2019-05-06 MDB Reflection- Paula Trepman
As she moved towards the exam table, the doctora gently requested “Abra la boca.” With assistance of her penlight and gloves, she carefully traced over every surface of the patient’s mouth. I was puzzled; I had never seen an Ob/Gyn examine the inside of a patient’s mouth during a prenatal visit. Later when I asked her why, she mentioned the association between cavities and pre-eclampsia, a hypertensive disorder of pregnancy that was highly prevalent in Riobamba, Ecuador. The doctora's attention to physical exam proved to be essential to caring for her patients: later that day, a 27 year old woman who was 2 months postpartum with no risk factors for breast cancer was found to have bilateral breast masses.
When the doctora wrote up the plan in her chart, there was a 20-item plan for every prenatal care visit, from dental screening to “psicoprophylaxis,” classes to prepare women mentally, physically, and emotionally for childbirth. In fact, I later learned that it was the responsibility of the physicians to make sure the patients attended a minimum of five prenatal care visits. In order to ensure this number was met, physicians would record the addresses of patients and perform home visits when needed.
While the methods of fetal monitoring were similar to the US—fetal heart rate, frequency and intensity of contractions, and if the mother felt fetal movements—there was one noticeable difference: the lack of technology. The majority of women admitted to Stanford’s labor and delivery service are put on continuous monitoring, but the Hospital General had only one monitor available for the entire floor of 30-40 women. So instead, we rotated from patient to patient with the fetal heart rate monitor throughout each shift. This experience provided hands-on practice with abdominal exams of pregnant women and significantly improved my ability to discern the difference between the fetal head, buttocks, and hands and feet, as well as to estimate the lie (cephalic versus breech) based on my exam. Additionally, we palpated the abdomen for 10 minutes and measured the number and duration of contractions, which in my prior rotations, was all performed by monitors. It seems basic, but spending a full 10 minutes examining the patient not only deepened my understanding of uterine physiology and labor on a fundamental level, it also provided me time to learn from my patients, understanding what the contractions felt like to them, how long they had been in labor, and what they were most concerned about.
While the Hospital General had significantly less technology than Stanford’s hospital, I left my experience in Ecuador inspired and impressed by the thoroughness of the clinicians I worked with and the strength of public health systems in place. Though Silicon Valley often boasts the benefits of artificial intelligence in medicine and deep learning algorithms, my time in Ecuador reminded me that sometimes the simplest actions, like a brief breast exam, can be the most powerful.
Paula Trepman is a 4th year Stanford medical student.
Her rotation in Ecuador was supported by the Mary Duke Biddle Scholars Program.