Sunday, February 27, 2011

Dilemmas

Yesterday a first time mom (aka:G1) came to the clinic in “labor”, but her contractions were abysmally short (25 sec) and moderate at best. The trouble was, they were frequent (q 1-2mins).

The women here believe that if labor starts they cannot drink water or their contractions will stop. They are right and wrong at the same time. Dehydration will cause muscle spasms and colicky contractions and even exasperate false labor, making it seem like she in labor when she’s not. But if a woman is in true labor, water will just help her muscles contract better.

This woman hadn’t taken any water all day, and could have been simply having painful Braxton-hicks contractions.

Not wanting to assume she was in dehydration-induced-false or early labor, I asked if I could do a vaginal exam to see if she was dilating. I told her what it would require; she seemed hesitant but willing.

Everything in me was saying she was in early labor and not to bother with the exam, but I’ve seen women here with contractions like this, deliver within the hour. I didn’t want to mess up.

Seconds into the exam, she refused to let me continue. So I stopped, never having found her cervix.

Now, I have had several pelvic exams in my many, many years; not one of them was painful -- uncomfortable but not painful. I’m told however, that in labor, exams are painful, and I always try to be considerate of my patients needs.

She needed me to stop, so I did.

Here is my dilemma. Based on the little I knew of what was happening cervically, and the small contractions she was having abdominally, she was in early labor and should go home.

I was told home was a 30 minute walk away. If she went home, she most likely wouldn’t return. In her head, I would have sent her away without help. If she stayed, a G1 like her could go on like this for hours and who knows days-- especially if she was refusing fluids.


We don’t have room to house women in early labor. We don’t have food for them and cannot accommodate the crowds of family members that come to visit. Or do we?

During prenatals, I encourage these women to come and deliver with us, but then send them away when they come. This must be confusing to them.... thus my dilemma.

Do I just let them labor here in the future, even if labor could be the next morning? But if I admit them, then I feel conflicted as to who will take care of them.

This is hard to admit, but we are not equipped to handle long labors. The translators/health workers haven’t grasped the idea of monitoring women in labor. I could go back and forth from the compound to the clinic all day, checking on her myself, but then she is taking a bed that we many times need for emergencies.

Plus, I’m not on-call at night. If I admit her, Margaret would be responsible for her throughout the night. I know she could handle it, but... is it fair to her to add this extra load of work?

Right now, I am the prenatal program. Everyone else rallies around me when there’s a problem, but when push comes to shove, it’s just me.

Margaret (bless her heart) delivers the babies that come in at night and allows me to be rested for prenatals in the morning. But that’s it. She takes no ownership of the preggos; she has too many other responsibilities to worry about and the clinic is much more than just the prenatal program.

It hurts my heart to send these women away in early labor when it’s clear they want to stay.

I know that birth is different all over the world. I know that what worked in the Philippines and what works in the States may not work here. I just can’t seem to get a grasp on what is appropriate for this culture and this stage in the clinic’s growth.

Pray for me... my heart is to admit them all now, and just let the cards fall where they may. But if I do, am I opening pandoras box?