Comadrona training in Jacaltenango

This is Kristen Jamsa blogging tonight from Casa del Mundo, a lovely spot on Lake Atitlan, where we are spending the weekend.  The past few days have been incredibly rich and varied.  Yesterday we started off with a full morning of training in Jacaltenango with a group of 29 local midwives, known here as comadronas.  As the lone midwife on our team, I was thrilled to be working with my sister comadronas in Guatemala, a group of hard working, under resourced and often unappreciated women.  Most of the comadronas in Guatemala speak only their regional Mayan language and have little or no formal education, yet they provide care for the majority of birthing mothers in rural Guatemala. They are hungry for knowledge,  adequate resources to provide for women in their communities, and respect for their profession. 

 We had 7 "training stations" set up in one large, cement floored space, each with a different educational topic-  warning signs in pregnancy and labor, nutrition, hemorrhage, shoulder dystocia, newborn resuscitation, breech delivery, and a "birth kit" station which I manned.  We provided a very simple bag containing some essential equipment needed for a birth to each midwife that attended.  My job was to explain the contents of the bags to the comadronas with the help of an interpreter.  The flashlights and digital thermometers were the big hits of my station.   Use of a digital thermometer seemed to be a new skill for all of the women, and they were fascinated by the beeping sound it made.  It was humbling to witness the outpouring of appreciation these women expressed at such a small offering on our part.   Their needs are so great and our ability to meet them so inadequate. 

comadona ice breaker

Yasmin explaining danger signs

Kristen birth kit station

After our morning with the comadronas, we loaded into the PCI trucks which have made our travels here so easy and comfortable and headed back into Huehue and then onto Lake Atitlan, about a 6 hour drive in total.  We spent a fun evening in Panahachel,  a morning at a nature reserve near the lake, and took a short boat ride across the lake to Jaibalito and Casa del Mundo, arguably one of the loveliest spots in Guatemala.   We continue to eat delicious foods, meet wonderfully kind and generous people, and marvel that such richness and abundant beauty can coexist with so much poverty.   

Sunset on Lago Atilán

San Andrés Huista

Poco a poco (in English: step by step) was the general theme for me today. On this trip we have had the opportunity to be trained on the use of ultrasounds by Chris and Brenda (two experienced family practitioners). For those who haven't used an ultrasound before, it can be quite difficult to figure out the gentle movements and nuances to the machine. Jemie and I, along with local practitioners, have been lucky to get one-on-one training over these last several days. It takes a lot of patience and guidance to get through each ultrasound as we discover discrete structures to bring into focus and measure. Ever so slowly, each of us have been gaining comfort with their instruction. This is of great benefit to us in our future practice, and for the local physicians to provide improved care to their patients.

Jemie doing ultrasound on a patient in San Andrés Huista

Today we traveled to San Andrés Huista, a beautiful town that seemed to appear out of nowhere amongst the forested mountainside. Upon our arrival, we were greeted by many pregnant women dressed in colorful traditional clothing, with toddlers hanging from their backs, while others ran and played. Most of the women spoke only Popti (see our language map below) and little Spanish. We were very dependent on our Spanish-Popti interpreters, although we did manage to learn a couple of words (girl = Ix 'eesh', boy = Winak 'wee-nahk'. Poco a poco we saw each woman; they were in various stages of pregnancy and for the majority of them it was the first/only ultrasound they would likely receive prior to delivery. Through these efforts, we diagnosed a missed spontaneous abortion, placenta previa, and helped confirm/change appropriate dates for delivery.

Our full team at the Puesto de Salud, including Dr. Dorian

While working in the capacity of a physician, you have the unique opportunity to get a glance into someone's life that you may not otherwise have. One such experience was when we offered contraception to a young woman who already had 2 children, that came in concerned she was pregnant again. She responded with, "I'll have to ask my husband," and quickly left. We later learned from the local physician and nurses that San Andrés Huista is an insular and patriarchal society, in which the husbands can choose if/when a women can receive medical care. Contraception is not permitted. Apparently one woman from the community died about a year ago from a postpartum hemorrhage after delivering her 14th child as she wasn't able to access appropriate medical care in time.

Women at the Puesto de Salud wearing their local traje (traditional outfit)

Poco a poco we make changes in our lives and the world around us.

Visiting Rio Azúl

On the way back to Jacaltenango, we crossed the Rio Azúl (Blue River), so called due to the calcium content from dissolved limestone upstream. It was amazing.

Jacaltenango

Jacaltenango is a city of about 40,000 people to the west of Huehuetenango. It is about a three hour drive along a road that passes less than a mile from the border with Mexico. Six years ago when we made our first trip, we met Dorian Rojas, a physician who has worked in Jacaltenango for the last 8 years at the CAP (clinic/hospital with 6 obstetrical beds for vaginal deliveries). He has managed to continue working at the CAP despite a period of 5 months without pay, and his boss being fired for arrogance and abuse of power. Today he is the medical director and has four physicians working with him. They were given an ultrasound machine eight months ago without any instruction. Today's mission was to work with Dorian and his partners on basic obstetrical ultrasound skills.

Suzy, Kristen, Dorian, Brenda, Carly, Jemie, Chris

We managed to leave Huehue a little after 6am and travel to Jacaltenango. Chris & Brenda focused primarily on working with the CAP physicians while Suzy & Kristen did some training with a group of comadronas (lay midwives). Jemie and Carly visited a couple of laboring women and did more ultrasounds as well. The day was partially hampered by lack of electricity, although fortunately the ultrasound machine loaned to us by Sonosite can operate on batteries as well. Jazmin, is a nurse who is working with PCI and joined us for the trip as well.

Yasmin, Carly, and Jemie demonstrating Ultrasound poses

A word on Guatemalan place names. When the Spaniards invaded Guatemala from Mexico in the 1520's they brought with them a lot of mercenary Nahuatl (Aztec) speaking soldiers and assigned place names in the form of [Nahuatl descriptive word]+[Nahuatl suffix]. Thus the Mayan city of Xinabahul became Huehuetenango (place of the ancients). Jacaltenango translates roughly as place of huts.

ULTRASONIDOS

As Jemie and Carly explored the hospital, Kristen, Chris and I saw patients at Casa Materna (CM).
Chris used our loaner portable sonosite "backpack" ultrasound while I became familiar with the (actually quite nice) ultrasound machine at Casa Materna that was donated from Japan, to scan pregnant women who came many hours to HueHuetenango from more remote areas, some of which were having their first ultrasound (and first visit of their pregnancy). Others had an earlier ultrasound but were approaching their due date and wanted to know if everything was "ok" (and if it was a boy or girl!)  I had a glitch or two (like how to clear the last person's info in order to scan a new patient - default is always "reboot" - so we turned the machine off and on again, and presto!) - but all in all pretty smooth of a start. When the ultrasound business slowed, we saw a "consulta" (primary care patient) or two. Mostly some aches and pains and urinary infections.
Kristen was busy doing women's health (pap smears, pelvics, removing some tough to get to nexplanon inserts ), and seeing children.

Suzy and Kristen had an opportunity to meet with some local midwives ("comadronas") in HueHue to discuss how they are working with women in the community - and Suzy (of course!) recognized one of 2 midwives she knew from 18yrs ago who she helped to get an education scholarship for (to attend an out of country conference)

The afternoon was filled with teaching ultrasound, by scanning the women who stay in Casa Materna, waiting to deliver in the following weeks.  I taught the local CM doctor, and one very cute and pregnant CM nurse Yasmin (who will be traveling with us this week to remote villages-- we would be all happy to attend her birth if it happened en route but we promised it would NOT) using the machine at Casa Materna.

Chris taught Jemie and Carly (using 2 different portable machines side by side in the same room--= such double tasking talent!)

...and tomorrow it is off to Jacaltanango! to work at the CAP with Dr Dorian.
Stay tuned!!

Sala de partos

Carly and Jemie (second year residents) were given the opportunity to observe four a few hours in the maternity unit at the National  Hospital in Huehuetenango next to Casa Materna.

We were greeted by Isaac, an OB resident, and given a short tour while waiting for deliveries. The floor is divided into three rooms: labor, delivery, and recovery for postpartum women. Additionally, there are operating rooms and a separate recovery room for Cesarean deliveries. Typically they have upward of 20+ vaginal and 10+ Cesarean deliveries in one day.

The labor room is a large open room with seven beds, full of many nurses and nursing students milling about. We learned about the admission and labor flow sheet that is used to document H&P data and to track progress of labor. The resident explained that many women present in labor without having had any prenatal care, so most of the routine labs are done on admission. Continuous fetal monitoring was not feasible as supplies were limited. We observed one resident using his stethoscope to check fetal heart tones. Women who are laboring towards vaginal deliveries do not get epidurals because there is not adequate anesthesia support, so only women going for c-section will get anesthesia. We watched several women progress to complete dilation before being wheeled into the delivery area.

In the delivery room, there were three stirrup beds. Women are placed in the stirrups and told to push.  We saw one woman who had a female family member with her, but no spouses were present. It appears to be expected that things progress very quickly at this point, and providers use fundal pressure maneuvers to push baby (including two men pushing with all their strength) down and primiparas frequently receive episiotomies. The three women we saw delivered within 3-15 minutes after arriving in the delivery area. After delivery, women are told to perform breast massage to stimulate oxytocin release, and intramuscular oxytocin is available as needed.

After delivery, women are transitioned quickly to the recovery room where they are observed for an additional 2 hours prior to returning to the maternity floor.

There is a heavy emphasis on medical education, as the students take a lead role in labor management, delivery, and episiotomy repairs with resident supervision; we did not see any faculty doctors. Medical school is six years long in Guatemala, and the students we observed were in their sixth year, so could be considered equivalent to first or second year residents in the US. 

Arrival

Estela

Things you can count on arriving by plane in Guatemala City:

- being hit by the humidity

- praying that the customs agents don't stop and search your bags

- Estela is waiting there to bring you to her hometel

Walking the streets of Anigua

Estela is a blessing for picking us up so reliably after a long day of travel. She runs a boarding house in central Antigua that has been a place where we can spend a transition day before heading to Huehuetenango and going to work. Travelers to Antigua will know it is one of the most beautiful cities in Central America with architecture dating back to the 1500s.

One ton float

Today we were treated to an enormous procesión (parade) through the center of town, celebrating 800 years of the Mercedarian order of priests. Iglesia de la Merced is a church founded by the Mercedarians in the 1700's that survives to this day. A few people we asked about the parade told us the church had been there 800 years, it did not add up that the Mayans living there would build a christian church. The centerpiece of the parade was a huge hand-carried float carried by more than 80 people and probably weighing more than 1500 pounds. Here is a link to an article in La Prensa about the parade.

Meeting with Pascal

Later in the day, we met with Pascal who is the head administrator of PCI in Guatemala, running hundreds of programs from Casa Materna to distributing food to tens of thousands of Guatemalan kids daily. We also met up with Amalia, who is an online Spanish teacher and also runs some donation projects with rural schools.

Ceiba tree, national tree of Guatemala

At the end of the day we got to explore Antigua on foot and made it to a place called Santo Domingo, an old convent previously left in ruins and now restored to a beautiful hotel and conference center. You can see the enourmous Ceiba tree growing in the central plaza.

Return to Guatemala

Guatemala has been in the news quite a bit lately. The recent eruption of eruption of Volcán de Fuego, (Volcano of Fire) in June near Antigua, President Jimmy Morales and his moves to exclude the the United Nations backed anti-corruption body, and of course about northward immigration by Guatemalans. Might not seem like a good time to return to Guatemala, and in fact tourism has dropped off because of those events. So you might ask why we are going back at all.

18 years ago in response to the high maternal & child death rate in Huehuetenango, Project Concern International started a place called Casa Materna, a place where mothers with high risk pregnancies (twins, prior cesareans) could reside at during their final weeks of pregnancy. Casa Materna is a one minute walk from the National Hospital in Huehuetenango, and can save laboring mothers lives by avoiding the potentially hours long trip from remote communities. 18 years later, there is still a need for Casa Materna, still a need to lower maternal death rates, and still a need for partners to help provide local training and assistance toward those goals.
C.

Kristen, Suzy, Brenda, Chris, Jemie, and Carly

This year there are six in our group: Suzy our leader is making her 5th trip to Casa Materna, and worked there in its early days. Her day job is a maternity nurse/lactation consultant who makes house calls to first time moms with challenging circumstances. Chris and Brenda are making their 3rd and 2nd trips respectively and both work as family medicine physicians. Kristen is a nurse midwife coming with us for the first time and works mostly doing prenatal and newborn care in a clinic setting. Carly and Jemie are two second-year family medicine residents. Like any amalgam of people, it will be a interesting collaboration, hopefully more akin to Friends than Gilligan's Island.