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Louise Kenny: Flying solo

9 Oct, 09 | by BMJ

After the blow to my confidence last week with obstetrics patients, I have developed a healthy fear of the uterus and have understandably been reluctant to see ante-natal, labouring, or post-natal patients.  Any organ that bleeds 500ml a minute is a thing to be feared in my book.  Of course the problem with my reluctance is that over 50% of what happens here has something to do with pregnancy, and again today we found ourselves without an obstetrician for both a delivery and also an ante-natal clinic.  Me, again? Oh no.

A lady was admitted last night during the shift of one of the Guatemalan doctors who receives normal deliveries.  Her shift finished this morning, and she handed over an 8 cm dilated primiparous labour, on a background of a small-for-dates baby and probable oligohydramnios.  The director of the hospital looked around the table, asking each doctor in turn, “puedes?” – can you?

Half an hour later, while the paediatric resident googled the foetal mortality rates of oligohydramnios, I had a super quick glimpse at those step-by-step cartoons of the stages of labour.

I’ve delivered quite a few babies now, both at medical school and during a week-long crash course before I came away, but I’ve never done it without supervision by either an obstetrician or midwife.  Questionable I know, but at 8 cm, a 90 minute transfer to Solola was not an option, and we were reassured by the director of the hospital, a senior Guatemalan doctor, who told us he would be around for the morning.

I’m pleased to say it all went very smoothly.  There was myself delivering, Emily our super medical student assisting, and Ilana, a paediatric resident ready and waiting to deal with resuscitation of the baby.  I ran through in my head, on repeat; push, guard, check for the cord, suction, anterior shoulder, posterior, clamp, and breathe.

We had multiple little conferences in-between pushes, which helped to calm my tachycardia and sweaty palms, but it wasn’t until long after it was over that I could actually smile.

The baby delivered fairly easily, with terminal meconium and required airway resuscitation.  The mother had a vasovagal episode after delivery, which was terrifying due to the difficulty of handling a very slippery baby, monitoring any bleeding, and directing nurses to assist with an unconscious woman.  We waited a good twenty minutes until it became patently obvious that the placenta had separated, and finished the delivery.

Both mother and baby, Diego, are doing just great.

At an early point Emily rang the director, just to inform him we were all go, and from his meeting up the road he reassured us that everything would be fine.  How right he was. He arrived to help us check the placenta and to let me know I could step away from the uterus.  I had got myself all panicked about a trickle of blood, but as I said, scary things those uteri.  For today, I won’t go into my insecurities about my abilities and the ethics of what could have gone wrong and I’ll leave it at that, my perfect little 2.4 kg story for the day.

Louise Kenny has completed F2 year in the Northern Deanery and is now working in Guatemala.

The patient’s consent was obtained for this blog.

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  • Aartee

    Great work !!:)
    Can understand what you may be going through at the moment hough – can get pretty scary !
    Hard work , but looks like it went very well ! cheers again !:)

  • Néstor

    excellent job ¡¡¡

  • Ilana

    Great work, Louise! I know this was a few weeks ago, but I hope you’ve gone on to get your confidence re-gained through many other experiences like this :)

    I was reading the comments on your previous blog and thinking a lot about the ones that suggest doctors should wait until they are fully qualified before working abroad in order to prevent that feeling of “in over your head.” While that’s a great thought, I’m not actually sure it’s ever possible to go into an experience in such a different setting feeling fully qualified. I would imagine one could have years of experience in OB or Pediatrics and still feel completely unprepared when faced with an infant in the late stages of sepsis who is covered in herbs, or a birth like the one you described above. I think that’s what attracts so many of us to medicine, that at any point in our career, we could be faced with situations that challenge and humble us, reminding us how little we know.

    Of course I say this as a relatively inexperienced pediatric resident, not as a seasoned physician. But what you don’t write about in your blog is how many patients you’ve felt confident helping and how much positive work we were prepared to do in such a resource poor setting. In many cases, we are better trained in western medicine than the alternative (either no doctor, a traditional healer, or some of the Guatemalan doctors).

    Ilana Sherer, MD

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