I had returned to Haiti after being whisked away in a helicopter just two months earlier #Manifestations. I'm still getting the feel for this whole Medical Director thing, but if it gets me into the beautiful country more then I support it. ServeHaiti is piloting a new data collection program that will (hopefully) allow for near real-time information to be easily organized and analyzed. We do (I say 'we', but it's definitely got nothing to do with my actions) amazing work in Grand Bois, but it's really hard to say those things without objective information.
That's why I'm here though. Help introduce the program. See it in action. Troubleshoot early problems. And obviously to work on my tan. #BeachSeason.
The first day was great! Abby and I were able to get the selected #CommunityHealthWorkers to the clinic and give them their "new" device. And by "new" I mean four-year-old, generously donated, tablets running Android platforms. But that's definitely #HaitiNew. Even Dr. Leo and Jean-Louis (JL), our hospital social worker, were in on the fun. The plans are to have our childhood malnutrition program data recorded, our pharmacy inventory, and then track the work of our community workers. Abby was able to walk everyone through the sample templates so they could familiarize themselves with #Collect.
Until
We're walking back to our motos Silianette tells me, quite plainly, "there's a woman in labor over there'". They wanted "the doctor" to check on her. When I get to the house I see this young woman laying on the floor, holding her pregnant belly, and another young woman sitting behind her so that she has somewhere to lean. She was term. First baby. She had been seen in the clinic for her prenatal visits and had not had any known complications. Her contractions started at 0400 that day. WHAT? G1P0 contracting for only 6 hours. Give me a break, take two Tylenol and sleep it off. I tell John that I'll make sure she isn't too far dilated, but that I think it'd be safest for her to take one of our motos back to the clinic and deliver the baby there. 6 hours. G1. #Laughable. Silianette was able to grab some gloves from her house out of her CHW supplies.
"Okay, I'm going to need to help you up into this bed so I can check your cervix" doesn't really have great direct translation into Haitian Creole. I think John basically said, "Get in the bed he's going to check your uterus." Message delivered. We help her climb off the floor and up onto the elevated mattress. "A little pressure annndd…." Oh boy. My body language said it all. Completely dilated. Bulging and tense amniotic sac. Still 0 station, but at this point I can't send her on a moto. "We're going to be having this baby here".
I look at my surroundings. Slabs of tin peppered with holes are over my head. Around me is a network of sticks and branches held together with dirt. The floor is dirt, tamped and swept smooth. A straw mat and blanket are still on the ground from where mom-to-be had been sitting. A child walks in carrying a plastic chair offering me a place to sit. A neighbor picks up my backpack and sets it on a table in the adjoining room. Clear off the schedule, we're gonna be here a while.
I step outside to discuss the plans with Abby and Jean-Louis. I have hand sanitizer, my stethoscope, and Silianette's meager supply of nonsterile gloves. Abby is quick to snap me out of my thoughts and keep me to task. "Yes, we need a razor blade, two pieces of string, and boiling water." Sure enough, within an hour Abby had sourced an unused razor blade and two eight-inch pieces of string, boiled them, and scooped them up each with a fork so that they could be kept sterile...ish.
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| Photos courtesy of @servehaiti on the gram |
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For anyone who has not had a baby it's a lot of misery and waiting. I didn't know when my training might be helpful, but basically I was sitting around talking and thinking. JL and Abby did take one of the CHWs to head off and start the data collection. Silianette stayed close, but took the opportunity to survey some of the nearby houses. John and I stayed in the house and learned about our 20 year old patient and her soon to be 0 day old son. The father of the baby had left shortly after they learned of the pregnancy. She had a strong support system including a sister whose toddler was absolutely petrified of me and a grandmoun who has had several of her own children. A midwife may or may not have been notified, but was not nearby.
Her contractions started before the sun came up that morning. Apparently, 4am is generic for "before the sun comes up". It could have been 8pm the night before for all we know, but we know it wasn't light out. I'm so used to having my patients walk in saying, "I started timing my contractions last night at 715 pm but they were only 12 minutes 32 seconds apart then, so I didn't come in, but then this morning at 2am I felt one that was extra strong, and I thought my water broke, but maybe I peed a little, anyways the contractions are 10 minutes apart and my doctor told me to come in if my contractions are less than 10 minutes apart. *breath* So, how far am I dilated?" #FirstWorldProblems
I encouraged walking, but she didn't have the strength for that. She tried to eat, but got sick. We treated some water and flavored it with Mio. That went down okay. She was breathing through her contractions and cycling every 2-4 minutes. Noon comes and goes. I have a few breakfast bars in my backpack, so John and I each eat one. A few of the kids running around outside share another one. I ask to check if she's made any progress, but she really hasn't.
I manage to break her water. Clear fluid. Hopefully this show can get on the road.
And this is where the panic and worry start settling in.
I set my phone out and play some music. At one point I had a "Push a Baby Out" playlist with Salt-n-Peppa, TLC, and Bieber, but I had to settle on whatever my Spotify favorites were. I look at my patient and the emptiness in her eyes. I look at my arms and my whiteness just glows in the dark hut. If this delivery does not go well I worry what this might due to the trust and relationship our clinic has with the community. Will I be blamed? Will the clinic be blamed? Such little control with so much pressure.
Another hour passes with her pushing with every contraction. I try to tell her not to push, conserve her energy. But you tell that to an unblocked pregnant woman and see what happens to you. I check again and get a sense of position. The baby is LOP and asynclitic. We try the floor again on all fours to see if that's more comfortable for her. Yes, the dirt floor. Her prayers start flowing. It's all rapid Creole, but I've heard them enough times to get a sense of what's being said.
She gets back into the bed. I check and we haven't made much progress. With her next contraction she pushes and I try my damndest to turn the baby's head using just my fingers. I have no way to assess fetal heart tones so every moment she's still pregnant is just taking years off my life. And yes, I know they aren't sound science, but when you've trained having that information most of the time then not having it is anxiety-invoking. Back to the floor.
Progress! We've delivered hair! I get to make the joke that all his hair slowed him up! It gets about as many laughs as you would expect. She's tired and over it. She makes slow and steady progress with each contraction now. The baby's crowning. Her pushes are near continuous, but she's running out of steam. I have her family help support her legs as I kneel on the dirt floor heart pounding. "Please God, healthy baby. Please God, healthy baby."
The head delivers and he's facing left. Shit. Tight nuchal cord. I grab for it and try to tell her not to push. I can't clamp and cut. It's tense. I don't think it would allow us to deliver through. With my second quick sweep with my left hand the cord slingshots from around his neck. Oh thank God. Head down. Shoulder. Back up. Grab the legs. POOF! Baby boy followed by a pile of poop. No screams. No tone. I grab the string and fumble through tying my long-forgotten surgical knots near the boy's umbilicus. Then another knot a few centimeters away. No time for theatrics. Grab the razor blade and put the business end against the cord. Saw away.
Separated, I turn to the bed behind me. My internal clock is both at zero seconds and a thousand seconds right now. Towels. Dry. Stimulate. I throw my stethoscope down... *bump * bump *bump * bump... right about the rate of a catchy pop song, so probably 120 BPM. That's good. Still don't see a lot of chest rise. I tell John to continue to vigorously dry the baby with a fresh towel as I tilt his head. No suction bulb, of course. Stethoscope back to the chest... same pace. No movement.
Seconds. Minutes. Who knows. I don't know about NICU attendings, but anytime I find myself in this situation I feel like I'm all alone and I have zero concept of time. Stimulate the body. Support the airway. Pump the legs. I'm almost about to lift him by his heel and slap his but when suddenly he sputters out series of coughs. Quite possibly the most beautiful sounds I've ever heard. I let out an audible sigh.
He's breathing. His skin slowly pinks up. And here comes the crying. I swaddle him and try to bring him to mom. She's not having it. Sister grabs him up and the rest of the family swarms her. I kneel back at mom, still on the ground, and twirl the umbilical cord around my right index finger. It comes easily. Seems to be intact as I inspect it on the straw mat. I'm not sure why but I do brief exam for lacerations or brisk bleedings. For real tho, what am I going to do? She has a small side wall laceration, but no deep perineal laceration. I apply a piece of gauze and hold pressure.
It's done. We have a crying baby. We have a mom who is standing up to put on underwear. We have an excited family rushing into the "delivery room". As I walk out the sun still hits my eyes. It's 4pm. I have John give Silianette instructions so the mom and baby will follow-up in the clinic tomorrow. Instructions if she has any further bleeding. Encourage her to breast feed as much as her body will let her. We say our goodbyes. Eat a small amount of the food they offer us. But the rain is coming and our moto driver wants us to get back.
Near perfect timing, Jean-Louis and Abby arrive at the crossroads at the same time we do. We course back across the Haitian landscape as storm clouds gather overhead. Back at the clinic we pay the drivers and find our food waiting for us on the dinner table. The rain falls as the sun fades away. The raindrops echoing off our tin roof with authority. The rain is welcome to the drought-stricken area, but I can't help but think of that tin roof sheltering that brand new baby.
