Tuesday, June 19, 2012

CLEMENTINE: A GROWING EXPERIENCE

Photo Compliments of the Talented Photographer Natasha Kanji


The hospital room held three beds. She was lying in the far bed next to the wall with a novel, reading and waiting. The downstairs of our 18-bed hospital is now open. We have three moderate size rooms each holding three beds and bedside cupboards. A fourth room is reserved as a private. A fifth hides behind the nurses consulting room as a semi-private ward holding two beds.

Although our patient was situated in the public ward, she had it completely to herself because the hospital portion of Buea Adventist Health Centre is only partially completed. We are waiting for hospital equipment to finish an operating and delivery room and bring the standards up to a full hospital before we advertise. So for now, only a handful of patients stumble in for hospital for admissions.

Today, Clementine seems content despite a rather sad prequel to her admission. One month ago she came to consult the doctor. “Is this your first antenatal visit?” I asked her then.
“Yes, doctor,” she said.
“Are you having any particular problems?” I queried as I continued my initial history.
“I am worried because I haven’t felt the baby move yet,” she replied. I think I am supposed to feel the baby kick by now. I haven’t seen my period for five months.”

Clementine strikes me as an intelligent, thoughtful Cameroonian. She is 22 years old. She has a boyfriend and is a student in the university. In the waiting room, she reads through the assortment of donated books and magazines. On her first visit, she is dressed in a neat skirt and blouse. Although women do not have maternity clothes here, they manage to dress quite smartly no matter how many months along their tell-tale bellies proclaim.

During the exam I am unable to find any fetal heartbeat with my handheld Doppler machine. We do an ultrasound later that same day. On the exam, I find a fully formed fetus but no heartbeat. The fetus looks like he was about 4 ½ months old when something happened. I cannot tell exactly what has gone wrong on the ultrasound. I hate breaking bad news, but Clementine seems to understand. Her boyfriend comes later and together we discuss why the fetus might have died. I don’t have any definite answers. I hope I can convey empathy and kindness to the couple. It is obviously disturbing. Unfortunately, less than a year ago, Clementine had another pregnancy that ended with intrauterine fetal demise. How can this happen twice? None of us have any good answers.

In the end, we have to face the reality too. “What now?” Clementine finally poses the question.
“Well, you can’t allow a dead baby forever in your womb. It will have to come out. It will be similar to last time.”
“Not again!” she moans. “Why?”

We finally get through talking and she leaves with her boyfriend promising to come back for admission and forced labor to abort the already dead fetus.  She doesn’t come back for a long time though. I wonder what happened. Did she go to another hospital for induction? Did complications occur? Is she all right?

Now unexpectedly she returns over a month later.  “I went back to stay with my family,” she replies when I question her why so long. “I did another ultrasound too. They told me the same thing.”

Clementine is finally admitted to our little health centre hospital. We don’t have a delivery suite, but, for this induction I don’t feel there is a high risk of surgical intervention so I allow her to have her induction here. The fetus was not too big – only 4 ½ months. Clementine begs to deliver here anyway. She likes our staff and feels comfortable here.

I ask Clementine who she has here to help her in the hospital – bring her food, wash clothes or sheets and the like. “No one really, doctor,” she answers. “There is just a little girl; ten years old who is around to help”.

I am amazed at this young lady’s courage. I am also proud of our staff at the hospital here. Although she does not say such in words, I know she has chosen to deliver here over other health center’s that might be closer to family support because she likes the staff and feels safer here.

We give her misoprostel, a drug that is designed to start contractions. I check on her frequently. Each time I ask, “How are you?” she has a cheerful reply.
“I’m fine.”
“Any contractions or pains?”
“Not yet.”

We wait through the night. In the morning, she gives an affirmative to my question about abdominal pains. “Last night I had some cramping pains. They have cooled now.” She says.

Her cervix is dilated (open) and I can feel the amniotic sac with the fetus inside bulging in the vaginal vault. We wait for a while to see if her body has any more contractions. Nothing happens all morning. We finally start an IV drip with oxytocin. Oxytocin causes the uterus to contract.

In less than an hour, Moriah, our nurse on duty for the day comes to my office where I am consulting. She informs me that Clementine has some more pain and now there is a bloody mess in the bed.

Although I am in the middle of an ultrasound on a lady in the clinic, I decide this sounds more serious. I wipe off the gel from the pregnant patient’s stomach on which I’m doing the ultrasound, tell her to relax and wait, and head over to the hospital.

On examination, brown ooze which was once amniotic fluids, forms a puddle on the bed. A small amount of pink tissue protrudes from the vagina. On closer inspection, it appears to be a small foot.

We take the patient back to our make shift delivery room. After some waiting at which time I almost walk out of the hospital, Clementine feels the urge to push. She delivers fetus and placenta intact in one push. The fetus has obviously been long dead. It is wrinkled and macerated. The good news is that everything is out now. The uterus contracts down like it should. There is limited bleeding afterwards.

Clementine delivers with our support and we help her clean up too. I am confident her physical situation is fine  but I worry about her mental and emotional recovery. She is here all alone. She lost two fetuses in the last year and a half. It is difficult emotionally for anyone. She does not have any visitors except a 10 year old girl. Thankfully, she has done much of her grieving already at the parent’s house in the village before she came.

“How are you?” I ask that evening.
“I’m fine, doctor,” she says quietly but emphatically. She smiles to reinforce her words.

The next morning, Clementine is ready to go. I am glad things have gone smoothly as far as her medical problems were concerned. I say a prayer for her and her future dreams of being a mother.

She has a simple, trusting smile. She packs her bag with her few articles she brought with her – one change of clothes, a cloth, a bed sheet, toilet paper, and of course, her novel. The little girl helps her.

For me, the case has a bittersweet ending. I am glad she is well and no complications occurred during her induction. I am sad that she had to lose a second pregnancy so soon from the first. I am glad that although we are an incomplete hospital, we could provide the care required for this induction of a second trimester fetal demise. I wish we could provide the same care for deliveries of full term and live babies too!!! “One day,” I tell myself. “One day we’ll have the capability to delivery live babies too – God willing”.

“If you then, who are evil, know how to give good gifts to your children, how much more will your Father who is in heaven give good things to those who ask him!” Matthew 7:11

Lord, I ask you for equipment and personnel to handle both operative and normal baby deliveries.