I never enjoyed Midwifery lessons in basic nursing college. I tolerated them. I was supposed to pass the gruelling Paper Two of the qualifying exams. Inexcelled. I swore to never work in a Maternity set up. I meant it.
Then I didn’t. The nun that ran the mission hospital I trained in hired me straight from college and graciously posted me in Maternity ward. Dark humor. Back then, a post in Maternity ward was deemed as punishment.
There used to be a charge nurse that ran the unit with an iron fist and a pitch black soul. Her motto must have been : of it doesn’t hurt it isn’t worth it. Patients and staffs feared and respected her in equal measure. Maybe she was an undercover agent for the Black Ops.
A few moons and some change, I found myself in yet another Maternity ward of a public hospital. I would work here for a while here until one day my love for kidneys was born. It is the day I met Jepkosgei. Jep, we will call her.
Just Another Admission
It was a normal Sunday mid-morning in July. Rain fell in scattered drops as it does every other July in Kenya and the temperature in Limuru town fell by a few more degrees. I was the nurse in charge of admissions for the day. Sundays were slow. Like the finance guy who takes a holiday to Kainuk when we all want his signature for our salary to be processed. Snail slow.
She wore an ocean-blue maxi dress that had seen better days. Black crocs were visible on her stout feet which she dragged along the cabro corridor like last year’s sins. She looked like she didn’t want to be here. Yes, she didn’t want to be here. I might have concurred but for the well-rounded protrusion of a pregnancy on her abdomen.
My eyes landed on her abdomen. When you’re a nurse-midwife, the abdomen of any lady attracts you. When you’re a ward nurse, the sight of a (wo)man with visible veins in the bus makes you want to say hello. Paediatric nurses fall for other peoples’ children and they want to find out why that one there won’t stop crying. You get the gist don’t you?
My attention seemed to alert her to the existence of the pregnancy. She parted it in one deliberate motion, gave her carrier bag to the lady that accompanied her and took shy steps towards the nurse’s station. Something in me wanted to make her comfortable. To reach out to her and make her feel at home. I did.
The lady accompanying her was her employer. This elegant lady who commanded the same cabro corridor to rise and meet her manicured feet. She dangled car keys and smelt of affluence. Probably in her early fifties, she took quick steps to catch up with the pregnant woman and came to the nurse’s station as well.
Jep and Mrs.Finch. Jep was her house girl. They had two days ago, returned from a holiday in the heart of Rift Valley. Mrs. Finch had learnt today that Jep was pregnant. She was not very happy. She couldn’t let her suffer either so she brought her to the hospital. The chief complaints were a mild headache and a heartburn. Jep couldn’t keep any food down without feeling intense heartburn. On physical examination, I found slightly swollen feet. No she hadn’t noticed but yes her shoes felt tight that’s why she wore crocs today.
She was not sure how old the pregnancy was. She never once attended antenatal clinics. She was hiding the pregnancy from Mrs.Finch. It was 34 weeks by palpation. She had been hiding it from Mrs.Finch because she didn’t want to lose her job. The responsible boyfriend had denied her three times before the cock crowed twice. I don’t know you! He had said, I don’t know you!
This tasteless Sunday was her first antenatal care. And only because her head hurt a little and the heartburn was distressing her. I was supposed to do everything that shouldhave been done in an antenatalclinic. In conjunction with Dr.E, we did our best apart from one thing; an abdominal scan.
We needed one because neither the doctor nor myself could hear the heartbeat of the fetus through the fetoscope. It was scheduled for Monday morning because welcome to public hospitals in Kenya; we do not do ultrasounds on Sundays.
I went home after my shift only to return on Tuesday morning and find my new friend missing. She wasn’t in the antenatal ward where I had admitted her into. She wasn’t in the labor room. She was not in the postnatal or post Caesarean section room either.
I always follow up where my patients go to after I handle them. You could say I’m looking for closure. Jep had been referred to Kenyatta National hospital on Monday evening where she had succumbed to acute renal failure.
Acute renal failure. A finality. A new phrase. An ominous harbinger. New not because I had never heard of it but alien since I had never handled it. What changed between her admission and the referral? What did I miss? What did the doctor miss? One thing the public doesn’t know is that every death weighs heavily on healthcare workers. Especially nurses and doctors as they are in direct contact with the patient.
Dr. E was on shift as well and together we went through her file. Jep had suffered one convulsion episode on Monday morning which had led to a diagnosis of Eclampsia even before the planned ultrasound. I will never forget her blood pressure reading on admission; 124/82mmhg.
Kidneys and pregnancy
We ask you to attend antenatal clinic not only for the life you carry but for your own. We need to establish a baseline for your observations especially blood pressure. To everyone, Jep was not hypertensive. That reading (124/82mmhg) was an okay blood pressure. However, we did not have any baseline to compare it with. At eighteen, Jep lost her kidneys;and two lives.
Pre-Eclampsia is a life threatening condition only present in pregnancy. From the word you can tell it is a precursor to something. Pre means ‘before.’ We can rarely tell who will get it and who won’t. It is characterized by elevated blood pressure, proteins in urine and sometimes severe headache. Eclampsia occurs when a patient fits (convulses). It is one of the leading causes of maternal mortality. It shuts down kidneys as fast as a morning run. It shuts down the heart and the liver with total abandon.
You want to have your antenatal clinic as soon as you discover your pregnancy. You want to encourage women in your circle to seek antenatal care if only to have baseline observations established. You do not want to take pregnancy casually. It isn’t. Please attend your clinic appointment.
Our kidneys contain tiny micro filters that allow certain things to pass into urine and others not to. Red blood cells and proteins are not allowed to pass through the kidneys. If red cells pass through, urine appears like some Coke soda.
If proteins pass through in large amounts, the urine appears foamy. One of the nurses on shift on Monday had written that Jep reported deep-coloured urine a few hours before the fit. This had been attributed to dehydration and patient encouraged to drink more fluids. Maybe I would have thought and done the same.
Acute Kidney Injury happens when bad chemicals in this condition called Pre- Eclampsia are deposited in the kidneys clogging the filters we talked about. This leads to shut down of the kidneys. If our kidneys go to sleep, then we cannot be able to remove wastes from our bodies.
These waste products therefore get reabsorbed into the body and they get packed in all vital organs where they cause untold misery. That is where early recognition and intervention is paramount. Eclampsia happens when the body can’t take the toxic waste load anymore.
In Jep’s case, the progression from mild symptoms to a cardiac arrest was abrupt. Perhaps, if we had handled her in previous occasions; had she attended even one single antenatal clinic, we may have found out a huge discrepancy. Still, I wonder what the doctor and I missed on admission.Everything on paper looked great given our resources but I still wonder…still.
This calls for active management of pregnancy. The mere act of carrying another human being puts immense strain on our hearts, kidneys, blood itself and blood vessels to mention but a few.
I carried the pain with me. I wrapped it in the garment of my heart. Every day I handled a pregnant mom, the hem of the garment broke loose. The fabric was giving way in places it shouldn’t have.
I still see her. In that once blue maxi dress I see her. I feel her breath down my arms; forming rounded frosty puffs that swirl into the fog of my mind. I wish I knew then what I know now. I wish many things. I wish she was still around.
We are heavily advised against forming attachments in our job. I couldn’t help it. Every time I see laboratory results of kidney function tests, I feel her looking down my shoulder to interpret with me. I hope we get it right Jep. I hope we do.
The kidneys, I’ve learnt, will always find a way to be related to every organ in your body. That includes those that you may host for a while.