Labor Repose

Labor Repose
LaborPayne during her 6th homebirth (9th baby) at age 44

Monday, May 23, 2011

Big Pharm or Big Phuck?

Today I spent with Monseiur in his clinic. The patients started early and stopped coming at midday during the heat of the day, then they resumed coming in the late afternoon. We saw two patients today who were coming after self-induced abortions after taking cytotec. Apparently this was not unusual. I asked Monseiur where these women would get cytotec. He said from the pharmacy, they can just walk in and purchase it. I had no idea. I asked him if the women ever had complications from it. He said sometimes he had to do a D&C but not often. I asked them how much they took. The first patient today coming in for this reason had swallowed two pills and placed one in her vagina! (This is a much greater dose than is given for induction or even postpartum hemorrhage, but I don't know the protocols for abortions.) Monsieur did ultrasounds on both women to see if all had been expelled. I asked him later what Haitian women did for birth control, not knowing what answer I would get in such a Catholic country. He said that they preferred birth control pills and depo. We saw several women for prenatal visits and women of all ages for GYN concerns as well. In all Monsieur saw about 35 patients today.

After the postabortion patients, the patients I found most interesting were for HPV follow ups. Monseiur explained that he had particpated in a drug study with one of the big pharmaceuticals that involved screening 10,000 Haitian women for HPV. When the results were returned, the drug company asked physicians to biopsy (take a tissue sample) all the women whose tests came back positive. Monseiur refused. He would only biopsy those who showed abnormal cervical tissue on a colposcopic exam at follow up. He was not going to biopsy healthy tissue. This started a day long dialog about the exploitation of third world women by drug companies, NGOs and even charitible and religious organizations. I knew all too well what he meant. Hadn't I myself many times particpated in the ''treat 'em and street 'em" brand of healthcare both at home and abroad? This company was not offering treatment to the women who tested positive, only a testing of their screening product. This whole conversation got my blood boiling- again. Monsieur told me at length how again and again he had entered into agreements with individuals and organizations that promised this or that but in time, they all leave. Here he remains, carrying on the work that must be done.

My time here becomes clearer as the days pass. Monseiur exemplifies that model of care that I want to emulate: long term solutions rather than half-assed quick fixes. Later that afternoon, during the break in the heat of the day, I walked down the dirt road to the Heart to Heart Clinic. This is where I had worked when I was here last October. In the courtyard under a shade tree, I immediately saw Wilifred, and Mose. I hugged them heartily. I didn't know it would feel so good seeing my interpreters again looking sturdy and handsome. They smiled and hugged me back. Then I went inside the house to say hello. I recognized the cook and greeted her, and then greeted the two individuals at the table. One was a Haitian whose job was to look after the house, the other was Nicole. We had not previously met. I introduced myself, and we each shared what we were doing in Haiti. She and a friend had actually rented a house for a year here in Leogone with the intention to start a charity/NGO to serve the HIV population. I shared my plans with her for my urban birth center. We walked a bit, and I introduced her to Dr. Delson. He made it plain he had no interest in her ideas. I, however, hope she gets to do all that she intends and more.

Dinner last night was a savory blend of rice and beans, green beans, and stewed conch and onions. I had not had this kind of seafood before but it reminded me of squid in its appearance, but was softer in texture. I enjoyed it very much. After dinner the clouds moved in. I was breathing a prayer of gratitude for the rain after a hot dusty day, when I remembered the poor souls in the tents across the roadway. I peeked out my door across at them, but I could see nothing- pitch black- there was no electricity tonight. We had some because of the back up generator, but elsewhere in the neighborhood, there was pitch blackness all around. I tried to imagine what it must be like in one of those tents, with the heavy rains coming down and sitting in the dark. I thought better of giving thanks for the rain, when I was warm and dry and had light to read by.

I stayed up reading for several hours until I heard Monsieur coming up the stairs calling my name. "Oui? Monsieur" I called out, wondering if he was coming to tell me the state electricity was back on. I had been sitting in the bathroom reading in poor light because my bedroom light and fan had no electrical current at all. Better, a woman had arrived in labor! She was dilated to six with baby number three. When I freshened up and arrived in the clinic (thank goodness I had not changed out of my clothes for the day yet), she was already on the delivery table with her legs in stirrups. I was surprised to see he had her laboring in that position. Her broke her water soon after I arrived, it was nice and clear. He ran back and forth, between the mother and his generator (he had workmen working on trying to get more electrical coverage- the delivery room had lights, but he was trying to get the fan going as well) I was able to give comfort care such as it was. I put a pillow under her head, a cool cloth on her forehead, and fanned her with a packet of sterile gloves. I soothed her with my minimal command of Kreyol. Her husband and two kinswomen waiting out in the waiting area, but every now and then, her nervous husband would stick his head in the door to see if she was alright. His anxious face made me smile, surely nervous husbands the world over have the exact same look. I smiled at him as I held his wife's hand to give him some reassurance. I wanted badly to wave him in let him hold her hand instead, but I have not seen this be the custom in Haiti, and I was determined to just observe (though by getting up and helping the mother I had already broken that deal with myself) and see how Monsieur does things without intervening. While I might later suggest this or that (if it is appropriate), for the first delivery I thought it best just to see what actually occurs in the course of a delivery here. The woman actually labored fine before her water was broke, but the contractions became noticably more intense afterward. With each contraction she would grab me around my waist and look into my eyes. I wished I spoke her language so I could comfort her better, instead I just returned her gaze and slowly shook my head yes, as if to say, "All is as it should be, all is well." As Monseiur predicted, she did not labor long. Within the hour after I arrived and her water was broken, she pushed out a fat juicy baby girl with a fat robust cord, wrapped loosely around her neck and a compound presentation as her head emerged along with one arm. I was surprised to see Monsieur dangle the infant by its feet, yet he was gentle and I saw fluids flow from her mouth. He never suctioned her, she never cried. She only looked around wide eyed and alert. Madam appeared to claim the baby. She never bathed her, but wiped her down, weighed her and dressed her in the diaper and clothing the family had brought for her. She was still covered in vernix, but all the blood and fluids had been wiped off. Madam then took the baby into the recovering room where the Father and two women waited. Monsieur had to do stitches and I assisted and observed. There was really not much for me to do since Monsieur was not used to working with a nurse assisting (even though Madam is a nurse- she did not help at all with the delivery and only appeared to care for the baby) so he pretty much did all the tasks I would have done. However, he did explain what he was doing to me. Then Madam came back and cleaned the mother up and we helped her walk into the next room where her baby and family were waiting. It was as calm and as simple a delivery I had seen in a medicalized setting. Madam and Monsieur hardly spoke, except to give a few directives. (Monsieur was actually much more animated about the generator situation.) I helped Madam clean up after the delivery. There was a lot of amniotic fluid, most of which came as baby was pushed out. The mother had recieved 10 units of pit in a IV Monsieur had started when she arrived. After she was in bed, he also gave her a cytotec pill to swallow with water. I asked Monsieur how long they would stay. He said about six hours, that they would leave in the morning. Sure enough, when I came down to breakfast, they were gone.


Anonymous said...

Re: Cytotec for abortion -- many women in the US and worldwide have died from being given 800 mcg (4 of the 200 mcg tablets) vaginally to induce an abortion. Apparently, this can lead to deadly infection [click here for more info], although oral misoprostol does not seem to have the same effect.

Hearing things like this makes me wonder if this is also a risk for a Cytotec induction. Perhaps it's not such a risk since it's just 25-50 mcg at a time instead of 800 mcg all at once.


LaborPayne said...

Thanks for the clarity. I don't know if when these women go to the pharmacy, the pharmacist tells them the amount and how to use it or if they go with that information from another source and simply purchase what they want. Both patients we saw yesterday had taken different amounts by different routes. One showed no contents in the uterus by US, the other clearly showed the egg sac still present. What I'm observing appears to favor the oral route (though I never saw misoprostol administered by that route back home in the US). If your source is correct, and oral administration does not lead as readily to infection, then this is a good thing.

As for your concern about cytotec induction leading to infection, this was a popular induction method in the hospitals where I worked and I did not observed a causality to infection (though there were certainly other complications going on- hemorrhage, hypertonic contractions, abruptions, fetal compromise, and such).

I have only observed Monsieur use cytotec postpartum, but he essentially augments everyone by putting 10 U pit in each IV fluid bag upon admission.