Thursday, February 19, 2009

Week 4

Morala: a basalt rock a laboring woman carries with her when leaving your home to make it to the hospital before you deliver.
I was undressing a woman in the labor room and I heard a clunk on the flour. I looked down and thought maybe I had dropped my reflex hammer. Instead when I looked on the other side of the bed I noticed a rock on the ground. I couldn’t imagine why this patient would bring a rock with her to the hospital. I picked it up and showed her the rock. She motioned for me to put it down on the table for her. When the nurse came back I asked her what the rock was for and she explained to me that women bring the rock with them from home. It is a special rock that they keep in their clothing until they get safely to the hospital. It is supposed to protect them from delivering the child on the way to the labor room. Once they get to the hospital the patient no longer needs the rock and discards it.
I have learned so many things in medical school and many of them are things I will never see. I saw one of those cases today. A 16 year old was brought in by her mother. She was in active labor. She was known to be pre-eclamptic. Pre-eclampsia is actually a common medical condition in pregnancy the world over. I have seen many patients in the US that present with swelling in their legs, protein in their urine and high blood pressure. I have cared for these patients and managed their deliveries. There is a certain sense of urgency in these cases. The babies need to be delivered rather quickly to avoid devastating outcomes. When my patient presented in labor she complained of headache and should have been started on treatment right away. Instead she was admitted and allowed to deliver. It wasn’t until after she had given birth that she had a seizure. She was seizing for quite awhile before she was finally started on the correct medication. After her first seizure she was no longer responsive. She continued to breath but she no longer had the ability to speak. The first time I saw her was the day after her first seizure. We checked her medications and discovered that the maintenance dose of the medication to prevent future seizures had not been given. The patient was also significantly anemic from all of the bleeding during delivery and needed a transfusion. Her blood type was O+ and there was no blood for her. Not one pint. Not even in the main blood bank in the capital of Lesotho. So there was nothing we could do. We asked her mother who was there with her if she could donate blood and she informed us that she was herself 6 months pregnant. She was holding her 16 year olds baby and rocking him back and forth as we talked. In Lesotho there is only one official blood bank and it is in Maseru. The government hospitals are very wary about blood banks given the pandemic of HIV. It can be completely frustrating because so many patients are anemic and in desperate need for blood transfusion. So we had to transfer this patient to the capital hoping that they would do something to improve her outcome but knowing that they would no be able to give her a transfusion and fearing that she would continue to be unconscious. This woman had had the dreaded outcome I had learned about in school. Something that I had never seen in the US. This was the end result of a seemingly simple complication of pregnancy. Who would care for her new baby boy?

Today we talked about abortions and I was amazed. In one day we had eight "incomplete miscarriages" and you wonder why. I have been talking with the doctors here and it seems that women seek out alternative abortions frequently and when they go wrong is when the hospitals see them. The doctors have said that on vaginal exams of these patients they find matches and leaves. Sometimes they can tell that the cervix has been manipulated and sometimes they have seen uteri that are completely punctured through. What has been happening is that the nurses watch the doctors do vacuum aspirations or D+C and then use this experience to open up their own practices outside of the hospital. They can then offer the abortion services at a much cheaper rate and in a much less safe environment. In the capital hospital one of the janitors was doing abortions in a hospital room and then just sending them to the doctors in house when things went wrong. This is very frustrating.

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