Before being allowed to commence the clinical rotations of our third year, my class has to witness three NVDs (normal vaginal deliveries). Today I went to a provincial hospital in the Eastern Cape for mine.
The Eastern Cape is notorious for its poor administration, but medical students love working or shadowing here as it offers valuable experience.
I had to wake up at 06:00 in order to be at the hospital by 07:30. When I got there, the PR-person who told me to meet her at this time in order to sign an indemnity, was on Christmas-leave already. We then discovered that the doctor I was supposed to shadow was also on leave. The next-in-line told us that he was in a meeting till 09:00 and that I should come by then. By 09:30 I was sitting in the Obstetrics doctors’ tea-room waiting to be told where to go while they attended to an emergency C-section.
SMS to The Boy at 10:15:54:
Don’t think I wanna do internship in EC one day anymore. I’m sure at least ten babies have popped out in the time that I’ve been sitting here just waiting for the doctor to show up!
Not long thereafter I met another student (a third year from another university) who was also shadowing. That was pretty cool and we ended up going everywhere together during the day. She showed me around and also translated a bit, as nurses here tend to speak in Xhosa in the heat of labour.
Before I move on to a description of cases (paying careful attention to their privacy and the sensitivity of my readers) I should mention that this hospital, which apparently average 30 births a day, was remarkably quiet today. Unfortunately for me.
CASE 1
The mother, whom I estimated to be about sixteen, was eighteen years old. I am not sure how long she had been in labour as I had just arrived in the labour ward. She was tiny for an 18-year-old. At some point she shouted something (in Xhosa) and everybody laughed (jovially, not mockingly). My new friend says she exclaimed that she will never get pregnant again. A third year nursing student was handling the birth mostly. She and the patient bantered quite a lot, I couldn’t quite tell if they were joking or dissing.
The patient had quite a bit of vaginal bleeding from the beginning of her water breaking. One of the doctors then tutored us on Placenta Praevia and Abruptio Placenta (I knew almost all the answers and felt rather chuffed), so I’m guessing the cause for the bleeding was Grade I or II Praevia.
This was where I saw my first bit of innovation. A nurse was told to put up an IV and he used a latex glove as a tourniquet.
The mom was in a lot of pain, but she pushed well and a baby girl was born at 11:05. Don’t take this as a racist statement but: I honestly didn’t know that black-African babies are quite so white (or rather pale) at birth. I suppose if one thinks logically, the fact that all babies are slightly blue immediately after birth does kind of lead to this fact though. I must learn to think further than my nose.
The mother also had a second-degree tear which had to be sutured. The nurse taught me that one first has to look for the apex of the tear (where it originates), which is quite a mission if there is a lot of bleeding.
CASE 2
There was nobody in labour, so one of the younger doctors (she is doing her community service year and is very nice) told us we could watch a C-section.
The patient is currently in jail, serving a twelve year sentence. There were three female guards from Correctional Services there with her. They weren’t allowed in theatre and had to observe through a little window. I think it’s good, shame, let the woman give birth in peace.
Did you know that they don’t do the full depth of the incision with a scalpel? They cut through the skin and fat, and then they tear the rest of the layers until they reach the uterus. It’s rather unnerving to witness, but apparently it aids healing a lot, as torn fibres heal quicker than sliced fibres.
C-sections go so quickly! I’m sure the longest part was suturing the patient up afterwards. It is quite silly of me, but I never realised that you suture the uterus up separately from the skin and muscle.
Another thing I learnt is that suturing in obstetrics is a challenge! One uses those tong-like scissors so that you don’t have to touch the needle – it minimises prick-risk, I suppose. It requires quite a bit of dexterity I think.
At 12:05 a baby girl was delivered.
CASE 3
A lady was brought in by ambulance from a satellite clinic. Her water had broken at 18:00 the previous night and by the morning she had no pain, no contractions and was 4cm dilated. She was scheduled for a C-section at 14:00, but upon the PV examination it was found that she was fully dilated (that’s 9cm, I think) with caput.
It seemed to be a rather large baby. That, along with the lack of contractions and the fact that the baby’s head was in the upper fifth made a senior doctor diagnose cephalo-pelvic disproportion, which basically means that Mom’s pelvis is not adequately shaped or sized for the size of the baby. One of the doctors even wondered if maybe there were twins, since the satellite clinics don’t have access to scans.
Another doctor did a PV and said that the baby’s head was engaged. That means that most of the baby’s head is in the pelvic inlet and the general rule is what goes in, must come out.
In this situation it is possible to deliver by Caesarean, but the doctor says it is a very messy and big operation. Somebody basically has to insert their hand vaginally and push Baby back up before they can remove him. It is safer for Baby, but should only be done if absolutely necessary.
Just before two a doctor decided that the baby needed to be delivered naturally, or at least attempted. The CTG (cardiotopogram) was beautiful by the way, so Baby was not in distress at all.
This was by far the most interesting case of the day. Despite oxytocin infusion, Mom still didn’t have contractions. But baby was somehow descending. Maybe she just has a crazy-high pain threshold? When told to push she didn’t really do it properly. The doctor then proceeded to apply pressure to her abdomen! That was shocking, I am sure we never learnt that in theory. This caused pain to the mother. The previously-mentioned com-serve doctor jumped onto the bed with the patient to give her something to hold on to.
At 14:10 a baby boy was born.
By the way, this patient was 31 years old and it was her first ever pregnancy. Some of the nurses actually shook her hand. In rural Eastern Cape, it is a huge achievement if you manage not to get pregnant in your teens.
The patient had gushing post-partum haemorrhage. She had a second-degree tear but it didn’t explain the gushing nature. The nurse removed some clotted blood that remained after the placenta had been delivered and the gushing stopped. I don’t know how that works physiologically, but it is one of the exact things we learnt in our Reproductive theory.
Baby was actually rather small, the placenta was normal and there was no twin. I still don’t know why he seemed so big upon palpation.
MORE GENERAL STUFF
There was a patient who was in preterm labour at 32 weeks. She was given steroids to increase surfactant production (basically: to mature the foetal lungs) and tocolytic agents to hopefully decrease or stop her contractions. I think they worked because if I heard correctly, she went from 4cm to 2cm. Is that possible?
I felt sorry for her because she has had a miscarriage and an early neonatal death before. She was so nervous and she cried a lot. She begged the doctors to “cut him” – the patient-colloquial for performing a C-section – but the doctor explained that the baby would struggle to survive. [Note, most South African public hospitals are not equipped well enough to deal with premies at the level of private hospitals.]
She really wants this baby. It is an amazing sight in a country where the birth of another infant often means another mouth to feed, another social grant to collect, another body that needs to sleep somewhere in cramped living quarters.
The goal was to delay the delivery by at least 24 hours. I do hope they succeeded.
I learnt so much today. After seeing an intern performing a C-section, I definitely want to do my internship in the Eastern Cape. I feel like I am studying the right course. I think I can do this. And I think that I would love to specialise in OBGYN.
Many of my friends spoke about an overwhelming feeling when a new life is brought into the world. Like an epiphany. I didn’t really feel that. It just felt… right, I guess. But tonight I watched the movie Faster, and it had so much violence and murder. And I cried! I have never cried in an action movie before.
Oh, I almost fainted twice. Not from the blood, but from the heat! It was quite embarrassing, although I didn’t attract attention at all. I learnt that moving around helps. I do hope that vasovagal responses don’t ruin my clinical rounds.
This is me in my scrubs after a long day - I am exhausted here so please don't judge 
I wore my navy scrubs (issued by my university) today. They are so comfortable; I wish I could wear them all the time. They also look rather smart, in my opinion. I took a bag along and packed my name badge, (pink)stethoscope and my protective eyewear (which I didn’t end up using). I also packed tampons (because I never go anywhere without them), a sachet of coffee and some money. I took my camera but didn’t even take a picture when I was all dressed up for the OR in greens. I think I looked funny with only my eyes showing. Furthermore I brought a clean shirt along, just in case. No sweater, because it is crazy hot in the hospital and it is summer anyways. And lipbalm. Never go anywhere without lipbalm.
But for the grand finale…
I forgot to wear deodorant!!!!
Who forgets to apply deodorant in the Summer, when you know you are going to a crazy hot hospital? I was so worried and considered “borrowing” some isopropyl wipes. But for some or other reason there was no sweat or if there was, not odour. Honestly no odour.
Tomorrow I’ll watch one more NVD… then I am ready for my obstetrics rotation!
