Baby David

The day began as every other – roosters and goats calling “Ma-a-a-a-a-a-a-t” until we all wake up and feed them mango peels. Patients were lined up outside before breakfast was on the table, including some of the women who followed instructions to come back one week after their speculum exam to see if the medication had improved their symptoms.

“Is your discharge better?”

“Well, I won’t know until my period.”

“Did your discharge get better from the day you were here in clinic?”

“I didn’t have it that day.”

What? Oh boy. The “buffet phenomenon” is a term coined (today by Matt) to descrive patient behavior at our big clinics. They see a doctors once every who-knows-how-long, so they complain of every symptom they may have experienced in the last year. Get their plateful since they paid their 50 cents for the medical buffet.

“Ok, did you take all of your medicine?” Yesterday should have been the last day of Flagyl 500mg BID treatment for the Bacterial Vaginosis we diagnosed per microscopic exam.

“Oh I still have a few left, I take it ever morning and when I have a headache”.

Fail.

Next patient – here for follow-up to enroll in our contraception project. Any woman interested in long term contraception – IUD or tubal ligation – was to follow-up with a pink id card so we can give them a progesterone shot now to ensure they are not pregnant when the surgical team from Iowa comes in January. We want as many women as possible informed and consented for procedures so we can have them roll in and out efficiently, and provide the service to as many women as possible.

The patient sitting before me has had 8 pregnancies and 6 children, and she is 33 years old. She is wisely inquiring about obtaining a tubal ligation.

“What form of birth control are you currently utilizing”

“None, God is protecting me”

“Ok. Do you use condoms, pills, shots, or anything at all?”

“My partner drinks Toro energy drinks and takes my birth control pills sometimes. It has worked well so far.”

Wow. Please don’t tell your friends about this method. And please tell your partner not to be alarmed when he develops breast tissue and emotional labiality.

The next few patients are my least favorite – kids under 2 who are lethargic, not eating, and parents complain of fever and diarrhea. So hard to watch sick babies lying on their mothers bony lap. They hate me for poking them to draw blood for malaria tests, sticking scopes in their ears, and forcing grape goo in their mouth. All that pissing them off, and I still feel helpless. I have finally become competent at peds dosing of antibiotics, but to say I am confident that they will help is a long shot. The need clean water, a steady supply of food, and DEET. So simple, yet so far fetched.

In the midst of clinic, a woman was brought to my attention. She was a referral from Dr. Matt who was currently in a nearby town talking to people about their need for a bridge vs road. She was pregnant and uncomfortably laboring. My bedroom has several unused extra beds and is located right next to our clinic room. We made her comfortable on the bed, gave her some Tylenol and a cold washrag. The health workers were too excited about delivering a baby to tend to the patients who were building up in clinic, and I’d be lying if I said I didn’t want to blow off every other patient to sit here by her, time contractions, and remind her to breath. Nola is one of the community health workers who has had some training as a midwife, and is also a neighbor to this lady. She gets a free pass to tend to her laboring needs, and the rest of us go back to work to finish up the patients.

            When I return an hour later, she is just miserable. She got up to squat out the back door, walked a bit, and regressed to writhing on her back. She was moaning about a “cesarean”. Sounds like she was begging for one. Sorry lady, you’re rocking this and there’s no way I’m touching a scapel to that firm belly.  Only one way out of this, and it involves stretching the most sensitive part of your body 1000x its original size. Doesn’t seem like a perfect design when you put it that way. But I must say, the natural progression of the labor was just beautiful. When contractions were only a minute or two apart, she was alternating between wailing and exhaustion. Even lower back pressure and sips of water weren’t of interest anymore.

            The younger girls I have been spending a good deal of time with are asking about class today. They have notebooks and eager faces, ready to scribble in whatever English or health lessons I can muster up. “Today we will talk about labor and delivery!” They head into the room with the laboring lady, and before too long, they begin doing what they do best (besides learn English). They begin singing at the top of their lungs, clapping, and swaying to the beat. “Jesus loves us, oh yes he does!” “Praise God!” and many other combinations of that sentiment. Nola takes off her gloves to join in the clapping. The laboring woman throws her hands in the air to clap and sing along between contractions. This is so much more fun than an epidural. Finally – I see a big thick head of hair peaking into the sunlight. “Puse!!!!!!” The room echoes “Puse!” And the singing continues. In about 10 more strong pushes, the head of a perfect baby boy emerges. He is not yet crying, but I grab him from Nola and begin warming and stimulating, suctioning his mouth and nose. Just a few days ago we reviewed in class the basics of a clean birth and neonatal resuscitation. I was happy to see the other health workers in the room, with faces glowing and cheering along. The baby let out a wail that was barely audible in all the singing. Mom was exhausted, and finally released the tension in her neck by collapsing on the bed.

            We got to use our first “Clean birthing kit” which were just decorating our small Coralville apartment. The sterile string which had been baked in our oven was tied on the cord, and the clean razor blade purchased down the street at the market effortlessly sliced through the cord. Placenta came out in no time. Mom and baby were both too tired to feed, but they snuggled and warmed each other’s shivers. While cleaning mom up, we took the baby for a little teaching on the newborn exam.  Matt drew up a modified Ballard exam, complete with pictures of baby nipples and testicles. It was perfect to have the universal pictures. For non-medical people, the Ballard exam was designed to estimate the gestational age of the baby at time of birth.  There are certain features in the baby’s position, skin texture, etc that can indicate if the baby is preterm or not.  We are hoping to get a good exam of all the newborns that the health workers provide prenatal care to so that we can see how accurate the fundal height measurements are. It is difficult to ever know for sure how far along a mother is without ultrasound, especially when all the women seem to measure so small when they are undernourished.

The girls assessed the baby’s posture, skin, vitals, and anatomy to determine he was of full gestational age and healthy. All of the attention must have finally made him hungry; his lips began puckering with intention. Time to put mom back to work. Baby rested on mom’s chest as he took he first ex-utero gulps. Remarkable instincts. Yup, back to accepting this as perfect design. I quizzed the girls on benefits of breastfeeding.

“It makes a healthy baby.” Absolutely right. Breast is best, tough to convince everyone of that, seems that kids get fed crackers, cheetos, rice, and other foods at much too early of an age. Matt informed me it is easier to feed babies a few little crackers than to buy mom an extra couple thousand calories so she can keep producing milk.

I explained that milk passes immunities, offers some birth control, and helps the uterus shrink back to size. We felt her uterus together, and as predicted it was firm and remarkably shrunken down.

The lesson was going so well until my stupid statement “Another benefit of breastfeeding is it helps mom loose baby fat” Blank stares. “Scratch that. I mean mom needs as much calories and nutrition as possible. Kill a chicken, figure out a way to get her some meat every day.”

I should have heeded that last statement more seriously. A few hours after delivery, things were calming down, and mom wanted to go home. Dad was nowhere in sight, and a friend had come with some baby clothes and a change of clothes for mom. She was sitting up, talking, and happy. Matt and I said we would help her get home. We packed up her goods, included the sterile sheet we used (she wanted to wash and reuse it) and the placenta (to bury at home). After walking a short distance at a rather slow pace, I graciously offered her Matt’s services. “He can carry you!” To all the readers -  next time you see Matt remind him how strong and brave he is.

We walk about 100 yards from our compound, and we need to stop and let him rest and give her a shot to take a few steps. Matt just barely gets her hands off of her, and she begins to wobble. Not in an organized dance kind of way. She slumped into matt and onto her knees, with a classic myotonic jerk as she went down in the gravel. We both swept under her as best as we could, her friend still walking off into the distance with baby David without a clue. I don’t think we even exchanged words, just knew we had to get her back to the compound. I boosted her up as Matt lugged her back into his arms. We got her snuggled back in my room, and to be honest I was pretty thrilled to keep an eye on her and the baby for the night. Once she was snuggled and they were both sleeping, Matt and I hopped on a Moto to quickly go into town and get some “fastfood” on the side of the road. Mmmm, rice and beans. She gobbled it up while we took turns goo-ing at the baby. Dad is here now, and they are all happily relaxing in my room.

Special birthday, and a wonderful day to be born! Gets to share with my favorite godfather/uncle Rick Fury. If this baby is anything like uncle Rick, Haiti needs a fair warning when David puts those feet to the floor with some Bachman-Turner Overdrive. Happy birthday to all who are blessed to share this day with David and Rick!

I admit, the recent “discharge study” was enough to make me question why I wanted to get my face between the legs of complaints of “itchy, smelly, thick discharge” every day for the rest of my life. I owe baby David a big thank you for reinstating my love of obstetrics and excitement for my future in Ob-gyn. What a joyful day!

Birthing kit finally put to use! It contains a bar of soap and gloves for the deliverer, sterile string and a razor to cut the cord, a sterile blue blanket for mother to lie on and to warm the baby if necessary, and some alcohol wipes to keep the cord clean in the weeks to come. Thanks Nurse Sue for the head start on the project!