Blood On My Hands

Content warning: Graphic description of a medical gynaecological procedure (D&C).

Image: Bibbie Friman

It’s around 2 am and I’m standing in an operating theatre in the bowels of Tygerberg Hospital preparing myself mentally to do a dilatation and curettage. Also known as a D&C or in layman’s terms - a womb scrape. It will be the second time I do this procedure. The first time I do it alone. My supervising registrar is at home sleeping and has “every confidence” that I can do the procedure without him. He’s an advocate of the surgical teaching method, “See one. Do one. Teach one.” No one has asked if I’m an advocate too.

I’m 24 years old. A recently qualified medical intern in my second week of a six-month rotation in the Department of Obstetrics and Gynaecology. At this particular moment, I’m dressed in surgical scrubs and a green surgical gown, neither of which were designed for my petite frame. The length of the gown drags along the floor making it difficult for me to walk without risk of tripping and the belt has been wrapped around my waist twice in an attempt to gather all the folds. Clearly, I don’t conform to the surgical mould.

My dark hair is hidden beneath a blue disposable surgical cap and my facial expressions are obscured behind a surgical mask. I’m not sure that I positioned it correctly because it’s pinching my nose, but I can’t do anything about it now. I stand with my hands held up in front of me, palms facing towards me so that I don’t touch anything with my sterile gloves, and I wait for the anaesthetist to indicate that I can begin.

My patient, a young woman and mother of two came into the ward earlier this evening with heavy vaginal bleeding. She claimed not to know that she was pregnant but the evidence on examining her was unequivocal. She’s had an incomplete miscarriage, which is why she’s bleeding so heavily and why we both find ourselves in an operating theatre at this ungodly hour.

The words scrape, scrape, scrape reverberate in my head. I read a novel a few years ago that began that way: scrape, scrape, scrape. In that story, a teenager was having an abortion. Is that what’s happening here? It’s 1991 and abortion is illegal in South Africa. Is that what I’m about to facilitate? I can’t be sure but my gut instinct tells me there’s more to this woman’s story than she let on. It’s safer for both of us if I don’t know.

She lies in front of me now, her unconscious body draped in green sheets. Her legs bent at the knees and spread-eagled in lithotomy stirrups to make it easier for me to access her womb. Her face is obscured from my view by the green curtain that separates the anaesthetist from the surgical field. The only evidence of human life amidst the sea of green is the discreetly exposed vulva that stares at me from between the sheets. Shaved, catheterised and stained with betadine solution. It strikes me as quite vulnerable and undignified - being a woman at the mercy of the medical system.

The anaesthetist finally confirms that the patient is ready. She may be ready but I’m not sure that I am. I take a deep breath, say a silent prayer and step forward. I tell myself that this is a necessary procedure to save her life now – perhaps in more ways than one.

I begin by inserting a speculum so that I can visualize her cervix. I go on to dilate the cervix with a series of rods, each one slightly larger in diameter than the one that came before. I'm not sure that it's entirely necessary because I can see that her cervix is dilated, but I follow procedure just in case. Then, I insert what looks like a spoon-shaped vegetable peeler into her uterus and begin to scrape. Scrape, scrape, scrape. Scrape away all traces of her pregnancy and the bleeding will stop. It’s simple enough. A routine procedure. Except tonight it doesn’t seem to be working. My patient doesn't stop bleeding.

I keep scraping. I try not to look at the contents of her womb as they fall into the kidney dish in front of me. I feel beads of sweat forming on my brow. My heart beating erratically. My brain racing with an invisible stream of panicked thoughts. On the outside, my demeanour remains calm and collected. On the inside, it’s a different story. The anaesthetist tells me to speed it up as my patient’s blood pressure is dropping from the ongoing loss of blood. I don’t know what to speed up.

The nursing staff look at each other over their surgical masks with a look I’ve come to know well in my time as a medical student. It’s a look that indicates that my performance is inadequate, but that they know it’s not their place to tell me. It’s also a look that suggests they know something I don’t, but they will withhold this information in the subtle powerplay that goes on between us. I’m the doctor and they are nurses. My authority and superior knowledge unquestionable, right? Right. That’s how the hierarchy works. Things go wrong when we forget our place in the hierarchy.

Which is partly why I find myself in this situation right now. I may be a doctor, but the truth is I don’t have the necessary experience. Right now, I have no idea why my patient won’t stop bleeding or what to do about it. I breathe deeply. Scramble for a coherent thought. Breathe deeply again. Try to think it through logically. I have scraped as extensively as I believe I can without causing damage to her womb. I don’t know what else to do and everyone in the room knows it.

A pregnant woman receives an abortifacient draught from a peasant "wise woman"; she falls ill but the physician cannot save her life; her funeral is attended by her family and neighbours. Colour lithograph by S. I︠a︡guzhinskiĭ, 1925. Wellcome Collection. In copyright

Finally, the anaesthetist looks at me from behind the green curtain and suggests I get my registrar on the phone. Of course. That’s what I’m supposed to do. That’s how the hierarchy works. I step out of the theatre and get the staff nurse to dial the operator and ask them to page him. He calls back an interminably long few minutes later and the nurse holds the phone to my ear so we can talk. I stare at the blood on my gloves while I listen. Blood on your hands, says a voice in my head. I ignore it and go back inside.

I do as the registrar suggested and instruct the anaesthetist to give her intravenous drugs that will constrict her blood vessels, and I scrape some more. I scrape until I am absolutely certain that there is nothing more to scrape. I scrape until even I can feel that I am scraping tissue that shouldn’t be scraped. It works. She finally stops bleeding.

I do many D&Cs after that one but she always stays with me. I don't remember her face or her name, but I do remember how it felt to scrape her womb. For a long time after, I lie in bed at night wondering whether it was a miscarriage or an abortion gone wrong (right?). Wondering if she ever fell pregnant again or if I scraped so much of her womb away that I took that choice away from her. I don’t really want to know. It’s safer that way.

Dr Maria Christodoulou