Day 7/8, Goodbye, Hello, Another Resuscitation

Saturday morning we said goodbye to Liz (the RN volunteer from New York). I was sad to see her go. In the week that we spent working with her, a lot of life was experienced. Raw, true, brutal life... Delicate, compounding, shocking, gut-wrenching, adrenaline pumping, beautiful, precious life. Liz is a stranger really, but I could not imagine this past week without her. I am thankful for our paths to have crossed. Liz- if you are reading this- you are the epitome of what a Midwives for Haiti volunteer should be. You are so kind, so compassionate, and such an incredible teacher. You have a way with words and teaching others. When we first met, I thought you were meant to be a midwife. Now I'm wondering if you are truly a NICU nurse at heart. Lord knows you have the skill. ; )

Liz taking care of a baby, after a full resuscitation

In the matter of the same day, Liz was replaced by a group of 11 new volunteers- some visiting Haiti for the very first time, others who have returned time and time again over the years. This house is hustling and bustling, filled with conversation, work, and laughter as they go. Glen and I have enjoyed the introductions and sharing stories with these strangers- hearing of their past visits and work with this organization. It just makes me want to come back. And indeed I will.

We worked the night shift last night, and for myself (not speaking for Glen), it takes the cake on experiences here.

We walked in- fresh, rested, and ready for a night's work ahead. As we walk in, we immediately see a mom in the labor bed straight ahead of the entrance, curtain drawn open, exposed naked body for all to see. No head can be seen yet, but I can tell by her bulging perineum that she is beginning to bear down.

Glen and I, as always, are very aware of our presence. We are not here to take over. We are here to help, we are here to teach. We quietly stand there, backpacks on, and observe. This would be completely inappropriate in America, but here, it seems to be culturally acceptable to have strangers coming in and out of the delivery room, and your curtain wide open. Of course I don't like this, but it is what it is. I want to observe and make sure she is safe. I make eye contact with the laboring woman and give her a smile.

I can tell by the fidgeting demeanor that the two midwives are unsure of themselves or something going on. Before I can say anything, one of them tells the translator something and he relays to us, “She says you can come in and help.” I find that interesting.

I immediately step alongside the delivery table, smile at mom, and introduce myself. It is the same introduction I always begin with. “Bonswa! My name is Tara. I am a midwife.” I ask the midwives if she has had any complications. They say yes, she is a severe preeclamptic, was 6cm, and has now had some abnormal bleeding. I can see from the sheets that yes, I'd say she's having some bleeding. I ask if I can listen to baby.

I put the doppler on and ..............................................thunk..............................................................................thunk.............................................................thunk.........................................................................I leave the doppler on and look up at Glen, seemingly confused, but in reality, knowing already but not wanting to believe it. He says to me, as if reading my mind, “Yes, that's baby's heart rate.” It was in the 50's. It's as if we can read each other's mind... Simultaneously I think and he says out loud the same thing, “We can deliver this baby vaginally quicker than we can do a section here.” Glen can't call or do a section independently here and the Haitian OB isn't even here.

Things happen quickly. The “I don't want to step on anyone's toes” concern flies quickly out the window and into the Haitian breeze. Glen goes into turbo mode and is buzzing around the room getting the delivery cart set up- instruments, pitocin drawn up, alcohol wipe, and ambu bag. He runs down to peds to inform them of what we have.

I tell mom the baby's heart beat is very low and she needs to turn onto her left side. “Respire,” I say. “Respire.” (Breathe). I mimick how I want her to breathe, to get oxygen to baby. Remember, there is no oxygen readily available here. I slap on a pair of gloves and check her and find that she's complete with a bulging bag, and Glen simultaneously check's heart tones. We are the in the 20's now. They don't have amnihooks or amnicots. DAMMIT, what I would give to have an amnicot right now! They use needles to break water and this baby is still high. I hesitate and doubt this new skill, thinking of the prospect of me putting a huge needle into her vagina and trying to break a bag at -1 station. I don't want to waste precious time messing around. I tell Glen he needs to break it for me. He is gloved up and with his left hand gives fundal pressure and with his right hand pops the bag of water forcefully with his fingers. Bloody water explodes everywhere. I am drenched in it.

It's as if the 'fast forward' button has been pressed on real life.

In the chaotic swirl that we were in, my thought process was still vivid. The thoughts are clear in my mind, “This is going to be the first baby I will have ever lost...The first dead baby I will have ever touched...” I look at my translator and I shake my head, trying to tell him that I don't think this is going to end well. I relay the information to the Haitian midwives. “She's complete, baby is in the 20's...” “120's,” Gladias, the translator asks? No. 20's. They seem to be moving as slow as molasses. Urgency does not exist here. I wonder if there is a Creole word for urgency. I need to learn it. They tell me they are going to call Dr. Celestin to do a c-section. “Tell them it's pointless!” I say to the translator. “By the time the doctor gets here the baby will be dead!” They cannot rely on that.

I tell the mom she needs to push as hard as she can, right where my fingers are. She pushes and I push down toward her rectum. “RIGHT HERE!” The baby moves down about 2 stations. We listen to heart tones. Still 20. Do we have a chance? I don't know, but we are going to give it all we've got. She bears down again, her perineum is so tight. We are MINUTES from delivery. We don't have minutes. I tell her not to stop pushing, I grab the scissors, and for the 2^nd time in my career and 2^nd time in a week, I cut an episiotomy. Only the scissors are dull. “These scissors are dull. I can't cut.” I say it out loud to myself and to my translator as if it matters to him. I gnaw at her perineum 3 times to get it cut. It is sickening. Right as the tissue opens, the baby delivers. Completely blue, completely limp. Unresponsive. Clamp 1 on, Clamp 2...drops from my hands and clamors to the floor. There is no other one in sight and no other option- Glen picks it up off the filthy floor and gives it to me. I clamp, cut, grab a towel, and whisk baby to the back counter where there is a clean, flat space to resuscitate. Glen starts to bag, and there is but one thump of a heart beat and I start chest compressions. 1-2-3-BREATHE, 1-2-3-BREATHE, 1-2-3-BREATHE. Check after check, the baby is still not coming around. We do this for 4-5 minutes. This baby is not going to die, if there's anything we can do about it. In the midst of this resuscitation, the Haitian generalist doc from the peds unit walks in to help. Only as has been the situation before, he sees what we are doing- we know what we are doing- and he tells us good job, and if we get the baby stable then bring her to him. Again- WE are the best chance this baby has? It's almost like a joke. (Though... I have learned through this past week that there is nearly nothing we cannot handle.)

I recheck the baby's heart rate and it is pounding away at 130 beats per minute. Wow. She is trying to take breathes. Glen continues bagging. I stimulate. She starts to breathe on her own. It's hard for me to believe that this baby was hardly alive just minutes ago.

Once we feel she's breathing on her own adequately, Glen scoops up this tiny baby into his arms and we whisk her to the peds unit. The Haitian midwives are taking care of mom.

They put baby on oxygen and start an IV of D5. Baby continues to breath on her own. The Haitian generalist is wonderful. Confident and seemingly experienced and competent. I am impressed.

Baby girl- alive and stable.

We remember that the metal clamp is still on the umbilical stump and so I go back to L&D to get a cord clamp. The midwives tell me they do not have any clamps. What am I supposed to use then? They have me a tiny piece of paper and I'm wondering to myself what the hell am I supposed to do with this? I think maybe the peds doctor will know. I walk back to deliver the piece of paper.

A piece of paper with string inside

Only I get to peds and they don't know how to tie off a cord with this. I take my translator back to L&D and have him translate as I say, “I have never used this before and don't know how. Would you mind teaching me?”

The midwives let out a laugh at the ridiculousness of this, and when they realize I am not joking, one of them hesitantly stands up, unwraps the piece of paper to unveil a string, and then uses Gladious's finger to demonstrate how to tie it. I thank her very much for taking the time to show me, and let her know that she has taught me something. She seems happy with that.

I return back to the peds unit and the thought of tying a cord with a string just freaks me out. I don't want the baby to bleed! So I make Glen do it.

The baby is stable, so we leave her behind, knowing there is nothing more for us to do. We return back to maternity to check on mom and find that she has had some bleeding. There is a blood-soaked towel under her and blood still trickling. I massage her fundus and express clots out. Her fundus is firm. I take her blood pressure- 105/60. She's nearly unconscious and can hardly open her eyes. Glen explores for clots. I ask the midwives if we can run IV fluids into mom. They tell me no. She was preeclamptic and they're worried about pulmonary edema. This is great that they are thinking of this and concerned! BUT- this mom has lost blood and is symptomatic. She needs fluids. Glen agrees. Thankfully they say ok. I put up a bag of fluids and run it wide open.

I spend the rest of the night monitoring this mom. She slowly comes around and perks up. In between checking on her and taking vitals, Glen and I go round on antepartum. He takes the high(er) risk moms and moms needing ultrasounds done. I take the others. He checks on a mom who is about 34 weeks and ruptured but not in labor. I am proud of his palpation skills. He says she's breech and then confirms it with the portable ultrasound that has become his bestfriend. I have a near-term mom who's belly is huge, fundal height 46cm. She fails to tell me she has twins but I quickly learn this with my hands. I tell Glen that the babies are breech. He comes over to ultrasound. They are indeed both breech.

We have 3 moms laboring through the night that we are intermittently checking on. Ultimately, no one delivers before our shift ends at 7am. Before we leave, we de-brief with the midwives about the birth the night before and how important it is to be prepared. I tell them, “If we are set up and prepared, it does not matter what walks through the door. We can handle it if we are prepared!”

I am looking forward to precepting students tomorrow and hammering this one home, leading by example.

We are not doing anything extraordinary or special. We are doing our jobs. Just two people who have skills and compassion to share and give, and a passion that fuels us in providing care to women and babies.

We look forward to what tomorrow brings...