“Morning report” is a standard phenomenon in medical education. Typically the morning report is a quick review of all admissions to the hospital on a particular service occurring over the previous 24 hours. It varies by clinical service; each service (medicine, surgery, pediatrics, obstetrics, gynecology) typically runs their own morning review. Today’s blog is a quick review of today’s obstetrical “morning report” at Ayder Referral Hospital in Mekelle, the major teaching hospital for the university.
Morning report is held in a small classroom just off the labor and delivery ward. It starts at 8:00 AM—the standard starting time here (more leisurely than what takes place back in St. Louis, where a start time of 6:45 AM—or earlier—is not uncommon). Approximately 30 people are in attendance, mainly residents and students with some faculty. Dr. Yibrah, the senior attending obstetrician-gynecologist (with a special interest in maternal-fetal medicine) is in charge.
Monday’s morning report is far more extensive than most, because all of the cases from Friday, Saturday, and Sunday are reviewed together, which makes for a long conference. The residents who are presenting the cases sit at a table in front of the room with the charts stacked in front of them. They review the total statistics for their shift (number of deliveries, number of admissions, number of surgical operations, etc) before presenting the individual cases.
For a ferengi like me (“ferengi” is Amharic for “foreigner” and, as far as I can tell, it is not a derisive term), Ayder morning report is a little hard to follow. First of all, cultural propriety in Ethiopia looks down upon loud speech, so everyone speaks softly, oh so softly, so softly, in fact, that unless you are sitting more or less on the front row, you can barely hear. This somewhat defeats the purpose of a general presentation and discussion of the previous day’s cases, but I shall adjust. The dates are all given in the Ethiopian calendar (which is, essentially, the old Julian calendar), which means that unless you know for sure, it’s hard to tell which month (or even year) we are talking about. Fortunately, they translate everything into standard obstetrical dating (“she is at 37 weeks and 4 days gestation”). That helps me a lot. Medicine is full of abbreviations (far too many abbreviations, in my view). When you change cultures—even when the language is English (and all higher education in Ethiopia is in English, particularly in medicine)—some of the abbreviations and much of the phraseology changes. I’m racing to catch up. On top of that, the Ethiopian English accent is quite different from what I am used to (it is very different, for example, from that in West Africa or the Caribbean), so I am triply challenged.
However, many of the clinical problems are the same, but at the same time many of the problems are quite different from those seen back at home. The infrastructure and resources to deal with the problems that arise are also quite different. Here are two contrasting cases from today’s review of the weekend.
Readers of the websites which link to this blog will likely be aware of the problem of obstructed labor in Africa, but for those who are not, here is a quick synopsis. Labor becomes obstructed when the fetus will not fit through its mother’s birth canal. The presenting fetal part (usually the head) descends as far as it can, but then, either because the baby is too large, the mother’s pelvis is too small, or there is some other problem with obstetrical mechanics, it reaches a point beyond which it can descend no further. It gets stuck. Because labor is an involuntary process (once those contractions begin, they will continue, “come Hell or high water,” until the baby is born or some catastrophe ends the process). The uterus continues to contract, trying to force the baby out, but it will not budge. This means that the fetal head is progressively wedged ever more tightly against the soft tissues of its mother’s pelvis, compressing them against her pelvic bones. If this process is not relieved (and usually to do so requires cesarean delivery) the blood supply to those tissues will be cut off and eventually they will die, forming a fistula (an opening between the bladder and the vagina or between the rectum and the vagina, through which urine and/or feces will drain continuously). When obstructed labor is prolonged, the fetus usually dies from asphyxiation, trauma, blood loss, and the like. Sometimes the mother also dies from exhaustion, infection, blood loss, or uterine rupture (a muscle like the uterus can only sustain so much stress before it gives way, a catastrophic end to obstructed labor that often kills both mother and child).
Two patients presented over the weekend with complications of this process. One ended tragically, the other will end happily. A young woman from Afar (a remote region of Ethiopia to the east of here) previously had a labor that was obstructed. She was in labor for several days, lost the baby during the process, and sustained a fistula as well. She was fortunate enough to have the fistula repaired successfully and she subsequently became pregnant again. Although she was living in Mekelle, when she went into labor, she did not present for care immediately, but labored for several days. Eventually she was sent to Ayder Referral Hospital.
On arrival, she was clearly in obstructed labor. Her vagina was found to be heavily scarred and narrowed from her previous labor and vaginal delivery was deemed impossible. She had not passed urine for over 24 hours because the fetal head was compressing the urethra and bladder neck so tightly, she could not urinate. Her bladder was clearly visible and distended all the way up to her navel. A catheter was placed to drain the bladder and she underwent emergency surgical exploration. Her uterus was on the verge of rupturing, but fortunately this had not yet occurred.
Unfortunately, the baby was dead, and a stillborn fetus was subsequently delivered by cesarean section. Few things in obstetrics are as unsatisfying as the cesarean delivery of a dead child.
The patient is recovering and will have a urinary catheter in place to decompress the bladder for the next two weeks. Hopefully, unobstructed drainage will allow the bladder to heal, but it is still possible that she could develop a recurrent fistula if this second obstructed labor caused enough damage to the bladder before the compression was finally relieved. We should know in a few days if she will escape a recurrence or not.
I am happy to report that the second case has a happier ending. The second patient is also a woman who developed obstructed labor in a previous pregnancy and developed a vesico-vaginal fistula as a result. She, too, had her fistula repaired successfully, after which she again became pregnant. This time she got prompt prenatal and delivery care, and had a child by cesarean section. She now is pregnant again—her second pregnancy after fistula repair–and presented to the hospital at term, before the onset of labor. She has a living fetus and is scheduled to undergo a repeat cesarean section this morning, which will likely result in a healthy, living infant.
These two cases demonstrate some of the challenges facing the healthcare system in this part of the world. Roughly 85% of Ethiopian women give birth at home, without the presence of a skilled delivery attendant. Some of this is a cultural preference for home birth, but much of this is due to lack of accessible maternity services (particularly in rural areas) and a lack of understanding about the potential problems that can arise when labor does not progress smoothly. The first case is a tragic exemplar of how badly things can turn out; but at least the woman did not die. The second case, however, demonstrates that even in the face of considerable challenges, happy outcomes are still possible when the patient is motivated, knowledgeable, and can get into a functioning maternity care system. The challenge in Mekelle, as it is throughout Ethiopia, is to eliminate the first category of cases and to dramatically expand the second.