Three months now in Guatemala. I’m acutely aware of hitting the 90-day mark because two days ago I had to do my visa run, the mandatory exit and re-entry that the long-term traveler faces. I hopped onto a shuttle yesterday morning at 5:30am to Tapachula, Chiapas, Mexico (a 2.5 hour drive from Concepción Chiquirichapa) where I spent the day with about 10 Guatemalans from Xela. The shuttle service helps foreigners and Guatemalans alike in their endeavors up in Mexico, whether it’s a visa renewal or shopping at larger stores like Sam’s Club (just like Costco) where they can buy much cheaper goods in bulk that one can find in Guatemala. By the end of the long day we were all friends and the bus full of people cheered for me when I re-entered into Guatemala and the border agent didn’t fine me for breaking the (loosely enforced) law that foreigners exiting Guatemala must spend a full 72 hours outside of the country before re-entering. Visa run success!
Our last stop of the day was at an art exhibit that was touring around Mexico- something I didn’t realize we were doing until we finished all our shopping and the shuttle operator Don Lucas announced that we were going to see something very special –an exact replica of the Sistine Chapel, vetted by the Vatican, that was created to be exhibited throughout Mexico. From the outside the building appeared non-descript, with no indication of the visual treasure that awaited us inside. We entered the first part of the tour and watched a video about the history of Michael Angelo’s assignment to paint the chapel- then we walked through to the actual replica of the church. The lights were dimmed so we could barely see the art, then turned off completely so we waited in darkness. As the lights came up and narration came on I looked up in amazement at the recreation. I couldn’t believe I was seeing something so beautiful on my somewhat dreaded visa run to Tapachula, where we were temporarily transported to Rome. Photos were strictly prohibited, so I can’t share those, but below you can see the view from the building’s exterior:
I got home to ACAM in the evening and arrived to find a 16-year old first time Mother in labor. Two of our most experienced midwives were on call. They told me that they had started an IV to hydrate her as she’d been progressing slowly all day. They asked me to check her dilation.
She was moaning in the bed, surrounded by her female relatives. She was a baby herself, working hard to meet her own baby inside of her. Beads of sweat ran down her forehead as she worked through painful contractions, exhausted by her long labor. I introduced myself and sat down with her on the bed. I put on gloves and checked her cervix, anticipating she would be nearly completely dilated by looking at her. My exam revealed something unexpected and my heart sank. She was 6cm dilated, but when I reached to feel the baby’s head, I didn’t feel the normal smoothness of the skull nor the familiar suture lines between the bones. Instead I felt irregularity, soft spots, the features of the baby’s little face beneath my fingers. Carefully assessing the contour of the nose and mindfully avoiding poking my finger into its eyes, I removed my hand and took a breath. The baby was in face presentation. The patient needed an immediate transfer to the hospital as a baby presenting face first can have significant swelling and trauma and may need more extensive neonatal resuscitation at delivery. It may also be recommended to deliver by cesarean to avoid injury to the fetus’ neck. In a face presentation, the fetal head and neck are hyper-extended. In a normal presentation the head is flexed, so the baby’s chin is tucked down toward its chest. I have only seen one other case of this in my five years as a midwife. Face presentation occurs in about 1/600-800 births and looks like this:
When I checked the patient and felt the baby’s face, I was instantly transported back in time. In my first few months in practice as a midwife back in 2012, I managed the labor of a first time Mom in the hospital. She had a similarly slow progression and I remember checking her cervix throughout the day and feeling the baby’s head, but feeling some irregularity to it. Similar to the ACAM midwives, I thought it felt funny but I reassured myself that the head was down and I continued to manage the labor normally. When she got to complete dilation, she began pushing and the baby descended quickly. The baby was so low with the pushes that I could see the presenting part. However, instead of seeing the typical swath of hair on the baby’s head, I saw a swollen pair of baby lips, confirmed by putting my finger in the baby’s mouth and feeling it suck! Horrified that I hadn’t identified the abnormal presentation, I called in my OB doctor to come evaluate and told the patient to stop pushing. He arrived and calmly confirmed that it was a face presentation and recommended proceeding with a C-section to avoid injury to the baby’s neck. I was traumatized to see the baby’s swollen purple face and her need for prolonged resuscitation at delivery. Thankfully that baby in that case did fine and her swelling went down after a few days. But I remember crying in my on-call room after the delivery, vowing to never EVER miss an abnormal presentation again. Thankfully, this mistake, which has stuck with me for years, served me in this case. As soon as I checked her I had no doubt that I was feeling another face presentation.
I sympathized with the ACAM midwives, who felt similarly terrible about not knowing what they were feeling. They admitted that they thought the exams throughout the day had felt odd, but since they were sure the head was down and the baby was not breech, they didn’t know that they needed to act. They had never seen a face presentation before.
I wrote up a reference form for the hospital and we called the volunteer firefighter who came with his ambulance. The patient was quickly transported and they did a C-section shortly after she arrived. I spoke with the family the next day and the baby is now in the NICU. The doctors told the family that the baby (a girl) is “not okay” but stable and that she was extremely swollen. Unfortunately, there’s no way for me to get any official report or records since the hospital doesn’t collaborate with midwives, so my best source of information is regular check ins with the family.
In Guatemala, I find myself praying all the time. I’m not religious, but I have a regular spiritual practice and for the last few years I meditate fairly regularly. But in rural indigenous Guatemala, you just have to pray. You have to hope, otherwise your heart will break. The inequality is just so GREAT and the healthcare disparity is so staggering that you do what you can and ask whatever God (or Goddess) that you believe in to please send some light. You pray that the baby in the under-equipped NICU lives. You pray for that 16-year old Mother who could have so easily lost that baby had someone not realized at the last moment that something was wrong. You pray for relief for the crying 70-year old woman with decades of pain who likely has a deadly cancer growing in her womb which nobody has ever screened for or diagnosed. You pray that the woman with severe pre-eclampsia is allowed by her husband to go to the hospital. You pray that someone in that hospital takes the time to treat her like a human being, with empathy, dignity, and respect. The praying helps. I feel connected in a profound way to the rawness of human existence. I do what little I can and we fight for the poor and the vulnerable with the tools that we have. The longer I’m here, the harder I want to fight and the deeper my understanding of this place becomes. The midwives are my allies in the fight, my sisters, and my dearest friends.
In other news, I’ve accepted an offer from ACAM to extend my time here for an entire year. Instead of working my original plan of six months and coming back in December, I’ll now be working through the first half of 2018. They’ve offered me a generous salary by Guatemalan standards complete with paid vacation and a round trip ticket home to Seattle to visit family and friends for a few weeks. After a lot of deliberation, I decided to take this incredible opportunity as I fall more and more in love with this place, this work, and the special people who have come into my life.