uterine rejection

Midwifery is not always a happy field. Perhaps what we dread most is birthing an unexpected still born baby. Or a late term fetal demise - one in which labor needs to be induced to birth the now-still child.

Yesterday, while not so dramatic, reminded me of the sad components of both life - and reproduction.

Our first patient was a 30 year old woman, there for her first prenatal visit. She was 13 weeks and 1 day pregnant - and was coming to us for her labs, her physical work up, and a long discussion about the signs and symptoms of pregnancy. Before I geared up for my shpiel, I asked her the standard questions. "Do you have any vaginal bleeding, any loss or leak of fluid? Can you feel the baby move?" Now, 13 weeks is too early for fetal movement, but not, in her case, too early for bleeding.

When I did her exam, I felt she was 1 cm dilated, and I saw blood in the hole (os) of her cervix. I knew in my heart that she was having a misscarrage. She had been trying to get pregnant for 5 years (since the birth of her now 6 year old boy). She was a recent immigrant from Mexico - and had no insurance what-so-ever. She had already had one miscarriage at 12 weeks (3 months) and now, I was going to have to tell her she was having another. Her husband was in the room, excited to hear the heart beat for the first time. But, of course, we found none.

She cried and cried when we told her. She kept asking "why?" Was it something she did? or ate? or a problem with her? We had no answers. Expensive genetic tests and infirtility work ups are the only possible way to find these answers. But for an undocumented worker with no insurance and minimum wage - well, the explination that "we don't know." Will have to suffice.

Our next patient was HIV positive. She was staying in a half way house, and admitted to me early on that she was coming for an annual exam just cause a doctors appointment was the only way to get out of the house. She told me - when offered condoms - that she didn't want to have sex ever again. "I have the virus, and I have my toy. No condoms, thank's any way."

Our next patient was a 16 year old girl - who had a baby about 2 months ago. Two weeks ago, I had put in an IUD. THis week? It was falling out. Her uterus expelled it. This girl made me sad - her BMI was 38 (ie: She weighed 274 lbs on a 5'5 frame), her teeth were chipped and grey, and in the 3 times that I'd seen her since the birth of the baby, never once had I met the little tyke.

The day continued, in a more normal patter of pre-natal checks and acute complaints. But the start of the day sobered me up a bit. Sometimes the uterus rejects. And our system is not ready, willing, or able, to be there.