Basic medical professionals were posted in the districts with difficult communication, bad terrain and roads. Sometimes they worked single-handed, with no other professional peers for advice and support for skill reinforcement. Diagnostic facilities were very limited and the medical officers working in rural or district areas had to rely on his own clinical acumen and rational judgment based on memory recall from the textbooks he had read in medical school and the professors lectures and experiences shared during teaching sessions. There were probably a few medical journals around but the only one we could refer to was the Burma Medical Journal published by Burma Medical Association. Cases usually present at a late stage of disease pathogenesis and diagnosis was obvious and straightforward. However, this was not always the case due to unusual presentations and absence of diagnostic facilities.
There were many difficult and complicated cases in all clinical fields and the author would like to start with obstetric emergencies.
Challenges in Obstetric Practice
My very first case in Obstetrics at the township level was a case of occipito-posterior. The patient was an elderly primigravida with delay in the second stage. The Township Medical Officer did not seem too worried and even left the labor room saying that the labor would be normal. Based on the findings on vaginal examination of the sutures and fontanellae, I noted that position was occipito-posterior and forceps extraction was done with the help of an “old-hand” nurse aid. The baby was extracted in the position of persistent occipito-posterior OP. That experience convinced of my limited knowledge and skills in Obstetrics.
Challenges prevailed in the border township where I was first posted as township health officer in 1972. Due to an undiagnosed transverse lie, hand prolapse and shoulder presentations were not uncommon. In this case, the fetus was dead with a prolapse hand with many bullae on the hand which were cyanosed and putrefied with very foul nauseating smell, which meant that it had been quite a few hours since obstructed labor had occurred. Internal podalic version and breech extraction was the procedure I needed to learn from the experienced staff or senior nurse.
One case was particularly unforgettable. When she was first admitted, I ordered the midwife to give an enema which was the practice in those days. However, the midwife reported that enema fluid came out both from anterior and posterior sides, actually through the fistulous openings in the bladder and the rectum. The actual condition was that the whole vaginal canal was transformed into scar tissue with one and half centimeter wide introitus opening, what the midwife interpreted as the cervix with one finger breadth open. The suprapubic swelling that I thought was a full bladder was the lower segment with impending rupture from which liquor was aspirated instead of urine.
I remember a case of placenta previa presenting with antepartum bleeding for which two bottles of blood were given. While preparing to carry out LSCS, very strong contraction of the uterus pushed the presenting part of the fetus, the head which cut through the obstructing placenta. Delivery ensued and both the medical officer and the patient were lucky as there was no need for operative intervention. It was probably a minor degree of placenta previa.
I was then transferred to a district hospital in the dry zone on the west bank of the Ayeyarwaddy River in 1974. The index case was the daughter-in-law of my colleague medical officer of the hospital. She was in labor and I was on standby to care for her. Someone reported that “something was wrong” and I found something abnormal which I had never seen before. It was an acute inversion of uterus. I tried the O’Sullivain method of hydrostatic pressure and it did not work. Finally she was taken to the operation theatre and anaesthetized, the abdomen and uterine muscles became relaxed and the inversion was turned up by pushing just as a lime fruit skin was pushed in from the center, not the first coming part first as was recommended by the text or the teacher.
One unusual occurrence one does not normally see in a professional career was post mortem delivery. A patient was reported to be in eclamptic fits in the pre-labor room. She was cyanosed and almost dead. In a minute or two, I noticed something moving about inside the mother’s womb and then remembered the baby. The baby was extracted with ordinary blades in the labor room but unfortunately, the baby did not survive due to early prematurity. There used to many cases of ruptured uterus admitted to my hospital on the west bank and some died due to late referral and delay in transportation across the swift flowing streams and over the difficult terrain.
I then moved to a rural station hospital in the same district but in another township in 1978. A multipara had developed early signs of pregnancy-induced hypertension and edema. Hydatidiform mole was suspected on clinical grounds and labor induced by Oxytocin infusion. The molar pregnancy eventually aborted and evacuation was done three times, preventing the risk of fatal choriocarcinoma.
Another case presented with pain in midterm pregnancy. I suspected something like appendicitis or other acute abdominal emergency, reflecting on the lecture on abdominal pain in pregnancy. The next day, the hydatidiform mole aborted by itself but the mechanism of how abortion occurred remained obscure in my mind.
Another case did not present with acute pain in pregnancy and history of amenorrhea was not given. However, she had repeated episodes of fainting attacks and marked pallor. Those symptoms justified the exploration of the reproductive tract of women in reproductive age and pregnancy signs of Jacquemier and Osiander were present. Severe tenderness was present and the patient actually yelled from severe pain. I was unsure of the pelvic mass on one side. Diagnosis was clenched by aspiration of pouch of Douglas and blood was revealed. Actually the medical officer saw the case for the first time after internship but the case was recognized easily because the pathogenesis and features about the condition had been thoroughly read jogged the memory towards the correct diagnosis.
One case presented during pregnancy with impending shock and hypotension. The patient was suffering from dysentery and somebody “tread” on the abdomen to relieve the colicky pain of dysentery. Hemoperitoneum was suspected and aspiration from both flanks revealed blood. Laparotomy was done and on opening the abdomen, normal atmospheric pressure was exposed and the fetal sac exuded from the rent with intact membranes. I do not remember the sex of the baby as I had to carry out a subtotal hysterectomy in that small rural hospital with whatever blood transfusion was available.
Another gynecological case was an eight year old girl presenting with a big mass in the abdomen arising out of the pelvis. The mass extended well beyond the umbilicus. Although it was of the ovarian origin, the mass was solid and as big as a large bowl (about twelve inches in diameter), not cystic as I thought earlier. The sample was sent to National Health Laboratory and the result was adenocarcinoma. The patient has survived until today although she had not received any other treatment. A wide length of greater omentum was excised then.
Dr.YeHla
Department of Medical Research (Central Myanmar)
