Wednesday, March 28, 2012

Placental "revision", site visit from Congo

March 21st

*Warning – this entry contains fairly graphic descriptions of post-birth gynecological procedures, involving blood and placenta and such things. Again, feel free to skip, I promise the next entry doesn't come with a warning :)

What a day, eh? Yesterday was the stillborn twins. Today was a healthy birth that delayed PAM nearly 2 hours, because the placenta tore and Belem had to keep “revising” the uterus. We had set everything up, I'd matched all the health notebooks to the record cards, but since we didn't have the key to the store room we couldn't actually start distributing. I went to get the key, but since the birth was imminent I just stayed to watch. Out came the baby, a girl, giving a nice healthy wail immediately after her feet came out – the most beautiful sound in the world. Good muscle tone, she was moving around so much they had a hard time weighing her because the scale kept bouncing! The problem was that the mother kept bleeding. I assumed this was kind of normal, after all the book I'd just finished (Contraceptive Technologies – 1998, yes I'm a little nerdy) said that some women continue to bleed for several weeks. But Belem said the difference was that this was bright red blood, which meant there was active bleeding from somewhere. Time to start feeling nervous.

When that happens, that means there's been a tear somewhere, or that part of the placenta is still in the uterus. A revision involves pulling out that material, which involves my accoucheuse with her arm halfway up to the elbow inside this poor woman's vagina, with the other hand pushing on her stomach to bring the uterus into range. I was totally fine with the blood, and even when she started pulling out bits of placenta and blood clots. The part that made me almost faint was the obvious pain and distress this woman was in. Remember, people speak about “birth without pain” (aka, with an epidural) as something only rich ladies in Ouaga have – they'll give you a local anesthesia if they stitch your episiotomy, but not before they cut it. Even with no painkiller involved, the woman, exhausted from the birth, was still able to fight Belem quite effectively. Burkinabe women are almost always silent during births, it's culturally unacceptable to cry or scream or even moan. The fact that this woman was making noise at speaking volume was indicating that she was in severe pain. And watching her distress was really hard for me, especially knowing that there was no alternative. If they left it alone she would get infected and most likely die. There was nothing to be done but apologize and keep at it until it was done.

We left her under the watchful eye of the village midwife, did a super fast PAM distribution, and then it was back to the maternity to check on the woman. One more revision later, and the bleeding had stopped so she was able to go rest with her newborn. Yay happy ending! We also checked on the pre-mature baby born last night, convincing the mother to go to take her to Seguenega. It was heartbreaking and miraculous, this tiny creature that truly looked more like a fetus than a baby, only 1.2lbs. I couldn't believe she was still alive, but lo and behold she was breathing, her heartbeat fluttering almost visibly beneath her thin skin. The woman's story sounded like something out of a soap opera. She'd left her husband in Cote d'Ivoire to travel, had ended up here with her in-laws, had experienced “stomach problems” that her mother in-law had tried to treat unsuccessfully, and then they brought her to the CSPS where she gave birth about 3 months early. The mother in-law was unaware of the pregnancy, I certainly hope the new mother had noticed!

So that was the morning. It's so dusty right now, and definitely getting hot even though the dust actually keeps things looking a bit overcast for most of the day. I went home, had an amazing grilled-Velveeta sandwich (thanks Aunt Sue!), read, and tidied up the house. I was just opening my gate to go back to the CSPS to organize the PAM paperwork when the PC car pulled up. Congo even gave me a hug! And then Pascal showed me that I had a care package! Does it get any better? The SSC (Safety and Security Coordinator) from Mali spoke nearly perfect English, without the odd pauses or cadence that most people here have when they speak English. The SSC from Togo was quieter, but very polite. We had “American coffee” (Starbucks VIA instead of Nescafe), and sat and talked for a bit. Congo reviewed the materials kept in all PC cars, Pascal fixed my bike, we talked a bit, they saw my house. We went to the CSPS to talk with my major, and I was super proud to show my staff off to my Bureau staff. They had wanted to take a village tour but it was getting late, so we stopped to say hello at the Mairie, walked around the Prefecture even though the Prefet is in Ouahigouya, and then they dropped me off at home before heading to Kongoussi. The SSCs from Mali and Togo are visiting Burkina for a week to train with Congo, since he's the best SSC in Africa and knows how to make volunteers feel comfortable coming to him with safety concerns. They wanted to visit some sites, and asked to come to mine since they were visiting the mining area near Emily's village.

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