Wednesday, October 12, 2011

The Learning Curve

Etewa and her mum

On Wednesday morning Sebsabe was unwell, Her stomach was distended and tight and she was in pain. I felt sick at the prospect of what might be happening inside her abdomen and cursed myself for not listening to what the midwife had said the day before, not to feed her, to wait till her bowels were working again. Stupidly I had completely failed to recognize the obvious huge difference between my usual post operative patient back home, a well nourished healthy and  vigorous westerner, and a chronically  malnourished, depleted worn out and sick young poverty stricken Ethiopian. One step forward four backwards! And now was she about to pay the ultimate price for my stupid arrogance?

Was an X-Ray possible? “No it is broken 5 months” Oh my God! My heart sank further.
“I’m so sorry, I should have listened to you yesterday” I said to the midwife.

Well, there was nothing more to do except stop her eating and drinking, keep the drip running, give her some antibiotics and wait. Maybe they would pray, but I would not pray to a God who would let that baby come sideways. I would be angry at such a god, but I was angry with myself, and scared for Sebsabe.

But I was not to be permitted the luxury of wallowing in self pity. A woman arrived by stretcher from somewhere out there, she had been in labour a long time, the baby had not come out, and if I had thought Sebsabe was as sick as you could be in labour, I was shocked at how much worse this little woman was. Sebsabe at least could move and cry out, this one was silent and still, breathing quite slowly with deep sighing gasps, barely able to move her head from side to side, or open her eyes. She was almost unconscious. She had no recordable Blood Pressure and the pulse at her wrist couldn’t be felt. The heart beat that we heard was fast enough to be a baby’s, but it was hers, and a scan quickly showed another dead baby. But first of all we had to try to revive the mother with intravenous fluids. Again the midwives proved their exceptional practical skills quickly finding a vein even though she was so severely dehydrated and “shut down” and her arm didn’t move as they searched with the needle. We squeezed the bags of fluid into drips in both arms and then I examined her to see why the baby hadn’t been born. It was a “brow presentation” which means instead of the baby having its chin tucked in, like you do when pulling a tight jumper over your head, it was extended so that a much wider diameter was presented to the pelvis, and it wouldn’t come through. The forehead was all swollen and spongey. Brow presentation is a rare situation but in the west usually recognized in early labour and easily treated by safe caesarean section long before things get to this ghastly state. But here, in this horrible predicament caesarean was not an option. It would kill her for sure.

We took her down to the Delivery Room and placed her on the delivery table. She barely new what was happening. I thought I should try to deliver the baby with forceps if I could somehow change its position but within a few minutes I realized I could not. I looked at Mesaye, a horrible dread in my guts, knowing what he was going to tell me “I think you will have to do destructive delivery Doctor“ he said. And he handed me the instruments.

I have to say that Mesaye and the others there were unbelievable in the way they helped me and assisted me to do what certainly is the most gruesome thing I have ever had to do. At times they wanted to step in – they had already seen me cry once - but I insisted I would do it, it was my job, I needed to learn and I would be OK. And so I was. But the baby went to the incinerator with the placenta, too awful to even look at, and still hardly a murmur or movement from its desperately sick mother, whose family carried her back to bed number two.

But against the odds our patient, Etewa, survived. We had given her 4 litres of fluid in the first two hours and at the end of it a tiny amount of urine appeared in her catheter, as before, mostly blood but as the hours went by the blood was more and more diluted with urine. The next morning she was still terribly weak and unwell but I could feel the pulse at her wrist, and she muttered a few words. Her poor undernourished mother nursed her continuously, feeding her and climbing onto the bed to embrace and support her from behind, in a room where the mothers in the other beds had babies to feed.  At least Etewa had her life, but theres no grief counseling or social worker support for her, no farewells for the baby, just a grim life of poverty waiting for her to return.

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