I was pleasantly surprised that at Mawenzi, women are allowed a “trial of scar”. Also known as TOLAC, trial of labor after cesarean. A woman presented in labor Thursday night. She had a prior cesarean section in 2005 for failure to progress. The chief of the department assessed the patient Thursday night. She was 1cm dilated, had strong contractions and an adequate pelvis on exam. He recommended a trial of labor.

Friday morning we had 3 major cases scheduled in the operating theater: a total hysterectomy for symptomatic fibroids, and 2 myomectomy cases. Chief asked me to supervise rounds and assess the woman with the previous scar. The nurses and two young doctors in charge of the ward were exceptionally nervous to care for this woman. By morning, her cervix was 4cm dilated and thin. With the help of medical students from New Zealand, we timed her contractions. Contractions occurred every 2 to 3 minutes and were strong to palpation. She had evidence of scarring from a genital circumcision; however, the introitus was adequate and the majority of the scarring involved the superior aspect of her labia and clitoral hood. I placed her on EFM and started IV fluids. She immediately had 3 deep decelerations of the fetal heart rate to 80 beats per minute. The fetal heart rate responded well to position changes and IV fluids. I counseled the staff to leave her on EFM and continue trial of labor. We completed rounds and I joined Chief in the operating theater. I told the students from New Zealand to keep a close eye on the woman by instructing them to move her from side to side if the fetal heart rate went down, and to alert anyone if the heart rate did not respond within 2 minutes. I was confident that the students would not ignore her, and would also be able to offer her empathy and support. I continued to check on her in between cases. Our final case ended around 4:30pm. To my dismay, the woman had only progressed to 5cm. Perhaps we could start oxytocin? Invariably that would be extremely cavalier, as an emergency cesarean section would fail to occur within 30 minutes given the present resources. Additionally, the woman was crying out for me to help her. She wanted surgery. She wanted the pain to end. I sympathized and concluded that she had every right to a cesarean section. I informed the staff. Since it was not an emergency, we ate lunch (I was grateful to eat, although I was filled with guilt knowing that we still had work to do). I spoke with Chief and he agreed. The only person that was not satisfied with our plan was the anesthesiologist. There are two anesthesiologists at Mawenzi. One has been out of work for the past 3 days to attend a funeral. The anesthesiologist informed us that he was too tired to complete the procedure. Our only other option was to transfer the patient to a larger, private hospital in the area. I stayed at the hospital until the patient was transferred. I walked home grateful that she would receive the appropriate medical care.

I met my host mama V and her friends, and we decided to go to the sauna. I had some reservations, as I felt as though I was already living in a sauna on a daily basis and I couldn’t possibly need to expose my body to any more heat and water loss from excessive sweating. We entered the facility only to find out that there was no electricity and no water. And not just at the sauna, but all of Moshi. V’s friend turned to me and said, “pole (sorry), this is Africa, welcome”. I laughed and was secretly relieved. Then my thoughts passed to the woman I had sent for cesarean section. Was she able to have the operation? Maybe the other hospital was capable of labor augmentation with oxytocin? But still there is no option for pain management with vaginal deliveries and labor augmentation would prove to be excruciating. The power has gone out at Mawenzi before. There is no back-up generator. I wonder if the larger hospital has a back-up generator.
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Questions and scenarios whirled in my mind. I realized I would never know what happened and I submitted to having wine with V and her friends in the dark.