Monday, January 26, 2009

It just never stops...

Friday's wee preemie died on Saturday afternoon He lived for a day and a handful of hours. Very early on Sunday morning, a woman delivered precipitously in the ambulance. Her breech baby was born still. Both mothers were gone from the floor this morning. I think that amounts to 8 late fetal or neonatal deaths in some 150 births, most from prematurity or unexplained stillbirth.


This morning at about 10 am we received word from the ER that a38 week woman had presented after having a seizure at home. She began seizing again in the ER and was then transferred to Maternity. She was indeed in the throws of a grand mal seizure, and despite everything we did, she continued to seize. Her differential diagnosis was clinically fascinating, but watching a heavily pregnant woman 'fitting' as they call it here is nothing short of pretty bloody terrifying. Initially thought to have eclampsia, she was normotensive, though there was slight proteinuria. She was mildly febrile, but nowhere near the 40 degrees C which is usually the threshold for febrile seizure. She had no history of seizure disorder or epilepsy. What was even freakier was that after great whopping doses of magnesium sulfate, valium, and then phenobarbitol, she continued to seize. Next stop on the ladder - test for malaria and in the meantime begin treatment with IV quinine, and cephtriaxone: if she has either malaria or meningitis we might be doing some good.

I took fetal heart tones every 15 minutes while she was there, fitting continuously. Baby vaccilated between ominously low and mildly tachycardic. Ultimately the test for malaria came back positive and the diagnosis of the very rare and catastrophic cerebral malaria was settled upon. Case fatality rates (that is the risk the mother has for dying) for cerebral malaria seem to sit around 33.1%. Rates of fetal mortality are also staggeringly high. Bottom line, 4 hours after she came to Maternity's care, she was shifted to the medical ward, still seizing constantly. There they will try to stabilize her condition, and if baby is still with us tomorrow, we'll try to help her baby. There is a very real possibility that both of them will die.


In the meantime I can report the safe, happy births of three more babies ('my' babies #101, 102, 103!). Two boys and a girl, all to mothers who said as they began pushing "I can't do this!", but then did. Boy #2 for the day became my very first OP baby, his fat face grimacing up at me, confusing me slightly as to where his shoulders were as he untwisted his neck, owl-like. Even better he was a little moose (3.9 kilos) and his mother's tissues were beautifully intact! Last baby of the day extended my 8 hour shift to 11hrs when her nulliparous second stage unfolded in a blisteringly fast 12 minutes. Her unbelievably powerful pushing efforts brought forth a petite 36 and a bit week 2.4kilo boy, along with an outrageous 3rd degree tear (also my first) despite my attempts to slow her pushing down, and support her tissues. I could feel everything 'giving' before even the perineal tissues gave. His hand up by his occiput, elbow by his ear, did her no favors at all!

The nasty laceration extended deeply down both posterior sulcus', down her perineum, through the sphincter capsule and (for want of a better term - forgive me) ' filet-ed' both labia majora from fourchette almost to clitoral hood bilaterally. It was nothing short of gnarly. I delivered her placenta, had the NA draw up a good 10cc's of lidocaine which I injected all over the place immediately before finding the OB on call, and then assisted him as he repaired her extensive tears. I'm officially a huge fan of morphine during these procedures and sims specula for retracting sufficiently to get deeper into the vaginal vault though for the record, I highly doubt I'll ever attempt a repair this extensive when I get home. I'd be far more likely to throw in a couple of interrupteds to stem any active bleeding before heading in to the lovely docs with the nice drugs for this sort of thing. :)

It was fun watching the repair though. Not quite as complicated ultimately as it looked initially, just three packets of suture (2.0 and 3.0), good pain control and lots of time and skill. Good also was the opportunity to spending time chatting with a couple of nice docs about the amazing craziness which is life in OB here in Vanuatu, and elsewhere in the Pacific. Some grumbling about the fact that the international efforts to stop Malaria in the pacific is being focused on the low incidence countries, rather than the high-incidence ones (like Vanuatu).

He also gave me a heads up on another set of twins (twin A cephalic!!) who should deliver this week or next. Fingers crossed with me that I'm on when she comes in!


Shamefully bad day on the 'self-care' front. All that and I managed to snarf down a peanut butter sandwich and 500mls of water. In 11 hrs. Boy was baby hungry this evening!

It was an intense, busy day today. But it feels good. At some point over the last couple of years I've become a midwife. I'm increasingly confident in my knowledge and with my practice. I have held on to the love I have for walking with women through the challenges and pain of birthing, and I feel more confident in the day to day tasks of catching babies, managing (or referring) issues which come up, even the big bad and scary ones. Here I've been privileged to work with outstanding midwives, who each have literally THOUSANDS (20 year careers, 35-45 births a month, you do the maths!) of births to their credit. Hundreds and hundreds of women and babies whose lives they've saved with their care. I've enjoyed the respect and tutelage of the resident and consultant physicians here. I've worked in a team, providing good, safe and effective care to a much more risk-diverse population than I'm used to (or would ever serve at home!) with minimal resources. Working here has reinforced for me that the midwifery skills and knowledge I have are substantive, real, incredibly valuable and make such a positive difference to the women and families I serve. I'm not sure why the real meaning of that eluded me so much before I came here, perhaps because midwives at home must spend so much time (and frustration and energy) campaigning simply to be able to do their jobs. Have to fight to serve the women who seek our services, and suffer still the irrational and unfair attacks from many in obstetrics who are, quite simply, ignorant. No matter, I really no longer care what they think. I no longer feel like a second-class provider (and part of me has in the past). I'll start my career with a great foundation. I'm well on my way to becoming a fine midwife. Simple as that.

How'd that happen, y'all? ;)

So it goes...


Rixa said...

I don't know if I've commented much before, but I find your adventures amazing and sad. I always look forward to reading about your midwifery experiences and I think this exposure will do you loads of good for your own practice.

Aimee said...

Congratulations Louisa! I love that it just hit you that you ARE a midwife! Although I've never thought of you as a student, I love that you came to a point where it isn't just practice anymore. I always knew you'd be one of the ones from our class who would go the distance. Your passion is unmatched and my respect and admiration for you continues to grow.

I'm sorry to hear that you've had to deal with yet more late fetal and neonate deaths. It can't get easier but at least you're gaining the experience among teachers who understand the blessing that your service represents.

Much MUCH love to you!

One Hot Mama said...

Awesome read, yo. I am so jealous, and yet not, as I read of your joys, trials, and difficulties. I laugh with you, rejoice with you, cry with you. You are my colleague and my sister.