C-section, anyone?

I've just recuperated from a busy night on call working on labor and delivery, where they average 15-25 deliveries in 24-hours. I delivered my first Nicaraguan baby, a 3400 gram porker (considered large here), to a first-time mom. When I told the resident and nurse I was *not* going to do an episiotomy (they do it on all primips), the fourth-year resident snickered back, "That's fine. Just have fun stitching up your big-ass tear..." It turned out thanks to Felipa teaching me about super-crowning and controlling the head at the perineum, the patient had only a very small 1st degree tear that needed one stitch. The nurse and med student were quite impressed. I received a "Muy elegante, Dra. Su." from nurse Carolina which helped bring down my blood pressure and heart rate, as I worried I was going to blow it and they would laugh at the ignorant and haughty American who was suturing up a large 2nd or 3rd degree tear. Phew.

The amount of c-sections in the hospital is hovering around 40% and the past 24-hours in the hospital were no different. Perhaps, actually, there were slightly more c-sections than normal, vaginal deliveries. I miss those! A couple of thoughts why the c-section rate is so high: 1) VBACs (vaginal births after prior c-section) at all, 2) limited use of fetal monitoring, and 3) hardly any use of instrumental delivery (no vacuums or forceps). Reason number two is mostly from my own personal observation. They have only one fetal monitor machine and use it on a limited basis. For example, yesterday there was a woman who came in at 3 cm and hadn't progressed after a few hours on pitocin. They decided to put the fetal monitor and toconometer on her and saw a 20 minute strip of tachycardia with a couple of variables (not decels). She ended up with a c-section because of that strip. In another case, a woman with preeclampsia had a somewhat flat-looking 20 minute strip (minimum variability) but otherwise was asymptomatic and having contractions. She went to section. When I asked the residents if they had the ability to have an indefinite number of fetal monitoring machines would they be inclined to use it on all patients throughout their entire labor. Their answer was yes. It seems to me that they should either use it all the time or none of the time. Otherwise, sometimes decisions to have a c-section are based on a twenty-minute snapshot fetal heart strip.

Another woman had a primary section without a trial of labor because on clinical exam (including the beloved pelvimetry exam we residents in the States get poor training on) and some "Johnson formula" they use to calculate macrosomia suggested that there was going to be cephalopelvic disproportion. The baby turned out to be 3800 grams so not meeting macrosomia by our definition (their argument is that Nicaraguans tend to be smaller than North Americans, which is true, but I've had tiny Mexican women deliver 7, 8, 9-lb babies vaginally). It would have be interesting to see if she might have been able to deliver that baby vaginally if given a chance. A last comment is that so many of the fundal heights at term measure 30-34 cm. I was pretty shocked, at first thinking oligohydramnios, IUGR, or just something bad in general. The residents argue that it's a combination of Nicaraguans being smaller people and the prevalence of malnutrition in the country. I think I agree with them on that one.

Overall, I have been impressed, though, by the residents and the way they run the hospital. For the most part, in labor and delivery anyway, they manage complications like we do. The residents are incredibly smart here, as there are only two public medical schools (one in Leon and one in Managua) and they are super-hard to get into. It is the only field where the tuition is free, making it that much more competitive. Thus, these residents are the creme de la creme. They are intelligent, hard-working, passionate, and quite amiable. Their clinical skills and knowledge base are quite immense as they are always reading textbooks and studying.

My partner in crime, Amy, is currently crawling into bed because our apartment is on a loud street and she hasn't been sleeping well. While I was on call last night, she was putting together a 56-slide powerpoint presentation for a 6:30 am meeting with an anesthesiology attending, Dr. Gomez. As expected, he was impressed, and she was doing intubations with him all morning. Good job, Amy!

So we are working hard on our elective away, getting to know the residents, attendings, and nurses, and just enjoying being in Nicaragua, where everyone we've met has been so friendly and welcoming. The hospital doesn't get too many foreign visitors (we may be the first from the U.S.) so they are all eager to ask us about life in the States and to practice their English. I'm hoping to spend the majority of my three weeks doing OB and weaseling my way into actually doing the c-sections , while Amy will be spending a few days in each department (surgery, anesthesiology, pediatrics, and OB). We're also hoping to try to head out to a rural clinic for a day or two at the end if we can.

By the way, for those not in medicine, I realize much of the blog is filled with medical jargon and I apologize. It's hard when most of our days have been in the hospital. This weekend we'll be going on a two-day camping trip to a volcano so will have more "non-medical" things to share. And hopefully lots of pictures as well! Stay posted!

Cindy