. There is no counseling, no psychiatry, no social work available. There is no support. And without the family’s support, the girl is unlikely to get any help from the police.
We are also worried that she will abandon the baby. Apparently, it is very common here – people leave babies in garbage piles, in ditches, in medical clinics and hospitals, on the side of the road. Can we find somewhere the baby can stay until her situation stabilizes? But she seems to have good feelings toward the baby, and it can’t possibly be good to separate them.
While I am trying to think of something I can do to help, keep repeating supportive things to the girl, and I occasionally take her hand. Culturally, this might come off as really weird here, I’m not sure. But I can’t think of anything else to do.
Finally, we decide that she will stay for a while until her stitches heal completely. That way, she will be safer for now, and maybe we can think of something in the meantime.
Every day, I stop by and see her. The stitches are healing very well, and there doesn’t seem to be any damage from the incident with the mother. I can’t tell if she is improving emotionally, but the medical student says he has seen her walking around, and talking more.
There is a midwife in our clinic, R., who used to work on labor ward. I tell her about the situation, and she says she knows of a social worker for the hospital. The next day, R. tells me that she went to see the patient and had a long talk with her. R. then informed the social worker about the case, and is hopeful that the social worker might be able to arrange social and even financial support for this girl given her extreme case. I am so glad to hear that there is something like that available.
Today, I go to see the patient, but she is gone. A midwife tells me that the patient was not discharged, but she left on her own. No one knows to where or with whom. “It happens all the time,” she says.
