Day 10- Crazy, sweaty day at the hospital. Extreme jaundice, scary preeclampsia, births and a surprise.
Alarm goes off and I am excited to get up and get ready for work today. I put on my scrubs, drink coffee and eat a fried egg sandwich. I load my fanny pack up with everything I think I could possibly need and can barely close it. Gauze, sterile and non sterile gloves, lubricating jelly, alcohol swabs, hand sanitizer and snacks. I fill a water bottle up and grab one the bags and blankets my Mom made. I can’t wait to give it to someone. Stethoscope around my neck, name badge on and hair in a bun. I know I am going to be busy and hot so I don’t want to wear my hair down. It is time to go. Nervousness and excitement hit me. This is it. This is what I have been looking forward to the most. Emily and I take the short five minute ride to Ste. Therese hospital. It is very, very busy. People laying on the ground, with their pots of food and blankets. Joanne show us around the hospital and explains what the various buildings are for. We walk into the maternity unit and a ‘triage’ is right there. We were told that last month a nurse came down for 6 weeks to try and implement a triage system as there really wasn’t one. A woman was waiting to be seen and had a seizure. Both her and the baby died. They knew they needed to fix how woman were assessed when they arrived to the unit. Unfortunately, it didn’t last long. After the nurse left the country, the hospital and the midwives didn’t do what she set up to do. It is still there but not like she had implemented and trained the midwives to do. The triage is not triage today though. There are 4 woman there. 2 laying on examination tables and 2 on the floor. They are postpartum and have their babies with them. It was a very busy night. The postpartum room is full. They have to wait for woman to be discharged so they can move. Emily and I do vital signs on all the Mom’s and babies there. When we are done, Emily walks over to the postpartum areas to check on Mom’s and babies. She walked past a baby and noticed it was severely jaundiced. It has no tone and is posturing. She starts to talk to the Mom about it and encourages her to breastfeed. The Mom mentions she cant because she has some ‘heart’ issues. Emily takes her blood pressure and it is in the severe range. She could have a seizure at any moment. She complains of a headache and awhile later when her urine was dipped it had 4+ proteinuria. That means that the amount of protein in her urine from preeclampsia is critically high. She is very short of breath and is tachycardic. This Mom is up and walking around doing things that the hospital is requiring her to do. We look at her chart and all the blood pressures charted were all within normal limits. We think they weren’t even doing them. Emily tells the nurse that the baby is extremely jaundiced and the Mom needs antihypertensives asap. She leaves and comes back to the maternity unit where I am. She tells me what she found with the Mom and baby and we plan to go check on both of them later. When we walk into the unit there is a woman who is loudly moaning, in active labor. There is another woman directly across from her, facing her, in a paper gown. She has unfortunately had a fetal demise at 42 weeks and needs a cesarean section. She is having one because she has a vertical incision on her uterus from previous pregnancy and cesarean delivery. She can not have labor induced because of that. It is such a horrific situation. Here she has lost her baby. In the same room she is facing and watching a naked woman actively laboring her alive baby. I feel absolutely empathetic to her and I wish I could take her somewhere else. The active labor patient needs to be prepped for cesarean section. I ask why and I am told it is because she is HIV positive. I couldn’t understand why that was an indication for cesarean delivery. I later find out that the obstetrician wants to do cesarean delivery so he can give her a bilateral tubal ligation, ‘tubes tied’, against her consent!!! He doesn’t want her to become pregnant and ‘infect’ any babies. Super upsetting. After all the prep work including 5 attempts with an 16 gauge IV catheter, shaved with a surgical blade, foley catheter placement and prophylactic antibiotics given(way before headed to the OR, normally given within 1 hour of incision), I give her labor support carefully due to her HIV positive status. It is not my first patient with HIV and I have been trained well how to care for patients with blood borne pathogens. I support her during and after her pre-op for about 2 hours. She is pushy but has gone from 6cm to 7cm. She isn’t changing quickly and the another young girl next door is getting more vocal. I head over to her to provide support and I find out she is 10cm and ready to push. While she is pushing, the HIV positive patient goes to 10cm. It’s okay because she was waiting for the OR to become available and now she could deliver vaginally. I had told Emily that she will likely deliver before she goes to the OR and I secretly hoped she would. How could an OB tie someone’s tubes against her consent!!! The girl I am with is a 15 year old primip(1st baby). She has total control and is quiet. I encourage her and tell her how proud I am of her. The midwife needs to go deliver the HIV positive multip(someone who has had at least 1 baby before) and is literally 5 feet away from me separated by a half wall. My patient doesn’t push long and she starts to crown. I tell the midwife to come, and another midwife comes for the delivery. She provides perineal support and eases the baby’s head out. The shoulders come very easily and so does the body. She places the baby on the Mom’s abdomen and Emily and I stimulate the baby to cry. Beautiful delivery that I will remember for the rest of my life. We wait for the cord to stop pulsating and clamp it twice. I cut the cord and we give intramuscular pitocin. She checks to see if the placenta is ready to deliver. It is ready. She asks the patient to push and she gently pulls on the cord. The placenta easily comes and when most of it is out, She slows down and twists the placenta/membranes. The membranes easily came after. Fundal massage was given and it firmed up quickly. I had just labored and delivered a baby for the first time in Haiti. I couldn’t have been happier.
Later, after she was all cleaned up, I brought her one of the blankets my Mom made. I asked the interpreter, Shelly, to tell the patient that my Mom had made the blanket for me to give to new mothers in Haiti and that I was proud to give it to her. She smiles and says ‘merci’ or thank you.
We go check on the Mom and baby from earlier. Note much has happened!!! The nurse acts like she wasn’t told about the blood pressure or the baby. But even if we didn’t tell her, you could see from across the room that the baby was as yellow as a sunflower and the Mom could barely breath. We were so upset. Is this why woman die in Haiti? We check the blood pressure and it is still severely elevated. Finally, the nurse calls the pediatrician and the OB. The doctor won’t even see the baby til it is named and the chart has been made. This baby likely has Kernicterus which causes athetoid cerebral palsy and hearing loss. Basically severe brain damage. The way the baby was acting it likely had something wrong with her brain. No tone, eyes rolling back into head, body and neck arching back, not crying when painful procedures like an IV were done, not eating. But the doctor won’t see her until we get a chart made from the chart building. Isabella gets started on that while I give the Mother lasix for her pulmonary edema and hydralazine and metoprolol for her blood pressure. The midwife had pushed some magnesium earlier but noticed the mother was short of breath so she thought the mom was having a reaction to the magnesium and stopped it. The Mom does feel a little better after she received some of the magnesium. She is getting transferred to the medical internists unit. Shelly and I take the baby finally to the pediatric unit, not the NICU, and get it situated. Orders are written for a bilirubin test as well as other things.
Knowing that the baby and Mom are getting some help finally, Emily and I leave the hospital with our translators, Shelly and Isabella, and go back to the MFH house to eat lunch. Emily and Shelly first go to 8 pharmacies to look for medication for the jaundiced baby. Emily pays for it and they bring it back to the hospital. After lunch, Emily and I are eager to get back to the hospital as it was pretty busy and we want to help. Isabella accompanies us back. We really want to know how the Mom and baby are doing.
We take the mototaxis back to the hospital. We go and check on the baby. She has the IV fluids that Emily bought infusing. Not much has changed with the baby. I ask what the bilirubin level was and the midwife looks and realizes that it hasn’t been drawn yet. We take the order for the lab to the lab so they know to come draw it. Then we go and check on the Mom in the acute care area. She is smiling and feeling much better. She thanks us and is happy that we helped her. No more shortness of breath or headache! While we are in there, a family is loudly talking over a woman. I had to take a second look to realize they were praying over here. She unfortunately looked as if it was her final hours. Isabella tells us alot of people in that unit are HIV positive. I feel a tap on my shoulder and turn around to two young women. One of them talk to Emily and I. Isabella talks back to her and then translates for us. These ladies are begging us to assess their Mom who is very ill. They see Americans and think we can help her. Isabella explains to them that we are Obstetrical nurses and we wouldn’t be able to help her. I empathetically apologize to the ladies and tell them I wish their mother well.
We go into the maternity unit and I see a woman that was walking around the courtyard earlier. She is now in active labor. Emily and I provide compassionate labor support to her. This is something the midwives do not provide. I mention to Emily that she has a large belly ‘she has a big baby in there.’ The woman is doing well and before long she starts to push. We instantly see head. Emily was the only one with gloves on so I said ‘Emily you have gloves, I don’t.’ We call for the midwife and the baby is crowning. The midwife is right there and delivers the baby and places her onto her Mom’s tummy. I give pitocin intramuscularily. Emily reaches up to the fundus. I will never forget the look on her face. “Jessica, feel this.” But I instantly knew. I feel her belly and there is another baby in there!! Oh my, what a wonderful surprise! We tell the midwife and she does an examination while I doppler the fetal heart beat. Strong, normal heartbeat!! The baby is head down and we break the water. She starts to push and the head crowns within a couple pushes. When the head fully emerges, the anterior shoulder gets a little stuck. We encourage Mom to push harder. We try to wiggle the shoulders out. It is not working. After a few more pushes, the midwife grabs the head and gives it a pull. It is still stuck. The Mom adjusted her hips and pelvis right about that time and the shoulders easily came and the baby girl was placed on her Mom’s tummy. The baby doesn’t look good. It is limp, blue and has no respiratory effort. I stimulate her to cry over and over. Emily tries to as well. Still not breathing. I am given a bulb syringe and I suction the baby’s oropharynx. I listen to the babies heart beat and it is okay at minute one. Still not breathing though. We continue to stimulate and suction the baby. If I was in the hospital I work at, I would have started giving the baby PPV or positive pressure ventilation, or forced oxygen into the lungs. But I don’t have that in Haiti and I need to use what I have to help this baby. I listen to the heart beat again and its about 90, low but not low enough to start CPR. I start to bag the baby. I place the ambubag over her mouth and nose and start to squeeze. I can’t get a good seal. The bag has some remaining water in it from being cleaned. It is not working. I review in my head what steps to take, lightening fast. I need to readjust the mask. I do that and try again. Out of every 4-5 breaths I give, maybe one of them goes into the lungs. Still no respiratory effort after a minute of half ass bagging. I listen to the heart beat, very slow. We are loosing this baby. The baby is about 2-3 minutes old. If we were at the hospital we work at, I would’ve started CPR. The midwife cuts the cord and tells us to take the baby to the NICU. HUH??? What? We have to run this baby outside and down the hall to the NICU? Okay, whatever we have to do to give this baby a chance for survival. Emily tells Isabella to come with us. We need her to translate. Emily grabs the baby and we make a careful run for the NICU. We come out of the maternity unit and rush to the NICU. She takes a breath on the way there. We rush into the NICU and alert the nurse. We place the baby down and she takes over. She stimulates and dries the baby. Nothing. I begin to bag and mask the baby but notice her abdomen is filling up with air. The nurse tries to place a blood oxygen saturation monitor on the baby. She tries 3 different probes because none of them are working or sticking to the baby’s skin. I don’t know why she is so focused on that. I tell Emily that this is a situation where you need to look at the patient and not the monitor. We suction the baby again and bloody secretions come out of her nose. Baby starts to do some shallow breathing finally! She slowly starts to come around and become pink. Phew! She is going to make it. I leave Emily and Isabella there and go to tell her Mom that the baby is breathing and doing okay. She is relieved. I notice that the Mom is having some minor vaginal bleeding. The midwife had delivered the placenta while we were gone and said that the patient didn’t like her doing fundal massage. I said we need to. She is at risk for postpartum hemorrhage because she had twins. I give her a gentle yet firm massage. Blood clots come flying out and land on the floor. I massage till the bleeding slows and her fundus is firm. Emily comes back and I give her a heads up about the bleeding. She continues to have some trickling of blood. We feel her belly and realize her bladder is very full. Emily places a 10 french catheter and drains at least a liter of urine. It just sits there and drains onto the pad she is sitting on. Her uterus still is firm and the bleeding slows down.
The midwife is getting ready to leave and says bye to us. I have read alot about this midwife on the MFH website. Her name is Genette and she is one of the first trained midwives in Haiti. Now she is a preceptor. She is so beautiful. I ask her if she has checked the patient for a laceration. We are concerned because she still has a constant trickle of blood. She puts her stuff down and places gloves on. She examines the patient and she has no tears! But she is still bleeding. I say we should give the patient another dose of pitocin and she agrees. This doesn’t help and she is still bleeding. I have misoprostol in my pocket and ask the midwife if she wants me to give the patient some. She says yes and I give her 800mcg per rectum. We give it time to work and check again, are still bleeding. We can’t give her methergine, a stronger medication, because she has elevated blood pressure and it will make it go higher. We are kinda stuck. They don’t have the strongest medication in the hospital which is hemabate. So, I ask the midwife if she would like to do bimanual massage. This is where she places one hand, usually the whole hand, into the vagina and massages the fundus with the other. It can help evacuate any clots in the uterus or firm up the lower uterine segment. She gets out a few clots but nothing major. The poor patient is having such a hard time dealing with all of this. She isn’t given any pain medication and is begging us to stop. But we can’t. If we stop doing all these things to her, she could bleed to death.
After the bimanual massage, the bleeding is the same. I am starting to get a little nervous. Emily and I try to guesstimate how much blood she has lost. We think we are at about 1500mls at this point. This Momma is very small, maybe 4ft 11in. She doesn’t have much blood volume because of her size. I look at her chart to see what her hematocrit was upon admission, 28.4. This is low. A woman who is not pregnant has a hematocrit anywhere from 35-45. When women are pregnant it is usually in the 30-35 range. With it already being low and now she is hemorrhaging, we don’t have alot of wiggle room before she would need a blood transfusion. I ask Isabella if Ste. Therese has blood we can give her if it is needed and she said yes. That is great news!!
We decide to give her more pitocin. We fill a syringe with 10 units of pitocin and stab the top of her IV bag and inject it. We shake the bag and open the IV up to flow quickly. We wait awhile and check her bleeding again. She expels alot of clots and blood. She has a firm fundus so what could be causing the bleeding. The is no vaginal laceration but maybe a cervical? I ask the midwife if she has called the obstetrician yet. She said no but she would call now. I ask if she wants me to give more misoprostol. I had rechecked the patients blood pressure because she was feeling light headed and dizzy. She asked us to take her baby because she was weak. This wasn’t a good sign. Now the patient is becoming symptomatic from her blood loss. The blood pressure is still elevated, 140/90’s. So I still couldn’t give methergine. Midwife tells me to give her one more dose of 200mcg of miso, so I give it. We wait a few minutes and check again. Still bleeding. It isn’t a whole lot, but she still is. Emily and I have a talk and put our heads together. What could be causing the bleeding? What haven’t we tried yet? I ask if the midwife wants more pitocin. She can have more. She said yes, give her 1 more dose of 10mul of pitocin. So I get another bag of ringers lactate and stab a needle with pitocin and inject it into the bag and shake it up. We wait a few more minutes and check. Still the same. Tickling blood, enough that we are changing the pad under her every 15 minutes or so. But, maybe we are getting on top of it as it isn’t as much as when this started 2 hours ago. We realize that her bladder is getting full from the IV fluids and so we place another catheter. This time attached to a bag. She will keep it in. Emily has been trying to get the patient to breastfeed. It can help with the postpartum hemorrhage. She keeps telling us she doesn’t want to do it plus the midwives keep taking the baby to do all the stuff to her and want to give her to the family. A normal practice in this hospital. But we ask that they don’t take the baby so it can breastfeed. It is 2 hours old and hasn’t feed yet. While we wait, Emily and I start to do nipple massage. If she won’t feed the baby, maybe nipple stimulation can help with the bleeding. We are literally trying all we can to stop the bleeding other than surgery. After the catheter placement and nipple stimulation, we watch the bleeding for the next 15-30 minutes and realize the hemorrhaging has stopped!. Oh what a relief. We saved this Momma from bleeding to death.
Emily and I walk into the room where our water is and I drink the whole bottle. It is extremely hot and humid in the maternity unit and I have probably sweated out everything I had drank and more. We snap a photo of ourselves to document the achievement and the sweaty look. We both agree that we are buying some adult drinks on the way home as we have earned it today. We helped a severe preeclamptic, a critically ill baby, 1 delivery each, surprise twins, neonatal resuscitation and a postpartum hemorrhage. What a day. I tell Emily that we likely will never have to do anything like that again in our career.
We walk out of the hospital and Isabella has already alerted our mototaxi driver that we are ready to be picked up. Emily and I get on one and she puts on her googles and I put on my sunglasses. I start to sing the song ‘I wear my sunglasses at night’. We don’t want dirt and dust to get in our eyes while we ride back. We get dropped off and walk over to the small shack across the street from the house. Joanne is there and we are happy to see her. She can translate for us and tell the man what we want. One bottle of rum, 4 cokes and 1 beer. $19 is the total. We share the cost and walk back to the house. I open my nice cold beer immediately and drink it. It tastes so good and refreshingly cold. The girls ask how the hospital was. We both say it was a tough day at the office but we need to shower before we can explain. I haven’t peed in hours. I assume it is from the lack of water but also I have 5 layers of sweat on me. My scrubs were stuck to my skin most of the day. There is one fan on the ceiling in the labor area but they turn it off when babies are born. They don’t want them to get cold. I kinda chuckle at that because it is probably over 85 degrees in the hospital and the humidity has to be over 90%. Plus ,we put the babies skin to skin with their moms. So the room gets really hot and we get very sweaty.
After I shower, I eat dinner. I wait for Emily to be done and then Donna and Shani come out to the table with us. We tell them about our delivery and postpartum hemorrhage while we drink rum and coke. They are happy we saved the lives of the mom ‘s and babies today and I get a little emotional as I say ‘When I started this adventure eight months ago, these woman just became pregnant. I said then that if I can save one family from a catastrophic outcome, then I have achieved my goal.’ Today, I achieved my goal. More than once. These women have such horrific odds, they have a high chance of dying, while creating life. Their babies have even worse odds at a chance at life.
Emily and I stay up a while longer chatting. The coke and adrenaline has us awake. We have an early morning so we finally say goodnight. I take my malarone and climb into my net covered bed. I blog for awhile and then play on my phone til I am sleepy. Good night Haiti
