Thursday, December 27, 2012

Day 2:Haiti

Day 2
I woke up earlier than I would have liked but I heard voices and felt guilty being in bed. It was around 6 am. I must have had a few mosquitoes in my net last night as I woke with a dozen new bites. These ones are mean and the itch was driving me mad. I walked out on the deck to Mary doing her daily devotional. We talked a bit and got ready for the day. I went down to discharge the mom who came in false labor again last night. She headed home. I was not feeling well at all.Some sort of cold probably caught on the plane. Breakfast was scrambled eggs and the most delicious pineapple I have ever tasted. 

Friday is the day MBH teaches Family Planning and Mama Baby classes. We also saw a few kids for a national program called Medika Mamba. Mary went to teach the baby class with an interpreter, and Martha who is a nurse, helped do informed consent and screening for women wanting the Depo-Provera injections for birth control. Two new women came, and six returned who had come before. Of those 6, 2 were risked out due to high BP. It is amazing to me how often high blood pressure is a problem here. It leads me to ponder everything I have studied. Is it nutriton, genetics, stress or a combination?

It got really busy quickly. I helped with the Medika Mamba program. Medika Mamba means "peanut butter medicine" in Haitian Creole. Each child is weighed and measured and then compared to a chart that rates their malnutrition, severe, moderate, or mild. There were 6 children today. Two of them were in the healthy range and sent home. The others were given a certain number of Mamba packets and instructed to mix the peanut, oil, sugar and vitamin formula in clean water and administer several times a day before meals. They are expected to gain a certain amount per week. To learn more about the Medika Mamba program visit


Photo Meds and Foods for Kids
They are also administered amoxicillin and a deworming pill the first visit to eliminate bacterial or parasite issues. I got to snuggle a 10 month old little girl for almost 20 minutes while her mama went to go get some food. She was a doll and after she would fuss and I would get her calmed down she would do that little shutter babies do when they relax. Melted my heart. A very young mom, my guess would be 15 brought in 12 month old twins a boy and girl. 

Severely malnurished little tiffi twin

Moderately malnurished gason twin

The girl was severely malnutritioned and the boy moderate. They were both so cute but their little skinny legs didn't look like they had enough muscle to ever support them.The little girl vomited up the dewormer and I had to go get a syringe and figure out a different way to help her take it.  She was a good attentive mother and still breastfeeding them both. There was a Mama Baby Class taught by Mary after clinic that day with about fiveteen mothers and infants. The other mothers were so impressed when this young mom easily and with little fuss breastfed her two 12 month old twins while listening intently.
After Medico Mamba was done I helped with 2 postpartum visits. A 1 month old had gained a whole kg since birth and mom was so proud. A second mom was having high blood pressure at 1 week post partum and had me check her sutures. She was healing well but we asked her to return next week after cutting MSG from her diet to recheck her blood pressure. 
 I was doing an exam of a 6 month old baby with a cough when they announced a laboring mom came in, Madeline. I admitted her quickly. She had only had one visit and had never returned with hey HIV or syphilis testing so we did a rapid HIV test. We had trouble getting enough blood and the first one was inconclusive, but maybe positive so we did a second that came up negative. I checked her to be 1 cm so I told her and her friends to go walk around the yard. This was her second child. I have been surprised how most of the Haitians I have met only have 2 or maybe 3 children and they are spaced often 4 or more years apart. The average Haitian breast feeds for 18 months. 
I helped with the rest of the sick child visits, gave some opthamalic eye ointment, amoxicillin, and vitamin C. Then ate lunch, rice and beans, and stripped all the beds and changed them. Mary noticed I was still not feeling well despite all of my water and Emergence c packets so she told me to go lay down. I took a nap out the outside deck after covering myself with bug spray. The power has been off since yesterday and that means no fans. It is really hot with no airflow. Medeline was more active after my nap. After she vomited I checked her again, 2 cm. Her friends all left, she had bad back labor and a terrible headache but didn't want me to help. She was much poorer than the other women who have been in. As I wrote earlier most of the women who come in are very clean and although poor their clothes are well kept. Medeline was different. She was very dusty and just looked plain exhausted like she had had a harder than average life, even for a Haitian. She labored mostly naked out in the yard after the sound and smell from the generator pushed her out of the labor room. A few of her very young teen age cousins came for a visit. They laughed a lot and Medeline basically ignored them. They poked fun at her labor noises and nakedness. She had had some mild bloody show that was concerning to her but she labored along.
 I continued to feel worse and worse physically. Dinner was some sort of spicy green soup with fish and crab. Just the smell made me feel nauseous. We all climbed up on top of the roof and spent some time looking at the cities and countryside around us. The houses are all made out of concrete and many of them are huge but almost all of them are unfinished.

Next door neighbors house

 I asked Claudin about it and he said that is the legacy parents leave their children, a huge unfinished house. At around 8 pm a friend of the mamas came and gave her a hard time for just laying in the bed. I checked her again, no change. We told her that she needed to either drink and eat or we would have to start an IV. She drank a little water and Emegcen-c and we put her to bed with Martha checking on her every few hours through the night. The power was still out and the center was hotter than it had been since I had been there with the power out for 36 hours. I made a cup of chicken noodle soup and instant oatmeal, took a bucket shower and headed to bed. It was so miserable. I moved from bed to bed trying to find a cross breeze. Nothing worked. I was probably the most physically miserable I had ever been without pain. I felt like my skin was burning up from the insect repellant I covered myself with. Finally some time after midnight I felt the fan start up and the power was on. With Martha downstairs I moved the fan right next to my head and between the cool  breeze and white noise, I couldn't wear my ear plugs due to my cold, I finally fell asleep

Tuesday, December 18, 2012

Day 1 in Haiti

Day 1 Mamababy Haiti

A 3rd time mom N., and  her husband have arrived with mom in active labor at 7 cm. In my practice in the states women very rarely have internal cervical exams. The clinics policy is a check at arrival and then no sooner than 4-6 hours later if not necessary. They had one midwife who came who was very upset about the frequency of exams so she did a mini class for the staff midwives about other ways to assess dilation. Her main emphasis was the purple line. As the woman dilates and the baby moves down deeper in the pelvis and pushes on the sacrum the tissues spread from the buttox crease revealing a purple line.

Photos credit of

The clinic tried it with the next mom who came into the clinic. The woman ended up delivering alone in the bath room 10 minutes after arrival when the purple line said she was 3 cm.  Needless to say they check everyone now at least once.

She is a very calm birther and smiles when I talk to her in English. I am to only watch and chart for this birth. Her labor progresses slowly and she doesn't end up having her baby until much later. Another woman J, comes in with short spaced contractions. We check blood pressure FIRST THING. This is really different than in the states where I usually listen to baby first before assessing mom. They check blood pressure first thing as high blood pressure and pre-eclampsia is a real problem in Haiti and they send them to the hospital right away if there is a problem before mom starts seizing. Blood pressure is fine. A cervical exam is done by the student and I follow her to double check. She is only 2-3 cm. We tell her she can stay and encourage her to walk to speed up her labor. When I ask her when she ate last she says yesterday at noon. I bring she and her friend a mango and cassava bread with peanut butter. They hang out in my favorite decorated room.

Prenatals start at 9 but the women start arriving as early as 6 but most come at 8. Dressed in their best they sit on the covered porch and talk with each other. They are lovely people. I am so excited to be working with them. They laugh quickly and are so kind to each other as they tease and poke about the different aspects of pregnancy. There are 28 today. A small devotional with a scripture, prayer and song is done at 9 and then prenatals start. The interpreters gather their names and pull their charts as well as do weight and blood pressure. The two native midwives are away for some midwifery training so it is just Mary, Martha (the advanced student), myself and a native student Genni. We do two prenatals at a time with an interpreter by ourside. I watch Mary do one but she gets distracted with Martha and I work through the rest with Genni. It is very different doing prenatals when you do not know the language and culture. Thank heavens pregnancy is universal and most mother love talking about their cute growing bellies. I ask questions and they are repeated by the interpreter.  That takes some getting used to, but the interpreters are kind and very experienced. It makes me smile that they are all male. I asked a mother once if she minded having a male interpreter and she said no most of the doctors are male so she sees the interpreters in the same way.  Most of the moms are happy and healthy. They are all severely anemic. We talk and measure bellies and listen to babies. Every mom is sent home with 10 days of prenatals and iron supplements with a prescription to purchase 30 days worth. Most don't have the money to buy them so they wait until their next appointment a month later to get more. Common complaints were acid reflux and lack up appetite. I only saw one with morning sickness. More common in Haiti is "spitting" during the first trimester. An abundance of saliva causes the women the spit frequently and some of them carry around a cup. A first time mama lay down so I could do fundal height. It was the first time she came to the clinic, she was 29 weeks. When I went to touch her belly, they have the softest skin ever by the way, I palpated belly only to feel fetal head and a tiny ear right under the skin. I pulled back surprised. Sure enough you could palpate every fetal part. It was concerning. Measurement was right on and FHT strong but I called in Merry and we agreed a sonogram (costs $25) would be best. Baby implanted out of uterus? Bicornate uterus? Additional note: baby was indeed implanted out of the uterus. They did a c-section at the hospital and baby did not survive but mother did. After I wrote the prescription for the ultrasound Mary called "Baby is coming!". The mother handled her labor like an expert.  Mary broke her very, very bulging bag of water to avoid a shower and baby boy came easily over intact perineum born on a birth stool. Baby born at 11:49 and while drying baby on mom we heard a plop at 11:50. Placenta had come out in bowl. I had never seen a placenta come out so quickly. One shot of pit was given but there was no bleeding as per their protocolls. The odd thing for me was mother had no desire to touch her baby. Very different than in the states. I have seem women who have had a very undisturbed birth often wait a moment or two to touch their baby. Almost like they are waiting to come out of labor land back into reality. More often is is an ecstatic smile or sound. I wonder how much of that is cultural? We are told over and over and shown in videos that you are supposed to be very happy and reach for your baby. I wonder if that would be the case in the States if there was not that expectation. The baby was very healthy and so beautiful. The family is just beautiful together and very happy. I don't get to observe the post partum procedure because there is other work to do.

 I went back to continue prenatals and did a couple post partum exams. A mom with a 5 mo with a cough. A mom who birthed at the clinic 3 days earlier with foul stitches. In the states many women due to good nutrition do not tear. If they have a slight tear we often encourage natural healing methods such as seaweed and staying in bed for a week. Staying in bed for a week is not an option in Haiti. Women tear more frequently due to poor nutrition so they do more suturing. The Haitian people are very very clean often doing bucket baths several times per day, but even with that being around all of the dust and rural living infection is common. The woman was sent home with antibiotics. Things calmed down.

We ate lunch of corn mush with black beans and a sauce made of okra and crab and beef. It was very good. Breakfast had been pancakes and dinner was spaghetti, only spicy with hot dogs in it. They tend to make everything spicy here.
 Around 6 Claudin, an interpreter who has been giving us Creole lessons in the evenings, asked Martha and I if we wanted to go on a walk around the block. We agreed and it was fun to be out in the community. The women smiled and a few men cat called but everyone was very nice. After our walk we talked about culture, marriage, and homosexuality. There are many different religious views in our little group including.. Mennonite,Mormon, Baptist (preacher in training), ex- Methodist preachers daughter, and vudoo. It was a nice evening but the mosquitoes were out in full swarm so Martha and I hid under a big white mosquito net while sitting on the deck looking ironically like two lesbian brides. We laugh a lot and Claudin likes to poke fun at our names comparing them to Creole words. Mine is similar to diarrhea, Mary means husband and Martha is similar to liar.

I went to bed when the power was turned off only to be called back by the 2nd mom from earlier who had gone home around dinner when her labor stopped. She was back but after exam was found to be no different. 2cm. She was exhausted. I gave her Benadryl and sent her to bed at the clinic. I took a bucket shower; like it sounds you sit in the shower and poor cup fulls of water from a bucket over you. It was actually very refreshing. They have running water from a well when the power is on. The city doesn't have enough power for everywhere in the city to have it at the same time so they cycle through and randomly turn off the power. You could go weeks with out there being city power. City power is also shockingly expensive even with how rarely it is on it is not uncommon to cost close to $500 a month.  The clinic uses a generator to pump water from the well into the storage containers on the roof to be used for showers and toilets. They also turn on the generator at night once a laboring mother is close to pushing.  A bucket shower is quite nice. Then I crashed and slept hard.

Monday, December 10, 2012

Haiti Travel Day

Haiti by the Numbers:
  •  Less than 45% have clean water
  • 74 babies due per 1000 births
  • 12% of all babies die before their 1st birthday
  • 1/3 of all children die before they reach the age of 5
  • 1 in 71 women will die in pregnancy or childbirth
  • 50% of the population earns less than $60 per year
  • The average life expectancy is 53  
Travel day July 2011

I was so anxious I hardly slept. The kids and I were very emotional when I left. Ben drove me to the airport. It was nice to spend the time with him alone. He was kind enough to help me with the 150 pounds of luggage I had to carry. The first flight from Vegas to Miami was uneventful. I had a window seat over the wing which is my favorite place to sit. I love watching the wing adjust as we fly. The plane had substantial hail damage which was a bit concerning. My two seat mates were two late twenty something brothers from Australia. A third brother sat across the isle.  They reminded me of my boys. There were two that were very similar in height and one suave looking youngest one who was much shorter. They were very nice and we spent a good amount of the time discussing similar places we had traveled over the world. 

 I arrived safely and got my bags only to have several urgent emails from Mamababy Haiti saying my flight must be wrong since the only 1130 flight arriving in cap Haitian was a cargo plane. Of course the ticket office wasn't open so that began the anxious night of attempted sleep. Every 15 minutes a loud speaker would come on and announce the time in both English and Spanish. There were several other repeating announcements in between. I had three sleep options. To try to sleep sitting up in the divided chair, to sleep alone right under a large speaker or to sleep with a bunch of traveling hitch hiker hippie surfing guys. I tried my luck by myself and got a little intermittent sleep. Evidently the Miami airport goes dead at 12 am only to wake up fully at 2 am. So I was up then as well sharing the airport Dunkin doughnuts line with cops and foreign travelers. I woke to these men walking around wearing black jumpsuits with wide green stripes running down the legs.I could not figure out who they were or what they were doing. They started pulling covers off of these contraptions that I assumed were napping pods (yes I think these napping pods to not exist but they seemed like a great idea to my exhausted body at the time.  A little pod you could climb into and nap with a secure place to hold your luggage. Why not?)  Turns out they are baggage wrappers. Wrapping you luggage in green saran wrap to keep it safe from theft. It cracked me up to see every ones luggage a bright green color.

 After walking for over an hour I finally found the tiny ticket counter in what looked like the Miami airport basement. I stood in line with many colorful Haitian people and eves dropped a bit. They were obviously wealthy in order to be able to fly to the states. I got to the ticket counter and everything was explained regarding my ticket. We would be stopping over in a city called Marsh in the Bahamas to drop off some people and refuel. The plane was small and we had to pay a ton for extra baggage and they weighed us before we boarded.  You always know the plane is small when they weigh the passengers this I learned while traveling in Africa. We proceeded to sit and wait. Two  Haitian business men started up conversations with me about what I did and what they did. One in particular worked for the better part of an hour trying to convince me that my time in Haiti would be better spent with him getting the royal tour of the city than at the clinic. I never wear jewelry when I travel internationally but sometimes a wedding ring would be nice. Our conversation ended when I showed him adorable pictures of my family and he commented that I looked too young to have a 9 year old.

The flight was very bumpy and I nearly vomited several times. An extra take off and landing didn't help much with the air sickness. I don't hate flying but I don't love it either especially flying over open ocean. The seats were so small I don't know how anyone larger than me could have folded themselves into them.

I arrived safely greeted by Mary the Mamababy Haiti site director and Martha a student intern and Otair an interpreter. They were lovely and helped me make it through customs easily.  They even got it cleared that customs did not examine by bags which turned out to be a fortunate thing. It trying to save space and weight I had taken all of the probiotics, garlic pills, cranberry pills, and prenatal vitamins out of their original packages and jars and placed them in huge gallon sized bags. I had four gallon sized bags full of questionable material. I had also taken a gallon sized bag of vanilla protein powder. It looked like a bag of cocaine and even felt like it through the bag until you opened it and vanilla filled the air. Do they make vanilla scented cocaine? They would have been confiscated for sure and I would have been detained for who knows how long if they had searched them. The men in the airport were very helpful with luggage and eager for their $1 tips almost ripping the heavy 150 pounds of luggage out of my hands. 


We rode to the clinic in the MBH ambulance, a Tan Landrover, was intense with many near death experiences and gawking people.  We stopped to get native cassava bread which they baked from cassava ground and cooked on large round flat stones. It is delicious and interesting to watch then make. Things are very expensive here. Gas $5 a gallon. I joked with Otair that he liked honking the horn and siren on the ambulance when he smiled and said "We are here and this is how they know to open the gate." Sure enough a compound on my right with bright red doors swung open to welcome me to Mamababy Haiti. 



There was a birth going on when I arrived attended by the two native midwives. I was quickly oriented and unpacked. I share a room with 3 other midwives. It is so hot and humid. I struggle with claustrophobia from the bottom bunk and mosquito net. Dinner of black beans and rice with some sauce was served and it is delicious. I crash early around 8 pm only to wake up delirious several hours later in a hot sweat. The city power had gone off, something that happens nearly every night, and with the lack of power went my fan and my sanity.   I stumbled out to the people talking on the porch and moved my bed to a top bunk in the overflow staff room which is attached to the dinning room and family room and is much more open.  Much less claustrophobic. It slept restlessly until I was woken at 5 am with two moms in labor.

Wednesday, December 5, 2012

Tongue Tie- My Personal Story with Two Different Babies

Tongue and lip ties are present in about 10% of the population and are slightly more common in males. In the 1950's or more years ago in both the US and UK or more it was semi routine to snip a baby's frenulum as part of the post birth care. With the rise in bottle feeding in the 1970's the practice fell out of favor and professionals lost the ability to detect tongue ties.

Maternal presentation is commonly characterized by:

  • Nipple pain and/or erosions that do not improved after the first few minutes of nursing and improve greatly over time
  • A clamped or pinched look to the nipple
  • Painful breasts
  • Persistent Thrush
  • Low milk supply
  • Plugged ducts
  • Mastitis 
  • Frustration, disappointment, and ddiscouragement with breastfeeding
  • Untimely weaning

Infant symptoms and signs include:

  • Poor latch and suck 
  • Inability to latch to a bare breast
  • Inability to stick tongue out past the baby's gums or lips
  • Clicking sound while nursing (poor suction)
  • Ineffective milk transfer
  • Inadequate weight gain or weight loss
  • Irritability or colic
  • Fussiness and frequent arching away from the breast 
  • Acid reflux or excessive gas
  • Fatigue within one to two minutes of beginning to nurse
  • Difficulty establishing suction to maintain a deep grasp on the breast
  • Gradual sliding off the breast
  •  “Chewing” of the nipple
  • Falling asleep at the breast having taken less than an optimal feed, as proven by “test weight” on a digital scale 
  • Weight loss of greater than 10% in a newborn
  • Milk running out of the sides of the mouth when bottle feeding
  • A heart shaped, forked or little butt shaped tongue
What does it look like?

This is my fourth baby, Oliver getting his newborn exam performed and you can really see the lower tongue tie on him.

Here are some other examples

Experience Number One

My third child, Everett, was born with a tongue tie. This was not something that was pointed out during the newborn exam by my midwife. He nursed decently but I attributed that more to me being a third time mom and breastfeeding champ then to him. He made a terrible clicking noise when ever he swallowed and I still had nipple pain and bleeding when he was three weeks old. I started doing some research and a midwife apprentice friend of mine stopped by to visit and picked out the short frenulum right away. She shared that it was much more common in baby boys and tended to be genetic. I called my fraternal grandmother and sure enough my father had been tongue tied, had never nursed successfully and had it clipped when he was about five years old for speech problems. I called around several places and no one seemed to know what to do with me or willing to help me. The hospital IBCLC recommended using nipple shields, which based on my doula experience and problems I had seen them cause I was not willing to do. Because he was a happy baby and gaining weight well I decided to wait it out. I would rub his frenulum between my fingers and have him mirror me often sticking my tongue out as far as it could go. Over the course of the next few months his frenulum eventually stretched and the nipple pain ceased. He is almost six now and has a little bit of trouble saying certain words and definitely has a "butt shaped" tongue, but for our situation I felt like I made the right choice.

Experience Number Two
My fourth child,Oliver, was also born with a tongue tie. We picked it out right away. Having been down that road before it was a problem I wanted to identify early on. He nursed but not very well. He was a very fussy baby and would cry often. He did not gain weight well and seemed generally unhappy all the time. He would only nurse for a minute or two and then would fuss and nurse again twenty minutes later. I assumed that his frenulum would stretch just like his older brother. We did the same massage, tongue exercises, and nursing like before but no change. At about six weeks postpartum with bleeding nipples and a unhappy and underweight baby I took him to see my family doctor. After a short consultation he agreed that the tongue tie was severe enough that it needed to be clipped. As a mother I was very stressed about the surgery but I knew that what we had been doing was not working for either of us. The doctor took a piece of gauze and grasped his tongue and pulled it out and up. Then he took a blunt ended pair of scissors and clipped the tiny piece of tissue that was ruling out lives. There was one spot of blood. Oliver cried when this tongue was held by the gauze but not with the cut. He latched on and nursed perfectly from then on out. What a different experience.

My Role as a Midwife
As a midwife establishing a good breastfeeding experience is imperative to not only mothers emotionally, prolactin hormones make you happy, but also physically as breastfeeding reduces your chances of post partum hemorrhage because it keeps the uterus clamped down. Although my experience's regarding tongue tie were far from fun, I am thankful to have the different experiences to help my clients in assessing and improving their nursing relationship.

What Can Be Done?
Nothing- if you and baby are doing fine nothing needs to be done.
Massage- as I wrote about massage to help the tissue stretch can help some
Breastfeed- the nature of nursing helps to stretch the frenulum and eventually things can improve
Clip the Frenulum- as in the story above this is a simple procedure can can be performed by multiple care providers including a doctor or dentist