Fresh Stillbirth

I still remember the first patient I ever had to tell that her baby had died. It is an experience and an emotion that I don’t think anyone ever forgets. There have been many women and families since the first one, though in a multitude of different situations. Here in Kenya it is a daily experience and on a busy day it is more than once per day. The statistics are very difficult to come by and most likely underreported, since many women who have a stillbirth do not seek care or are not seen in a health care center where they will be “counted.” The best information I could find from 2009 WHO data (https://www.quandl.com/c/health/stillbirth-rate-by-country) quotes the United States stillbirth rate as 3 per 1000 births, whereas Kenya’s stillbirth rate is 22 per 1000 (which looks good compared to Pakistan’s rate of 47 per 1000).

The term we use here if the stillbirth is delivered & there are signs that it has been dead for a while is a macerated stillbirth (MSB). If it has died recently, usually in the course of labor, it is called a fresh stillbirth (FSB). When a woman comes into the hospital they are initially seen by the nurse and clinical officer (CO), who take their history, vitals, and check the fetal heart rate with the fetoscope. If they cannot find the heart rate, they bring the patient to the room where we have an electronic fetal monitor and ultrasound, where they will most likely see the midwife or I.  Usually I have to explain that we do not know why this has happened, but that it will most likely not happen again- that they hope for their next baby to survive. Often I have to explain that they are very sick with high blood pressure or preeclampsia and that is why their baby has died. It is harder to explain to the chronic hypertensive patient that when she was seen in the rural clinic 2 weeks ago and her blood pressure was high they should have sent her here or that if she had not waited until the 42^nd week of her pregnancy we might have been able to save her baby.

But the fresh stillbirths are the worst. I already wrote about my first Monday working here, but it has taken me much longer to write about my second Monday. It has been hard to find the words to explain what happened and how it felt. Just as we were finishing our sign out to the night team, a young patient who had already lost her first pregnancy came in late in her labor with the baby in breech presentation. Our team discussed the pros and cons of doing a breech vaginal delivery or cesarean delivery, but there was no theatre available and she quickly began to push. We performed a breech vaginal delivery that went very smoothly. I was assisting the midwife who is far more experienced in breech vaginal deliveries. I was eager to learn and happy to be improving my skills to help the next patient I see, when I may not have the midwife to help me. I was also happy to be helping the patient avoid a cesarean section, an intervention far more dangerous here than in the US. Although we are lucky to have safe cesarean deliveries in our facility, the future with a scarred uterus here is much less predictable than in the United States. In her next pregnancy she may not be close enough to a hospital to have a safe delivery. If she chooses to have a trial of labor, she will not have continuous fetal monitoring to catch a uterine rupture before it kills her or her baby. Although I do not have any statistics, uterine rupture is much more common and deadly here, where blood products are hard to come by. Just this past week there was a maternal mortality from a ruptured uterus in a woman with 5 small children at home. 

The breech delivery went easily, but following the delivery she had a large gush of blood and the placenta delivered too quickly thereafter- a placental abruption. We quickly clamped & cut the cord & began resuscitating the baby. Neonatal resuscitation is done entirely by the obstetrics team- the nurses, registrars, midwifes, and physicians. There is no NICU team- we can only alert the newborn unit (NBU) if we are bringing them a baby after we have fully resuscitated it. After the usual efforts did not work and the baby continued to be limp and not breathing, we had to move it to the other labor room, the only room with an infant “warmer.” I put warmer in quotes because it is an old warmer in which the warming bulbs broke years ago. We began CPR because we could hear a slow heartbeat. I performed chest compressions while the intern gave positive pressure ventilation with an ambu bag for 30 minutes. Intermittently we would hear a heartbeat but never any breathing and on our last check there was no heart rate either. I was devastated. I wrapped the baby in the most lovely soft, white cable knit blanket the family had brought for her. I wrapped her the way I would wrap a live baby, so the mom could see just her small, beautiful face. I brought the baby to her mother and had to explain what had happened. It is hardest when you feel guilty about what has happened, when you feel that there must have been something you could have done to prevent this terrible outcome. She was all alone at that point and was trying to be strong, holding back tears, reluctant to reach out to hold her baby girl. The midwife and I stayed with her, told her it was ok to cry, told her it was not her fault when she asked what she could have done differently. Her husband came in and they prayed over the baby. He asked again why this had happened and told us he was so sad because this was the second baby they had lost.

As she drove me home in the dark that night, the midwife explained that when she first came to work here the nurses would admonish her for doing what we did that night. That they would tell her to completely wrap the baby so the mother could not see it, to take it away quickly, to not “upset” the mother more by encouraging her to grieve. She explained that the perspective is that they are trying not to let the woman be traumatized by something that happens so frequently. That if they “move on” from this experience quickly it will be better off for everyone. I was struck by the difference from my experience and learning in the US. We are encouraged to grieve with the mother, to allow her to spend as much time as she wishes with her baby, to take pictures and keepsakes that she can have to remember the baby she was only able to hold for a short time.

The next day the midwife and I saw the mother walking in the hall before I had the chance to seek her out to check on her. She took my hand and held it in both of hers and just looked at me and smiled sadly. I asked how she was and she just nodded, smiling softly and said she was going home soon. I didn’t have much to say either, but it didn’t matter because I think in that moment we were both finding our peace with what had happened.

Earlier this week I was triaging women with fetal monitoring and ultrasounds when I was called by my intern that there was a fresh stillbirth. The baby was lying on one of the makeshift baby beds in the labor rooms- really an old hospital crib with one side dropped down. I talked to the nurse to find out what had happened. She said she was very busy taking care of 6 patients actively in labor, one of whom she had recently delivered. She hadn’t checked the fetal heart rate in 2 hours when the patient, a 17 year old girl, began pushing and quickly delivered a fresh stillbirth. The nurse had tried to resuscitate the baby but it didn’t work. As I found out, earlier on there had been some question of the fetal heart rate being low by fetoscope, but it had never been rechecked by electronic fetal monitoring. As the nurse was cleaning up the patient after her delivery and I was wrapping the baby in her brown animal print blanket, the patient’s family asked me what had happened. I explained that I didn’t know but that the baby had not survived through the labor, and offered for them to hold her but they did not want to. Once the mother was cleaned, I brought the baby over her but she only spoke Kiswahili. I offered the baby to her to hold as I said one of the most common things I say all day long here: “Pole, mama” which means “I’m sorry.” She did not want to hold the baby but sobbed inconsolably.   

Needless to say, I was happy to accept an offer to get away this past weekend. We drove 5 hours along bumpy dirt roads and bigger paved roads with drivers (including ours) constantly passing each other such that most of the time when I looked out the front window I would see oncoming traffic in both lanes. Suffice it to say, I kept my eyes glued to my side window to see the interesting sights- mostly lush, green trees, grazing cows, sheep and goats, and women sitting on the roadside selling their produce. We spent the weekend at Lake Naivasha, a beautiful lake with incredible wildlife. The town is known for its flowers which are shipped all over the world, but which has unfortunately caused the lake to be polluted with pesticides. But the real reason no one swims in it is because of the dangerous (but beautiful) hippos! We took a bike safari and went hiking in nearby Hell's Gate National Park. Below are some of my favorite pictures. 

My Retraining- Week 1

My first thought- my first second to think on my first day- as I was leaving the hospital today was “what the hell am I doing here?” Not because I don’t want to be here or because I am scared for myself. It’s because on that day I did not think that I can possibly do anything at all here. It seems so far gone that nothing I can do will ever change it or make it better for anyone.

That night I though of my mosquito net-encased bed as my hide-away. When I got home all I wanted to do (after taking mildly hot shower) was to climb in. I imagined the mosquito net protecting me from the outside world, which I never knew could be as bad as I saw it today. And the funny thing is, I know that it will get much worse. Nobody died today. Nobody even almost died today. Although I can’t stop thinking about the woman I left who was laboring with a breech, preterm baby with a BPP of 2/10 (for those of you who don’t know, that means it is very sick) & I dread tomorrow when I will try to find her to find out what happened. The baby is too small to likely survive so no point in doing a cesarean section for her. “Try to find her.” Those words make me sick to my stomach. That is what happens here. Patients are there one second then the next time you check on them they are gone. Moved, delivered or dead? It’s hard to find out which.  I dread seeing the faces of the patient and her husband when I find out the baby has died. The line between life and death is so blurred here, every time I try to pin it down I feel like I am trying to hold on to sand. Our cut off for survival of a fetus in the US is theoretically 24 weeks & sometimes even less than that. Here it is 28 weeks or 1500 grams or anything that would cause a baby to need intubation as they do not have any ventilators in the NICU.

But then I think about the mom who delivered the first twin at home with a traditional birth attendant only to find out there was a second “retained” twin. We admitted her and monitored her closely, treated her when she became infected, and performed a cesarean delivery when she did not progress in her labor. The care we gave her saved her life and the life of her second twin baby. In the hospital system here the residents do the surgeries by themselves with only a scrub tech to assist. So I sent her off to the “theatre,” as they call the operating room- everything here is based on the UK system- and I don’t know what happened to her after that.

My favorite patient that day was a primip (as we call women pregnant with their first baby). She spoke perfect English & was accompanied by her friend, both of whom were clearly pretty & fashionable. She would grab my wrist and push my hand into her back so I would rub it to ease the pain during a contraction. Here there are no epidurals and only minimal IV pain meds as they are reluctant to have a "slow to start" baby (understandable when the nurses are the ones who do all resuscitation and there is no ability to "call the NICU"- as we do so easily in the US). 

I spend all day on the labour ward trying to monitor the fetuses. I am being retrained in when fetal monitoring is indicated. Here we all listen with fetoscopes (something I am still trying to get the hand of) & only do electronic fetal monitoring when it is absolutely necessary. The paper for the machines is in very short supply so I am being trained to guard it with my life. We keep it locked away & dole it out in small stacks at a time, after questioning- "is it really needed?" We only have 2 machines for a labour ward with 20 beds & 15,000 deliveries per year.  That's over 3 times more deliveries than our busy labor & delivery in Syracuse, NY. There was only 1 registrar (resident) who was mostly doing cesarean sections all day. The interns were on strike because they had not been paid in 6 months. So me (the attending aka consultant) & 1 midwife, along with many nurses & some clinical officers (similar to PAs) took care of all the patients. 

It makes me laugh (but mostly cry) now how much discussion we have about epidurals in the US. There is no such thing here. And that’s not even the start of it. I think about all of the women- and all of us healthcare workers- in the US who have NO IDEA how good they have it. In this labor & delivery there are no sheets on the beds. When a woman breaks her water or pees or we use a catheter to empty her bladder there is nowhere for the fluid or urine to go except to pool underneath her. The midwife showed me how she presses down on the bed to try to make a path for it to flow onto the floor so it doesn’t flow up & soak into the patient’s clothes. I tried hard to find a blanket for a patient who was chilled (likely from an early infection) & I could not find one. There are no towels with which to wipe my hands after I wash them- I was told that the curtains separating the beds was the best I was likely to find. When a baby is delivered we hope the mom or her family has brought baby blankets to keep it warm because we do not have any to provide them with. 

The rest of the week was much better as I got the hang of how things work. The interns returned once they started getting paid again, and the interns & residents (called registrars) are eager to learn, conscientious about caring for patients, and wonderful to work with. Plus when it is less busy it is easier to handle. Still no paper towels & no vicryl suture. Another third degree laceration, another stillborn.   I am starting to enjoy it & see the benefits of my work. The patients are so thankful and so are their husbands. Everyone is smiling all of the time, no matter how much pain they are in or how sick they are or how much work they still have yet to do.

Meetings with administration of the registrar program make me optimistic about what I may be able to do & hopeful that it will actually happen! I will be using my skills & experience in graduate medical education (both from being a leader in my residency & my experience working in the national graduate medical education organization) to improve the training program here. Think about what an impact that can have both on the care of the patients here now and the patients of these future ob-gyns of Kenya!

A long post for a long week! Luckily by the weekend I figured out where to buy some wine so I am drinking a glass as I write & then crawling back into my hide-away to rest up for another long week! Below are some pictures (not such great quality because I am taking them quickly as I rush through my day)

Outside the hospital family members & visitors relax & wait on the lawn.

Our room for ultrasounds & non-stress tests (only 1 other similar monitor to push from room to room when needed)

One of the 5 labor rooms (this room has another side for total 6 beds, other rooms have only 1 side with 3 beds)

NICU rooms

Market stalls in downtown Eldoret

 Crazy street driving.. still haven't tried driving yet but hope to do so soon!

HIV Clinic

My first day I spent working with Dr. Joe Mamlin, the founder of AMPATH, who has been living & working here with his wife for over 15 years.  We went to one of the rural healthcare centers in Turbo, a small village ~45 minute drive from Eldoret. All along the road there so many people walking & carrying things to sell at market. When we drove by the market area everyone had their wares laid out on tarps on the side of the road- piles & piles of clothes, shoes & food (I remember a particularly large pile of what looked like heads of cabbage covered in dirt). We saw a young man holding up a few fish which Dr. Mamlin said were caught in the small lake I could see a short distance from the side of the road; on our way back hours later he was still there with his fish! There were plenty of crazy drivers on the road with no traffic lights, no lane markings, & no rules. Motorcycles (piki piki), bicycles (boda boda), overcrowded passenger vans (matatus), petrol tankers, cars & pedestrians all vying for space & speed on a pot-hole filled road, sometimes with a muddy sidewalk & sometimes without any at all. On our way back it was raining hard & schools had let out for lunch so children in school uniforms (different colors depending on their school- blue, red, green) were everywhere running through the mud carrying their shoes. Along the way Dr. Mamlin pointed out a “truck stop”- an area where long-distance truck drivers on the road that runs between Kenya, Uganda & South Sudan can stop for sex workers. I didn’t see any obvious signs of it except a hut with a sign saying “The Drip Hotel & Bar”— quite the fitting name!!! This practice is one of the ways in which HIV has spread not only in Africa but throughout the world.

The clinic had started as 1 room with 1 provider & since expanded to 2 buildings with clinics for maternal/child health, family planning & chronic disease, all with a medical records system. In the same building they have a social worker as well as job training & nutrition programs- very comprehensive & self-sufficient. They also have an x-ray machine, some lab capabilities & 2 pharmacies- a free one stocked by the government which is often out of even basic meds & another that is funded by the community which has very cheap meds. This ensures that people can continue to take important meds continuously. A small, free inpatient unit including a delivery room (staffed only by nurses) was made up of essentially a few bare mattresses with IV poles & delivery instruments sitting out on a table, but was currently unoccupied.

In clinic we saw all HIV positive patients, ranging from 19 to 82 years old. Some had great stories: the 82-year-old man has been on first line HAART for 10 years with a normal CD4 count & undetectable viral load. His only complaint was that he had to get up at night to pee too many times. His grandson accompanied him, translating & supporting his arm as they left with his medication refills.  Another woman had come to Dr. Mamlin when she was pregnant with untreated HIV & septic, near death. Her family wouldn’t pay for her to be hospitalized so Dr. Mamlin admitted her anyway & paid for her care until she improved.  She came in today for a regular check up & HAART refills. She has a chronic rash all over her body, which has been improving after treatment recommended by a dermatologist from UCSF who Dr. Mamlin sends pictures to for help with diagnoses. She came in today with her beautiful 4-year-old daughter, who is HIV negative!

Some stories were much worse: the 19-year-old girl had been diagnosed with HIV at 17. Her disease was resistant to first line HAART, so she is now on second line therapy with persistent pneumonia, possibly TB. She has been in & out of the hospital & therefore having difficulty finishing school. A 25-year-old woman (who looked 40) had wasted away to 80 pounds with a GI infection & pneumonia- also possibly TB. Today the lab was unable to test viral loads for us because they didn’t have the necessary tubes in which to collect the blood. This is because the supply chain had been disrupted by recent political changes in which the responsibility for payment moved from the national to county government. But we were able to do chest x-rays (no computers here- only film & light box!) & sputum testing for TB, provide antibiotics & arrange for transportation to the hospital when needed.  However, in the case of an emergency there is no ambulance & if they don't have someone with a car (none of the clinic employees seemed to have one) they would have to send them on public transportation (the aforementioned crazily-driving, overcrowded matatus).  Imagine if something goes wrong during the delivery of a patient & the nurse needs to send her & her baby to the hospital 45 minutes away??

Unfortunately I didn't take any pictures because I didn't want to look too much like the mazunga (foreigner) tourist. But here are some pictures of where I'm living- as you can see, not too shabby! The flowers are growing right outside our living room window & smell amazing! Feel free to post questions- I'm happy to answer anything I can. I will post more pictures soon! Monday I start working full time on L&D so wish me luck!

“Where?”

"Where are you going?"

"Kenya."

"And you're excited about that??"

That was the most entertaining of the many question and answer sessions I've had about the trip I'm embarking on today. The second & third most commonly asked questions were "What are you most nervous/excited about?"  The most truthful answer to that is “I have no idea.” Any preconceived ideas I have about what I should be nervous or excited about are probably wrong and most certainly apt to change quickly. But so far the answer is the same for both: "Caring for women in Kenya."

I am most excited about caring for women in Kenya because it is what I have wanted to do for as long as I can remember (in the abstract sense, anyway- the when, where, & how details fell into place in the most unexpected & wonderful way- perhaps a subject for another post). I have finally finished all of the training to prepare me to be useful in a place that can really use skilled obstetrician-gynecologists with a passion for contraception and teaching.

AND because having the past 2 months off (as much of a blessing as it has been & as much as I have enjoyed it) has caused me to go slightly stir-crazy, so I am realllly ready to start working. 

I am most nervous about caring for women in Kenya because physicians in the US are incredibly lucky to be able to practice in a setting where we (usually) have any and every tool (test/device/medicine/operating room/etc.) available to us to provide the best care possible for our patients. I will surely learn how to be flexible and creative, to use whatever tools are available, and to advocate for any additional tools my patients need & deserve... but it will be hard when I can’t provide enough care to save someone.

That’s really why I’m going to Kenya (and why I’m excited about it). Because this is what I need to do in order to be the best physician I can be, to reach the most women I can, and to continue to strive for the goals I believe in- global health equity in access to care, health outcomes, and reproductive choices.

Thank you to everyone who has helped me to be headed where I am (literally and figuratively). From my upbringing in a wonderful hippie household full of love and extended family, through my many years of studying (and playing) with wonderful friends, to the hospitals and clinics where I have learned everything I know from amazing colleagues, teachers, and patients… for every one of you who has told me you are proud of me, I am who I am and doing what I’m doing because of you.

I’ll be writing here to keep all of you updated on my adventures and to help me process what I’m doing and going through. Feel free to pass it on to anyone who might enjoy it.