Wednesday, April 3, 2013

Day 4, God Knows

It's still hard for me to believe that the account I'm about to give you was what my morning consisted of. It was all before our lunchtime at 2pm.

We got to the hospital at 8:30am. Nothing is going on at L&D (which, I've now learned that just because no one is laboring in there, doesn't necessarily mean that there is no one at the hospital laboring. What a false assumption on our parts!). Glen takes off like a kid in a candy store to help with the morning's surgeries. He literally waves goodbye to me as he's halfway out the door. Our translators laugh at him. Liz and I are assigned to postpartum. We walk out along the crowded outside corridor and arrive. Only I'm confused. Only about 3 women in this crowded unit have a baby with them. The rest appear to be pregnant, though none in labor. I ask for claification. "Are these moms all pregnant?" "Yes," my translator says. There doesn't seem to be any ryhme or reason. I tell her to pick a bed and we'll start there. Liz is going to start on the opposite side of the room with her translator. The mom in bed 1 is completely fine. Her vitals are normal and her baby's heart tones sound fine. I move on to mom 2. I introduce myself, taking breaks after every sentence to allow my translator to ranslate what I'm saying. "My name is Tara. (Pause). I'm a midwife. (Pause) I'm going to take your vitals and listen to your baby. (Pause) How are you feeling? She honestly appears to be feeling well. She has no complaints. She denies any pain. She denies headaches or blurred vision. I notice her feet are like stuffed sausages. It looks painful. I push in on the top of her foot and it remains dented in. Severe edema. I take her blood pressure and I hesitate to say the reading. I take it again just to make sure. It's the same. 180/115. I finish by palpating her baby. I get an idea of size and make sure baby is vertex. It is. I listen. Baby's heart tones are 128bpm. I leave her bedside but tell her that her blood pressure is dangerously high and I will be back. I motion with my fingers as though I'm saying, 'I am keeping an eye on you.' She smiles.

I tell my translator that this patient is very, very sick and that she needs medication and to be delivered. I need to speak to the midwife in charge. She speaks to one of the other Haitian midwives and is told that the head midwife is next door doing a delivery and can't come over yet. But they will tell her as soon as she returns. With nothing left to do, I say ok and move on to the next mom. Patient in bed #3. I introduce myself and ask her if it's ok that I take her vitals and listen to her baby. She says yes. I then ask her what brings her in. High blood pressure she says. Lovely. I jump right to her blood pressure and it's compltely normal. This is good. I then go on to measure her belly. She is supposed to be "7 months" but my tape measure tells me 45cm. I re-meausre. It is 45cm. As I go to palpate her belly she must have seen the look of confusion on my face. She tells the translator something and then the translator tells me, "She says she has two babies in there." I laugh and say, "Well heck, that makes a lot of sense!" I palpate and very distinctly can feel two heads. I would have figured it out. ;) Both babies sound fine. We move on.

I keep looking back at the suspected severe preeclamptic. 15 minutes has gone by and still no midwife to report to. I tell my translator that we must get her taken care of. She goes off to relay my concern and comes back to tell me, "Yes, they will give her medication in a bit to see if it comes down." I realized at this point that directness was in order. Haitian's are different than American's at that there is very little urgency in anything. I do not say this badly. I think that with most things with Americans, there is too much urgency placed unnecessarily. But in this case, right now, this mom needed help. On the inside I was getting upset. But just like with every situation so far here, I reminded myself to take a step back and realize that there seems to be reasons for things. Even reasons beyond my understanding.

I look at my translator and say, "She not only needs medication but she needs to be delivered. NOW. Her blood pressure is dangerously high and I'm afraid she will seize." I see a couple more moms and, still waiting to see what can be done about the patient with the dangerously high BP, I see Glen outside in the hall. He looks concerned and says, "There's a baby that needs to be resuscitated. Where's Liz?" I tell him she is nextdoor, he goes to get her, and I drop what I'm doing to run to Labor and Delivery. I walk in and there are 4 midwives there, with what looks like a dead baby, gently rubbing it to provide stimulation. I know we are waaaaaaaay beyond stimulation. Even in this emergent situation, I am still mindful of my presence and that I do not want to overstep boundaries. I'm not sure if this is an attribute or a fault at this point. I say, "He needs PPV and chest compressions." No one is listening. "I want to help." No one turns. Liz arrives. I say we need to get in there. This blue, lifeless baby is going to die. We gently push our way to the baby and mechanically begin to do what we need to do. I get a bag and mask on baby and put in room air. We have no oxygen yet. I listen to the baby's heartbeat and it's thunk..................................thunk...............................thunk.......................................there are several seconds between beats, almost non existent. How long ago was delivery? We have no clue. But we work. Liz does compressions and I bag. Somehow we get oxygen but we don't have the type of bag that oxygen hooks to. This is frustrating. But we continue to work. We get him off the cold tile counter and I ask for a hat. We continue our full on resuscitation. One of the students comes back and hands me a hat. I turn to take it from her and when I saw the hat my heart skipped a beat. I say out loud, "This was in one of our donations. This came from us." We are enveloped in trying to save this baby, and in the midst of it all, I find myself wondering if the person who donated this hat realized what it would do? If she realized how very much that hat would be needed. If any of you who donated realized how much these supplies were needed and the amount of GOOD they would do. It's almost too much for me. But we go on. The pediatrician arrives. It has now been 5-10 minutes. We have stopped chest compressions and just continue with the oxygen that finally came. Baby is taking breaths on it's own. The pediatrician looks at us and tells us we are doing a good job...we are doing everything that can be done here and there is nothing more she can do. Is this good? Is this bad? I don't know how I feel about this. THIS (WE) are as good as it gets for this kid????? There is no warmer, there is no intubation, there is no stable transport, or even a true NICU to take him to. Once the pediatric unit can get the oxygen set up, she will take him over there. Liz takes over monitoring baby and I glove up to assess a mom who just arrived in labor. The Haitian OB has checked her and she is complete. She is not yet pushing though, so after I take her vitals and listen to baby, she gets up and goes outside to walk. Imagine that.



Haitian baby with a Rudolph the Red Nosed Reindeer hat


The premature baby (who we estimate to be about 32 weeks) gets picked up by peds and whisked off. She promises to tell us what the outcome is. A mom walks in in hot and heavy labor and is told to go and get on the bed, across from where the mom who is complete and just went walking was laying. They are about 5ft apart. Only thing, the bed is not clean. In the midst of the resuscitation, I somehow managed to tell Glen about the severe pre-eclamptic and that he needed to make sure she would be ok and get delivered. They brought her in, prepped her, and off she went for a section. Had I not been pre-occupied, I would have reassured her by telling her that he was my husband and she was in the very best hands. There is blood from her several attempt would-have-been IV (the midwives tried about 5 times but couldn't get it), and a mound of black pubic hair on the bed. In other words, the bed that is supposed to be this new patient's is not clean. She stands against the wall, we put a bucket between her legs, and Liz checks her. She immediately feels a bulging bag of water. We have learned about these bulging bags.

I am a midwife. I do not routinely artificially rupture membranes. It is a rare occurance and I only do it if needed, and with my client's permission/desire. But as much as AROM is almost always an unnecessary intervention in America, it is not the same here. We do not have labs for any of these patients. We do not know their Hep B or Hep C or HIV status. We have one towel and one towel only for delivery, and the conditionn of the L&D unit is unimaginably unsanitary. If we make a mess, it will most likely stay there for quite sometime. Liz does not hesitate to break the bag. I would not have hesitated either. She gets a needle and releases it. She turns around (perhaps to dispose of the needle?) and in that second I tell her I wouldn't do that, she needs to be careful...(simultanesously the mom bears down). Yep.
It aint my first rodeo.

Liz goes to put her hand there and the head is out. Mom pushes again and the rest of baby (nearly) comes out- only it's entwined in its cord and is stuck at the hip. I jump in to help unravel it, and as I unravel, Liz hands the mother her baby. All while she is standing and leaning up against the wall.

I'm simultaneously looking back on the other mom in labor to make sure that we can't see head yet. The patient has returned from her walk, pushing.

I get up to take my gloves off and the mother of the woman who just delivered says something in Creole. My translator translates. "She says the sonogram told them she has two babies."
"Huh?" Liz and I have to take a second to process what that means. We just delivered baby A. And there is a baby B in there! I look up into the old woman's eyes (the mother of the patient) and she smiles warmly. She says something. It's translated. "GOD KNOWS."

That baby was Liz's very first delivery. She looks at me and asks, "Have you ever delivered twins before?" I say no. I tell her now we need to get mom on the bed. First thing I do is make sure baby B is head down. Yes, it is! Then we wait. Ultimately, about 15 minutes later a healthy baby B was born. Both are boys. The placenta comes out easily, with seemingly no complications. Shot of pit in the thigh and minimal bleeding. Except later on, mom would have large blood clots come out, earn a sweep to check for retained placenta (which there was a bit of membrane), get a shot of IM methergine, some cytotec rectally.




Meanwhile, we move over to the next bed. We are starting to see head. Glen listens to the baby and heart tones are 80. I'm fine, he's panicked. I tell her to push hard, that her baby is not liking this now. She is exhausted and dehydrated and hardly has any energy to lift her head, let alone push hard. I put my fingers in her vaginal and firmly tell her in Creole, "PUSSE! (PUSH!)." Glen listens again. 80. We change positions and again, but we have no oxygen to give. I breathe how I want her to breath. I tell my translator to tell her that baby needs to be born now. WE keep pushing. Glen listens again. Baby is in the 60's now. I have no choice. I have to cut an episiotomy. I have never done it before, never seen it before. It's some foreign procedure that I have  only heard about, learned about, and read about. I take the pair of scissors in my right hand, put my spread left middle finger and index finger in her vagina, and at the peak of her next push, cut down into her perineum. Hard, fast, controlled. The cold scissors quickly sliced the soft tissue as if it were nothing. She's screaming. I don't know what the word is in Creole but in English it sounds like, "WHHHHHY?????" I yell that she needs to push. She can't understand my words, but I hope for my tone is universal. I hate what I just had to do, but I want her to take home a live baby. I know I had to.

Baby comes out and as I hand the new 17 year old mother her baby, I tell Liz to be prepared for a resuscitation. Liz stimulates and the baby wails. No resuscitation needed.



God knows.

The birth team. Baby and mom are well.

9 comments:

  1. Samantha Van VleetApril 3, 2013 at 3:47 PM

    Oh man. I started tearing up over the resuscitation.

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  2. Omgoodness you guys <3
    -Christy

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  3. I'm addicted to your daily accounts of this trip. I'm so envious of what you're doing, but will have to live through you for a bit. Someday I hope to go. Strong work guys. This is incredible. -Abby

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  4. Tara!!! I SO want to be there with you guys. Thank GOD you are such a good writer!!! I feel like I'm right there with you. Awesome! awesome! awesome!

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  5. You guys are doing such amazing things - I'm so glad that I have gotten the chance to experience My girls pregnancies with the both of you! :)

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  6. Where was the mother while the baby was being worked on? Was she OK?

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    1. We have no idea where the mother of the premature baby was. She was not on the labor and delivery unit, no where to be found. From what we are assuming, we think she was likely on the antepartum unit, being "treated" for severe preeclampsia, and unexpectedly spontaneously delivered.

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  7. Was there any pain control available for the episiotomy? Was the necessity explained to the mother afterwards? That poor mum! Mine hurt badly enough WITH a local, I understand why she screamed :(
    One more question: why did the mum of twins need to get on the bed?
    What difficult conditions you are working in. My mind boggles. Thank you for sharing.

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    Replies
    1. Thank you for your comments! And great questions!
      There was no anesthetic used for the episiotomy, and a few reasons for this. 1) It was an emergency. Baby was in severe compromise and needed to be born. With that said, lidocaine isn't something that is routinely drawn up and at the bedside of a delivery.
      2) With an emergent episiotomy (which is the only time it should be done), if there is time to draw up lidocaine and numb the area, then it is likely not a true emergency.
      3) It's also common practice to cut an episiotomy at the peak of a push, to minimize the feeling. We also have to consider the pain that goes with injecting the sensitive tissue with a needle several times.
      4) Lastly, most of the basic supplies are either severely low in supply or simply not available. Lidocaine is like gold.

      Hope that helped to understand! : )

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