Saturday, September 20, 2008

Called to Deliver a Baby ‘Half-Born’: the Struggle to Survive in Rural Philippines



*Warning -- this blog entry is graphic*

After lunch Aiyanas and I were playing chess when there was a commotion in the clinic, and I heard “Martha” and “bata” (baby) and a bunch of excited talking, so I poked my head out front to see what was going on. The ‘ice candy lady’ from the elementary school was in the clinic with Josephine and Erwin, saying that Grace had delivered, but the baby was breech and only half-born; the Lola was there delivering the baby and now they need help. What is going on? I am full of disbelief; the baby is half-born? Why are we standing here talking? Josephine calls to Nanay, who comes running back to the clinic, I grab my backpack with my birth equipment, Aiyanas grabs me some pesos to pay for a hubble-hubble (motorcycle) and Nanay and I are off at a run up to the road to catch a ride to Grace’s house. It must have taken us 20 minutes to get there from the time I first heard the news of the baby half-born; we arrived just after 3:40 pm.

Why didn't they come get us sooner? I learned that Grace was afraid because the military detachment is across the road, and last night they were firing at random.

Entering the house I am struck by Grace’s position; Grace is up on the sleeping platform lying supine, knees bent, legs covered with a blanket, and Lola has her hands under the blanket. It is dark in the house though it is still light outside. Is there a baby I ask? Yes, they say, half-born up to the neck. Without thinking I am pulling off the blanket and calling for Grace to turn so the breech hangs; somehow I have gloves on, but I barely remember getting them and my kit out as we entered the house. I put my hand inside Grace’s vagina to feel what is going on. I feel the baby’s face anterior, his little body is so blue and cold and his back is anterior, his neck is twisted, he is obviously dead. He is so small I am suspicious, since it doesn’t fit with how pregnant we thought Grace was.

I feel another head following - twins. Gently I push the second head back up the vagina; Nanay gives me some suprapubic pressure and the first twin disimpacts and is delivered onto Grace. Then directly the second twin is delivered up onto Grace. I feel the cords of the babies and the second twin has a pulse, so I grab my clamps from my kit and clamp the cords, free the second twin first, and start to ventilate him. I check his heart rate, but it is so chaotic in the house I can barely hear, I think I get about 60 beats per minute. I show Nanay how to do chest compressions while I ventilate, but we can’t get coordinated, so after perhaps 15 seconds I listen with my Doppler and count 100 bpm! We clear the small table and place the second twin onto a pair of soft track pants I grab from the clothes pile nearby. I instruct Nanay how to ventilate, make sure his little chest is rising and he is getting at least 40 breaths per minute.

Time to switch my attention to Grace, who is lying supine with her eyes closed. Is she conscious? Is she bleeding? Is she in shock? I cut the cord of the still born twin, bundle him, and set him next to his brother. I coax Grace awake and up into a squat to get the placenta out, intact, great, just to be safe I quickly draw up one of my precious vials of oxytocin and give it to her. Her BP is good, 120/80. Nanay checks Grace’s perineum, and there is only a very small tear, which is good because there is no time to suture. I am very worried about Grace and her emotional state, so Lola comes to sit with her and hold her hand. Time to switch back to second baby boy and make sure he is doing OK.

Before I take over ventilations again, I listen with the Doppler one more time so I can hear his heart rate clearly in the noisy, crowded hut. Why are there so many people here? We shoo some people outside, and listen, getting a heart rate of 140, with my stethoscope I can hear air entry with ventilations, his lips and face are pink. Why isn’t this little guy breathing? I quickly examine him and can see he is quite premature: smooth foot soles, smooth scrotum, soft ear cartilage, testicles undescended. Grace wasn’t 8 months pregnant, as I thought; I realize she was likely only 7 months but big due to the twins. The lack of adequate prenatal care in the communities is outrageous. This little guy needs intensive care; we need to transfer him as soon as possible. I take over ventilating again, and Nanay is freed to help with the transfer.

This discussion takes a painfully long time. The babies were born at 3:45 and 3:46, and it is now after 4:15 and they are still talking about what to do. I explain, hoping that it will be understood, that they can decide to transfer to the hospital or they can stay home and the baby will die. It sounds crass, but I realized that they have to make the decision about what is right. Now that I write this, I wonder, did it sound judgemental? It is not the way I intended it to sound and I hope it wasn’t taken that way. But this persistent little boy is taking some breaths! The conclusion is they will go to the hospital; now we need to get the truck so we can ventilate the baby on the way. This will require permission and a driver from the Barangay Capitan. There is a problem, I still don’t know what, with the local Barangay Capitan, and so they have to ask in Hilaiton which is 45-60 minutes away.

Nanay and I hunker down to business, and develop a rhythm of adding 3 breaths between each one of little baby’s so that he is getting 40 breaths per minute. I balance my newborn stethoscope on his little chest so I can time my breaths to his heart rate, hear the air entry, and monitor his independent breaths. We request some hot water bottles which we tuck around his body. I place a nasogastric tube, but I do not carry an ET tube and laryngoscope, so we use a mask to ventilate. After an hour or so I am exhausted, and I want to examine the first twin and the placenta, so Nanay does an ambubag shift. I go to pee, and see the military watching from the detachment across the road. This just enrages me – 10 times the funding of the health care system and they sit and watch as babies die.

Very carefully I pick up the first little guy and take him to the adjoining Nipa hut so I can examine him thoroughly without so many observers. He is so tiny, weighing in at 1.5 kilos including the weight of his blanket. It feels like his neck is broken, and he has dark bruises on his abdomen over his palpable liver. I wrap him in a blanket, lay him on the pretty blue fabric of my scale sling, and quickly take his photo for Grace and Randy. My belief is that these are mono-chorionic, mono-amniotic twins, with the first twin transfusing blood, oxygen and nutrients to the larger and more robust second twin, but this is only a guess. There is only one placenta with two cords of close insertion, and for the life of me I can only see one sheer set of membranes, but it is impossible to tell and I am rushing; in any case we will bring the placenta with us.

Now back to business of ensuring the ventilation is going well and preparing for transport. We hear news that the truck from Hilaiton is on its way! Great, this little trooper is hanging in there, so we will make it! I take over ventilations again and Nanay gets a board and some blankets ready so we can ventilate in the back of the truck. Finally after 6:00 pm the truck arrives and we are off on the long trip to the hospital. Sometimes the road is so bumpy the board is bouncing, I try to protect his little head, and the little guy’s heart rate is always over 100. After what seemed like an endless journey of heart beats and breaths, heart beats and breaths, we arrive at the hospital.

As the truck pulls up, Nanay calls out ‘emergency, emergency’ and an orderly comes running. We get baby boy out of the truck and quickly onto the examination table in the ER operation room. I keep ventilating until the doctor comes and takes over care of the baby. The doctor quickly concludes that the baby is premature and needs CPAP (continuous positive airway pressure) and I completely agree! Great! Let’s get it going! But… there is no equipment for premature babies at this hospital, so we will have to go to Dumaguete. Why is the nurse not ventilating the baby? What is going on?

Randy, the father of the baby, shakes his head and sadly explains there is no money for going to a private hospital in Dumaguete. The doctor then asks Randy if he will admit the baby at this hospital, and Randy agrees. But what will they do here? They provide free-flow 100% oxygen through an ET tube, which it takes 20 minutes to place because they can’t find an ET tube small enough in their ancient crash cart; the baby is only breathing ten times per minute and there is no equipment to ventilate. They give him dextrose through an IV. I know that he will die, but my heart still hopes. Randy and I sit with him, and Randy asks me why the first twin died. I gently tell him I think he was born too early and his lungs were not ready, but I can’t bring myself to mention his injuries. Randy thinks his second son is a fighter, and I agree with heavy heart, knowing he isn’t getting the care he needs to give it a fighting chance.

Nanay and I are exhausted, it is now after 9:00 pm and I need to wash and lie down. We will spend the night at Nanay’s Auntie’s. After sleeping in fits and starts we return at 6:00 to learn that the baby boy died at 3:00 am and Randy has already taken him home. I am so angry! I am so sad! The pictures of Gloria Macapagal Arroyo smiling on the wall of the hospital are enraging! How can she justify a national budget where debt payments are 63 times the national health budget? How can the military, which harasses and intimidates the people, be a priority over equipment necessary to save newborn babies? How can the military sit and watch while Randy scrambles to find a ride to the hospital? It is so backward I feel like kicking over that stupid (and grossly under-stocked) crash cart that sits nearby. I cry on the hubble-hubble ride home, thinking how Grace and Randy must be suffering, and my beautiful little patient who didn’t make it.

Now we are home and the story is already widely known. Will anything change? Perhaps more people will join the rally in Guihulgnan Town on Sunday. Perhaps the People’s Organization will gain more members as the string of injustices that lead to the deaths of these boys is discussed in the community. I am moved by the strength of the optimism, even among those who suffer terrible injustices; hope that things will change if the people are united, committed and share a common vision of justice for all.

3 comments:

Jan said...

Oh Martha! I've just discovered your blog and have only read this one post. Big hugs to you and your family for being there and doing all that you are. I know how much it meant to me to hear from people at home when I was in Africa. I will try to follow your blog ... in this term of the graduation paper. Thank you for letting us know about life in the particular corner of the world.
Jan

Unknown said...

Dear dear Martha, thank you for sharing this. It is the most graphic depiction of the failures in global maternal and child health I have ever come across. I hope it will be used as a teaching aid in an effort to prevent this cycle of death and sadness. I found myself gasping and weeping as I read through it, still hoping it would end well right up until it didn't.

incendiary tey said...

martah, belieev it or not, i'm in tears, reading this. i picture it out ad it's all very clear in my head.
ahh, the philippine health care!

anyways, you take care of yourselves too, you guys, ayt? hugs and kisses! especially to Billy! we think of you all the time!