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Tuesday, February 06, 2018

The least of these...

As I (Scott) arrived at the hospital this morning, I did my usual preliminary pass through the Labor & Delivery area scouting for potential problems or emergencies.  The day shift midwife was bustling amidst at least ten pregnant women in various stages of labor and informed me that there was a mother who just arrived and needed a C-Section.  I nodded and asked her give me a short summary.  

“She’s a  32 year old mom in active labor at term with four previous scars.”  That means she has had four previous cesarean sections.  Some mothers are able to have normal vaginal deliveries after one (or even two) c-sections (called a VBAC: vaginal birth after cesarean).  But a mother whose uterus has been cut four times would be at very high risk of a uterine rupture if she were permitted to labor.  I took one look at the mom and could see she was really contracting.  She was flexed at the waist, leaning on her elbows on the bed, eyes squeezed shut as she endured a long hard contraction.  The midwife was preparing to examine her cervix so I waited to find out how urgent this case was going to be.  The midwife gasped.  “She’s eight centimeters.”  That’s 80% of the way toward the baby’s delivery.  So we needed to act quickly.

It took about a half hour to get her prepared and into the operating theatre (shockingly efficient for our hospital).  As part of the routine pre-operative care, I inserted a catheter into the mom’s bladder and found the urine to be bloody.  The baby’s head was like a battering ram, propelled by the strong uterine muscular contractions, smashing against the mom’s pubic bone - and the poor bladder caught in the cross-fire.  But at least there was no evidence that the uterus had ruptured…

Doing a c-section on a mother who has had four previous c-sections is no small challenge.  It often seems like someone has poured glue into the abdomen and let it set.  Everything is adherent to everything else.  In this case, the bladder was stuck high up on the uterus making access to the baby difficult.  But we manage to deliver a healthy baby - 3.2 kg.  As I put the mom back together, I conversed with the senior nurse who assisted me in the surgery and we discussed this mother’s story.

“Did you know this mother is from The Bush,” she said.  Typically that means “far away.”  However, it this particular case, this patient came from a village so far away, that the actual name of the village is “Bush.”  Prior to the surgery I was looking at her little blank notebook which some women use for antenatal care.  The entirety of her antenatal care consisted of two third-trimester dispensary visits where they measured her blood pressure only.  The routine antenatal blood tests (such as blood typing, HIV & syphilis testing, and hemoglobin level) were never done.  No advice was given about the need for or timing of an elective cesarean.  She didn’t know the date of her last menstrual period so there were just question marks about the dating of her gestation.  No ultrasound.

Last night, the patient went into labor, but she lives in Bush and her husband has no means of transport.  So they waited until morning.  They had to ride three different matatus (12-person mini-van) for over three hours to reach our hospital.   As we explained the need for a C-section, she quietly nodded.  We handed the consent form to her sign, but there was an awkward pause and look of confusion.  She could not read or write and didn’t know what to do with the pen.  I felt so sad for her.  She managed to make some semblance of a signature.  And then we went through the same awkward process as we offered and explained the option of a tubal ligation.  Thankfully, she was eager for a permanent family planning solution.  This could potentially save her life.  Today was her fifth C-section.  Going for a sixth could be deadly.

This afternoon, I have been thinking about this patient.  I’ve often said this year that I find it so difficult to understand what my Kenyan medical colleagues are thinking.  But wow - trying to get inside the experience of a patient who does not read or write is nigh impossible for me. What I can imagine though is that her life is defined by her family and tribe.  That she loves her new baby more than life itself.  That she came to our hospital hoping against hope that she and her baby might somehow survive.  And I count it a privilege to be part of a team that laid our hands on her and assisted in that miraculous process of a new life exploding from the inside of a woman.  

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