Aviva Romm's Blog

Day 14: Episiotomy and Cultural Competence

avivaromm — Fri, 27 Jan 2012 19:22:24 -0700

On any given day there are so many things that happen that are worth a whole story, and for every incidence there are about 50 more observations, thoughts, and feelings. Then there is the backdrop of color, sound, and odor. It is a complex mélange of experience and witnessing, and on top of it there is the very busy work of being a family doctor doing OB in this place of mountains and people, people and mountains.

My days begin early (I am writing this at 6 am), go long, and end late. Last night we were checking on newborns and stopping in on L&D at 10 pm, as we often do, making our final rounds for the night. Often we have skipped at least a meal that day, and while we are sometimes a little hungry, who can even think to be bothered by it when the last child you’ve checked on before, during, or after a missed meal is literally dying of starvation. By 11 pm, when I am finally winding down, my intention to write is strong, but I merely jot an email to my family, and then sleep wins.

My intention in writing today is to start to fill in some of the gaps of missed days of writing.

So what are some of the back-stories, the side stories, or the stories that have not gotten a headline? The thoughts, musings, conversations with my attending or local docs about health care here?

Here we go… The next few posts will be shorter and come at a brisk pace.

Again, delete at will….

Every primip (first time pregnant mom) here gets an episiotomy. Even before one can medically determine if one is needed. Even if one is probably not needed…

Episiotomy here is a complex matter. Nurses, whose training appears to be about at the level of a CAN (certified nursing assistant), are actually the ones who do ALL of the normal deliveries here because the hospital can’t afford to keep the midwives they used to have. There are two remaining nurse-midwives of the nine previously working here. They are trained in a 14-month program in Port-au-Prince and they primarily do prenatal care, though one seems to do admin for the maternity floor. There are 3 OBs; they do the c-sections and are called in for obstetric complications, such as eclampsia. So the nurses do all of the normal births.

This is, on some level, a testament to how uncomplicated and simple birth can actually be. It is equally a reflection of a severe lack of resources and the acceptance that neonatal death is commonplace, and even maternal death is not an unacceptable outcome. The episiotomy, here, therefore becomes not an unnecessary intervention for the mother, but one that potentially prevents her from developing a fistula from an improperly repaired tear, or a tear through the anus or rectum should a tear occur naturally that the midwives are unable to repair.

You see, everything done here by the nurses regarding births is rote and mechanical. The woman comes in and gets an IV into which 20 units of Pitocin is placed and is run very slowly. At about 6-8 cm her membranes are ruptured. At 8 cm she is placed, basically in lithotomy position, on a delivery table that barely works, and which is broken down (a term we use in the hospital to mean that the removable 1/3 of the bed where the legs and feet rest is removed), and the woman spends the rest of her labor on her back, feet in stirrups. She is told to push somewhere between 9 cm and completely dilated and I am told that, prior to our arrival and encouraging more breathing and gently pushing, the women were spoken to very firmly by the nurses. A large mediolateral episiotomy is cut when the baby’s head is still at +2 station -- thus not even on the perineum and before there is an actual medical indication for the epis, and rarely is there a true medical need for one.

But in a country like this one must suspend US-centric judgments and look for the why behind the what before forming an opinion or offering a suggestion for what one might think is an improvement. One must also consider the long-term potential consequences of the improvement -- can the system bear and sustain the change.

Our suspicions have been confirmed in the 10 days since our arrival on L&D. The nurses here are not skilled in irregular tears. They only know how to repair the episiotomy that they do each time. And they do a large, generous episiotomy which thereby prevents most of the incisions from extending as can happen with an inadequately cut incision. It also mitigates the risk of large tears which could extend into the anal sphincter or rectum, which would render a woman fecal incontinent or with a fistula, if improperly repaired. And there are not enough attendants skilled in the art of a proper repair. The episiotomy here, is therefore, an adaptive, preventative procedure.

Does this mean I condone it? No. I don’t. Episiotomy increases a woman’s risk of postpartum bleeding, trauma, and pain, both immediately and long after birth, compared to a well-repaired physiologically occurring vaginal or perineal laceration. Further, I believe that tears are more preventable here -- dorsal lithotomy position places all the forces of the head and posterior shoulder as they emerge from the birth canal onto the perineum. Upright and squatting positions reduce this force and lessen the likelihood of tears. So do hot compresses applied to the perineum as it stretches -- not really an option here where clean water is scarce.

But it does mean that we understand the reasons for the practice and respect that there are sometimes reasons for things that we don’t understand. We also don’t earn the trust required for change by blindly imposing our outsider ideas in an established community. Cultural, social, and emotional intelligence are required. We watch, learn, and when it’s appropriate, or if asked, we offer our knowledge freely. We practice consistently with what we know, and we try to generously include those interested in what we are doing.

At this point the nurses know our names and the OBs ask us questions, ask for our opinions, and include us with great welcome into their OR. The nurses offer us gloves and move aside to allow us receive the baby. They watch us in resuscitations and see what we are doing. Most importantly, they joke around with us, help us practice our Creole and laugh at us, and in small but important ways let us know we are no longer just intruders, if not yet trusted allies. We are building relationship. It takes baby steps, but that’s okay, we’re in the business of babies!

pure delight!

DAY 12: 1/25/12: Have a Coke and a Smile

avivaromm — Wed, 25 Jan 2012 21:48:27 -0700

A Real-time Google Chat Between Aviva and Tracy Romm

4:29 PM tracyromm: nice day?

4:30 PM me: strange day...got invited to go into the community with the midwives. this was especially good timing since Geoff woke up with a not-too-fun GI thing and wasn't gonna do much good on L&D. so i went....we have been wanting to do this since we got here and today is the first opportunity. Just sorry Geoff couldn’t go. And remembering we ate popcorn out of the same bag last night which we joked about because he was already feeling kinda’ not so great yesterday…

The trip into the community was way the heck out in the countryside about 45 minutes from here.

tracyromm: tell me more

me: it was me, 2 nurses who didn't speak a word of English, a driver (Haitian of course, no English) and fortunately James, the translator who found me this morning to see if i needed any help.

tracyromm: right

4:33 PM me: a young nurse who is going to be here for a year asked if she could shadow me and Geoff today and I’d said sure so she rode along, too.

tracyromm: so how was it strange?

4:34 PM me: we got into a pick up and listened to Haitian radio the whole way -- music and church preaching. it was a bumpy ride (right now I feel the bruise where I bonked myself) in a pickup with a cracked windshield. some roads had potholes as big as a car so there was some swerving. and of course no seatbelts

tracyromm: ah, an adventure. my first thought was about the car ride

4:35 PM me: we get to this clinic in the middle of nowhere. I’ll send a few pics

tracyromm: do Haitians drive like Jamaicans? with no abandon?

4:36 PM me: no, more careful driving than that by the hospital staff, but didn't I tell you the other day about the lady who got crushed right by a tap tap (bus) right in front of the hospital and needed an emergency amputation? the thought did cross my mind today…

anyway, the clinic is barely a building. one of these places that looks like it could serve as a medical facility in the bush somewhere. or a place in a movie or on the news where prisoners are taken in some foreign country to be tortured and disappear if you know what i mean. It does not have 4 walls…

tracyromm: got the pic, yup

4:37 PM me: anyway, we get there and it's ME doing to the clinic. I get taken into a spare but clean exam room, given the big old leather chair behind a large old oak desk, some charts, makeshift scraps of paper to write scripts on, and the interpreter talks me thru the prenatals. I taught the young nurse how to do a basic prenatal exam.

ok, then the pickup which had gone off with the nurse and driver to get some unesco or unicef "pudgy packs" which are these calorie and protein dense packets of peanut butter mixed with nutrients, returns for us. These nutrition packs are important. There is kwashiokor here, tracy, HERE, just offshore of Florida!

So in the backseat of the pickup they've got this mom whom they found by the side of the road with a baby in her arms and they want the doctor to take a look at the kid. Ok, so that's me, right?

4:39 PM tracyromm: getting more involved by the minute, or keystroke

4:40 PM me: oh I forgot one part. you’ll need the comic relief later, trust me. on the way before even getting to the clinic in the middle of NOWHERE Haiti we are stopped by 3 guys who are using a branch as a make shift road-block. they’ve got this big branch across the dirt road and said the government won't fix the road so they are and they want people to pay money to pass. all the Haitians in the front seat have no money and are just sitting there like whadda we do. so I asked James the interpreter how much and he said a dollar so i gave the guys a dollar. (that becomes part of the story later on the return when I also gave a dollar)

tracyromm: wheee. welcome to Haiti. reminds me of my first trip to JA except that was a real roadblock. one dollar. geez.

4:42 PM me: anyway, I get in the back of the pickup next to this gorgeous young 19 yo Haitian mom of 3 kids -- her oldest being 7 years old i think she said, or was it 5 yo, anyway, either way the math is simple and astonishing.

so I take a quick look at this way too itty-bitty 18-day old baby. the mom pulls off the baby’s hat and I am looking at a funky crushed infected skull base and I’m thinking, shit, I’m in way over my head. I wrap the timon (= baby/child in Creole) and give her back to her mom, with reassurance that we are going to help. As we start driving and I call Geoff and we get to the road block on the return trip I tell him “Hold on we’re at a road block and I have to pay money to get through” and later he tells me he thinks “Oh shit, my resident is gonna get kidnapped because I have diarrhea!” I laughed fit to split when he told me that 'cause I wasn't in peril at all!

I tell him whazzup, and mind you I’ve not eaten yet that day except a few almonds and raisins and we have no water with us and by now it's like 2 o'clock. we get back to the hospital and do a thorough eval of this baby and get more of the story now that I’m not in a pickup on a bumpy road and can hear the mom talk and have the interpreter near me and her not in the front seat as he was.

tracyromm: I hope you are high tailing to the hospital. why call? to get him ready?

4:45 PM me: oh, I called Geoff to make sure he would be able to help me and not too sick and so he'd have his thinking cap on by the time we arrived and so that he'd be ready to meet me at the pedi part of the hospital. we actually stop to pick him up and the nurse grabbed a coke for me at base camp so I could hydrate a bit....

so the story is that this 18-day old baby was actually born at 7 months of pregnancy. the mom tried to get to the hospital on a motorbike when she realized she was in labor, but ended up delivering on the motorbike and isn't sure if she hit the baby's head when it was coming out. It is really hard to get to the hospital here; remote, few cars, few phones…

so now we're thinking infection? burn? Giant lymph nodes: mumps? Tropical infection? The baby also has a giant birthmark all around the area and it's not normal. so maybe cavernous hemangioma has ruptured?

tracyromm: that is a devastating story

4:48 PM me: Yeah...you do and you don’t get used to them here...

So while I’m holding this tiny little baby girl -- her name is chiffi --and trying to be oh so tender to her, and trying to get her a spot in the hospital, Geoff goes to find this neonatologist who is visiting for 2 days and he comes over and confirms what I’d said in the car that we were looking at open skull (and adds that the fluid that was coming out was CSF), and as I speculated to Geoff and he’d concurred, that maybe this was a ruptured cavernous hemangioma now superinfected into the skull and possibly brain. The neonatologist says nothing can be done, even if we were back in the states, "the baby's a goner" he said. so I wrap the baby and take mom and baby outside to sit somewhere more private. rick, the neonatologist is clearly overcome emotionally and just devastated and shocked at what he is seeing here in this live action moment.

I give the mom my coke and rick goes to get one of the interpreters so I can give her the news, which I’ve been asked to do and which is appropriate. I’m a mom, I brought her in. she knocks back half of the coke like someone who hasn’t eaten in awhile (during the ride to the hospital she’d confided that she had no food at home for her children) and while she’s chugging I have this weird screwed up ironic mental image of being in a Coca Cola commercial, you know “have a Coke and a smile”-- the nice white doc giving a Coke to a poor Haitian mom only it's over me about to tell her that her baby daughter in going to die in the next day and there’s just absolutely nothing to smile about in this situation.

the neonatologist comes back with the interpreter and walks away because he's really sad. Geoff comes over and stands by where I’m sitting with the mom and her baby, whom she is now tenderly dressing back into her little tiny clothes. and I am telling the interpreter what to say and he just can't believe it and he tells me he cannot tell a mother her baby is going to die. and I said we have to and I don't speak enough Creole so I know this is so hard but I really need him to tell her so I know she understands. The mother is clearly not getting that there's nothing we can do to help her baby. Finally she starts to get it. It sinks in. But true to my experience of Haitian patients her countenance remains cool, calm, stoic. There’s some mixture of denial and resoluteness.

4:57 PM tracyromm: you ok? can it get sadder than that?

4:58 PM me: Sadly it can get sadder than that here. We’ve got a premie in the NICU we’ve been taking care of. His mom died in childbirth…This Haiti. It seems it just keeps getting sadder!

Interestingly, it is clear that this young mother does not want to see or hear our sadness for her situation because in her mind, God can save this baby if God wants to. So through the interpreter I honor her belief by saying, “It's in Gods hands,” which is how Haitians seems to accept things going one way or the other; it allows hope and it also allows acceptance. Not my religion or language, but really important to support.

Geoff gives her money from his pocket as she has literally nothing, and otherwise there is no way for her to get the 45 minutes back to home. Another woman appears from nowhere. It turns out it is her sister (whether literally I don't know, but I’m just so glad she’s not alone). We didn't want to just have her go 45 minutes home alone in a tap tap! The other woman just happened to be at the clinic that day. She might be pregnant. Couldn’t tell for sure.

The momma has the remaining coke in her hand and turns to give me the rest for me to finish and she thanked us very much. I told her to keep the coke and she handed it to her sister who began to drink it as they walked away....More Coke commercial images give me this sense of irony that blunts my sadness for the moment…

5:00 PM tracyromm: resilience, or resignation?

me: It's both, T. How the hell else do you survive in a place where middle class means that you have a roof over your head -- literally even if you have nothing else -- just the roof!

5:14 PM tracyromm: gotta run. maybe we can connect later.

5:15 PM me: yeah. we might go to deliveries, but if not let's catch up around 9:30 ish. want to tuck in earlier and read this evening. Family medicine is amazing, eh? Truly cradle to grave medicine, though sadly in this case that only encompassed 18 days for this tiny girl. So glad to be a family doc and midwife. It’s an amazing combo in a place like this…Anywhere, really.

5:16 PM tracyromm: indeed. xoxox

me: ciao! xxoo

all photos in my blogs from Haiti were taken and shared with permission

the more joyous side of things some lovelies who will make it past 5 yo here

the women of Haiti are the mountains of the country

admin — Mon, 23 Jan 2012 06:22:05 -0700

Milot, Haiti, 11:23 PM

Between 3 and 6 pm today, did 3 births of first-time moms. They were literally in 3 consecutive beds. Two birthed within minutes of each other so Geoff received one and I the other, literally watching each other as we worked. Both had tears so I did the repairs. Between the second and third women a woman came into the ward having an eclamptic seizure. Geoff treated her while my patient was pushing, then he joined me for the birth. Oh and somewhere in there a pregnant woman came in very sick. Fever > 103, rash, conjunctivitis so severe she was unable to open her eyes. It was determined she has measles. We worked so hard this afternoon! We also spent a lot of time with the wonderful OB I've been learning from, discussing the measles case, reviewing protocol, and laughing over our attempts to communicate -- him in English, me in Creole.

It is so gratifying to work with these amazing, powerful, Haitian women. They are so strong -- there are no epidurals here. The women chant through labor. The women of Haiti truly are the mountains of the country, as a Haitian saying goes. I am really loving being here. There is so much to learn and so much to share. We have "delivered" 60% of the babies born here in the past 5 days, all with no episiotomy, delayed cord clamping, and initial skin-to-skin contact between mom an baby. We missed dinner and decompressed over some mini Cliff Bars, almonds and raisins I brought as snacks. But we were more tired than hungry.

Off to sleep. More babies are sure to come tomorrow...

Day 8 in Haiti: Reasons? Outdated Practices? Or Just Plain Lack of Knowledge…and a Walk in the Jungle

admin — Sat, 21 Jan 2012 23:45:04 -0700

FYI -- this is totally out of order. I wrote this today, 1/21/12. I have several days to catch up on. I have been non-stop busy with births, patient care, and studying. I will outline past days in a future post….

It’s Saturday, 5 pm. Saturday evening festivities in Milot are gearing up -- I hear more activity than usual from the street; more motorbikes and more music and more people chattering and laughing. My small room at the hospital compound is not too far from the main road and I have my window and door open to enjoy the cooler air in this latter part of the day. I am under my mosquito netting, still in a pair of scrubs I wore to the hospital this morning. My roommates have gone back to the States and I have a quiet little space to myself. It’s so intensely social here between patients, other medical staff, and the volunteers, and communicating in Creole requires some effort, so I appreciate these few moments of solitude to rest, gather my thoughts, and write.

Geoff and I have just returned from a long, wonderful walk along a less beaten path. Usually we walk through the main part of town and then off into little sub-towns -- the various neighborhoods that blend one into the next. Today we went left out of the compound gates and found ourselves seemingly in the middle of a jungle neighborhood, walking along a path that is actually quite a well-travelled path to the neighboring town, but no blans were there -- it’s not the tourist path.

Large stretches of our walk were quiet except for birds. We chatted and marveled at the amazing array (and size!) of the plants and trees. Large birds were chatting above us, we passed locals whose stoic faces break into ear to ear smiles as they reply to our greeting of “Bon Swa.” We agree that if we were women in labor, it would not be appealing to make the long walk all the way to the hospital, and we might also choose to stay at home with our mother, sister, or neighbor to give birth as so many of the women here do. After all, most of the births happen easily and naturally, so what’s the big deal? Except for the small percentage of time that it is…

Along the way we recognized cacao, grapefruit, and banana trees, an aloe of some sort, and found an orange tree with a fruit low enough that Geoff could jump and reach one, which we split. At some point one forgets about all the hands we’ve shaken along the way -- the kids are always reaching out to touch our hands and the adults love to high five and shake hands, too -- and then you just eat. One can only remember Purell so many times in a day. It was a delicious orange -- clearly edible and normal -- but we did joke about diarrhea and Pepto-Bismol. It’s hard not to. Diarrhea is prevalent here and we walk through the cholera tent to check on patient hydration status every couple of days.

Our workday began at 8:30 this morning. It’s a perfect morning. The temperature is in the 70s, there’s minimal humidity, and the sun is shining. There are few vendors on the street so our few hundred meter walk to the hospital is brisk, rather than slightly encumbered as usual by the men and women who call out: ‘Aviva, Dr Geoff, you remember to buy from me before you leave.’ We now know many of their names: Charlie, Henri.

We begin the day with a stop by the NICU. We are bringing the cardio-thoracic team by to help evaluate a 3-week old baby with a possible congenital lung problem. We need an echocardiogram and an assessment and they can do it. A wonderful surgeon named Andres, a handsome man built like Arnold Schwarzenegger, and with a German accent, carries the baby’s heavy oxygen machine while I carry the baby to another building of the hospital to do the evaluation. I am moved by this giant man tenderly talking to this tiny baby, the baby’s hand in the giant man’s hand, through the procedure. No major heart defects. We’re still not sure what the problem is, imaging is limited, and even if we know, what can we do about it?

We walk up the steps to maternité, passing the usual array of patients and family members of women who have delivered, are here to be assessed, or are waiting for some other purpose, and past the security guard, and enter the maternity ward.

By ten o’clock I had first-assisted a cesarean that resulted in a neonatal death. The woman had initially been laboring at home for a long time with a matwan, the local midwife, usually a completely untrained older woman in the community (more on that another time), then she went to a clinic, and after 24 hours of ineffective labor with prolonged pushing, she came to us, as our hospital here is more like a tertiary care center. She was quickly evaluated and found to be completely dilated, with the baby’s head too high in the pelvis for how long she’d been in labor, and a lot of swelling of the baby’s head. Her abdomen did not appear to have the normal shape, suggesting a possible malposition of the head. She’d received Pitocin at the previous clinic, and the surgeon I’ve been working with daily, Dr. Romeus, made the reasonable call to go straight to cesarean. The baby was born without a heartbeat. As the baby was coming out I quietly said to Geoff, who was in the OR and in-waiting for possible neonatal resuscitation, that this one was gonna need some help. The baby was limp, lifeless, and had just emerged from a uterus filled with pea-soup meconium. I handed the baby to Geoff who adeptly whisked the baby out of the OR and across another room where resuscitation occurs. It was not a seamless transition -- nothing really seems to be here. There are too few hands, needed equipment is just not within reach -- sometimes it’s not even available.

In another minute I broke scrub from the section to join him in the area for “reanimation de neonate” -- a room we’ve tried to stock with adequate neonatal resuscitation equipment beyond the two broken baby warmers and various supplies that were haphazardly stuffed under the warmers. Neonatal resuscitation requires two people to be done properly. There was only Geoff and a nurse with no neonatal resus skills with that baby. Sure enough the extra pair of hands was needed.

The baby still had no heartbeat or respirations. We proceeded to work in unison for the next 7 minutes to jump-start that baby into the world of the living. Other than a slightly misshapen head, he looked perfect and was full term. He was still warm and initially, mostly pink. We were both teary-eyed as it became evident that this little beautiful baby was not going to take a breath – ever-- and I think we were both thinking if we just wish hard enough and just keep resuscitating he’d open his eyes and gasp and have a beating heart in that tiny chest we were taking turns compressing. But did this not happen and we were now part of the infant mortality statistics of Haiti. We examined the baby’s body. We wrapped him. We watched as his skin became more bluish.

We talked with the OB after the birth. We asked if he was sad. He was sad for the baby, and while he was non-judgmental of the mother, he wished she’d have come in sooner rather than as it was, too late. Geoff and I took a little bit of time to deconstruct the situation. We realized there was nothing we could have done differently, but that there are big cracks in the system that could lead to a problem because valuable time is lost going from one room to another, or reaching/finding supplies, initiating resuscitation. We talked about how to fix the cracks -- which always leads to a larger discussion about how to be culturally appropriate and also realistic about what is possible. We talked about the futility in saving babies in a social environment where there is no support for children with developmental delays, nor for their families. This is a well-accepted reality by the physicians and families here and is in stark contrast to the US where we save every baby we can regardless of the long-term consequences. We talked about the social consequences of this in the US and also about the fact that had there been a neonatal death in a US hospital, the National Guard and CIA would practically be called to investigate, not to mention the lawyers who would be following not far behind. Here it was just a matter of fact, no different than had she birthed normally. It wasn’t ignored; it just wasn’t newsworthy. We talked about that, too, and whether as a culture Haitians are just very accepting of the natural flow of life and death, or whether as a culture, Haitians are just so accustomed to a high infant mortality rate that they just accept it as normal.

Early in our visit, we observed practices that, to us, seemed outmoded. Routine episiotomy is the most glaring example. Our overwhelming conclusion has been that the reason for the routine episiotomies is that the nurses who do the deliveries just don’t know how to do any other type of repair, so they do a long, lateral epis, which to our horror, they close with one continuous running stich, including an external running stich of the perineum which ends up looking the seam of a baseball when the repair is completed. We have struggled with the possibility that there are reasons for some of the practices here. We’ve tried to change things by example, demonstrating birth “pas epis” and practicing delayed cord cutting with skin-to-skin contact between mom and baby. But we don’t just want to be blans (= gringos) coming from the US imposing our views and opinions.

Respectfully trying to communicate our observations to the Medical Director, and our willingness to do some teaching to help contemporize practices, Geoff diplomatically said (I am paraphrasing something he said more eloquently), “There are some things that we do that are different. It’s not that what is being done is wrong, it’s just that what we do is based on more recent evidence.”

Weeeelllllll….today we had a change of heart. Some things are just done wrong. They are done because of lack of resources including training, knowledge, proper equipment. We are not just blans trying to bring in western technology. We are blans coming into an environment where western technology is already being used -- sometimes just ineffectively. We are blans coming in and recognizing that the neonatal mortality rate should not be 15%.

We barely had time to integrate the baby’s death when another woman was ready to birth. I had examined this woman yesterday afternoon. She was a first-time mom who came in because she though her water had broken that morning. She was not even examined when she was given 20 mg of Pitocin in an IV. When I checked her she was barely dilated and a sterile speculum exam revealed no signs of her membranes being ruptured. But it was late and she was tired, and she’d been given Pitocin, so she spent the night at the hospital. Of note, when I was checking her for ROM I asked the OB if he had nitrazine paper, which is a standard in every US clinic and costs pennies. This very competent young Haitian doctor replied honestly, “I’ve read about nitrazine paper in books but I’ve never seen it.” Fascinating…

12:24 AM: The tree frogs have their regular evening chorus going. Just back from the hospital. Well, that’s not exactly true. I got back about and hour and a half ago. The time since has been spent variously between deep, serious, and sincere conversation about medicine in a 3rd world country (I can’t quite call Haiti a developing nation. It’s not quite there. But there are many here who are trying) and outright hysterical laughter over the sheer preposterousness of some of the situations. You see, Geoff and I were leaving L&D after a long and satisfying talk with Dr Romeus, who to our delight, had no idea that routine episiotomies were occurring on L&D and who agreed that this needed to stop immediately, when we were asked by a young Haitian intern to check on a patient who needed an IV but didn’t have venous access. Basically when you’re a family doc down here you can get stopped to care for anyone with anything from a baby being born to placing an IV or catheter to treating someone presumably in congestive heart failure like we ended up doing for this man. But it’s hard to treat without access to necessary lab tests and medications, and there are ethical issues of whether to start treatments that the patient will have no way to access or afford down the road. It’s not funny but at some point it becomes comical; or perhaps comic relief becomes necessary to cope with the actual devastating realities here.

Oh, tasted rum and coke for the first time tonight. It was Haitian pineapple rum and real Coke like we have in the US. Delicious. I just had a sip but if there’s more tomorrow night I might have to make it a cup…

Thanks for listening, amis!

~ Aviva from Milot, Haiti

Day 3: “Coucher pour la examin, s’il tu plait”

admin — Thu, 19 Jan 2012 06:45:52 -0700

The clinic day starts at about 8:30 in the morning. The morning buzzes were that

the girl who reportedly drank the water and hadn’t gotten sick, leading to lots of “hurrahs” about how we could now brush our teeth with the water, was actually up puking all night and was now getting an IV. I had chosen not to brush my teeth with the water -- made that mistake at a rural homebirth 20 years ago and wasn’t gonna make it again.
a nurse had a tarantula on her shoulder last night. It had shimmied up her pants, and her shirt leading to some hysterics. Note to self: Tuck pants into socks at night!

We have breakfast and walk past the usual array of vendors. It is cloudy this morning and smoke from the wood and coal used to cook in the town float heavily in the air, unable to disperse to a higher altitude.

Today was our first day of work in earnest as Saturday is considered a transition day and Sunday little work is done so it was hard to find a translator to help us integrate into OB.

We arrive at prenatal clinic where we are asked to help out this morning, to find 3 benches of women, with about 20 women to the bench, already waiting for prenatal appointments. At the start of the clinic day, these women break into a hymn -- the singing is gorgeous -- followed by the Lord’s prayer, all in Creole, all in perfect unison. There is always music here. Throughout the clinic day, we hear American pop music the nurses are playing on a radio in the background. In spite of the poverty, Ipods are not an uncommon sight (and everyone under 60 has a cell phone).

We divide up, Geoff seeing patients with the aid of a woman interpreter named Maurice, an Alfre Woodard exact look-alike, and I pair up with a midwife named Luna.

The prenatal encounter is as brief and sparse as the offices in which they take place. The clinic room I am in is long and narrow with a desk, a chair, a fan mounted on the wall above the desk so it blows on patient and provider, an old exam table equipped with stirrups, and a table with supplies that, while clean, made me, a non-religious person, pray that I never need surgery in this environment. The walls appear to be plaster with dingy, peeling paint and the floors are some kind of old linoleum, I think. The exam table is covered with a paper blue sterile gown rather than a sheet or exam paper. This is changed only if a vaginal exam has been performed on it; otherwise one woman after the next lies on it for her exam. There’s an ultrasound machine that works, and a colposcope, which I don’t know if works or not, but given the current bottles of white vinegar and betadine, used in the colpo exams, it is definitely put into action.

I saw about 15 women in the course of the morning. The midwife did the interview and I did the exams. I’ve learned to say “Coucher pour la examin s’il tu plait” (lay down for the exam, please) or something that sounds like that, which signals the pregnant woman to go the exam table, take off her shoes, put her feet in the stirrups, lie down, and hike her dress up over her belly. If it’s a vaginal exam she drops her panties and does the same. There are no drapes for modesty, the door is not closed, and people come into the room as needed. Even if there is a vaginal exam in process, the women seem non-plused. HIPPA is absolutely non-existent here and it is probably this exact lack of privacy which keeps people from being open about stigmatized subjects here, like HIV (which here is VIH, by the way, or depression).

Listening to Luna interview our patients in Creole, I caught many of the words and a good bit of the gist, though couldn’t keep up with the conversation in detail. I repeatedly wished I’d paid more attention in middle and high school French. But I am actively registering and processing the language, and in the deep recesses of my brain I can feel my French vocabulary file opening.

While the prenatal questions were fairly standard, i.e., do you have bleeding, contractions, swelling, do you smoke, do you drink, it was interesting to notice what was not discussed. For example, we had a woman at 34 or so weeks who’d lost a previous pregnancy at 28 weeks, as it was recorded, to oligohydramnios (of note, oligo is not a cause of fetal death, it is a result of a number of different conditions that could lead to fetal death -- the reason in this case was not noted in the chart). There was no discussion of or inquiry into how she was feeling emotionally in this pregnancy regarding pregnancy loss -- did she have worries? The fetal death rate here is astronomical, 1 in 12 children die before 1 year of age, so it’s common and seems to be taken for granted. I am sure people feel it; they just remain silent.

Also, clinical findings that would concern me both as a homebirth midwife and as a family doc don’t seem to phase the midwife. For example, a woman at 28 weeks with noticeable generalized edema, headaches and a diastolic BP of 80 caught my attention. I asked the midwife if she would usually check protein. “Vous chequer protein din pipi?” I ask, I am sure sounding ridiculous. But something registered and she grabbed a lab slip and checked off protein in the urine to send off.

In the afternoon the women who were sent off for labs come back to clinic for results and any treatments. We have a surprisingly large formulary here, so we can rx metronidazole for bacterial vaginosis, amoxicillin for UTI, B6 for nausea. (I also recommended fresh ginger juice in water with lemon today for a woman who got side-effects she thought were from the B6 she’d tried.)

Between it all we check on kids with cholera, a woman who might have leprosy (I did a scraping and a KOH prep and did microscopy here in the lab), and a newborn who likely has hypoplastic lung. His respiratory rate is 60 and he will not likely survive, but is a trooper….

Off to sleep…..

30 Days in Haiti: Day 2

admin — Mon, 16 Jan 2012 07:52:59 -0700

It's 10:30 am. Geoff and I ended up going to the hospital this morning, instead of the Citadel hike. We were both eager to get to work. It's nice to have someone familiar here, especially because the language barrier is so great. I do understand some French, but Creole is a whole different thing. Then again not so. For example, butter = beurre, this I know, but in Creole, it's bu. You can see where that comes from and with the accent it still sounds like beurre. So i think maybe I'll catch on a tiny bit. But then there are words from who knows what African languages mixed in, and then there's the patois, and the accents. Oh boy! Toto, we're not in Kansas anymore!

First we went to the NICU with Nandina, a lovely Cuban doctor who speaks Spanish and Creole. This was helpful because Geoff is very competent in Spanish and I can understand enough to listen without having every word translated. And she could talk to the patients. The language barrier will be my greatest impediment to patient care. By the way, do you know that many of the interpreters here are men who were busted on drugs charges in the US and deported? They speak English so are highly employable here! This is not a joke -- it is true.

We then spent a good bit of the morning going around with Dr CC. He is from Guinea Bissou and here for 17 months now. We went around to see the newborns, little kids, went to the surgical wards, and then through the ED and med-surg tents.

There are a great variety of conditions here. In the NICU was a baby born macrosomic and hypoglycemic; the mom was not diabetic according to the charts (which are in Creole, by the way, so it takes some deciphering), but really the NICU docs don't know anything about the moms or the babies, or just the most minimal information.

Another baby is in the NICU for 3 months getting AZT therapy which appears to be available on some kind of grant. Most of the mothers breastfeed very openly here but because of the HIV this baby can't be breastfed, so he's here for feeding. Another baby has RH-incompatibility and needed transfusions for severe anemia. She's been here for a month and would practically fit into Michael Jordan's shoe (i.e. she's really small even if his shoes are big).

I went to change the poopy diaper of a crying newborn, only to discover there were no diapers. I saw some on the windowsill near the next bassinette over, but Geoff smartly pointed out that they probably were brought in by a different family. He was right. In fact, families bring in almost all the necessary supplies for their hospitalized family member.

The kids had a variety of conditions: traumas including scooter (that is, motorcycle) accidents, burns, and other accidents. There are many skin infections. I've never seen filariasis before; just in pictures. It's very common here. (I think I'll keep my shoes on and probably won't wear flip-flops outside of my room and the shower!) Filariasis is the parasite that causes what is more commonly known as elephantiasis. Look it up and you'll recognize it. I felt the leg this morning of a woman with it. It's incredibly large and taut. I was unable to ask whether it is painful.

Scooter accidents are incredibly common. People squeeze as many as 7 people on them. This morning I saw a dad with a toddler in his lap driving one, and sitting behind him was the mom with a very young baby lying across her lap.

We checked on the woman who had an above-the-knee amputation last night. She was sitting up, happily, with a family member caring for her. She looks amazing!

The porch is cool and comfortable. There is choir music in the background. This is a very religious, spiritual, and superstitious country. I'm going to read up on a few things that are going to be especially helpful. I am going to especially brush up on my neonatal resuscitation. It sounds like efforts are sketchy here but that they do have Ambu bags, so at least I can do what I can if a baby is born distressed, which in all likelihood will happen.

There is loud call-and-response hallelujah coming from a church nearby. Cars, trucks, scooters going by. It seems anything bizarre is possible here.
------------------------------------
As I left off this morning, we were planning a horseback trip up the mountain. As you can see from the photo, this actually happened. I only wish you could see a film of what I saw/heard/experienced today. It was incredible on so many levels. And it was just pure taking in with some thoughts interspersed, but not many. It was all new and fresh and technicolor. The colors, air, sounds, scents of Haiti -- they are so rich and stimulating, but in a non-hectic soothing sort of way. I feel like I got to see the lesser-seen parts of this town today. And with a bit of Creole schooling along the way. Thank goodness for middle school French. It's actually surprisingly helpful.

The journey started with our guide telling us he was ready. We were to paying $25 dollars (US) for the horses. We walked toward the hospital gate, which is open during the day, and where three small horses (we'd call them ponies at home but they are full-grown horses, just some small species) were waiting for us across the road. There was a group of youngish Haitian men with the horses. Between us and the horses was a security guard and a group of men in outrageous and intimidating black costumes, masks, and wigs fake verbally accosting the security guard. It took me a few minutes to sort out that this was just a theater group and not some outburst in the making. Our guide got us to the horses past the ruckus of the actors, and we began our 7 km round trip journey from sea level to 3000 feet where the Citadel is located, and back. It is so high that you can see the DR from there. We were to ride there and walk back. It was a several hour journey that began at about 1:30 and we just returned at about 6pm. It's been dark for about 30 minutes.

My horse was led by a young Haitian man who periodically reminded me not to forget his name and his good service (not too subtly prepping for a tip at the end -- this is ubiquitous here). We not quite trotted not quite walked through town over cobble-stoned roads filled with people walking, children playing, dogs, and goats. We cut up narrow little side alleys between homes, and through parts of town iId surely not venture to on my own, but which are fascinating and colorful. It's Sunday, church is out, and people are everywhere. Walking, sitting on front stoops, and on porches. Stores seem closed but vendors have simple wares and food here and there. The streets have much litter along the edges, but are generally clean on a macro level. On a micro level -- well I'd not walk barefoot here under any circumstances, but children everywhere, of course, do. Little girls are curling their mom's hair, moms are combing out their daughter's hair; families are together just hanging out. There is music -- live and radio. Every kid wants a dollar. A few toddlers yell out "Blanc" as we stride by (Blanc just means white person, it also sort of means "gringo"). The horse ride was somewhat relaxing (my thighs are now killing me! and Kim Land, my dear friend, I now know why at 45+ you still have the most kickass legs!) though there were some steep inclines. And there was that road grate that my horse suddenly decided to jump. The trip was a botanical paradise: cacao, breadfruit, soursop, grapefruit, oranges, mango, coffee, squash, sugar cane, okra, fava beans, castor bean, poinsetta trees, bananas, and so many herbs I wish I knew but didn't, all growing by the side of the road. There were gardens in seemingly impossible places. There was a small open building with colorful paper cut outs hung all around like Tibetan flags and a chair tied high up on a pole with a picture of perhaps a saint on it. I later confirmed my suspicion that it was a Voudon house -- a place of worship. It was both bright like it could have been somewhere that a child's birthday party just happened, but also foreboding and not somewhere to trespass or photograph.

The air became cooler as we climbed, and it was slightly cloudy, so the temperature was comfortable. I relaxed into the semi-rhythmic pace of the ride, just taking it all in. The view also became breathtaking and I understood why Paul Farmer's book was called Mountains beyond Mountains. We could also now see the sea. So lush. Not the deforestation I'd so heard about Haiti, not here in the north.

We arrived at the base of the Citadel, paid our 'horse men' not $25 dollars but $25 per horse, including the guide’s horse, and a $5 tip was expected for each of the 3 'horse men.' We explored the Citadel for a long time. That same king, Christophe, built this fortress, which my co-Haiti colleague said is larger than many of the fortresses and castles he's seen in Europe, to protect himself and his kingdom from Napoleon. We saw many of the over 200 cannons that were hauled up by slaves, cannon balls in the fort, the prison, and the cisterns and water system. This is an impressive feat architecturally at that altitude and just generally. It's also beautiful. The whole place is built of stone and the mortar is a mixture of cow blood, gelatin, limestone, and some other ingredients. It's 200 years old and this is how it's held together.

The descent on foot was long and the road very uneven stone. We walked passed scads of interesting homes and families, men in groups, women in groups, tons of children and a lot of goats. The babies -- both human and goat -- are ridiculously adorable. On the way down our guide cut pineapple sugar cane with a machete and gave us each about a 12 inch piece to eat on the way back. It was sweet but not too much so, and refreshing.

We arrived in the main part of town nearly at dark. The town was still bustling and colorful and alive. My legs ache and I am tired but peaceful, and feel so enriched seeing how people here live. It's bare bones, low carbon footprint, remarkably simple, and while poor, rich in other ways.

I am tired. I start on ob at 8:30 tomorrow morning, actually, a very decent hour! So I'm going to sign out after a private email to my guy manning the fort at home, and get some sleep.

Bon nuit, amis!

30 Days in Haiti: Day 1

admin — Sun, 15 Jan 2012 10:33:23 -0700

It is incredible here -- a strange mix of intense beauty and poverty. My little bed is in a room with 2 surgical residents. I have a tiny hard little cot that is a little like sleeping on a cardboard box, but I've got good drinking water, electricity for the minute, food and feel generally safe as long as I am within the work place or with someone.

We got here safely and easily – a bunch of docs in a van seated sideways like a police van. All of my luggage arrived intact and I am unpacked. I have a sink in my room and a shower nearby. We had a tour of the hospital which is really an amazing place. They have built a whole maternity ward and even have a surgery just for sections. There were at least 10 women laboring when I was up there. I suspect I will be kept busy, though was given today off, and tomorrow, too, if I want it, though I will likely go to work. Dr. Previl is the director here AND he is OB, so I am golden and will be working with him and the midwives. I'll also scrub in on sections.

People are very nice. Warm. Appreciate the simple "bonjou". The Pedi ward and NICU were heart wrenching. My colleague, Geoff, said he hadn't even seen that level of malnutrition in Cameroon! So many premie babies in a primitive NICU. Severely sick little kids. And then there are the ICU and cholera tents. Rough...

I went into 'town' with Geoff after lunch, for a couple of hours. It's a short walk past the hospital. Milot is made up of streets of hundreds of funky shanties made of everything you can imagine, and very artful looking. There is tons of music, from American-sounding hip-hop to choirs to religious stuff, to stuff I'm sure is stuff I should stay away from. Lots of scooters and overcrowded cars traveling fast that sometimes honk but sound loud enough on the gravel roads and usually have music or something blaring. Practically every kid asked for a dollar. I told them I could give them "high fives." They mostly seemed happy with this. There are dogs, goats, horses, pigs, cows, chickens, everywhere in the streets. At one point I pulled Geoff to the side because a scraggly, cute pony was loose, running up the road straight toward us. The town and the people are so colorful, and the landscape is verdant, rich, and beautiful. There are coconut trees and flowers all over. It is sweaty humid hot, like July in Atlanta. Feels good. Need tank tops!

We went to the Palace Sans-Souci (“palace without grief”). Built by King Christophe who ironically to the name of his home, ultimately shot himself with a silver bullet. Also, 20,000 slaves died building it. But it is GORGEOUS, or what's left of it. Took pictures but haven't uploaded yet and can't send too many from here 'cause it costs them a lot when folks do.

Lunch was delicious. Healthy. Some meat, rice, veggies, and local chilled grapefruit already sprinkled with sugar. Meals are at specific times and if you don't eat then, you don't eat. No room for picky here (and definitely no space to be a vegetarian -- you'd literally become malnourished).

We have dinner at 7 and then a meeting, I think that tonight I'm going to shower early and get into my mosquito netting and review some ob reading.

Last week a pediatrician visiting here got bitten by the compound dog. She is being treated for rabies. The dog was put down. I asked if they sent rabies pathologies. The reply was "this is Haiti." It's a controlled environment but there are overt reminders that this is a seriously impoverished environment in a developing nation.

Apparently voodoo drums start at dark and go all night. That will be incredibly weird and spooky and fascinating and I find myself in awe of folks like Richard Schultes who plunged into unknown worlds so completely. I'm just not THAT brave. We are supposed to stay in at night but I could have to go to births on some nights. This is exciting but I will not be going alone, that's for sure! There is a good bit of local security here. They are as ominous as they are reassuring.

Aviva

P.S. If you do not want to read about my travel adventures feel free to delete any emails from me or my website with any subject line including the word Haiti. I will not be offended.

There’s No Place Like Home

avivaromm — Mon, 26 Dec 2011 15:44:02 -0700

One week ago today I had the unique honor and pleasure of being the midwife at the birth of my granddaughter who was born at home. The labor was neither quick nor easy, giving me ample time for reflection and contemplation on the process of birth, place of birth, and the work of being a birth attendant.

Here’s the back story: My son, well, he’s the child of a midwife-now family doctor who attended the homebirths of his 3 younger sisters and his nephew, whose birth I midwifed 20 years ago -- not to mention the ones he attended on my back as an infant in a backpack. For him, homebirth is a natural choice. My daughter–in-law is a Harvard pediatrics resident. This is not a trivial fact. In Massachusetts, it is the pediatricians, even more than the obstetricians, who have been the most vociferous about the dangers of midwives -- they’ve tried to shut down birthing centers because they consider those a dangerous place to have a baby -- so you can imagine the attitudes about homebirth!

When my daughter-in-law became pregnant, I shared my joy about the pregnancy, but withheld all opinions about pregnancy and birth, making it clear to her that my strongest abiding belief is that women birth best where they feel safest and if for her that is the birthing center or hospital, she had my fullest support. I let her know I was available for questions should she need any information, but I had no expectations of involvement on any level. And this was completely true and authentic.

Early in the pregnancy she opted to birth at the birthing center across the street from and affiliated with the hospital where I attend births as part of my residency program. It took a few tries for her to find the midwife with whom she felt most compatible, but she seemed pleased with her choice and settled into her prenatal care. That is, until a few weeks later when she received a report that her thyroid test was abnormal and that she might need treatment for thyroid problems, which can be dangerous for the baby if left untreated. She called me for advice and was clearly anxious and upset. Here’s the problem, I told her: We really shouldn’t be checking thyroid tests in early pregnancy in women who don’t have thyroid disorders because pregnancy normally causes thyroid tests to come back abnormal. To reassure her of this fact, I confirmed this information via a former mentor of mine, a world-renowned expert in maternal fetal medicine. Sure enough, a few weeks later, a recheck of her thyroid test was normal. The experience left my daughter-in-law feeling less than confident in conventional prenatal testing. Strike two against conventional medical prenatal care happened later when she went through a similar misadventure regarding prenatal glucose tolerance testing. She was beginning to feel that the over-medicalization, and worse yet, mis-medicalization, of her pregnancy was a distraction from her confidence in herself -- and her care providers.

At this point my daughter-in-law started reconsidering her birth options and after initially asking me if I would be her primary birth attendant at the birth center, which I couldn’t do because of restrictions in place at the birthing center, she opted for a homebirth and asked me to be her midwife. Now you might think that my midwife inner self was jumping up and down with excitement over her decision; I mean, really, how cool is this! But I wasn’t. While I was deeply moved and honored when she told me that I was the person she most trusted in the entire world to “deliver” my grandchild, my respect for birth is profound. I know that most of the time things go without a hitch, but it was also a big responsibility -- when things go “wrong” with birth, the stakes are high.

Further, the situation for me was politically complex. I am not just a homebirth midwife with 30 years of experience with birth; I am also a medical resident whose autonomy as a doctor is not fully granted until residency completion. Thus my role at a homebirth, and especially as the midwife to a family member (and in my supervisors’ eyes, doctor to a family member) is subject to the position of my program director. After all, I am covered by medical insurance provided by the program and they determine whether my conduct is considered “professional.” And on top of it all, I would also be personally and professionally judged, as would my daughter-in-law, by the pediatric and obstetric communities in which we both regularly participated, based on the outcome of the birth. Rough waters to navigate!

A further consideration I had about being the primary midwife for my daughter-in-law revolved around my experience that when push comes to shove (or should I say when birth comes to push?), a woman doesn’t necessarily want her mother-in-law down by her coochie. I wanted my daughter-in-law to have an “out” clause in case she changed her mind about me being at the birth at the last minute.

We settled on bringing in another midwife to join me at the birth, to provide options should my presence at the birth not be ideal for any reason, and on some level, for political protection for me “on paper” as my program made it implicitly clear that it was not appropriate for me to take care of a family member. This is quite different than in the midwifery model, where many women have welcomed their grandchildren into the world. It is also quite different from the way medicine is practiced in small communities where the presence of only one doctor in a town or village might necessitate caring for family members. But that’s another story…

Fast forward to December 18th, 2011. My daughter-in-law went into labor at 40 weeks and 3 days gestation. Labor began in earnest in the early evening, and by midnight when I called to check in before heading to sleep, I could tell by their voices on the phone that they’d feel more settled in if I came over to their place and just went to sleep there. So after 6 years of medical school and residency, I got dressed, packed my midwifery supplies into my car, and headed to my first homebirth in six years.

I never did go to sleep that night. Or until 2 am the following day. Contractions were close together and on the longer side, not allowing any rest for the laboring momma through the night. Toward morning we called my companion midwife to join us, thinking things would move fast as she was already 6 cm dilated and contractions were getting closer together and much stronger. But the day dragged on as nearly relentless labor persisted. We did all the usual things homebirth midwives do to support the natural birth process and help the mom feel comfortable, while keeping an eye on mom and baby’s wellbeing. Showers, back rubs, hydration, reassurance, etc. By about 4 pm my daughter-in-law began asking for an epidural, telling us she just could not do it. In the typical birthing environment, a quick call to the anesthesiologist would have been made and mom’s wish granted. To the homebirth midwife, such plaintive requests typically harken to what we call “transition” -- that place when a laboring mom is about 8 cm dilated and has to be cajoled into a second wind.

Sure enough, she was 8 cm and hung out there for about 5 more hours, receiving intense emotional support and labor guidance between contractions. About 2 hours of those were spent with my daughter-in-law sitting between my legs on her sofa, me talking her through contractions and then her deeply sleeping, resting on my chest for those precious moments between, recapturing her energy for the remaining labor that was to ensue. Baby’s heart tones stayed rock steady throughout, with intermittent auscultation done alternately by my co-midwife and me.

Finally, at about 7 pm, it was time to push, and after another 2 hours my gorgeous granddaughter was born, her crowning head supported by my hands, and then her little being gently lifted from my hands into her parent’s loving arms, three generations touching her little wet self in her first seconds “planet-side.” The parents were tired but triumphant and exhilarated. The labor did not fit Friedman’s curve. The labor was a normal, unique, non-linear process.

During the long labor I reflected on so many things. I had sentimental, emotional moments watching my son dozing on the sofa or kissing his wife affectionately on the head, or encouraging her to take sips of water or tea between contractions, wondering where the time had gone since his birth, which I remember as if it were yesterday. I also sometimes just reflected on the transcendental, spiritual connection I felt with my granddaughter in labor -- that somehow I just knew deep inside me that she was doing well.

But mostly I reflected on the role of the birth attendant. Homebirth midwifery, done properly, requires a lot of hands-on support and decision making by the primary attendants(s). During this labor I’d felt moments of concern, wondering if the long labor was dysfunctional and would result in a hospital transport, and how that would shape the psychology and confidence of the new mother. I had to consider how to intervene in supportive ways to help what was likely an asynclitic head shift in the pelvis to allow labor to effectively proceed, and I had to find ways to help an exhausted laboring mom sleep without an epidural.

I reflected on just how much work it really is to be a homebirth midwife. This was in direct counterpoint to my experience as a physician attending births where the thinking process is much different. For the most part that kind of thinking is algorithmic and predetermined; it’s not really even thinking, but only following a set of rules. If labor takes this long you do this, if mom has pain you do this, if labor is slow you check dilatation every XYZ hours. And so on. Honoring the natural physiology of birth and its unique manifestations, while attending to safety, requires a different type of thinking. Let me explain.

Two nights prior I had attended a birth in the hospital. The mother, a patient of mine in my residency clinic, had received nearly ten ultrasounds in her pregnancy because the obstetricians and ultrasound experts could not see the baby’s hands on any of the ultrasounds. They had told the mom, and me, that the baby most likely had serious deformities. Based on this I transferred her care to a high-risk setting for birth. She was induced at 38 weeks because her amniotic fluid level was considered low, and she spent 3 days undergoing medical induction. I was called on the evening of the third day of her induction. “Doctor, what time would you like us to call you to come in?” I was asked. Given that it was Saturday evening, and I’d been on call the night before, I asked to be called when she was 7 cm dilated. I was called as I’d asked to be, and when I arrived at the hospital she was fully dilated. She “labored down” -- sleeping with the help of an epidural -- for about another 2 hours. Finally, with 3 obstetricians and an obstetric nurse in the room literally screaming at her to push, and 5 pediatric staff on the sidelines waiting for the baby to arrive, her baby was born and whisked over to the awaiting pediatric staff. The baby was normal and healthy with normal hands. No problems. Inaccurate tests had led to unnecessary anxiety for the mother, and intervention in the pregnancy and birth, much like my daughter-in-law had experienced with prenatal testing, though she avoided the unnecessary interventions.

The mother was quite exhausted and had minimal interest in holding her baby, though she was relieved that he was not deformed. There was little about this birth that seemed to honor the sacredness of motherhood. The mother was treated as a passive participant in a process that one would hardly consider pleasantly memorable.

Now please don’t get me wrong; I do believe there is a place for hospital birth, induction, ultrasounds, and epidurals. I am a rational radical. But the two experiences were so perfectly juxtaposed for me in time and tone that I could not help but consider the differences. I realize how much harder I had to think as a homebirth midwife, making tiny decisions continually along the way as to how I can best support the process and intervene the least, how I had to pay attention to subtle details about the mother’s sounds and words to determine dilatation to minimize unnecessary vaginal exams too often done in the hospital and too often leading to maternal infection. There are so many details, too many to recount.

The sacredness of the birth at home, which I experienced hundreds of times as a midwife before becoming a doctor, struck me to the core. There was no screaming at the mother to push, there was no passivity on the part of the mother -- she was the leading lady in a many act play -- and in the end she deserved a standing ovation! The birth was sacred, peaceful, and beautiful. I can truly and honestly and clearly say that being the midwife for my granddaughter was not an ethical compromise or an infringement of professionalism. It was a completely natural act in a completely natural process. The bond that deepened between my daughter-in-law and me is profound. And the confidence I have witnessed in her as a mother is clearly different than the insecurity I have observed in so many women who leave the hospital after a depersonalized birth experience. Can hospital birth be different or better? Yes, but only if lessons are learned from homebirth midwives.

Now that we are all a week postpartum after welcoming this wonderful addition to our family, I can joyfully click my ruby slippers three times and say, “There’s no place like home.” My daughter-in-law, I know, feels the same way.

Journey to Haiti

admin — Fri, 16 Dec 2011 20:43:39 -0700

I have some inspiring news to share with you. In 4 weeks I will be traveling to Haiti for 4 weeks to provide maternity care services in a town called Milot in northern Haiti. I will be volunteering as a family doctor at Hôpital Sacré Coeur, the largest hospital in this region, attending births full time alongside the midwives who deliver 99% of the babies there, and assisting the OBs when their involvement in the birthing process becomes necessary.

Haiti has the highest maternal mortality rate in the western hemisphere, with an astonishing loss of 800 mothers per 100,000 births. I anticipate that being there will be a profound experience with a lot to learn, and I am deeply grateful for this opportunity.

There is so much to do now — in a short time -- to get ready for my trip. I’ll write again soon, but in the meantime if you are interested, you can watch a photo essay about the midwives of Hôpital Sacré Coeur here.

In good medicine,
Aviva

How Doctors Die

avivaromm — Tue, 13 Dec 2011 21:24:11 -0700

Being a midwife was the most powerful preparation I had for being an excellent doctor. (Sort of like all I really needed to know I learned in kindergarten.) Perhaps where it prepared me most, aside from the mama and baby care, was actually in palliative care -- talking with and helping patients accept, plan for, integrate and prepare for death. It's in the caring, in the truth telling, in the space holding, love giving, touch generous, compassionate listening ability to openly and authentically talk with another human being about the hardest part of life we face. This article came to me yesterday. It's not the cheeriest topic -- it is about death. But it is a powerful piece about how doctors die -- with much less intervention than most other people -- often at home, no heroics. It's a tale of how birth can be, death should be in most instances, and perhaps how we can reframe medicine into something about compassionate humanity.  

http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/nexus/