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.

 

1 comment:

Sunita said...

Wow...I'm here if you need an ear.