Sunday, March 15, 2009
A Haitian Birth-day, or ,The 3 S's
Dear Nadene and Steve,
As I fly home to Dulles, I want to thank you (??!) for the casual encouragement you gave me that "it would be great if I could take some student's over to L&D and deliver a baby in Haiti" before my week was out. Well, my friends, I did that, and what an experience it was! I tend to believe God has a plan in all situations, so I guess I was meant to grasp in huge experiential detail what it's like to lack what I will now call the "3 S's ": STUFF, trained STAFF, and STABLE surroundings (like water and electricity...) The language barrier added a special thrill as well!
So, I chose the 2 students who had no birth experiences except their own. On Friday pm at 2, they dressed nicely in their pink scrubs and followed me over the the Salle Maternite. I saw no one in the delivery area, so I introduced myself to the nurse at the maternity desk as one of the "Saj Famn pou Ayiti" midwives from the US, and said I would be happy if I could help with a delivery. Of course this was thru the interpreter, so I hope that's what I said. But perhaps this meant to her " I am WonderWoman!!- Bring it ON!"...I don't know.
The nurse said that "OK they got somebody for you" and they got a laboring lady out of bed and walked her across the hall to the delivery area for me to examine. She got up on the table, I found some gloves, and examined her. Her cervix was 6 cm dilated and she was having strong contractions. She was having her second baby. While I was explaining this to my students, I was slightly disconcerted that more women were being brought in and helped onto more tables--- they kept coming!
The next one was 5 cm dilated, fully effaced, 1st baby. OK...but here comes #3. She's only 3 cm, but making lots of noise and obviously laboring actively. I was starting to feel confused...do they just hang around those tables until they deliver? What about the labor area? And the nurse who was leading the stampede was doing almost nothing to organize or help me! ( I later learned she was the only nurse for ALL the maternity patients.. including rooms full of postpartum women, including some receiving blood. Aha.) NO STAFF. So I found a doppler and started checking fetal heart rate on everybody-- let's see if all the babies are OK! They were. Praise God. Next, I figured, OK, They've already invented Group Prenatal Care: let's try Group Labor! So while lady #4 was climbing onto her table, I did a round of Blood Pressures; this was hard because it was so loud in there with all the laboring and hollering. As far as I could tell, nobody was over 140/90. The nurse asked did I want to give the one with the 140/90 BP some Aldomet? Well, No thanks, I said, but could we dip her urine? We could, and cup of urine and sticks were given to me which showed negative protein, so I decided to just watch her. I did manage to explain this to the students for minute, before lady #3 got off her table, pooped in the plastic bucket at the end of the table, and vomited on the floor...likely not 3 cm anymore!
I already understood that we had almost no help; there was nobody consistently nearby except me, my students, and our interpreter. But they were getting some labor and delivery experience, by golly!!
Now I was acutely aware of NO STUFF. NO gel for the doppler. NO Kleenex to wipe off the doppler. NO paper towels (or anything) handy to wipe up the floor. The water did work, so I did wash my hands as much as I could, but did not have towel to dry with. There were also flies around-- not quite #3, a "Stable situation". Each woman had brought some type of cloth from home to put under her on the plastic-covered table. Some had pieces of sheets, some had a night gown or a skirt spread out beneath them. Now, I understand that this is meant to get them through an entire birth, and goes home with them to be washed. The thought of a full bag of chux and a roll of paper towels ran through my mind and seemed like something I saw in another life!
Next, the infermiere brought me--WOW!--prenatal records on each of the laboring women! They had all visited the prenatal clinic at least once! Nobody had a hemoglobin under 10, and no one had tested positive for HIV, and they had all taken some vitamins at some point. No babies were coming breech, no twins; hey, It was my lucky day!
Danise came over about 3:30 and I felt like the cavalry came over the hill. I told her I was staying until Ronel came for me with the truck at 5pm, and she and the students all said they would stay with me and work. More trained STAFF! Hurray! Our lady on the third table had been getting more and more active labor...actually, at some points all the ladies were yelling and crying; quite the drama! Despite having locked away the medical boxes for the end of the week, I did have a small bag of STUFF that I'd carried with me "just in case", - I had some gloves, a gown, suture, Pitocin, Lidocaine, and syringes. I broke open a few of the diaper & onesies kits, and placed a new clean diaper under my patient who was ready to deliver. This move was greeted with disapproval by the Haitian staff, that I was using that nice clean cloth in this manner!
At this point I couldn't really communicate with anyone around me, because the birthing mom had her arms wrapped around the interpreter, screaming and pushing the baby out. God Bless her, Danise was there to help me, so we actually checked the baby's heart rate a few times, and she found me a few instruments that I can only hope were sterile; there were 2 clamps and a small scissors. Soon, we delivered a baby, a girl, and she cried right away. I had Camina stand by with a clean diaper (another one! I was tearing through the resources like a crazy person by Haitian standards) that we used to dry off the baby. We suctioned her, cut her cord, and wrapped her in a clean blanket. My heart was full of gratitude to the friends and moms who had donated all that STUFF. God bless them, too. We did active management of 3rd stage since I had the Pit, and bleeding was well controlled. Hooray for stuff and staff.
Next, the perineum needed a small repair. I was so happy that I could give this lady lidocaine for local anesthesia, as it is not routine there; I just happened to have some. HER lucky day! When I had the syringe loaded and went to inject the area for stitching, I realized I had no light but daylight. This lack, the third "S",I call STABLE Situation: the need for power & water. We angled the table so that afternoon sun gave me light. I asked for a stool to sit down on while I stitched...one was placed under my bottom, but oh dear, it was actually a seat not connected to the frame. So, with a loaded 10-cc syringe and and uncapped needle, I fell backward on my butt, onto the filthy floor...waving the syringe around and trying not to get hurt or puncture anyone! The girls caught me before I whacked my head or poked anyone,picked me up, got me on a chair. I went ahead and used the lidocaine as I felt it was still uncontaminated and that's what we had. I had the scissors and 1 small straight hemostat left, and Danise indicated that this is what I had to use to suture with. So nevermind, Steve, teaching the students the proper way to suture, with pickups! I did the repair with one hemostat and some Vicryl. The students were thrilled to observe hand ties and instrument ties, and were able to identify them as I did them!
In the end, we had caught a baby in Haiti, and I had to go home with my truck before the other ladies delivered. I was soaked in sweat and very tired! It was absolutely mind-boggling to me that this chaotic escapade, the craziest 3 hours in labor and delivery I ever spent, had actually been a big improvement over the usual birth scenario at this hospital. It's also astonishing that most of the women in Haiti do not get prenatal care, and do not deliver in any facility or with anyone with training, so that this story actually is a best-case scenario. My patient was attended by trained midwives, and had more care, more precautions against infection and hemorrhage, actual local anesthesia, and even some clean linen. Midwives for Haiti and the people supporting us can do so much better, if we keep going. I am grateful for the eye-opening adventure, and I am inspired to try to supply the 3 S's, and keep working for birth to be safer, and better, in Haiti.