Nothing in life can prepare you for the day you
ride in a tuc tuc bag masking a baby in every effort to save his life.
Absolutely nothing in life can prepare you for the minutes the 3 wheeled mildly
powered vehicle bumps in and out of potholes, around cars, bicycles and other
motor operated tuc tucs, pedestrians and crowded market shoppers, no doors,
sliding from side to side, while holding the new born baby tightly in an effort
to keep him warm mostly, and also to prevent his small body from flying out of
your arms onto the dug out road with every hard drop into a pothole.
Nothing could have prepared me for the language barrier that I had with his
grandmother sitting on my right side, emotionless from her lack of
understanding of what is happening, almost nonchalant because of not knowing
how "white" this little African baby emerged from his mother’s
infected womb. She doesn’t know how he was not breathing when he was
born, she doesn’t know his heart rate was 30 when he was born, she doesn’t know
the pus filled meconium stained fluid that came before and after his large body
expelled from his mothers small pelvis after great assistance. Maybe to
her it was normal, normal that her daughter or granddaughter, I don’t even know
whose grandmother she is, the baby’s or the mother? But maybe it was
normal to her that this mother was in labor since Thursday, today is Tuesday! ,
in labor for 6 days, then travelled 6 hrs by tuc tuc to the clinic.
She arrived in the clinic just as I was in the next
room with my American attending, talking to midwives about newborn resuscitation,
ironically enough. She commented on expected skin tone, muscle tone,
vigor and breathing. I sat across from the mom who delivered 10 hrs ago,
holding her quiet beautiful infant and smiling at the midwives as we
demonstrated. Then in walked the "head midwife" at the clinic
to tell us that a patient had arrived "complete and ready to deliver"
she says casually and walks back to the delivery area. Everyone
rushed out the room to learn from Dr. C about delivering a baby. I stayed
behind using the huggies wipes I had bought for my own personal use in times of
unpredicatable toilette situations, to wipe the dried poop off the little baby
boy's bottom and thigh, it's the least I could do as he was so quiet during our
demonstration to the midwives during our newborn assessment. I cleaned
the dried green poop from his small bottom and changed him into his reused
resale but “new clothing”. I wrapped him tightly handed him to his
mother, with the package of buggies wipes, to which she smiled, and bid her
farewell by saying “Merci Madame” and headed to the next room. I walked
in to see about 16 midwifery students surrounding the bed of a laboring
mom. She was 21 years old but looked no older than 17 years old, laying
in the bed with her legs shyly opened for delivery. The word pushed being
spoken in three different languages, all out-drowning the other, Dr. C saying
"push, push", then translated to french "Pousser" then the
Malagasy people yelled " Manilika". I placed gloves on my hands
to try to help Dr. C and hopefully reduced the chaos. But I only added to
it, joining with all words simultaneously I yelled, “Push!”,
Pousser! Manilika! I wasn't sure at the time why we were saying all three
words or even which language the patient understood but as I got closer I was
stopped in my tracks by the strong stench of infection I smelled coming
from the bed where she laid. The smell of rotting skin or pus
collection filled the room. I made my way over to the young delivering
mom's bed, I wanted to say her name but I don’t even know her name, I am
ashamed I don’t know her name, I don’t even know what she wanted to name her
baby, my mind wrestles but there is no time for formalities, it was clear that
her baby needed to be delivered and soon!
It was her 6th day of
labor, with a narrow pelvis, the obviously large baby became wedged tightly in
her pelvis, we should have known because as we continued to tell her to push,
there was no movement of the baby's head. I placed my fingers at her perineum
and yelled “Pousser”, twenty French instructed “Pousser” later, a midwive says,
“she doesn’t understand French”. I become quickly frustrated by how long
it took us to realize that and ask, “How do you say push in malagasy?”, that
was first translated to french to the midwife by Darwin our french translator
and team member, to which the midwife responded “Manilika”. As the entire
room instructed the patient to push, she appeared to be doing so with all her
might, but the large infant would still not move.
Dr. C applied a vacuum we had brought in her back
pack for teaching purposes with some maneuver of the labia in the tight area
that this baby was expected to come through. But still even with our
American equipment there was no movement. We don’t have the ability here
in Madagascar to continuously monitor the baby’s heart rate like we do in the
U.S. but I am certain at this time if we did it would be having a sustained
decrease in the heart rate and be in the least favorable category. She
called for a pair of scissors, which like every other request resulted in a
frantic run outside the delivery area to return what seemed like 10 minutes
later. An episiotomy was made to create more room for this clearly large
baby, and with the vacuum, pressure on the patient’s fundus (belly) the infant
was expelled in a pool of the baby’s poop and pus.
I stood still thinking why is this baby gray,
literally gray! This baby should be another color besides gray, I am sure of
it. I run around the bed to the baby’s head and start rubbing the baby
vigorously, “Stimulate, stimulate, stimulate”, okay what else did you learn
from that “Neonatal resuscitation course you took more than a year ago, come on
think!”. The nurses or pediatric team was always at the delivery waiting
to take the baby back at the hospital where I work in the U.S., I realized then
I had not been practicing the skills I once knew so well. “You know this,
wake up! Heart rate, breathing!”. Dr. C is steps ahead of me, and checks
the baby’s heart rate and counts it as “30 bpm”, I start bag masking as she
gives compressions. A midwife walks over with what looks like a silver
blow horn puts it over the baby’s mouth leaving the nostrils uncovered.
She blows into it with all her might and out of the baby’s nose comes meconium
and mucous. There is chatter and laughter in the background, the others
aren’t as frantic in what is likely a familiar situation, neonatal and maternal
sickness and death is seen far too often for the Malagasy people to be
alarmed. Dr. C stops her from re-using the blow horn (later I
realized it was an old fashion obstetrical stethoscope now being used in a
new way) in fear of her forcing all the mucous and stool into the babies lungs.
The midwife then throws alcohol on the baby’s chest, just missing
his mouth and starts vigorously rubbing the baby and pinching him. Dr. C
and I look at each other and then resume bag masking after now realizing
the baby's HR is normal. Somewhere in between our researched and
implemented neonatal resuscitation and the local medical practices of the
midwives the infants color was slowly retuning with tiny sporadic shortened
cries. We wrapped the baby in a small flimsy thin blankets and I hopped
in the tuc tuc waiting outside. I hop in and Darwin stuffs a wad of ariary 10,000 dollar bills into my pocket.
On the way to the hospital, I continued bag masking the baby while
occasionally turning him and patting his back firmly to help dislodge any
mucous and to essentially perform chest physiotherapy as I would occasionally see
the nurses do when I looked over while caring for a mom in the delivery room
back in the U.S. As the tuc tuc fell into pot holes the baby muttered
little cries. In that moment, my eyes began to well up, I held my tears
back and said “keep fighting, you’re a fighter, I know it little guy”. I
looked into his now opened eyes with a male midwife bent over me now bag
masking the baby occasionally to keep him breathing while I kept him
warm. We made it to the hospital, seconds later the pediatric consultant
arrived. We exchanged information regarding the patient in the little
English she knew and the little French I knew. She then says “bien, it’s
okay now, you can go”. I went to the pharmacy and paid for the medicines
with the money Darwin had stuffed into my pocket. I thanked the
midwife, gave the grandmother more money for medicines and walked away knowing
she didn’t understand what happened and being totally incapable of comforting
her in any other way. I rubbed her shoulder, smiled and walked away.
I hopped back into the tuc tuc waiting outside and retuned to the clinic.
On the way back I rustled with the motion of the vehicle, stunned and
overwhelmed with self-evaluation, nothing could have prepared me for this, I
couldn't help but wonder, "Am I really ready for this?!"
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