Tuesday, March 17, 2009

Birthing Stories

2/18: Today I got a chance to work with nurses in delivery again. I am fascinated by childbirth and I really want to work in the delivery room. I walked in and there were two women on the laboring tables.  The women were completely naked and each sitting on their own respective yellow trash bag. The trash bags are meant to catch any leaking amniotic fluid or unexpected excretions. My favorite nurse was sitting in the room watching the women. I walked in and took a seat on the counter in the corner so as to be out of the way.  The nurse and I just sat in the room talking about our families, childbirth, and men. As we sat there chatting the two women continued with their labor. I noticed that the women were having their contractions at the same moment. There are no monitors here and the nurses listen to the fetal heart tones with a fetoscope. This instrument looks like a cone and they just place it one the woman’s abdomen and listen. General monitoring includes listening every hour and doing vaginal exams every 4 hours. As the pains increased the women began walking around the room and holding their backs. Every few minutes when the pains came they would reach for the bars of the bed and brace for the next wave. The woman were completely naked walking around and pausing every now and then with the pain. The nurses let me do some of the vaginal exams on the patients so that I could learn. One of the women was HIV positive and the other was HIV negative. The mother without HIV had a considerably larger belly but both moms were at term.

At one point I was sitting on my own in the room while the nurse went to go care for a lady next door. While I was sitting there alone one of the patients surprisingly vomited and ruptured her membranes in the same instant. It was quite a surprise. The vomit was bright green and the amniotic fluid splashed onto my foot. There are times when crocs are good and other times when I wish I had chosen the shoes without all the holes in them. The first woman to deliver was the woman with HIV. I was assisting the nurse with the delivery and when she handed me the baby I was scared. It wasn’t breathing and looked very purple. I did what I knew how to do to resuscitate the baby. I used the bulb syringe to suction any of the amniotic fluid that might be making a breath difficult. I rubbed his back and hoped to stimulate him to cry. Nothing. The nurse quickly took the baby from me and brought him into the other room to be resuscitated. I was left alone with the laboring woman and she had not yet delivered her placenta. I stayed with her to complete the work of delivery. The placenta came out easily but the woman had a rather large tear. I waited for the nurse to return so that she could repair it. What had happened to the baby? Did it take its first cry yet?

After this delivery the other larger woman approached delivery quickly. The water had broken and the fluid was meconium stained. Meconium is generally an indicator that the baby is under stress and that the labor may be complicated. It is a greenish color and makes what is normally an essentially clear amniotic fluid tinged with a yellowish color. The head seemed to be stuck and the nurse was yelling at the patient. I couldn’t understand what she was saying but I believe it was something to the effect of “Push. Stop crying and Push”. The woman seemed to be giving up. The baby was centimeters from delivery and she just couldn’t push. The nurse was frustrated and as she was yelling at the patient. The nurse started using her hand to coax the head out. It seemed almost as if she was trying to get a good hold on the head so she could pull it out.

I was dumbfounded. Finally the head did come out and like the first birth the baby didn't cry. The baby was purple. Limp. I suctioned and suctioned. Nothing. This time I rushed the baby to the resuscitation room. The resuscitation room is no different from the delivery room really. There are no fancy miracle machines or treatments to save babies, it just allows the provider a chance to do what they can in a more controlled and quiet setting. The baby was very strong and kicking but it wasn’t breathing well and hadn’t cried. So the nurse pushed a foot pump across the floor to me and asked me to start pumping. My foot moved quickly back and forth on the pedal to power the suction. The nurse suctioned the baby’s nose, mouth and even feed the tube down the child’s trachea to get any secretions that were deeper down.  She did it rather forcefully and the secretions became slightly bloody. The baby wasn’t crying but was so strong and it was at least two times the size of the first baby. But she was a gray color. The oxygen we were giving did seem to pinken her up a bit. I wished that the other doctors were in the room to help us and I asked the nurse if I should go and get them. She quickly responded yes and I left the room in a hurry to find help. I walked to the conference room and popped my head in to look for Sebaka or Fadya. I saw Fadya and from the way she looked at me I realized that I was still wearing the plastic apron that the delivery nurses wear and that it was splattered with blood and that my shoe was covered in blood and amniotic fluid. She sensed the urgency in my face and followed me. As I was giving her the birth history we walked into the room. She was there and yet there was nothing we could do. We took out the intubation equipment but realized that even though we could visualize the vocal cords we had no intubation tubes and would not be able to suction the amniotic fluid out of her lungs. So we stepped back and looked. The baby was still grunting and hadn’t cried. There was nothing we could do. So we left the room and left the baby in the care of the nurse.  I came back a few hours later and found the baby alone on the exam table. The baby was crying now but still rather grayish and the nurse had taken off the oxygen. 

Thursday, February 19, 2009

Malealea: Horse Riding

Week 4

Morala: a basalt rock a laboring woman carries with her when leaving your home to make it to the hospital before you deliver.
I was undressing a woman in the labor room and I heard a clunk on the flour. I looked down and thought maybe I had dropped my reflex hammer. Instead when I looked on the other side of the bed I noticed a rock on the ground. I couldn’t imagine why this patient would bring a rock with her to the hospital. I picked it up and showed her the rock. She motioned for me to put it down on the table for her. When the nurse came back I asked her what the rock was for and she explained to me that women bring the rock with them from home. It is a special rock that they keep in their clothing until they get safely to the hospital. It is supposed to protect them from delivering the child on the way to the labor room. Once they get to the hospital the patient no longer needs the rock and discards it.
I have learned so many things in medical school and many of them are things I will never see. I saw one of those cases today. A 16 year old was brought in by her mother. She was in active labor. She was known to be pre-eclamptic. Pre-eclampsia is actually a common medical condition in pregnancy the world over. I have seen many patients in the US that present with swelling in their legs, protein in their urine and high blood pressure. I have cared for these patients and managed their deliveries. There is a certain sense of urgency in these cases. The babies need to be delivered rather quickly to avoid devastating outcomes. When my patient presented in labor she complained of headache and should have been started on treatment right away. Instead she was admitted and allowed to deliver. It wasn’t until after she had given birth that she had a seizure. She was seizing for quite awhile before she was finally started on the correct medication. After her first seizure she was no longer responsive. She continued to breath but she no longer had the ability to speak. The first time I saw her was the day after her first seizure. We checked her medications and discovered that the maintenance dose of the medication to prevent future seizures had not been given. The patient was also significantly anemic from all of the bleeding during delivery and needed a transfusion. Her blood type was O+ and there was no blood for her. Not one pint. Not even in the main blood bank in the capital of Lesotho. So there was nothing we could do. We asked her mother who was there with her if she could donate blood and she informed us that she was herself 6 months pregnant. She was holding her 16 year olds baby and rocking him back and forth as we talked. In Lesotho there is only one official blood bank and it is in Maseru. The government hospitals are very wary about blood banks given the pandemic of HIV. It can be completely frustrating because so many patients are anemic and in desperate need for blood transfusion. So we had to transfer this patient to the capital hoping that they would do something to improve her outcome but knowing that they would no be able to give her a transfusion and fearing that she would continue to be unconscious. This woman had had the dreaded outcome I had learned about in school. Something that I had never seen in the US. This was the end result of a seemingly simple complication of pregnancy. Who would care for her new baby boy?

Today we talked about abortions and I was amazed. In one day we had eight "incomplete miscarriages" and you wonder why. I have been talking with the doctors here and it seems that women seek out alternative abortions frequently and when they go wrong is when the hospitals see them. The doctors have said that on vaginal exams of these patients they find matches and leaves. Sometimes they can tell that the cervix has been manipulated and sometimes they have seen uteri that are completely punctured through. What has been happening is that the nurses watch the doctors do vacuum aspirations or D+C and then use this experience to open up their own practices outside of the hospital. They can then offer the abortion services at a much cheaper rate and in a much less safe environment. In the capital hospital one of the janitors was doing abortions in a hospital room and then just sending them to the doctors in house when things went wrong. This is very frustrating.

Wednesday, February 11, 2009

24 school children oh my!


The highlight of my day today was at the outpatient clinic. We showed up at 2pm ready to see patients. Caitlin and I being mentored by a doctor visiting from Ohio State. When we came in the door one of the assistants approached us and told us that she had 24 little children who have all had fever and cough since Sunday. The children were boarding at the primary school and had all caught the same illness.

I looked at her unbelievingly and thought Really? 24?. I suggested that we have them come into the room 4 at a time so we could see them in groups. The first four came in and they were so shy.  They each held their green Bukana with a temperature written in it that had been taken by the nurse. They weren’t actually very sick and only a very few of them had a fever. Even so, Caitlin and I examined every single one of them and wrote them all for Tylenol syrup.

The matron had these children very well disciplined and they were so good about letting us listen to their hearts and lungs. They also were very good about letting us get a good look inside their mouths. Probably seeing their peers go through the same thing and not come out crying made them feel a little more at ease.

One of the cutest was a little girl named Palesa, which means Flower in Sesotho.  She was only 2 and a half and was dressed in a green and yellow school uniform. She had been watching us examine the bigger children and she walked up  to my chair and without request began taking deep breaths just like she had seen the other children do. I didn’t even have my stethoscope out yet to listen to her lungs.  It was such a joy to see so many healthy young children at the end of a hard day.