A Brief Life

DETAILS CHANGED OR OMITTED TO PROTECT THE PATIENT'S PRIVACY

Medical Presentation:  (Note, if you want to skip this part, just know that this was a healthy young woman at term with her first baby in latent labor, without any problems or concerns.  The details are given merely to emphasize that there were no warning signs for what happened.)

ID (identification): 20 year old woman, somewhere in her third trimester with her first pregnancy

CC (chief complaint): small amount of blood and white discharge per vagina, and contractions hourly

HPI (history of present illness):
She's been having mild irregular contractions for the last day or so.  The blood is much less than a period.  The discharge seems normal to her, she thinks she's going into labor.  Baby is moving normally.  No rupture of membranes.

ROS (review of systems): no fevers, vaginal pain or itching.  No headaches, vision changes, RUQ (right upper quadrant, referring to the abdomen) pain, or ankle swelling.  No nausea or vomiting or diarrhea.  Denies any other symptoms.

Antepartum history:
By her report of last menses, she is 32 weeks along.  She has been seen at another clinic in town three times for prenatal care, starting during the second trimester.  At her first visit there, she says they did an ultrasound and gave her a due date that makes her currently 36 weeks along.  She has no lab results (and my nurse says that clinic is too small, they don't do labs there).  She has never been to here before.  The paper she brings from the other clinic shows normal blood pressures on those three visits.  She says she's had no problems with this pregnancy.

PMH (Past Medical History): Denies any medical problems.
PSH (Past Surgical History): Denies any prior surgeries.

Medications: reports she is taking prenatal vitamins only
Allergies: NKDA (no known drug allergies)

VS (vital signs): entirely normal
PE (physical exam):
General: normal, no distress, contractions appear extremely mild, does not look like active labor
Heart, lungs, reflexes and legs normal.  No edema of the face or extremities.
Fundal height is 31 cm.  (Note: in the States this corresponds to a gestational age of 31 weeks, but here women and their babies are often smaller at the same gestational age.  I don't have a good adjustment scale.)  Leopold's (where you feel the mom's belly): cephalic presentation, estimated size 6 pounds.
Cervical exam: 1.5 cm dilated, 25% effaced, -3 station, soft, posterior, cephalic presentation

Ultrasound (I did one first, then the OB confirmed):
Fundal anterior placenta with some mild calcifications (note, it gets more calcified with time, so this was reassuring that the baby was not very early), no previa.
Baby in cephalic presentation, heart beating, practicing breathing, actively moving around.
Estimated GA (gestational age) based on biparietal diameter, head circumference, femoral length, and abdominal circumference: 37 weeks and 2 days.

EFM (external fetal monitor): baseline 130s, moderate variability, accelerations present, no decelerations.  Category 1 strip.  (Note, this is perfect, strips don't get any better than that.)
Tocometer: contractions every 5-8 minutes.  (most of them are so mild that the woman doesn't appear to notice them.)

Assessment:
20 year old G1P0 likely at term or slightly early
in latent labor
no concerning signs or symptoms, anticipate normal vaginal birth

Plan:
Okay to go home now, return here when labor is more active or if any concerning symptoms
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What happened:

I explained to her that she was in very early labor, and that everything looked good on the ultrasound and the monitor.  We drew the usual complement of prenatal lab tests.  I told her that her body was preparing to have the baby, but it was still going to be many hours, possibly even days, so she should rest at home until the contractions were stronger and more frequent.  I discussed other reasons she should come back sooner, including heavier bleeding, decreased fetal movement, etc.   This was in the morning.  She left with her family.

That evening, she came back saying she'd been having contractions every 5 minutes for the last 6 hours.  She still didn't look like she was in active labor.  I repeated the cervical exam, and other than a slight increase in effacement (50% now), her cervix was unchanged.  We got another 20 minute strip on the monitors, and the baby still looked great.  Her contractions on the monitor where now every 2-3 minutes, but she was still not feeling most of them.  I told her everything still looked good, and her body was continuing to progress towards labor but it was still going to be away, and she could rest more comfortably at home.  She insisted that she wanted to stay in the hospital overnight.  She was the only patient there, and they pay for this themselves, so I said fine.

The next morning I checked her cervix again, and it was now 75% effaced, but no more dilated than it had been 24 hrs prior.  The woman still appeared to be in only mild discomfort.  Again I told her she could go home if she wanted, and return when the contractions were stronger.  Again I reviewed the reasons to return.  She left with her family.

I went off duty, but encouraged the person on duty to call me for the birth (I enjoy delivering babies more than many doctors do).

I checked in that evening, but we hadn't heard from her again.

I checked in the next day, and was told the following story:
She went into active labor at home.  They went to a pharmacy.  She pushed there for 4 hours.  The baby was born alive, and nursed a few sucks, then died.  Then they brought it here, to the hospital.  Resuscitation was attempted, but the baby had already been dead too long.  The mouth and nose were filled with thick meconium, according to the doctor who was on call.  Oh, and yes, it looked like a full term infant, no signs of prematurity.  Weight 3.2 kg.  7 lbs. Bigger than I had thought.
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Discussion:

WTF?

A pharmacy?  Why?  Was she put off by my telling her it was okay to go home so many times?  Did she think I wasn't taking the birth seriously?  Why oh why didn't she come back here?  We would have suctioned that meconium out!  This is just sad.

I deal with primips (women having their first baby) in latent labor all the time.  I send them home all the time.  They come back.  They don't go to a pharmacy to push.

Did my cultural incompetence kill this baby?
No, I know that's not my blame to take on, but really... what role did my behavior play in her decision to not return here for the birth?  Can I learn something?  What, exactly?

Furthermore...
There are things that we see here that we just don't see in the states, because the massive healthcare delivery system that I work within has hugely reduced their frequency.  Yes, I've seen meconium aspiration, but the vast majority of babies born through meconium are perfectly fine.  The worst case I saw had to be hospitalized for a few weeks. Why don't we see bad mec asp in the States more often?  Because it's standard protocol to suction any meconium out before stimulating the baby to breathe.  And if the baby has problems, we have oxygen and other equipment there to help, right away.  Plenty of babies get a little PPV (positive pressure ventilation) after birth, or a little meconium suctioning.  I guess my point is that these interventions happen so routinely where I usually work that I don't always fully appreciate the dangers of going without them.

This was the second birth here since I've been here, and the first vaginal birth.  And the baby died.

Along the same lines, they see pregnant ladies with eclampsia (no, not pre-eclampsia) here about once a month.  Why?  Because they weren't getting prenatal care, so no body took their blood pressures.  Until they came in seizing.  Some of these ladies die.

I think the benefit of seeing these things is appreciating those aspects of our healthcare system that really do prevent serious disease.  Some of what we routinely do is bureaucratic.  But some of it very definitely prevents morbidity and mortality, and it's sobering to see the reality of that so directly.

What are the barriers to good care here?


1) Money/Resources of the hospital: this one is obvious.  No blood bank, no CT scanner, only 3 labs on the weekend (urine dip, urine pregancy, and blood glucose), no general anesthesia.  Not enough money to pay all the doctors, so many of them are volunteers, like me.  This feeds into problem #3 (see below).

2) Impoverished population + fee for service model.  They have to pay for every pair of sterile gloves I open, every minute that their toddler is on oxygen, every medicine, every packet of gauze I open.  I often have to prescribe only half a course of antibiotics because they don't have enough money with them to buy the entire course.  (I tell them to come back for the rest.)  Many patients simply can't afford the health care that they need, even at the dirt bottom prices charged here.  So people come in late, leave early, and refuse needed interventions.

3) Cultural beliefs and communication: this is the stickiest one.  Partially because it's so hard to understand what's really going on, and partially because it's the one an individual like me feels ought to be most addressable.  I don't need to be a millionaire or solicit donations.  All I have to do is relate well to my patients, hear their concerns, educate them on their condition, and make sure they understand what I recommend and why.  Right?  I'm a family practice doc, I should be able to relate to my patients and make them feel heard and cared for.  We do that really well in Family Practice Land, right?  But it's not that easy.  We kinda share a language.  (Their first language is the local Mayan dialect, and mine is English, but the nurses all speak both the Mayan tongue and Spanish, so I can communicate with my patients via nurse translator.)  But we have deep seated differences in our beliefs about health.
For example, I think the toddler with increased work of breathing, breath sounds consistent with pneumonia, oxygen saturation in the 80s and a fever of 38.2 should have oxygen by nasal canula, acetaminophen, a chest x-ray, and maybe some antibiotics.  The parents refused the x-ray, so I offered empiric antibiotics, which they accepted.  They accepted a few hours of oxygen supplementation, but then insisted on going home, no matter how many times I showed them her O2 saturation was still in the 80s, and why that was important.  Oh, and they dressed her like she was going skiing on their way out the door, including a ski mask that covered her mouth.  (Temperature here is in the 70s, I'm comfy in a t-shirt.)  Their reasoning was that too much air was dangerous when you have a fever.  I showed them on the O2 monitor that her saturation went up if her mouth was not covered by the ski mask, which I think convinced them to leave it off.
But I still don't really understand the structure of the belief system that says too much air is dangerous when you have a fever.
It's differences like these that are so hard to overcome.  We are just not working from the same set of beliefs, so nothing I say makes sense to them.  And I don't know or understand all of their beliefs, so I don't really know what I'm trying to work with.

Solution
We teach "cultural competence" in medical school, but all that can do is enable us to recognize this problem for what it is.  To actually fix the problem, I have to become deeply familiar with each and every population that I work with.  (And of course most people are the product of a complicated blend of populations, so really knowing the individual is optimal, go continuity of care!)
Hey... you know what would be a really useful series of books?  Medical Cultural Competence for Population X.  I'm thinking pocket book sized and not too thick.  It was explain the underlying beliefs about health and disease that lay people in that population often hold, with examples.  There's an opportunity here to publish hundreds if not thousands of books in this line.  Each medical practitioner would want several, based on the specific populations they serve.
Alright, who's feeling entrepreneurial?