Monday, October 4, 2010

Mulling over a miscarriage.

Right before I left on break (Yes, almost a month ago.) I had a patient come in with a history of heavy bleeding and clots with what turned out to be an incomplete abortion (aka: miscarriage).

I was so rattled and yet ... impressed by the encounter, that I’m only now able to write about it. I’ve had a month to think it over and ... well, I’m still unsettled. But at least now, I’m ready to write it down.

She came alone and toward the end of the day - almost as if saying she had better things to do that day. She sat still and quietly explained that she was bleeding big clots. She was miscarrying but something was wrong. She said the bleeding started four days before and didn’t want to stop. That is why she came.

She was thin in the way years of working fields and nursing babies make you thin. And she was strong. Long muscles defined by endless grinding and sweeping and caring for kids. But it was her eyes that did me in. They were no-nonsense-black and piercingly serious.

I explained to her that I needed to do a speculum exam to see what was going on. She agreed and that’s when I saw the extent of the miscarriage. Fortunately there were no signs of infection, so I called Dennis in to see if using the manual aspiration vacuum would be appropriate. He said that it wouldn’t (I forget the reason why now.) and recommended I send her to Wau.

Here’s the thing. Women like her (no family support group with her, tattered clothes and worked-to-the-bone thin) don’t tend to have money to go to Wau. I’m tired of referring women to Wau that cannot realistically go. I feel like I’m failing them. I’m not doing all I can do.

So I told her we had too options. One, she could go to Wau and get a D&C because to do nothing would lead to sepsis and further problems. Or two, I could try and do an internal manual exploration to get the rest of the fetus out. BUT that an internal exploration is EXTREMELY painful and I would prefer she go to the hospital.

She explained that she had no money and she wanted me to do an internal exploration. My heart skipped a beat.

Any woman who has had this procedure can tell you it’s worse than the pain of birth. I’ve had to do it a few times (right after a birth) and each time the woman crawled the walls and screamed my ears bloody in pain. My heart shrinks in despair every time I have to do it.

For those who don’t know, an internal exploration requires I reach a gloved hand inside and manually remove the fetus, placenta or membranes from the uterus allowing for it to clamp down and stop bleeding.

It’s a lifesaving measure in preventing postpartum hemorrhage... but this is the first time I considered doing it for a miscarriage. Would it even work? Is the benefit worth the pain? What if I do nothing? What if she goes septic and dies?

I had my translator explain over and over again what it required and how painful it was going to be. I asked her to be strong and try not to pull away. I made sure she understood and again asked her permission to do it. Was she sure?

I was stalling. I flat out didn’t want to cause her the pain. But I wanted her to live more. So I did it.
Here’s the thing. She never once flinched. Nor did she make a sound. She lay still and stoic - shockingly so.

As I removed the fetus from the cervix, I discovered half of it was still inside the uterus. I had to manually dilate her cervix to get it out. This must have been blindingly painful but you would never have been able to tell by her reaction. She was motionless and... resolute.

Once I finished, I asked her if she wanted to see her child. She only hesitated a moment then gathered herself together and sat up. She looked long and hard then said “Thank you”.

I apologized over and over again for the pain I caused her and told her how brave she was. I warned her of signs of infection and instructed her on how to care for herself. I was almost certain I got it all out but she needed to come back for a check up in a day or so, etc. She listened carefully to each instruction while quietly gathering herself together.

Again I found myself apologizing for the pain I caused her and telling her how sorry I am that she lost her child. Only then did she speak.

“Please don’t be sad.” She said. “I am not sad. I am glad that you did it. Now I know that I will not die. Thank you.”

Even now, as I think of her I want to cry. Here is a woman who has not had an easy life. Yet when she loses a child, and suffers severe pain... she ends up comforting her midwife.

My world feels a little upside down.