Sofia with the twins

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The past two and a half weeks have been remarkable ones on labor and delivery at the Hospitalito. We’ve delivered about 14 babies, which is about twice as busy as normal. But what’s most impressive is not the volume of the deliveries but the degree of acuity and complexity involved in the care of the mom-baby pairs. In Santiago, 50% of the women plan to deliver at home with comadronas, traditional birth attendants. Of the remaining 50%, the half deliver at the public centro de salud, which has one small delivery room and relatively few resources and half deliver at the Hospitalito.  In the home births, the comadronas do a fine job when low risk moms have straightforward deliveries.And in the centro de salud, the doctors do a great job with the resources available, but they are unable to deal with anything that involves a higher risk situation.  That makes the patient population that shows up at the Hospitalito a high risk subset of the prenatal population in town. It also highlights the importance of having a hospital that can deal with acute complications of childbirth in a town that has over 50,000 people. Some care simply could not be delayed the 2 hours that it would take to get to the nearest hospital outside of Santiago. All of these factors demonstrate the important role the Hospitalito plays in providing essential maternal-child health to the people of Santiago Atitlan.

Here is a summary of some of the cases from the past couple of weeks

· A 30 year old woman came in with vaginal bleeding at 30 weeks of pregnancy. She had not received any prenatal care. At the Hospitalito we quickly diagnosed placenta previa by ultrasound, administered steroids to help the baby’s lungs develop and transfered the patient to an outside hospital more equipped to manage her care.

· A 27 year old woman at 35 weeks was transferred from the centro de salud for an abruption. On arrival the baby was in acute distress. Despite arriving in the evening when only 1 doctor was working, 3 volunteer doctors answered the call to come in and do anesthesia, baby resuscitation and help out with the surgery. They baby was born within an hour of arrival.

· A 31 year old woman was induced for being passed her due date. She was given medicine to start her labor and monitored closely. 15 hours later a perfectly healthy boy was born.

· A 21 year old woman was transferred from the centro de salud for high blood pressures. On arrival to the Hospitalito, she was diagnosed with preeclampsia and started on magnesium to decrease her risk of seizures. She did not progress past 5cm and ended up needing a c-section. Despite the fact that it was 5am when the decision was made to do a c-section, 2 volunteers doctors came in from home to do anesthesia and surgical assist. The baby was 9 pounds which was very big for a 4 foot 11 inch, 160 pound woman. During her post-operative time in the hospital her blood pressures were monitored closely and she and her baby did great.

· A 19 year old woman was transferred to the Hospitalito after she had 3 eclamptic seizures at home. On arrival she quickly got magnesium, an ultrasound, and was put on the fetal monitor. After a couple of minutes of seeing the baby on the monitor, it was decided that she needed a c-section. She got pre-operative antibiotics and anti-nausea medicine within minutes. Despite the fact that it was a Sunday afternoon, again 3 volunteers were present to do the c-section, anesthesia and baby care. The c-section was uneventful. Post-operatively she developed a very rare and extremely dangerous condition called HELLP syndrome. The team was prepared for the worst but ecstatic to see her make a complete recovery.

· A 24 year old first time pregnant woman at 38 weeks was transferred from the centro de salud, contracting with preeclampsia. She had not received any prenatal care and was brought in by her comadrona. On arrival we confirmed what the centro de salud had diagnosed: twins! The second twin was breech. Given that this was her first pregnancy and that we didn’t feel safe attempting a vaginal delivery, the patient elected to have a c-section. We suggested that she deliver at the government hospital because the babies looked little; about 5 pounds each.  The family refused the transfer and were talking about going home.In the end we convinced them to stay. We did a c-section and she had two very vigorous and healthy, although small babies: 4 pounds 6 ounces and 4 pounds 2 ounces. The babies ended up getting transferred in the morning and have done great at the government hospital.

· A 22 year old 40 wk G2P1 was transferred from centro de salud at 10cm. She had been pushing for “hours” without progress. After an hour of no change here, she was taken back for a c-section. The baby came out great. Mom (who had a history of post-partum hemorrhage that required an operation after the delivery of her first kid) however had a massive postpartum hemorrhage.In total, she lost about two and a half liters of blood. Thankfully we were able to stop the bleeding with medicine and fill her up with many liters of intravenous fluids and transfer her to the government hospital where she could get a blood transfusion. After several days and a couple of return trips to the operating room, she is finally improving.

· A 34 year old woman could not get past 6cm and had a c-section for failing to progress.  At the c-section the baby was found to be “sunny-side up”.  Mom and baby did great.

· A 28 year old woman who had a history of 2 prior c-sections came in and was found to be 10 cm. As we prepared the operating room for an emergency c-section (no one in the US would ever plan to do a VBAC on a woman with a history of 2 prior c-sections), she had an uneventful “VBAC” (vaginal birth after c-section)

· Two separate cases of women who were unsuccessfully pushing at home for several hours with comadronas came in and needed vacuums to pull the babies out due to maternal exhaustion.

 In each case, the health and welfare of the mom and baby was dependent upon having a safe place to deliver, a well staffed labor and delivery ward and hospital, a clean operating room, the resources needed to provide care (suture,surgical tools, medicine,ultrasound machine, vacuums, etc), and a robust group of physicians who were available on call whenever help was needed. I don’t know what would have happened to all the moms and babies over the last few weeks if the Hospitalito wasn’t here. But I think the care they received is a very real demonstration of what Hospitalito Atitlan has to offer to this relatively poor, indigenous Guatemalan town.

submitted by Dr. Andrew Smith

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