7-1 to 7-16-11

7-1-11

So…so many things to write about always…it would be easier if I could tell these stories face to face…
Today we had 2 births…one was a super easy spontaneous fast labor/birth with a 3rd-timer…the other was a 6/5 with pre-eclampsia who they wanted to do a c/s on because her cervix was swollen because she had been pushing on it for awhile at 5cms and a few other reasons…anyway, we helped her to birth…when we arrived, she was laying on her back (with a swollen ANTERIOR cervix) and she was 6cms and her ctx were weak…we started pit on her and put her forward-leaning and then hands and knees…then I simply held back her cervix she pushed and the baby almost flew out.
When we arrived they had stopped her mag sulfate drip because her urine output was scant and very bloody (really BAD sign)…she was ok though and after she birthed she started peeing a lot and it was clear…huge relief…we put her back on mag and everything was great…
That’s a summary of it…
Last week we had 3 really great births too…the students really have their hearts in the right place…they are doing so well supporting women in labor, doing labor monitoring, etc…I am so proud of them…this year is a lot different than last year…we really started off on the right foot with this group…
5 babies who died this week…2 apparently were stillbirths…one was yesterday, a 25-week baby born alive who died in my arms over the next while…it was with that or let the baby die by herself on the counter…
One died yesterday--I’m sure this baby had aspirated mec…born in the morning, died in the afternoon…
Anyway…there’s always a lot of this…

So I have been trying to get a kind of visa called permis de sejours…it allows you to live here for 1 year, and you renew it each year…it has been so hard…I can’t even explain it in writing…imagine in a country with no infrastructure, no real systems for anything…you have to make a long trip in person each time, only to find out that you are missing more documents or their fingerprinting machine is broken so you’ll have to return…
Well the 3rd and final time I went (to PAP to finish the permis stuff), I went with Blada. We had the most interesting ride up there. You ride there in either a tap-tap, which is a pickup truck, or a papadap, which is a minivan…either way everyone is super crammed in there, sitting on one buttcheek…well, this time, we had the luck of having a very entertaining crazy person in the papadap with us…it was hilarious…someday I will tell some of you who are interested in hearing about it…I will be able to explain it better…not only did we have the crazy person, we also had a woman sho in the middle fo the ride suddenly started screaming and writhing in pain…she was on her period…it was like she was having an abortion or in labor…so everyone supported her, and then after her pain started dying down and she was sleeping between the contractions, everyone started talking about how their labors were and about how boy babies hurt more than girl babies…it was really interesting…
One thing here is that people talk about everything in a group…like, you’re in the minivan and the whole group of people is having a conversation or an argument about something…people don’t hold back their comments…no one is immune to criticism…I don’t know how to describe it…it’s almost communal in a way…like, people keep each other in line in the street…everyone disciplines each others’ kids…

I feel like I’m riding the crest of a wave with the creole language…like, learning at a fast pace…catching more and more little things…

7-11-11
Today is Monday, a class day…the students are taking a test right now…
This past Friday…each day at the hospital this past week was very interesting and good with the students…we did some labors and births together…too many things to describe but one that has been on my mind was on Friday….
We had this woman who was in active labor, 6cms in the morning. When the student checked her, she popped the bag of waters accidentaly and there was very thick
me conium. But, the fetal heart tones were great. Well, her labor never went anywhere all day and although the FHT’s were always good, there was just something wrong, something that was preventing her labor from progressing. Her cervix had been 5-6 cms in the morning and in the afternoon was 4-5 cms and less soft. She didn’t have signs of infection but that could be a reason for the reverse dilation. Her contractions were strong but farther and farther apart. We tried a lot of things, and nothing helped. We had advised the Dr in the morning about her and he had actually decided to do a c/s since 9:30am. Then, for the next 4 hours, he was running around trying to get them to fix the generator, because apparently the generator was broken and so there was no power and no possibility of doing a c/s. well, after 4 hours of trying, it was clear that it couldn’t be fixed. He resigned himself to telling her: “ there is nothing I can do for you.” that is literally what he said. He left. He works all the time, gets called in all the time….he went home to eat something. You wouldn’t believe how hard people work here.
In the meantime, we had also been trying to find a way to transport her to a different howpital. In Cange--about 30-45 minutes away between Hinche and Port au Prince. Well, Cange does have an “ambulnce” which they send here sometimes for really grave cases…we thought they were coming and then they called and said they couldn’t come. Our jeep, the Midwives for Haiti jeep, that is used for mobile clinics, was broken down, but in the process of being fixed. By the afternoon, around 3pm or so, the jeep was fixed and Ronel (the driver) brought her to Cange. A graduate MW went with her.
It was hard--it was like, she was stuck there with this dysfunctional labor and thick mec getting more and more exhausted. Eventually we actually gave her mag sulfate to tocolyze her (to slow down the ctx) because we had already tried augmenting her with pit, and then when I checked her again and saw that she was reverse dilating and also was pushing on her cervix and tearing it and bleeding, we stopped the pit and tocolyzed her instead.
It was a team effort between myself, Genette, the students, the other graduate MW Bienaime, our driver…I imagine that things turned out ok for her and the baby because the baby had been stable all along and she was also not super compromised yet.
The most striking thing to me of the whole situation was when Dr C, the OB, said to her: “there’s nothing I can do for you.” I mean, for an OB to have to say that to someone--for an OB to have to tell a woman this--for an OB to have their hands tied like this and to have to simply tell a woman that there’s nothing else they can do for them---that is really sad. That is a reflection on the entire eituation here--the act that we had to wait all day to transport this lady to a hospital 45 MINUTES away--and that there are no public services like ambulances…

There was another really intense situation this week….a birth on Wednesday…a 5th-timer (5/4) who was diagnosed with “CPD” (it is the largest reason they do cesareans here)--(CPD means that the baby’s head can’t fit through the mom’s pelvis)---
Anyway I advocated for us trying for a vaginal birth and got a lot of hell for it but eventually she progressed to complete (she had been 9cms with an anterior lip only, laying on her back--when we arrived)….this lady was really out of her mind--wouldn’t let us help her at all, wouldn’t cooperate at all…had it in her mind that she was going to die if she didn’t get a c/s….it was really chaotic and crazy---her yelling, her family yelling, everyone upset and scared, them mad at her for not cooperating with us, her mad at me for saying she didn’t need a c/s--anyway it was really crazy until she started pushing…then, she calmed down and started focusing and pushing and working with us…she was on the floor, almost outside of the L&D area…her dad, who had been praying over her, stayed there and held her as she pushed…
Pushing stage proved very difficult…probably her other babies had been smaller than this baby…very hard with fetal heart tones that started getting bad (around 70-80, staying there, with the head still not through the bones)…I called in help from another American MW who was there at the hospital too because I knew she could help me get the baby out…we were doing everything and finally the baby came and was ok after a few minutes of artificial respiration…
The whole thing was intense too because besides the birth being hard, besides the possibility of having a damaged or dead baby, and all the grief that would cause, there was the other reality that I had been the one who opposed the c/s earlier, so if we had a bad outcome, it would have been my fault, in everyone’s eyes. That would have been really bad. As it was, with everything ok, the mom was so so happy and so thankful etc during the postpartum, and so was her family…she had lost her voice from all the screaming so she just kept whispering “thank you so much, thank you so much…” and her family was like “you should always stay here and save mothers”…I was happy for their happiness but I also knew that if the outcome had been different, and it could have been, it would have been the opposite…
The thing is, earlier on, she really didn’t have any real indication for a c/s. one reason for it was that people didn’t want to deal with her crazy screaming anymore.
I’ve had lots of births here where they were headed for a c/s for “CPD” and I helped them birth vaginally…the week before I had another 5th timer with “CPD” who just needed some pit augmentation, a change in position from flat on her back to hands and knees, and then to push back her swollen anterior cervix--then the baby flew out.
Anyway….writing about something never captures the reality in full but atleast it can give an idea.
The students, I am so proud of them. They are doing so well in the hospital. Last week I was able to suture with on eof them and do PPV 2 times with her as well. (PPV=artificial respirations for a baby who needs help to start breathing). It is so satisfying to help someone else do something, to put your hands over theirs and feel them do it with their own hands.

The time here has been flying by. The energy in the house has been easier than in the first several months, which has been so great, because after the first 5 months or so, I was really really FRIED, and the volunteers could see that, and that made some of them feel unwelcome, but there was nothing I could do about that because it was our living situation that was really really unbalanced…the last 2 months have been better--with some breaks from visitors (volunteers) and with Kirsty and Mackenxy moving in a month ago…

Anyway, time is flying and in less than a month, I am leaving Haiti to go to the US for almost 2 months…first I’m going to El Paso for 3 weeks, then to NC for 4 weeks. One of the big reasons for my trip is to go through all my stuff in EL Paso and pack up what I’m keeping and ship it all to NC. So that, when our fiance visa petition gets approved next year hopefully, we can go to NC directly. I feel sad about rapping up my life in El Paso, even though I know I have to and I know that life changes. It was just such a big part of my life for so long, and I feel really connected to the midwives there still. And to the people of Ep Paso/Juarez. I had many friends who birthed in my hands 3-4 times and whose sisters’ and cousins’ births I attended…
I will be so happy to see everyone there again, and relieved to deal with my stuff and move it, but also sad to be wrapping up things there…I would love to visit MLL & El Paso one day with Blada…would love for him to see where I was and for my friends there to meet him…
Also really excited about going to NC and being there with family and friends…
Another part of my trip besides moving my stuff is doing things like renewing my CPR and IV certifications in order to be able to renew my midwifery license when that comes up…hopefully I can do everything I need to on this trip so that I don’t need to leave Haiti again until I leave with Blada…whenever that is…(we hope next year but you never know with stuff like this). And of course the other big thing I am going to do while in EP is to send off our visa petition. That will be such a relief!

This past week at the hospital also, I enlisted the participation of a group of auxilliare students who are in their maternity rotation. The last groups we’ve had, they’ve been awful, so we mostly ignore them. They just sit there all day, not trying to help or learn, playing with their phones…well, the group that started this week is a different story. They are helpful and get their hands in there. I’ve had them come and do massage for laboring moms…I’ve taken time to show them things like explain things to them while I’m suturing…so, we had one birth on Friday where the mom pushed and had her baby on the floor (on a sheet)---and there is a guy in the group, who is really open and had already been doing massage for the laboring mom. So, while she was pushing, I had him squatting behind her supporting her. For like 45 minutes. It was great. This is the only time in their training they will ever see something like this. I talk to them about how to talk to patients. How to be gentle with them and show them that they can trust you. So, it was really great that they could help us in this birth--actually the guy student, he was more positive and helpful than the females. I joked that we will pick him for our next MW class.

7-16-11
So, it has been 2 weeks that the hospital has been without power. The midwives do births at night with their headlamps. There is no functional OR. We’ve had to transport women who needed c-sections to a different hospital in Cange, about 45 min away. If we didn’t have the MWH jeep, some of these transports would have not been possible. Like the woman I wrote about last time, who we transported a week ago, who was stuck at 5cms all day, with thick mec. If the jeep hadn’t been available, she would have eventually lost the baby and if her labor didn’t progress she would have ended up with a ruptured uterus (and would have died).
Not only does the hospital have no power (the whole town of Hinche has no power. Anyone who has power has either solar panels or a generator))---but now, the Red Cross, down the road form the hospital, had all of their 8 solar panels STOLEN a week ago. Which means that all the stored blood was lost, and there is NO blood available for transfusions. There are 2 ladies at the hospital with 4 hemoglobins. There are people worse off than them, I’m sure. Ayway, whoever stole the solar panels is going to cost people their lives. If the town finds out who did it, they will probably kill him. I’m serious. Thieves are punished severely here. One time, Blada witnessed a thief get tied up, beaten and dragged through town, and then burned to death.
Anyway, so the hospital is pretty bad off right now. Sometimes I give some of the patients who are really bad off a little money. Like, a woman in post-op with a 4 hgb whose family is only feeding her some crackers and juice every day, and who doesn’t have money to buy iron injections. One of the students has taken on making food for her and told me about her situation, so I gave her the money to buy the iron. Out of leftover house food money. Sometimes you just have to, people are so bad off.
We had a 15 day postpartum woman come in on Wednesday, having eclamptic seizures. Her parents came with her….she had been seizing all day…we had to restrain her to give her anti-seizure meds because after you’ve been seizing, your brain is abnormal and you are really deranged and out of it---she was trying to bite me and scratch me…the next day, she was a lot better and has been better each day. But she’s not totally here yet. She can’t really speak yet. But, she is holding and BF her baby. Her parents are so dedicated to her…they came from far away, with nothing…nothing to wrap the baby in…everything was dirty…bloody and smelly…so so sad…they didn’t even have a sheet to put down on her bed…I looked through our stuff at the hospital and neither did we…sometimes we have stuff, like baby blankets, baby clothes, etc, but they get used and then there’s nothing…anyway, I gave them some money so they could eat and feed her…really humble and caring people…I talked to them a lot about keeping the baby on the breast, about giving their daughter good food once they get home…
We had another pre-eclamptic woman yesterday, who is 7 months pregnant, 21 years old, who lost her 1st baby at 7 months due to the same condition. I talked with her for a long time yesterday about the fact that right now, her pre-eclampsia appears “light”--it’s not severe/full blown yet, but that that can change at any moment--we had a woman a few weeks ago who had been seen at the hospital 3 days before with a B/P of 90/60 and everything appearing fine, who then came in seizing 3 days later…anyway, I was talking to this woman about the fact that we reall yneed to induce her labor, and that yes, her 7-month old baby probably won’t make it…it was so heart-wrenching because this woman really, really wants her baby…she is still sad about losing the last one…she kept saying that she feels the baby moving in her belly…she kept asking me what I thought were the chances of her baby surviving…at the same time, understanding and resigning herself to the induction, in order to save her own life…
And in talking to her, I just kept coming back to this: that this is so unfair…that in the US, we would be monitoring her condition continuously with blood tests, to know how much longer we could wait to deliver her, to balance the risks for both her and baby and she most likely would not die…it is so unfair that women here have to make this choice…this woman yesterday, she is an intelligent, normal woman, who deserves the options and choices of any other woman…the women here are no less, and they deserve no less.
Yesterday in case studies class with the students, we were talking about eclampsia. I was asking them if they have known women who have had eclamptic seizures, who have either been normal afterwards or been kind of off mentally, or even crazy. (years later). I just wonder, because obviously, you can suffer brain damage from an event like this. Well, almost half of them have had cousins, aunts, sisters, etc who have had eclampsia. This is shocing. This shows how common it is here. All of them said that the people have been normal afterwards. I know that there is different research about how PEC starts, like with placental attachment in the 1st trimester, genetics, etc. but to me, the most obvious cause is malnutrition and dehydration. People here do have chronic dehydration and malnutrition. A pregnant woman needs more of everything, and needs to expand her blood volume by 50% over what it was, by 28 weeks pregnant. These women are HYPOVOLEMIC. They have a thick, contracted blood volume. This leads to placental insufficiency, fetal growth restriction, high blood pressure, kidney damage, etc. the body responds to the hypovolemia the same way it does to a big hemorrhage: the kidneys release renin, to raise to the blood pressure, in order to keep circulating blood through the body, and to the placenta. They also start reabsorbing water, in order to keep the blood volume out. Lack of adequate protein and salt causes plasma (the fluid part of the blood) to leak out of the blood circulation, which causes pathological swelling. This is a simplified explanation of a multifaceted syndrome. There are surely other factors that can exaserbate the process or augment someone’s risk. But, I really feel that this is the underlying cause. It is so clear. When you see it here, it is so clear. When you read about it and put all the pieces together, it is so clear.

The choice that ended up being made, in light of her fervent desire to save her baby if possible, was to bring her to Cange the next morning (this morning), because at least there they have the capacity to care for premature infants…I don’t know if a 7-month baby will make it there, but it’s her only chance.

We only have 3 weeks left of classes, until we start the last 10 weeks of the program, which is almost all clinical. I regret that I will be gone for 2 months of that. I feel really attached to this group of students and will miss them so much and also be sad to miss out on a big part of their learning. There is never a convenient time to leave Haiti. Even though I am excited to come home, to see everyone…it is also hard to leave and I will really miss people here…

What else…the weeks are passing fast.