Tuesday, September 20, 2016

Moments of a Midwife

Water broke and hour 20 with no action. Tick tock, tick tock...if the damn clock was working, that's what it'd say. That's what is on everyone's mind, anyhow. They know what the birth center regulations say, and that hour 24 seems so near. Sent them to the mall for a walk, but they return with nothing to report. Smiles, yet underlying doubt and discouragement. My best midwife reassurance that there is still "plenty of time," and not to worry. Even if that midwife herself had doubts. An hour later and that 4th time momma labors hard, her first unmedicated birth. Sirens blazing outside in downtown Anchorage and roads surrounding us blocked off. A suspected bomb right down the road. Sirens, fireworks, people in the streets. I reminisce to myself, "This sounds like Haiti." Downtown Anchorage on a Saturday night. We ain't in Palmer anymore, Toto. 

Low quiet noises and that momma repeatedly apologizes for how loud she is being. This is a real-life lesson on our individual Reality and Perception...such a funny thing. Wanting a waterbirth and realizing it ain't for you. That's ok. Pushing past that pain, and a baby boy is born. 
Those parents thanking you for what you've given them, but you being thankful that there are families out there who give you the opportunity.

The very next day, in that very same room, within those 100 year old walls...

First time momma contracting every 2-3 and she means serious business. Partner like a deer in the headlights, looking at anyone, everyone, whoever for reassurance. Little does he know he is probably one of the best support I've ever seen. He asks the midwives, "Are you scared?" He's stone faced serious, but we laugh. I would hope the midwives aren't scared! A room full of strong women, supporting this first time momma. She doesn't bat an eye at the laughter and clatter in the room...she is what we call In The Zone. Mary is primarying- midwife speak for the person primarily responsible and catching the baby- she's front and center. I'm directly behind her on her left, but even more so her proverbial "Right Hand Man." The head comes out and Mary looks at me, and states matter-of-factly, so, so serious, "The.head.is.out." I'm not by any means normally witty- it's a characteristic I seem to have been born without- but it comes out without skipping a beat, "Thanks, I see that." We laugh at that she felt the need to state the obvious. We can pretty much read each others minds, so this makes it even more comical. A baby girl is born, welcomed into the world by the hands of a midwife that I trained, and the hands of her mother and father. The sun shines in through the window. It's 8:58 am and a beautiful Fall day in Alaska. 

I've been up for two days straight...but all I can think is...
This. Right. Here. 

Wednesday, July 13, 2016

50 Questions For Your Dr./Midwife When Planning a Birth Center Delivery

 At Integrated Women's Wellness & Center for Birth, we offer a monthly Birth Center Orientation class, to give new and potential clients the opportunity to learn about our free-standing birth center, the services we offer, and what to expect when you have a baby with us!

Here is a list of questions that might be helpful in interviewing or getting to know your doctor or midwife! 

Pregnancy

1. What is your philosophy regarding pregnancy and birth? What is your role during the pregnancy and birth of your clients? 

2. How long have you been a midwife/doctor and how many births have you attended? 

3.  Have you ever had a mom or baby die under your care? (What is the maternal and infant mortality rate?) What was the situation? 

4. Who is on your birth team? How many midwives or obstetricians? Do you have students? Nurses? Medical Assistants? Who will attend my birth? Do I have a say in my birth team? Will I be certain to have you attend my birth? 

5. How many births do you attend per month? Do you have a cut-off for the amount of clients you accept? 

6. How many women are under the care of one midwife or doctor at a time? How much will you be with me throughout my labor? Will anyone else be providing care to me or supporting me during labor?

7. What happens if I go into labor at the same time as another mom? 

8. What does a typical prenatal appointment consist of? How often will I be seen? How long is each appointment? Who can be present for my appointments? 

9. How do I get in touch with you after hours? Can I call or email you with any questions? 

10. What are your thoughts on weight gain, nutrition, and supplements during pregnancy? Are you familiar with alternative and complementary therapies such as essential oils, homeopathy, acupuncture, massage therapy, chiropractic care, etc.? How, if at all, are these a part of your practice? 

11. What are some reasons, as well as the most common reasons, why a client "risks out" of your care? What can you do to help me avoid "risking out?"

12.  Do you offer childbirth classes? Any other educational offerings? What is the cost? 

13. What prenatal testing do you recommend and why? 

14. Do you recommend or offer GBS testing? If so, do you offer any treatment for GBS positive moms? What? 

15. Do you recommend ultrasounds? When, why? Who performs them? 

16. Do you typically do vaginal/cervical/pelvic exams prenatally? If so, when and why? 

Labor

17. What happens if I deliver early? How early can I be and still deliver with you? What happens if I go late? How late can I be and still deliver with you? 

18. What would happen if I had pre-term labor? What would happen if I went past my due date? What testing is available and when would it begin? 

19. Do you do vaginal exams during labor? If so, when and why? 

20. What type of monitoring do you do during labor? How often? For how long? What are you looking for and why?
21. Will I get an IV in labor? When would I need one? How often do you place IVs? 
22. What are my options for pain relief? 
23. Is waterbirth available? What percentage of the births you attend are waterbirths? 
24. Am I and the baby still able be monitored while I'm in the water? 
25. Are you comfortable working alongside others such as a doula or birth photographer? 
26. What kind of circumstances would you recommend induction for? Are you able to offer natural methods of induction? If I had to have a hospital induction, would you be with me? 
27. If my water breaks first, without me being in labor, how long do I have to get into active labor naturally? 
28. How long can my water be broken when I'm in labor? How long can I be in labor? 
29. Who attends births? (Other providers, apprentices, students, nurses, medical assistants?)
30. Do you ever artificially break water? Under what circumstances? How is this done? 
31. What is the percentage of moms who need to transport in labor to the hospital? What is the most common reason? What does that scenario look like? 

32. What is your episiotomy rate? 

33. What is your cesarean section rate? 

34. What is your postpartum infection rate? 

35. Can I eat and drink in labor? Do you provide food? 
36. What positions are an option during labor and birth? Would there be any restrictions on what I am able to do? 
37. What are the reasons why a transport to the hospital would be necessary? Which hospital do you use? Why? 

Postpartum & Newborn Care

38. Do you practice active management or expectant management of the 3rd stage, and why?
39. How long do you allow for the delivery of the placenta? Do you offer delayed cord clamping? If so, what is your definition of delayed cord clamping? Do you offer cord burning? Do you offer placental encapsulation, or can you refer me to someone who does? 
40. What if I tear and require stitches? Are you able to repair a laceration? What if I have an extensive tear such as a 3rd or 4th degree laceration? 
41. How long is the typical stay after birth? What is the soonest I can go home? What is the longest I can stay? What post-partum care do you provide? When? How many appointments?
42. What does newborn care consist of? When and where does this occur? Under what circumstances would my newborn need to be taken away from me?
43. Are you trained in and do you hold a current certification in Neonatal Resuscitation? Is everyone on your birth team trained and certified in neonatal resuscitation? 
44. Are you trained in and do you hold a current CPR or BLS certification? Is everyone on your birth team trained and certified in CPR/BLS? 
45. How often do you perform resuscitation efforts on a newborn? 
46. What resuscitation equipment do you have? 
47. What newborn testing and/or procedures do you recommend? What is available at the center? 
48. Are you comfortable with me declining any recommended testing or procedures? 
49. Do you offer breastfeeding support?
50. Do you offer continued care or support, beyond the first few weeks postpartum? 

Can you think of any thing else to add to this list when interviewing or getting to know your doctor or midwife? 

Thursday, October 29, 2015

Can a Shot in The Vagina Change Your Life?


Integrated Women's Wellness had an exciting month this month! An important new service has been added to our Center's array of services for women: Platelet Rich Plasma injections (also known as the O-Shot). And yes, it does go you-know-where. Stop cringing. Don't revolt just yet.

Many people are unfamiliar with the what and the why of PRP and have never heard of either PRP (used in various ways, in various areas of the body), or the O-Shot. Up until a couple of months ago, we hadn't either. As a doctor (Glen) and midwife (myself) we have heard time and time again from women struggling with the pain and/or frustration due to sexual problems. Statistically, we know that only a small percentage of women will actually talk about their sexual problems with their care provider (though as a woman and a midwife, I feel more women are much more open with me about sensitive issues such as this). The reasoning behind women being hesitant or resistant in bringing up any sexual dysfunction is multi-faceted: 1) It can be embarrassing. Sex is personal. Relationships and feelings are personal. Talking about your vagina and subjecting your body to be examined- even when needed- can be difficult. I know I sure hate being on the patient side! 2) With the exception of short-term hormone replacement, there are few proven treatment options. Both provider and patient would be discouraged by discussing a problem that has no proven solution- so often times it doesn't get brought up by patient or provider. 3) If indeed hormones are already being used as treatment (or the woman is pre-menopausal), the only solution, per the official recommendation of the American College of Obstetrics and Gynecology, is considered to be psycho-social therapies. 4) For problems with stress urinary incontinence, surgery is often the treatment. Surgery is serious business, with the risk of complications to be considered.

So, what is PRP? It's a specific procedure using blood-derived growth factors to rejuvenate the vagina, and the treatment of urinary incontinence and various sexual problems. It involves drawing a small amount of blood from the patient, spinning it down to separate the plasma that is rich in platelets, and then using this as an injection into the vagina and clitoris. Yes, I just said that. And no, it's not as bad as it sounds. We have, and utilize, numbing cream.

On the first day of doing PRP, Glen had a full day of doing PRP injections. The indications for PRP varied from each patient, including pain with sex, inability to achieve orgasm, vaginal dryness, and stress urinary incontinence. So far, the results have been significant! 

PRP and the O-Shot has been in national news and magazines, hyped up on television and in Hollywood...but...it's now available at Integrated Women's Wellness and changing lives. Though, unlike the cover headlines of Cosmo and other magazines touting it as "Hollywood's new sex trend..." and the "treatment for female impotence," the fact of the matter remains that this non-invasive, all-natural treatment is truly helping women restore sexual function and is treating urinary incontinence.



Thursday, October 1, 2015

Perspective

Perhaps it can be said that the last birth Glen and I attended in Haiti was the perfect birth. Perhaps I shouldn't use the word "perfect." After all, I know as a midwife and as a woman that has given birth, the word 'perfect' in reference to birth is highly subjective...and sensitive.  It wasn't a glorious birth by our standards at home, by any means. If you've read even one other blog post regarding maternity care and birth in Haiti, you will understand this. A typical birth back home takes place in a pristine and beautiful birth room that is private, surrounded in candlelight, endless hot water, a walk-in glass shower, a deep soaker tub, clean instruments and supplies, and...just simply...Calm. Birth in Haiti is quite a different experience. When basic care and a trained birth attendant is the exception and not the norm, it puts all of the other "luxuries" into perspective.

There had been four women all nearing delivery. The mom who had induced an abortion had just delivered. I had just held her one pound baby girl in my hands, holding her as she took her first breath and holding her as she took her last breath. My heart was sad as I processed this. I retreated to the back storage room for a clean place to rest, where I sat and thought in the still quietness. Camille was not feeling well and needed to lay down and rest. As she laid the camping mat down on the storage room floor, she questioned the rat situation. I assured her that there were no rats on the inside of the Labor & Delivery unit. I had only ever seen them on the exterior corridor. I told her I would keep an eye out and let her know if I saw any though.

Awhile later, Glen had gone to make rounds on Labor & Delivery and listen to heart tones. After a bit, he hadn't returned, so I ventured out to see what he was up to. I won't ever forget what I saw and what he said. With hands on the belly of a laboring mom and a big grin on his face, he exclaimed, "Look Love, I'm a doula!" I think of it now, and I smile. The laboring woman wouldn't let him leave her. He had tried to walk away, and she had insisted that he stayed.

The needs of humans are actually quite simple, when you take away the materialistic possessions and perhaps more importantly, the ego. This woman simply needed a human presence; the comfort and touch of someone who cared. The fact that he was a male obstetrician, nearly from another world, made no difference. She was in need. She didn't want to be alone.

I walked over and relieved him of his new-found, slightly awkward doula duties. I placed my hands on her belly, and ever so gently, just touched her. Without hesitance, she grabbed my hands and put them exactly where she needed them to be, getting a reprieve from the pain, with my hands gently rubbing her belly as she had a contraction. As she progressed over the next hour, she would grab my hands and move them to her hips, then the small of her back, telling me with not a single spoken word, that she was having back labor. Occasionally she would look into my eyes and nod her head, as if saying to me, "Yes! That helps so much!"  Isn't it fascinating, certain situations in life where spoken words are irrelevant, when the most insightful, effective form of communication is simply through the eyes and subtle, unintentional body language? Two people, two strangers, connected only by the human experience...one in pain and afraid, the other simply having understanding and compassion, and their connection not extending beyond that simple awareness.

As we pushed with this woman- supporting and encouraging her in birthing her babe, I saw something out of the corner of my eye, running on the floor. "GAAAAHHH!" I nearly jumped 3 feet in the air, hardly an exaggeration. "GLEN! Do you see that?!" I pointed to the mouse that was now contently resting in the center of the L&D floor.

I thought of Camille, sleeping on the floor just a few feet away. "Should we wake Camille and tell her?"

We decided that it was just a mouse, not a rat, and well, I had told Camille that I would wake her if I saw a RAT. All about perspective, right? No need in waking her up unnecessarily. I got a little chuckle at that, but vowed that I would be keeping a good eye on the little guy, to ensure he didn't make his way to the storage room.

The birth would be what we might call "uneventful"...except for the obvious, of course- a child, as well as a mother, was born. As Camille and Sheily (our translator) rested, Glen and I would attend this birth together. We had a language barrier that made verbal communication nearly impossible between us and our patient (without our translator), but even without a language barrier, Glen and I needed just as few words between us. Perhaps that is a benefit of a husband-midwife team. We are confident in the each other's ability; we can read each other's minds simply with subtle looks or gestures.

I don't remember if the baby was a boy or a girl. I don't even remember which one of us "caught" the baby. I remember the calm. I remember the Haitian midwives quietly watching, the intact perineum, cleaning her up, placing the makeshift pad of folded cotton fabric between her legs, and helping her to slowly get dressed. There was no bed for her that night. Imagine that: a woman who just gave birth and yet there is no bed in the entire hospital for her to sleep with her new baby. In the wee hours of the morning- some time after midnight but yet still hours before dawn, freshly dressed and brand-new bundled up life in her arms, she shuffled herself to the entrance of the Labor & Delivery unit, laid down a sheet, and spent the first night with her baby on the cool concrete floor.

And yet, she was beaming with happiness and pride.

Friday, September 25, 2015

Blood, Sweat, & Tears...and Love


Often times in life, we are our biggest critic and our own greatest set-back, allowing idealistic perceptions define what is “good enough,” and inevitably, setting our very own limitations. One of my favorite quotes speaks to this thought- “If you limit your choice only to what seems possible or reasonable, you disconnect yourself from what you truly want, and all that is left is a compromise.” (Robert Fritz)

It is not just the rare occasion in which I feel inadequate myself...Am I good enough? Am I competent enough? Am I worthy enough? Does any of what I'm doing matter? I'm tired...I'm scared...I'm unsure. These are a fraction of my own internal limitations. It is a continual effort to remove my own limitations and push myself past these internal barriers. Yes I am good enough. Yes I am competent enough. Yes I am worthy enough. Yes, this matters.

Last night we arrived on the Labor & Delivery unit to a young woman writhing and moaning loudly in pain. She hardly looked pregnant. When I questioned the Haitian midwife on why the patient was there, I was told that the patient was “4 months” pregnant, and had fallen. As I spoke with the patient and took her vitals, I suspected that the patient may be lying about falling. She had no tenderness, no bruises or abrasions. Induced abortions with Cytotec here are rampant- Cytotec is inexpensive and easily obtainable. Whatever the cause- a fall or an intended abortion- the patient's cervix was dilating and she would no doubt be miscarrying. There was nothing we could do. Soon after our arrival, things became more intense, with it apparent that delivery was imminent. I looked to Glen and said, “I can't do this delivery. Will you please do it?” He asked me why and I answered honestly. “I'm scared. I've never seen or touched such an early baby.” I didn't know what to expect. I didn't know what this baby was going to look like. Would this baby come out intact? Damaged? Bloody, gory? I was afraid I did not know how to serve her well. I had no clue, and the unknown is frightening.

As we were expecting an imminent delivery, we would find out from the patient's family who accompanied her to the hospital that she had indeed taken Cytotec. The loss of this baby was intentional.

Around us, all Hell breaks loose. Four patients, all near delivery, are contained in a small room the size of my master bathroom at home. The walls contain the yelling, screaming, moaning, and shouts to Jesus. “Jesus, I am dying!” is exclaimed into the air.

The patient begins pushing and in two pushes, the baby's butt becomes visible, revealing to us that this baby is breech. Glen delivers the butt, legs, and abdomen, and as this limp baby girl hangs out of her mother, she suddenly wiggles and kicks fiercely. Glen and I both startle. Glen looks at me and states the obvious, “THIS BABY IS ALIVE.”

He delivers the baby's head, and places her in my blanketed hands. I gently place the baby on her mother's abdomen, gently wipe her dry, cradle her body in the blanket, and place my stethoscope over her. Her heart rate is strong and steady at 160 beats per minute, and she is making an effort to breathe.

Her heart pounding strongly.
My heart racing wildly.
I am dripping sweat and nauseous, my stomach contorted, feeling as if it is in my throat.
The stagnant air is relieved by a breeze coming through the window from the storm that is brewing outside.
“Camille, can you close the window? I don't want her to be cold.”
Camille closes the window.
Dripping sweat, my back is aching, I'm leaning over listening to the baby girl's heart beat.

I begin to cry and don't even try to refrain myself. Tears are streaming down my face; big fat tears fall to the already saturated, filthy floor beneath us, joining the mom's blood, sweat, urine, and every other patient's blood, sweat, urine, and vomit. This floor knows my sweat well, and now, my tears join it all. This, THIS, is the definition of Blood, Sweat, & Tears.

I am sweating and crying for this baby, and my heart aches so bad for this baby girl that it could bleed for her as well.

She wasn't just “4 months,” she was probably about 22-23 weeks...but she didn't even have a chance. Not here. I cried as I heard her heart beating because I knew I was the first to hear her heart, and I would also be the last. I cried because she was living. I cried because she was dying. I cried because there was nothing I could do. I cried because this didn't have to happen.

I looked to Glen, me having never done this before and not knowing what to expect. “How long will she live?” He says to me that it could be just a few minutes...or a couple hours.

I look into the mother's eyes and tell her that her baby has a heart beat, but will soon die. I ask her if I can hold the baby up on her chest, and wait. She nods yes. This is a big deal. I tell her that I will continue to listen to the baby's heart and will let her know when it stops beating. I ask her to look at her baby. I ask her to touch her baby. I tell her that I'm so, so, so very sorry. There is so much I could say, but right here, right now, it's not appropriate and it doesn't matter anyhow. I want to pray but my mind is not able to assemble any coherent thoughts. I simply say quietly, over and over, “Lord Jesus, please be with this baby; please be with this mother.” I know The Lord doesn't need my words. He knows my thoughts, and knows what is in my heart.

Slowly, the baby's heart would gradually slow...160...130...120...100...and finally, just simply stopped. Over the course of that baby's hour here on earth, she was against her mother, and in my hands, wrapped in not only a blanket from Alaska, but also wrapped in prayer. I said to the patient, “Your baby's heart has stopped.” She cried. I cried.

Eventually, after I had carried the baby away, I placed the baby on the scale, looked her over, and weighed her. I wrapped her gingerly in her blanket, and then placed her in the box that was given to me.

In the beginning, I doubted myself and my ability to do a good job and serve this mother and her baby well. I was fearful. I felt I lacked the “right” words. But in the end, my own expectations and self-imposed limitations didn't matter. In the end, I gave my blood, sweat, & tears...and love. That mattered.


I took my gloves off, washed my hands, and walked away.

Thursday, September 24, 2015

Reverence for Life

Before I write the story of the last shift, I want to first say this: There are many people who have read this blog and who have subsequently saturated us with thanks and praise, pouring us over with statements of what great things we are doing, how selfless this work is, and how we are doing such phenomenal things. While this praise does indeed lift us up and make us feel good, I want to acknowledge that we are doing nothing special, nothing requiring anything but a love and respect for life, and the heart to care. The word 'altruism' comes to mind, and there are times I wonder if true altruism exists. Don't we all do things for a purpose of our own heart and conscience? I cannot say that volunteering my time does not make me feel “good,” simply. That in itself is a selfish reason.

I've recently finished a book that was very insightful. It gives an understanding of early Haiti, how Haiti came to be the Haiti that it is. Mainly, it is the story of an ordinary man and woman, not much unlike you or me, detailing how these two individuals did extraordinary things in Haiti. This book I speak of is called Song of Haiti, which details the lives of Dr. Larimer and Gwen Mellon. The recurrent theme (and purpose of Larry Mellon and his philosophical mentor, Albert Schweitzer) speaks to what draws me to Haiti: “Reverence for Life.”

What is Reverence for Life? It is recognizing the value of all life, with the fundamental principle of morality being that good consists in maintaining, promoting, and enhancing life. I value my life. I value the life of my children. There is nothing more valuable to me than this. I see my own life and the life of my own children here. We are not so different. I value life and the right to live without pain and suffering- no matter in my own country, or half a world away. I it's because of this that I cannot have a skill that I can share and not share it, which I know will save lives and help to ease suffering.

A little girl at the feeding center


“The fundamental fact of human awareness is this: 'I am life that wills to live in the midst of life that wills to live.' A thinking man feels compelled to approach all life with the same reverence he has for his own.” -Albert Schweitzer






Our evening started off rather eventful, and not in the usual way. We rode to the hospital in the usual fashion, riding on the back of a moto. This is something that I fear dearly. The black and white logical thinker that I am, has mulled over many times the various ways that we could come into harm while in Haiti, and I've concluded that the moto is likely the #1 culprit for injury. Further add that we are most often on motos during dark hours- going to the hospital in the evenings after the sun has set, and returning in the morning, before the sun has fully risen. The darkness adds the factor of limited visibility, in addition to the dirt roads entrenched with large stones, rolling and bumping land, that further creates an unstable journey on two wheels. As we were riding to the hospital, I thought to myself, “I wonder if we are going faster each time, or if I am becoming more paranoid?” It was as if Glen read my mind because as soon as I finished my thought, he says out loud, “It seems like the moto drivers are going even faster than before!” Oh Lord, it wasn't just me. Not 1 minute after that, I look forward and see the single headlight of another moto coming straight at us, both us and him going full moto-speed, directly toward each other. I think, “Oh shit, we are going to die,” and instinctively yell out, “SHIT!” My hands fly up to grab the first thing they could grasp onto to brace myself- that being the drivers neck. As I yelled, “SHIT!” I felt my nails sink into the driver's skin. Thankfully both motos slammed on their brakes, bringing us to a halt right before collision. I am also thankful that SHIT wasn't my last word before I died. I apologized profusely to the moto driver, and even though he spoke no English, I am certain he got the gist of what I was trying to convey, as I tapped his neck and said repeatedly, “So sorry!!!!”

Our view from the back of a moto


Planting my feet firmly on the ground, I was relieved to get off the moto and walk the few hundred feet from the outside gates of the hospital compound, to the entrance of the Maternity Ward. As we walked through the hospital grounds, the sky above was thundering and rain started to fall down on us. I stopped just before the metal gate entrance to the ward, and stood there under the falling water. Even in the dark night with a deep blanket of clouds above, the air here remains thick. The cool rain felt good.

We began our night by making rounds on the antepartum, postpartum, and post-op units. These are each one room units, lined with beds on both sides of the room, each bed numbered on the wall above. The first patients we see is a mom and baby. The baby is about a week old and is being watched for a low-grade fever. The first observation is that the baby is swaddled up tightly with a thick winter blanket. It is hot as hell in here, and no one should be using a blanket, baby included. I have no doubt this is likely contributing to her low-grade fever. We take her vitals and do a full assessment. I see that the baby's diaper is full, and note that it is soft, yellow stool. Just as it should be. I help Grandma change the baby's diaper and discover that this baby girl dressed in all pink, actually has a penis. I laugh at my own assumption, because really, using whatever clothing you have is simply practical.


As we are doing our rounds, one of our favorite Haitian midwives Carmell says to us, “I will let you know if we have anyone in labor come in. I know you like to do deliveries!” I smile at that. I know she likes the help, and she is right- I do like birth.

At 9:50pm I catch a baby- a normal vaginal delivery, a healthy mom and healthy baby. As I am finishing up and helping the new mom get cleaned up, Glen listens to heart tones on another patient who is being induced with misoprostol due to severe hypertension. This mom looks terrible and seems to be very sick. Her whole body is extremely swollen, tight from the fluid that is collected in her body. Her face is so swollen that even her eyelids are puffy. I am certain she is nearly unrecognizable from what she normally looks like. Just looking at the woman is a reminder that hypertension in pregnancy is no joke. It may cost this woman her life, or her baby's life. Glen puts the doppler on and we hear clunk.........clunk..........clunk......................clunk. The baby's heart rate is in the 80s and stays there. They reposition her and continue to monitor baby. There's no oxygen available. The baby continues there, sometimes skipping beats. With this mother's hypertension and severe symptoms, along with misoprostol induction, there is no doubt that this baby has little reserve. Glen checks her to see if we are close to delivery and can somehow expedite it. She's only 3 cm. We know that this baby is not going to tolerate labor much longer. He calls a c-section. It's 9:55pm. The Haitian midwives call the Haitian OB. He's busy and can't come. He says that Glen needs to do the c-section. The midwives hang up and jump into action. Within mere minutes, a foley catheter has been placed and the patient is prepped for surgery. Honestly, I'm dumbfounded. I have never seen anything happen so fast in Haiti. There is true urgency in the room, and I have never before witnessed this in Haitian culture. Maybe I'm naïve, but this is my honest observation. Glen tries to listen to the baby again and can't find heart tones again. Is it because of a positional issue or have we lost the baby? We are all wondering the same thing. He continues to try, and nothing is heard. The clock is ticking...ticking...ticking...we wait and the minutes pass by. The Haitian OB who they previously called cannot get a hold of the anesthesiologist, and neither can they. She isn't answering her phone. Glen can't do a c-section without anesthesia. Tick...tick...tick...the minutes are ticking by, and this baby is dying with each tick. Finally, an ambulance arrives to the hospital, and in the ambulance emerges not a patient, but the anesthesiologist and a scrub tech. How interesting that the ambulance brought them to us. As we would find out, this crew is Cuban and only speaks Spanish.

So there they went, an Anesthesiologist and scrub tech who only speak Spanish, an OB and RN who only speak English, and a Haitian O.R. assistant who only speaks Creole. As Glen leaves he shakes his head and tells us that it is inevitably too late. There is no way this baby is still alive. My chest is heavy as I think that we listened to that baby's heart slow down as it gradually stopped beating altogether. I walk to the storage closet, to where Shelly was, and I ask her (as if she were more insightful than I was on the matter), “Do you think the baby is still alive???” I feel as if I am grasping at straws, wanting some reassurance that this little life is still in existence, that we even have a chance. Not just the he or she has a chance, but that yes, WE, have a chance. This life is valued. This life matters. I don't know the swollen face of the mother from any other random face of the day, and I might never know her baby, but in these fleeting minutes, tick, tick, ticking away, there is Reverence for Life.

Shelly looked at me and answered my question. “I don't know...probably not. But I hope so.”

I would walk away to another mom laying on an exam table who was pushing. I would do this delivery by myself, as Glen and Camille were likely just beginning the c-section. I couldn't help but to think that as one life blazed into the world screaming, one life was ending, coming into the world silent. That is a profound feeling. As Glen and Camille would later tell me, Glen would lift the blue, lifeless baby boy from his mom, hand him to Camille. He was certain this was a lifeless baby he was handing over, and contemplated this as he sutured this mom's very sick body back together.

I had just finished with this mom when Camille entered the room with the tiny bundle in her arms, pressed against her body. I heard her say my name, “Tara.” She called it out firmly, not exclaiming but still, making a statement.

I knew when I heard her that the baby was alive. I asked her, “Is the baby breathing?” The baby was trying to breathe, though not very effectively. The conversation between Camille and I is a blur. I took Camille's stethoscope and placed it over the baby's heart and was surprised to hear a heart galloping away; 140 beats per minute. A couple breathes of PPV and some stimulation and this baby was breathing on his own. My fingers remember what that limp body felt like under my fingers. This baby was not even two pounds. So delicate, so frail. We wrapped up this tiny, flopping body who was now making an effort to breathe, and carried him down the hall to the NICU. A pulse ox was placed and showed that his heart rate was 160 bpm and oxygen saturation was 87%. Astounding. We would leave the baby there, under the care of the NICU team. We walked away having done what we could, leaving him in the care of others who will hopefully do what the can.

Meanwhile, we do an intake assessment on a young and very tiny mom whose water has broken. She is a first time mom, looks to be about 100 pounds, and is about 28 weeks pregnant. There is amniotic fluid everywhere- the exam table is drenched, and as Camille and I speak to her, our shoes are in a sea of in her amniotic fluid. She lays on the exam table, without underwear, her legs spread. Her vulva and legs are dripping with fluid, smeared with mucous and blood. I place my hands on her belly, and see that her abdomen hardly looks pregnant. The untrained eye would likely not suspect this naked abdomen to be a pregnant belly. My sweaty, gloved hands could hardly palpate a baby. Her muscles were taut and solid, her skin and muscles from not having held a baby before. Her vitals were normal and her baby sounded fine. She was not contracting. The Haitian midwife had already completed a vaginal exam and said she was 1cm dilated. I went over to the Haitian midwife and asked if we were staring steroids, to help mature the baby's lungs. She shook her head no. I asked why. She said because the patient was already dilated and it was too late, steroids would not be useful. I felt the need to clarify how dilated this mom was, and asked again. She said 1cm. I had so much to say but recalled a good piece of advice that I had just read in the Midwives for Haiti volunteer manual...the best place for questioning something and to correct or teach, isn't in real time, in the clinical setting. This is, after all, their territory, we are just here to help, and teach by example, or when otherwise appropriate. I walked to the back room where Glen was and explained the situation. He agreed that the mom should get steroids and antibiotics. I asked Shelly how I might say this, to let the midwife know, “This is what we would do at home...” Shelly ended up doing a great job with translating this, and in the end, the midwife was very receptive to it, asked Glen the appropriate medicine and dose, and then said she would do it. [The next day we would find out that this mom would subsequently deliver her 28 week breech baby into the hands of another midwife volunteer with Midwives for Haiti. No one knew if the baby was dead or alive, and when the baby's legs were delivered. Jamie was surprised when they started to move. As I write this, the baby is alive and well in the NICU. I hope those steroids got to where they needed to go.]

We would have another delivery later in the night, and this one wouldn't be easy on use either. I wouldn't have expected anything less. The Haitian midwives were taking care of a mom in labor. I had previously told them to just let us know what we could do to help, that we were available if need be. While pushing with the mom, the midwife heard that the baby's heart rate was having decelerations. It would go from 140 to 80...70...and then slowly recover back to baseline. That's not something that we don't sometimes see. Except then she noticed that the baby began to have repetitive decels that were taking longer and longer to recover, now staying a good bit of time in the 70s and then not recovering. She asked for “Dr. Glen” to come help. At this point we were seeing baby's head at the peak of the push, but not crowning. The Haitian midwife asks if Glen can do an episiotomy, but he explains that this will be useless because the baby isn't to the perineum yet. The midwife nods in undertsanding. I see her contemplating something, and as I open my mouth to offer a suggestion, she says the same thing, but in Creole. “What about a vacuum,” we both ask? Glen looks surprised and says, “Oh, do we even HAVE a vacuum?” Why yes, yes we do. I had seen them in the storage closet. He says ok, and a vacuum is retrieved. He puts it on, mom pushes, and he assists her pushing with the traction of the vacuum. A baby girl is born, screaming.


All in all, a busy two days...reminding us and revealing to us in new ways, how delicately precious life is.

Tuesday, September 22, 2015

A Pot to Piss In...and So Much More


Welcome everyone.  If it doesn't become obvious momentarily, I (Glen) have been handed the reigns for today's blog.  Thankfully, I have had a bit of help with the editing to give it a bit more of a writer's flare.  Never fear, I'll make sure Tara picks back up tomorrow!

I'm glad our first day started off so quickly- it gave Camille a taste of what it could be like. But, this last shift would allow us to sit back and take it all in...and that might not be all good. We started the day off nice and slow, such a difference from yesterday, when we literally walked into two simultaneous deliveries. This shift, we were able to help take care of some of the tasks of a busy ward. Tara and Camille set off with our translator to do vitals. Certainly an eclectic mix of antepartum, postpartum, and post-op moms to be seen. One of the most interesting was a mom admitted from mobile clinic for suspected early labor. (Because she lives so far away, she may end up staying there until she delivers.) On exam, Tara noticed something odd about her lower belly. It was obvious she was pregnant, but her bladder was so protruding that it was noticeable with her laying on her back. Tara expressed concern to me; dare I admit Tara's perplexed concern was somewhat comical. She wasn't quite sure what the problem was, as I don't think she had ever seen a bladder so obviously distended. Upon questioning, the patient stated that she did not feel the need to urinate. Tara palpated her abdomen and felt her bladder. The patient didn't flinch, and appeared to not have any discomfort. Clearly though, she had to pee. But where? In what? There are no restroom facilities anywhere. Remember the saying your mom always used to say...'she ain't got a pot to piss in.' I laugh at this...perhaps that was just MY mom, growing up in rural Kentucky. But, I remember hearing it and it never was quite as vivid as here. We found her 'pot,' which was a large bucket that the family had brought with them. Camille held it under the mom as she stood at the side of her bed (not 2 feet from a postpartum mom and baby couplet) and peed. Nearly filled the bucket. You look around and everyone has their pot to piss in...well, everyone except the birth team. Thankfully Tara and Camille somehow have the capacity to hold their bladders for 12 hours. But...that's a different story.

Just when you think that we have everything, or that you can do anything, you're thrown a curveball. Dr. Celestin had apparently seen this young, first-time mom in his outside office and sent her to L&D to get a D&C due to a miscarriage that had not passed. This patient had had consistent bleeding for 8 days that was not slowing down. D&Cs aren't the most glamorous procedures to do here as they are typically done without much in the way of anesthesia and such an invasive procedure which is normally (back home) done in private, is done here in plain view of everyone. Tonight would be no different, except for one twist. As I'm preparing myself for the procedure, I go to the stand beside the patient and look over my instruments. I expect to see all the usual: speculum, tenaculum, dilators, and a currette. Instead, I see no currette and a plastic iPas device. I've seen this manual suction device before, even thought of buying one for use in the office for miscarriages, but this is not my typical go-to device. And here it is in front of me.Thankfully, it wasn't very difficult and all things considered, the D&C went pretty well. Tara stood by the patient's side, holding her hand and caressing her face to help her relax through it, while Camille assisted with holding a leg. One of the Haitian midwives oversaw, and hopefully now could use the iPas device, should she need to. The best part for me was that at the end, the patient looked to Tara, took her hand, and said (in clear English), “Thank You,” for helping get her through it.

Something is brewing in those clouds

It's never fails to amaze me that women come and go in Labor and Delivery here. Somehow, the midwives keep all of these women straight. One such woman had apparently been there all day. When I asked what her status was, the midwife says, 'Dr. Celestin is coming in to section her at some point.' “Why,” I ask? “Transverse lie and her water is broken.”

I decided to examine the mom myself and confirm that the baby is vertex! The baby is “Cephalique” and shouldn't need a cesarean section. A few hours later, Dr. Celestin comes in and does a vaginal exam and doesn't feel a presenting part and finds the head is the right lower quadrant.

In our discussion about abnormal lie (breech, transverse), I ask if anyone there does versions. A 'version' is a procedure where a baby is manually turned to get it to head down. A fairly common procedure in the states, but not here. I ask why they don't at least try- certainly an attempted version is safer than a potential cesarean section- and am told by Dr Jean Baptiste that they learned in training that versions will cause the placenta to pull away and harm the baby. This just goes to show that you just never know what is common sense and commonplace in one place, may be literally a foreign concept somewhere else.

Eventually, we take the patient back for section. Dr. Celestin jokes in Kreyol that I am the primary and HE will be assisting me. Apparently, not only am I the primary surgeon, but the scrub tech as well. I stock the Mayo stand, prep and drape the patient. Everything, except the sharps, eventually winds up between the mom's legs...placenta, retractors, scissors, blood clots...everything. It isn't exactly the prettiest, but it did get the job done. Camille would join Dr. Celestin and I for the cesarean and be responsible for the baby. After delivery, Camille would take the baby to Tara, who was awaiting in Labor & Delivery. I can't say that the protocol for having an assistant in charge of baby's care has been implemented, but as Tara reminded me, we did get to model this for the Haitian providers. An assigned care provider for baby to company during the surgery, and someone waiting, prepared to assist with care on the ward.

Preparation for the c-section baby

As our 4 year old Adria would say, this baby was a 'fat man' (this is her term of endearment for Callen), at a whopping 8lb 13 oz. Except, apparently it is a curse in Haiti to call a baby 'fat' because those 'fat' babies will then lose weight and not thrive or do well. In doing postpartum rounds, Tara proudly exclaimed, “The baby is so fat!” Our translator had to inform her that she should not say this, since it is not a good thing for he family to be told. Lesson learned. No “fat garcon” or “fat tifi” here!

One of the things about birth that we take for granted back home is that women, and our culture as a whole, value and celebrate the 'birth experience' when the baby is born. It has been my experience that moms and dads often cry when their new baby is born. Emotions are abundant with birth in our own culture. However, birth is not typically a time when Haitian women express emotion. Nor are babies often named at birth. We often get asked regarding this by friends, why it seems as though Haitians seem irreverent for new life. While it may appear this way superficially without understanding Haitian culture, we slowly understand that this is not the case. At the very basis, we need to consider and remember that if a baby is born alive, BIRTH is the first of many hurdles that the baby has to cross to get to adulthood. Enough babies die after birth that it seems recognized that the newborn's life may be short-lived.

A baby girl we assisted with...photo with permission. 
2 kilo budle of love

#clothdiapering


I will admit that I was once perplexed over a total lack of emotion in Haitian people, in birth and in death. But last night changed that. In the overall quietness of the night, a spontaneous commotion erupted within the hospital compound. A woman sprung from the dark, exclaiming, yelping, and wailing, making us question whether she was having a mental breakdown. The exterior hallways within the hospital are as pitch black as the night sky, making visibility in trying to visualize the happenings hardly possibility. In the wee hours of the morning, with wards overflowing with admitted patients and no where but the outside for some patients and their families to sleep, the halls are lined with sleeping bodies. The shrill hysteric outcries of this woman startled all of these slumbered bodies, resulting in a scattering of the people that laid surrounding her. What is going on? What is happening? I am sure these were the questions in everyone's mind, us and Haitian alike. The woman's hysterical screams and outcries continue, as random voices yell to her in the dark. Though we had no idea the specifics of the situation, it was obvious that this woman was grieving. One thing is certain, the translation of loss and grief transcends cultural and language differences. As we would learn from our translator, someone had just died in the ICU. The yelling sounded despaired and grieved, and that it was. This was the first overt display of emotion that I had witnessed in Haiti. Through the pain of labor, the separation of family, the death of a child, nothing we had previously seen provided a glimpse into one's personal feelings of their pain and suffering.

As those of this blog would know, hypertension in Haiti has been rampant in our previous trips. As we take vitals in labor I'm amazed that more often than not, the women have had normal blood pressures. Obviously there has not been a dramatic change in diet, but perhaps an increase in prenatal and intrapartum care availability? This of course is anecdotal... I don't know the answer, but it is very apparent that something is changing. 

Sunrise behind the Midwives for Haiti compound.