I close my eyes and take a deep breath. For a second I let my mind wander back to the views I saw from the small propeller plane the day before en route to Khost from Kabul. The vistas of snow capped desert mountains fill me with calmness. I open my eyes and exhale, ready to take on the chaos in front of me.
There is a sea of patients and their female caretakers crowding the hallway in front of me, some in blue burkas, others wearing multiple layers of colourful cloths and scarves. The women smile at me and gently reach for my hands as they speak to me in Pashtu. “Pashtu nishta” I reply with a hurried smile as I carve myself a path. I do not speak much Pashtu and I need to get to the operating theater. It’s urgent.
A patient had arrived to our hospital with strong contractions after receiving multiple injections of oxytocin, a drug to enhance uterine contractions, in a private clinic. This is all too common a practice in this region of Afghanistan. Labour inducing drugs are easily available and widely prescribed in Khost. There are certain situations where its use is appropriate but when not used properly, the drugs can be dangerous for both the mother and baby.
She had previously delivered a baby normally a few years back but this baby was not coming. When she arrived at the hospital she appeared distressed, her pulse racing. A quick ultrasound revealed that her baby had a very large fluid filled head, called hydrocephalous, most commonly a result of a neural tube defect or malformation. It would be nearly impossible to deliver this baby normally. The baby was dead, but most seriously, it was completely outside of her uterus – the uterus had ruptured.
In the operating room we assessed the damage as the anaesthetist resuscitates the patient with fluids and blood. As soon as we cut into the abdomen the baby emerges followed by the placenta, completely detached, and over a litre of blood. We then see the uterus, the lower aspect of which has completely exploded. Like a complex jigsaw puzzle, we try and put it back together again. But the pieces don’t fit and others are missing. We have no choice but to perform a hysterectomy to remove the uterus.
Under any circumstance this is a sad story, but for a woman in Afghanistan, it is that much more devastating. Culturally, women are expected to have many babies and it is not uncommon to see women who are pregnant for the 6th or 7th time.
While doing inpatient rounds later in the day, I notice a beautiful young patient with the most captivating green eyes. She had delivered twins vaginally the day before and had bled significantly afterwards. This is not uncommon, that a tired uterus does not contract as it should to stop the bleeding. She was now doing much better. “Mubarak shah!” I say, congratulations in Pashtu.
She smiles and touches my shoulder as I pick up her chart. I can barely believe what I see as I flip though the pages. I confirm through the translator that at 30 years of age she has already had 9 pregnancies and 8 deliveries including this most recent set of twins. One of her babies had died, so with her new twins she now has 9 children. Prior to discharge we discuss contraceptive options. She thinks for a minute, but wishes to discuss with her husband first. She is still young and will likely be expected to have more babies.
Family planning is offered in Khost to help women space or prevent future pregnancies. Especially in women who have had direct obstetrical complications, family planning can truly be life saving.