Birth Day

Sorry, but my Massai Land posting will have to wait till another time. I had a pretty special day today and I wanted to write about it while the memories are still fresh and vivid in my head. Today, in the Kenyan slums, I delivered my first baby. It’s an event that I studied and trained for but was something that can only be experienced firsthand. It was a unique mix of terror, excitement, and joy. Like a soldier training to go into combat, its something that you can only prepare so much for, but when the proverbial shit hits the fan, you quickly find out if you’re ready or not. And like battle, it’s an event that is both feared and anticipated. There is much riding on it and many things can go wrong.
The day started off like any other. Last night, we got two new volunteers: Agneta from Denmark and Kensey from Canada. Both of them are doing the HIV program and are here for one month. They’re fun and easy-going, and I know we’ll all have a great time together. It’ll be interesting sharing a small cramped bedroom with three girls; I’m sure my menstrual cycle will sync up with theirs at some point.
We all grabbed some breakfast and made our way to the Wema Clinic in Kawangware. Dr. George wanted me to give the other volunteers a lesson on injections and sutures outside and would let me know if anything interesting came through his door. About an hour later, an expectant mother came in. Dr. George and I examined her and placed two IVs in her arms. She was severely anemic (the capillary beds under her eye lids were totally white) and she needed a blood transfusion, a service we couldn’t provide. She would need to go to the central hospital downtown and her husband would have to come get her. There was only so much we could do to stabilize her until he showed up. Dr. George went back to seeing patients and left me in charge of keeping an eye on her. All I could really do was chart her vital signs every few minutes and try to keep her as comfortable as possible. For a few hours, I went between showing some volunteers how to start an IV using a banana and checking up on the mom to be.
Things didn’t look good. She had a rapid and thready pulse, shallow respirations, and her blood pressure could have been better. These were some of the signs of early shock. If she totally crashed on us, we would be screwed. That would be a problem that could only be fixed by a surgeon and something beyond the scope of our modest clinic. She was also only 7 months pregnant. We gave her some fluids to get her pressure up a bit and some dextrose (sugar) to perk her up a little and give her some much-needed energy for the exhausting task which lay ahead. Odds were good that there could be a miscarriage or other complications because the bun wasn’t fully done cooking in the oven, so to speak. I had some of the other volunteers help me rummage through the medications and equipment to find resuscitation supplies to prep for a worst-case scenario. Let me walk you through the scene:
Remember that part in the movie Apollo 13 where the scientists and engineers at Mission Control had to improvise a CO2 air filter using only the parts available to the astronauts? It was a lot like that. We had no oxygen available for use. The resuscitation drugs available to us hadn’t been used Stateside since the 1970s. We had to cut up tubing to make makeshift airways for the baby and mother. We were blessed to have an old battery-powered suction unit. I looked over the equipment spread out before us and shook my head. There was much to be desired: defibrillators, monitors, endotracheal tubes…The list went on and on. But this was what we had to work with, and we were ready to improvise and make the best of the situation. We loaded up syringes with life-saving drugs, prayed for the best, and prepared for the worst.
I checked the cervical dilation. Nine centimeters. Strong contractions every couple of minutes. Oh crap. She was going to deliver here even if her husband showed up right at that moment. And where the $@#% was her husband?!? We figured he was probably enjoying a Tusker beer and some chips at a nearby pub while his wife was writhing away in agony on a foam and vinyl pad. Kenyan mothers don’t have the luxury of epidurals or any painkillers.
I tried remembering everything I could about pediatric resuscitation while I was donning my plastic apron. I looked more like a butcher than a medic. I would be taking the baby after I delivered it and doing whatever needed to be done with the equipment available. I had a small table moved beside the mother to use as a peds resuscitation table if it came to that point. I put down a scalpel, some gauze, Betadine, and an IV catheter on the table beside the other equipment in case I needed to do an umbilical cord catherization to deliver drugs and fluids to the premature baby. This was a procedure that would have been performed by a neonatologist in a well-controlled and clean setting back home. This baby would have to settle for a paramedic and a card table.
This baby would be coming out whether we wanted it or not. Now it became a waiting game. The other volunteers stood around, grasping syringes and gauze, waiting for directions from me on what needed to be done. After the water broke, things moved quickly. Dr. George said that the woman would need an episiotomy, a cut made to the vagina to make birth easier. Hanna and I spread the woman’s legs and handed him the scissors. He didn’t even bother with a local anesthetic beforehand; he just took the scissors and cut. I’ve seen some pretty appalling things before, but seeing that made me cringe a little.
In the 5 or 6 births I’ve seen before, things moved slowly and everything was very predictable. It happened over the course of hours. The birth today happened suddenly and without much drama or warning. The mother was barely awake to experience the moment she had been waiting months for. The baby, tiny and blue, just sort of suddenly plopped out onto the table. When I observed births before, I was doing just that: Observing. I could stand back with my arms crossed and marvel at the miracle of birth from a distance, comfortable in the knowledge that experts were around to handle any problems that might come up.
I didn’t have that luxury now. There were a million things that were going through my head at the time and I couldn’t appreciate the moment the way I imagined I would, especially since I was expecting the worse given the situation. When the baby was finally born, I wasn’t thinking “Cool! I delivered my first baby! I hope the mother names it after me!” I was thinking “Clamp the umbilical cord 7 and 10 inches away from the baby after it stops pulsating. Keep the baby the same level as the mother. Suction the mouth and then the nose.” The baby was covered in a smelly green-brownish crud called merconium. A merconium-covered baby is not a good sign. Besides not looking and smelling pretty, merconium means that the baby was likely distressed in the womb. If merconium gets aspirated into the lungs, it can easily cause a deadly pneumonia.
My heart stopped for a few seconds as I waited for the baby to start breathing after it was born. In paramedic school, we learned about something called the Pediatric Resuscitation Triangle. Ninety percent of pregnancies turn out totally normal. There isn’t much involved on our part with these pregnancies. You just basically make sure that the baby doesn’t hit the ground (it’s tougher than it sounds; newborns are slimy and slippery), suction the airways, clean the baby off, and hand the bundle of joy to the grateful mother. Think about it: Humans have been having babies for millions of years without midwives and hospitals. It’s a natural act.
It’s the 10% you dread and prepare for. The base of the triangle is stimulating the infant by rubbing it with a towel and maybe flicking its feet a little. This is the base of the triangle because more often than not, it perks up the infant. Above this is blowing a bit of oxygen in its face. As I mentioned, this wasn’t an option for us. At the tip of the triangle are advanced heroic measures like drugs and CPR. Thankfully, hardly any newborns require this level of care. But when you get to this stage of the game, the situation is likely headed for heartbreak. When people watch shows like ER, something like three-quarters of people survive cardiac arrest. In real life, the figure is less than 10%. I love that show, but damn it for getting people’s hopes up.
I stopped holding my breath when the baby took her first one. I clamped the cord and cut it (a task which I would have given to the deadbeat dad had he been around), rubbed the baby down with gauze to dry it off and stimulate it, and suctioned the mouth and nose. The baby was blue but breathing. Its heart rate was good. I just wanted it to cry and move around a little. I think it was the first time in my life that I actually wanted a baby to cry. I moved the baby to the bed, shoved a tube down its throat, sucked everything out of its tiny stomach, placed an ill-fitting mask over its face, and started to force air into its lungs using a bag. For you medical folks reading this, the 1 minute Apgar Score was 4. For you non-medical folks reading this, that’s bad. Eventually the baby pinked up a little and stabilized (5 minute Apgar of 7, FYI). I did a quick exam (a “10 fingers, 10 toes” sort of deal) and weighed it: 2.4 Kg, which was great considering it was premature.
So. I had just helped bring a new life into this world. Delivering babies by the side of the highway in America with fancy equipment and trained help would be cinch now. And I wouldn’t have to tell the fearful mom-to-be that it was my first time. And to those volunteers there that day helping me out: Thank you! You guys were awesome!
After some antibiotics to prevent pneumonia and some steroids to help develop its premature lungs, I think <*fingers crossed*> that the baby should be fine. Welcome to this crazy, exciting, and wonderful planet, little kid; you’ll have a great time here!