The cesarean section rate at The Hospitalito is surprisingly high at around 50%. I was initially shocked when I heard this statistic given how efficient Guatemalan women are at having vaginal deliveries (it’s true! They genetically have gynecoid pelvises that often accommodate 8+lb infants) and the unavailability of emergent anesthesia. The statistics are explained by the fact that women generally come (or are brought by their comadronas) for obstetrical complications and because anesthesia isn’t readily available that they have a lower threshold to perform c-sections.
My first c-section experience seemed indicative of developing country obstetrics, a startling contrast to my training experience in the US. Back home, we learn to make evidence-based mental algorithms for each situation and apply them to each individual with the aid of clinical judgement, labs and imaging, and sometimes, instinct. Here, I only have clinical judgement and instinct – all based on just 2.5 years.
That was what I was feeling when I got called by the Centro de Salud for a transfer of a 16 year old G0 at 41.5wks with decreased fetal movement and suspected IUGR as she was measuring much smaller than her dates would suggest. (I was sure at this point that I was a black cloud of death given my experience thus far). The young girl arrived with her comadrona, husband (no older than 18 and likely a shotgun wedding) and her mother. I put the fetal monitoring on and was relieved to hear a heartbeat but I see intermittent variable decels. I performed a biophysical profile – 4/8 – no breathing and an AFI of 3.4cm. EFW was approximately a month behind. It would have been an easy decision in the US: admit to L&D, induction of labor for IUGR, oligohydramnios and postdates with Cervidil.
I spent an hour discussing the diagnosis and the need for delivery. The comadrona was on board and played a vital role in convincing the patient and family to stay. The mode of delivery was another battle, and it took me some time to figure out which side of it I was on. The obvious choice in the US was not the obvious choice here.
On one hand, a c-section would be the safer option. They don’t have Cervidil, only Cytotec. The risk of fetal intolerance or tachysystole would have been acceptable if a stat c-section was possible – it was not. Anesthesia was at least 30 minutes away and performed by the hospital medical director, a generalist taught to place a spinal but with limited general anesthesia experience. In addition, considering the variable decels without labor, oligohydramnios and a BPP 4/8, there was a slim chance the fetus would tolerate a long >24hr primiparous induction.
On the other hand, a vaginal delivery is generally safer and is associated with less long-term risk for the patient. She was only 16 years old, and in Guatemala, likely to have 4 or 5 more children. VBACs are not rare but need to be performed in a hospital with an available OR and blood bank, which incurs a greater cost for her and her family. And of course, c-sections are not without inherent risks, especially at place without general anesthesia and blood products… and me as the primary surgeon…solo.
In the end, we proceeded with the c-section. I held my breath as the spinal went in, steadied my hands and talked myself (and my assistant, the generalist on call, who it turns out had never done a c-section) through the section (with Dr. Khoury’s Lebanese voice going “hurry up, she has a spinal and you are not an intern”) and let out a huge sigh of relief at the last subcuticular stitch. I survived my first solo c-section (with a Rani Ramaswamy tiny Pfannenstiel incision, no less)!
When I first got here, I was adamant that I would provide the same care to these patients as I do in the US and thought that if I made different decisions based on outside factors that I was compromising this promise. I very quickly realized that here, medical decisions are heavily influenced by cultural, social and economical factors, and sometimes, the best patient care is not free of compromise.