Thursday, December 22, 2011

Third Time Lucky

She is very happy but there is good reason for the sadness in her eyes
This is a story which nicely illustrates, among other things the difference made by  having someone in Motta who can do a cesarean section., and is about a woman I saw in clinic about a month ago. She was sent to me so I could do an Ultrasound scan and try to work out when her baby was due. As usual I asked if this was her first pregnancy and was told it was her third. “And how did the first two go?” I asked. “Both alive but no any more” – a tragic and too common sory round here, for someone to have children which subsequently die, usually of infectious diseases. But I dug a bit deeper and found out that they had both been delivered here in Motta and one died within a few hours and the other in a few days of  their birth. The only other detail I could get was that they had both been delivered with forceps, and the mother described what sounded like some sort of a head injury to at least  one of them as a result. None of this was recorded in her notes because the old file was lost and as usual the midwife filling out her new one didn’t make any attempt to find out what had happened to her children other than recording there had been two. Inadequate history taking is one of the deficiencies in antenatal care that Myrte and I have both identified but to date we have been too busy dealing with acute clinical problems in the Maternity ward to have time to get to the Clinic to do something about it. The “History” we were taught way back in Med School will give you 80% of the diagnosis, and its no different here.

Now there are many possible reasons why her babies could have died, varying from prematurity, infection and haemorrhage to birth injury and congenital abnormality, and so to try and prevent her losing a third baby we needed to find out as much as we could. The Medical Records system here –and elsewhere in Ethiopia – relies on the patient remembering the unique hospital record number  which is written on a small piece of cardboard and given to them when they first enter the system. If the patient loses the card or cant remember the number  - both are much more likely than the card being kept - it is impossible to find the old file and a new one is started. In this case however I was able to track it down by looking in the Birth register for the day  a couple of years back when she said the second baby had been born. I should have expected it, but after the excitement of finally tracking them down, the notes were a disappointment, and contained almost no useful information. The brief description of the labour and forceps delivery contained not even a hint that it was all anything other than routine. Indeed just about every “Delivery Summary” is usually the same three or four sentences with only the sex and weight of the baby changed!  So I was no further ahead but I wrote in her now combined old and new notes that I wanted to review her in three weeks and that I was to be notified immediately when she came to maternity in labour.

The usual "Delivery Sammery"
In fact I didn’t see her again till she was a week overdue, last week, when she returned for a check up.  Simagnew, an excellent senior midwife who had been away when I first saw her, recognized her immediately  because he had been present when the second baby was born – he described a ghastly horror of an instrumental delivery that was hugely traumatic to the  mother as well as the baby whose head was barely in the pelvis when the forceps were applied, and the babies death was no surprise to him.  The poor woman had been through this twice, and her husband - a teacher at a distant rural school - actually used the word "killed" when describing the births of their first two children to me later. The  only other option on those two occasions would have been to transfer the mother to Bahar Dar, by which time the baby may well have succumbed, and possibly  the mother also from a ruptured uterus. And in Bahar Dar forceps delivery may have been attempted with the same results both times - its impossible to know.

Obstetric Forceps : Scary but Life-saving instruments usually
However I suspected that this womans pelvis was just too small for safe normal birth, but to be certain I had wanted to see her in early labour,  when there would be time to arrange a caesarean if the head wasnt fitting nicely into the pelvis . However , here she was, a week overdue and when I checked, my suspicions were confirmed - this babys head was what we call "floating", not showing the least sign that it would fit into the pelvis. Sometimes its difficult to decide if a caesarean is necessary but this decision wasn’t and the next morning we delivered a healthy baby girl.

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