Friday, November 5, 2010

Death on a Tuesday ~


(This story is hard to write. It might be hard to read. Proceed cautiously.)

Mike our compound manager came to my door early Tuesday morning saying he’d got this call. Someone saw a pregnant woman being carried down the road on a home-made stretcher. They wanted us to pick them up. Would I come with him?

I quickly changed and ran out the door, wondering if I’d need gloves. Was she delivering on the road? 

When we arrived, fifteen people rushed her to the truck and loaded her in. She was quiet but moaned each time we hit a bump on the road... which happened often.

Once back at the clinic, I tried to get her history. Name. Age. Number of pregnancies. Her name was Elizabeth. As it turned out, this was her 8th pregnancy but only two were still alive. Two died during delivery. The rest died at various ages for various reasons which she couldn’t explain. They just died.

Meanwhile, I measured her, took her vitals and searched and searched for the baby’s heart beat. Nothing. She calmly stated that her baby wasn’t moving anymore. I continued to search. 

It was silent in there. Eerily silent. I couldn’t even hear placental sounds. Strange.

She went on to explain that her labor started the night before but after a few hours, lots of blood gushed out. Several hours after that, her water broke. At which point, her family and friends insisted she start pushing. She pushed all night. When the baby didn’t come, they finally decided to get help.

But by then it was too late for her child. When I explained her baby was likely dead, she turned her face to the wall. But she didn’t cry. In fact, she didn’t do anything. Her blood pressure was bottoming out from exhaustion and blood loss, so I pumped her full of fluids.

I asked her husband to explain again the sequence of events. How much blood did she lose? Did the water break first or the bleeding? How long exactly did she push?

I also did a vaginal exam to see what could be causing the problem. She assured me she had never pushed so long before. I couldn’t find anything significant. All I noticed was a very large caput (or swelling on the baby’s head) and a slightly contracted pelvis.
(For those midwives out there: She was fully, 0 station, caput at a +2 station. Her pelvis seemed somewhat platypelloid in shape but adequate. The baby’s head was extended but otherwise normal.)

Since her contractions had stopped completely, I started her on an oxytocin drip. I figured her uterus had just become exhausted. All that was needed, was a bit more oompf and the baby could be born. I barely opened the line, expecting the drugs to jump start things.

But nothing happened. Nada. Zip.

I opened the line completely and let the medicine storm in -- still nothing. Not even a twitch. This has never happened before. My magic solution failed. How was I going to get this baby out without a contraction?

I started talking about going to Wau. I told them that I would do everything in my power to help, but they might need to prepare to go for a cesarean. The husband, understanding the seriousness of the situation said, “I know that my baby is dead. Please, just save my wife. Do whatever you can.” I promised I would.

As I considered the situation, I realized I hadn’t tried EVERYTHING yet. I just wasn’t sure I was READY to try everything.  My everything included some painful and unpleasant procedures.

I told them that since the Oxytocin wasn’t working. The only way I could think of pushing, was fundal pressure. (*Side note: I’ve never done fundal pressure before. It’s dangerous. A lot can go wrong.) I didn’t want to do it, since it’s outrageously painful but I couldn’t think of anything else.

So I explained what it was, and told them that I’d try to flex the baby’s head and turn it in a more favorable position while they pushed. My assistant and her husband would both need to help do fundal pressure.

She pushed. They pushed. I turned. Nothing. An hour went by.

And when I say an hour, I mean a full hour of sweat, pain and intermittent progress. One minute the head would descend and I’d think we were in the clear, the next, it would be all for naught.

With each push, my heart would sink and I’d pray harder. This is not the sort of thing I learned in school. I’d look up and see her face contorted in pain. I’d look at the men pushing with all their might and think, “This is crazy. She needs a cesarean. Get her to Wau. And fast!” But then, we’d all take a deep breath and try again. I could actually feel the skull shifting and crackling beneath the swelling. Not good.

I was so stressed, worried and scared by this point that I yelled at anyone who barged in the room. And yes, I had people barge in -- translators, patients, looky-loos! And when I had reached the very end of my strength and patience, a pregnant woman stormed in and threw herself dramatically to the floor. Apparently, she too was in labor. But I had NO time for her -- no compassion, no patience, nothing. My hand was elbow deep in the middle of a stillbirth. She was making it worse.

I screamed for her to leave, but it took 8 more looky-loos to fix the problem. I was on my last nerve. What madness had descended on me? I continued to pray.

But I was running out of ideas. I had only one plan -- fundal pressure the baby out. It wasn’t working. I have no vacuum extraction. I have no forceps. I was running out of options.

Only then, did I remember a procedure called internal version. I had studied how to do it in school. But since I have yet to do an external version, why did I think I could do an internal version? I didn’t. Would it even help THIS situation?

For those who don’t know. Internal version is when a baby is repositioned (usually) from a breech position to a cephalic (head down) position by reaching inside the uterus and turning the baby. It is most often done when dealing with multiple gestations, etc.

But this case was different. I had the baby in a cephalic position. I was thinking of turning it breech. What if I delivered the body and the head still wouldn’t come out? Was I just making things worse?

But I didn’t think about it long. I acted. Some would say foolishly. I pushed the baby out of the pelvis (into her uterus) and was instantly splashed with a gush of bloody amniotic fluid. The baby’s head had been sealing it off. Now it covered me....  and the floor and everything in between.

At the sight of it, my assistant nearly lost it. I had to ask him several times to mop it up. He froze in horror.... and disgust.

Meanwhile, my hand was floating inside her uterus. Let me say that again. My. Hand. Was. Floating. Inside. Her. Uterus. (Slight, freak out moment.)

Slowly, I started identifying parts and pieces. I felt a hand. I identified a foot. Oops, that’s the cord. Yep, that has to be the face. My patient looked calm. She didn’t seem to even notice what was happening. It was strange, warm and horribly fascinating.

My assistant was still trying to figure out what a mop is for, so I called for more help. Dennis and Margaret came in to find me covered in blood with my arm lost inside my patient. Dennis reconnected her IV line, while Margaret managed to get some of the chaos re-organized. It was good to have them there.

I firmly grasped both feet and turned the child breech. I delivered the feet and then the legs. The body came out with relative ease but the arms got trapped behind the head. It took me several minutes to get the arms un-trapped. I prayed earnestly for God to remind me of all the steps I learned in school. I sighed and ... maybe even laughed, when they finally did come out. You can’t imagine my relief. But the head still needed to be born.

At this point I was so passed the point of exhaustion my hands shook. I was stressed, covered in blood and sweating like mad. “Lord! Please help me get this head out!” Images of me decapitating the child in the effort flitted through my brain. “Lord, by your grace. Help me.”

It took me several more minutes of maneuvering, suprapubic pressure and a lot of pulling before the head was born. I wanted to celebrate but I couldn’t. My heart hurt too much.

This birth was anything but gentle. It was flat out traumatic. Horrifying even. And yet, we all rejoiced. The father rejoiced that his wife was saved. The mother rejoiced that her pain was over. I rejoiced that God had answered my plea.

But as I stood there, holding this beautiful boy in my hands I couldn’t help but shake in exhaustion. It had taken every ounce of me... and I wasn’t even the one in labor!

I, then, rushed off to get out of my blood-soaked scrubs and shower. I had to take a moment and pray. I needed to cry. My first stillbirth. It was awful. Terrible even.

When I returned, my assistant had cleaned up most of the blood. The mom was recovering well. She even smiled at me, then went right to sleep.

So there you have it. It’s not beautiful. In fact, it’s not far from nightmarish except for one thing. She lived.

Some of you might read this story in shock and horror. Rightfully so. I’m sure you can find much to criticize. I did many things wrong. But I’m not sure what I would have done differently -- except barred the looky-loos from the clinic. Ha ha!

Side note: The woman who barged in and threw herself at my feet in labor, delivered soon afterward with Margaret’s help. In fact, I don’t even think she realized I had a patient in my room... let alone my hand inside of her! Ha!

Update: 
Both Elizabeth and her husband came in today for a check up. She is in pain from the fundal pressure but otherwise doing well. Please lift her up in prayer. Thanks.