Thursday, March 29, 2018

The Things That Medical School Won't Teach You (7): A mother is not supposed to die in childbirth

I always knew I'd wind up coming back to the Obs/Gynae Department, a treasure trove of crazy medical experiences. Suffice it to say, my drama in the department began as early as the very first day that I set foot in it. I didn't have the joy of being eased into the department in the manner I would've appreciated. Right after I finished my Surgical rotation, I moved into the Paediatrics Department along with 3 of my other colleagues; my time in Paediatrics was short-lived because an inadvertent gap had arisen in the Obs/Gynae Dept, occasioned by the early departure (read completion) of some of the interns who were in the department at that juncture. So I ended up being cherry-picked to be moved into Obs/Gynae after only 3 weeks in Paediatrics.

So the memory I'm choosing to highlight is Day One of Obs/Gynae, with all the machinations having already taken place.

We began the day with a mortality meeting to discuss the demise of a mother (the dreaded "maternal mortality"). So I sat back listening to one of my fellow interns highlight the patient's history: the patient had progressed to full-blown Eclampsia and had to be placed in the ICU; in addition, the patient's blood pressure had been very difficult to control and the patient's urine bag from her catheter was filled with frank blood where ideally there should have been urine. 
Now in my mind, I'm logically reasoning out that the eclampsia has caused major organ damage and that in addition to ICU care she would also need Dialysis if she was to have any chance of survival; surely there wasn't much that could've been done for this patient. 

This is where the story took a bit of a twist; after the intern had finished her deliberation, the Medical Officers went into attack mode and basically acted like they were pinning the patient's demise on the interns' follies. I even remember that one of the medical officers had rather scathing remarks for the intern who had used intravenous Hydralazine to try to control the patient's blood pressure. 
Interesting side note: (Intravenous) Hydralazine is one of those drugs that medical personnel are very very afraid of using. Quite a potent vasodilator - especially in its intravenous (IV) form - many a medical professional has had the misfortune of having a patient rapidly progress from high blood pressure to low blood pressure/shock or even death after administration of this drug. Some nurses are so afraid of the IV formulation of the drug that they will reconstitute it, and then give it to the doctors to personally administer it. 

Truth be told, the intern was merely following orders of that very same Medical Officer who had recommended the infusion when consulted for help via phone, but it would have been considered sacrilegious to bring it up at that Mortality meeting, especially against a superior. The blame game only ever seemed to have a downward trajectory at those meetings.
In case you aren't aware of it, working in the Obs/Gynae Dept is one of the hardest tasks ever. In most places, particularly public hospitals, the workload is immense; however, it has the added dimension of having the most medico-legal ramifications tied to it. The death of a child is definitely a bad outcome, especially if it ends up being a "fresh still birth", which can pretty much be construed as the medical professional having failed to act in time. On an ever worse scale than that is THE MATERNAL MORTALITY, which, at any time that it happens, generates a storm of controversy that will require explanations to higher-ups in governmental oversight organizations.

I remember one time during a ward round, one of the Obs/Gynae consultants made the following observation:
Childbirth is a natural process. Mothers who come to a hospital to deliver should have a better outcome, otherwise they might as well just deliver at home.
Superficially, this would appear to be an ever-abiding truth, but anyone who has ever worked in an Obs/Gynae ward should know better; after all, "the greatest untruths are truths slightly distorted."  Childbirth is not merely the number of hours that a mother spends in labour and delivery; rather, it is the culmination of roughly 9 months of nutrition, care/neglect, wisdom/folly, health/disease and development that has already occurred prior to actual labour and delivery.

The more distant someone is from the reality that goes into a successful pregnancy and delivery, the more they embrace that aforementioned untruth; in my experience, top brass (especially those in government) are the most likely to be ensnared by this untruth. I remember that when my country (Kenya) initiated a Free Maternal, Child Health Program, they simply declared Maternal Child Health services free at government hospitals, and made sure the public knew as much. So you had mothers rushing in en masse to have their deliveries at hospital, which should have been ideal, right? Actually, because the referral system isn't at its best, mothers overloaded certain hospitals of their choosing (Kenyatta National Hospital - bearer of most suffering - being one of them). Imagine the pandemonium when the medical professionals encountered massive patient loads against no capacity building efforts whatsoever, and handcuffed to the mantra that "a mother is not supposed to die in childbirth".

In my opinion, that mantra needs a little bit of tweaking; a better way of stating it would be that "it is undesirable for a mother to die in childbirth". This reflects the truly complicated dynamic that exists between pregnancy & delivery, and antenatal & post-natal care. When you deal with the common mwananchi, and even people who seem to be of an upper echelon, you get the vivid impression that people "freestyle" this whole pregnancy business. Many were the times that we were discovering a mother's medical problems as we had her up on the table prepping to perform a Caesarean Section (C/S); or better yet, we learnt it as the mother was wheeled screaming into the maternity ward. Here's a taste of that litany:

  1. The patient who has managed to go all 9 months without any sort of medical checkup whatsoever. 
  2. The mother who has been pushing with each and every one of her contractions, before she was even adequately dilated; her whole vulva and cervix are so oedematous that any chance of normal delivery is gone.
  3. The dear soul who chose to augment her contractions (using herbs et al) so that she could speed up the whole process of delivery...which actually only ended up causing foetal distress.
  4. The lady with multiple previous C/S scars who chose to stay at home till labour was dangerously upon her, convinced that she could perhaps deliver naturally this time around; unwittingly, she instead puts herself at risk of suffering uterine rupture.
  5. Slicing through a placenta during surgery because the mother had an anterior placenta; something that we might've been prepared for if she'd had a recent ultrasound done.
  6. The mother who has been suffering from Gestational (aka Pregnancy-induced) Diabetes and hence she's carrying around a massive (macrosomic) baby.
  7. The woman who has been blissfully walking around with blood pressure readings that are so off the charts (for example 200/130) that you wouldn't be surprised if she had a stroke right there on the table as you're trying to operate on her.
  8. That perfectly healthy young lass so overwhelmed by the whole mystique surrounding childbirth that she insists from the very beginning that she wants a C/S. Worse still if she's gotten reinforcement from friends or unwitting clinicians. Without the proper psyche, good luck getting her to cooperate with the midwives. As an added bonus, this is also the type of patient who the anaesthetist will have an especially hard time administering spinal anaesthesia to. 
  9. The mother who has been manhandled or neglected at a peripheral facility, and usually ends up spirited to your facility a bit late in the game. Congratulations, all her problems now become your problems
  10. The patient who, despite being an adult of sound mind, is unable to commit to being taken to theater for a C/S without her husband first showing up in person to give consent; this despite the medical professionals being pretty sure that they have a Non-reassuring foetal status (NRFS) on their hands, and that urgent surgery is the best course of action.
  11. And with any pregnancy, you face the twin threat of massive bleeding events before or after delivery (aka Antepartum and Postpartum Haemorrhage).
    The causes are many, but by the time they are upon you you'd better act quick or risk losing your patient.
I'm pretty sure that there's more that could be added to the list, but it should at least be an eye-opener. My point in all this is that if you want to have the kind of health outcomes for Maternal Health that are the pride of developed countries, then you have to realize that your outcomes can only be good as the quality of your patients; you also have to be prepared to put in a lot of work.
  1. Education of the common people about the importance of Antenatal and even Postnatal care; 
  2. Massive investments have to be made into capacity building, because hospitals, and all classes of medical professionals (especially nurses and doctors) won't just appear out of thin air. 
  3. Outreach must be emphasized; it''s time to embrace preventive medical aspects wholeheartedly.

    I have a personal gripe with how this was done in Kenya because part of it ended up as the "Beyond Zero Campaign" under the First Lady, which in my opinion is misplaced despite the well-meaning sentiment behind it. This decision would be on par with the president deciding to outsource the leadership of the Ministry of Energy's fledgling Nuclear Energy Department to someone without any experience in the field. This is not a pet project, and needs to be recognized as a pillar of healthcare in this country.              
  4. Funding needs to be increased, and has to be targeted especially at mothers with High Risk Pregnancies.
    In line with this, ultrasonography has to be considered an essential service for mothers to have access to, and should be covered under Free Maternal Health.

There really are no quick fixes to any of these issues, but I think there is hope for useful course correction if we can all have a clearer appreciation of the bigger picture. I have hope that this would benefit everyone, especially the mothers (actual, potential and otherwise) who are such an important part of our lives. I also hope that I won't be scaring any students away from this Department; even if you won't be specializing in Obs/Gynae, it is still a delightful rite of passage that you shouldn't do without.

God Bless.

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