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…
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!