Friday, April 26, 2013

Do Good

Before every surgery, before every birth, I always speak the same words to Glen... “Do good.” It is not a grammatical error of the intention “do well,” but rather very intentionally, DO GOOD. Do good with yourself, your skill...go and do your best...but also, do good for that person and by that person. It never gets old, it never gets repetitive or irrelevant.


We went to Haiti to do good.


In the 3 weeks we spent in Haiti, we worked our asses off, were thrusted beyond the uppermost thresholds we had ever reached, pushed from our comfort zones- physically, emotionally, mentally, and professionally (and probably in just about every other capacity). We taught, but we also- more than anything- learned. Oh, did we learn.

We were so eagerly welcomed by the Haitian people- the midwives, the students, the mothers and their families. These people so very much wanted our help, wanted us to be a part of their care. They were so thankful, so appreciative. I am grateful to have been not only been allowed but welcomed into the lives and births of these women.

There were times that I felt hesitant, even inadequate in many situations. But then, with the realization that what I had to give was better than the alternative- nothing- I trudged forward. The situations I was in and the stories I will now forever have as my experience are endless- I was a teacher, a preceptor, an obstetrician, a pediatrician, and a NICU nurse. But more than anything- I was a MIDWIFE.

To be a midwife and practice midwifery is a beautiful thing. It is to be with a woman. To support her and guide her when needed, to not intervene unless needed, but to also recognize when things are abnormal and then have the skills to handle the situation appropriately. I laughed with mothers, experienced what it is to be with a woman even through language barriers, I welcomed new life into my hands and I also had a baby die under my hands. The emotional spectrum I felt and continue to feel toward Haiti is a vast abyss. It just cannot even be expressed.

Here at home we struggle on a daily basis in the battle to decrease unnecessary interventions, lower the cesarean section rate, and bring birth back to the hands in which it belongs- women. It is not about the doctor, it is not about the midwife, it is not about a committee, or a lawyer, or someone with ulterior motives. It is about practicing evidence-based, providing evidence-based information to the woman, and supporting that woman in birthing her baby safely, but also in how she has informly chosen.

It's an interesting thing that here at home we are struggling with decreasing interventions while we drown in a sea of gadgets and machines and various interventions at our disposal, and in Haiti we hope and pray for access to these same interventions. Here in America, the war wages for midwifery to survive and continue, the battle of recognition and legality and CNM versus CPM continues on. But yet in Haiti, women and babies are DYING- dying EVERY DAY- because they NEED midwives. Is this not a terrible, sick predicament of this world? What a contradiction of situations.

And so we are back...back from Haiti, back to our “everyday life.” We have returned to our work- our comfortable office, finalizing plans for our beautiful new office and birth center, and back to our healthy moms. Even in just the two days that we have been back, the memories of Haiti are beginning o fade in our busy, occupied minds.

But let's not forget. Oh Tara, I tell myself, do not forget. Haiti seems to be a world away. But it is not. It is so, so close. And regardless of language and cultural differences, women and babies are dying, and that is just not acceptable. Not when there is something I can do about it. Not when there is something we can do about it...

A typical sight in Labor & Delivery


A premature baby girl dies.

The safe delivery of healthy twins, breastfeeding soon after birth.

A placental abruption, neonatal resuscitation, and likely long term complications.


Hope

A happy, healthy delivery and new life.
 


I will end this blog entry with my 3 very favorite quotations, which are entirely independent of each other and seemingly unrelated, yet cumulatively, they sum up my feelings of my experiences of Haiti and really, my life in general...


"...I feel that same intricate delicacy for the life within me. Everything in life and the outcomes that transpire are ever so fragile. We, like a developing life, are hanging on by a thread. Will it work out? What will tomorrow bring? We don't know. The thread is delicate and can break at any given moment, sending us down another path, or taking it all away..."
-Me

"You are a midwife, assisting at someone else’s birth. Do good without show or fuss. Facilitate what is happening rather than what you think ought to be happening. If you must take the lead, lead so that the mother is helped, yet still free and in charge. When the baby is born, the mother will rightly say: 'We did it ourselves!'
~ from The Tao Te Ching
 
"I slept and dreamt that life was joy. I awoke and saw that life was service. I acted and behold, service was joy."
~Rabindranath Tagore




If you are interested in learning more about how you can help, please visit MidwivesForHaiti.org.
 
And... Do good.

Thursday, April 18, 2013

Day 19...A Silver Lining

Our next to last night at St. Therese started just as every other night shift. We meet our translators, set down our stuff in the call room and get a feel for what is happening. Tonight, it's obvious we have just missed something. There are blood trails from the birth room to the 'shower/bathroom' as a mother had just given birth and was getting cleaned up. We find out through the translators that the mom had delivered twins. One had survived, the other had died. Apparently, the baby had been dead for some time.

Now knowing the Haitian way things worked, I looked for the baby. I knew I would find it. The cardboard box. And there it was...parked inconspicuously in the corner, a cardboard Lactated Ringers box. Curious, I open it and confirm what I had figured. No bags of LR IV fluid, but instead the body of the deceased baby was unceremoniously placed in a box and left in the corner. There it would stay, too. It stayed there throughout the night. Patients came and went. One woman was there to be evaluated for bleeding. She kicked off her shoes and stepped up on a step stool a mere 6 inches from the box. She never knew what lay beside her. Her baby was fine and she was sent home. But others came and went and still the box stayed.

But, that seems to be the way it's done. It happens so frequently here.

We check with antepartum to see if anything needs to be done. The midwife brings over a woman with preeclampsia that has been 'induced' but it has failed. The term 'failed induction' here has a completely different meaning than what we use. This particular mom had been on the antepartum unit for at least 3 days. She was admitted with high blood pressure and 3+ proteinuria, about as good a definition of preeclampsia here as you are going to get. There isn't a way to do a 24 hour urine protein, a full CBC with platelets or a chemistry panel. So, it's blood pressure, urine dip, and symptoms. The first morning she had 25 mcg of cytotec placed. The next morning she had 50 mcg of cytotec placed. In reading her chart (in Creole) it is apparent that during that time she had been given apresoline, both as an injection and as a drip, methydopa, hydrochlorothiazide on multiple occasions. But it all seemed random, as I've found most orders here to be. I have at times quipped that doctor's orders at home are merely 'suggestions' because good nurses will do what needs to be done, regardless of what I write. Here that couldn't be more so the truth. There aren't parameters to do A, B, or C if the blood pressure is high. There are no orders to repeat the Cytotec if she isn't contracting. No orders to repeat the blood pressure meds if the first hasn't worked. It just seems that if the next midwife happens to round and find something askew, then it might get addressed. Otherwise, it might sit for another day. And so it goes...

When this mom got to Maternity, we did our initial intake. Her blood pressure was 220/120. She had bags of fluids hanging. LR, apresoline in LR and magnesium in LR. All were running at some apparent random drip per minute rate. The Haitian OB happened to be there and I expressed my concern to him. He asks a few questions. Do you have a headache? Not now, but earlier, she says. Do you have any pains? No, just a few contractions. He looks at her sclera, presses on her legs to look for edema and then says that we should work tonight to try and get her blood pressure down, and if we are not able to then she could be sectioned in the morning when he comes back in. That's not reassuring! I am not exactly comfortable with this plan at all. But, I can't do a section on my own here.

The midwife on last night has to be commended though. She does a stellar job. Actually, probably one of the best I've seen. She takes and documents her blood pressure and babies heart beat every half hour, all night long...which may not sound like a lot, but without an automatic blood pressure cuff and continuous electronic monitoring, meant she was bedside nearly constantly throughout the night, manually taking pressures and listening to baby. It doesn't come down much at all, until I decide to just take matters into my own hands. I rummage through the cabinet and find Labetolol. I tell the midwife to give her 200mg orally. Her next few blood pressures are the best of the night, but it doesn't last all night. By the time we leave in the morning, her blood pressure is back up to 190/110 and we heard from the next shift that she did end up getting a section. None too soon in my book.

The other patient we triage last night had come in from 2 hours away, from a town called Thomasique. She had possible premature, preterm rupture of membranes. Tara is doing the evaluation. She is gathering supplies to do a speculum exam. There are no fancy tests to prove rupture of membranes. No nitrazine paper (although apparently that is here occasionally) no Amnisure, no fern testing, no fetal lung maturity on pooled fluid. A speculum exam is the best that it gets.

Just as she is about to start, the power goes out! And everyone pulls out a phone and shines a light. Tara is able to find one of our headlamps and she continues on with her evaluation, mostly in the dark. Yes, the fluid leaking appears to be amniotic fluid. Damn. This is not a good situation here.

On the wall, behind the midwife's desk are a list of protocols. There is one for preterm rupture. It looks reasonable. I bring the midwife to the desk and point at the protocol. THIS is what we are going to do, ok? She needs dexamethasone 6mg every 12 hours for 2 days, ampicillin 2gms every 6 hours for 2 days, gentamycin every 24 hours for 2 days, then amoxicillin for 5 days. All of this plus or minus tocolytics, nifedipine or magnesium depending on contractions. It all seems reasonable.

I go over and over and over this with the midwife. Yes, yes...I can give the ampicillin and gentamycin. OK, but what about the dexamethasone? 'I'll get it' was the response. Hours later, I ask if everything was given. Yes, yes...I've given the ampicillin and the gentamycin. Ugh. Who knows if she got or will get the medicine? And the ampicillin, will it be dosed every 6 hours? Doubtful. There just isn't a mechanism to force a reminder that meds are due at 8 and 2 or 6 and 10. There's no such thing as a MAR and verbal hand-offs are nonexistent.

The rest of the night was uneventful. A somewhat restful night. We have one more day shift followed by a night shift left before we depart. I have seen some things seemingly get better even since we have been here. The midwives seem much more prepared for birth now. Pitocin, instruments, and ambu bag are readily available more often. But, so much is left to fix. And it all seems to boil down to follow through and initiative. Patients need to be triaged and have a plan developed and followed through. There should never be an 'induction' for preeclampsia here that is a single dose of Cytotec daily. That shows lack of follow through. Either she needs to be induced or she doesn't. If she does, then follow-up after that first dose.

As a final note, I should mention a patient I first saw on Tuesday. She was brought to my attention by the midwife on antepartum rounds. According to the midwife, she had come in from a village the night before with a cough and the midwife thought she had a 'respiratory' issue. The patient had been given a slip for labs, but hadn't done them yet. Apparently, she thought her sister could go do the tests for her. I do a quick obstetrician's assessment and ask a few questions and listen to her lungs. The right side sounded awful. I knew it was beyond my scope, so I found the internist making rounds. At that point, I felt like the idiot medical student, because she grabbed the chart and found out that she had actually been on the ward since the Friday before, so now day 5 on the ward and no internal medicine consult. She read through the chart and saw that she was started on erythromycin. She asked more questions and found out that the cough had been ongoing for 21 days. She had night sweats, weight loss, but no dyspnea on exertion. She agreed with my physical exam at least.

She needed a PPD, a sputum culture and a chest x-ray at a minimum. We went to radiology to see if we could beg to get a chest x-ray. As it turns out, they had one film left. Then the argument got to whether or not they had a lead vest for the pregnant patient. Nope. They had A vest, but it was for the technician and couldn't be used on the pregnant patient. Fine. The radiation from a single x-ray is miniscule and likely less than we get from walking outside on a daily basis. This was a battle we weren't going to win. Oddly enough, the x-ray was taken with the mother AND the technician unshielded. Ugh. There is NO accountability here.

An hour later, the internist pulls out the film. We don't need a lightbox. She has a consolidating mass in the right upper quadrant. TB until proven otherwise. The PPD and sputum test will be two days. She goes back to antepartum ward, supposedly with a mask, but that's all the precautions she has.

The next day she is a little better, and her ppd is starting to indurate, but it's too early to read. The next day, she is gone. Whisked away to the TB ward to be treated there. What could have been two days of exposure to a room full of pregnant women ended up being nearly a week, because a plan wasn't made and the proper people weren't consulted. Looks like I'll be getting a PPD when I get home.

I hope that all of our emotions and feelings have translated through this blog as a true testament to our time in Haiti- depicting not just the negative...because even with the negative- hurt, loss, frustration at a chaotic environment and lack of system, there is still good. There is a silver lining. The hospital itself, the midwives, and the facilities have apparently gotten MUCH better over the years. We can see that the midwives trained with Midwives for Haiti are the brightest and the best that they have. Last night I saw one truly have follow through and take vitals and document vitals regularly. There is some obvious critical thinking going on. In the patient with the preterm rupture, I had told the male midwife, a graduate of last year's class, that he could give nifedipine to help calm her uterus. When he took her blood pressure and found that it was low (normal-low, 110/60), he questioned giving the meds. That made me proud. I know he's going to do good by his patients. So, there is a hope here. Certainly, a few things need to be changed, but as time goes, the students from Midwives for Haiti will begin to exercise the change that they are taught and improvements will be made- in the hospital, and for maternal and neonatal health in Haiti.




Wednesday, April 17, 2013

Day 17/18- Placental Abruption

I'm irritable.

Maybe it's the heat. Maybe it's exhaustion. Or even more so, a combination- the physical toll of working like a mule in the Haitian heat, and the emotional tax that is entwined in the work that is birth, covered in blood and sweat and tears, literally- and then often returning to do it again for nightshift with very little sleep. Maybe it's because this is the 3rd week of essentially being a siamese twin- never being very far from my husband- living, breathing, working, sleeping, everything, never far from one another, and the stresses that come with that (No, The Amazing Race is simply not for us. We would, in fact, claw each other's eyeballs out). Maybe it's going on 3 days of living off of brownies because my stomach has reached it's limit and cannot (CANNOT!) handle more rice and beans and goat meat. Compacting all of the above, I think my irritable demeanor is also attributed to the fact that after working in the Haitian hospital for nearly 3 weeks, I feel like we've seen so much and seen what works and also all that does not make sense. Seeing things take place that have no rhyme or reason is just simply irritating.

Yesterday was the second day in a row that I have had a handful of students. Tuesday I had 2 midwifery students and two nursing students. Honestly, from the get go I was a bit irked. The nursing students have nothing to do with the Midwives for Haiti midwifery training. I am not here to teach nurses. I am here to help train midwives. I should have questioned it, but I didn't. The labor and delivery unit consists of 4 bays divided by plastic shower curtains, with one of the bays having two beds, making a total of 5 beds. The musky, sweaty, putrid box of a room is filled with cockroaches, flies, and mosquitos. Women have sheets under their bodies to absorb the bodily fluids associated with birth, and each woman usually brings a bucket to void in. Once the sheet holds it's max, everything drips to the floor, flies swarm. It's not uncommon for a mom to be laying there with flies on her bloody perineum. Picture these conditions- dirty and cramped- and add midwives. Then add midwifery students. Now add a handful of nursing students. It is ridiculous. It adds to the chaos of the environment, does not create a mother-friendly care environment, and it takes away from the good of this midwifery program.

Yesterday the preceptor tells me that she wants the nursing student to do a vaginal exam on my laboring mom. OK...this is the nursing student who cannot even get an accurate blood pressure or respiration. She has no business sticking her fingers into my patient's vagina. (Yes, I think I'm a bit bitter...) So I ask the preceptor, “Has she ever checked a cervix before?” “No,” is the answer. “Ok...has she been practicing with a dilation chart or a model?” “No.” I shook my head and shrugged my shoulders but said nothing more.

So this nursing student checks my mom and of course she has NO idea what she's feeling and what she's doing. And in the meantime, the MIDWIFERY students are standing around watching. THEY could be doing this. They SHOULD be doing this and learning from this.

Afterward, the preceptor tells me that she wants me to help the nursing student with the delivery. Looking back, I wish I would have said something. But I didn't because I did not want to create tension. There I was helping this nursing student catch a baby- who just minutes before had done her very first vaginal exam and who was not even competent enough to take accurate vitals. I may have had smoke coming out of my nostrils. It's not the preceptor's fault, it was what she was told to do by the higher-ups in the hospital.

After delivery and some skin to skin time, the baby is taken to the back counter to be weighed, measured, and examined. I have learned by observing the midwives and students that really, there is no such thing as a newborn examination, if only in textbooks. Their newborn exam consists of weighing baby, measuring baby, erythromycin in the eyes, vitamin K shot in the leg, and dressing baby in a full get-up.

After mom is stable I walk back to find a fully dressed baby on the dirty chipped countertop. Two students are standing next to the counter. Only 15 minutes or so has passed since delivery. There is NO WAY that a newborn exam has been done. I ask, “Have you done a full head to toe assessment of baby?” They look at me, hesitate, and like stuttering John's try to say yes. Almost immediately they start to undress baby so they can actually do the newborn assessment that they know they bypassed altogether.

I am angered. This isn't just a problem with the students, it is also with the midwives. I look at them and ask a simply question- “If you did not do a full assessment of this baby, who would do it?” I already knew the answer. “Would it be done in postpartum?” They acknowledged that the answer is no.

What if there was an abnormality? Would you find it if you did not look?” No.

I ended by saying, “We do not only have one patient. We have two- mom and baby...And by being a part of this birth and taking the baby to be assessed, you are accepting responsibility for this patient.” We then went on to do a full newborn exam together.

It's amusing, the contradictions of myself.

I knew what to expect with Haiti. Yet I knew nothing. I understand Haiti's problems. But I don't know the half of it. I know anything is fair game in the realm of birth here, and to expect anything and everything- but yet I continue to be surprised. And then, after the initial jolt has worn off and the adrenaline recedes, I find myself surprised that I'm surprised.

The shoulda coulda wouldas can debilitate your mind. Rehashing, rethinking, recreating the events and wondering what you could have or should have differently... It's not good, but yet for me, the process is needed. It helps me to understand and to learn from my mistakes. Life can be a series of mistakes or decisions with not ideal outcomes...but in midwifery, some of these are just not acceptable. And my mistakes can ultimately mean the loss of a mother or her baby. And so I sit here and I do the "shoulda coulda woulda.”

We had a seemingly normal woman in labor, with the typical Haitian history of gestational hypertension and possible preeclampsia. Lack of testing and a sketchy chart always makse it like putting together a 5,000 piece puzzle...so rather than sit for hours trying to put together the whole picture, often times we must resort to putting together the focal point of the picture.
During our nightshift there are 3 moms in labor, all in transition simultaneously. The 3 women walk the outside corridor and in and out of the unit, each harmoniously moaning, singing, praying, chanting. It is a form of music to listen to these three women. I try to lay down in the storage closet in between listening to heart tones and the harmony is getting louder and louder. 2 of them are multips and I am having visions of a baby being born onto the cement in the corridor, with the cat-rats for an audience. I get up to be prepared. The two moms come back in, one is beginning to bear down, the other is close behind. I slap on some gloves.

The Haitian midwife (who happens to be a male midwife) is using my doppler to listen to heart tones, but between the position of baby, a lot of amniotic fluid, and the doppler battery dying, the heart beat is very faint sounding. He puts it up to his ear to listen. He can hear it, but I can't. He accepts what he hears.

Mom bears down in a big push and POP, her bag of water EXPLODES, drenching Glen who is standing 4 feet away, in clear fluid. His pants are soaked down into his underwear. We laugh. He leaves to go find a change of clothes. I ask the midwife to listen to heart tones. 128 bpm.

At one point I listen myself and baby is in the 80's. I listen again and baby was at 120. I give the doppler back to him. Baby is on the perineum now. I don't like that I can't hear heart tones and I verbalize this to Glen, who has now returned in dry scrubs. Glen asks me if I want him to get the portable ultrasound to see the heartbeat. I say something I will later regret. “No, it's ok. The midwife is listening, I was just saying I don't like that I can't hear it very well.” I don't like not hearing the clippity clop of the galloping horse, that I am sure any midwife understands. That very sentence will forever hang on my conscience. What if the heart tones were low and he wasn't hearing them, wasn't saying something? I could have expedited the delivery. I don't know if it would have made a difference with the ultimate outcome, but still...I should have done it differently. Always, always listen to your instincts.

Baby's head comes out and there is an eruption of dark, bloody fluid that goes everywhere. My hands and arms are covered in her blood. I bring baby up. Baby looks lifeless and blue. We can tell that it was an abruption. We clamp and cut immediately and I whisk baby to the back, leaving the male midwife to care for mom. I know Glen and I are the only ones that can resuscitate. The baby is not breathing, heart rate is about 40. Glen bags, I do chest compressions. There is blood everywhere. Glen stops bagging for a few seconds to suction with the delee. We continue and send our translator Gladias down to the pediatric unit to get peds. In the middle of chest compressions I look up and see the Haitian midwife standing there watching. I tell the translator to tell him he needs to take care of mom. Is she bleeding?! He cannot just leave her!

I do 4 rounds of chest compressions and baby's heart begins pounding...130 bpm. Glen continues to bag the limp, baby that has the tone of a ragdoll. Once we know baby's heart is continuing to beat, we wrap the baby in a towel and walk as quickly as we can to peds, Glen carrying the baby in his arms. We enter the room, bloody, sweaty messes, say nothing, find the nearest bed, and assess baby again. Glen keeps bagging. I listen. Chest compressions are needed again. Covered in the mother's blood and dripping sweat, we work harder than we ever have to not give up on this baby until we know we have done all we could. 1-2-3-BREATHE, 1-2-3-BREATHE, 1-2-3, BREATHE...

The baby needs to be intubated but no one can find a tube small enough for a baby. We need to go to the OR. People are trying to arrange for us to take baby to the OR, walking back and forth to see if they will “accept us.” No on is running. They are walking as if on a Sunday stroll. I will never be able to get past this cultural difference. It drives me bonkers.

We finally get approved to take baby to the OR to be intubated and when we get there, the OR tech at the door blocks our way in and yells at us in Creole. He is saying, “No, you cannot go in. This is a sterile environment, you need shoe covers on!” This baby has gone 2 minutes now without being bagged...the walk from peds to the OR is not a short one. We are yelling that this baby needs help, there is no time for that. Gladias is trying his best to keep up with the translation. The man is adamant. There is a stretcher in the hallway and we rush to it to put baby on so we can continue bagging so that baby is not left without oxygen. The man is yelling at us, probably because we are using the stretcher. I lose my cool. My professionalism goes out the window, and I yell in disgust, “THIS is why babies die in Haiti!” Gladias looks away, hesitating to translate what I've just said. I yell at Gladias, “Gladias, TELL HIM WHAT I JUST SAID! THIS is why babies die in Haiti!”

I am referring to the lack of understanding, the lack of urgency, the lack of action. I'm referring to so much with that sentence.

The man grabs a pair of shoe covers and puts them on Glen's feet. Glen tries to grab the baby and enter the OR and the man blocks him again. He needs a head cover. Dear God.

We get in the OR and as soon as Glen lays the baby down, she begins to breathe on her own. We can hardly believe it. An oral airway is placed, and another woman is trying to start an IV for us. After several attempts, she looks to me to ask if I could try. Oh no. I've never in my life even seen an IV on a baby started. I can't. I shake my head no. Next time...I will know how...
 
 
 

After 10 tries, she gets the IV placed. We are left to our own devices. Everyone goes back to wherever they came from and it is just Glen and I left with this baby. We hang D5. It's the only thing we can find. It dawns on us that we know nothing about the infusion rate for a baby. I have internmittent cell service and I try to send a text message to the first person I can think of who can help us- Jenn. I am swearing at my phone because the message won't send. On the 3rd time it goes through. At what rate do we give D5 to a baby, I ask? She responds immediately. Is the baby term, how much does the baby weigh, what's the baby's blood sugar? She says we should ideally give D10. We don't have D10. In between texts I am rummaging through the OR. I find a vial that says it is Glucose 50. Can we add this to the bag? Jenn says yes. She calls more people, for more help. How can we combine this Glucose 50 to a liter of D5 to make it more equivalent to D10? There is math involved in this and my brain is shot.

Somehow we muddle through it and do it.
 
D50 just happened to be laying around
 

While I am figuring this out, the baby begins to shake. At first we think it's because she's cold, but then we realize that she is seizing. We don't know what to do. Glen and I are alone and we have never done this before. Gladias goes to find someone from peds and he finds the ward completely empty of staff. No doctors, no nurses, just patients. We get a hold of the pediatric resident from Ireland, who is who we have come to call when we panic. She arrives in 10 minutes. She finds valium and together, along with a dosing book, we figure out the dosage for baby. We are guessing 3 kilos for her weight.
 
 
 
 
Giving the first dose of Valium
 
After this, there is nothing left to do for her. Nothing left at our disposal. She continues to breathe on her own. We take her back to the pediatric unit, I take a video of the room so that I can always remember. There is one last thing to do before we leave...speak to this baby girl's mother.
We walk into the postpartum unit, lined with beds. Her bed is the last one against the back wall. I sit down beside her as she lays and say, “As of right now, your baby is alive...her heart is beating and she is breathing but she isn't stable. We had to resuscitate her for a long time and now she is having seizures. She might not survive.”

The mother looked away and nodded, saying nothing, showing nothing, acting as if she were dismissing me. I asked if she had any questions I could answer...she hardly looked at me and just said no. There were no words needed.

Today the baby is still alive and still breathing on her own. She isn't conscious or responsive though, so the overall prognosis doesn't seem very good. I guess the next few days will tell.

And that...that's really all there is to say...
 
The ridiculousness of my outfit and expression on my face says it all.

 
 












Monday, April 15, 2013

Day 16- A Shower Curtain Between Life and Death

We walked onto the maternity ward this morning to find two women in labor. They had both just arrived and were in the process of being evaluated. In one stall, a first time mom, in the next, with just about 5 feet of separation and divided by a plastic shower curtain, surrounded by a wall of a midwife and 5 student midwives, was a 2nd time mom who had had a prior c-section.

The students had struggled to find heart tones and now the midwife was apparently struggling- moving, turning, and adjusting the doppler in search of a heartbeat, but to no avail. I look at Glen and tell him he should just grab the portable ultrasound. He grabs it and begins to speak with the VBAC mom, introducing himself.

While this is transpiring, I go to tend to the first time mom. The Haitian midwife assigns two students to me- one a nursing student and one a midwifery student. They will be assisting me with the birth and she would like me to guide the student midwife during the birth, explaining things as I work, and hopefully allowing the student to get some “hands on” experience.

I watch as the students take her vitals. The student nurse tries to tell me that mom's respirations are 6. I say I sure as heck hope that's not the case, and we re-do it. She is in fact alive and breathing normally. We listen to baby and they are confused at the concept of counting for 6 seconds and multiplying by 10. I tell them perhaps an easier option is counting for 30 seconds and doubling. They look at me equally confused. I explain maybe we should stick to counting for a full minute, but eventually they will learn by ear what 120's, 130's, 140's, 150's, 160's, and what abnormal heart tones sound like.

I check mom and she is 8cm with a bulging bag. I ask her if she would like to go walk but she does not want to. We tell her she is doing great and we stay beside her to support her.

Through the plastic, tattered shower curtain I hear Glen, in the soft, gentle voice that I love- as it is his and only his- say, “I'm sorry, but I don't see a heartbeat.” I have heard these words come from his mouth too many times. It doesn't matter- at home or in Haiti, someone I know or someone I will never know- the words slice like the dirty razor blade that is sitting contaminated on the counter to cut cords.

The mother says nothing. I can't see her but I am sure she is stoic and just nods. It is not that she doesn't care. Not that she does not feel the spiraling panic and loss that you might imagine or even know yourself. It's something beyond our understanding- she knows it happens. Babies die. Especially here in Haiti.

I stop what I'm doing and go to the bedside...to support mom, to support Glen? I don't know.

The baby starts to slowly crown and Glen touches the baby's head. He looks at me and whispers that there are no bones. I do not know what this means.

The baby starts to slowly come out and the sight of it causes my translator to instinctively recoil and close her eyes, as if the sight is equivalent to a hand touching an open flame. I want to look away too. I want to leave. But this is real. I can walk away and block my eyes and my heart from what is happening and go on with my life, but this shit is real and THIS is forever this mother's story. She cannot escape. Haiti cannot escape from this reality. And so I stand firm, eyes and heart open.

The baby's head comes out and it is like a half deflated water balloon- bouncing and sloshing around as if here is nothing within the skin of the face and scalp. The baby has been dead so long that the brain has liquified.

I cringe on the inside. My imagination is running wild and I wonder if the baby's head might pop, letting what once consisted of brain with dreams and thoughts and potential, ooze onto the bed.

When baby is out, it is apparent what likely caused this baby to die- he is wrapped up in his cord. Glen places him on the bed and covers him with a towel, trying his best to form the towel around the deflated head. Mom glances down at baby and quickly looks away.

I look at mom and tell her, “There is nothing you did to cause this, nothing you could have done differently. This just happens sometimes and we just don't know why.” She looks at me, says nothing, expresses nothing, but nods in acknowledgment.

The midwives take baby away and put him in a cardboard box, which will sit under the delivery table for hours, 3 feet across from where my patient will give birth.

A shower curtain away, my laboring mom begins to involuntarily push, preparing to give birth to her living baby.

I go back to my patient and two students. I talk to my students and explain the importance of frequently listening to heart tones during pushing. The student midwife is in charge of heart tones and she does a great job.

Mom is pushing and baby is ever so slowly stretching the perineum. As baby encroaches on a full crown, mom stops pushing and baby retreats back. We watch for about 30 minutes as this happens. The students anxiously tell mom to push harder, and I have to let them know that what she is doing is great. She does not need to push harder. As she pushes baby closer to a full crown, it is ever so slightly stretching her tissues and hopefully will prevent a tear. They absorb my words and just watch.

Mom pushes and slowly the baby's head begins to fully emerge. I put my hand out to guard the perineum and verbalize that she's doing great, to keep guiding the baby out nice and slow. The student midwife's hands are right with mine. Baby comes out into our hands- a double handed catch, and I swiftly show the student how to unwind baby from the umbilical cord that this baby is wrapped in.

And the baby in the cardboard box remains on the floor.






Sunday, April 14, 2013

Day 14/15- A Healthy Reprieve

Yesterday we said goodbye to the group of 11 volunteers that were here with us last week. It had been nice to have the full house bustling with the noise of projects being accomplished and laughter and conversation filling the walls, but once the van pulled away, the silence was a nice reprieve from the organized chaos of the week before. The loudest sound that projected through the house as we walked back in was Ina May and her incessant meows.

A few hours later, the pink Midwives for Haiti jeep pulled up, bringing the next new volunteer. Funny how that works...It's constant change around here- constant new names and new faces, starting from scratch and starting at the beginning- yet not. Somehow with the constant ebb and flow of new people coming and going, the program continues and trudges on making progress. It's interesting to sit back and be able to see how so many different, unconnected people, with varying experiences, backgrounds, and motivations, all come together at varying times to support an organization and its cause. Most paths do not cross- as Liz, the RN from Brooklyn, was departing, another volunteer- a chef from Brooklyn, was arriving. As we depart on Saturday, a CNM from Homer, Alaska will be arriving. The never ending story of paths nearly crossing, but not quite. And so goodbyes are said, volunteers return home to city life or suburbia, to go back to work in their busy practices...and life here in Haiti goes on. Carrie walks out to greet the jeep, she says, “Welcome”, she introduces herself, she gives a tour of the house. I wonder how many times she's given the same schpeel, how many times she has said those same words and answered the same questions. Things around here are like a well-oiled machine. It's fascinating how small pieces- individuals each bringing very small pieces of themselves- contribute to making a whole.


We rested up all day yesterday, knowing the demand that the nightshift would bring. At about 6 we ventured on a walk behind the house, as the sun began to lower in the sky. Glen and I walked up one of the hills and then just simply sat together. We sat and stared off onto the endless land below- a picturesque vision of anorexic cows grazing on intermittently green grass, a sprinkling of one room homes made of cement blocks or scrap wood, each with tin roofs, in a valley lined with mountains, under a sky of rolling dark clouds which promised to bring in the evening ritual downpour.

As the sun began to set, various Haitian men and women joined us on the hilltop, some clutching bibles, some not. As the sun receded lower, bringing to close another day of life in Haiti, soft but strong voices began singing- rolling, floating words in Creole surrounded us- the meaning of the words unknown to our ears, but the heart of the purpose translating across cultural and language barriers. I imagine they were thanking God for another day of life...another day in Haiti, and praying for the potential of what another day can bring. Ah, potential. Even in the most dire of circumstances, there is always hope and potential.



Our night at the hospital included no death but only life. We welcomed two new strong Haitian babies- one boy, and one girl.

I have to be honest and say that I do very much enjoy practicing here and being watched by the midwives. The nightshift midwives have been so welcoming and thankful for the help. When someone comes in, they welcome my help and seek me out to ask if I would like to care for the patient. I usually take the lead in a collaborative manner, explaining things as I go, but also taking the time to ask, “What would you do?” Or, “What do you think we should do?” It gives me the opportunity to learn the what and the why behind their practices, but also opens the door for me to say, “This is what I would probably do (and why...).” And we go from there, understanding each other better, and each learning a thing or two.

The first mom in labor last night was a primip who had been stalled at 6cm for several hours but at her last exam at 4pm had finally made change and was 8cm. It was now a little after 8pm (4 hours after she was found to be 8cm). I introduced myself to the mom, asked if I could take her vitals and listen to baby, and then spent some time with her. In the 15 minutes that I sat there, she didn't have one contraction. Situations like this are challenging for me here in Haiti. She obviously has a long, stalled labor. Mom is not having strong, frequent, regular contractions, which you would expect (and need) at 8cm. With the history of an already long, already stalled labor earlier in the day, I found myself pondering what to do next. I know what I would likely do if this were a client of mine at home- but the plethora of tools and options we have at home are just not available here. No breastpump, no herbs, no shower, no food to snack on to fuel mom, no electrolyte drink, and very often times, not even clean drinking water. IV fluids is as good as it gets. Further, Mom was exhausted already from walking the grounds of the hospital all day.

I asked if I could check her and she said yes. I found her to be the same- 8cm, with a head too high to safely rupture her bag of water (hoping that that would get things going again). Hmmm. I asked the midwife what she thought. She says pitocin. Eeek. I hate it, but I think I agree. This mom would likely be a transport to the hospital at home. There was, of course, the option to do nothing and wait. But how long? To what degree do we wait and push it? I talk to mom and she agrees to pitocin. Watching the midwife prepare it scares the crap out of me. She takes 10 units of pit, plunges the needle directly into the plastic IV bag and injects it, and opens the drip, seemingly measuring by eye. Now, this is only my perception. She could have used some mathematical equation to calculate how much pit she injected and what speed the drip should be. But it's unbeknownst to me.

I stare wide-eyed and say, “Since mom is now on pitocin, we need to be diligent with listening to baby to make sure baby is tolerating it.” She nods in complete agreement. It would be nearly impossible to continuously monitor mom with a doppler indefinitely, but I spend the rest of the night never venturing far from mom, very frequently listening. At one point I listen to baby and baby is in the 90's. I ask mom to get on her left side, take nice deep breathes for baby, and we turn off the pit. Baby recovers and we have no more issues. The good news is that mom is now complete and pushing.

The midwife supports the primip, while I triage another mom in labor who just arrived- a mom on her 9th baby. I welcome her, take her vitals, listen to baby, and then check her...she's 7cm. I encourage her to be upright and/or go walk. In the meantime, I make sure we have another delivery set-up ready to go. She comes back and for some reason one of the midwives tells her to stay on the exam table. When I go back to check on her, Glen is watching Glee out in the corridor and the midwives are nowhere to be found. Perhaps they've gone over to check on the postpartum and antepartum unit. The primip is still pushing. Baby sounds great. The multip is saying she wants to be upright. “Well let's get you up then. You can be in any position you want to be in,” I say to her. Gladias, my translator, reminds me that the midwives don't like this- the floor is dirty. “I know Gladias, I know...” And I smile big at him. “The worst position a birthing mom can be in is on her back. It can be the most painful and least productive.” Gladias hopes to go to medical school. He soaks it in like a sponge.

As the mom is getting off of the table, I slowly get my gloves on. Gladias looks at me and laughs and says, “Oh, you are getting ready...” I say to him, “Of course. You do see the events that are about to transpire, yes?” He understands what is about to happen and smiles.

Mom squats down and her water breaks. I squat down beside her, just in time for her to bear down. I extend my arm and her baby slides out, supported by my hand and the length of my forearm.

“Would you like me to call Dr. Glen,” Gladias asks? Sure, Gladias. I'm thinking a little bit of help up would be nice.

Glen comes in to find mom and I squatting on the floor together, each supporting the baby up to mom's chest. Baby needs a little suction and possibly PPV so we clamp and cut. Baby perks up, mom delivers placenta right there on the floor, and we get mom and baby together on the delivery table. Mom and baby are healthy and mom is happy. It makes me feel good.

Taking baby with mom over to the postpartum unit.


As soon as I can, I go back to the primip to be with her while she pushes. The midwives return and I tell mom that she's doing great but baby is just not coming down, and it would help if she got upright to push. The midwives look at me like I am crazy. We continue pushing for another hour. I go take a break and am slightly frustrated that they seem to have an aversion to pushing in any other position other than on mom's back, on the exam table.

I come back 5 minutes later and when I see the scene, a big smile spreads across me face- The midwives have mom off the table and in a standing squat. Pretty awesome.

We push for another hour like this. This baby is right on the perineum but is not budging. We continue to push, in every position known to midwife-kind. I'm desperately looking around for a birth stool or a something I could turn into a birth stool, but to no avail.

I get two large pads to put under mom and we squat on the floor, then slowly work our way down to the floor to do side-lying. The midwives watch and thankfully, don't say anything about the dirty floor. Yes, it's dirty. But like I've said before...everything else is just as dirty.

After more than 3 hours of hard, active pushing, a healthy baby girl is born over an intact perineum. I make it a point to tell mom that she worked so very hard for this baby and she is so strong. She is obviously proud of herself. She thanks me for helping her. Wow, what a feeling.

Mom wanted to have her leg up. And so my shoulder was the resting spot. ;-)

Gladias and I with the new baby girl. We make a good birth team!


We leave the hospital as the sun is rising, to go home and get ready for church, and begin our Sunday.

Our day of rest could not have begun any better.


Saturday, April 13, 2013

Day 13- Quite the experience...


As Tara put it yesterday, our day on Friday was trip. It was filled with things we had never seen, and things we hope we never see again.

My day started with the usual...'Dr. Glen, sonographie' aka, there's someone (or multiple someones) that need an ultrasound. One because she was preeclamptic and they couldn't figure out what part of the baby was presenting. One because she was unsure of her dates and her fundal height measured 33cm and she actually measured 33 weeks (odd to see a supposedly normally grown Haitian baby.) One because they thought she might have twins. The usual rundown of things for me to do in the morning. Then things started to get interesting.

Dr. Celestin, our local Haitian OB, sent a patient over with a note stating that the patient had an incomplete abortion (miscarriage) and to start IV antibiotics, give pain meds and prepare for a possible D&C. What this translated to, was that I would be doing the D&C in the labor area. So, I ultrasounded her again to confirm his findings and then set about getting everything ready. I collected my gloves, the instruments, some gauze and then made sure that all of her meds were given.

Tara was there to comfort the mom as I went about my business. Business as usual, right? Another incomplete abortion. There seems to be one most days. Between that and mid-trimester or term IUFDs, there is a never ending stream of sorrow. It is a normal and accepted part of pregnancy here. But, this case was different and brought to light a disturbing trend. You may remember that about a week ago, we saw a woman that had tried to induce an abortion with misoprostol (cytotec) but wasn't successful. I hadn't known then that the use of cytotec was so rampant here. Tara and the translator were able to get from this young woman that she had known she was early pregnant with her second child. She was excited to be pregnant. Her oldest was 2 years old and she was ready for another. Her husband, was not. On the night before she presented to me, her husband had spiked her juice with misoprostol. How many pills? Where did he get them? We didn't have those answers. But, his plan worked. She miscarried that night. Ultimately, he admitted what he had done. Confessed that he hadn't wanted another.

D&C's done without anesthesia are painful and not something I would ever want to do at home. I like the comfort of the operating room. I like that my patients don't have to feel the physical pain of what's going on. Not this mom. She knew very well what was happening, she could feel everything that was happening. She was crying, but not from pain. As Tara recounts, she was crying for the child that could have been, the child that SHOULD have been. Babies face enough tough odds in this culture, but tricking a woman into causing an abortion should never happen. Tara told her several times, 'this is not right. This is NOT ok. He should never be allowed to do this to you.'

Gladias, my translator, handed me a written note. 'Pt to see Dr. Glen to confirm prolapse and possible pessary.' Great...clearly Cindy, the CNM that works with Haiti Kidz who had sent this patient, doesn't know that I have never had a fondness for pessaries. Oh well, we will see what we can do. Maybe it's not much. Our patient arrives in her wheelchair. I know you are all thinking of our normal wheelchairs, but this was no ordinary wheelchair. It may be a bit hard to describe, but if you took the wheels and the frame and replaced the seat with a plastic lawn chair and then duct taped them all together...this, would be her wheelchair. Uh huh. I thought such a thing only existed in Kentucky.

We find her a bed, the family gets her up on the table. We find out that she is paralyzed and can't walk. We bring back her legs and find that her prolapse is in fact a complete procedentia. The entire cervix is outside the body, along with the anterior vagina and her bladder. The cervix is irritated and sore. The cervix is clearly not meant to be outside of the body. What she needs is surgery, but there are just not the capacities here to do such a case. Maybe I'll do some research this weekend and decide that I can do it. But, it will be a hugely difficult case without proper instruments and lighting. As Tara so often times says though... “If not me, then who?”

While I was off ultrasounding, Tara had been working with a young mom in labor with her first baby. She was term and obviously in labor. There were multiple students helping with her care. I was mostly watching peripherally. The midwife in charge wanted me to take a look and make sure it was vertex. Apparently, when she checked she couldn't exactly feel the babies head. I did a cursory ultrasound and confirmed it was vertex. I wish now that I had taken bit more time to discover the real culprit in this labor, but I didn't. About an hour later, the midwife asks me to see her again, they think she has a face presentation. Awesome! I haven't seen a face presentation in a while. (if the baby is looking at you, you have to section....that mantra kept running through my head.) On exam, she's only 3cm and the head is super high. It can't be a face yet, since the head isn't even in the pelvis. I tell her that and we move on. An hour later and they are prepping her for section. She is given IV antibiotics, her catheter is placed, her surgical site is meticulously shaved. I question why and I'm told that she hasn't made any progress and the head is still really high. OK...I'll concede this one. That head WAS really high and I wasn't convinced that it would get into the pelvis.

We head off to section and I'm the one doing it. Things are routine and baby comes out screaming. Thank goodness! I pull out the uterus to begin sewing and realize what the problem had been. There is a 8-10cm fibroid posteriorly, just above the cervix. There is NO way this kid would have ever fit. (OK, never say never, but highly unlikely) and they made a good call. It was an odd closure over the fibroid, but another 5 lap, no bovie section was complete.

Typical OR setup.
Suture storage in each room

I come back from the section and as usual, walk into a cluster. I come in to find the mom that we had been inducing for two days with a 26 week breech IUFD and preeclampsia had partially delivered. I had diagnosed it yesterday and placed the first dose of cytotec before we left, 200mcg as opposed to their usual 50mcg. Overnight, she hadn't gotten any more doses. First thing yesterday, I put another 200mcg in and she was 3cm and the buttocks was starting to protrude. The midwives wanted to move her back to antepartum, but at my insisting, they left her in labor and delivery. I knew she had to be close.

When I walked in, the body was out to the head. Limp, peeling and trapped. I'm glad I hadn't seen the scene, the debacle that had preceded me walking in. The midwife in charge had told Tara that she was completely dilated and then proceeded to spend several minutes trying to pull the baby out. She pulled and pulled, pulled with all of her might trying to get the head out. So hard, that Tara, Jenna, Phoebe (our other volunteers) and Shelly (our translator) all stepped back from the table expecting at any minute that the body would become detached and the midwife would fall back, leaving the head inside.

“You shouldn't pull.” Tara had said. “You should just wait until the baby spontaneously delivers. The head is the largest part of the baby and the cervix is obviously not dilated enough.”

“You're going to detach the body from the head if you keep pulling,” Tara had tried to tell the midwife.

“How far dilated is the patient,” Tara had asked? The midwife assure her she was complete.

Thankfully, the baby stayed intact. Partially. Dr. Celestin and I walk in at that time. He checks and realizes it isn't coming and gives his usual 'ok, ok' and leaves. Ok, Ok...thanks. I check and see that the cervix is only 4cm, not complete. They never really are in this circumstance. I'm surprised the midwife would ever think otherwise.

The mom has essentially stopped contracting. We decide to add some pitocin to her bag. It can't need much more dilation. It certainly doesn't need any more pulling. Ten minutes after we add the pitocin, the baby delivers, followed quickly by the placenta. I inspect the baby and it is mostly normal appearing. The only problem is one caused by the forcefulness of the pulling. The baby's jaw had been broken completely in half and was protruding out of the skin. It clearly was birth trauma, caused by too much pulling and tugging. Even though the baby was already demised, it is still sad that she was treated this way and suffered such indignity.

We leave one mom at 16 weeks with an induction for a demise. She had fallen while balancing a large bucket of water on her head and lost her baby. She had been laboring all morning and we had thought it was inevitable. But, she labored on into the afternoon.

Back at the house, the incident with the breech delivery weighed heavy on us. Not only with sadness for the mom and baby, but concern over what the students witnessed and what knowledge (or lack thereof) they will take with them to future breech deliveries. Tara debriefs the midwifery students about what went on, and why pulling on a breech (either alive or not) is not acceptable and should never be done. She discussed the appropriate way to assist in a breech delivery and the students ask questions. It seemed well received.

Teaching midwifery students
 
Sage Femmes pou Ayiti
 
  Our afternoon was another glorious trip to the waterfall, swimming in crystal blue water and feeling the warm water of the waterfall crashing on our backs like an expensive massage. The local kids that gather around the tourists are fun. They want to do anything to get you to pay them; help you walk up the hill, help you get up on the rocks or simply entertain you. They also have learned a few key phrases that are most likely to get an American to open their wallet. 'Hello. What is your name? My name is.... I have no mother or father. I have no money to go to school.' I'll never know if it is true or not, it probably is true, but it certainly has the ring of a con game.



This is safe, right?


 
Gladias and Tara in the hot sun!

Pretty sure I'm going to roast in this heat.

Our night saw us off to the local disco for a night of dancing. Tara and I get a rum and Coke and a rum and Sprite and pay $2.50 for it. Total. I can't argue with the drink prices, for sure. We watch in amazement as nearly every man and every woman get on the dance floor and salsas and cha chas to the music. The men are smooth partners, effortlessly guiding the women through complex dance moves, switching between partners and never missing a beat. All with a little different flair, but still stunning to watch. It makes a night at the local dance spot at home look like juveniles. This is what dancing with a woman you love is about. We must learn to salsa before we come back.


Translators and volunteers

What a stunning couple!

Today was a challenging day, but a day that we can look back at and know that we contributed to the education of the next generation of Haitian midwives. I doubt they will forget what we've taught. I hope they don't forget.

Until tomorrow.

Haitian sunset








Thursday, April 11, 2013

Too Early, Too Late


Maybe it's the Barbancourt, maybe it's the company. Maybe it's Haiti. Or perhaps all of the above...
We had a large dinner tonight with the group of volunteers who are here- to include the people with Haiti Kidz, Midwives for Haiti, and the three Brothers who run Maison Fortune Orphanage. Glen and I chatted with Brother Bill for a good 20 minutes and on several occasions I nearly teared up because of the profoundness of his words. It's nothing I could ever repeat and do justice- so many things- so much emotion and insight into the world and Haiti and why things are the way they are, how things came to be, and how we as human beings have a responsibility and obligation to help in the ways that we are able to help. It struck my mind, my heart, and my core.

As we ate we sat between Brother Bill and Brother Harry. Brother Bill told the story of a nun who had served 50 years in Kenya. At the celebration of her 50 year anniversary the nun made a speech. In it she said, “After 1 year in Kenya, I could have written a book. After 25 years in Kenya, I could have written a paragraph. After 50 years in Kenya, I could write a sentence.”

In other words, as time went on she realized that she understood less. There was so much more to it than she could originally see and understand.

As we said our goodbyes, Brother Harry, without even attempting to be deep or profound, made a simple statement... “The longer you stay, the more complex the questions become.”

Yes.

Glen and I were taking a nap this afternoon and were awakened by a knock at the door. It was Carrie saying that the midwives at the hospital had requested help because they had a 32 weeker about to deliver. I already knew it was too late. I know the MO here. It meant she was pushing and it meant the baby would be born way before we got there. But of course we still went.
We rushed to get there and right as we were leaving, we got word that the baby had just been born. The motorcycle ride was a bit scary for me- Gladias, one of our translators, took us on his motorcycle. He went as fast as he safely could- which is a lot faster than what we are used to. I had to close my eyes so I couldn't see the bumps and rocks and crevices we approached and flew over.

We zoomed by people and cyclists and other motorcycles, all the while Gladias was laying on the horn. It seems to be Creole for “Watch out! I'm coming and I'm not stopping.”

We arrive at the hospital and it was as if we were in a movie- we jump off the motorcycle and literally start running.

We find baby and jump in. The baby was not breathing and had no heart rate. But to hell if we weren't going out without a fight. We've become efficient with resuscitation and immediately Glen resumes his role- he bags and I start compressions. I listen to baby and nothing. No heartbeat at all. What the hell, let's keep going. What do we have to lose? We keep on keeping on. But it's apparent that this baby is long gone. It makes me mad. It makes me sad. But I knew from the time that we left the house that this baby didn't have a chance. I had held out Hope though.
She's too early. We're too late.

I ask what the baby is and Glen looks. She's a baby girl. I tuck her into her towel and I ask if I can take a picture of her. I want to remember this. All of this.




We take our gloves off with heavy hearts, throw them in the trash, and walk away...

Day 12- Learning as we go...

We worked the nightshift last night. I've come to really enjoy the nightshift at St. Therese Hospital. It's a cool reprieve from the intense sun of the day. It's quiet. It's personal in comparison to the chaos from the sweaty, compacted, disjointed day shift. There are no students to teach. Just Midwives to teach...midwives to set an example for. One on one time to show, explain, work and be intently watched. I feel as though it's just as much needed. And probably even more needed.

As we triage patients, speak to them, touch them, explain things to them as we go, and collaboratively make decisions, the midwives watch us and listen as we go. There is no doubt in my mind that this makes a difference. Maybe not just because of Glen and I, but cummulatively, with the next group, and the next group, and so on...if we continue to build on this, THIS will continue to set the path for growth and skill, which will lead to improvement of care and better outcomes for mothers and babies.

Last night we arrived at the hospital in a dark, torrential downpour. We were soaked, trying our best to manuever through the flooded ground and then careful not to slip on the flooded, slippery sidewalks within the hospial. As I walk the corridors, I am now on the look-out for cat-rats, as the last nightshift we worked, I had the displeasure of seeing a rat larger than Ina May, the Midwives for Haiti house cat. Now, I can handle quite a lot- put me in a hostile climate of an environment, with limited medical supplies and resources, take away running water and readily available clean water, my protein rich diet, and work me like a mule- that's ok. I'm down for it. But the thought of crossing paths with a cat-rat in the wet darkness of the hospital pushes me to my limit!

As we walk by the antepartum unit I briefly see a group of people gathered around a bed, but I don't think to stop and investigate. We arrive on the maternity ward, set our backpacks down and get our supplies in order. We have learned to carry everything we might need on our bodies, in a pack around our waists. Yes, a fanny pack. Ha.

We had been there a few minutes and a midwife walks in and goes straight to the back counter. It didn't even register with me that it was a baby in her arms. She says something in Creole. Our translator says, "A baby was just born on the antepartum unit." And then next, "She says the baby is not breathing." It's apparent that the midwife either does not know what to do or does not want to do it. She is continuing to stimulate, but I already know we are in secondary apnea. I have a hunch that this baby has likely been stimulated for 2 minutes+ and it obviously needs more than that. I immediately go over and see a blue, limp baby. I say out loud that we need the ambu bag. There is not one in sight. Glen darts to go get it from the back and comes back with one in about 2 seconds flat. The midwife says no, it's dirty. She doesn't want to use a dirty ambu bag. In the heat of the moment I say, calmly, but directly, "A dirty ambu bag is better than a dead baby." Later I wonder if I could have said it in a better manner, but at the time I just wanted to get the point across.
She says nothing and continnues to watch. Glen and I open the baby's airway and start to bag. I listen to the heart rate and it's pounding away...no need for compressions. Well isn't this a treat tonight. No compressions! After several minute of bagging, the baby begins to breathe on its own. I have Shelly, our translater, plug in the warming pad. I scoop the baby up and hold it in my arms to keep it warm in the meantime. Baby is flaring and retracting so I put it on oxygen. The baby calms down and doesn't seem to struggle as much in my arms.

The midwife asks if the baby is a boy or girl. I haven't a clue. I was a bit preoccupied. I tell her I don't know, but as soon as the baby is stable, we can look. In other words, it's really irrelevant at this point.

A couple minutes later the other midwife asks me how much baby weighs. I really have to bite my tongue with this. I smile and say that I haven't weighed baby yet, and as a general rule of thumb, we shouldn't worry about things like weight and measurements until baby is stable. She nods her head.

The peds resident arrives to assess things and see if we need help. We are a bit unsure of our abilites. I explain that honestly, I have no idea what I'm doing. And yet here I am, stablizing a 4 lb preemie. How long can he be on oxygen? How do I know when to take him off? Once he's stable, then where do I take him? Ah! It's funny really. Funny but not! She leaves us to continue doing what we're doing.

Glen goes to lay down and I stay on baby duty. I watch him like a hawk. Literally. I'm sitting above on the dirty counter, gazing down on him. I turn my roaming data on my iPhone on and I 'Facebook' in between taking vitals. I do this for a good hour and then decide that before I take him to his momma, I need to do a test run without the oxygen.
Preemie baby boy in his surgical towel "cloth-diaper."
My view from the counter top, as I monitor baby.

He's doing better, with some intermittent flaring. It's now been a couple hours after birth and he has yet to meet his mother, let alone have skin to skin or nurse. I start to worry about his blood sugar. Again, I have no idea what I'm doing. Well...I do, kind of. I am a trained and licensed midwife. But  prior to coming to Haiti, I had never cared for a premature baby. Never even seen one, actually. I decide he's stable enough to go see mom for some skin to skin and hopefully some suckling.

I swaddle baby and so very carefully manuever through the dark, wet corridor of the hospital. I sit and talk to the young mom, who is accomplanied by her parents, and explain that her little guy has had some problems breathing but I would really like them to be together and see how he does. We put him to the breast and he nuzzles in and falls asleep. His flaring has subsided. We sit for 10 minutes to make sure he is stable, and then I feel semi-comfortable leaving him. I tell the mom and grandparents that they need to make sure he stays skin to skin with mom, stays warm, and does not begin to breathe quickly or make noises when he breathes. I explain what nasal flaring and retraction is. They nod and veralize that they understand and promise to come get me if he starts to struggle again.

The baby lasted 30 minutes with mom and we ended up taking him to the peds unit. I felt much better at this point. As of this morning, he was still on oxygen but doing fine.

The rest of the night included a D&C done in the L&D room for a girl who was "2 months" pregnant but having severe cramping and bleeding. Glen scanned her and saw nothing in the uterus, but the unpassed tissue still in the cervix. Keep in mind there is no anesthesia for this, no pain medicine available. I felt bad for her, but I was glad that she came in and we were able to take care of her and monitor her, in case of hemorrhage.

The filthy room with a toilet (a toilet that is not actually functional, just a place to catch your pee)- which smells so bad, the air is thick with the scent it makes it difficult to breathe- is locked. Rather than go outside like I have done every other night without hesitance, I squat inside the storage closet and pee in a bowl. My lovely interpreter takes my bowl and dumps it out for me. Anything to avoid the cat-rats.

We complete our shift with me catching a healthy baby, with no complications for baby or mom, and Glen doing a c-section. One of the midwives assists me with the delivery and is good help. I am impressed with her forethought, her interaction with the patient, and her attention to getting heart tones. Immediately after delivery she asks if she can take baby away to weigh him. I smile and say that the best warmer is on mom's breast, and weighing baby can wait. She nods her head and says, "Ah," as though she is processing this for the first time.

A healthy, term baby boy, born OP.


Tuesday, April 9, 2013

Not here. Not in Haiti, Anyway...

This morning we lost a baby. The first baby we have 'delivered' here- even through countless emergencies and resuscitations- that has not survived. The first birth I have ever been a part of that has not ended in a live baby. And so I'm thoughtful this blazing afternoon, and my heart is sad.

Today we were accompanied to the hospital by two other Midwives for Haiti volunteers- Jenna and Phoebe. Jenna is a Labor and Delivery nurse from Illinois and Phoebe is a nursing student from Virginia. They were both excited to be helping at the hospital.

Our team for the day! Nursing student, Doctor, Midwife, and L&D Nurse.
Shortly after we arrived, the Haitian midwife told us that there was a patient in labor who was complete. They believe that this patient is possibly pregnant with twins. Whoa. “Possibly?” As if, we don't really know for sure? As it turns out, this is the mom that Glen and the Haitian OB had scanned yesterday with such difficulty. They thought they saw two bodies but could not make out the second head, and therefore were left puzzled with a “We're pretty sure this is twins, but we're not really sure.” Keep in mind the portable ultrasound that we have to use is about exactly what you would expect to have in Haiti- ancient, dusty, on it's last leg. This patient had ruptured early this morning and according to the midwife, had filled a very large bucket with amniotic fluid. I understood one word as she spoke in Creole- “Polyhydramnios.”

The midwife then asked for our help. We entered the unit, happy to be asked for help, and proceeded to set up for delivery- again, emphasizing to the midwife and the students the importance of preparedness. While the delivery instruments, bulb syringe, and pitocin wasn't out, I notice that each delivery station is set up with the supplies to start an IV. I also notice an Ambu bag at two of the stations. I comment on how great this is.

The girls and I make a plan for after delivery. They are each in charge of a baby. If they need resuscitation, Jenna feels confident that she can do it. We do a 10 second NRP refresher, she nods, and we move on. We do a quick run down of supplies, get the towels, blankets, bulb suctions, and everything laid out on the tile counter, which is our makeshift resuscitation station. I feel confident in our team.

The midwife asks me if I would like to check the patient for myself. I decline and tell her that there is no need to re-check since she had just checked. If the patient is complete, then we will just wait until she gets the urge to push. Simple. Easy. No rush. But then she says that she really would like me to re-check. I honestly don't understand why she wants me to re-check the patient, but I shrug and take the cue and tell Jenna and Phoebe that perhaps she is feeling something she is confused about. I joke and say, “Maybe it's baby's butt instead of head.”

I introduce myself to mom, “Bonswa. My name is Tara. I'm a midwife. I'm going to be taking care of you today.” I ask to check her, she nods, and I find that she is indeed complete, and the baby's head is +3 station. I explain to Jenna, Phoebe, the Haitian midwife, and the 2 student midwives what I'm feeling, and they all peek to see baby's head, just visible.

I ask Glen to check heart tones. They are great. 140's. Only he doesn't seem to be finding a distinctive heartbeat for baby B. It's very difficult to tell via doppler (especially with someone with poly), if you are picking up the same heart beat or not. I tell him to stop trying to find it. We are going to deliver, and like we've already learned, there is no such thing as a STAT section here. We can get these babies out quicker this way, so is our plan of care going to change? He listens again and baby A is in the 70's. And stays there.

I explain to mom (and everyone else) that the baby's heart rate is low and the baby needs to be born. She needs to push hard. I'm thinking to myself that this seems to be a repeating chapter here in Haiti...it feels like deja vu. Low heart tones...episiotomy, full rescusitation. Only I exhale with some relief thinking to myself that this mom has plenty of room and no tight band in the vagina. She can do this quickly. I realize I don't even know her history, but I can tell that she's likely had babies before.

We push a few times- a room full of people (literally, we are like packed sardines), encouraging this mom and telling her to push hard! Baby needs it.

Baby comes out and I immediately see her face and know that something is wrong. I say nothing. I put the tiny, limp baby on mom's belly and unwrap her from the tangled cord. I try to stimulate while Glen is clamping and cutting. I pass the baby to Jenna. We don't skip a beat.

I'm expecting baby B now. I think. I get my bearings, but I can see Jenna struggling out of the corner of my eye. Jenna says my name, calling for help. Glen jumps in in my place and I go to Jenna. I only need to see baby a split second and without words, I know why Jenna is struggling. The baby has no lower jaw. She can't breathe and Jenna can't get air in because there is no jaw to open for an airway. I verbalize it and we hope that perhaps we can bag just through the nose. Only, without the jaw, it is so very difficult to get the mask with a firm placement. We do it though. Jenna continues bagging and air is going in. The chest is rising, the baby is pinking up.

Glen discovers that there are no twins. Just a massive belly and a case of polyhydramnios. He continues to care for mom and deliver the placenta.

I listen to baby's heart rate and it is thumping away at 140 beats per minute. She is trying to cry and attempting to take breathes. We keep bagging because they are insufficient gasps. We try to suction with the bulb syringe but the tip is way too big for this tiny baby. I get the delee and I suction out her nose. I try to find a hole where her mouth should be, but there's nothing there. She can't breathe on her own. We continue to bag. As long as we are bagging, she's pink, her heart is beating. She's gasping for air but she can't get any in through her nose. She's trying to cry, but she can't even do that.

We move her to a heating pad, wrapped in blankets, atop a filthy delivery table. We continue our resuscitation efforts. The peds resident, Aisling, arrives. We are doing everything that can be done, but t's apparent that this baby cannot survive. Not here. Not in Haiti. As soon as we stop bagging, the baby cannot breathe. Her heart rate declines.

We stop our efforts. Baby is trying to take sporadic breathes, her heart rate keeps declining. I ask the translator to tell mom that we have done everything we can do, but there is nothing left and the baby is not going to survive. We ask mom if she would like to hold her baby. She says yes. Aisling says that I should be the one to bring her baby to her. I struggle to keep it together. I pick the baby up, wrapped in her towel, and I bring her to her mother.

I show mom her baby and explain that she was born with a congenital abnormality that has made it so that she could not breathe or eat. We don't know why it happened, we don't know the cause, and there is nothing that she could have done to prevent it. I open the blanket and I show her the rest of the bay girl. Everything else is perfectly formed.

Showing baby to Mom and Dad.

Mom asks for her husband to come in so he can see the baby. He comes in and I explain the same things I've just said to mom. I ask if he wants to hold the baby. He says that the baby has already died and he does not want to. They are ready for me to take baby away. I place the baby down on the delivery table that we were just resuscitating her on and I begin to cry. “I'm sorry,” I apologize to the peds doctor. I'm not apologizing for anything I have done wrong, but apologizing because I feel like an idiot. I am standing in a room full of people and I'm the only one crying. I can't keep it together. I cannot honestly say that I am mourning this life. She was not my baby. I do not know these people. I have known them for mere minutes. I do not even know this mother's name.

I am not only sad for this loss of life, I am not only sad for this mother's loss of her baby, I am sad because that baby girl never even had a chance. Not here. Not in Haiti.

What if she had been born in America? In Australia? Canada? The UK? Any other developed nation? What if her mother had had prenatal vitamins, a healthy diet, access to a 20 week fetal assessment? Could it have been prevented? Could it have been detected? Could the baby have survived in a controlled setting and an appropriate hospital environment? Here in Haiti this- this dirty, run down place we are in- is called a 'hospital', but it is merely just a word.

What if you or I had been born into a developing country? What is it- chance, happenstance, divine delegation? Because I don't get it. Could have been you, could have been me. We have human beings dying because they do not have food or clean water, or access to basic healthcare. We have women dying from pregnancy and childbirth complications because they do not have trained attendants to care for them. We have babies dying because of this same reason- a lack of trained attendants, as well as no access to higher level of care.

A baby girl was born and died today. She lived for mere minutes. She never got to see her country or know her culture. She never got to experience life.

Not here. Not in Haiti anyway.
Sweet baby girl who only lived for a few minutess.