Happy Labor Day everyone! Today we’re sharing the latest post from Jackie Candido, who’s been writing about her experience volunteering as a nurse with Saving Mothers in Guatemala.
Obstetrics without a safety net
In case you only read the first line of this post, I am going to start off with a plea: If you are an obstetrician and are looking to do some volunteer work, please come to the Hospitalito Atitlan. We are in desperate need of someone who is capable of performing c-sections. Please spread the word.
Now let me rewind and start from the beginning. Yesterday evening a patient arrived in early labor, complaining of painful contractions every 4-5 minutes since the morning. She’s 31 years old and this is her second pregnancy/second baby. She’s 41 weeks and 2 days and has had no medical problems orcomplications with this pregnancy or with her last pregnancy/delivery. She is 2 cm dilated and about 50% effaced with intact membranes and a reactive NST.
I asked Dr. Matt and the medical students on call if we could send her home, but they all agreed that because she lived far away and didn’t have available transportation, it would be better for her to just stay in-house until she delivers. I did succeed in advocating for intermittent as opposed to continuous fetal heart rate monitoring, though my fellow nurses were nervous about this (apparently this is not the norm at the Hospitalito).
I won’t bore you with all the details of her long night of labor, but basically she arrested at 8cm and the baby did not descend beyond -2 station despite hours of Pitocin augmentation and frequent position changes including standing, squatting, and ambulating at the bedside (my co-nurse Alfredo earned my deepest gratitude for taking turns with me standing and squatting behind her to keep the FHR on the monitor. What an amigo.).
At 7 am, our FHR variability had been persistently minimal for an hour and the baby started having deep variable decelerations. I brought Matt in to check her cervix, hoping that maybe it would be time to push. But she had made no change in the last 6 hours, and as she lay back for the exam her water broke to reveal pea-soup style meconium. I’m talking the really nasty green kind complete with huge chunks of black baby stool (oops, sorry to you readers who may have just had lunch). At 7:30am we were going on 1.5 hours of minimal variability with now deepening decelerations.
Dr. Carlos, the day-shift MD coming on, rechecked her cervix. No change and the head was still “sky high.” You may remember from my previous post that the closest operating room is about 2 hours away at the Hospital Nacional Sololá. I was nervous. I pulled Matt and Anjie aside as they were about to go home. “When is it too late to transfer her to Sololá?” I asked.
Matt asked if I thought she needed a c-section. “Look, if it was just the heart rate or just the mec or just the baby not descending, I’d say ‘let’s stick it out.’ But it’s all 3, and something has to be going on here. If we were in NY she’s have been sectioned hours ago for failure to progress, and I worry the longer we wait the worse this is going to get, and we can’t spend 2 hours in an ambulance with a bradycardic fetus.” So Matt went off to consult Carlos, who agreed with me to transfer her.
As we waited for the Bomberos (it took them 40 minutes to arrive. I almost killed myself with worry. If your hospital has a spare ambulance lying around, please consider donating it to the Hospitalito), the nurses and I prepared supplies for me to bring along on the ride- a vaginal delivery instrument kit, oxygen tank, ambu bag, IM Pitocin, blankets, and a portable Doppler. There would be no MDs coming, just me and one of the “auxiliary nurses,” Andrea. Before leaving for Sololá, Dr. Chuc, the head Hospitalito MD, did one last cervical exam. No change.
My ride from the airport with Aclax (see previous post) was smooth sailing compared to the Bombero experience. I consider it one of my greatest gastrointestinal achievements that I kept my dinner down. My patient’s mother was not as lucky, and spent the entire trip sitting across from me with her head between her legs, vomiting onto the floor.
I was half-sitting, half-squatting at the foot of the stretcher, trying to stabilize my patient’s torso between 2 pillows, as I’d noticed as we set off that her pregnant belly was slamming into the stretcher’s metal side bar with every bump in the road. I intermittently checked the FHR with the Doppler, knowing full well that there was nothing I could do if it was down. But we were lucky, 150’s with each check.
We rolled into Sololá 1 hour and 40 minutes later, and I finally felt relaxed (good work Bomberos. I now forgive you for hitting every pothole along the way). We did it. We were here. Stat c-section and everything would be fine… And it is here that I must restrain myself from printing exactly what I think of the Hospital Nacional Sololá for fear of government retaliation. I will just tell you what happened—
Andrea brings our patient into the ER and starts giving report to the nurses there (I was told to stay outside. Something about foreigners). I’m pacing in the doorway watching through the window, and see the Sololá nurses roll their eyes, sigh, and say “oh, it’s just labor.” One nurse starts telling my patient to calm down and starts taking her blood pressure. I wait about 2 minutes before storming into the ER. “They don’t have a fetal heart rate monitor?” I say to Andrea in Spanish. The Sololá nurse looks at me and asks if I’m a doctor. No, a nurse, I say.
She ROLLS HER EYES otro vez and pulls out a tiny Doppler, which she applies for approximately 2.5 seconds before removing it and telling my patient to relax because everything is fine. Just as I’m about to round house kick this fool in the face (deep breaths Jackie, you’re not in Jersey anymore), a stoic MD appears, does a cervical exam, tells the patient she’s only 4 centimeters, and basically kicks Andrea and I out of the ER. I have no idea what ended up happening to this woman or her baby.
Guatemala has the highest maternal mortality rate in Central America. Yesterday I saw why. When your so-called “safety net” is miles below you and made of tissue paper, you hit the ground pretty f-ing hard.
I will ask uno vez mas — if you or someone you know is an obstetrician, please consider spending some time at the Hospitalito Atitlan so we can do our own c-sections. Gracias.