Vaginal Breech

I arrived at Diquini Adventist Hospital for my last day in Haiti, this past Saturday. I knew the 3 midwives that I enjoyed working with would not be there, as it was their day off. Instead I found 2 young American OBs. Since it was their first day and they were getting acclimated to where things were, I was able to give them a quick orientation to where things were located. (I had helped one of the midwives organize the supplies a few days before- so glad we did that.) The maternity unit is located in a separate building from the main hospital. It is just adjacent to the hospital in a little one story building that houses pediatrics, maternity, and the GYN clinic. A cloth curtain separates the pediatric section from the maternity section. To reach the GYN clinic, we have to exit the building and walk around to the other side. There is much construction going on that separates the two ends of the building. The GYN clinic is basically done on the 'back porch' of the building. The maternity clinic has a 4 bed 'ward' with 4 more beds added in the hallway for a total of 8 beds. One of the OBs has a great idea to number the beds and locate all the charts for each patient. Simple as it sounds, this has not been done. I set to work making signs from masking tape and markers. I locate current patient charts stacked on the nurse's desk. We file away the patients that are no longer there, and place signs on the charts denoting which bed each patient is in. Now that we are organized (somewhat) we can better manage our care. Miraculously, the Haitian nurse assigned to this unit, seems to know all her patients, where to find their charts, and is very on top of the patients assessment and medication regimens. She carries on with her duties quite oblivious to us, and seems more annoyed than amused by our attempts at 'organization.' I decide not to give any medications because I'm afraid they'll be given twice, as she has not missed a dosage for any patient. Instead I assess new patients coming in who think they might be in labor. As usual it is a busy day. I set up for deliveries in the delivery room. Our delivery room, and the three surgical suites in the hospital are the only air conditioned rooms to be found in the hospital. As result, we get lots of staff wanting to 'visit' us. But its nice to meet and talk with folks when we have the time. Today the pediatric unit is staffed with ER nurses that came from Quisqueya with me this morning. We had a group of about 14 providers come to Diquini today- a huge group, including several physicians who will be kept busy all day in surgeries. There is never an inactive moment on the maternity unit. I do labor checks on the pregnant women, and postpartum checks on the recovering mothers. I make sure babies are getting on the breast, bleeding is under control, and that vital signs are normal. I chat with the two OBs who are adjusting themselves to the circumstances. One OB orders pain medication for a laboring patient. I assure her I have seen no such meds and that all labors are unmedicated. The other OB goes over to the hospital and brings back one small vial of nubain (1 vial!) It was all he could find. We treat it like gold. At one point, early in the day, the two OBs go over to the hospital to scout out the facilities, while I hold down the fort. While they are gone, one of the ER docs (whom I met at Quisqueya this morning on the truck) comes running in to tell me that a woman just arrived in the ER on the back of a truck in obvious labor. They didn't even get her out of the truck, they are just driving her right over. Do we have a stretcher to bring her in? Well, of course we don't, but no worry, a minute later she comes walking in between two of her relatives, and get on the delivery table (which is really just a rickety old GYN examining table without the stirrups attached.) I shoo everyone out so I can check her, one of the ER nurses from pediatrics stays to help me. I do a vaginal exam to check for dilation (she does appear in great discomfort) and the following thought pops into my head: "What the fuck is that?" I'm feeling something that I have never felt before after doing hundreds of these exams. It was bony and angular and I could not find cervix no matter where I "looked" (ie. touched). I'm not entirely sure what I'm feeling, but I know it is not a head. Besides that, mom was making pushing sounds. I check for cord, but do not feel that either (thank goodness). It occurs to me that I have never felt and actual breech presentation before, because in the US these patients are scheduled for cesareans before they start labor, typically. I withdraw my hand and attempt to find heart tones. Not sure of what exactly I felt, I placed the doppler at the base of her belly, and find heart tones of 110s. At this point the ER doc comes back in, and I relate to him my heart tone and exam findings. Did you check mom's heart rate, he asks. Great question. I get my stethoscope and get an apical pulse of 90s. What I heard on mom's lower belly could have been her. I had placed the fetoscope on her upper belly earlier and couldn't find heart tones. The ER Doc picks up the doppler and finds heart tones on her upper belly in the 130s on the first attempt (shoulda used my Leopold's!). We say simultaneously, 'breech'. Where are my OBs? The ER guy asks, Do you think they'll want to do a cesarean? I said, I'm sure they will. It just so happens I overheard a conversation they had with one another earlier about breeches. One asked the other if they had ever done vaginal breeches, and the other answers they had done 3 or 4 but that they would rather not. ER Guy leaves to scope out the possibility of a surgical suite for a cesarean. I get vitals on the woman and hope the OBs show up soon. I still don't know if she's complete or if I just can't feel the cervix, but I do know she is pushy. If there's going to be a cesarean I'll have to start an IV and foley. Just then, they return, I explain what's going on. (There's been a lot of commotion in the hallway with relatives, ER staff, interpreters, and pediatric staff). They both want to do a cesarean, but when the male OB checks her again, he says, it's too late. The pediatric nurses rush in and set up the warmer (newly arrived and circa 1980s) for infant resuscitation. They spend the entire delivery trying to figure out if and how the thing works, and getting the oxygen going (bless their hearts, they were working really hard with such limited supplies- they kept bringing in supplies from their area when they couldn't find them in ours). The male OB preps for delivery, sending me on a frantic search for a gown. (The midwives didn't bother, but both OBs insisted on being properly covered for deliveries.) I found one, helped him get it on and gloved and the patient is still pushing. We get her into pushing position (I hold one leg, the other OB holds the other) and on the first push like that, out pops a little leg. A couple pushes later, we get the other leg, and the OB delivers the baby to the armpits and wraps a blanket around the body (baby blankets are hard to come by around here, its really just a square piece a fabric we found). Next the OB doing the delivery (the male OB) reaches in to manipulate the arms out. With that done, the baby is out except for the head. We expect baby to be born any minute, but that is not what happens. It takes at least a full 10 minutes of manipulation, praying (The OB doing the delivery was praying audibly right next to me as he worked frantically to get the baby out. At one point the ER doc returned to report back about the availability of an OR. There are no phones, no intercom system, no pagers, nothing. The only way to communicate with another part of the hospital is to send out runners. That's why folks just walk back and forth when they want to find something out. So the ER doc comes back to say that there won't be an ER available for at least 30 more minutes. (Either its still in use or being cleaned.) The OB had just a few minutes before mentioned again the possibility of a cesarean and pushing the baby back up,but now without that as an option, he redoubled his efforts at manipulating the stuck head. I remember shouting to the ER nurses where things were located as they frantically tried to put their supplies together while I held on to mom's leg, tried to comfort and reassure her (in a foreign language!) and instructing our interpreter to glove up and hand the OB whatever he asked for. The other OB offered to do fundal pressure. Not sure about the merits of fundal pressure, I offered to apply suprapubic pressure. He said okay to both. We both applied pressure, the OB on the top of the fundus, and me with a fist right above the pubic bone, with mom's pushing. This made a little progress, then, with time quickly ticking by, the OB handed the wrapped baby to me (limp and blue in my hands) and cut an episiotomy and with a little more manipulation, baby's head finally came, followed immediately by the placenta. (more on that in a minute). We were all holding our breaths and praying. We all thought the same thing, this poor baby probably won't make it. He quickly clamped the cord and passed baby off the the waiting team of nurses at the warmer, two ER nurses and a family nurse practitioner leading the team. (Not a NICU nurse in the bunch!) I quickly turned my attention to mom as the OB and I worked to control her bleeding. I gave her pitocin IM and then set up supplies and lidocaine for a repair. I had the interpreter scrub into the sterile field and hand instruments to the doc because I ran between mom and the baby fetching supplies and equipment for both teams. Several minutes into the repair, we heard a baby start crying! Incredible. Surely this baby was snatched back from the jaws of death. I was amazed that our hodge podge team with our pieced together supplies and equipment had been effective. Even the OB was startled to hear the baby crying, and looked up from his repair with surprise and relief. Later as we all tried to piece together the delivery summary with the correct times (keeping track of the time everything occurred was actually MY job as the delivery nurse, but I had not looked at the clock even once during the entire ordeal) we mused about the placenta. It was worrisome, because we had no way of knowing how long that placenta was dislodged prior to the baby being born. It appeared to already be right there after the head was born. There was some risk of hypoxic injury to the baby, but we could ony speculate. The female OB thought there might have been an placental abruption, but I still wonder if fundal pressure might have had a role in dislodging the placenta prematurely. After mom and baby were stabilized, they were placed in a bed and left to breastfeed. We went on to another delivery.

Last Day

Today is our final day at Quisqueya. Even though it has only been a week, I have made family. Grace the neurologist, Junith, the Hatian American OB, Matt and Emma, Ki Ki my interpreter, Kathleen, Lorraine and Dee the midwives at Diquini, Shawn the videographer, Wendy, our roommate, Art and Miquette, our hosts, Bly, Robert, Morio, Roodly, Alex and several other young Hatian interpreters, Dan our driver (and Miquette's brother). I have made friends and some family. It has been good. I am content to go home, but I am blessed to have come. I will miss Ki Ki, he is my Haitian son, and the hope of Haiti. I got word this morning that the 31 week baby survived the night. Yet another miracle in Haiti. It has indeed been a week of miracles. We fly to Ft. Lauderdale this morning and back to KC Monday morning. I'm hoping for a much needed massage and manicure once I hit the states. A walk on the beach might be in order as well. Yes there are beaches here in Haiti, but the once we had access to were polluted. I look forward to blogging more in depth over the next few days about my experiences. Stay tuned...

Diquini III

Had an awesome day at Diquini (pronounced de ken ny). Arrived to find my 3 lovely American midwives away on a day at the beach, and the maternity unit staffed by 2 young American OBs (one African American, the other Haitian American). We had a very eventful day together that included a vaginal breech with infant resuscitation, a first time mom with a postpartum hemorrhage, and a preeclamptic mom with out of control blood pressures who needed an emergency cesarean (at 31 weeks!) None of the other hospitals or even the Red Cross tent hospital would take her because you really need a NICU for any hope for a 31 week baby. Diquini doesn't even have an incubator. But since skyrocketing blood pressure can lead to seizures and death for the mother they elected to go ahead. I helped take mom to the ER and then had to leave for the day. I'll never know how things turned out, but I can guess...
My time at Diquini was my absolute favorite. I loved going to that hospital. Because I had been there two other days, and had helped one of the midwives organize all the supplies, I could really help the OBs find what they needed. I knew immediately if they asked for something, if we had it or not (mostly not). They wanted to medicate the laboring mothers, but I told them there were none of those medications, everyone delivered naturally. They were astonished. They then let me take the lead in laboring the moms and managing the flow of patients. It was fantastic. We really worked as a team, and they were very humble in the face of such a drastically different work environment. I told them I had homebirths and was comfortable managing natural labors and they seemed to breathe a sigh of relief. I got to say goodbye to my beloved midwives, I ran into them returning from the beach. I so appreciated my experience with them and the OBs, and my time at Diquini. I hope to someday return to Diquini.

Haiti Family Mission

I feel badly that I haven't got to post like I really want to. The internet connection has not been good, and my time to post has been very limited. My days have been long and eventful and I have so much to tell. Once I get back in the states tomorrow, I will go back and review everyday. Yesterday we were assigned to Haiti Family Mission, which was an outdoor clinic (not even a tarp this time, we were under an almond tree). It was another busy day of seeing women and babies (they were specifically assigned to me- no men). I treated lots of yeast infections, bacterial vaginosis, and bladder infections. Even though I was given a private space to do exams, I got very good at diagnosing by getting the patient to describe their symptoms, so I didn't have to examine them on the hard ground. White lumpy discharge? yeast infection, yellowish discharge with fishy odor? bacterial vaginosis, greenish frothy discharge? trichomonas. I knew my vast knowledge of vaginal discharges would come in handy some day! My saddest case was having to explain to a young lady that that 'bump' in her vagina was herpes. When I asked the interpreter to ask if she currently had any sexual partners, she said she " had a man back at the house". For the rest of the day we all joked, that we had a 'man back at the house'. After returning to Quisqueya (pronounced "kisskaya" by the way) I finally gave a call to my 'man back at the house." It was good to hear his voice.

Diquini II

Well apparently, Quisqueya crisis center is in the 'good' part of town. Yesterday, when I was assigned to Diquini Hospital, we were driven for an hour and a half through some of the worst urban landscape imagineable. As we neared the 'downtown' area of the city, we saw the worst destruction, and people just lived on top of the rubble. Its difficult to put into words how I saw people living. Piles of rubble everywhere. Sewage filled canals. People living in shanties in the middle of the street. Tents pitched right on sidewalks and in every spare corner. There were thousands of people EVERYWHERE. So many people. The dust from the gravel roads, or burning garbage, or both forced us to wear masks during the long bumpy ride there and back. At Diquini I found 3 American midwives who welcomed me warmly. The rest of my team was assigned to the very busy ER and OR. The maternity unit was a separate small building adjacent to the hospital. The building held the 4 bed maternity unit, a gyn clinic, a pediatric unit, and a tiny room devoted to the NICU.

Diquini

I have so so little time to write. Yesterday morning I couldn't get my computer to work, and last night we returned to the compound very late after dark- no internet connection. It has been very eventful, but no time to write. Yesterday and today I go to Diquini Hospital, the smallest of the three hospitals we are being sent to. I spent yesterday with an American midwife, running the maternity ward. Assisted with two births. Will return today. The need is so great. Saw the presidential palace, crumbled in on itself. Looked much worse than on tv. So crowded, so poluted, so many people, so few resources. Have to go, will try to write tonight if we don't get back too late...

Jungle Medicine

Just returned from practicing true guerilla medicine/nursing. None of the luxuries of yesterday. Gone was the cool comfortable ( not air conditioned)church building with a separate building for waiting patients. Today we were sent to another tent city. Our 'clinic' was under a tarp and our pharmacy inside a parked tap-tap. We saw many more patients with totally different problems. Our open air tarp covered clinic was hot and dusty and crowded. Internet went out, will have to finish this post at a later time.