News from the Edge

From the Journal of Dr. Michael, ASOSAP Medical (part 2)

…Continued from Part 1

Conzuelo, the senior nurse, comes over and interrupts to say that there is an emergency. In five years working with her, she has never said this. “Now?” “Ahorita” (right now), she answers. My pulse jumps a bit. The madrona, the traditional midwife that delivers virtually all the babies born here, has a woman in active labor with the baby in a transverse position. My pulse now races. With the minimal I know about caring for complicated deliveries, I do know that babies don’t come out that way! I remind Conzuelo of the former, but say I will come and see what I can do. I ask which of the nurses has the most experience with childbirth, Emilio volunteers. I grab my portable ultrasound and we’re out the door.

The slippery muddy trail gets worse as we turn onto the more used twisting tree lined path into the village. It’s steeper and, in spite of the sense of urgency, I pick each step carefully. At least I am distracted from the visions of what I may find when we finally arrive. I am about to walk into a clothesline of multi-colored shirts on a level section of mud and realize that we’ve arrived.

I enter the home; the door is open. It is a single room, perhaps fifteen feet square, horizontal wood-slatted walls, light entering between. The floor is dirt; the ceiling/roof is rusty corrugated sheet metal. In the corner is a 5×5’ bed made of the same slats as the walls. The bed, in fact the room, is empty. My inquisitive look is clear to Conzuelo and we are then directed around the side to the similarly constructed kitchen. There is a smoldering fire in the middle of stained stones in the middle of the dirt floor, the underside of the grass roof is black from daily smoke, some beans and corn are drying in baskets above the fire pit. There are no windows and, again, the only light comes from between the wood slats of the wall. In the far corner is the only furniture, a small wood prep table. Behind the wood door is a 3 x 5′ area cordoned-off by two sheets of hanging black plastic. There, with only a piece of new yellow plastic between her and the dirt floor, is the small, 30 year old woman laying and leaning back on her elbows, a small and relatively clean old multicolored piece of cloth is between her flexed knees. The madrona stands near, who advises us that this is her sixth pregnancy, and her contractions are coming 5 minutes apart.

I kneel next to her and feel her abdomen and understand the madrona’s concern, the baby’s spine lies across her abdomen. Then I take out my ultrasound and put it on her abdomen, and quickly show that the head is in the left lower quad of the abdomen; not nearly as malpositioned as had thought, but still not right. With my obstetrics skills now to the max, I turned to the others. Emilio, Conzuelo and I concurred that she needed a hospital, but that was for us a 90 minute drive and then an hour and a half walk. Patients in need of emergency services at the small hospital in San Cristobal were typically carried on the back of one of men in the community out to the road! We are all in fact more concerned about the life of the mother, who has five other young children, than that of the baby. We agree that, in spite of the distance, she should be moved. This is carefully explained to the madrona and then the patient, who says she is unable to make the decision as her husband is out working somewhere in the mountain fields. She then says that she wants to have her baby on the floor of her kitchen as she has done 5 times before, but will consider going to the hospital in two hours if she hasn’t delivered.

And so, Emilio says that he’ll try some exercises with her. Having her stand up, with her arms around his neck, they do squats together. After about 10 minutes of this I see Emilio is exhausted, and can barely imagine how the mother feels. But she then lies down again, Conzuelo does an internal exam, and finds that the baby’s head has moved into proper position in the pelvis, exercises worked; it was a “learnable moment” for me. With her next contraction she pushes, while squatting, the madrona holding a clean towel under her. After another few sets of contractions, we leave and return to the clinic, leaving the two Mayan women to their timeless task, both having done this multiple times before. We hear that 20 minutes later the mother had her baby, in her kitchen on the floor, exactly where she wanted.

I step back into the dark church for another half day of difficult decisions in the setting of profoundly inadequate resources. It is their reality, and now for a short time it is mine. I have chosen to be here.


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