NVD

So I narrowly escaped having my baby cut out by a gynae.

Due to unforseen circumstances, I ended up having my baby in Cape Town. This meant I had to find a new gynaecologist/obstetrician. My cousin suggested her gynae and I went with him.

I started having contractions last Tuesday morning. As I've mentioned before, my first labour went very quickly, so I was anxious about waiting too long before going to the hospital. When my contractions started getting reasonably strong I decided that maybe it was time to go in. My partner suggested I rather call the gynae first. So I did and he suggested I go to his rooms and he'll check me out. When I got there, I was having fairly strong contractions. However, my cervix was still closed, but because my first labour had progressed so quickly and I was already having strong contractions, the gynae wanted me to go in to hospital. Both my partner and I were uncertain about this but we decided to go through.

We went home first (my parents' home) to pick up our son and my mother to go along to the hospital. When we got to the labour ward, the nurses remarked on how the gynae had been phoning constantly to see where I was. Not a good sign.

The midwife set me up in the labour ward and gave me an enema as per the doctor's instructions. Unpleasant. Anyway, she then told me she would call the anaesthetist to get me an epidural. I said I felt it could wait (I wanted to know how far I had progressed first because I didn't want to have the epidural too early) but she told me the gynae had said that the anaesthetist was very busy and that if I didn't get it then I might end up not getting it at all. My contractions were starting to get quite painful and I didn't want to end up not getting an epidural. Also, I knew they could top it up if started to wear off, so I agreed to go ahead with it. The anaesthetist who was first on call was indeed too busy so the second on call came in. He also apparently had alot lined up that night so in the end I was happy I'd gone for it then.

The epidural was much more painful than my first one had been and I reacted quite badly to it. At a stage the anaesthetist even dropped my bed and drew up some adrenaline. I recovered with only fluid resus though. I felt terrible though and at a stage I even wondered what was worse: the pain or the effects of the epidural? (The epidural started to wear off later though and I came to the conclusion that the pain is definately worse!)

Then my gynae came to see me. He remarked to the anaesthetist that he was exhausted. I knew this didn't bode well. He did a PV. I was only 1cm dilated. He seemed unhappy. It was already about 8 in the evening by now. He decided to rupture membranes to speed things along. He came back to check on me about an hour later. 1 and a half centimetres. I knew he would soon try to sell me a caesar. He started talking about how I should have progressed much further by now and started throwing around phrases like "big baby" and "malposition of the head". Then it came: he said that we could either wait and see or we could just call it quits and go for the caesar then. We told him we'd wait.

He decided to go home and asked the midwife to check my progress in about another hour. My partner and I discussed the situation. I felt he should only check on me in another 4 hrs seeing how I was still in passive labour. We both knew there wouldn't be much change in an hour. We knew he would try to coerce us into taking the caesar.

After about an hour, the midwife came to check on me. No change. She called the gynae. She came back with the message. He had given it a chance but I was not progressing so he would book theatre for a caesar. I said no. I told the midwife that as far as I was concerned there was no rush. I was still in passive labour and doing fine and the baby was being monitored and she was fine. If anything went wrong, we would know immediately and then we'd agree to a caesar, no question, but right now, there was no need for it and we were happy to wait.

She seemed to agree with me but said she'd give us time to discuss it.

We agreed that there was no reason to have a caesar. My partner decided to call my original gynae (a colleague of his) to cover our bases. He confirmed what we suspected. We turned down the caesar. The midwife relayed this to the gynae and he asked us for a time frame for how long we were willing to wait. It was nearly 11 at night by then. We said we'd wait until 6 in the morning. She came back and said that he'd told her that if nothing had happened by 06h00 he would book theatre. I was still not happy with that and told her that if nothing had happened by then we could discuss it again. She said that would be easy enough to do.

We decided to try and get some sleep. I was unable to rest easy though. At about 02h30 the midwife came to check on me again. She said she thought something was happening. She was right: I was 5cm dilated. Relief washed over me (and my partner when he woke up an hour later. He slept slightly better than I did ;) ).

By about 05h30 I was fully dilated and the midwife called the gynae. At 05h47 I delivered a perfectly healthy little girl. (He made some remark about how the head must have turned at some stage. Yeah right.)

I ended up having an episiotomy and a vacuum extraction as the baby's head remained high, so it wasn't actually an NVD, but at least I escaped having unnecessary major abdominal surgery.

It's a girl!

So I've finally given birth, yay! It's a beautiful little girl and she was born yesterday morning :) Quite a story about how it happened but I'll tell it next time. Right now I'm just going to recover and spend time with my family.

Family make the worst patients

I'm not sure if this is universal, but in my personal experience and those of my close friends and colleagues, your own family members and close family friends are always the worst patients.

Maybe it's because the transition from 'lay person' to doctor happens in front of them so they don't view you as a real doctor, but invariably, when they ask you for advice, they don't take you seriously and they don't bother to take it. It's quite frustrating because you think "why did they bother to ask?" but after a while you just get used to it, shrug your shoulders, shake your head and brush it off.

And they tend to be non-compliant. My dad has essential hypertension. He's had it for years. Still, he tends not to take his meds on time and sometimes even skips a few days. Two of my uncles have type II diabetes mellitus yet still continue to eat poor diets, but not only that, all their kids are obese! If I were faced with such a terrible affliction, I'd make damn sure my kids don't get it, but it's like they're making sure their kids do! All advice falls on deaf ears.

Then there are the phone calls saying they have x, y and z signs and symptoms. You ask a few questions to guage the severity, but whenever you think it might be something serious and suggest they go see a doctor in person to be examined, they say they don't think it's necessary. So why did they ask you wonder once again? But it's pointless trying to get them to listen to you.

And whenever you suggest a certain treatment or specialist, you're invariably faced with "but can't I just do this or use that?". "No" you say. They never listen.

A close family friend told me she had a personal problem. "Yes?" I asked and listened. "I have a painful swelling on my vagina", she told me. Knowing her personally, I wasn't keen to examine her, but she gave me enough information for me to make the tentative diagnosis of a Bartholin's abscess. I told her what I suspected the problem was, advised her to see a doctor asap and told her it would have to be cut open. "But can't I just put antiseptic ointment on it?" she asked. "No" I replied. She didn't listen. About 4 days later, in the middle of the night of course, the pain apparently became completely unbearable and her husband had to rush her to casualties. I laughed when I heard this. She was probably seen by some poor casualties officer who wondered why she had waited so long and until the middle of the night. I'd often wondered that myself whilst draining an abscess in the wee hours of the morning, now I seemingly had the answer.

But what can you do? They're family, so when they ask, you have to listen and advise, even if you're smiling to yourself knowing they won't listen anyway and wondering once again why they even ask and why you even bother.

Birth day

The time is drawing nigh and I'm actually getting a bit nervous.

With my first pregnancy I decided that I didn't want to be one of those annoying women (like many a patient I've seen) who comes in claiming to be in labour, turns out to have a cervix that's 1cm dilated, gets told the true signs of labour and to come back when she's got those but shows up again the next day and is then only 2cm dilated.

Maybe it's because I did all my obstetrics in the state, where days are long and beds are few, that I always got annoyed by those women. In private, you probably get admitted if you want to, but in the state, your admission ticket is active labour and nothing less.

So I decided, armed with my knowledge, I was going to do everything right. And I did. But things actually went too well. When I showed up at the labour ward, my cervix was 4cm dilated. I got my epidural and then, even though I was a primigravida, within 1 hour I was fully dilated and ready to deliver.

So this time around, knowing that the second time everything goes much faster, I'm nervous because I know I have to get to hospital asap!

I have great respect for midwives. Most babies can actually be delivered at home by a midwife. A trained midwife though, because although most pregnancies are actually uneventful, when things go wrong, they go very wrong and you want someone who knows what to do and when to get you to a doctor. Having said that, there is no way I'd deliver at home. I know too much and I'm way too paranoid. I want to be in a fully equipped hospital with lots of drugs readily available and a fully trained obstetrician. But I have to get there on time to have that.

I always find it amusing in movies and TV when the expectant couple rushes to hospital at the first sign of labour, tearing up the streets, only just making it there in time before the baby pops out, because real labour is nothing like that, but I've really been worried this pregnancy that that might really happen to me.

Today I had a few mild contractions. I was pretty sure they were Braxton-Hicks, but when they started coming approximately every hour, I started thinking it might be early labour. Then I started wondering if I should go to the hospital. Like I said, I've already decided to make haste this time, but then I started thinking: how early is too early, even with a history of a previous short labour? Also, I wasn't convinced they were real contractions. So I decided to wait and see. I thought I might be taking a gamble, but it turned out ok because after a few hours they stopped.

So in the end it was good I didn't rush off to the hospital because I would have looked like a fool.

But now I'm really left with the predicament of how soon I should act.

Corruption

Corruption in Africa is widespread. So widespread in fact that most us aren't even suprised by it anymore. Occasionally, however, someone comes along and takes corruption to a whole new shocking level.

Just as common as corruption around these parts is the desire for a DG or disability grant. It is highly sought after. Scoring a disability grant is almost like scoring a jackpot to alot of patients around here. It's a strange phenomenon. Even better than getting a DG for a serious illness though, is getting one for no good reason at all.

What I am about to say is absolutely true.

A group of staff members at a community clinic were caught trying to abuse the social welfare system. In South Africa, the government grants DG's to HIV patients with CD4 counts less than 200. So what these people did was intercept the blood specimens of HIV positive patients who looked very ill and send the blood away for a CD4 count under their own names. In this way, they had a legitimate record of a very low CD4 count which qualified them for a DG.

Fortunately though, the actual application for a DG has to be filled in by a doctor (usually one who does nothing else but that) and when one of these people approached one, he was suspicious of a very healthy looking person supposedly having such a low CD4 count. In this way, this person and eventually all of them were caught out. They even received disciplinary action. Now that's something that's rare in Africa.

Too late

One of the most difficult things in medicine is accepting that there was nothing more that could have been done.

One case that affected me quite badly was that of a young pregnant woman with TB .

When she came in she was already 7 months pregnant and had been on TB treatment for a few months. She was in a bad way. She was wasted and malnourished, had oral candidiasis and was short of breath. She tested HIV negative on rapid test. I didn't believe the results so I sent stat blood to the lab for an Elisa. It also came back negative.

In the meanwhile, she'd had a chest x-ray which should extensive infiltrates and lung damage - she barely had any normal lung left.

I made a tentative diagnosis of multi-drug resistant TB.

The baby was also not doing so well. There was very little amniotic fluid and although there was a heartbeat on ultrasound, there were no foetal movements.

The patient also complained of abdominal cramps and on abdominal exam she did seem to be having some mild contractions. On vaginal exam her cervix was very posterior and very difficult to assess.

I sent her to the state hospital with a diagnosis of probable multi-drug resistant TB, oligohydramnious and possible early labour.

She was reluctant to be admitted but her mother seemed to understand the gravity of the situation and talked her into it.

Next day, on enquiring after her at the state hospital, it seemed there was no record of her being in either the gynae or obstetric wards (the baby was viable, but the state hospital did not have adequate staff or resources so whether the baby was considered viable by them probably depended on whether they had a neonatal ICU bed. Nevertheless, she was apparently in neither ward.)

I remember thinking that she might have absconded, considering how reluctant she had been to be admitted. More likely though was that she was in fact in the ward but the hospital staff were just too lazy to look and claimed they had no patient by that name (very, very common in South Africa. In fact, if you enquire after a patient, it's the exception rather than the rule that anybody bothers to make any effort to help you).

About two months later, I saw her mother again on an unrelated issue. She told me that her daughter had been admitted to the hospital. She said that the baby had died in utero and that her daughter had then died a few days later.

I was devastated.

She had essentially died from a curable disease.

What had happened up to the point that she'd presented to me was uncertain. Whether the system had failed her, or she had been non-compliant, I don't know, but from the time that I saw her, it was already too late it seems.

Love and devotion

With HIV positive patients you get two types of families. Either the family abandons the patient altogether, or they are highly involved and do everything they can to ensure the patient gets help.

(Unfortunately, even with the latter type, patients who have been away from their families often only return to their families when it is too late and sometimes even refuse treatment even when the family members -usually their mothers - do everything they can - even forcing them to go to hospital etc.)

One day I saw a very elderly woman who tested HIV positive. She was about 75 years old and demented. She also had a previous stroke (found on examination, not history), was blind from cataracts, and was in
adult nappies (diapers) with a severe nappy (diaper) rash.

I couldn't help wondering why, with all these co-morbidities, she had been brought in to test for HIV. I was even more surprised that she had tested positive.

The only thing that could really be attributed to the HIV was that she also had a severe peripheral neuropathy. The dementia may also have been attributed to the HIV but AIDS Dementia is really a diagnosis of exclusion and I thought it was probably due to something else in her case considering her condition. According to her family member though, she had been quite functional before and had rapidly deteriorated in the last month or so. I felt that she was in a dismal condition, but in view of this, decided to do a work up.

The family member who accompanied this woman was her 20-something year old grandson. He had been taking care of her for a while. This was an exceptional case so I didn't expect him to fall into either family category frankly. In fact, I felt quite sorry for him: I thought his sick grandmother was probably quite a burden for this young man but that he had been caring for her out of duty and now needed some reprive.

I got the social worker involved. My plan was to admit her to hospice, treat her other problems symptomatically and do a work up for the dementia. Thereafter I planned to place her in a long term palliative care facility. I decided that if the dementia was due to AIDS Dementia Complex, I would start her on ARV's, otherwise I didn't think it would be practical or beneficial.

I asked the social worker to explain the situation to the grandson and then arrange placement. The grandson however was not happy with this plan. He did not want his grandmother to be placed in a palliative care home, he wanted to take care of her himself!

I was amazed. Here was a young, single male telling me he wanted to care for his sick elderly moribund grandmother.

As it turns out, this woman had only one child - a daughter. Her daughter in turn had 3 children. The youngest of these was the young man now accompanying his grandmother. His mother (the patient's daughter) and 2 siblings (the patient's other 2 grandchildren) had all passed away (I didn't ask what of but in our setting it's likely it was also due to HIV). This sick elderly woman was therefore the only family he had left.

I was so touched I nearly cried.

I had such sympathy for this young man, but more than that I was deeply impressed by his devotion to his grandmother.

It seems there really are selfless people out there willing to do whatever they can for the people they love.