Birth chasm

My patient is from a developing country. She speaks no English, and I do not speak her language. We communicate through her husband and the female friends who sometimes accompany her. It is clear that the translation is imperfect. It is hard for it to be otherwise: we have completely different sets of cultural norms to work with. My patient will not allow herself to be seen undressed by a male physician, even with her husband and a female chaperone in the room. She does not allow a pelvic exam.

She experiences everything as a maximal stimulus. Every ache and pain, even every fetal movement in the first months, prompts an office visit without appointment. She complains of these problems to her husband, who responds by bringing her to me. Yet vaginal bleeding at 17 weeks, which generates genuine fear in her husband, is brushed aside as unimportant when she is told it necessitates a vaginal exam.

She does not convey to me where her worries come from. Any form of questioning that I pursue through her husband, who appears genuine, concerned and, most important, unimposing, is generally met with a shrug. He asks good questions. But they seem to come from him, not from her. I get the distinct impression that she is relying on other women for the real lowdown on being pregnant and what to expect in childbirth. I don't know what she knows and I have no way of finding out.

At 23 weeks she delivers a stillborn child. This tragedy has a history: bad endometriosis with surgery twice in her native country, attendant relative infertility and late maternal age. Compounding her grief is the fact that this was a son, a highly desirable first child in her culture.

She grieves in a way I don't understand. I am sure that my empathy and concern do not survive the translation. I hate the fact that I sound clinical with my explanations and discharge instructions, even to myself. I can find no way to reach her across the chasm that divides us.

Richard Gruneir Obstetrician-gynecologist Leamington, Ont.