Tuesday, September 22, 2015

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

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

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

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

Something is brewing in those clouds

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

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

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

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

Preparation for the c-section baby

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

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

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


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

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

Sunrise behind the Midwives for Haiti compound.

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