T.O.P. Clinic: Day 1

MATURE READERS ONLY

Today marked my first day in the termination of pregnancy clinic or "T.O.P. clinic." The women are gathered in a waiting room at 8 AM. A "sister" (what they call all the nurses here) then briefs them on what they will be doing today. First step is each woman comes in to the consultation room to have HIV testing done. I performed all 35 of the HIV tests on the women ranging in age from 15-43. The HIV test involves a quick finger prick similar to those used for blood sugar testing for individuals with diabetes. The blood droplet is placed on a testing strip and buffer is applied. It takes about 10 minutes to get results. Thus, the women are filed through quickly until everyone is tested. Then they are called back in to be given their results. If someone tests positive a confirmatory test is done that is more sensitive then the first. In addition, they have their blood drawn in order to get their CD4 count. I also performed three blood draws and confirmatory tests for the three women who found out that they were HIV positive today. It was exciting but also disturbing to see how excited some women were to hear their HIV negative status. The reason I say this is because firstly that it is relieving to discover that you are safe, especially in an environment with a 60% HIV infection rate. However, it was disturbing at the same time because these women had no idea whether they were negative or positive because they weren't taking the necessary precautions to protect themselves from such a devastating disease. I will speak about this more when I touch on the counseling sessions.
After every woman is told her status, the physician performs ultrasounds at rapid speed. I have never seen something as efficient as the system they have in place at G.F. Jooste. The physician arrives at 10 am and is gone by 10:30 am, having performed about 35 ultrasounds. The ultrasounds are done in order to find out the gestational age of each fetus or embryo. A bi-parietal diameter (transverse skull) measurement is taken for fetuses over 14 weeks, a crown-rump length measurement is taken for fetuses between 8-13 weeks, and a sac measurement for anything less. They only perform terminations up to 20 weeks. Therefore if the gestational age is found to be 19 weeks then the woman can still have the termination done on Thursday that week.
Each woman is invited back into the consultation room one at a time. A brief patient history is taken and they are counseled on contraceptive use. Most of the women were not using condoms or taking contraceptives of any sort. This is unfortunate because they are not protecting themselves from pregnancy, HIV, or STI's. The sister counseling each woman was terse and adamant about condom use. This is the one thing they drill at each counseling session. I took down a big box of condoms and put it in front of each patient. I was hoping to encourage them to take a pack with them in the privacy of the office. Condoms are free virtually everywhere here, yet a stigma still exists and people are embarrassed to take them in public. Quite a few woman, I believe, felt more comfortable taking some with them in the privacy of the consultation.
The terminations are divided into first trimester and second trimester. The woman are then given an appointment date on Wednesday, Thursday, or Friday that week according to their category. The second trimester individuals are given Cytotec. Cytotec is a drug that causes the cervix to dilate in preparation for the abortion. They take 2 tablets every three hours beginning at 3 am of the day they come in.
Overall, it was a very interesting first day in the clinic. I learned a great deal about gestation, ultrasounds, and counseling methods that are effective in this community. Tomorrow is a public holiday in South Africa so I will be back in the clinic on Wednesday. Although this is a sensitive subject I am approaching it from a purely medical point of view. These women need quality medical care and that is what is being provided at this clinic. I am certain the next three days will be an eye-opening experience.