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

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