Today was my first day working on labor & delivery. It was pretty darn insane. The laboring room is a large shared room where about 15-25 women wait to be completely ready to start pushing and give birth. While they wait, most lay completely naked, legs spread open, screaming in pain as others walk by ignoring them. Everyone at the hospital seems very used to the fact that women are screaming all the time and ignore it, some even laugh at a particularly vocal patient. At one point today, a woman was screaming so much so I went over to her to check to see if she was complete (ready to deliver). One of the residents stopped me and said, "Don't worry. Ignore her. She will learn we don't give preferential treatment for being loud and she will quiet down." I felt so awful that I had to ignore this woman who was shrieking in pain. It felt so wrong to let her deal with the pain by herself. In case I forgot to mention earlier, patients are not allowed to have visitors so they go through all of labor, delivery, and postpartum alone; they can't see anyone outside the hospital and no one can see their baby until they leave.
Another fantastic quote from today... a patient was just admitted from the emergency department in labor. It was her first time giving birth. She didn't want to lay down on her hospital plastic mattress because there were no sheets on it and it was dirty from someone else's blood. When she told the resident who tried to get her to lay down on the mattress so he could examine her, he laughed and said, "This is a public hospital stupid. We don't give everyone bed sheets. Lay down."
The lower level residents deliver the babies. The upper level residents wear white and therefore usually only stop by if needed. For the most part, we are on our own in the delivery. The goal of the residents in the delivery is to get the baby out as quickly as possible. If the woman is scared or isn't pushing "enough" , everyone in the room laughs at the patient and tells her to "stop dreaming and grow up." Some of the residents smack the patient on the forehead if they think she needs a "wakeup call" and needs to push more. If you are taking too long in the delivery, the senior resident comes by and says "This is taking too long. Cut her right now" (cut means cutting an episiotomy to make more room for the baby to come out). During one of my deliveries today, the baby was making good progress and was coming out just fine. This patient was young and this was her first delivery so she was scared and needed some coaching; she had only tried pushing 2 or 3 times. When the senior resident said the patient was taking too long, he told me to cut her. I hesitated, not just because I didn't have experience with episiotomies or not just because I thought that she didn't need to get cut (even though I don't think she did), but also because this woman did not receive any pain killers or analgesia of any kind before he wanted me to cut her. He pushed me aside, took the scissors and cut about 2 inches into this woman's perineum. Despite seeing many natural child births back home and all the births I see here are without analgesia so I had heard my share of screaming and pain, I had to look away from this patient when she started screaming. I have never ever in my life heard that kind of a scream. The resident gave her a large episiotomy and pulled the baby out without any consideration of pain relief, not even local analgesia. He walked away and the woman was left there alone, bleeding, still shocked by what had just occurred. She laid there alone, naked, with her legs still in the stirrups, bleeding because the resident had to go to another delivery and didn't have the time to stitch up her wound for another ten minutes. When I finished with the patient, I walked away and realized that my surgical mask was wet and that at some point during this episode I must have cried.
As I mentioned before, physicians here do not use ultrasound monitoring to hear the fetal heart beat; instead, they listen using their stethoscope. This is a technique that I am still working on. One of the residents teased me that I didn't know how to do anything here and asked how we could possibly monitor patients differently in the US. As I looked around the crowded room full of women in labor, windows open, with flies accumulating on the patients that were too exhausted to scurry them away... I didn't know where to begin describing the difference. I started telling this resident that where I trained, every patient was constantly monitored for contractions and fetal heart tones. I didn't even bother to describe that every patient had a private room or the other luxuries patients have in the US. I could tell that talking about constant ultarasound monitors, let alone central stations with computer access to these monitors was an entirely different world. I'm learning tons from my experience, some are positive experiences and some are negative experiences but all are great opportunities for learning. That said, I know that I will come away from my month here with an extreme gratitude for the medicine I have a privilege to practice back at home.
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