Huarmey hospital attends to about 18-20 births each month. I would like to be able to see all of them, but many women go into labor during the night and it's not safe for me to walk in the dark by myself. As a result, I haven't been able to see as many births as I would like. One day I was extremely frustrated to walk into the hospital at 8am to see two women in the delivery room, both having given birth within the last ten minutes. I just missed them!
However, one of the benefits of shadowing here for so many weeks is that, every once in a while, a gestante will be obliging enough to 'dar a luz' during the day. Saturday featured just such a woman. She was admitted to the hospital around 7am, 3cm dilated with her second baby. (The second baby part is important to me because it often means that the labor will go more quickly. First-time moms are more likely to have labors that last 12 hours or more.) Within a couple of hours her contractions were coming every minute or so and she was howling in pain with each one. There is only one doctor at the hospital who knows how to give epidurals, and he was busy. Thus she felt the full force of each contraction. It was painful just to listen to her scream.
The doctors here want me to practice giving internal exams. This involves inserting your (gloved) hand into the vagina and measuring with two fingers the diameter of the dilating cervix. It's extremely difficult to do. For one thing, you can't see your hand inside the woman and have to estimate how far apart your fingers are spread and compare it to a dilation chart. For another thing, the cervix is not rigid, and it's easy to spread it open a little bit as you open your two fingers. And then sometimes the woman cries out in pain as you try to examine her. So I give my best guess with this gestante, somehow managing to do the exam in between the contractions that force her to writhe and twist awkwardly in the stirrups. I'm only off by 1cm, which I'm proud of.
By 10am the gestante is brought into the delivery room. She is progressing too rapidly for the staff and me to properly scrub in, but I throw on a gown and gloves and feel semi-clean. As the obstetrician, Margot, starts talking and showing me various instruments, I realize that I have graduated from the umbilical cord-cutting stage of my apprenticeship. She mentions things that I should hold when the baby starts crowning, and keeps asking me to examine the gestante and monitor the baby's descent. This becomes more difficult than I have seen before, as the poor woman (in more pain than I've seen the other women here) is screaming bloody murder and keeps trying to swat my gloved hands away. At one point she aims a kick at Margot, but can't get much force behind it with her legs in the stirrups. Amidst the din I understand Margot explaining to the woman that she's trying to get the baby out faster, and thus is helping to ease the gestante's pain. But the explanation falls on deaf ears as the gestante screams louder and her eyes glaze over.
Thankfully, the baby descends rapidly. I'm told to pick up this one piece of gauze and put it at the base of the vaginal opening, then take my other hand and put it at the top. Margot puts her hands on top of mine and guides me as we push the baby's head out by forcing the vaginal lips away from the curly damp hair that is emerging. And then all of a sudden the head is out. You have to turn it like 90 degrees to orient it properly, then push down to get one shoulder out, and then pull up to get the other shoulder out. The rest of the baby emerges with a gush of fluid. I place her on top of a towel on the mother's belly and within a few seconds it starts to cry (HUGE sigh of relief on my part). I clamp and cut the umbilical cord, a task that seems ridiculously simple now, and after a few minutes I pull out the placenta. It's large (I can barely hold it with one hand) and purple and warm, in case anyone was interested. Margot then takes over and makes sure none of the membranes are left inside the mother, which could cause dangerous bleeding. The gestante looks half dead, eyes still glazed over, limp, and minimally responsive to questions from the doctor, but I think she's just exhausted. She did not have much tearing and did not need any stitches.
Afterwards, I take off the gown and plastic apron and realize that my entire shirt is damp with sweat, both from the heat and my nerves. One doctor goes out to the nearbye tienda and buys me and Margot cold Cokes, for a "job well done." I'm not entirely sure if I did a good job or not, but at no point did anyone shove me out of the way and start yelling angrily, so I know I didn't do terribly. Dr. Meza says that next time, I will do more of it by myself. I just hope this next birth is normal and without complications.
Sunday, February 21, 2010
Tuesday, February 16, 2010
Blood and Loss
The majority of pregnancies result in miscarriages. Most of the time a woman is not even aware she was pregnant before she loses the embryo, so it's hard to obtain accurate data of how often miscarriages occur, but most doctors agree that a full term live birth is relatively rare.
Probably the most common reason for gestantes to come into the emergency room here is because of bleeding. Bleeding during early pregnancy is a telltale sign of spontaneous miscarriage (in Spanish it's called aborto, which signifies something distinctly different in English). However, before Sunday, the bleeding women have presented with very little drama. The blood is more like spotting, and they are admitted to the hospital and placed under observation, rather than subjected to any invasive procedures. Often the bleeding stops on its own in a day or so and the pregnancy continues.
Sunday was different. A gestante, 12 weeks pregnant, staggered into the emergency room, blood soaking through her pants and dripping onto the floor. She left a messy trail down the hall up into the stirrups, and I heard the word hemorragia thrown about by the on-duty obstetrician. Nurses and technicians started running around in response to the ob's orders, fetching gloves and gauze and the box of specula. The ob took one look into the woman's vagina and said, el cuello está abierto. Meaning that the cervix had opened and the contents of the uterus were being expelled. Sure enough, when she reached in with the gauze on the end of a metal pincer-like thing, chunks of red gloopy stuff the consistency of jello plopped out.
This was a case of a partial miscarriage, in which some of the contents of the uterus were leaving through the open cervix, but some of the products of pregnancy were still inside. The fetus is no longer viable at this time, and any remnants of it or the placenta left inside the body have the potential to cause massive bleeding. And so the gestante was wheeled into another emergency room, where the on-call doctor performed what's called a legrado uterino. Basically, she inserts this metal rod with curved ends into the uterus and scrapes out all the contents. It's super disgusting and sad to watch, manually removing what could have resulted in a baby under different circumstances (actually many spontaneous abortions are the result of chromosomal defects in the embryo/fetus, so it could never develop into a normal baby, but environmental factors can also harm an otherwise normal embryo). I saw mostly the same red gloopy stuff as well as a miniature placenta exit, but no tadpole-fetus, for which I am glad.
The procedure was successful, meaning that the now non-gestante stopped bleeding and was allowed to leave the hospital at the end of the next day. It turned out that she had reported bleeding, in the form of spotting, as much as two days before the emergency. She had even been checked out by a different doctor the day before but had refused hospitalization. This was her sixth pregnancy and had said that her five children and husband needed her at home. The ob was highly critical of this decision, for obvious reasons, but I think it's relatively reasonable to want to take care of your family and forego hospitalization. She'd done the whole pregnancy thing before and there's a good chance she'd experienced harmless bleeding. Plus, I find it difficult to be disdainful of a patient whose just lost her pregnancy, no matter how careless she may have been.
Probably the most common reason for gestantes to come into the emergency room here is because of bleeding. Bleeding during early pregnancy is a telltale sign of spontaneous miscarriage (in Spanish it's called aborto, which signifies something distinctly different in English). However, before Sunday, the bleeding women have presented with very little drama. The blood is more like spotting, and they are admitted to the hospital and placed under observation, rather than subjected to any invasive procedures. Often the bleeding stops on its own in a day or so and the pregnancy continues.
Sunday was different. A gestante, 12 weeks pregnant, staggered into the emergency room, blood soaking through her pants and dripping onto the floor. She left a messy trail down the hall up into the stirrups, and I heard the word hemorragia thrown about by the on-duty obstetrician. Nurses and technicians started running around in response to the ob's orders, fetching gloves and gauze and the box of specula. The ob took one look into the woman's vagina and said, el cuello está abierto. Meaning that the cervix had opened and the contents of the uterus were being expelled. Sure enough, when she reached in with the gauze on the end of a metal pincer-like thing, chunks of red gloopy stuff the consistency of jello plopped out.
This was a case of a partial miscarriage, in which some of the contents of the uterus were leaving through the open cervix, but some of the products of pregnancy were still inside. The fetus is no longer viable at this time, and any remnants of it or the placenta left inside the body have the potential to cause massive bleeding. And so the gestante was wheeled into another emergency room, where the on-call doctor performed what's called a legrado uterino. Basically, she inserts this metal rod with curved ends into the uterus and scrapes out all the contents. It's super disgusting and sad to watch, manually removing what could have resulted in a baby under different circumstances (actually many spontaneous abortions are the result of chromosomal defects in the embryo/fetus, so it could never develop into a normal baby, but environmental factors can also harm an otherwise normal embryo). I saw mostly the same red gloopy stuff as well as a miniature placenta exit, but no tadpole-fetus, for which I am glad.
The procedure was successful, meaning that the now non-gestante stopped bleeding and was allowed to leave the hospital at the end of the next day. It turned out that she had reported bleeding, in the form of spotting, as much as two days before the emergency. She had even been checked out by a different doctor the day before but had refused hospitalization. This was her sixth pregnancy and had said that her five children and husband needed her at home. The ob was highly critical of this decision, for obvious reasons, but I think it's relatively reasonable to want to take care of your family and forego hospitalization. She'd done the whole pregnancy thing before and there's a good chance she'd experienced harmless bleeding. Plus, I find it difficult to be disdainful of a patient whose just lost her pregnancy, no matter how careless she may have been.
Wednesday, February 10, 2010
In the Family Way
In the States, it's relatively rare to see an obviously pregnant person. I know I always do a bit of a double-take whenever I see a woman with that huge protruding belly walking down the street. In Peru, it seems like every other woman under the age of 30 is either pregnant or nursing a baby. My first thought was that because the country is Catholic, there was no form of birth control available, but this is not the case. Condoms, pills, and hormone injections are all available free of charge at the hospitals and clinics.
Even so, the average age of the gestantes in the hospital is around 17 or 18. It's certainly part of the cultural norm to have children young. Despite realizing this, I find it extremely difficult to listen to a 16 year old girl, a few weeks pregnant, talk nonchalantly about having regular unprotected sex with her boyfriend while jiggling her two year old son on her lap. Peru is a poor country and I feel a certain feminist indignity well up inside me when I think about how these girls become so limited as soon as a child comes into the picture. Some of them have husbands and most have at least boyfriends, but how many of us can claim to have met our soul mate before our 20th birthday?
Girls in the mountain regions fare worse. The doctors all blame a lack of education, despite reported access to free family planning options. The most dramatic example was a girl who came to Huarmey hospital at 38 weeks (40 is full term) in order to be near a hospital with more resources when she went into labor. She is 12 years old. It completely boggles my mind that this is even possible. I wanted to ask her who the father was (older boyfriend or sadistic uncle?), but her labor was deemed to dangerous for the capabilities of Huarmey and she was taken to a larger hospital two hours away, and I never got my chance.
When I shadow in the gynecology clinic, where gestantes come in for routine checkups and minor problems with their pregnancies, the patients are typically 15-19 in age. Patients in the family planning clinic, which distributes the condoms/pills/hormone injections, are quite different. These women are generally older, in their 20s and 30s, and they invariably carry their babies/young children with them. And so the pattern appears to start a family early, and only after establishing one, to limit its size. Again I realize that I am in a different culture and that not everyone wants to or thinks about waiting to establish financial stability (at the very least) before having children, it's difficult to see teenager after teenager burdened with such heavy responsibility.
Even so, the average age of the gestantes in the hospital is around 17 or 18. It's certainly part of the cultural norm to have children young. Despite realizing this, I find it extremely difficult to listen to a 16 year old girl, a few weeks pregnant, talk nonchalantly about having regular unprotected sex with her boyfriend while jiggling her two year old son on her lap. Peru is a poor country and I feel a certain feminist indignity well up inside me when I think about how these girls become so limited as soon as a child comes into the picture. Some of them have husbands and most have at least boyfriends, but how many of us can claim to have met our soul mate before our 20th birthday?
Girls in the mountain regions fare worse. The doctors all blame a lack of education, despite reported access to free family planning options. The most dramatic example was a girl who came to Huarmey hospital at 38 weeks (40 is full term) in order to be near a hospital with more resources when she went into labor. She is 12 years old. It completely boggles my mind that this is even possible. I wanted to ask her who the father was (older boyfriend or sadistic uncle?), but her labor was deemed to dangerous for the capabilities of Huarmey and she was taken to a larger hospital two hours away, and I never got my chance.
When I shadow in the gynecology clinic, where gestantes come in for routine checkups and minor problems with their pregnancies, the patients are typically 15-19 in age. Patients in the family planning clinic, which distributes the condoms/pills/hormone injections, are quite different. These women are generally older, in their 20s and 30s, and they invariably carry their babies/young children with them. And so the pattern appears to start a family early, and only after establishing one, to limit its size. Again I realize that I am in a different culture and that not everyone wants to or thinks about waiting to establish financial stability (at the very least) before having children, it's difficult to see teenager after teenager burdened with such heavy responsibility.
Friday, February 5, 2010
Surgery!
Every Tuesday, a gynecologist comes to Huarmey Hospital. He's the only one in the area who is able to perform Cesarean sections. Usually, when a woman is having trouble with her labor and needs this procedure, she needs to be ambulanced to Chimbote, a large city two hours away. Many women with at risk pregnancies are told to go straight to Chimbote and avoid Huarmey Hospital altogether, and so we see fewer 'gestantes' than I would like. Supposedly, a full time gynecologist and a surgeon were supposed to start work on February 1st. I've yet to see them.
Huarmey Hospital does have a surgical wing for times like this Tuesday, when Dr. Pinillos comes in for a scheduled Cesarean section. Whenever I ask nurses and passing doctors when the surgery is supposed to take place, they say only 'soon.' I don't want to be forgotten when all the action happens so I loiter around Dr. Pinillos as he chats with the staff. Nurses in another room dress the woman in a green scrub gown and get her cleaned up.
The head enfermero (nurse) in the hospital eventually waves me over the the surgical wing. He gives me green scrubs to wear, plastic bags as booties again, a mask and a hair net, and then takes me into the procedure room. He says a lot of things like, 'This area is sterile, over here isn't. Make sure you never touch this or go here.' I plan on just standing in the corner and touching nothing; this seems like the safest bet. Eventually a few other doctors show up and get dressed with the gown and gloves and everything. Again, I can't believe how hot it is. The room is so bright and without air conditioning or fans, summer near the equator is brutal.
We're soon ready to begin. I am waved over from my silent post in the corner to stand directly across from the gynecologist, right at the body of the gestante. Another obstetrician has taken the post of 'person who hands over surgical instruments when Dr. Pinillos calls for them,' for which I am grateful. I don't know the names of all these scissor-, pincer-, and clamp- like things even in English. I'm content to just watch the procedure from my front row seat.
When Dr. Pinillos makes the first cut, my first thought is, 'wow, that's what fat looks like.' It's so unbelievably cool to see the insides of a living person right in front of me. I should have expected that I would be doing more than just watching, but I'm still surprised when I'm told to dab gauze in the surgical area when blood starts to collect. Easy, but I feel super important. What undergrad in the States is allowed, no, expected to touch things during surgery? I'm also given retractors to hold at various intervals. I'm trying really hard to remember the names of all these instruments in case the doctor yells for them, but so far I've only really mastered 'gasa!' (gauze).
Dr. Pinillos calls me 'doctora' whenever he wants me to hold something or dab at something. I've tried to be very clear when I say I'm a student here and not try to claim that I have any real skills, but I sometimes fear that the hospital workers think I know more than I do. Many of them call me doctora, but for the most part I think that is because Brittany is hard to pronounce in Spanish. At least I hope this is the reason. I'm not ready to fly solo just yet.
Before I know it, Dr. Pinillos has reached the uterus. He instructs me to use this suction thing to suck up all the liquid as soon as the baby comes out. My rudimentary language skills are just enough to recognize a cognate between the name of this instrument (which I now forget) and it's function. The baby emerges, I suction furiously, and no one yells angrily at me like I've done something wrong. Success! The baby even starts to cry within a few seconds, and then is carted off into another room to be cleaned up.
The whole process of retrieving the baby takes about ten minutes. It seems like such a simple operation: cut through skin, fat, muscle, uterus, grab baby + placenta, then sew everything up in reverse order. It takes much longer to do the sewing, obviously, and every few minutes the nurse has to wipe of Dr. Pinillos' forehead so that he doesn't drip sweat into the body cavity. He keeps yelling 'dry!' and I can never tell if he means his forehead, or the body, which intermittently needs to be cleared of blood with some gauze.
Before the Cesarean even started, another doctor who was not participating in the surgery asked me if I had my camera. When he offered to take pictures for me, I thought he meant one photo of me in my surgical getup before anything happened. But no, this guy went to town with my camera. He bopped around the room and snapped over thirty pictures during the 90-minute surgery, even capturing the exact moments when the baby emerged. What's even crazier is that no one else in the room seemed to mind that this guy, who was not wearing a mask or anything sterile, was running around with my camera in their faces. They completely ignored him. And I have documentation of my first experience assisting in a surgical procedure.
I can't wait for next Tuesday, when Dr. Pinillos returns.
Huarmey Hospital does have a surgical wing for times like this Tuesday, when Dr. Pinillos comes in for a scheduled Cesarean section. Whenever I ask nurses and passing doctors when the surgery is supposed to take place, they say only 'soon.' I don't want to be forgotten when all the action happens so I loiter around Dr. Pinillos as he chats with the staff. Nurses in another room dress the woman in a green scrub gown and get her cleaned up.
The head enfermero (nurse) in the hospital eventually waves me over the the surgical wing. He gives me green scrubs to wear, plastic bags as booties again, a mask and a hair net, and then takes me into the procedure room. He says a lot of things like, 'This area is sterile, over here isn't. Make sure you never touch this or go here.' I plan on just standing in the corner and touching nothing; this seems like the safest bet. Eventually a few other doctors show up and get dressed with the gown and gloves and everything. Again, I can't believe how hot it is. The room is so bright and without air conditioning or fans, summer near the equator is brutal.
We're soon ready to begin. I am waved over from my silent post in the corner to stand directly across from the gynecologist, right at the body of the gestante. Another obstetrician has taken the post of 'person who hands over surgical instruments when Dr. Pinillos calls for them,' for which I am grateful. I don't know the names of all these scissor-, pincer-, and clamp- like things even in English. I'm content to just watch the procedure from my front row seat.
When Dr. Pinillos makes the first cut, my first thought is, 'wow, that's what fat looks like.' It's so unbelievably cool to see the insides of a living person right in front of me. I should have expected that I would be doing more than just watching, but I'm still surprised when I'm told to dab gauze in the surgical area when blood starts to collect. Easy, but I feel super important. What undergrad in the States is allowed, no, expected to touch things during surgery? I'm also given retractors to hold at various intervals. I'm trying really hard to remember the names of all these instruments in case the doctor yells for them, but so far I've only really mastered 'gasa!' (gauze).
Dr. Pinillos calls me 'doctora' whenever he wants me to hold something or dab at something. I've tried to be very clear when I say I'm a student here and not try to claim that I have any real skills, but I sometimes fear that the hospital workers think I know more than I do. Many of them call me doctora, but for the most part I think that is because Brittany is hard to pronounce in Spanish. At least I hope this is the reason. I'm not ready to fly solo just yet.
Before I know it, Dr. Pinillos has reached the uterus. He instructs me to use this suction thing to suck up all the liquid as soon as the baby comes out. My rudimentary language skills are just enough to recognize a cognate between the name of this instrument (which I now forget) and it's function. The baby emerges, I suction furiously, and no one yells angrily at me like I've done something wrong. Success! The baby even starts to cry within a few seconds, and then is carted off into another room to be cleaned up.
The whole process of retrieving the baby takes about ten minutes. It seems like such a simple operation: cut through skin, fat, muscle, uterus, grab baby + placenta, then sew everything up in reverse order. It takes much longer to do the sewing, obviously, and every few minutes the nurse has to wipe of Dr. Pinillos' forehead so that he doesn't drip sweat into the body cavity. He keeps yelling 'dry!' and I can never tell if he means his forehead, or the body, which intermittently needs to be cleared of blood with some gauze.
Before the Cesarean even started, another doctor who was not participating in the surgery asked me if I had my camera. When he offered to take pictures for me, I thought he meant one photo of me in my surgical getup before anything happened. But no, this guy went to town with my camera. He bopped around the room and snapped over thirty pictures during the 90-minute surgery, even capturing the exact moments when the baby emerged. What's even crazier is that no one else in the room seemed to mind that this guy, who was not wearing a mask or anything sterile, was running around with my camera in their faces. They completely ignored him. And I have documentation of my first experience assisting in a surgical procedure.
I can't wait for next Tuesday, when Dr. Pinillos returns.
Monday, February 1, 2010
The Birth
On Saturday, I was witness to "the miracle of life." A baby was born about two feet in front of me. It was quite the experience, but only read on if you have a strong stomach. Baby-birthing is NOT pretty.
I went into the hospital at 8am, like always. I've decided to show up seven days a week because there's literally nothing else to do in Huarmey. The hospital itself typically has few patients, but sometimes I get the chance to talk with the health workers while waiting for someone to come in. When I arrived on Saturday, there was already a gestante (pregnant woman) in the bed. She had been in the hospital since the night before, slowly, slowly progressing. She was dilated to 7cm when I came in, and since you need 10cm before starting to push, she had at least a couple more hours to wait. I was surprised, however, at how calm she looked. Her contractions, when they came, were mild and brief, which is unusual with a woman in that stage of labor. The obstetrician on duty and I sat with her off and on for the next couple of hours, but by 10am she was only at 8cm, still dilating too slowly. The obstetrician gave her an injection of oxytocin in order to speed up the contractions.
This particular obstetrician, Heidy, is friendly and really wants to teach me things. While sitting with the pregant woman (Nelly), Heidy takes out a book of common obstetrical emergencies and flips to the appendix entitled, Receiving the Newborn. She then starts talking to me about where to place your hands when the baby's head is coming out, to make sure to check that the umbilical cord is not around the neck, and to push the baby down, then up, to get each of the shoulders out in turn. I start to get just a little nervous. Surely she can't think that I'm going to receive the baby, right? I've seen one other birth a few days earlier, but that almost didn't count because it happened dramatically fast (in less than 5 minutes) and I didn't get to see anything. I know the people here are willing to let me learn, but shouldn't I see how things are done at least once before trying them myself? Holy crap.
My fears are not alleviated when Heidy takes me into the next room and starts showing me videos of "epistomias" (sp?) on YouTube. ***DO NOT continue reading if you have a weak stomach*** Epistomias are a commonly made incision into the vagina, opening it up so that the baby has more room during the birth. Heidy demonstrates how to make the cut, saying things like, "make sure to guide the scissors with the fingers of your other hand," and "make the cut at 45 degress." She then takes a couple of pieces of spare gauze and shows me how to do the stitches that one uses to sew the vagina back up once the birth is over (this is done in the room with Nelly, whom Heidy assures that I am learning fast). I still don't know if I'm actually supposed to do any of this, and am giving myself a monster headache while trying to concentrate on Heidy's Spanish.
A couple more hours pass, but still Nelly's contractions are too far apart. She is hooked up to a fetal monitor, which we watch for a while, and then the doctor comes in to give her an epidural. I'm a little mystified as to why the epidural was needed, because it is a sophisticated procedure, nonessential (in a place where the patients, always poor, pay for their own meds), and Nelly doesn't seem to be in much pain. But she readily accepts the injection into her back after she is given the promise of a "painless birth."
Finally, around 1pm, Nelly is deemed ready for delivery. The epidural has made it impossible for her to walk, so she is wheeled into the delivery room and gets comfortable in the stirrups. Everything is done very slowly; no one is in any rush to get this baby out. I had thought that as soon as the woman reached 10cm, it was game time and everything happened at once. Alas, no. I am instructed to tie small plastic bags around my feet (surgical booties), and then to put on a plastic apron. I then wash my hands in soap and water, and, now sterile, put on a clean surgical gown over the plastic apron. Heidy puts my hair in a hairnet and attaches a surgical mask over my face. We walk into the delivery room and I put on sterile gloves. I look around the room, and no one else seems to be similarly attired. Nervousness threatens to bubble into panic. Why am I the only sterile person in the room? I do not want to receive this baby!
Thankfully, finally, another obstetrician shows up and dons the gown, hairnet, etc. It's a shift change and Heidy is leaving, and the new ob is much less a learn-by-doing teacher. I could not be happier. It's about 85 degrees in the delivery room, and with the surgical getup I feel a touch of dizziness as sweat begins to collect in the small of my back. Of course I can't sit down or touch anything, because I need to remain clean.
Some instruments are laid out on a table before me and named. I look at them skeptically but am unable to determine their purpose. Now we are ready to deliver the baby, and with each contraction, Nelly is instructed to "puja!" (push). This is the part that I've been waiting for, but like everything else today, it happens so slowly. The new ob, Joel, examines the position of the baby every once in a while, and invites me to do the same. I put my hand in and feel gingerly around. All of a sudden I hear a pop! and some fluid explodes on my feet. Crap! I broke the baby, and it's head exploded and it's all my fault! is the first thought that enters my head. But the doctors just laugh and tell Nelly that I was kind enough to break her water for her. Um, you're welcome.
Nelly's contractions continue but the baby is descending too slowly. To help her along, two doctors press on her stomach each time she pushes. One even climbs into the bed and literally puts all of his weight onto the top of her belly. Everybody is sweating profusely. Also, during each contraction, Joel at Nelly's nether regions opens up her vagina and stretches it, hoping this will help give more space. He is the one who does that awful slicing thing (anesthetic first) to give even more room. About half an hour of intermittent contractions go by, each with Nelly pushing the baby, two doctors pressing on Nelly, and Joel widening her vaginal opening. Considering all this, there is remarkably little blood, and I'm able to watch from about two feet from the baby's area of expected entrance.
The baby is just about out. We can see the head in the vagina but Nelly is still unable to make that final push. A third doctor instructs me, as the only other sterile person in the room (actually there's a nurse in sterile garb as well, but her job appears to grab the baby and whisk it away as soon as it emerges), to first hand Joel this instument, then this second one, then a third. I have no idea what any of them are but pick up the first two, ready to go.
With one last push, baby arrives! It comes with a gush of fluid and is completely blue. I hand Joel thing 1 and then thing 2. I attempt to hand over thing three but he motions me to do it myself. I look over at the baby and see that the first two things were clamps for the umbilical cord, spaced about a half inch apart. Thing 3 is apparently a pair of surgical scissors used to cut the cord. So I cut it. It's all over in less than ten seconds but I feel like I've accomplished some major surgical procedure. What's even better is that the baby starts crying right away. He's still blue, but I think the most dangerous part is over.
We have to wait a few more minutes for the placenta to be delivered. It's this large, blueish bag that looks absolutely disgusting. I know it's full of nutrients and even that some people eat it, but that seems unsanitary beyond comprehension. Joel patiently sews up Nelly's vaginal tears (she's been given a shot of local anesthetic) and she soon stops bleeding. It was a difficult birth, apparently, but the baby and mom appear to be all right. I finally get a chance to take off that awfully hot gown and apron and booties, my shirt sticking to my back and my hair plastered to my face. I leave the hospital to go home for lunch (its now 3:30pm), thankful that I never threw up.
I went into the hospital at 8am, like always. I've decided to show up seven days a week because there's literally nothing else to do in Huarmey. The hospital itself typically has few patients, but sometimes I get the chance to talk with the health workers while waiting for someone to come in. When I arrived on Saturday, there was already a gestante (pregnant woman) in the bed. She had been in the hospital since the night before, slowly, slowly progressing. She was dilated to 7cm when I came in, and since you need 10cm before starting to push, she had at least a couple more hours to wait. I was surprised, however, at how calm she looked. Her contractions, when they came, were mild and brief, which is unusual with a woman in that stage of labor. The obstetrician on duty and I sat with her off and on for the next couple of hours, but by 10am she was only at 8cm, still dilating too slowly. The obstetrician gave her an injection of oxytocin in order to speed up the contractions.
This particular obstetrician, Heidy, is friendly and really wants to teach me things. While sitting with the pregant woman (Nelly), Heidy takes out a book of common obstetrical emergencies and flips to the appendix entitled, Receiving the Newborn. She then starts talking to me about where to place your hands when the baby's head is coming out, to make sure to check that the umbilical cord is not around the neck, and to push the baby down, then up, to get each of the shoulders out in turn. I start to get just a little nervous. Surely she can't think that I'm going to receive the baby, right? I've seen one other birth a few days earlier, but that almost didn't count because it happened dramatically fast (in less than 5 minutes) and I didn't get to see anything. I know the people here are willing to let me learn, but shouldn't I see how things are done at least once before trying them myself? Holy crap.
My fears are not alleviated when Heidy takes me into the next room and starts showing me videos of "epistomias" (sp?) on YouTube. ***DO NOT continue reading if you have a weak stomach*** Epistomias are a commonly made incision into the vagina, opening it up so that the baby has more room during the birth. Heidy demonstrates how to make the cut, saying things like, "make sure to guide the scissors with the fingers of your other hand," and "make the cut at 45 degress." She then takes a couple of pieces of spare gauze and shows me how to do the stitches that one uses to sew the vagina back up once the birth is over (this is done in the room with Nelly, whom Heidy assures that I am learning fast). I still don't know if I'm actually supposed to do any of this, and am giving myself a monster headache while trying to concentrate on Heidy's Spanish.
A couple more hours pass, but still Nelly's contractions are too far apart. She is hooked up to a fetal monitor, which we watch for a while, and then the doctor comes in to give her an epidural. I'm a little mystified as to why the epidural was needed, because it is a sophisticated procedure, nonessential (in a place where the patients, always poor, pay for their own meds), and Nelly doesn't seem to be in much pain. But she readily accepts the injection into her back after she is given the promise of a "painless birth."
Finally, around 1pm, Nelly is deemed ready for delivery. The epidural has made it impossible for her to walk, so she is wheeled into the delivery room and gets comfortable in the stirrups. Everything is done very slowly; no one is in any rush to get this baby out. I had thought that as soon as the woman reached 10cm, it was game time and everything happened at once. Alas, no. I am instructed to tie small plastic bags around my feet (surgical booties), and then to put on a plastic apron. I then wash my hands in soap and water, and, now sterile, put on a clean surgical gown over the plastic apron. Heidy puts my hair in a hairnet and attaches a surgical mask over my face. We walk into the delivery room and I put on sterile gloves. I look around the room, and no one else seems to be similarly attired. Nervousness threatens to bubble into panic. Why am I the only sterile person in the room? I do not want to receive this baby!
Thankfully, finally, another obstetrician shows up and dons the gown, hairnet, etc. It's a shift change and Heidy is leaving, and the new ob is much less a learn-by-doing teacher. I could not be happier. It's about 85 degrees in the delivery room, and with the surgical getup I feel a touch of dizziness as sweat begins to collect in the small of my back. Of course I can't sit down or touch anything, because I need to remain clean.
Some instruments are laid out on a table before me and named. I look at them skeptically but am unable to determine their purpose. Now we are ready to deliver the baby, and with each contraction, Nelly is instructed to "puja!" (push). This is the part that I've been waiting for, but like everything else today, it happens so slowly. The new ob, Joel, examines the position of the baby every once in a while, and invites me to do the same. I put my hand in and feel gingerly around. All of a sudden I hear a pop! and some fluid explodes on my feet. Crap! I broke the baby, and it's head exploded and it's all my fault! is the first thought that enters my head. But the doctors just laugh and tell Nelly that I was kind enough to break her water for her. Um, you're welcome.
Nelly's contractions continue but the baby is descending too slowly. To help her along, two doctors press on her stomach each time she pushes. One even climbs into the bed and literally puts all of his weight onto the top of her belly. Everybody is sweating profusely. Also, during each contraction, Joel at Nelly's nether regions opens up her vagina and stretches it, hoping this will help give more space. He is the one who does that awful slicing thing (anesthetic first) to give even more room. About half an hour of intermittent contractions go by, each with Nelly pushing the baby, two doctors pressing on Nelly, and Joel widening her vaginal opening. Considering all this, there is remarkably little blood, and I'm able to watch from about two feet from the baby's area of expected entrance.
The baby is just about out. We can see the head in the vagina but Nelly is still unable to make that final push. A third doctor instructs me, as the only other sterile person in the room (actually there's a nurse in sterile garb as well, but her job appears to grab the baby and whisk it away as soon as it emerges), to first hand Joel this instument, then this second one, then a third. I have no idea what any of them are but pick up the first two, ready to go.
With one last push, baby arrives! It comes with a gush of fluid and is completely blue. I hand Joel thing 1 and then thing 2. I attempt to hand over thing three but he motions me to do it myself. I look over at the baby and see that the first two things were clamps for the umbilical cord, spaced about a half inch apart. Thing 3 is apparently a pair of surgical scissors used to cut the cord. So I cut it. It's all over in less than ten seconds but I feel like I've accomplished some major surgical procedure. What's even better is that the baby starts crying right away. He's still blue, but I think the most dangerous part is over.
We have to wait a few more minutes for the placenta to be delivered. It's this large, blueish bag that looks absolutely disgusting. I know it's full of nutrients and even that some people eat it, but that seems unsanitary beyond comprehension. Joel patiently sews up Nelly's vaginal tears (she's been given a shot of local anesthetic) and she soon stops bleeding. It was a difficult birth, apparently, but the baby and mom appear to be all right. I finally get a chance to take off that awfully hot gown and apron and booties, my shirt sticking to my back and my hair plastered to my face. I leave the hospital to go home for lunch (its now 3:30pm), thankful that I never threw up.
Sunday, January 31, 2010
The Hospital
In Peru, medical school starts after high school and lasts seven years. You have to take an exam and pass with a certain percentage to get in, but there's no such thing as undergraduate education before medical school. With this in mind, I've been introducing myself as an American medical student, in my third of eight years. I also give the disclaimer that I'm in the "general sciences" part of my education, and I haven't started the practical part yet, so no one thinks I'm capable of actually taking care of patients on my own.
The doctors, nurses, and technicians at Huarmey Hospital accept me right away. Most of them are very patient and take time to explain interesting cases to me and show me what they're doing. They also invite me to do exams myself, especially with pregnant women (feeling where the baby is located inside the mother, detecting heartbeats, doing internal exams). Because I can't understand everything, I write down key words and look up the illnesses when I get home. It can be really frustrating to see a sick patient and then not know what's wrong with him or how he's being treated, but I do my best to ask questions and realize that I will not always know how they are being answered.
Besides the language difference, the hardest part about being in the hospital is that it moves very slowly. I work in the emergency/obstetrics/long term care wing, which means that we occasionally get lots of excitement when a car accident victim or a woman in labor comes in, but often there are few patients to observe. For example, yesterday I spent seven hours with one woman in labor and helped with the delivery, which was exciting and traumatic and fascinating (this experience deserves its own blog post). Today, Sunday, there were two patients in five hours. I'm finding that just about every patient that is admitted has something to teach me. I only wish there were more sick people in this city.
The doctors, nurses, and technicians at Huarmey Hospital accept me right away. Most of them are very patient and take time to explain interesting cases to me and show me what they're doing. They also invite me to do exams myself, especially with pregnant women (feeling where the baby is located inside the mother, detecting heartbeats, doing internal exams). Because I can't understand everything, I write down key words and look up the illnesses when I get home. It can be really frustrating to see a sick patient and then not know what's wrong with him or how he's being treated, but I do my best to ask questions and realize that I will not always know how they are being answered.
Besides the language difference, the hardest part about being in the hospital is that it moves very slowly. I work in the emergency/obstetrics/long term care wing, which means that we occasionally get lots of excitement when a car accident victim or a woman in labor comes in, but often there are few patients to observe. For example, yesterday I spent seven hours with one woman in labor and helped with the delivery, which was exciting and traumatic and fascinating (this experience deserves its own blog post). Today, Sunday, there were two patients in five hours. I'm finding that just about every patient that is admitted has something to teach me. I only wish there were more sick people in this city.
Thursday, January 28, 2010
The Language
Today marks the first full week that I've been in Huarmey by myself. The volunteer group is all safely back in the States, despite a transportation strike on the day they needed to take a public bus back to Lima for their flight.
I'm living with a wealthy family who have often worked with Professor Duffy. They have high speed internet, toilets with seats, and a washing machine. They even have a fridge, which is odd in a country where most people buy food fresh every day (preservatives don't exist here). I took a peek in the fridge and it's basically only beer and condiments. Reminds me of college.
The first thing that hit me once the Americans left was the immediate construction of the language barrier. I've never been in a position before where I am literally at a loss for words, all of the time. I took Spanish in high school but stopped after Junior year, so it's been 3.5 years since I've had any formal training. It's both intimidating and stressful to try to communicate with people. Especially in the first few days, everything I said had to be dredged up from some dusty corner of my brain, and everything that was said to me had to be repeated at least twice.
It's extraordinarily difficult to live entirely in Spanish. My head throbs at the end of each day from all the concentrating, and I think I sometimes freak people out when I stare at them intently, trying to figure out what they're saying. (I know enough to be able to answer direct questions and obtain basic necessities, like food and directions and clean clothes, but rapid conversations between Peruvians go straight over my head.) I try not to get too frustrated when I'm unable to understand someone, but this is sometimes impossible. However, even after one week by myself I notice some improvement. And each understood sentence is all the more exciting because of previous difficulties. It's definitely a painful way to learn a language, but poco a poco, I think I will get there.
I'm living with a wealthy family who have often worked with Professor Duffy. They have high speed internet, toilets with seats, and a washing machine. They even have a fridge, which is odd in a country where most people buy food fresh every day (preservatives don't exist here). I took a peek in the fridge and it's basically only beer and condiments. Reminds me of college.
The first thing that hit me once the Americans left was the immediate construction of the language barrier. I've never been in a position before where I am literally at a loss for words, all of the time. I took Spanish in high school but stopped after Junior year, so it's been 3.5 years since I've had any formal training. It's both intimidating and stressful to try to communicate with people. Especially in the first few days, everything I said had to be dredged up from some dusty corner of my brain, and everything that was said to me had to be repeated at least twice.
It's extraordinarily difficult to live entirely in Spanish. My head throbs at the end of each day from all the concentrating, and I think I sometimes freak people out when I stare at them intently, trying to figure out what they're saying. (I know enough to be able to answer direct questions and obtain basic necessities, like food and directions and clean clothes, but rapid conversations between Peruvians go straight over my head.) I try not to get too frustrated when I'm unable to understand someone, but this is sometimes impossible. However, even after one week by myself I notice some improvement. And each understood sentence is all the more exciting because of previous difficulties. It's definitely a painful way to learn a language, but poco a poco, I think I will get there.
Thursday, January 21, 2010
The Cloud City
There are many small villages in Peru that still do not have electricity. They are typically small and isolated, accessible only by footpaths and populated by a few families, all interrelated. The Lowell group that I am traveling with does not seek to provide electricity to the entire town, but instead installs solar panels on top of schools or medical postas so that the community as a whole benefits from a small amount of power.
To get to one such town we have to drive for about five hours along a narrow dirt road that winds itself through the mountains. I find myself screwing my eyes shut for most of the ride in order to avoid looking at the steep dropoff just inches away as we ascend to 10,000 feet above sea level. The town at the end of the vehicle-accessible road, Malvas, is built into the side of a mountain. Unlike most buildings in Peru, the houses are all unpainted adobe and are connected by steep staircases that slope downwards.
We spend the night with friends of Professor Duffy who make us a terrific dinner of soup and spaghetti. The senora of the household is an accomplished singer, complete with CD, who puts on a performance along with her son on a harp. I never expected to see a harp in a town that is only accessible by a one-way dirt road, but the music is wonderful and we all start dancing.
The next day we load up the burros (donkeys) and head off to the unelectrified town, Huataspin. We are told that the hike can be made in two hours. Peruvian time tends to work differently than gringo time, but I expect to make it to Huataspin in less than four hours. Six hours later, after scrambling among rocks and getting lost for a while (our guide had not been to this town in ten years), we finally arrive at the school. None of the solar panels have broken and the large 40lb battery has not overturned, preventing its burro from an acid bath. We are all tired but want to get the solar system installed before nightfall.
Huataspin is a city of clouds. They blow through the fields throughout the afternoon, and come into the open door of the classroom. It's impossible to see more than about 40 feet, but somehow there is light to work by. The entire town gathers to watch the installation. Gringos have not ventured this far in 40 years, when some Canadians came through to help out after an earthquake. After the lights go on, it takes some convincing to get the villagers to let us go to sleep on the classroom floor, and we hike out early the next day. By that evening, we are back in Huarmey (the main city), and it seems strange to all of a sudden be transported back into the "real world" of telephones, internet, and street signs.
To get to one such town we have to drive for about five hours along a narrow dirt road that winds itself through the mountains. I find myself screwing my eyes shut for most of the ride in order to avoid looking at the steep dropoff just inches away as we ascend to 10,000 feet above sea level. The town at the end of the vehicle-accessible road, Malvas, is built into the side of a mountain. Unlike most buildings in Peru, the houses are all unpainted adobe and are connected by steep staircases that slope downwards.
We spend the night with friends of Professor Duffy who make us a terrific dinner of soup and spaghetti. The senora of the household is an accomplished singer, complete with CD, who puts on a performance along with her son on a harp. I never expected to see a harp in a town that is only accessible by a one-way dirt road, but the music is wonderful and we all start dancing.
The next day we load up the burros (donkeys) and head off to the unelectrified town, Huataspin. We are told that the hike can be made in two hours. Peruvian time tends to work differently than gringo time, but I expect to make it to Huataspin in less than four hours. Six hours later, after scrambling among rocks and getting lost for a while (our guide had not been to this town in ten years), we finally arrive at the school. None of the solar panels have broken and the large 40lb battery has not overturned, preventing its burro from an acid bath. We are all tired but want to get the solar system installed before nightfall.
Huataspin is a city of clouds. They blow through the fields throughout the afternoon, and come into the open door of the classroom. It's impossible to see more than about 40 feet, but somehow there is light to work by. The entire town gathers to watch the installation. Gringos have not ventured this far in 40 years, when some Canadians came through to help out after an earthquake. After the lights go on, it takes some convincing to get the villagers to let us go to sleep on the classroom floor, and we hike out early the next day. By that evening, we are back in Huarmey (the main city), and it seems strange to all of a sudden be transported back into the "real world" of telephones, internet, and street signs.
Monday, January 11, 2010
The Postas
It´s been a busy couple of days. I have been traveling with professor Duffy to some of the remote villages where he is checking on the radios. It seems as though every place he visits has something wrong with the antenna, although most of the problems can be solved in a few minutes. The people are all really friendly but often evasive as to how things have broken. They all greet professor Duffy with smiles.
We went to a ''village'' today that was composed of a few dozen houses made out of some woven material, not cement or logs or anything. The houses were on the beach, straight on the sand, and there was no greenery to be seen. Professor Duffy wanted to check on the radio in the posta medica (as he had heard that it was not working), but the technician had taken a leave of absence and the posta was closed. I didn´t understand why the technician had left, it may have been some medical emergency. The town, constructed 12 years ago, has no electricity or purified water. Apparently the people who live there are all fishermen.
Tomorrow we are going to try and find the director of the hospital in Huarmey and ask him if I can stay and observe. I want to emphasize that I can only observe at this point or perform very simple tasks, because my Spanish only allows me to understand about half of what is going on around me.
I miss everyone, but more than that I miss toilets with seats. My squatting muscles are not up to par.
We went to a ''village'' today that was composed of a few dozen houses made out of some woven material, not cement or logs or anything. The houses were on the beach, straight on the sand, and there was no greenery to be seen. Professor Duffy wanted to check on the radio in the posta medica (as he had heard that it was not working), but the technician had taken a leave of absence and the posta was closed. I didn´t understand why the technician had left, it may have been some medical emergency. The town, constructed 12 years ago, has no electricity or purified water. Apparently the people who live there are all fishermen.
Tomorrow we are going to try and find the director of the hospital in Huarmey and ask him if I can stay and observe. I want to emphasize that I can only observe at this point or perform very simple tasks, because my Spanish only allows me to understand about half of what is going on around me.
I miss everyone, but more than that I miss toilets with seats. My squatting muscles are not up to par.
Subscribe to:
Posts (Atom)
