flying solo

Week of 19 March 2012.

"It's all you today, Cristin." Olen said to me as I was walked, a bit late, into the maternity on Monday morning. "Baikao is at a conference and Danae is home today, so you are the only one covering maternity." Baikao is the sage-femme (midwife) and one of the few really trusted and respected nurses at the hospital. She is awesome. She shows up, is conscientious, knows when to ask for help, but has the confidence to do things on her own, too. Baikao, as it turns out, was to be at a conference on Cholera prevention and treatment in Kelo on both Monday and Tuesday. Danae was home with her sick baby. There is usually a nurse-in-training that also covers maternity, but due to a recent mass exodus of staff, she was hired by the hospital and so was now working the second shift. So, just me. "You okay with that?" Olen was asking. "Sure." I said. We only had 4 admitted patients, no one currently in labor and it was Monday. Monday is a not typically particularly busy for out patient visits.

And Monday was quiet. I passes out meds, started a few IVs, and saw 5-6 patients. It was fun - like being in clinic in the US, except here I was the one deciding what each patient needed. In the US in a clinic the med student might go into see the patient first and get the history - maybe do a bit of physical exam. In gyn, though, the med student wouldn't normally do a vaginal exam unobserved. After the med student sees the patient, you go back in with a resident who either watches the med student do any necessary exams, or does them herself. Finally, both resident and med student discuss the patient with the attending, decide on a plan , and send the patient home. But there I was, on my own. So I would do the history and physical, come up with a plan and as long as it was uncomplicated, write for whatever prescriptions or tests were needed and send the patient home.

For me, even though I knew I was doing what needed to be done, this was very nerve-wracking. All those levels of oversight, just gone. For any one even mildly complicated, I did go find one of the docs to precept with. But they kept telling me, "you are doing fine. You don't have to ask permission to do these things. If you know the answer, just do it."

Tuesday was a bit more exciting. Tuesday and Thursday are designated prenatal visit days, and so we expected a much higher volume. Plus, I had admitted a patient with pre-eclampsia (high blood pressure and protein in the urine during pregnancy) and a dead baby at 33 weeks the night before. She had been started on misoprostol (for induction of labor). By morning, The miso had finally kicked in, so she was starting to labor (which made me really happy as her increased blood pressure was really making me nervous). There was also a woman who had come in over night in labour with her 6th pregnancy. Danae did come in on Tuesday morning, thank goodness, and she said that she wanted to get the dead baby delivered first, and then we could do the other.

I had never seen a dead baby delivered at quite so late a gestation. It was the woman's first labor and she was understandably very upset. She had been having 3 contractions every 10 minutes since midnight, so was uncomfortable, emotionally worn out, and just generally unhappy to have to go through labor. The delivery was not easy. The baby had probably been dead for a couple of days before she came to us, which means that everything had softened in a way which made getting the baby out very difficult. Danae tried to let me do the deliver, but my hands kept slipping on the fragile skin, and I couldn't get the head to budge. Danae took over, and finally, the baby and placenta were delivered and the mom was left to grieve with her child.

Danae checked the other lady in labor, found that she was 7cm dilated. She asked me to watch for any bleeding and do regular BP checks on the first lady and just keep an eye on the second lady. She then grabbed a stack of prenatal visit cards and went off to the office.

I checked on the other patients, saw a few simple consults and handed out some meds. After about 30 minutes, I was able to transfer the woman who'd delivered back to a regular bed and her family cleaned up the birthing room. I was sitting in the office doing some paper work a few minutes later when the mother of the woman in labor came and got me. She spoke no French but made clear that her daughter was wanting to push.

I went into the labor room, found that there was only a lip of cervix left, and that mom was already pushing. I tried to get her to stop pushing, but she wasn't having that. I called Danae on her cell to tell her what was going on. "Are you okay for the moment?" she said. I was. "Okay, then, I will be over in a few minutes. I'll keep an eye out the office window, yell if you need anything."

And then things took on that odd quality where everything is happening very, very quickly and yet time seems a bit slow. I did another exam and the cervix was now completely gone, the woman gave a big push and the water broke, and then the head of the baby was coming down fast. But, I was still okay. And then I noticed that the cord was wrapped around the babies neck. I tried to loosen it up, to slip it off, but was unsuccessful. I used hand signals to communicate to grandmom: "Find Danae Now." I was able to convince mom to stop pushing for a minute, and was (finally) able to reduce the cord. And then, the baby was out. I held the (very quiet) little boy by his feet, smacked him on the back, and asked him to breath. After what seemed like an hour, he coughed and started crying. Taking that as my cue to start breathing again, I was able to clamp and cut the cord, despite being terrified that I would drop the now wailing (and very slippery) little boy.**

Luckily, at that moment Solomon and Mayline (the nurse from surgery and one of the volunteers) rushed in. Solomon said, "Ai! Cristin! Ou est Danae?" and then "Donne moi le bebe" (Where is Danae? Give me the baby.) I was thrilled to hand him over. He and Mayline took the baby over to the bassinet to clean him up and wrap him in a receiving blanket, while I delivered the placenta. Then Danae came flying in. "Everything okay?" She said. "I think so." I responded. (I know she was asking about mom and baby who were just fine, but I was still having to remind myself to breath normally.) Together we checked mom for tears (there were none) and Danae started a oxytocin drip to help mom's uterus cramp down.

"So now you know how to deliver a baby on your own." she said. "Strong work."

Me and the baby

**all in all - this was a pretty easy delivery. I probably only had trouble reducing the nuchal cord b/c I was nervous. This is the first time I was the ONLY one in the room before, hence the drama. After all, most women, given the opportunity, would deliver the baby on their own with no interference from anyone.