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.