One of the things you notice most about Haiti is the sheer number of kids running around. It is a young nation demographically.
So one of the spin offs of this notable fact is that there is LOTS of obstetrics. Now most is done out of hospital (with no prenatal care as we know it and no technology) and some is excellently done in hospital either by midwives or Haitian doctors with no involvement by visiting teams. This leaves the challenges …
The usual things like multiple gestations, hypertension in pregnancy, failure to progress are all there, but full blown eclampsia with seizures and maternal and fetal compromise is common in Haiti. In fact on the cupboard door in the emergency room of the hospital is an excellent eclampsia protocol; all the nurses and docs working there are very familiar with the management of this problem.
On our first night in LaGonave we were called in to do a section on a lady who wasn’t progressing but had now thick meconium, indicating the baby was stressed. All our purchased drugs were locked in a room (since we were only meant to start the following the day) and we hadn’t yet done a careful inventory of what equipment and drugs were available in the OR – this changes from trip to trip and varies based on local drug availability and what other teams had left behind. As an aside it is interesting to note that medications are purchased in Port au Prince at retail pharmacies, with the buyer shopping around for the best price. There is no wholesaler that deals with the hospital as happens in Canada or the States. At any rate there was no functional anaesthetic machine and there were no paralyzing drugs to facilitate a general anaesthetic. Baby had to come out quickly and after a brief attempt at a spinal mom was put to sleep with ketamine. Chris had the baby out in a flash -amazing how quick these experienced OBs can be when necessary – but baby required resuscitation. He was intubated and hand ventilated. Thankfully after 3 hours the breathing tube came out and baby continued to do well.
And like a set of bookends, our last case was also an obstetrical emergency. The mom, who was 30 weeks along, came in with seizures and initial tests suggested meningitis and not eclampsia. But after a day of improvement with antibiotics she started seizing again and now she was obviously in full blown eclampsia and required an emergency cesarean section. One of the changes with eclampsia is that the clotting of the blood can be impaired (making a spinal anaesthetic unsafe) and unfortunately there was no way of measuring the platelets and clotting of the blood. So even though she was a thin woman who would have been an easy spinal, we chose to put her off to sleep. By now some paralyzing agent had been found and she was put to sleep, intubated and ventilated. She was kept asleep with IV meds as we had no functional machine, and again we ventilated her by hand. Mike and Aneal helped with the anaesthetic and then Mike moved to the next room to resuscitate the baby (Mike had just given a spinal for a patient with appendicitis, and Ravi had just finished the surgery so he was running). Once again in spite of the relative lack of resources, the teamwork between the Haitian nurses, the missionary physician, and the visiting team made the best of the situation. As we left the island on the small Haitian sailboat the next morning the news was good – baby was doing OK and mom was improving.