Wednesday, September 30, 2009

My First Vanuatu "Cesar" and Namesake

I've had a few very busy days at the hospital, the kind that you just work through lunch because there are so many women waiting to be checked, admitted, or are about to push their babies out. A few women and their experiences are to share......

I worked with a young, first time mom all day Monday and returned Tuesday to find her still at the hospital in labor. This was one of those primip (first time) births....... all you birth related folks out there know exactly what's to come.

Her latent labor started Friday and she came into the hospital when her contractions picked up around 8 am Monday morning. When I first checked her that morning, her baby was still floating very high in her pelvis, completely unengaged. Her cervix was dilated to about 3 cm and it was partially effaced (thinned out). Not much change happened over the course of Monday and when I retruned Tuesday she was 6 cm and her baby was engaged in her pelvis, all good signs that her labor was progressing. We suspected that her baby was also positioned posterior, which is a difficult position for any baby to come out, but especially with a first timer. As Tuesday continued, her contractions were irregular and spaced out, so the doc recommended we rupture her membranes and start an IV drip with syntocin (aka pitocin) to augment her labor. Upon rupture her water showed moderate meconium (the babe's first poop- a sign of some form of stress somewhere along the way). Her contractions did pick up more regularly with the Syntocin, but she started having the despised uncontrollable, premature urge to push while her cervix remained at 6cm. This mom was exhausted and as I have seen SOOOOO many times before with this same situation in the States, I was was hoping I could see a different outcome. Alas, the doc decided it was time to do a "Cesar"- C-section. I felt the same way I always do after these long labors, often several days, ending in a Cesar. I was able to scrub up for the surgery and receive the baby after he was born. There was a fabulous anesthesiologist from Australia running the show- a very personal, kind being, just the kind of person you want to be watching over you while you're having major abdominal surgery.
The surgical theatre was an interesting experience. Although I've never attended a Cesar in the US, I have observed them while in Costa Rica. This experience seemed overall the same, but it seemed more relaxed in lots of ways- not in safety terms, per se...... hmmmmm, not even sure how to describe the differences. I looked up at one of the surgery nurses in her scrubs, her mask, and her hair wrap, and amongst all the covering, there i saw a little white flower tucked behind her ear. Yes, in a way, that seems to sum up the experience...... if that makes any sense at all in this two dimensional story.
The surgery was a success and a sweet baby boy who had been not only posterior, but had a hand up near his head with the cord around his arm, was born..... gives some reasons as to why he couldn't come down or turn around to get out vaginally.

The Cesar rate here is around 5%, on average about 10 Cesars per month. During the 24 hour period leading up to this young mama's surgery, we had 2 others, filling nearly a third of those for the month in one day. One Cesar was for fetal distress with every contraction, and another for a pair of twins who had thick meconium and were showing some distress. As always, things seem to go in waves, and often in sets of 3.

Yesterday, Elias and I spent our first day together at the hopsital, as he just arrived on Tuesday afternoon. It was lucky that he was there because only one of the two midwives were there because the other had a family member pass away. So it was going to be just me and the other midwife, until Elias showed up. We had 4 births between 11:30am and 3pm. I caught the first 2, Elias took the next, and a student nurse who came on for the next shift took the last. I particularly wanted to write about the second mom that I worked with because she is what we call a Grand Multip. This was her 9th pregnancy. She has 7 children: 5 boys, 2 girls, and one of her pregnancies ended in a stillbirth due to a cord complication. She was planning a tubal ligation after this birth, so this was her last baby and she had recently found out that it was another girl.

She was 3cm upon arrival in the morning and when we watched the babe's heartrate on the CTG machine, we saw some decelerations with her contractions. At that point, her contractions were about 10 minutes apart, but it was undeniable that the decelerations were happening with the contractions. We moved her from side to side, started an IV to give fluids (especially as a preventive for postpartum hemorrhage since a uterus that has been stretched 9 times may have less ability to contract after the birth to stop the bleeding), and we broke her waters to see if there was meconium in her fluid, which there was a light amount. We kept her on the CTG to monitor the babe and meanwhile ran off to catch the first babe of our shift. At some point the midwife moved her into the other birth theatre, and she was just walking around, having a few more contractions here and there. I was finishing up with the postpartum events of the other babe, fondly referred to as "stickem and scalem"- giving them their injections and weighing them- when I heard lots of commotion and moaning. I ran back into the theatre literally just in time to put my hands on the babe's head as she came out, to keep her from shooting out like a cannon! She took awhile to come around and breathe, but within a minute with some good stimulation, she was breathing fine. I took her out for her pokes and to be weighed and when i returned, the mom told me that she was going to name her baby Molly. I think after 9 kids she either ran out of names, or she appreciated my care ;) I told her that there was a high probability that this little Molly would be a midwife someday, since there are so many of us "Molly the Midwife" from Bastyr. Although some women here have no interest in seeing their babes after they are born, this mom, even after 8 other births, was excited to see and asking for her baby. That's me and this little "Molly-the-Midwife-to-be" while she received her first swim-swim (Bislama for bath)!

Today I'm taking it easy and heading out for a kayaking adventure..... with a full moon in the coming days and the change in pressure we are experiencing, it's likely to make the babies drop!

Sunday, September 27, 2009

The Vasovagal Reflex.... Narrowly Averted! and more...

Friday I was at the hospital for most of the day. I walked into the hospital and heard a woman in the "theatre" pushing her babe out. There are several student nurses here who are also trying to get experience, so one of them was managing that birth. So I took the opportunity to just observe and give support as needed. Well the first thing I noticed was that it was particularly hot and stuffy in the theatre that morning..... this was the third birth that had happened since midnight, so there was the smell of birth in the room.

The AC wasn't working and I was standing next to the baby warmer. I felt just yucky.... wooozy..... and could feel the vasovagal reaction building. For those of you who have had the pleasure to be around me in the perfect circumstance when such a reaction has occurred, you can see it written all over my face, right? Pale as a sheet and a glazed look in my eyes. Yes, I've been a fainter my whole life, since the time when I was touring the hospital in my kindegarden "Brownies" troop (aka pre-Girl Scouts) and the smell and the warmth of the room was too much and down I went for the first time. As a 5 or 6 year old, that was a bit terrifying, especially when I awoke in a wheelchair thinking I might be dying. Well, I wasn't that time, nor was I the several other times that the lights have gone out and the sounds faded away.

So, you might be thinking, how is it that a fainter can be a doctor, yet alone a MIDWIFE, with all that blood and stuff? Well, I'll tell you I've never once felt faint at a home or birth center birth. It is something about the smell and environment of the hospital..... since I was a child, when I was in Costa Rica, now here in Vanuatu. It's undeniable and I am reminded how grateful I am that I won't be walking into the hospital every day of my working life as a naturopathic midwife. Yes, I prefer the hardwood floors, and cozy couches, and back porches, and sunny kitchens of home births. But I am here to work in the hospital, and I know that feeling was only temporary until I adjusted to this new environment, including the tropical heat. To shake it off, a cup of hot tea (per one of the Sista's recommendations) brough the blood and color back into my head, keeping me off the undesirable floor of the birth theatre, and I felt fine the rest of the day :)

On another note......
I got to give a sweet, 4060 gram baby boy a bath (a babe this size is a novelty of sorts here!) This is something that we don't generally do at home births since we test our moms for blood-borne pathogens and we value the coating that the babe is born with as protective to their delicate skin- so we don't routinely recommend bathing newborns immediately. But as the New Zealand midwife (who's here helping for a couple weeks while on holiday) said, this is the "hepatitis bath." It is given to wash any bodily fluids off since prenatal Hep. B testing is not done here. Ideally it is done before any injections are given, to prevent transmission from mom's bodily fluids that are on babe's skin, but it is generally done after the injections are given here. I am not sure why, perhaps just based on timing and to return the baby back to the mama to breastfeed after the injections are done as quickly as possible.

After finishing at the hospital, I headed down to the Vila harbor to do the "swimming course" in the ocean (that's the harbor above). This involves swimming out around a bouy, past a floating helicoptor landing dock, then if you're really feeling it, out to a large rock. Luckily I brought my swimming goggles, sexy as they are, because it was relatively shallow for most of the swim and there are a lot of fish and coral to see. Swimming in warm salt water is soooooooooooooooooo different from Lake Washington!!!!!! I'm really enjoying the added bouyancy.

Okay BEEF lovers! Apparently Vanuatu has some of the finest organic, grass-fed beef there is because that's just how all of the cattle are raised here. Some of my Australian Baby Doc friends were headed to the Raging Bull Steak House for dinner and live music. Yes, they convinced me to go to the steak house and yes, I ate a rump steak. And yes, enjoyed it. Sorry veg friends. Can't remember the last time I ate a steak..... tropical islands get you doing all kinds of out-of-the-ordinary things.....

Like SCUBA DIVING! I started my open water scuba certificate program on Saturday. After all, there is so much to do away from the hospital. This involves some classroom theory time, some pool time getting used to the equipment, and 4 ocean dives. Of the few people I encountered in the States who had acutally heard of Vanuatu (besides Bastyr and midwifery folks), 100% of them knew about this tropical island nation because of the incredible diving here.

well, good thing I bought that all-inclusive traveler's health insurance the day before I left, 'cause I really didn't think I would be diving. But I am, and I did my first ocean dive yesterday. What better souvenir to bring back from Vanuatu? We drove out on the boat to a beautiful cove, suited up, and walked off the boat into the ocean. The experience of breathing under the water is just incredible, and a bit intense! I felt I was dreaming, being down on the ocean floor, with the rhythmic sound of breathing in and out through my regulator. I love the feeling of putting my hands behind me and just giving the slightest kick of the flippers..... then sailing through the water amongst the fish and coral, supported by the water. Magical! Our first dive was 10m for 42 minutes. Not bad for a first time! Some of you know that I am actually part mermaid, so this experience was particularly fabulous. I need to learn more about identifying the tropical sea life, as it is all new to me..... sea anenomes, lots of colorful fish (neon blue to flourescent yellow), a huge clam, huge eels..... sorry i don't know the names yet. I have at least 3 more dives to work on it.

I postponed my other dives til later this week because my right ear had trouble clearing as I descended yesterday, and then was very clogged for the past 24 hours. It's feeling much better now, and one of the Baby Docs is gonna take a look in it tomorrow at the hospital.... I infused some garlic in olive oil and had a friend funnel it into my ear to help loosen any wax and prevent any organisms from multiplying in there (garlic is wonderfully antimicrobial). These other Baby Docs sure do think we naturopathic folks do some FUNNY things. Garlic ears? Clay packs on an infected foot? B vitamins to keep the mosquitos away...... I've forgotten just how "out there" this stuff is for most people. But this is what we're working with here, the basics, and what I always start with, tropics or not. I guess that's what traveling is good for..... to give you some perspective outside the normal bubble we create for ourselves. On that note, off to bed for an early start at the hospital in the morning.


Wednesday, September 23, 2009

First Day and First Catch

Just back from my first day in the hospital. A nice mellow morning of monitoring a women that was being induced since her dates showed she was over 42 weeks, cutting and folding gauze, giving BCG vaccinations (for tuberculosis) to the babes before discharge, and getting to know the midwives, nurses aids, and the general feel of things around here.

The woman whose labor I monitored today was very sweet. She speaks perfect English, which was a nice way of easing me into my first birth here since I could actually communicate with her. This was her fourth birth. She received her first dose of misoprostol intravaginally at 8:25 this morning and started having mild contractions around 11. I left for lunch and a swim around 12:15 since it seemed that things were still in the early phase, returning just before 2 to hear that she was 5cm. Her mother excitedly waved me in to the room and the laboring mother, clearly in a active labor, looked at me and said, "I'm at another level." That was clear and we moved her into the "theatre" or one of the delivery rooms. The nice thing about this room is that it is air conditioned so on a hot day such as today, it was refreshing for all involved. She climbed up onto the table, Sister Leilangi (the head midwife) checked her while I gowned and gloved up. A small anterior lip of the cervix was all that remained and then I was instructed to break her bag, by snagging it with a pair of forceps. That was a new use of this insturment for me, but here, where resources are precious, anything reusable is of great value (versus the disposable amni hooks we use to rupture membranes on other occasions). Within seconds her sweet babe's head was on its way out with her little hand up by her ear and her cord around her neck. With the next push, out she came, covered with vernix (the white creamy waterproofing agent that babies who are generally 40 weeks or less still are covered in- so clearly her dates were off, this was NOT a 42 week babe).

This woman has 2 other girls and 1 boy, and when she was in early labor, I checked her pulses since she didn't know if it was a boy or girl. Her sense was a girl, her mother thought it looked like she was carrying a boy. I thought her belly looked like a girl, but my reading of her pulses said boy. Clearly this is reading of pulses is not one of my strengths (yet). I'll keep working on it :)

One thing I'll really need to get used to here is all the needle pokes for mom and baby. All mom's here receive syntocin (synthetic oxytocin) immediately after giving birth, followed by ergometrine if her blood pressure is normal- both to control bleeding. There is very good logic to this here since prevention of hemorrhaging is of utmost importance- blood transfusions are hard to come by from what I hear and the blood is not super-purified like we have in the states. So the benefits definitely outweigh the risks of giving the meds.

For the babes, within the first 10-15 minutes they receive injections of vitamin K, hepatitis B vaccine, and BCG vaccine (or alternatively they may receive this before departure the following day- depending on whether the vial of vaccine is open at the time of birth and therefore needs to be used, otherwise they will open one vial and do all the babies at the same time the following morning). So yes, lots of pokes within a short period of time for both mom and babe.

I'm amazed by the efficiency here! It has to be this way since they are averaging 200 births PER MONTH on this island! I can't believe that 2400 babies each year are born here! This is not a huge island. Last April was their biggest month this year so far and they had nearly 300 babies that month!!! That's average 10 births per day! So today was my first catch and there is no question that second, third, fourth and beyond will likely be tomorrow or the following day. This is exactly how I like it- jumping right in.

Now, a shower and off to my first experience of a nakamel, or kava bar, to drink and be merry.... or perhaps very relaxed. Will let you know how it goes....

Tuesday, September 22, 2009

Arrival in Port Vila

Hey there, Molly here. Just a quick note that I have arrived as the latest midwifery student, to the smallest International airport I have ever been to, with the sweetest group of women singing a Vanuatu welcome song. A fabulous crew of baby docs (aka medical students) and midwives-to-be milling around the Port.

Last night, an outdoor, local showing of "The Age of Stupid" on a screen with the backdrop of the ocean, starry sky and setting moon- a bright smiling crescent in the western sky. I am disoriented without familiar stars, but at least the sun and moon still travel in their usual directions....

For any of you who have seen this movie, I found myself thinking how ironic it was to see this movie within 4 hours of arriving- a painful reminder of the enormous carbon footprint I had just created to get to Port Vila. I guess all those years of bikecommuting have perhaps offset my latest (and largest) carbon footprint (maybe.....). For those that haven't seen it, it's about global climate change and the dramatic and cumulative effects of our individual choices (like traveling around the world). So yes, carbon footprint aside, my hope is that I can make a larger (more sustainable) imprint here in Vanuatu with the care I provide for the local pregnant women and their babies. And have a lot of fun all the while.

So on that note, off to the hospital for a brief orientation and to drop off the 40lbs of medical supplies that I lugged here. Planning to spend the rest of today getting settled and oriented, swimming, and start in the hospital tomorrow bright and early.

Happy belated Fall Equinox over there-we're marking the Spring Equinox down here :)

Wednesday, September 9, 2009

Leaving For Malekula

Today Kelly and I leave for Malekula. We have been invited to join Project M.A.R.C. for one week and will be staying on 'The Alvei'. I am excited to see this very remote and traditional island and excited to join this organization even if it is only for a week. Many stories about Malekula and my final two weeks at Vila Central Hospital when I return!

Monday, September 7, 2009

Each Day I Am Learning...

at Vila Central Hospital. I have, lately, been delivering babies that are very healthy and normal but I am also involved in labors that are very different from what is within my comfort zone as well as my scope of practice in the States. At the end of last week I came into the hospital late in the evening to begin a shift. When I arrived there was only one young girl in early labor. She was 1cm, but was admitted to the hospital at an early stage because of a genetic heart defect. Her heart condition is known as Ventricular Septal Defect (VSD) and there was a concern that, even though this defect had been surgically corrected in 2006 (when she was fifteen years old), she might not be able to tolerate the stress of labor well and her baby may not either due to improper functioning of the maternal heart. The doctors who were monitoring this young girl’s case were worried about strong contractions and their impact upon both mother and baby so we were to give her 5mg of morphine if labor became too intense for her. Certainly labor is intense for any woman, but there are always women who seem to have a more difficult labor than others. This was one of those women. This poor thing, from 3cm onward, was wracked by the most intense contractions that, at most, gave her one minute of relaxation and peace in between. Ni-Vanuatu women are some of the strongest women I have ever met, this girl being no exception, but she was in such extreme pain, her cervix dilating so quickly, that she was just falling to pieces. I did something that is very rare in this hospital and I sat and held her hand for the duration of her labor. Usually the mothers are not particulary interested in being coddled, but this was a very different and intense case. The mother dilated from three to ten centimeters in a very short amount of time, under two hours, and her baby was delivered very quickly. The baby made no respiratory effort initially, though the heart rate was very good, and in just a couple minutes and with a little bit of oxygen, this baby boy to begin breathing on his own. He has remained quite stable and happy and although there was concern that he may also have some sort of genetic heart defect, this has been ruled out. He will need to have surgery at some point for bilateral syndactyly of his hands (both his second and third and his fourth and fifth digits are fused together, giving him a type of claw hand) and of one of his feet, but he is otherwise quite healthy and normal.

The next labor of the evening was fairly straightforward, although the mother ended up tearing rather significantly with the baby’s passage through the birth canal. I have learned to suture through my education quite a bit, but what I have not been able to always reinforce through practice in the States, I am reinforcing here since the Sister’s will watch over my shoulder and give me advice on my suturing. I have begun suturing quite regularly here and have even gone to sleep dreaming of various tears and how to fix them...great for learning but not the best for sleeping:) 

Friday, September 4, 2009

Catching Up...

Though Vanuatu’s weather is mild all year round, technically it is winter here and a busy season in terms of tourists coming from Australia and New Zealand to escape the cold. As is typical in winter, there are many little viruses going around and I came down with a pretty mean virus that had me in and out of bed for a week. It started with a sore throat and progressed to a fever and body aches that waxed and waned and left me felling fairly miserable for the last week and a half or so. It seemed that as soon as I thought I was well again, I’d work a hospital night shift (where two of the midwives were also sick, one of them so sick that I’m not even sure how she dragged herself in, and I know for a fact that she could barely drag herself home). The hospital, thankfully in a way, was not as busy as it can sometimes be, which gave us a bit of a reprieve.

Two Mondays ago, Kelly and I went in for a day shift and actually had no deliveries, although we did admit several women who were in early labor. We left that day feeling a little gypped, although I thought it was likely for the best since I was feeling pretty lethargic. Tuesday was a bit better in terms of how I was feeling, but Kelly and I have decided to take one day during the week where we go and do something fun on the island in order to break up our hospital time. We had decided to go to Hideaway Island, which is a popular resort area here with, what we had been told was incredible snorkeling. We invited a couple other ‘Baby Docs’ as well as some crewmembers from ‘The Alvei’ and had a wonderful time. There was minimal sand on the beach, just broken up coral, and the water was beautiful and warm with plenty of fish to see. We later had dinner on ‘The Alvei’, which was so much fun as I love being on that incredibly beautiful tall ship and the company is always great.

On that Wednesday Kelly and I worked the night shift and immediately upon arrival each of us delivered a baby. Both births were very uncomplicated, both sets of babies and mamas completely healthy, which is always lovely to see. Unfortunately the night was not all good, and if anyone reading this blog is sensitive to the details of death as it relates to birth, I recommend that you skip this section of my writing; I don’t know any other way to tell this story other than exactly the way it happened.

When I came in that night I saw that we had admitted a woman whose baby was determined to be dead when she arrived. This mother came into the hospital in labor and it was estimated that she was, at most, seven months along. Since she had no prenatal care, this was a rough estimate and this was to be her fourth child, but she had never felt the baby move in utero. This would be uncommon if she was actually seven months along, so either her dates were very incorrect or the baby had been dead for several weeks; either of these scenarios were likely. After I had finished delivering my first baby of the evening, the midwives asked me to deliver this woman’s child in the admitting ward. Although I felt nervous about this, never having delivered a stillborn, I said that I would. I went to rouse the woman from her bed just as she was complaining that her labor had changed from upper abdominal to lower abdominal cramping. I brought her into the admitting room and closed the curtains so that she could have some privacy between her and the rest of the hospital. She brought a woman with her (who I originally believed to be her sister but who I later found out was a friend, employing this woman as her housecleaner). The woman who was with the mama spoke English well, so she did some of the translating, which turned out to be extremely helpful. When I examined the mother vaginally I found that she had what we call “bulging membranes”, i.e., the amniotic sac that surrounds the baby in utero was still in tact and was bulging beyond the cervix. It was difficult for me to determine this mother’s dilation because the membranes themselves we bulging as far as 2cm into the vaginal introitus. In a mother who is full-term, the baby is too large to go that far until the mother’s cervix is completely open, however, in this situation, with a small baby who has been dead for potentially a while, the cervix would not have needed to be completely open.  I decided to rupture her membranes to help her labor progress so that she could have her baby more quickly. I have done this many times in healthy pregnancies and the fluid is usually clear. At most, I have seen meconium, which in the States can sometimes cause a mother to be transferred to the hospital but here in Vanuatu (since I am in a hospital) we just deliver the baby regardless of the amount of meconium. When I ruptured this mother, the fluid was completely bloody. I have never seen anything like it and it was an effort to keep my face straight and to not display any sign of panic. I felt that I displayed every sense of calm until the mother and her friend asked: “So the baby will be okay?” WHAT?!  I said to the mother, to her friend, “Did the midwives talk to you when you were first admitted?” The friend looked at me, said “No, not really. Is the baby okay?” The mother looked at me expectantly. Oh my God Oh my God Oh my God. “I’m so sorry. No. Your baby has died. I’m so very sorry.” It took every part of me to hold it together. I was angry. I was sad. I was afraid. This mother started to cry and her friend started to cry and I thought: WHY didn’t they tell her?!?! They told me she knew?!?! I excused myself from the room and said that I would be back in just a minute. I went to the front desk where the midwives were charting. I asked them if they had told the mother that her baby was dead upon admittance. The looked at me, confused. “Yes. Of course we did.” “She didn’t know! She had no idea!” “It’s okay,” they said, “Now you’ve told her. Just deliver her baby. Was her amniotic fluid bloody?” “Yes,” I said. “Okay, that’s normal for a baby that has died. Let us know if you need help.” I gathered myself, went back in, and the mother said she wanted to push. “Okay, you can go ahead and push.” I knew that she was not fully dilated, 8cm at best, but this baby was also not full-term so she really didn’t need to be 10cm (fully dilated). In one push she had delivered her baby…to the neck. Oh my God. When I had done her vaginal exam I had assumed that the presenting part, the part closest to my fingers, was a head. I knew that it had not felt the way that it should, far too soft, but I thought that this was due to the baby already being macerated or that the child was physically deformed, which had caused the death in the first place. It had not occurred to me that the baby was breech (bottom down rather than head). But yes, this was a frank breech where the baby’s bottom was delivered first and the feet were up near the ears. The cord was wrapped around the neck, which I easily pulled down over the baby’s body, but the problem that occurred was one that is very common with breech deliveries: she could not deliver the head. Whenever a baby is breech, the utmost care is used because of this potential problem. When a full-term breech is delivered  (which I have not had experience with since it is not within my scope as a midwife in the States), the woman must be, without a doubt, completely dilated. The head is the largest part of a baby, and if it is not the first part to got through the birth canal there is a risk of the baby having oxygen supply cut off because of the head getting caught behind the cervix after the body is already delivered. That is why most breech babies are delivered via c-section; there is a lot of fear around delivering breeches and not a lot of skill in delivering them left. Since this baby was already dead, there was not the stress of delivering the head in order to prevent death. That being said, this poor mother was stuck with her half-born, stillborn child. She was not dilated enough to deliver the head. I explained this to her friend who then explained it to the mother. “We need to wait,” I said. “You’ll be done soon.” She looked up at the ceiling. Away from me.  At this point there was a midwife in the room. We waited and waited. She pushed occasionally but her contractions were smaller, more spaced out. She wasn’t dilating any further. It had been half an hour that she had delivered only part of her baby, who was tiny and macerated. I asked the midwife if we could please please just give the mother some Syntocin so she could just be done (Syntocin is a drug used to increase contractions and augment labor). It took fifteen minutes for the midwife to decide that, yes, we could give her Synto. Once it was given the baby’s head was pushed out rather quickly. The baby was tiny, only three quarters of a kilogram, with deformed skull bones. I wrapped her tightly in a blanket and gave this little girl to her mother, who cried softly. She asked if it was her fault. “No. Of course not. Sometimes these things just happen.” After the birth I checked the mother’s blood pressure as we routinely do. I pumped the cuff up to 16o and heard nothing through the stethoscope. Hmmmm. Is it broken? I pumped it up again, much higher, apologizing for the tight squeeze on her arm. 240…..over 160. WHAT? No way. I took it again. The same. “Has anyone ever told you that you have high blood pressure?” “Yes,” she nodded. “Are you on any medications for it?” “No.”  This brought about a whole new list of concerns. Is she going to have a stroke right here? A seizure? WHY HASN’T SHE BEEN TREATED???  I checked her chart. No one checked her pressure when she came in so I had nothing to compare it to. I went to the nurse. She called the physician on call. I had checked the mother’s reflexes, looked for indications of clonus, and she didn’t complain of blurry vision or pain under her ribs (all signs of pre-eclampsia/eclampsia). That being said, for mothers with pre-eclampsia, the greatest risk for seizures is within 24 hours of the birth and the blood pressure, alone, without other symptoms of pre-eclampsia was more than enough to be alarmed. The doctor rang back. He prescribed 20 mg of Nifedipene. You have got to be kidding me. We give that to mothers who have blood pressures of 140/90. That won’t make a dent in her pressures. The Nifedipene exerted little to no effect in an hour. The doctor switched to a drug called Hydralizine, which is much stronger. The mother remained in the hospital for three days, being closely monitored before discharge.

I am left wondering things that I wonder often here. Any person looks, when they are distressed, for someone to blame. Blood pressure that high, untreated, can certainly cause a lack of perfusion to the placenta and result in fetal demise. Is it the mother’s fault for never receiving prenatal care? If she had, the elevated pressures would have been caught and treated. Why wasn’t she treated sooner? She said doctors had told her before and that she wasn’t on any medications. Would it have mattered? Maybe she couldn’t have afforded the medications to begin with. There are so many other questions. I ask myself these questions and then I let them go, even as I understand that I will never have answers. If I didn’t let it go, I wouldn’t be able to go back.