Sunday, October 31, 2010

Birth #25

Nyankiir has been back and forth to the clinic for 5 days now. She first came on thursday with labor pains... that somehow stopped once she arrived. I checked her out but sent her home. Later that night she returned in a lot of pain. But she still wasn’t in labor. She had malaria.

When a pregnant woman gets malaria, often the fevers it causes induce contractions. This is dangerous in early pregnancy as it can cause prematurity and miscarriage. 

I treated her for malaria and kept her over night for observation -- mainly because the fetal heart tones were too high. (180's with a baseline at 168) I treated her with IV fluids and paracetamol and discharged her the next morning.

She returned this morning in official labor. Fortunately all her malaria symptoms were better but she still looked weak. She wasn’t here long before delivering a healthy baby boy! Praise God!

Please pray for her. She is doing well but is tired.

Sweet as honey!

One of the translators brought us a gift recently -- sticky sweet wild flower honey. It’s the fist time I’ve ever had it still in the comb. It was amazing! Chewing on it reminded me of God’s version of gum.

Friday, October 29, 2010

6 years pregnant.

A woman came in today saying she was 6 years pregnant. She had no belly and looked on the older side... so I told her I'd see her for a prenatal. I was confident she wasn't pregnant but I didn't want her to worry.

When I talked to her about menopause and the symptoms of it, she told me she had them all. But ... she was sure she was still pregnant.

It took some intense explaining before she admitted it was possible... but even now, I'm not sure she's convinced. Sigh.

Anyone know how to convince a woman she's menopausal? I'm open to suggestions. I really am!

Thursday, October 28, 2010

Some men just take my words away...

First thing this morning, I was greeted by a husband who was very concerned about his wife. She was in labor. Would I see her?                                  Of course.

When I checked her in, she was ready to have her baby any minute. Her husband sat outside on the bench, head in his hands in worry. I could tell he wanted to be with her, so I asked if he wanted to help.                     Absolutely!

While we set up for the birth and I asked her what position she wanted to deliver in, he sat in a chair, fighting off sleep. It was obvious he’d been up with her all night. (Not common. Some husbands drop their wives off in labor at night and go home to sleep.)

Later, as she was pushing with all her might, he stood beside her. When we needed her in a supported squat, he crawled on the delivery bed and held her up. (Not at all normal!) After the birth, he was happy to hold his new little boy. He even knew how! (Surprising.)

As we waited for the placenta, he gently explained that his wife has always had trouble delivering her placentas. This is her fifth baby and each time, the placenta just wouldn’t come out. They’d wait and wait. Nothing. He continued, saying how they would have to take off her beaded necklace, place it in a cup of water and make her drink it. Only then, would her placenta deliver.

What impressed me about this story... wasn’t so much the strange disconnect between a woman’s necklace and her uterus. It was the fact her husband was keenly aware of this problem and wanted me to know how I could help. He cared.

I assured him that he could do that for his wife if he wanted. I wouldn’t stop them. (It wasn’t going to hurt her. It wasn’t going to do much of anything, except taste bad.) But I added that placentas tend to come out for me. Let’s see what happens.

Sure enough, I delivered the placenta not long after. (A little CCT to help things along since it didn’t look interested in coming at all. He was right.) But all in all, it was a loving birth with a loving husband to help.

I monitored her and the baby for the next few hours and watched her husband nurture her all the while. He got her water. He bought her lunch. He worked as her main care taker. (Most Dinka husbands don’t even stick around for the birth, let alone make sure their wives are comfortable afterward. This is woman’s work.)

Later on, as I got ready to discharge them I went over medicine, postpartum checks and the like. I then told them I wanted to pray for them... for God to bless their family in a special way. But before I prayed, her husband interrupted me. He had something to say.

He told me (through my translator) how thankful he was for my help. He was happy I had came from so far to deliver babies and care for the women here. He told me that he was amazed that I was able to deliver the placenta without having to take off her necklace. I had many special skills. He was grateful.

If I could have cried in appreciation without offending him, I probably would have. Instead I blinked back my emotions and smiled. He was so sincere. He too looked like he was ready to cry. He then added that in appreciation he wanted to give me a chicken.

I was speechless -- not because of the chicken but because of his heart. Here is a man who genuinely loves his wife... surprisingly so. Here is a man who isn’t too proud to care and serve... even though it’s woman’s work. He is the exception not the rule. And he takes my words away.... speechless.

I then prayed for them and sent them on their way.

Lord, may this land be filled with humble, caring men who can lead their families in love like this man. Amen!

They came back for a check-up this morning. Both are doing great. And as promised, he brought me a hen. They named their son Doctor in my honor. (Since that’s what they call me here. I don’t have the heart to correct them.) So in their honor, I decided to name my new chicken ‘Doctor’ as well.

Building for the future ~

Abraham the Ugandan
Compressed Bricks
The land is cleared. The metal frame is up. The footers are dug. Yet to look at it now, you wouldn’t see much -- except potential.

But when I see it... I see running water, tile floors and electricity in every room. I see a beautiful open room of row upon row of birthing beds. I see women coming for births and getting the best care possible. It’s really exciting!

Right now sand is being quarried for concrete. We are digging a hole on our property. I’m told it will be mixed with the concrete shipped in from Uganda then pressed into tight little bricks.

The Ugandan (Abraham) who came in to teach us how to make them, says that we are making about 400-500 bricks a day. That progress! If all goes to plan, we should have enough bricks in a few months!

Please keep this building project in prayer. We desperately need the space!

The brick making machine

Sifting the sand

Digging a sand pit

Wednesday, October 27, 2010

All in a days work.

Elizabeth looked 2 years pregnant when she waddled into the clinic for prenatals this morning. She was round in every place that could be round- obviously ready to have her baby any day.

Since she was the last to arrive, she was suppose to be the last seen. But she kept shifting her weight in pain and twisting her face with contractions. She was in labor. But she never mentioned it once.

I bumped her to the front of the line and checked her in to the clinic. She was already 9 cm dilated but the head was still high. I encouraged her to walk around a bit and empty her bladder. She agreed. And I returned to my preggos to click off a few more prenatals.

But half way through one of the prenatals, she stormed back in to the room and plopped herself in the corner on the floor. I had to step over her to measure the other woman’s fundal height. I asked her if she need to push but she didn’t. She just wanted to be near me.

The other woman smiled and said she didn’t mind if she stayed in the room. So I continued on with the prenatal trying not to notice the sweating, half naked woman to my right. It took everything in me.

Once the prenatal was over, I turned my attention to Elizabeth. She didn’t want to move. She didn’t want to get on the birth bed. She only wanted to sit in the corner of the room -- the sweat from her face dripping on her belly.

She stayed that way for some time with me coming and going trying to maintain the chaos of my Wednesday afternoon. (Another labor with twins was trying to decide whether or not she’d deliver with us. A woman five months pregnant struggled with an inevitable miscarriage. Meeting a young Sudanese girl who is going to help me do community outreach.)

Another hour went by before she wanted to get up. She was ready to push. Not long after, a very long and very loud baby girl was born. Woohoo!

But the drama continued.

She didn’t want me to deliver the placenta. In fact, she categorically refused to push it out and argued with me, stubbornly. She told me, “I’ve done this 4 times before. It will come out when it’s ready.” No doubt.

Once it was out, it wasn’t long before she stood up and walked out of the clinic toward the postpartum bed. Her bed was waiting for her. I expected her to be tired and ready to rest. I was wrong. She refused to sit down on it. She chose instead to sit on the hard bench next to it... bleeding through her menstrual pads and asked how long before she could go home.

She explained that she had work to do. Someone had to fetch the water for her husband. No one else would do it and she was burning daylight.

It was clear she wasn’t staying. She’d take off the minute I turned my head unless I discharged her immediately.

But there was just one thing... her baby girl had a fever. Normally, infection doesn’t start for at least 24 hours. If babies are born with fevers, it often means there was an infection in utero. Not a good sign.

I discharged her. I couldn’t NOT. But I made sure her baby had some medication for the fever and warned her of all the possible complications. She assured me she’d be back for postpartum checks. I believe her.

She does exactly what she says.  She says exactly what she means.

If I haven’t said it before, let me say it now. Women here are strong. Remarkably strong. Almost too strong for their own good. I admire them greatly.

Pray for Elizabeth and her little girl. They both had a long day and they need some rest. And especially pray that the fever goes away... miraculously. Thanks.

Monday, October 25, 2010

When God births a baby....

This afternoon, I woman came to the clinic in labor but she didn’t look it. She was too calm and seemed very tired. What was going on, I wondered.

Once I got a translator to help, her story started to make a bit more sense. Her labor started five days ago. The contractions got strong and then stopped this morning. She had very little to eat for five days and was near exhaustion. She walked five days to get to us. Five days. (She could have been in labor five days and walked two days... I’m not sure. But either way, not good.)

Her blood pressure was uncomfortably low (88/63) but she showed no other sign of shock. I rechecked it thinking my equipment was faulty. It came back 86/59. Low.

The fetal heart tones (FHTs) were also disturbing. They were consistently in the 60’s. (*note: FHTs should range from 120-160.) They were so low, I thought it might be the mother’s pulse I was hearing... but it wasn’t. I had a severely compromised baby on my hands.

I prayed while I put in an IV line and moved the mom around in various positions. My assistant got her some 50% dextrose ready and gave it intravenously.

I asked God for a miracle since He knows I never want to deliver a dead baby. We have this sweet agreement. He won’t give me more than I can handle. I can’t handle dead newborns. So I knew He was going to do something. But what He did surpassed my expectations.

Once the IV was in (I was watching the clock), exactly two minutes later I check all her vitals again. They were markedly improved. Her blood pressure went up to 130/70 and the FHTs jumped to 140!

I can tell you two minutes is not long enough for a significant change like this to occur but with God....

When I checked her dilation she was only 3 cm (70%, 0 station, but tight cervix) and her contractions were funky. I can’t tell if her uterus had given up or not. But she insisted that labor had been going on like this for 5 days and all her other babies came out after 2 or 3 hours. Something was wrong.

I decided to induce her with oxytocin in her IV fluids and barely let it flow when her first serious contraction started. And after 10 minutes, I shut off the drip and let her labor on her own. All vitals were normal so I left my assistant to watch her while I got lunch.

Not 20 minutes later he came running to tell me the water broke. Excellent. Progress. As I was going to check FHTs again, he runs back to me again saying the head is out!


I get there to see the membranes bulging and a mama making grunting noises (good sign) but fortunately no head. I ask her to breathe through the contractions. Last thing I want is her trying to push too soon.

Ten minutes later a baby boy was born! When I checked the chart, she dilated from 3 cm to baby out is one hour and one minute. Remarkably fast.

So this is what happens when God is the midwife. Miracles! 

They named him Yom Sabet until they can think of a better one. “Sabet” means Saturday the day he was born.

Saturday, October 23, 2010

Prayer Walk 2010

Today was the prayer walk to raise funds for an ambulance for the clinic. We all gathered this morning (staff, volunteers and random strangers walking passed) on the airport landing strip to pray.

We started with worship and then chose prayer partners and walked. I loved it.
Here are a few pictures to show you what it was like. Pray with us that we are able to get an ambulance soon. Thanks. 

Shoulder Dystocia ~

Madelina came in to deliver her baby at the same time as all my prenatal patients. When this happens... I always feel guilty sending them away. But I just can’t deliver a baby with 20 women waving their prenatal books at me impatiently. Right now I’m the only one doing them. (Anyone want to come help a sista out?)

So when I noticed contraction on top of contraction, I knew it wouldn’t be long but I still tried to get the prenatal women to come another day. No one wanted to leave. I knew I wouldn’t get to all the women out on the porch. But I didn’t care. Labors come first.

Madelina labored well, preferring to stay left-side lying. All was going well until her baby’s heart rate started dropping. She was only 8 cm but the babies heart was in the 80s, 90s. I moved her in various positions and wished to myself I had oxygen to give her but nothing changed.

I told the Clinical Officer on duty, Caleb, that I might have to resuscitate the baby and might call him in for assistance. He was just across the particle wood wall. He was ready.

But when I got back to Madelina she was fighting not to push and the fetal heart tones kept dipping and stayed low. I decided to try to help her dilate by massaging her cervix. It worked.

About 10 minutes later, she pushed out this whomper of a head. I saw him rotate somewhat but then shrink back in. (Turtle sign?)

I turned him this way. Nothing. I turned him that way. Nothing. He wouldn’t budge. My assistant (his first birth and with a jumpy personality to start) was trying to get her to sit up for some reason. (This is the OPPOSITE of what I needed but he was too high strung to hear me direct him.) Fortunately, Caleb walked in just at that time and got her in the lithotomy position. I did a bit of supra pubic pressure and climbed on the birth bed.

I’m guessing a minute passed at this point - maybe more. The baby’s head was tinged a bit blue but I’ve seen worse. I prayed and pulled and rotated. Finally something gave way and out squeaked rolls upon rolls of cubby!

Breathing, cubby, gooked covered loveliness weighing in at 4150 grams! Yeah!

Wednesday, October 20, 2010

Mike and Amy....

The Yordts are long-term missionaries out of CA who joined our staff a month back. Mike has been here on and off for years. He is our “get ‘er done” man and jack of all trades. His main role is compound manager. Today, he is putting electricity in our clinic! :- ) This makes for a very happy midwife!

Amy has been doing IDATs accounts for ages. She is still doing it, and now has added Clinic Administrator to her job description. It is so nice seeing all the wonderful changes she helped bring to the clinic so far. I’m so glad they are here.

Beauty from Ashes~

A few months back we had a spell of drama in our community. One of the Episcopal Pastors got a young girl from his congregation pregnant out of wedlock. She was only 15. Her brothers found out when her belly couldn’t be hidden anymore and retaliated by beating the pastor’s brother with a club.

He died in our clinic later that night.

Revenge killing is common in this culture. They don’t kill the offending person but someone close to him. They want to cause the offender as much pain as possible. If you only kill them... they won’t suffer nearly as much.

When there is a revenge killing in this culture, everyone goes into hiding --especially the relatives. Anyone can be victim. Mothers. Cousins. Friends. They try to find a close relative to kill but if they can’t they will take anyone they can find. But there seems to be a rule to all this killing. It must be done within three days.

Pastor Peter, when he learned of his brother’s death, decided to retaliate as well. He  (and a friend) couldn’t find any of Rebecca’s brothers within the time limit, so he found an old man from her village and killed him instead. He then ran off with Rebecca without paying the bride price. The whole town was a stir. The church was in shock.

Scandal. Rumors. Gossip.

A few weeks later, Rebecca and Peter were caught and BOTH put in prison.

I asked the locals why they would put HER in prison, as well, since her only sin was getting pregnant. The answer I got surprised me. They explained that it was also her fault since she could have refused him. (! Insert bitter sarcasm here and a few choice words! @%$^#*! This may be one thing I’ll NEVER understand in this culture.)

A few months later, they released her on bail. It's no good having a very pregnant woman in jail.

Fast forward a few months to last night.

Just as I was wrapping up for the day, Rebecca waddled in with her mother. She spent the first few minutes of our conversation on the floor in a strong contraction.

I didn’t recognize her right away.

Slowly, as we talked of contractions and ruptured membranes, did it occur to me this was THAT Rebecca. I couldn’t help but smile inside. Finally, something beautiful was coming out of this chaos and pain.

I checked her into the clinic even though she was only 3 cm along. I wasn’t sure how fast she’d go since this was her first baby. I guessed she’d deliver in the wee hours of the morning. But I was wrong.

She dilated to fully in only 3 hours while laboring almost exclusively on her knees. She pushed like a pro and breathed her baby’s head out! It was amazing!

When she was done, the smile on her face was contagious! She was radiant! What’s more is... she was delighted! It was a joy to see! Beautiful! 

So yes, this bouncy baby boy may have started his life in rumors and heartbreak but I don’t think it will end that way. He is the proof of the transgression. But he is also proof of love. The love of his Heavenly Father that knit him together and filled his lungs with air!

My prayer is that he will one day praise Him with those lungs and show the world what forgiveness and grace REALLY looks like!

Pray for Rebecca and her mother Mary.... and of course No-Name-Baby-Boy! Pray they’ll be accepted in the town they are moving to and have enough to eat. Pray God will provide all of their needs according to His glorious riches in Christ Jesus. Thanks.

Labor of Love October 2010 ~ Newsletter

I'm a little late in posting this... but here you go. October Newsletter: Labor of Love.

Sunday, October 17, 2010

The Griff!

A few months ago, we were in need (desperate need) of a Bible teacher for the fall semester months. As I prayed over who God might be calling to come, Joshua came to mind.  I mentioned him to Sabet and wrote him to see if he’d be interested.

Josh is a missions-minded man with a huge heart for Africa. He has been involved in missions work for years, working mostly in Mexico and Africa. You would never guess he’s done so much as he’s pretty young -- early 20s. But he understands God and what’s more... he loves Him!

When I told him about the opportunity to come teach the Sudanese pastors he was surprised. He’s never taught full time before. But when he prayed, God made it clear to him that he was suppose to come. God told him, “Of course you cannot do this work, Josh. But I can do it through you.” And that is what God is doing.

So each morning, he teaches until lunch. Then in the afternoons he records the Dinka New Testament in preparation for the talking Bibles. It’s a neat project! I can’t wait until it’s all recorded!

But what is more... he is mechanically minded. So far, he is constantly helping fix generators and fiddle with electrical problems. What a blessing he is to us!

Saturday, October 16, 2010

Manual Vacuum Aspiration ~

Today I saw my first manual vacuum aspiration (MVA) performed. It was hard to watch but gently performed. Dennis was instructing me how to use it, since, it will be my responsibility to do it in the future. I’m not looking forward to it.

For those who don’t know, an MVA is used when a woman has an incomplete abortion (aka: miscarriage). It is different from a D&C (Dilitation and Curettage) which is performed (at least in the states) under anestesia.

As its name describes, it uses a vacuum seal to draw the products of conception from the uterus through a thin tube inserted via the cervix.

I’m happy to learn this new skill and to provide such a needed service to these women... but I’m also sad. I never suspected that my work here would involve so many miscarriages.

In the Philippines, we NEVER saw or dealt with miscarriages. Once in awhile we had a patient that had a miscarriage, but the minute it occurred we transferred care to the hospital. But here, WE are the hospital.

Having this skill saves our women lives as well as the cost of going to Wau. It costs (I’m told) as much to have a D&C as it does a C-section. We of course, provide it for free.

Crusty Yellow Teeth Bark

In the states, we spend insane amounts of money making sure our teeth sparkle and stand unnaturally straight. In fact, the money we spend in toothpaste alone could finance a small European country. Lexumbourg perhaps.

Dental care looks a little different in the Sudan. I haven’t seen any dental floss for sale yet... but I see toothbrushes everywhere. In fact, they grow on trees!

To be more precise... they are trees.

I haven’t decided yet if they are oversized toothpicks or ingenious flaky bristle pads for your teeth! But they are fun.

I’ve watched some people clean their teeth with sticks 2 1/2 feet long. Somehow it works. I’m not sure how well it works on halitosis but hey... at least the crusty yellow teeth gunk is gone.

Tuesday, October 12, 2010

Abdominal Distention?

So I've been here 5 months now. I've done hundreds of prenatals.... hundreds. But today was the first day I asked my translator what he meant exactly by "abdominal distention".

Silly right?

Doesn't everyone know what 'abdominal distention' means. It's when your belly sticks out too much after a cheese burger and fries! The pregos here are often complaining of 'abdominal distention'. I write it in their charts as 'bloating'. But I was wrong...

Way Wrong.

After a bit of confusion and lots of explanations (on my translators part) of how eating traps air in the belly causing the abdomen to become uncomfortably distended, did I piece together that my women are complaining of gas pains.

Yep. Gas pains.

A better midwife would have figured out there was a difference between bloating and gas pains four months ago. But hey... we had a nice laugh about it anyway.

Ministry Video - Summer in Sudan

Summer in Sudan from Daniel Crawford on Vimeo.

This video was put together by the talented Dan Crawford, a short term missionary who came to Tonj to work. His focus was evangelism and pastor training but he also worked in the medical clinic.

It's an outstanding video which explains a lot of what this work is about and what life is like in Southern Sudan. I know you'll enjoy it!

To read about his adventures here. Check out his blog - Summer in Sudan. 

Saturday, October 9, 2010

Plaited, Weaved and Bleeding Scalps!

This morning I woke up happy, drank some strong coffee and skipped off to the Salon. Braided hair awaited me!

I was met by four lovely Kenyans waiting to cause me medieval torture! Under the veil of Kiswalhili banter which included a lengthy discussion on the extent of my dandruff, I quietly suffered.

If you have yet to have your hair pleated, let me explain. It’s a scary mess of hair knots, scalp stretching pain and tiny little braids. I honestly wanted to cry at least 3 times! What was I thinking!

Then... I looked in the mirror. What greeted me were tiny, meticulous braids that flared at the end (since my hair doesn’t stay put) and a balding look that only suits a select few. I’m not sure I’m part of that few but I don’t care.

I like the fact I only have to wash my hair every month or so... and get to use waxy-oil on my scalp. I like it a lot.

And frankly, I’m excited to hear what my Sudanese Pregos think of it all. I’m betting they laugh pretty hard! ;- ) I like it when they laugh.

Wednesday, October 6, 2010

Midwives Unite!

This week I had the delight of spending two wonderful days with Newlife classmates and friends -- Holly and Sarah!

I haven't seen them since graduation (a year or so back) and was overjoyed to connect in AFRICA! It was amazing to debrief in person on all the midwifery stuff I haven't dared write about... and hear all their great stories!

They are on a 6 week vision tour of orphanages, hospitals and medical clinics in search of where God might be calling them to work long-term. (I hope it's some place close to me... like Kenya or Sudan!)

I have been so refreshed by their visit and look forward to seeing what God does with them in the coming months!

Plus, Sarah got married a few months back and I didn't make it to her wedding. So, she did me one better and brought her new husband, Dan, for me to meet! What a great match they make! But we have to break him in to all the midwifery talk still!

I must confess, he did have some great expressions when talking of Pwerta juice, condoms and garlic suppositories! He he he... I'm sure he'll get used to it soon. If not... sorry Dan! :- )

Tea to R&B... and everything in between.

This week started out with a walk among the tea gardens of Brackenhurst - a retreat center an hour’s drive north of the city. I spent the day with new friends, enjoying kids and talking of babies to come. It was excellent in every way.

Later on I went to the Nairobi National Museum and saw centuries of African culture alongside giant stuffed animals. I think I would have enjoyed it more if I were eight. But as a whole I found it very interesting. Mental note: African art doesn’t come in frames. It’s on gourds, pipes and elephant tusks.

A few days later, I found myself blistering in the African heat, dancing to Christian Rap artists and R&B beat mastas at the Share the Love charity concert. I love learning about new artists but love live music even more. I got to know the Kenyan side of Christian Rap with Julianni and Javen - and hear the heart of R&B with Dietrich Hadden and his crew. What a blast!

Then to finish my week in style, I joined a friend on a day trip to the country. I spent 7 hours in a car but saw amazing things along the way! I got to meet her family, hike a mountain, gather avocados, catch a chicken ... and ultimately see a new side of Kenya. I loved every minute of it.

Monday, October 4, 2010

Can-buch-what? and the ‘Bean Sprout of life’.

When the nearest grocery store is 4 hours away, you tend to look at food a bit differently. Everything becomes intentional. You have to intend to eat that day. You have to wake up with a bit of determination and a lot of gumption. You have to think outside the rice crispy cereal box.

Such is my new life.

I’m not saying that I drink cows milk straight from the teat or slaughter monkeys for meat. In fact, I (thankfully) don’t have to think much about food. We have a wonderful cook who deals with that. But... for her, cooking means canned beans and toast.

Now, please do not think I’m complaining here. Because I am not. We eat very well in Tonj and I’m very thankful for it! I’m just saying... when the nearest grocery store is hours away, you tend to look at food differently. Yes, you even become a bit more intentional.

So, what are my intentions? Well these days, it’s Kambucha and Bean Sprouts.

Let me explain.

Kambucha for those who are unfamiliar is a chinese fungus that you culture in sweet tea for a week and a half until it ferments and grows even more fungus. This beautiful, petulant and freaky beverage is full of billions of little lactobacilli. It’s super healthy and yummy to boot! Love the stuff! (Side note: I actually found this in Kenya! Unbelievable but true! Thank you random health food store! You rock!)

The bean sprouts are another story. A friend gave me the starter kit and told me to grow my own bean sprouts in Africa. I didn’t know what to think at first but I’ve done it a few times and I love it! There is something extra special about having little plants grow on your window sill. It’s even better when you get to eat them.

So... there you have it. Two of my new coping mechanisms. They may seem strange to you. But to me they are the spice of life... achem... I mean the bean sprout of life!

Mulling over a miscarriage.

Right before I left on break (Yes, almost a month ago.) I had a patient come in with a history of heavy bleeding and clots with what turned out to be an incomplete abortion (aka: miscarriage).

I was so rattled and yet ... impressed by the encounter, that I’m only now able to write about it. I’ve had a month to think it over and ... well, I’m still unsettled. But at least now, I’m ready to write it down.

She came alone and toward the end of the day - almost as if saying she had better things to do that day. She sat still and quietly explained that she was bleeding big clots. She was miscarrying but something was wrong. She said the bleeding started four days before and didn’t want to stop. That is why she came.

She was thin in the way years of working fields and nursing babies make you thin. And she was strong. Long muscles defined by endless grinding and sweeping and caring for kids. But it was her eyes that did me in. They were no-nonsense-black and piercingly serious.

I explained to her that I needed to do a speculum exam to see what was going on. She agreed and that’s when I saw the extent of the miscarriage. Fortunately there were no signs of infection, so I called Dennis in to see if using the manual aspiration vacuum would be appropriate. He said that it wouldn’t (I forget the reason why now.) and recommended I send her to Wau.

Here’s the thing. Women like her (no family support group with her, tattered clothes and worked-to-the-bone thin) don’t tend to have money to go to Wau. I’m tired of referring women to Wau that cannot realistically go. I feel like I’m failing them. I’m not doing all I can do.

So I told her we had too options. One, she could go to Wau and get a D&C because to do nothing would lead to sepsis and further problems. Or two, I could try and do an internal manual exploration to get the rest of the fetus out. BUT that an internal exploration is EXTREMELY painful and I would prefer she go to the hospital.

She explained that she had no money and she wanted me to do an internal exploration. My heart skipped a beat.

Any woman who has had this procedure can tell you it’s worse than the pain of birth. I’ve had to do it a few times (right after a birth) and each time the woman crawled the walls and screamed my ears bloody in pain. My heart shrinks in despair every time I have to do it.

For those who don’t know, an internal exploration requires I reach a gloved hand inside and manually remove the fetus, placenta or membranes from the uterus allowing for it to clamp down and stop bleeding.

It’s a lifesaving measure in preventing postpartum hemorrhage... but this is the first time I considered doing it for a miscarriage. Would it even work? Is the benefit worth the pain? What if I do nothing? What if she goes septic and dies?

I had my translator explain over and over again what it required and how painful it was going to be. I asked her to be strong and try not to pull away. I made sure she understood and again asked her permission to do it. Was she sure?

I was stalling. I flat out didn’t want to cause her the pain. But I wanted her to live more. So I did it.
Here’s the thing. She never once flinched. Nor did she make a sound. She lay still and stoic - shockingly so.

As I removed the fetus from the cervix, I discovered half of it was still inside the uterus. I had to manually dilate her cervix to get it out. This must have been blindingly painful but you would never have been able to tell by her reaction. She was motionless and... resolute.

Once I finished, I asked her if she wanted to see her child. She only hesitated a moment then gathered herself together and sat up. She looked long and hard then said “Thank you”.

I apologized over and over again for the pain I caused her and told her how brave she was. I warned her of signs of infection and instructed her on how to care for herself. I was almost certain I got it all out but she needed to come back for a check up in a day or so, etc. She listened carefully to each instruction while quietly gathering herself together.

Again I found myself apologizing for the pain I caused her and telling her how sorry I am that she lost her child. Only then did she speak.

“Please don’t be sad.” She said. “I am not sad. I am glad that you did it. Now I know that I will not die. Thank you.”

Even now, as I think of her I want to cry. Here is a woman who has not had an easy life. Yet when she loses a child, and suffers severe pain... she ends up comforting her midwife.

My world feels a little upside down.

Medical Clinic Movie - October 2010