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Gravida 13

I was on call on a Sunday afternoon not too long ago when I got a call from the nurses’ station. “We have a 39 year old pregnant lady here in labor who is due tomorrow. It is her 13th pregnancy and she is contracting and is dilated to 5 centimeters.” Yes, I thought to myself, this lady is a pro and will have this baby in no time! I called the resident physician who was on with me and asked her to go down and break her water. Then, I thought that I should just go down anyways since she might deliver before I get there.

When I got in the room, I noticed that her belly was large. First red flag. Then, I noticed that she had only been to our clinic for prenatal care once to get treatment for a urinary tract infection. She wanted to deliver at home with a midwife and didn’t plan on coming back to the hospital per the previous note. Second red flag.

I started trying to get a history from her and her husband.
“This is your 13th pregnancy, right?”
“Yes”
“Did all of your other babies deliver at home?”
“Yes”
“Were there any complications when you delivered at home?”
“Yes, two of my babies were born dead.”
LOTS of red flags!!

Through more discussion, I learned that she had had 3 early miscarriages and two children that had died during birth as they were breech (bottom first) when they came out. She only had 7 living children, the oldest of whom was 20. She was planning to deliver at home, but had been having contractions for a while and was told by her partera (midwife) that her baby looked too big. So, she left her house in the mountains and walked 3 hours to the hospital, while in labor. She was done.

I ultrasounded her and estimated that her baby was over 10 pounds. None of her other babies were that big, and her labor was much more prolonged than typical for her. I offered her a cesarean section given the size of her baby and the fact that she had meconium (baby poop) stained amniotic fluid. She wanted to have her tubes tied at the same time. So, we went back for cesarean section.

Isaac did the section while I set up the warmer and prepared to receive the baby. I went through all of the things we could possibly encounter with an extra large baby: breathing difficulty, thick blood (polycythemia), low sugar. Soon, the baby was out. He took one cry, and then went limp and blue. He had breathed in the meconium-stained fluid. I had to give him positive pressure ventilation with a bag/mask set up for a couple of minutes until he started breathing for himself. Then, the retractions began. He started grunting and working very hard to breathe. The air didn’t want to move in and out of his lungs. We gave him some extra oxygen and started CPAP (sort of like breathing with your face out of the car window) to help open up his lungs. I was hopeful that his respiratory distress was only due to some retained amniotic fluid and not due to meconium aspiration syndrome, which can be serious and even fatal. The thick tarry stool blocks the airways and doesn’t let air past, and if it gets down to the actual lung tissue, it causes bleeding and inflammation. Time would tell.

In the meantime, baby boy’s mother started to have a horrendous post-partum hemorrhage. After having 13 children, the last of whom was 10.5 pounds, her uterus was floppy and would not contract down. It therefore kept bleeding like a faucet. She failed to respond to any of the medications or interventions we tried and we had to mobilize about 20 other people to keep her alive.
In a miraculous, God-ordained circumstance, the visiting ENT surgical team, which consists of at least 10 people, were in the hospital unpacking supplies at that late hour. A lot of them happened to have the same blood type as our patient and so she received 8 transfusions of uncrossed whole blood to keep her alive until our general surgeons could do a hysterectomy (surgery to remove the uterus). She ended up surviving and doing very well.

Baby boy did not get better within a day. He got worse, and on day 3 of life was really struggling to breathe and needing a lot of oxygen and support with IV fluids and CPAP. Usually meconium aspiration is at its worst in day 2 and 3 and then starts to get better. I told this information to his parents, letting them know that I expected to be sending their happy family back home in just a couple days.

A couple of days passed, and baby boy was still on oxygen. At times, his oxygen saturation would be 100%, very reassuring, so I started to try to wean down the amount of oxygen he was on. He would tolerate it for a while, and then he would all of a sudden drop his oxygen saturations into the 70s (90 and up is acceptable). I kept telling his parents to be patient, but they started to get anxious to go. The father worked for a daily wage of 150 lempiras (7 dollars) and needed to get back to work. The other children were caring for themselves at home. The mother didn’t want to be left alone in the hospital, so she wouldn’t let her husband leave without her.

Eventually, when he was 7 days old, the parents told me one morning that they were leaving and taking their baby with them. I told them that they would kill him if they did that. This did not seem to phase them whatsoever. They had already lost babies before. Sometimes patients do leave against medical advice, and that is their choice, but I felt it was wrong for them to make a life and death decision for their baby. We had already told them that the hospital indigent patient fund would pay for their hospital bill. I told them that I would have to call DINAF (Child Protective Services of Honduras) to stop them if they tried to take the baby away before he was ready.

A couple of days later, the pediatrician and I had a sit down meeting with the parents in order to explain our diagnosis and plan for the baby. He had developed a couple of dreaded complications from meconium aspiration syndrome. He had a small pneumothorax (where the lung lining breaks and air escapes into the chest cavity) and he had developed persistent pulmonary hypertension. The meconium was causing his pulmonary arteries to spasm, thus making it even harder for blood to circulate to the lungs and pick up oxygen. Unfortunately, the main treatment for this condition is oxygen, and time. The good news is that it is possible to completely recover from it.

Once the parents realized that baby boy’s hospital stay would likely be weeks longer and that we in no way expected them to be present for his entire NICU stay, they started to relax. They had to be reassured that their leaving him would not be seen as abandonment and that he would still be their son, ready to go home with them once he’s off oxygen.

Baby boy ended up staying on oxygen for a month in the hospital. His big sister and only brother, as well as some other family members, came down from the mountain in shifts in order to give his mom a break and a chance to go home. We had a few more run ins with the father, who became impatient every so often, and despaired that baby boy would ever be able to go home. At one point, his parents said that they would never ever come to our hospital again. Finally, when he was a month old, after failing to wean his oxygen several times, I knelt by his bed in despair, praying that God would heal him and fearing that I would have to send him home, even with a low oxygen saturation. Dave Fields came by and noticed my worry, and asked what he could do to help. I told him that the only thing we hadn’t tried, that they would do in the States, was to start Viagra. Most people don’t know this, but Viagra was initially developed as a drug for pulmonary hypertension. The IV form of the drug is often used in the US to help babies wean off of oxygen because it causes the pulmonary arteries to relax and dilate. We had toyed with the idea of starting the medicine, but since the only form available was oral, we were reticent to try it. However, after over a month of waiting for baby boy to improve, we finally had to take the risk.

Dave Fields went and bought the Viagra in La Ceiba, and I crushed 1/4th of a pill and diluted it into 10 cc of water. We gave the baby less than a cc of the medication every 6 hours. Low and behold, within a week of starting the medication, we were able to wean him off of oxygen! He ended up going home soon after that, and took the medicine for another month at home until we weaned him off the medicine. His parents have come back to the hospital several times for his checkups, and I am so glad that with perseverance, we have earned their trust in our medical care. We are grateful for the Lord’s provision and care for this mother and child.

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