Day 9 - Another day in Haiti

Bonswa! Tara has turned over the reigns to me for the day. Let's see if I can live up to her standards.

Today, we were back in the hospital. We were joined by Tina, a labor and delivery nurse from Champagne/Urbana. Tara and Tina were to take on two midwifery students and precept them. As the morning started, we walked into the student morning meeting. They were singing a prayer and then said a prayer that had the cadence of the Lord's Prayer. I'm not sure if it was, but it would have been appropriate for what they were about to do. 'Thy will be done, on Earth as it is in Heaven.' We will be doing God's work today.

We start our day by checking up on our last resuscitation baby. She is doing great. She had a bit of hypothermia the first night, but last night was breastfeeding! She's getting bigger and stronger each day.

She's getting big and strong.

Tara and Tina start tending to a mom in labor with severe preeclampsia. I'm learning that the tell-tale sign of severe preeclampsia is an IV and a foley catheter. When I see a foley, it's either severe preeclampsia or prepping for a section.

I leave the girls and head off with Gladias (my interpreter) to make rounds with Dr. Celestin. We start on postpartum. I am thankful to finally see a few of my section moms to see how they have done. Both have perfect incisions! Both are very thankful to me to have done their sections. One mom looks at me and says to the translator, 'I was too out of it earlier, but I am so thankful that you did my surgery. Thank you.' That's what it's all about, right?

The mom and baby that were mentioned a few days ago with the meconium and the resuscitation after 30 minutes was ready to go home. I got her to pose with her baby for a quick picture. I'm so thankful that that baby is alive and doing well.

 

 

Mom I sectioned and baby we resucitated.  All doing well!

We see the mom that on our first day had a breech demise and ultimately got a section. She is now about a week out from her section and ready to go home. Her vertical incision looks good. Sad that she will have to come back in a few weeks to have those stitches removed.

The rest of rounds include a few miscarriages to ultrasound, and then a confusing one. The mom presented with some pain from a remote location. I don't think she had had any prenatal care. She came in last night and is now being evaluated. She is apparently near term but her fundal height is near 50. They have suspected polyhydramnios (too much fluid). I ask if they have checked for gestational diabetes, but nothing yet has been done. I start the ultrasound before Dr. Celestin arrives. It is a VERY difficult scan. I see a head in the pelvis...that's a good start. I can follow it and find a chest with a good heart beat. Another good start. I then ultrasound her upper abdomen. What is this that I'm looking at??? My first thought was that it was twins with a demise of the second twin. But, wait. Something is moving. OK...maybe it's just generic twins. Eventually, I find a chest and heart beat that clearly seem to be separate from the first. But, I CAN NOT find the head. Dr. Celestin comes in and he scans. Yep, it looks like twins, but HE can't find the second twin's head. And that is where it is left. “You look like you have twins, but we can't see the second baby's head.” Tara's a bit freaked out. She will sit there until she goes into labor. I miss my sonographer!!! We both comment that we miss Andrea. This should never be the case that we are just making assumptions. But, the equipment is rudimentary and I'm thankful to just have an ultrasound.

Now I'm back in Maternity and Tara and Tina have stepped into a labor to assist. The Haitian midwife explains to them that the patient presented to the unit at 4am this morning and was 9cm. It is now nearly 9am and she has not progressed. The Haitian OB has been consulted and is on his way for a section. The patient has begun to be prepped for a section. Tara and Liz ask questions to get the basics on the mom. Tara asks if mom is ruptured. The midwife says no. Tara says this patient doesn't need a section. She tells the patient she would like to re-check her and if it's safe to do so, asks if she could rupture her. Tara has brought our one and only amnihook “just in case,” and decides this is likely the best case to use this precious resource on. Afterall, AROM is better than section, of we can help it.

I can tell that Tara has been stressing to the students to be prepared. The tray has the pit, the Ambu bag and the instruments. It's a good start. Tara announces that mom is now complete and she ruptures her. Thick meconium stained comes out.

I'm gloved up and ready for to help with the birth. But, before she delivers a mom rolls in with a distinctive sound. She's about to push!! I rush to the other bay to find the midwife delivering the head. I help get the baby to the abdomen and stimulate the baby. I holler for Tara...I holler again, and again. Finally, I get her. She needs her pit! Pit given and mom is doing well. I make sure the midwife delays cord clamping. I again have to convince mom to actually hold her baby. It seems to be a disconnect that I am not used to. The cord is clamped and cut and the placenta is delivered. A little later she has a hemorrhage, but the midwife is ALL over it and treats it well. I'm impressed.

Tara has now gotten the students to replace the pitocin that we just had to use. Again, you have to be prepared. The mom is pushing. It's her third baby, but she isn't pushing all that well and not bringing baby down. Through the midwife, Tara gets the history that her last two babies were born at home with a midwife. She has always stood and squatted to have her babies. She's never had a baby on her back, she says. Tina asks if mom can squat on the bed, but it's quite a feat. Tara tells her she can get up and stand beside the bed. The midwife shakes her head and says that the floor is dirty. Really? Is anything here sterile??? Tara asks her innocently, “Is the delivery table or the walls or the trays, or ANYTHING, any less dirty than the floor? Point made. Nothing is clean. Everything is contaminated. The mom gets up and squats, the Haitian midwife behind her for support, and Tara squatting down in front of mom. The woman is naked. In between contractions she is hugging Tara, her bare breast essentially pressed up against Tara's face. Tara doesn't bat an eye. Mom delivers her baby in three pushes, into Tara's hands but then directly up to mom's chest. Tina tends to baby, clamps, and cut, and mom back to the bed. All is well. The Haitian midwife tries to explain how they dose magnesium. It's a 50% solution and a gram of magnesium is apparently 2ml. I don't get it, but OK.



Healthy Mom and  baby and her birth team!

The midwife preceptor today was a rock star. Seriously. We were impressed beyond words. She is a graduate of the Midwives for Haiti program and recently moved back here from Port au Prince. She was absolutely stellar. She explained things well- both to the patient, as well as the students, and she had the students getting involved. She was on top of things. THIS is why what we are doing matters. When midwives like her start graduating and practicing, there will be improvement in the care of Haitian women and an improvement in maternal and neonatal outcomes. There is no doubt.

Tara and Tina have little to do the rest of the shift.

I watch Dr. Celestin do a full on D&C in the clinic for an incomplete miscarraige. I diagnose ANOTHER term IUFD and get her started on cytotec. I have to admit, that I lied a bit. Dr. Celestin ordered 50mcg of cytotec for induction. That's a great dose for labor in a normal baby, but it doesn't cut it for an IUFD. I ask why he picked that dose rather than 200 or 400mcg and he says there is a larger risk of uterine rupture. Hmm? Never seen it. I put in 100mcg because I don't want her here for days. I'll probably still see her tomorrow and re-dose her. I'd be surprised if the night shift re-doses her. And this makes about 1 IUFD either heard of or diagnosed per day that I've been here. It is so routine. Ugh.

Sadly, the last case of the day is the hardest. The Haiti's Kidz team that is here was doing a remote clinic, seeing moms, babies, and all fcomers. The see a lady that they had seen 6 months ago with a neck mass. She is now 8 months pregnant and has a larger neck mass. It has eroded into her mouth and has caused some skin breakdown. I'm honestly surprised she can still eat and breath with this. It certainly appears to be a malignancy. But, what to do? We don't have chemo, radiation, ENT. What would we do at home? A biopsy for sure, but then what? Probably an early delivery and starting treatment. Sadly, she will likely not survive this disease. The American internist thinks that we should delay treatment, Dr. Celestin suggests delaying treatment. I would have loved to have gotten her to a specialist, but it's not going to happen. I fear for her life. If the cancer doesn't kill her, the fact that she will soon not be able to eat or breath due to the mass will kill her.



Left sided head and neck cancer

 

Unfortunately, this invades into the palate and throat

 

The night has been a good evening of camaraderie. Greg has 'made' cookies that he brought from Great Harvest, we have drank some beer, some rum, and some wine, and shared stories of times in Haiti. Everyone had a different experience today. Some taught future midwives, some did a mobile OB/Gyn clinic, some did a general medical clinic. All with a common goal of making medical care and the delivery of medical care better. It was a good day all around.

Until tomorrow.