March 14th
Just assisted (well a few hours ago now) a woman in having a "normal" vaginal twin delivery (with no junior doctors or keen midwives wanting to conduct/do the delivery I am allowed to do this here- I enjoy this "hands-on" involvement although in all honesty I didn't really do anything other than be there in case there was a problem as the woman did it all herself).
She was a woman who had attended for antenatal care previously and thus we had diagnosed her twins some weeks ago. The news that it was twins didn't really surprise her as she has already delivered two sets of non-identical twins (predictably here one of the babies from her first delivery was stillborn but the other three are alive and well). The first baby was in a breech (bottom first) position and we also predicted (based on the position in the uterus) that the second twin would also deliver as a breech as well. When we saw her in clinic last week we recommended caesarean birth with tubal ligation to her- as this is recommended practice here the same as it would be in the UK although I have not been able to get a very concrete reason for this recommendation in view of the maternal morbidity attached to caesarean birth (both now and in future pregnancies) and the fact that the evidence from big studies suggests that there is actually only limited if any benefit for the babies in caesarean when they are breech in populations with a high perinatal mortality (which is definitely where we are here). However we do have difficultly in monitoring twins (most have continuous monitoring in the UK which is not an option her) and of course my resuscitation skills although now better honed than when I arrived are still not those of a neonatologist. So I decided that in spite of misgivings I would make the recommended recommendation!
Perhaps for the first time since I have been in Ethiopia the mother's response was to disagree with the recommendation and to say that she wanted to plan to deliver her babies vaginally- a long discussion with the clinic translator was roughly interpreted to us as "she says she delivered the other babies normally and two of them were bottom first , and also she needs to get back to working on the farm soon after delivery"-in the circumstances this did not seem an unreasonable argument. So we persuaded her that she should come to Gimbi Hospital for the births (her other births were at home) and she agreed that she would do this. She was 37weeks at this point looked marvellous and had no complaints about anything at all (not even backache) - I have a photograph of this tiny woman with a huge bump smiling that wonderful Ethiopian smile (shame I can't attach pictures with email postings!).
She arrived in the early hours of this morning in labour and was happy with her plan for vaginal birth. The labour progressed normal but as is sometimes the way with third babies it was not quite as quick as her second labour. The midwife Sintaiyu, who was caring for her seemed u happy that the woman had "chosen" to deliver vaginally against the recommendation of the doctors (the idea of patient choice in most things is at best embryonic in Ethiopian practice and it is something I have spent a significant amount of time "banging" on about to try to increase the acceptance of involving women in decisions about their care) and muttered repeatedly that she didn't want caesarean section in a slightly disapproving way. I had assumed that she was repeating the conclusion of the clinic counselling but it transpired that she was asking the woman again repeatedly through her labour if she would agree to have a caesarean section. This fact became apparent when Sintaiyu came to me 10minutes after we had diagnosed full dilatation (i.e. it is getting very close to the birth of the babies normally) so say (very proudly) that she had now succeeded in getting the woman to agree to have a caesarean section.
At this point anyone reading who works with me will be smiling, knowing exactly what my response to such a request at this point in labour would be in the UK- a straight forward and categorical "No" . I'm not mean but on the balance of risks we are now at the stage where safe vaginal delivery has become very likely and at the same time the chances of complications from caesarean birth are much higher so that for a doctor who wants to do the best for their patient and particularly if they want to do the thing that is likely to involve least harm it is a very easy decision. In Ethiopia the decision was even easier as although our caesarean sections generally do fine, they definitely have more complications than the successful vaginal births. You can add to this the financial argument (which in the past we have had the luxury of ignoring in the UK although I suspect those days may soon be over) which is that in this hospital normal birth cost about 400burr (£20) and caesarean section about 1200burr (£60) - I don't know if this woman will require the safe birth fund but the fund will go a lot further if women are able to deliver vaginally.
Unfortunately poor Sintaiyu is now confused as she felt that she was doing as I would have wished her to do by involving the woman in choices about her care- more work needed for a complete understanding of difference between choice and brow-beating I think!
Anyway the woman seemed to cope with my refusal to agree to her "wish" and 30-minutes later she delivered the first twin, a boy as a breech and 20-minutes after this a girl who somersaulted into the pelvis and came out headfirst. Neither baby required any resuscitation, weighing in at 2.5kg each. This weight would be considered respectable here for a singleton and for 38week twins are very healthy weights. When I think that this means shat this 45kg woman was carrying 5kg of baby (plus at least 3kg of fluid and placenta), I can only marvel at the constitution that allowed her to smile and make no complaint in clinic less than a week ago-not to mention the fact that between that clinic appointment and delivery today she has been out working in the fields where she will almost certainly be again in a few days with breast-feeding twins in tow.
I realise that I am going to have to steel myself for a reverse culture shock experience when I come home and in particular force myself to dig deep to find my old sympathy for the women in my antenatal clinic who come complaining of minor aches and pains but who don't realise how lucky they are not to have to work in the fields when heavily pregnant.
No comments:
Post a Comment