Friday, August 27, 2010

Day One in Hinche

WARNING: Graphic content. Read at your own discretion. This is the real Haiti.

It’s 1am in Hinche and there’s no one here in labor. It is a moment of peace and rest. A few of the midwives are chatting while the rest of them sleep in the front room on the hard floor. Four midwives who have graduated from Midwives for Haiti are working tonite, as well as the two students who are in training.

The Hinche Maternity ward of this public hospital consists of two rooms. The front room has a gyn table and hutch which stores the midwives’ equipment. The next room is newly “renovated” from just an empty room with rows of delivery beds to 4 partitioned areas for births. Each delivery bed is an old GYN table with stirrups. Some look like they were from the 1950s, others are a little newer. A square piece of plastic covers the bottom of some of the tables, cleaned and reused after each birth. Plastic shower curtains serve as mild privacy enhancers around each delivery area. This allows each woman to deliver in a somewhat contained area. The women labor by walking around the hospital and return to the delivery ward when they think they are close to the baby coming.

Ami, Dina and I arrived in Hinche this morning and were given the hospital tour by Reina, the American CPM who is employed by Midwives for Haiti. She showed us the postpartum ward which is a large room with 10 beds, each with a mother resting. There is an similar antepartum room where some of the women stay if they are laboring or live too far away to go home. There is no clean running water in this hospital and no bathrooms for the women. Each woman is required to bring her own bucket which she will use for elimination as well as catching any blood, amniotic fluid, the placenta and dirtied clothes or sheets that she has brought along to  have at the birth. The woman usually bring a small cloth or sheet to place on the table as well as clothes or a blanket for the baby and cloths to use for their bleeding postpartum. And their bucket. Some women are too poor to even have these few things. Then we deal.

As Reina is giving us the tour of the Maternity ward, she brings us through the front room where of the delivery area where there is a woman lying on the gyn table with her abdomen exposed. I later learned that she was post-op CSEC. In one of the back areas is a mother who is pre-eclamptic. She had already had 2 eclamptic seizures and was awaiting a CSEC. The midwives had already been waiting for 2 hours and didn’t know when the doctor would arrive. Before we left, she seized again. I saw her naked, slumped body shaking with the involuntary movements of eclampsia. The midwives are trying to hold her up, the woman had seized by the side of the bed and had slumped into a sitting position. I went over to them, asking how I could help. Reina was trying to access the woman’s IV in order to push Magnesium Sulfate and slow the eclampsia. I handed her a new angiocath and was looking for gloves. Where are they? Where is anything around here? Dina and Ami had walked out, not knowing what had occurred, but when they came back to find me, I said, “She’s seizing.” Dina looked pale and I tried to catch her eye to reassure her amongst the chaos. I made Dina run out to the pick up truck to grab our medical bag, if only to get gloves for myself and feel more of service.

The midwives hauled the woman, who was quiet now, with postictal foam on her face and chest, onto the bed. I ended up at the head of the bed, pressed into a corner. Reina inserted the new IV and “pushed the mag” while the other midwives tried to hold the woman down, her thrashing with contractions threatened to dislodge her poorly taped IV catheter. Poorly taped because resources are scarce. The IV was placed, Mag on board, and I squeezed my way passed the midwives in order to leave. When would the doctor arrive? If ever.

The Midwives for Haiti truck takes us back to Maison Fortune, the orphanage where we are staying. Lunch was small fried fish, white rice, white bean sauce and a beet salad. I am hungry and happy for the food- it seems a far cry from rice and beans.

In the afternoon, Ami and I go with Cara to the storage room that is a ride away. Cara is a CNM and Harvard trained-public health PhD who is personal friends with Paul Farmer, the legendary tuberculosis doctor who has changed the face of global public health. She is our “cruise director” for our time with Midwives for Haiti. Both Ami and I have hauled 50 pounds of donated medical supplies and baby supplies. We sort supplies and take back as much as we brought, vowing to stock the “cabinets” this evening.

Ami and I arrive at the hospital after dinner. There are already 5 laboring women in the delivery ward.

 Sandie is the woman in what I will call Room One. It is a three-sided area that has a long countertop below a bank of windows. The walls are painted green two-thirds of the way up the walls which off sets the rust on an old medicine cabinet that houses the “sterilized” instruments. A GYN table with rusted metal stirrups is where Sandie is lying. She is on her back, knees up. In labor. The student midwife, Lidemila is taking care of her but she is not with her now. Sandie is alone, legs open. This is her third baby.

Next to Sandie is Denise. She’s 23 and this is her second child. She is quiet but lying in the same position as Sandie, on her back, knees up and open. I can’t tell where her labor is because she is not making any noise. She is in Room 2.

Room 3 is a GYN table that is being used as our charting station. The midwives sit here and document each birth in the big maternity register.

Room 4 has a woman, Christiane — same position. There is a plastic sheet underneath her and a small piece of colorful cloth that she has brought to lie her bottom on. The GYN table is bare, thankfully all of them are cushioned. But that’s the extent of the amenity. Women are required to bring their own cloth or towel to lie on, a blanket for the baby, any clothes for the baby. Midwives for Haiti supplies most of the medical supplies, all from donations from the US. However, if you have a postpartum hemorrhage, you need to supply your own tubing and IV fluids — available at the pharmacy.

Christiane’s baby is dead and preterm at about 32 weeks. I didn’t know that when the head was crowning and noone was with her. Ami and I stepped closer to deliver the baby. The head was small and misshapen. Maybe that was when Ami told me it was a stillbirth. We delivered a small girl, stillborn. Our first official birth in Haiti. The rag-doll limp of preterm death mocked a perfectly formed baby girl. We rested her body on the table underneath the mother’s bent knee. The placenta soon followed. I wrapped the baby in a blue surgical cloth and we showed the mother the baby. She murmured quietly in Haitian Creole, showing no demonstrative grief, simply compassion for the “poor little one.”

Now what? What do they do here with the bodies, so many bodies. Quickly one of the midwives brought in a small cardboard box. Even at her 1.5 kilos, the baby girl needed to be folded up to fit. Her coffin and resting place. I was told to just put the box aside. Where? Just leave it there along the wall, they will throw it out in the morning.

From my knowing that things can be different, I insist that we treat this baby with dignity. From my knowing that change comes slowly, I leave the box by the wall, covering the baby completely with the blue towel. Later, when the room is emptied and another laboring woman assumes the position, I insist on moving the box into the front room, onto a metal table. This is her final resting place, quiet and away from other women’s travail.

No one was with Christiane because everyone’s attention is on Anise in Room 5. Even a young doctor named Carlos is here. Anise is receiving blood — a rarity here. Her hemoglobin is 4, she is dangerously anemic.

But Carlos is not staying. This is not his shift and he’s going home. Anise is not in labor but her baby is dead and she is sick. Her mother is with her, mopping Anise’s neck and face.

Back in Room 1, Sandie has a normal birth — a baby girl at 8:55pm. I witness the birth and am impressed with the student midwife’s skills. Bon travaille to both midwife and mother.

But Anise’s condition has worsened. She seems to be having a bad reaction to the blood transfusion. Her pupils are non-reactive, pulse 100, respirations 32 and very labored. Her lungs sound wet as she breathes heavily in and out. There is no oxygen here to give her. A doctor is listening to her lungs. Her mother is at her side — silent, mopping.

Anise is 26 years old and 26 weeks pregnant. This is her 6th pregnancy. She has 5 living children at home. At 9:10pm, I count her respirations to be 36, too fast. I am much more in EMT mode than midwife mode for the moment. The medications that the doctor prescribes are unavailable at the pharmacy. She is in critical condition.

I leave to check in on one of the women in one of the rooms. Christiane, who had the stillbirth, has gotten up and dressed and is walking out the door. I thought she was going home, but I was reassured that she was just going over to the postpartum ward.

Then I heard SheLove, our interpreter say, “She died.” I flew around to look at Anise and her labored breathing. She was still, eyes wide. I was drawn to her, incredulous. It is 9:20pm. We had only been in the hospital for 80 minutes and already we had delivered a stillborn, witnessed a live birth, and now a maternal death.

She died.

There was no chaos, no uproar, no kicking and screaming about this untimely death. Mothers die here trying to give birth. Women risk their lives by becoming pregnant.

Anise laid there on the table. Her mother was gone. Anise’s body was naked and alone. I moved closer to touch her foot — urgently feeling the need to honor her, give her some dignity in her passing. I was so inadequate. I moved to her side and began to cover her body with the blue surgical paper that was beneath her. Someone had moved to close her eyes. We crossed her arms over her body.

She was brought to the morgue by two men who came by with an army stretcher. I followed them out, through the hospital pavilion guided by the light of my headlamp. We passed people sleeping on benches and broken hospital beds. I followed them out, wanting to know what they would do with her body. I was the procession as we walked out back behind the hospital to the tomb-like morgue. As we turned the corner to get to the back of the hospital, the men carrying the stretcher began singing, low. The moon had been full the night before so the night light was indigo blue. A few other women were following too. As we watched them open the morgue and bring her in, they asked me questions about what happened. “M’ pas comprend Kreyol.” I don’t understand Creole. I guessed what they were asking and told them the baby was still inside. Anise’s mother’s keening had begun from somewhere in the hospital.

At 10:12pm, Denise had a big, healthy boy. He is alive.

At 4:00am, Melange is here. First baby. 33 weeks. Baby stopped moving a week ago. The baby is dead and she was given a drug to induce the labor at another hospital, then referred to Hinche. Now she is having trouble giving birth.

Melange says she is 20 years old, but since many Haitians do not have a birth certificate, this is just a rough estimate. She looks younger to me. She wants something for the pain, but of course we have none. She does not like any exams, so we let her labor on her own and wait.

At 5:50am, Melange’s baby is born having presented arm first.

This is Day One in Hinche.

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