Saturday, August 6, 2011

A Birth at St. Therese

(Days have been so packed that I fell asleep last night while writing this. All good in Haiti, “tout bagay anfom”. I’ll try to send shorter, more frequent updates this coming week.)
Wednesday night was our first overnight at San Therese. For Susan, this would be her first real introduction to birthing in the Hinche hospital. We are told that there is no running water (turns out no standing water either) in the hospital and now, there is no electricity at all. Because of that, there is no available operating room to do Cesarean sections. There would be a remote possibility to transport someone to Zanmi Lasante, Paul Farmer’s hospital in Cange, 45 minutes away if we needed. As the evening progressed, we would find out that the remoteness of that possibility means that only in the most dire of life and death circumstances would there be enough motivation to put all the pieces together for this type of transport. Here’s how the evening went:
When Susan and I arrived at the hospital, around 9pm, the antepartum room seemed full of women laboring. The antepartum room is a wide, open room with 10 beds, 5 on each side. The women labor here, sometimes with family, sometimes alone. The postpartum room looks similar, but there were only a few women there. A few days earlier, we met a woman in postpartum with a 27 week old premature baby. He was “wearing” normal sized newborn clothes that betrayed the size of his small body. Only his tiny head and legs foretold a story that this baby was probably not going to live. He was breathing well for now, and the mother and father were being counseled to take this baby to Cange, to go to Zanmi Lasante, where he would have the smallest chance of surviving. ZL has a “NICU” with 4 incubators, but that doesn’t mean that there is oxygen or the correct resources or personnel to care for an extremely premature child. The family said they would go and they were trying to find the money for the 45-minute ride. The nurse midwife was being summoned to break the news that this woman was also HIV positive.
That family was not there on Wednesday night. Only a few women were sleeping quietly in the dimly lit postpartum room. Some had newborn infants, more did not. In the delivery ward, which has 4 old, torn, and rusted gynecology tables for birthing, all was quiet for the moment. Susan and I took the opportunity to stock the cabinets with the supplies that we had carried on the moto taxi—the two of us on the back of a small motorcycle, loaded down with my jump bag and each hand full of a plastic bag with supplies. Susan is feeling more comfortable on the moto taxis if she sits in the middle. I love every minute of it, riding on the quiet streets in the otherwise pitch dark, a cool breeze relieving some of the heat of the day.
Through most of the night, we end up with only one person in the delivery room. Her labor is slow, finally reaching complete around midnight. She pushes for more than 2 hours with little progress and not very effective contractions. I check her around 2am and her cervix has closed down to 9cm around the baby’s head, a tight ring that is most likely the cause of the slow progress. We decided that it would probably be best to have her stop pushing for a while and wait until she was complete.  We started a pit augmentation, which I hadn’t seen before, Haiti-style. A Pitocin augmentation in Haiti means that they put the Pitocin in a bag of Lactated Ringer’s and manually manipulate the drop rate until it is dripping at 1 drop every 5 seconds. Susan says that this is the way we did inductions and augmentations in the US in the 60’s and 70s.
Around 4am, we were concerned about signs of an obstructed labor. This mother still hadn’t delivered and her cervix had stalled. The Pitocin was turned off because at one point she had a long, continuous contraction.  Her cervix was edematous and not complete. The staff midwife floated the idea that we transport this woman to Cange for pain meds and a possible C-section. When Susan and I started making phone calls to the in-country directors of Midwives for Haiti, no one was answering their phones. We finally called the driver, Ronel, directly, but he said that he would not drive because it was windy and rainy. It actually wasn’t raining, but the weather report was predicting a tropical storm within hours. Ronel wasn’t moving, he wouldn’t take us to Cange. This was certainly our darkest hour, having a mother who needed help, no possibility of Cesarean in Hinche, no one answering our telephone calls, a tropical storm coming, a driver who was unwilling to drive with superstitions around the impending storm.  Susan and I sat back for a while, watching the now busy labor ward swirl around us, matching the energy of the intensifying storm winds gathering outside.  A pregnant midwife was in one of the “rooms”, having her third baby. The woman in room 2 was keening in pain, finally settling into a dark corner on the floor all by herself. She needed doula support so I asked one of the midwifery students to support her by coaxing her out of the corner and rubbing her back. Another woman was suffering from the painful, spasmodic contractions of an incomplete miscarriage. We had gone from a fairly quiet and controlled space, with one woman in labor, to now all the rooms being full. I parsed out 1 student per laboring woman until the delivery area seemed in better control.
Back to our woman with the obstructed labor—to Susan and I, the idea of transport to a higher level facility seemed like the most natural and safest thing to do. Now we were left with the reality that that would not be possible. Would this baby die? Would this mother die after days of an ineffective process? Around 5am, I noticed that her “labor song”, as Susan calls it, had increased and she was really in a lot of pain. I went to her side and found that the student was no longer there. I spoke to her in Creole that we were trying to find a driver to bring her to Cange, that she might have a Cesarean there. Her wailing quieted down and she did not seem upset about this prospect. It seemed that she simply needed some companionship in her travail and some hope that it would be over soon. Truth be told, I didn’t know what was going to happen next. With the coming of daylight, would Ronel be willing to drive to Cange? Would anyone answer their phones? Would a dokte (doctor) magically appear from nowhere with the 8am shift? Were we really going to experience a tropical storm? I decided to give her one last check of her cervix. Lo and behold, she was COMPLETE!! Yay, some kind of change that we could work with. I found Susan and asked for her help, everyone else was sleeping now, but we were going to try to push again.
The midwifery students helped us with the pushing, and by 5:30am we were seeing a significant amount of the baby’s head, enough to give us hope that this baby was finally coming. We encourage and cajoled her in Creole as she pushed and pushed. The mother did a fantastic job and finally, at 5:59am, one minute before our shift was over, we had our first baby of the night—4300 grams! While doing the suturing, we heard the hearty cry of the midwife’s baby: 2 healthy babies, a successful night after all.
Susan and I soon packed up to meet our moto taxi for the ride home. The mom with the incomplete miscarriage had returned to the antepartum room and was now sleeping, having been given the only pain med that they had here. The mom with the doula was sleeping or walking about, her birthing slow but progressing. All was quiet and calm except for the bustle that would always come with daybreak.
Literally, right before we left, the staff midwife drew our attention to a stillborn baby on the counter. WHERE HAD THAT COME FROM?? Was it from one of the mother’s that we had initiated an induction on because their babies were no longer alive? Did someone new just walk in? I did not know. I only know that Haiti was sending us a clear message, “All is not well. “
Here are some photos from the last few days:
Manushka, orphan girl

Rachel, orphan girl, treating her for eye infection

Spaghetti for breakfast, everyday

Woman in the market

1 comment:

Louella said...

Our world are so far apart- yet we are all human, together, same body parts, same planet. Shocking and sad and beautiful.