Macrosomia

In my first test of being an intern on call I failed miserably.  Yesterday evening I was just finishing up my previous blog post anticipating a quick call back home to Rachel and my parents, when Angie got the call.  It was a woman who only spoke Creole.  Not helpful.  And kinda odd since Angie hadn't given her number out to anyone aside from our translators.  The only words we could make out were a frantic "M' maladi".  "M' veni".  It's only9 o'clock, but already it's pitch black out.  Great...

She calls back.  Still frantic.  Still parle-ing some gibberish that I can't comprehend.  "M' pa konprann."  I say that a lot around here.  We pass the phone to one of the girls so they can attempt to translate the message to us.  The patient is at Carrefou Poi (Literally 'Crossroads Beans').  She's pregnant and is experiencing a lot of pain.  Oh, by the way, apparently Guireline gave the patient Dr. Angie's phone number.  #NotHelpful.

She was not a new patient.  She had come to our clinic for routine obstetric care.  Based entirely on LMP she should have delivered on Monday of this past week.  Just like a baby not to come when it's convenient or expected.  The patient was getting a moto to drive her up here.  Definitely not the safest way to relocate a laboring woman.

We wait.  I have my headlight on and wheelchair at the ready down by the gate.  Angie prepares the procedure room for what appears to be another delivery.  I can't even hide my tiredness as I sit on the gate and yawn.  Fifteen minutes pass and still no sign of the patient.  One of the girls calls her back.  The moto broke down and she was in the process of walking up here.  Ugh.  I run get my phone.  Thankfully a number of moto drivers have given me their numbers because they like charging me twice what they charge a Haitian.  We call one and have one of the girls describe what's going on.  He accepts the job.

Another eternity seems to pass before we finally see the lone headlight making its way up the road.  The patient dismounts and I hand the driver 10 Haitian dollars.  It seemed appropriate given the circumstances.

The patient foregoes the wheelchair and hikes it up our long driveway to the procedure room.  She's a big girl.  The baby will be big, but this is her second child so hopefully it'll go smoothly.  We try and get her comfortable on the bed before we examine her.  She's 100 percent effaced and dilated to 3 cm.  She reports that she has not broke water yet.  Angie tells the patient that there is still plenty of time to go to the hospital if she wants, but that it's her decision.  The translator, however, puts her own little spin on it (paraphrasing), "You need to go to the hospital to deliver this child."  Luckily I know just enough vocab to catch when translators are missing key words.  This certainly wasn't the first time this 'translator' tried to discourage patients from coming here without our approval.  And this has been a point of frustration with her since we've figured it out.

The translator reports that "she will go to the hospital."  I very directly tell the translator to tell her that if she would rather deliver here that she can, but we can help you get to the hospital.  She needs to make the choice.  Ah, the patient wants to stay here to deliver.  #ThoughtSo #ScoreOneForKnowingJustEnoughCreole  #IWishSheWouldHaveGoneToTheHospital

She walks, a lot.  She doesn't even pause for contractions.  Just keeps plodding along.  She sounds pretty miserable.  Minutes turn into hours.  Unfortunately battle fatigue has led me to becoming rather cynical.  In a cruel bit of humor I decide to make a playlist to "encourage" her to deliver her baby.  The songs ranged from Justin Bieber's "Baby to Vanilla Ice's "Ice, Ice Baby" to "Baby, It's Cold Outside."  The irony was not lost on Dr. Angie or myself.  I even had a couple friends wisely suggest I add Salt-N-Pepa's "Push It."  Great decision.  Didn't seem to help.  The playlist went from 47 minutes to over 2 hours.

Midnight came and went.  I know this because I added Eric Clapton's "After Midnight".  Her water still hasn't broken.  Better add some songs calling for water.  Brad Paisley made two appearances, one with "Water" and the other with "Don't Drink the Water."  TLC's "Waterfalls" and The Temptations "I Wish It Would Rain" were a couple other late additions.  It wasn't until Led Lepplin's "When The Levee Breaks" that she finally came in.  Her water had broke.

Sweet.  She was  a multip.  The delivery should go smoothly from here on out.  Angie does a quick exam.  Butt.  The baby is breach.  Damn.  This won't be as easy as we thought.  We gameplan.  Our primary concern is going to be the mother.  We're going to try and avoid a cesarean because we are not equipped to stop any hemorrhage.  That's our only option at this point.

Her contractions are more frequent.  Her prayers become louder.  The baby is still riding high.  She's near complete dilatation.  We have her give some pushes with her next contraction to try and speed things along.  Two a.m. comes and goes and she hasn't progressed.  She's getting tired.  So are we.  Angie and I keep nodding off while we're sitting and waiting.  Her family is asleep in chairs in the room next door.

Dr. Angie performs another check.  Wait a minute.  We grab a speculum and look.  It looks like there is another amniotic sac.  We pierce it with a scalpel and fluid gushes out.  Sure enough, she hadn't broken her water.  Another manual exam.  Head!  It's the baby's head!  It's large but it's lined up the right way.  The bag that we thought had ruptured just distorted the previous exams enough to convince us the baby was breech. Of course, we were probably assuming the worst to begin with since that's what we've grown accustomed to.

She continues to contract and continues to shout for Jesus to make this stop.  At four o'clock the decision is made to take her to the hospital when dawn breaks.  The fetus needs to be evaluated just to make sure everything is going okay.  She's exhausted and her contractions are weaker and less frequent.

By this time I feel downright awful.  My stomach hadn't been sitting right for most of the day.  I am not sure if it was the eggs at lunch or the bean sauce and rice that I had tried Thursday while I was out in the community.  Seeing this woman labor for nearly 10 hours wasn't helping matters.  No anesthesia.  No pain killers.  No IV fluids.  Just her walking around with a baby trying to come out.  Glad I never have to do that.  I've always had respect for the childbirth process, but I still can't understand why women would want to go through with it.  I can't handle any more.  She's not progressing and I have already dry-heaved outside a couple times.  I give up and go to bed.  I was probably 45 minutes shy of 24 hours straight.  Guess I'm not ready to be a resident yet.  Dr. Angie soldiered on.

Morning dawned.  There was still no baby.  Her contractions had all but ceased at this point and the patient was exhausted physically and mentally.  We called for transportation to take her to the hospital.  We sent one of the girls to travel with the expecting mom and her sister.  Fortunately our CHW had had a full night's sleep.  Dr. Angie also received a bit more history before the patient departed.  Her first child was premature, by a lot.  She had had a miscarriage.  That explains the "quick delivery."  Unfortunately she failed to mention those key details.  Not that it would have changed our management much more, but we would not have been anticipating a relatively easy delivery had we known.

She got to the hospital.  We didn't have to pay a nurse $30 for her to stay and she didn't get sent to Port-au-Prince for some mysterious cholera.  She was seen, examined, ultrasounded, and eventually delivered a healthy baby without surgery.  They had to have given her some pitocin to encourage contractions, but I am still amazed that she did not go to section.

This was an interesting story, I thought, because the patient specifically requested that we handle the delivery.  She assumed that by us being 'blan' that we'd be better equipped to guide her through a smooth, painless, quick childbirth.  Maybe in the U.S., but not in Haiti where we only have 1 more liter of normal saline, no cord clamps, no pitocin and no anesthesia.  She ended up being much better off at the hospital.  Certainly the culture around here will never change.  I would guess that 80% of deliveries happen at home and that's totally fine.  The hospital couldn't handle all of them.  But what I do hope is that by her having a successful delivery that we've somewhat aided in restoring one family's faith in the local hospital and system. That would be a victory rivaling holding a brand new, healthy baby girl in my opinion.