So yesterday I was saying how very little had been happening around here. Well yesterday afternoon that changed...
Maria, who looks to be in her late 20's, pregnant with her 7th child (the six other children were home deliveries) arrived after being unable to successfully deliver at home. From what we gather she is at 43 weeks gestation. For reference 40 weeks is full-term and in the states we have started inducing women at 41 weeks to avoid the morbidity associated with post-dates pregnancy.
"How long have you been pushing," I ask.
"Hasta ocho," Maria says.
Since eight this morning and it now being noon seemed reasonable to me. However, to arrive at the hospital Maria was carried in a hammock for four hours until they arrived at a road where they flagged down a truck, and then driven an additional 45 minutes and finally arriving at our doorstep. So we figured she hadn't started pushing this morning.
"Hasta ocho esta manana," queries Carrie, one of the nurses who is learning to do OB.
"No, hasta ocho anoche (since eight last night)."
So Maria had been pushing for 16 hours.
Fearing the worst we search for the fetal heart rate with doptones and are relieved to get a rate in the 140's. I examen her cervix and find that she is not completely dilated. She has what is refered to as a thick anterior lip that is very swollen. Likely, she had started pushing prematurely against a non-complete cervix. To compound the issue she had thick meconium which signifies that this infant had experienced a significant amount of stress as well as presents a challenge in neonatal resucitation.
We make the decision to transfer her the hour to la Ceiba to the public hospital. A few calls are made on the radio to rouse the troops. Dave, as he frequently does, volunteers to drive. He is a former volunteer firefighter and EMT so this work is right up his alley. Amy, an RN volunteers to ride along in case of an emergency, i.e. delivery.
Prior to transfer we pray...
"El nino esta llegando," Maria says upon termination of the prayer.
I lift the sheet to verify what she is saying and sure enough there is the head on the perineum. We quickly switch to delivery mode.
Maria delivers easily at this point with only a couple pushes...a girl...a lifeless girl...
We quickly bulb suction the infant (we didn't have time to get the equipment to perform endotracheal suction). No response...no respiratory effort...no heart beat...
We start the code...providing ventilations via the bag-valve-mask...start chest compressions...we call for more help... shortly thereafter Shaw and Sharon arrive....we place an umbilical line and start to administer IV fluids as well as epinepherine..atropine...sodium bicarb...we get her intubated...tube placement is confirmed...check the monitor and see a rhythm...check the pulse...present but slow...we continue respirations...heart rate slows...we restart chest compressions...more epi...more atropine...more fluid..more bicarb...
Reflecting over medical school and residency training you realize there is no way to prepare a physician for events like this. Laying before you is an apparently healthy looking full-term infant that just needs to breath and move...but now matter what you do you cannot will it to happen...
After an hour of resucitative efforts we declare the obvious, that the infant is dead and further efforts are futile.
Carrie, with excellent spanish explains the outcome to the mother...while tearful Maria is at peace..."es la voluntad de Dios (it is God's will)," she says.
A few hours later Maria leaves, to be driven, then carried the 4-5 hour trip to her village...along with her newborn baby who is to be buried...
Maria, who looks to be in her late 20's, pregnant with her 7th child (the six other children were home deliveries) arrived after being unable to successfully deliver at home. From what we gather she is at 43 weeks gestation. For reference 40 weeks is full-term and in the states we have started inducing women at 41 weeks to avoid the morbidity associated with post-dates pregnancy.
"How long have you been pushing," I ask.
"Hasta ocho," Maria says.
Since eight this morning and it now being noon seemed reasonable to me. However, to arrive at the hospital Maria was carried in a hammock for four hours until they arrived at a road where they flagged down a truck, and then driven an additional 45 minutes and finally arriving at our doorstep. So we figured she hadn't started pushing this morning.
"Hasta ocho esta manana," queries Carrie, one of the nurses who is learning to do OB.
"No, hasta ocho anoche (since eight last night)."
So Maria had been pushing for 16 hours.
Fearing the worst we search for the fetal heart rate with doptones and are relieved to get a rate in the 140's. I examen her cervix and find that she is not completely dilated. She has what is refered to as a thick anterior lip that is very swollen. Likely, she had started pushing prematurely against a non-complete cervix. To compound the issue she had thick meconium which signifies that this infant had experienced a significant amount of stress as well as presents a challenge in neonatal resucitation.
We make the decision to transfer her the hour to la Ceiba to the public hospital. A few calls are made on the radio to rouse the troops. Dave, as he frequently does, volunteers to drive. He is a former volunteer firefighter and EMT so this work is right up his alley. Amy, an RN volunteers to ride along in case of an emergency, i.e. delivery.
Prior to transfer we pray...
"El nino esta llegando," Maria says upon termination of the prayer.
I lift the sheet to verify what she is saying and sure enough there is the head on the perineum. We quickly switch to delivery mode.
Maria delivers easily at this point with only a couple pushes...a girl...a lifeless girl...
We quickly bulb suction the infant (we didn't have time to get the equipment to perform endotracheal suction). No response...no respiratory effort...no heart beat...
We start the code...providing ventilations via the bag-valve-mask...start chest compressions...we call for more help... shortly thereafter Shaw and Sharon arrive....we place an umbilical line and start to administer IV fluids as well as epinepherine..atropine...sodium bicarb...we get her intubated...tube placement is confirmed...check the monitor and see a rhythm...check the pulse...present but slow...we continue respirations...heart rate slows...we restart chest compressions...more epi...more atropine...more fluid..more bicarb...
Reflecting over medical school and residency training you realize there is no way to prepare a physician for events like this. Laying before you is an apparently healthy looking full-term infant that just needs to breath and move...but now matter what you do you cannot will it to happen...
After an hour of resucitative efforts we declare the obvious, that the infant is dead and further efforts are futile.
Carrie, with excellent spanish explains the outcome to the mother...while tearful Maria is at peace..."es la voluntad de Dios (it is God's will)," she says.
A few hours later Maria leaves, to be driven, then carried the 4-5 hour trip to her village...along with her newborn baby who is to be buried...
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