Monday, April 30, 2012

Ethics


Today I saw my first live C-section. I don’t ever want one. Ever.

Before I launch into the details, I need to take a moment to flesh out some of thoughts I have on ethical dilemmas one can encounter when working in developing countries. The truth of the matter is, you have many more opportunities for research, medicine etc. in developing countries, but just because you have the opportunity does not mean you should seize it. Just because you’re in a country where patient rights are not as salient does not mean you should breach them.

When I was in Haiti I had the chance to see a vaginal birth, and it was one of the most amazing experiences I’ve ever been a part of. But, it raised a lot of questions for me. The Haitian midwives knew I wanted to see a birth, but they didn’t call me until the woman was 10 cm and ready to push, probably thinking that I wouldn’t want to wait hours and hours in the birthing room. However, that meant I first entered the room when the woman was clearly distressed and not in a place to consent to me being there. I asked her if it was okay if I was present for the birth, but I was uneasy about the situation under which this “consent” occurred. Moreover, I was completely uncomfortable just sitting and watching. It felt voyeuristic, impersonal, and just plain wrong. As the pushing became more intense I got up to help hold the woman’s legs. By doing so, I was part of the birthing team. I helped encourage the mom to breath or push in my pseudo-Creole. At one moment I took my hand off of her foot and she screamed at me to put it back so she could have something to push against. Suddenly I felt like this birth was personal. I was invested in her and her baby. With each surge of contraction I became more and more connected to her. When it was all over she thanked me for helping her, and I thanked her for letting me be a part of the birth. I wanted to hold her little one so badly, but she hadn’t held him yet and I did not want to be the first person in this world to do so.

Here I’ve also had some ethical questions arise in relation to my research. First of all, I chose to ask older adolescents about sexual behavior retrospectively because of the sensitive nature of the topic. Anecdotally I’ve heard plenty of stories of 13 and 14 year olds giving birth here, but just because they’re mothers does not mean they are emotionally or mentally mature enough to consent to research. Second of all, several people have asked me why I am doing this research in a school setting. Why don’t you ask the village women? They are more likely to have children younger because they’re not in school. I chose a school setting for two principal reasons: 1.) Research points to the fact that school-based interventions are efficacious when implemented correctly 2.) I need a venue through which I can act on the research. I’m not going to do research for research sake. I’m not going to ask village woman about their sexual behaviors if I can’t do anything tangible to help their situation, or attempt to help their situation. Coming up with an intervention for women in the village is an endeavor that is bigger than me, and I’m not going to do something if I can’t do it well or if it won’t carry any potential benefits for the participants. Sometimes you have to know your limits.

And so now we arrive at the c-section. I’ve become close with two of the surgeons here. One is a Gabonese guy doing his residency in surgery here. He’s in his early thirties and he lovingly refers to us fellows as “les jeunes” (the young ones), even though one of the fellows is also 30. The second is a young Swiss doctor who is here for about two months and is training to be an OBGyn. One night at dinner, surrounding by two other doctors, I asked if they thought it would be okay if I observed a c-section. All of the doctors responded: “not a problem, we’ll call you the next time we have one.”

Again I though to myself: just because this is so easy to do, should I really do it? I have no idea what sort of hoops I’d have to jump through in the states in order to observe surgery, but I imagine there would be quite a few. And there was no possibility for me to help in this case; I would literally just be a fly on the wall.

In the end I decided to do it. I can’t say I have a good reason other than curiosity and the fact that one day I may find myself in the position where I need a cesarean and TLC “A Baby Story” is rather poor preparation. This is admittedly selfish, but I decided that if the surgeons didn’t find my presence objectionable, it was okay to be there.

The woman initially needed a c-section because they baby was transverse. The baby did end up moving but the midwife saw meconium (a.k.a the baby was in distress) so they needed to get her out ASAP. The mom was wheeled into the operating room and visibly distressed herself. It was her third baby, but first c-section. She opted for general anesthesia because she was so nervous. I’m sure if I were in her position I would be terrified, but it’s equally bizarre to wake up and have missed the birth of your child and suddenly have sutures in you. I would have stayed awake.

The baby was out in about four minutes, though it felt longer than that. It was so strange how they place the blue sterile draping around everything but the belly, as if it were totally disconnected from the human body on the table. I watched them cut through layers and layers and finally the baby! She was actually in a breech position at that point. The midwives and pediatrician took the baby to the other room and thankfully she was just fine. I watched the surgeons close up, which took about half an hour. The layers upon layers they have to suture….oh my. The uterus was basically out of the body cavity and it needed two rounds of sutures. This is an awkward comparison, but it was so large and round it looked like a Thanksgiving turkey. The final layer of skin was stitched from the inside so you could barely see a thing, but man was it hiding a mess of stitches underneath.

In the end I’m glad I was there. Thankfully it was a “normal” cesarean without complications, but it was far from the joyous, invigorating experience I had in Haiti. This was surgery, plain and simple. I have a feeling this is just the beginning of processing this situation.

1 comment:

  1. You are so brave! I don't know if I could watch a surgery up close like that without passing out.

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