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Diagnosis Deconstructed

Diagnosis Deconstructed: Hardship Borne by Half of Humankind

Morchi, Ravi MD

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doi: 10.1097/01.EEM.0000450852.69851.b3

    It is not just one case but a conglomerate unfolding daily. It is not events transpiring at one site but what happens in urban centers, rural district hospitals, health clinics, and village huts. It is a global problem that says as much about our inequity of resource distribution as it does about our views on who should get those resources.

    The woman is usually in her 20s, and she has been in pain for more than a day. The pain will come in waves. She will writhe. It will radiate to her back and down her legs. Sweat covers her forehead and neck. Dry mucous membranes, a tachycardic and prominent PMI, clear lungs, and warm extremities with bounding pulses round out her exam. She screams at times. In between she drops on her cot in exhaustion.

    Perineum. Her labia minora are edematous and ecchymotic, mucosa everted out under high pressure. Look closely at her vestibule; blood could be at the urethral meatus. You have a whole other problem if it is coming from the vagina.

    Abdomen. It is distended; a firm mass extends well above the umbilicus. Our second and possibly third patient is housed there. We know that mom is in distress and our first aim is to treat her, but management decisions in active labor also depend on how and where the baby is.

    By sterile bimanual exam the fetal head sits apposed to the pelvic rim. Tightly wedged. No space for your finger to run the rim between head and bone. A small, soft perimeter of cervical tissue may not be completely dilated so pay attention as you palpate. When you run over the top of the head, you find it is boggy. Edema built up from hours and hours of pushing. Bones are overlapped at the sagittal suture if you can feel through the edema to the skull, a cranium compressed in an attempt to navigate the outlet.

    Bloody urine. A fetal head smashed so tightly against the pubic symphysis that the fragile bladder neck and urethra are caught between skull and pelvis. Ischemic compression macerates urothelial linings. The result is hematuria today and a vesicovaginal fistula tomorrow — if she lives.

    Spontaneous rupture of membranes occurred hours or days ago. Start antibiotics. Start crystalloid. She should be treated like others in distributive shock: low intravascular volume, hyperdynamic cardiovascular response, and chorioamnionitis.

    Ultrasound. A fetus in vertex position. Heart rate may be 140 or 60 or 0. Even if it appears adequate on this spot-check, we have no continuous fetal monitoring. No ability to follow decelerations. No appreciation for the history of that heart rate. Just one snapshot of activity repeated a few times to get a sense of how our second or third or fourth patients may be doing.

    Obstructed labor is a major player in global maternal mortality. Grand multipa-rous patients with seven other living children delivered at home may present to you very late in this format.

    Do not attempt a statistical analysis of multiparous patients in general. Beware of cursory logic applied to that population. Logic that sounds something like this: She has had seven other vaginal deliveries; she really should be able to push this one out, too.

    If she presents with a tightly apposed head, heavy caput, overlap at the sagittal sutures, and bloody urine with ecchymotic labia minora, that logic is flawed and potentially fatal. This patient in my mind is no longer a member of the larger population of multips that statistics dictate should have a generous pelvic outlet and all the uterine mechanics for a swift second stage of labor. Her particular physical features today have disqualified her from that population.

    In such instances I say instead: The very fact that she is lying in front of me in distress, dragged in by family only realizing the severity of her illness at this late stage, means that she could not deliver vaginally. We need never have met if she could have.

    Employ spinal anesthesia when time permits. Heavy lidocaine into the thecal sac and a slight Trendelenburg position. I opt for ketamine in a pinch and a narcotic and a low-dose sedative like diazepam, or I use local anesthetic in the seizing late-stage eclamptic patient whose hypertension has given way to hypotension and decompensated shock and whose airway will be lost upon sedation.

    Rather than a standard Pfannenstiel, in an emergency I choose a vertical, infra-umbilical midline incision. Whatever abdominal opening used, the uterine incision is almost always low and transverse. Take care because the lower uterine segment thins in prolonged active labor of a multip, and it can tear inferiorly. The rare patient with a transverse fetal lie or another malposition may receive a vertical uterine extension (called an inverted T) if basic delivery techniques have failed.

    Amniotic fluid is turbid. Meconium heavy. The neonate is limp and apneic.

    Fetal death is not uncommon in these circumstances. Do not be dismayed. Surgery is really to save mom and the other children who already depend on her. She is the backbone of society here. She is the center of family and village. Young bodies will be fed and minds sculpted by her. All relationships go through her. Our duties are to her.

    At times there is a low-lying anterior placenta or true previa. Then delivery of the fetus at Caesarian section has to occur through the placenta. For that moment, you have to accept horrendous bleeding. The reserve of our mother will be tested. A baseline hemoglobin of 8 from daily battles with malaria and malnutrition. And now in the throes of distributive shock, she will be asked to shed another liter or more of blood as her fetus is drawn through placental tissue. A limited blood bank means we have little to offer as replacement. With amniotic fluid soiling the field, we certainly cannot autotransfuse. Hemorrhage, like obstruction, plays a large role in global maternal mortality.

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