Sunday, January 26, 2014

a story of life (and its many surprises)

There are many ways to tell a story.  Five people in the same room would all choose different details to share. The more experienced midwives and nurses would tell this story with far more sagesse (wisdom) than I, but they are exhausted from using their wisdom so stinkin much this last 36 hours. They elected me to write this story. 

Midwives love telling birth stories. It is kind of their thing. After DOING birth stories; their second favorite activity is TELLING birth stories. When I wasn't in the club I used to feel very left out. Half the words start with V or P and none of it sounds earthly to a novice.  The stories fishermen tell always evolve until the fish is bigger than the boat. If you had only been there before it got away, you would believe it, too. The stories midwives tell evolve until the maneuvers they used to get the baby out mirror that of a martial arts master. If you had only been there, you would know about the back flip I did with that mother in my arms. Every midwife at some point or another has thought of themselves as Bruce Lee.  The stories are told and their husbands roll their eyes and slowly back toward the nearest door. Their good friends either come to accept and enjoy these special stories, or they do what husbands do.

This is a fact of midwife life.  The story-telling and shoptalk cannot be stopped. To love a midwife is to love birth stories.

~          ~          ~

Last Thursday, we posted this photo of the classroom on Prenatal Day.  More than a few people commented on "yellow shirt girl" in the front row. A few wise bookies and numbers runners even placed bets on yellow shirt to pop next. She can't even sit up, they astutely noted.

Truth be told, we were all getting impatient. We had a 23 day streak with no births, and had not yet welcomed a baby in 2014. We hoped all you bet makers were onto something.

After class on Thursday all the midwives and nurses went about doing prenatal visits. On Thursdays we yell from room to room, "Hey, come feel this, this is unusual" - or - "You guys, tell me if I am right here, this feels like a breech baby."  The way we go about it is not all that polite, but our leader is Bostonian and we have all assimilated.  Her nickname is 'boombox'. She bellows. We bellow. 

Dr. Jen happens to be in Haiti for a couple weeks.  While prenatal ultrasound is not her specialty by any means, she is better than the rest of us at ultrasound. Our machine is older, but still very useful to us during key times in a woman's pregnancy. We had accepted five new ladies into the program Thursday and Jen was "dating" (not going out for coffee, rather finding out how pregnant they were) a few of the brand new ladies for us. 

When Beth McHoul got to the prenatal visit with yellow shirt, she said, "I need to see what this is all about", she asked Jen to do an ultrasound.

Stephanie (yellow shirt) was measuring very large and other midwives and nurses had been seeing her on and off for many weeks, but Beth felt something was off about her fundal height (the measurement of her large tummy). An ultrasound was done. We all gathered round to watch. Five sets of eyes looked on with Jen. As a group we saw a head down and we saw a vant that was plen (a tummy that was full). There was agreement in the room that Stephanie would deliver her baby soon, hopefully very soon. The midwives stripped her membranes and tried to get her to a place where she'd begin contractions soon.

Jen, Beth, Beth, Tara (a few others were also in the room at this time)

That evening, around 7:30 pm, Stephanie came back to the Maternity Center having regular, intense contractions.  That was what we had hoped for at her afternoon consultation. The team of Beths (count them - 2 Beths) got her settled in and decided this was the real deal.  They made calls to let others know that Stephanie had come back.  We labored with her until 2am before putting her to bed to sleep (it is not sleep so much as it is a darker room with the same contractions but a little bit more relaxing atmosphere) for a couple of hours. All night long Stephanie labored. She was vocal and miserable, as laboring women are sometimes known to be. In between contractions she snoozed. 

Morning light came, Stephanie had made some progress. She did some walking and stair climbing and took a shower in between her vocal exercises. She worked hard all morning and into the mid afternoon.  Her blood pressure was high and the appropriate steps were taken to manage that.  Stephanie said every hour or so, "I can't do this anymore. I feel that I have suffered too much."  

That is an understandable way to feel. These are things women in labor say. When those things are said, we say, "di tet w, mwen ka fe sa, mwen gen fos" - "tell yourself I can do this, I have strength."  These  are easily the most often uttered words during a labor at the Heartline Maternity Center. Di tet w - 'MWEN KA FE SA.'

Around 4:30 Friday afternoon, Stephanie had reached the magical number we all love to hear; ten centimeters.  

Our team at the Maternity Center varies from time to time, but as of last week the group that will be in place for the next six or seven months all found their way back to Haiti after short and long breaks. Dr. Jen was the bonus player in house.

At each birth we generally take turns playing different roles. We all have a turn assisting, we all get to be the primary, we rotate spots and try to know how to do everything, should we ever find ourselves alone to deliver a baby. Our entire team knows how to act as a team and knows how to play varying roles. 

Because I am so near finished with my clinical requirements, I was being supervised by Beth Johnson (my official preceptor and an experienced midwife) and was ready to catch Stephanie's baby. Stephanie leaned on the side of the bed with her knees on the floor. We watched and encouraged as she pushed. Jen popped in and out to see how the pushing was going.

I debated writing this story for the other midwives, using all the jargon and asking the wiser ones to edit me and make me sound smarter.  In the end I decided everyone can enjoy this story if I write it for everyone, (less gore, detail, and official vernacular) and leave the sounding smart part to the very smartest people.

Stephanie wanted to be where she was, at the side of the bed. She continued pushing and pushed for about 30 minutes. As each contraction subsided, she rested.  Everything was going beautifully, even with the IV lines she was forced to deal with due to her blood pressure and signs of preeclampsia, and even in spite of her fatigue from 24 hours of labor. Her baby's heart rate remained strong and steady. 

A few minutes after 5pm Stephanie pushed her baby's head out.  I felt a hand up near the baby's neck and called out that we had a nuchal hand but no cord around the neck.  As it turned out the baby had her right hand up next to her left ear.  (Take your right hand, put your arm on your chest and rest your right hand so it is touching your left earlobe. That's your visual.)  

Because of the position of that right arm and hand, we had about a 90 second delay between the delivery of the baby's head and completion of delivery of the body.  Beth J. was great at coaching and telling me how to proceed and allowing me to learn and do the delivery.  

Helping a woman deliver is technically a plyometrics workout. We did our workout and a shoulder and then an entire baby emerged. Once the baby was out we passed her through so she was on the front side of Stephanie and we had Stephanie turn around and lie down on her back on the edge of the bed to deliver her placenta. Her baby had a very short cord, making that a little bit interesting, but the flip happened (this is where Bruce Lee and some fancy-pants moves come in handy.)  

Wini and Beth M and Dr. Jen and Jenny, the photographer that caught this excitement on camera, were all in the room helping and playing their roles. (There are people with towels ready to dry baby, there are people with pitocin ready to stop a large hemorrhage. There are people handing supplies to the primary. There are people charting the time and vitals.) 

L to R - Wini, Beth M., Tara, Beth J.
A few minutes post delivery Stephanie began to bleed pretty heavily. Midwives with some experience under their belt don't flip out about blood gushing, it is part of the story sometimes. Beth J. calmly watched and directed and said, "I think we need to get this placenta out, don't you?"  Meanwhile Wini had pointed out that Stephanie's tummy was still pretty large. 

Beth J. asked me if I was comfortable going in for the placenta.  I basically said, "No, but I'll do it."  (Beth McHoul cheers out loud for you when you do and say things like this. Who doesn't love a good cheer from Madame John?)  I put on new sterile gloves and reached in to try to manually remove the placenta. Below you will see the face a person makes when a placenta feels like a fluid filled sac with a thing that is not placenta-like inside. I pulled my hand out and said it doesn't feel like a placenta. Later I added, it felt more like little bones. Wini tossed the doppler back onto Stephanie's uterus to listen for another heartbeat. It was sort of a moment of the entire room adding up the puzzle pieces from Thursday and Friday and a collective, "YIKES" was screaming from our souls.

At that point so much happened so fast that I know each one of us would recall different parts of the story.  Beth J put on new gloves to confirm the second baby herself. I think Wini went to get the ultrasound machine.  I think Jen cut and clamped and took the first baby out of the picture. I think Beth M. abandoned her charting job and get in on the action. I think Jen put the ultrasound probe onto Stephanie and said, "that looks like a butt first". I think I pooped my pants. I think Beth J, the most experienced in the room, turned into a ninja midwife warrior.  I think Beth McHoul hurriedly called Troy from two blocks away to ask him to high-tail it over to the ambulance and be ready with whatever his mid-husband duties required of him. I think Wini put the oxygen on Stephanie.

We talked to Stephanie.  "Stephanie, nou gen lot baby. W' gen marasa." (Stephanie, we have another baby. You have twins.)  I am still very amused at how Stephanie handled this announcement. If anything, she seemed kind of entertained by this news. She smirked and said, "I have two?" Later I asked her about twins in her family.  She said yes, her mother, no longer alive, had been a twin. 

Twin B's heart rate was sketchy. (Fancy medical terminology here, try to stick with me.) It had dropped to 60 beats per minute. A decision was made to break the amniotic sac and try to get the baby delivered as quickly as a breech position would allow. I held the baby from the outside with my hands as Beth Johnson broke the sac and touched the baby from the inside. Beth J. had Stephanie flip back to her hands and knees. 

She was near the edge of the bed so three of us sort of supported her and gave her help by pushing back on her as her feet pushed into our legs while we stood at the bedside. We figured another plyometric workout was in order. After-all, it had been six or seven minutes since we last worked out. 

Stephanie followed instructions like delivering surprise twins - one breech - was a thing she had been practicing doing for decades. She pushed hard when asked. 

Troy came into the delivery room and said the ambulance was ready and available. We started bossing him around. Beth McHoul asked him to move a few things in the room. He was given the camera. (Those photos are amazingly beautiful but far too personal for the Internet.) In the minutes that felt like hours, Stephanie delivered one foot, then the butt, then the second leg came, then the torso of her second daughter. Beth McHoul wrapped towels around the baby to keep it warm and hopefully prevent it from taking a breath before the head was delivered. The fan in the room was turned off. 

We were all sweating bullets of nervousness.  I dripped on the people around me. I wish we had audio on these moments, people just kept praying out loud as needed. Jesus was asked to protect, guide, and direct. (Multiple times by multiple people.) 

At 5:34pm the limp little baby's head slowly emerged, in fact we saw the chin pop out, and then a little pink tongue.  We could feel the heart beating as the baby hung mostly outside of her mother. "Baby is alive" was announced. Once the head was fully delivered, we cut and clamped quickly and Dr. Jen (trained in Emergency Pediatrics) went to work on baby B while Jenny held baby A and the rest of us (Wini, the two Beths and Tara) focused on Stephanie. The amount of blood and fluid was abundant. We had it up our arms and splattered all over our feet.

Troy told me late that night, "I really wanted to cry at what I was seeing but I looked around the room full of women doing their jobs without melting down and decided I best not do that."  

Instead of crying, Troy captured many beautiful images...

At that point, we were finally in a position to actually deliver a placenta. 

Back in the day, surprise twins were a thing. It happened. Technology has meant that it is not typically a surprise anymore, especially in the developed world. We are not in the developed world and we don't routinely do ultrasounds; obviously we hadn't ever done an early ultrasound on Stephanie. The babies were positioned in a way that made it really difficult to detect. We certainly did not see twins at the Thursday ultrasound. 

Delivering a breech baby is a lost art. There are many newer, younger docs and nurses that won't ever see it because C-Section has become the answer for a breech baby. The reality is, knowing what to do when a C/S is not an option is a really wonderful thing. We are 20 minutes from the hospital in the best conditions and you don't even want to know what the worst traffic conditions could mean. We need to have plan A and B.  Midwives learn about breech deliveries, they read birth guru, Ina May Gaskin, and they hear older midwives tell their stories and while they may never see it, they know what to do. Thank the good Lord, Beth Johnson took charge of the situation and those of us around her knew how to support her and we did what we have been trained to do. 

Without being uber dramatic and self-congratulatory, we do want to acknowledge that had Stephanie not been in our program and had she chosen to deliver at home, two and possibly three people wouldn't have lived. The first baby was not an uncomplicated delivery, the second was the opposite of uncomplicated and many measures were taken to stop bleeding. Giving birth at home without help is risky business in Haiti. Most women do it because they don't have access to better options.  

We quickly took turns getting showered and changed. Nirva (nurse on staff) arrived. She and Jenny helped feed the twins a breast milk snack while Stephanie underwent some pretty major repair work.  Wini started the repair, and Nirva and Dr. Jen jumped in to help. Beth and I began charting the insanity of the previous hour and we all collectively sighed our "thank you Jesus" prayers.  

Within a few minutes of starting the repair, Stephanie began to bleed very heavily again. That took us back into adrenaline mode. Orders were shouted to those in a position to help and many measures and maneuvers to stop the bleeding were done. 

After a lot of investigation and repair, it turned out that poor Stephanie also had a cervical laceration. At this point, the bleeding was under control but we always want every woman to be given the treatment we would want. Because the cervical tear was of questionable severity it was decided that we should try to see if we could get a second opinion. We called the hospital and they said to come. Troy fired up the ambulance and we transported Stephanie to another hospital with OB doctors on staff. The hospital staff and OB doctor looked at it and agreed it was torn but said they felt that repairing it could potentially worsen the bleeding (which had since slowed considerably) and cause more damage. We took Stephanie back to Heartline and got her settled in for the night. Her bleeding continued to improve overnight. 

Nirva, Jenny and important nutrition while Momma is off in the ambulance

Twin B (left) 4lbs 13 ounces - Twin A 5lbs 13 ounces

the face you make when you see a miracle

the face you make when you are in love

At this hour the baby-girl-twins and their Mama, Stephanie, are resting in the post-partum area. Help will be given for days, maybe weeks, as Stephanie is cared for, encouraged, and helped to breastfeed twins.  

They have been joined in post-partum by Lonecia, who delivered her baby girl into Nirva's hands - sans drama - Saturday morning.  That makes two births, three babies for 2014. 

We were grateful that many had said they were praying for Stephanie's birth. It takes a team to do this work, and we consider you a part of that team. We know that statistically-speaking things as complicated as this don't always have such a happy ending. During the labor portion of this many hour event, I had turned to Stephanie's aunt and asked where her children were born.  She said, "both at home", then she added "all normal".  At the end of the birth the aunt's eyes were doubled in size and she knew she'd seen some not so normal things. 

This experience may very well be a once in a life-time for all of us. We're aware we witnessed something unusual and miraculous. 

How blessed are we to get to be there when God shows up?

Mesi Jezi.

Photos courtesy of: Jenny Duhm, Troy Livesay, Beth McHoul


Troy Livesay's Post
Beth Johnson's Post