Welcome back, reader! This week I am dealing with the task of planning our eighth mobile prenatal clinic in Haiti. The undertaking of saving the lives of pregnant women in rural Haiti sometimes leaves me in a dense fog of thoughts, opinions, and beliefs. Here are some examples of what I’m talking about:
- “This is a huge project!” OR
- “I am not good enough to deal with all of this.” OR
- “I am going to fail at my objectives.” OR
- “This is not realistic.”
You might actually hear these conversation amongst your friends and advisors as well. Isn’t it interesting how quickly a dream can be put on hold in the name of being “realistic”? A word to the wise: Beware of people who want to be realistic: people who are “realistic” just don’t want to be responsible for what is possible. You can’t prove what you can’t do–you can only be right in it not being done.
So to empower Mimsi, what do I do? I make a list. I love making lists! Lists place everything you want to create into reality; they come in handy when you are trying to save pregnant women from complications and death all over the planet. So I write down precisely the things that I want to create and by when I want to create them. Something has dawned on me: maybe you like to make lists too…maybe you will enjoy the Mimsi process if I make lists for you as well. So that’s what I am going to attempt to do with this next entry, and I hope you like it.
Mimsi’s success is predicated on dealing with the top three killers of pregnant women worldwide, no matter what context they might find themselves:
- Blood pressure that are life-threateningly high
Let me explain each one in a little more detail.
Bleeding–or what we like to call Postpartum Hemorrhage
When babies come into the world, there are a number of things that must happen in order to have mother and baby exist individually and safely. The separation is a natural process that consists of contractions; these contractions push the baby through the mouth of the uterus into the vagina and ultimately outside of the woman’s body. This process is called parturition and every woman goes through it to bring the next generation into the world. This is quickly followed by the delivery of the afterbirth, or placenta.
At term, the uterus with the growing baby inside is receiving half a liter of blood per minute to support the baby. When the baby has delivered and the placenta has separated, the uterus has to contract firmly and quickly to shut off this faucet of blood flowing to the baby that is no longer there. If this is not performed successfully, the mother will experience bleeding, or postpartum hemorrhage. The volume of blood loss depends on the speed with which the condition is recognized, addressed, and treated. If any part of the process is delayed, a woman can quickly into shock, where her blood volume can no longer support her blood pressure and her vital organs start to die. A quarter to a third of mothers who die during childbirth die for this reason. A mother is at highest risk for bleeding during the first 24 hours after delivery.
Blood pressure that are life-threateningly high
Pregnancy is a unique time where the growth of the baby is made possible by the mother’s blood pressure dropping to levels typically below her baseline. This drop in blood pressure is accompanied by an increase in her blood volume, which effectively allows more oxygen and nutrients to be transported to the rapidly growing baby and transfers all of the baby’s waste out of the mother. This drop in blood pressure is also the reason you might see women complaining of lightheadedness, dizziness, and fainting.
Now toward the end of the pregnancy, a woman’s blood pressure will trend back up toward her baseline pressures before she was pregnant. However, sometimes a mother-to-be’s blood pressure may go above her baseline into a range significantly higher than her baseline. When that happens, it is cause for alarm because the mother may be developing life-threateningly high blood pressures from a condition called pre-eclampsia. To understand what your organs might be experiencing with high blood pressure, imagine what it might feel like to be choked with the fingers tightening around your neck and constricting your ability to breath. I like to think that this is what is happening through a pregnant mother’s body when she has pre-eclampsia.
Pre-eclampsia can be recognized when a woman experiences blood pressures above 140/90 and is associated with symptoms of headache, blurry or spotty vision, and pain in the right-upper quadrant of the belly. Frequently it will be found with signs of end-organ damage like protein spilling in the urine (proteinuria), elevated levels of enzymes spilling from liver cells exploding, low platelet concentrations, and elevated levels of waste products–i.e. creatininebecause the kidneys are not filtering the blood properly.
In one of our first months, we encountered a pregnant woman (see insert on the left) at roughly 34 weeks with really high blood pressures, the last one being 226/128. She was so swollen and complaining of a headache and spots in her vision. She was immediately transferred to the hospital for treatment and delivery.
Recognition of the condition’s presence is essential to saving the lives of both mother and baby.
Usually the mother is transferred to a center where a higher level of care can be given along with magnesium sulfate to prevent life-threatening seizures and medications to control the blood pressure as measures are prepared to stabilize the baby and effect delivery of the baby.
Untreated, this condition can spiral out of control leading to seizures–or eclampsia, strokes as blood vessels in the brain pop or areas of the brain are starved of oxygen, brain swelling, and death of the baby through premature separation of the placenta (also known as placental abruption–see right) from the mother.
Delay in recognizing the signs and symptoms or sluggish response to initiating treatment of pre-eclampsia can result in very poor outcomes for both mother and baby, including death. Pre-eclampsia is the #2 cause of death in pregnant women worldwide, taking 12-15% of mothers who die during childbirth.
Bacteria–also known as Puerperal Infections
Pregnancy is time where mother’s immune system is a little sluggish in order to allow a new life–the growing baby–to growth without the mother’s body attacking it. However, this diminished immunity places mothers at risk for infection at any point during the pregnancy.
Although an infection during pregnancy can be dangerous, especially if recognized too late, an infection during childbirth and after delivery is life-threatening to mother and baby. During childbirth when the vagina opens the sacred space of the uterus, bacteria like E. coli and Streptococcus like to invite their host of friends into the uterus and cause an infection called chorioamnionitis, which can lead to infection of the baby and dysfunction of the uterus after delivery. These very same bugs can also cause an infection in a woman who was previously without symptoms of an infection after delivery of the baby and placenta, especially if the labor and delivery process was prolonged or complicated by a C-section; we call this infection endometritis.
Puerperal infections can be recognized when mother’s temperature is 38º Celsius (100.4º Fahrenheit) and when the mother exhibits signs of a tender uterus when it is examined. The presence of foul-smelling vaginal drainage can also point to the diagnosis. Without broadly covering antibiotics, mothers can slip into septic shock, where the infection spreads into the bloodstream and causes an exaggerated drop in blood pressure that leads to end-organ damage and death in both mother and baby.
This is the longest entry to date and I thank you for reading this far. I promise to keep it shorter the next time, but I feel passionately that you need to understand how we are training our volunteers to see how these volunteers are now empowered to make a difference by recognizing these players in maternal deaths:
- How do you recognize a woman at risk for postpartum hemorrhage, and how do you treat it?
- What blood pressures signify the presence of pre-eclampsia (life-threatening blood pressures that are new to the pregnant woman and place her at risk for seizures, stroke, and death)?
- What are the signs and symptoms of an antepartum or postpartum infection, and how do you treat it?
These questions are a part of the everyday conversation in which our volunteers are steeped. The more they confront the issues, the better they become at recognizing it in women they encounter in our mobile prenatal clinic, and the faster we can act to save the lives of mother and baby. I hope you have found this entry informative and empowering. Remember that Mimsi saves lives by confronting the Three B’s: bleeding, blood pressures, and bacteria…
Thank you for reading.