The clinic day starts at about 8:30 in the morning. The morning buzzes were that

1. the girl who reportedly drank the water and hadn’t gotten sick, leading to lots of “hurrahs” about how we could now brush our teeth with the water, was actually up puking all night and was now getting an IV. I had chosen not to brush my teeth with the water -- made that mistake at a rural homebirth 20 years ago and wasn’t gonna make it again.
2. a nurse had a tarantula on her shoulder last night. It had shimmied up her pants, and her shirt leading to some hysterics. Note to self: Tuck pants into socks at night!

We have breakfast and walk past the usual array of vendors. It is cloudy this morning and smoke from the wood and coal used to cook in the town float heavily in the air, unable to disperse to a higher altitude.

Today was our first day of work in earnest as Saturday is considered a transition day and Sunday little work is done so it was hard to find a translator to help us integrate into OB.

We arrive at prenatal clinic where we are asked to help out this morning, to find 3 benches of women, with about 20 women to the bench, already waiting for prenatal appointments. At the start of the clinic day, these women break into a hymn -- the singing is gorgeous -- followed by the Lord’s prayer, all in Creole, all in perfect unison. There is always music here. Throughout the clinic day, we hear American pop music the nurses are playing on a radio in the background. In spite of the poverty, Ipods are not an uncommon sight (and everyone under 60 has a cell phone).

We divide up, Geoff seeing patients with the aid of a woman interpreter named Maurice, an Alfre Woodard exact look-alike, and I pair up with a midwife named Luna.

The prenatal encounter is as brief and sparse as the offices in which they take place. The clinic room I am in is long and narrow with a desk, a chair, a fan mounted on the wall above the desk so it blows on patient and provider, an old exam table equipped with stirrups, and a table with supplies that, while clean, made me, a non-religious person, pray that I never need surgery in this environment. The walls appear to be plaster with dingy, peeling paint and the floors are some kind of old linoleum, I think. The exam table is covered with a paper blue sterile gown rather than a sheet or exam paper. This is changed only if a vaginal exam has been performed on it; otherwise one woman after the next lies on it for her exam. There’s an ultrasound machine that works, and a colposcope, which I don’t know if works or not, but given the current bottles of white vinegar and betadine, used in the colpo exams, it is definitely put into action.

I saw about 15 women in the course of the morning. The midwife did the interview and I did the exams. I’ve learned to say “Coucher pour la examin s’il tu plait” (lay down for the exam, please) or something that sounds like that, which signals the pregnant woman to go the exam table, take off her shoes, put her feet in the stirrups, lie down, and hike her dress up over her belly. If it’s a vaginal exam she drops her panties and does the same. There are no drapes for modesty, the door is not closed, and people come into the room as needed. Even if there is a vaginal exam in process, the women seem non-plused. HIPPA is absolutely non-existent here and it is probably this exact lack of privacy which keeps people from being open about stigmatized subjects here, like HIV (which here is VIH, by the way, or depression).

Listening to Luna interview our patients in Creole, I caught many of the words and a good bit of the gist, though couldn’t keep up with the conversation in detail. I repeatedly wished I’d paid more attention in middle and high school French. But I am actively registering and processing the language, and in the deep recesses of my brain I can feel my French vocabulary file opening.

While the prenatal questions were fairly standard, i.e., do you have bleeding, contractions, swelling, do you smoke, do you drink, it was interesting to notice what was not discussed. For example, we had a woman at 34 or so weeks who’d lost a previous pregnancy at 28 weeks, as it was recorded, to oligohydramnios (of note, oligo is not a cause of fetal death, it is a result of a number of different conditions that could lead to fetal death -- the reason in this case was not noted in the chart). There was no discussion of or inquiry into how she was feeling emotionally in this pregnancy regarding pregnancy loss -- did she have worries? The fetal death rate here is astronomical, 1 in 12 children die before 1 year of age, so it’s common and seems to be taken for granted. I am sure people feel it; they just remain silent.

Also, clinical findings that would concern me both as a homebirth midwife and as a family doc don’t seem to phase the midwife. For example, a woman at 28 weeks with noticeable generalized edema, headaches and a diastolic BP of 80 caught my attention. I asked the midwife if she would usually check protein. “Vous chequer protein din pipi?” I ask, I am sure sounding ridiculous. But something registered and she grabbed a lab slip and checked off protein in the urine to send off.

In the afternoon the women who were sent off for labs come back to clinic for results and any treatments. We have a surprisingly large formulary here, so we can rx metronidazole for bacterial vaginosis, amoxicillin for UTI, B6 for nausea. (I also recommended fresh ginger juice in water with lemon today for a woman who got side-effects she thought were from the B6 she’d tried.)

Between it all we check on kids with cholera, a woman who might have leprosy (I did a scraping and a KOH prep and did microscopy here in the lab), and a newborn who likely has hypoplastic lung. His respiratory rate is 60 and he will not likely survive, but is a trooper….

Off to sleep…..