Real Medicine

Delivering the Children of Positive Patients

In medicine, every single patient potentially has HIV.  You can run tests, but the chance remains that your patient could be in the window period. So you don’t know. And your patient may tell you that she doesn’t sleep around, has a faithful partner (who has also been tested), has never been raped and never, EVER shoots up. But as everyone’s favourite MD says, “Everybody lies” and so, you just don’t know.

Thus we take precautions, even with the doe-eyed religious married young women.

In obstetrics we wear goggles and gloves and, if the temperature allows it (which it doesn’t, in South Africa), we cover every inch of skin in thick green sterile coat.

But what if your patient is positive?

What do you do when a woman at term walks into the ward, presents her antenatal clinic card and next to RVD-test accepted, it also says Treatment Given, along with a CD4 count?

As health care professionals, even at the most junior and insignificant level of a third year medical student, we have an ethical and moral obligation to provide health services without discrimination. Fear of contracting HIV should never be used as an excuse for allowing someone else to handle the delivery.

And so you take the extra time to wear not only goggles, but a visor. You wear double gloves – which is probably one of the most taxing things to do, especially with unpowdered gloves.  No matter the heat, regardless of whether the ward has air-conditioning, you wear that thick theatre-coat. All the while behaving in such a way that your patient does not feel discriminated against, diseased or repulsive.

Because she is not. She is a woman about to go through the worst pain imaginable in order to give life to a tiny human. And she will then proceed to take care of this child, all the while preparing for that day when HIV becomes full-blown AIDS, and someone else must take care of her flesh and blood.

During my three weeks of delivering babies, three of my patients were HIV-positive.

One of them had defaulted from her AZT treatment six months ago, making it certain that her viral load would be high and almost certain that her child would also contract the disease. The delivery progressed at such a speed that there was no time for me to double-glove or get all covered up. And when we delivered the shoulders, a huge gush of amniotic fluid spewed all over the place – soaking the assisting nurse’s shirt and leaving me untouched.

A rapid progression in labour is beneficial when one is trying to minimise mother-to-child-transmission. Unfortunately it also meant that this patient received only one stat dose of ARVs, at the beginning of labour. By the time three hours had passed for the next dose to be administered, Baby was already delivered.

Another time, we were trying to deliver the placenta of a positive mother. It was difficult, and when the placenta finally appeared at the introitus, a splash of blood arched onto my sleeve. The assisting nurse’s eyes stretched wide and although it clearly had not touched skin or mucosal surface, she ordered me to go change. A fellow student made me turn in circles so that she could inspect me to ensure that I truly had remained untouched. Only then could I return to my patient.

I was fortunate enough not to have a single mucosal splash, needle prick injury or any other insult that may have exposed me to RVD – our nice PC word for HIV.

But the truth is that you soon stop thinking about Mommy in labour as Mommy with an infectious disease.

You simply think of this mother, who has carried her child for 9 months and that this completely unglamorous process of giving birth must somehow be made as pleasant as possible.

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