Tuesday, July 24, 2012

In which I attempt to be a qualified prenatal nurse

Yesterday was antenatal (british way of saying prenatal) day in Obule health center. It is fun to have been doing this long enough now that a few of the ladies’ pregnancy cards land on my desk I recognize my own handwriting (and appreciate my much more thorough notes so much more. Yeah charting skills!) But there is one young mother, Aruto Esther,that really stood out even without my great notes on her case. Three weeks ago she came with her mother for her first ever antenatal check. She has a diagnosis of epilepsy and is on phenobarbital. (I’ll save my medical friends the look up time. Phenobarbital: preg risk class D- known adverse effects in human fetuses) She started the drug a while ago and went from having 2-3 seizures a day to 1 every few months. This seems like really good control and the only other med used for seizures here is thorazine, besides that she told us she is pretty sure she is 16 weeks along so she is well into her second trimester already anyway. I wasn’t going to be the one to take her off it.  While talking with them it became obvious that she has some other mental handicaps also but seemed really sweet and pleasant.  Her mother really cared about her and was clearly trying to take good care of her. After a few other history questions it also became clear that Esther had been taken advantage of. I’ll even go so far as to say that she was raped. She may be physically 20 years old but her mentality is more like that of an 8 year old. The man who impregnated her is known to the family and already has a wife.  This lead to a question or two about STDs and the pt’s mother agreed to testing. As we stood up to leave the consultation room and go to the exam room it was immediately evident that she was well beyond 16 weeks. She measured at 28 weeks. But I couldn’t palpate any baby body parts! I’m not greatly skilled in this area but by this far along I can discern head, butt, limbs and back. However, not on this one. And there were no discernible FHT’s by stethoscope either. (Didn’t have my doppler with me.) As we sat back down to discuss the need to go to Soroti for an ultrasound (few of the mothers here ever get an ultrasound for any of their pregnanacies) the lab results came back. HIV positive. Seriously?! So more bad news, more teaching and encouraging them to go to Soroti also for a CD4 count and ARVs (treatment that can decrease the risk of the baby also contracting HIV).  By then there were 20 other cases waiting so they left and I tried to put them out of my mind. (Without success.) I’ve been asking after them every time I’m back in Obule and yesterday they came back to the clinic to see me. Her mother had found the money for the Ultrasound and they gave me the results. It is amazing how terrible the report is. I quote:
Norm preg 23/40 weeks normal placenta over abundance of amniotic fluid.
End of report. At least I kind of have an EDD (estimated due date) now but, to my medical friends, is polyhydramnios ever benign? What was the point of having them pay for the scan?! Deep breath. They had also gone to one of the HIV resource places but had been turned away as they didn’t have enough shillings. I was under the impression that HIV care was free in the country especially for pregnant women but it turns out it is free AFTER you pay the “registration fees” and pay to have your CD4 results. Then it is free. Anyway, I confirmed that she was still taking the prenatal vitamins I had given her, we gave some malaria prophylaxis and a tetanus shot in case she delivered early at home. I stressed the importance of the ARVs and encouraged them to try again. The mother told me transport was a problem (it is about a 10 mile walk to the hospital) so I offered to pick them up tomorrow.  If nothing else it is a chance to spend a little more time with them. 

1 comment:

Karebear said...

Oh, and the story just gets deeper. Thanks for sharing.