Thursday, July 1, 2010


I stop by Labor Ward to drop off an operative note I had written on a patient earlier that day. The midwife tells me “There are patients for you.” I tease her that she is drumming up too much business for me. Then I ask her the details.

There are 3 women who need D&Cs (uterine evacuation). One is a person I had seen yesterday who had an early pregnancy that failed. The plan is to do a D&C but she ate lunch, which means she can’t undergo anesthesia today. I write a prescription for misoprostol in the hope that she can avoid a D&C altogether, but at USH 3000 ($1.50) per pill and needing 4 pills, I highly doubt she can afford it.

The other two women are lying in beds on labor ward. Instinctively, one seems sicker than the other, so I start with the sick-looking one. The nurse tells me that she was “BBA” and she has “retained products”. BBA means birth before arrival, which implies a third trimester pregnancy in which the patient delivered at home (or on the way) but came in after delivery, usually for a complication. However, “retained products” implies that the patient had a first trimester miscarriage, but not all of the products of conception came out of the uterus at the time of the miscarriage, and she still has pain, bleeding and possibly infection.

It doesn’t make sense for the patient to be BBA and have retained products – but then I think that maybe the midwife means that part of the placenta is still inside. I try to ask the details, but it seems that the patient has been referred from elsewhere, and it wasn’t the midwives at TDH who diagnosed the “retained products.”

I find that often these terms are thrown around at random, and often the actual complaint has nothing to do with the supposed presenting description. I can’t count how many times I have been sent patients with “cervical prolapse” who actually turn out to have abdominal pain (and no prolapse at all).

So I always start from the beginning, by interviewing the patient. I walk up to the patient and greet her.

ME: Do you speak English?

PATIENT: (blank stare)

Often when the patients don’t speak English, they don’t recognize the word “English.” The word for English in the local languages is “Luzungu.” The prefix Lu- implies language, so the Baganda people speak Luganda. And –zungu comes from mzungu, the word for foreigner. So Luzungu is literally the language of mzungus (actually the prefix Wa- is for plurals, so more than one mzungu becomes wazungu).

ME: Do you speak Luzungu?

PATIENT: I speak.

(Which means she speaks English).

ME: So what happened?

PATIENT: (blank stare)

MIDWIFE: You tell doctor what happened!

PATIENT: (blank stare)

MIDWIFE: Did you have a baby?


MIDWIFE: Boy or girl?


ME: Then what happened?

PATIENT: (blank stare)

MIDWIFE: You talk to doctor! Did the placenta come out?


MIDWIFE: Who removed it?


ME: Then what happened?

PATIENT: (blank stare)

MIDWIFE: What happened after that. Why were you sent here?

PATIENT: (blank stare)

OK, we are not getting anywhere. The patient won’t give us any narrative at all, and I haven’t been able to discern why the other health center suspected retained products if the placenta was removed. Was it removed in pieces? Is she still bleeding?

I decide to examine her. I realize that if I need to remove products of conception from both patients, I will need 2 speculums.

ME: Are there speculums?

MIDWIFE: Yes. I sterilized.

ME: How many?


Well, hopefully only one will need a speculum. The midwife brings me gloves to do a vaginal exam and see if the cervical os is open. Immediately, I feel that there is a large chunk of products hanging out of the os, which is open about 2-3 cm. The patient is uncomfortable, but I encourage her to bear the discomfort. If I can yank out this piece, this might be all she needs to stop bleeding and get her cervix to close. I might not even need a speculum. I pull it out, and see that it is a chunk of placenta.

I reach in again to palpate inside the cervix to see if there is any more placenta left inside. The cervix is so dilated I can actually reach inside the uterus. My finger touches something surprisingly hard inside the uterus. What is that? Is it bone? That doesn’t make sense – she said she delivered a live infant. Where would bone come from?

I reach further in and the patient struggles against me. The midwife admonishes her.

MIDWIFE: You bear! Doctor is helping you!

I manage to hook my finger around the hard thing and pull it out. It’s a stick. I stare at it in shock. The two midwives watching me both shriek with surprise.

MIDWIFE: It is criminal abortion!

I don’t like that term at all. I suppose in actual meaning it is no different from “illegal” abortion, but it sounds much more judgmental. It also reminds me of a quote I heard at FIGO: “The discussion is not ‘is the fetus a life from the time of conception and has moral value?’ The discussion is ‘should women who have abortions be criminalized?’” No law has ever stopped abortion; law has only made it illegal.

But at that moment I am too shocked to react to the term. I know that people use sticks to induce abortions. I have heard horror stories of patients coming in with holes in the uterus, sometimes with the sticks still poking through. But I have never seen it myself. I can’t stop staring at the stick. It is about 4cm long, such a hard, vulgar piece of plastic. I can’t believe I just pulled it out of this poor girl’s uterus.

Suddenly I realize that the midwives are talking loudly, chastising the patient, and public discussing the patient’s “criminal abortion” with the family member of the patient in the next bed. All three are shaking their heads and publicly bemoaning the discovery. I feel badly for this patient, who is probably terrified on several levels, and who was so desperate to abort this pregnancy that she let someone do this to her.

One of the midwives is telling the patient she could have died. I’ll admit: this is true. I get chills thinking about how easily that stick could have punctured her uterus. (In fact, it still might have, I need to evaluate her more thoroughly). The midwife tells her that last year, there was a woman who died after coming in with sticks in her uterus like that. The patient maintains her blank stare, which I suppose is an effective protective mechanism.

I try to get the midwives to stop loudly chastising the girl, and try to offer comments about how she must have been desperate, and how we should be sympathetic, but I am ignored. I decide to just move on to the next patient and hope they settle down.

But while I am trying to speak to her, I can’t even hear what she is saying because there is so much loud bemoaning. Finally I call for quiet, and they realize and stop.

Both patients need ultrasound. I go back to the clinic to get the machine. I am still pretty stunned from finding that stick in the uterus.

I scan the first patient, and find that her uterus is still thick with blood and probably some products, and she needs a D&C. A D&C is probably optimal because it will allow me to clear the rest of the uterine contents, and also to make sure there are no more sticks inside. There is no free fluid in her abdomen and she has no signs of uterine perforation, which is good. The second patient is fine and I send her home.

The D&C is uncomplicated, and I find no more sticks, only blood and some small amount of membrane. It could have been so much worse.

No comments: