Saturday, November 20, 2010

Silence in the womb.

*Caution: This story isn't for everyone. It's a story of death and heartache but needs to be told.

I was told in Midwifery school once, that after a birth... you’ll always know why the birth went the way it did. If there is bleeding or fetal distress... or even death, it is often only afterward that the cause is made clear.

We cannot see inside the womb but it doesn’t mean we are blind. A watchful and attentive midwife will know when things are not going well. There are signs. There are precautions to take.

When Achol came in on Tuesday last, she was tired. She had been up all night in labor but was otherwise doing well. But I couldn’t say the same for her child. Her waters had broke at home several hours before, pouring out slimy, thick, brown amniotic fluid. And as I listened to his heart beat... my warning alarm went off.

They would go up and down with and without contractions. I had to keep moving her around to find a position which didn’t cause the heart beat to drop. I immediately suspected a cord compression of some kind, but which kind? It didn’t appear to be a prolapsed cord. But I wasn’t ruling it out. 

My heart bonded to her immediately and I have to admit, I smiled at her antics. This was her first pregnancy and as a teenager... she acted like it. (I’d guess her to be about 14-16 years old). As she moped about the clinic, she cried out loudly for God to “just let her die!” and for me “to give her a cesarean! Now!.”

I knew she was tired but I had to smile. She was just too adorable. I was strong with her though and warned her repeatedly that her baby wasn’t doing well. That she needed to listen carefully when I asked her to get in different positions. It was for her baby’s best. Sometimes she complied. Other times she didn’t.

As she labored that afternoon, some of her relatives explained a bit of her story. They said that her husband was a soldier. He wooed her and took her as a wife without paying the bride price. They ran away to Tonj together. And all was fine until six days earlier, he was killed in a car crash. She had just returned from his funeral. This was his only child.

It explained why her husband wasn’t there and her brother-in-law was. It also explained why she was so scared. Her family and friends lived very far away. She was alone in many ways.

She kept trying to push prematurely which caused some cervical swelling and a notable caput (swelling of the fetal head) to form. The thing was... each time she pushed prematurely her baby’s heart beat would drop. I begged her NOT to push. Everyone did.

In my head, I was pretty confident I was going to need to resuscitate this baby. I was prepared for it and so was the rest of the team. My hope (since I couldn’t get her the cesarean she needed) was to get her to breathe through her contractions until the very last moment and then push like mad.

She kept pushing each contraction so I did another vaginal exam. Finally, she was fully dilated and the heart tones were good, so I asked her to push. But as she pushed, the heart tones dropped. She moved in various positions and pushed. But since this was her first child, it took her time to figure out how to push exactly.

We worked feverishly to get the baby out. But I couldn’t get Achol to hurry. She had no sense of urgency. I don’t know if it was her age... or if my urgency was lost in translation. All I know is she dilly-dallied. (But as I look back at the chart she really only pushed about 45 minutes - which is short for a first time mom.)

Again, I found myself wishing for a vacuum extraction. Again, I did perineal stretching -- anything to get this baby out quickly. I had people searching for heart tones every few minutes. They were there for the first 15 minutes or so... then disappeared completely.

My hope was that the baby was just too low in the pelvis for us to hear them. But I wasn’t convinced. Ten minutes went by. I begged Achol to push with all her might. Another 10 minutes went by. Still no heartbeat found. I kept praying and with each passing minute I prayed even more.

It’s at this point I asked for the episiotomy scissors. I’ve never cut an episiotomy before. But the head was finally low enough for it to work. We hadn’t heard the heart in almost 30 minutes and the head was dusky.

I cut. She pushed. And he was born -- Limp, ashen and lifeless. Thick, sticky, meconium oozed from his mouth and nose. No breaths. Not even a grunt. No heart beat. Silence.

We started PPV and chest compressions but he didn’t respond. All the while, Achol watched in confusion. While resuscitating, I verbally walked her through what was going on. “Your baby isn’t breathing... we are giving him oxygen. Your baby’s heart isn’t beating. We are going to try to get it started.”

She seemed very confused and wildly looked from face to face in the room. Only after we gave up resuscitation efforts did she fully grasp her baby was dead. She wailed and mourned loudly, calling out to God. I cut the cord and she took him in her arms -- crying even louder than before. Desperate pleas of ‘Why!’ along with a warm, stream of tears filled the room... and the silence. 

I didn’t have to speak Dinka to understand her words. They were universal. Part of me wonders if her brother and mother-in-law didn’t grieve even harder. They were equally devastated holding that beautiful boy in their arms. He was all that remained of their son... and brother.

Afterward, I had to suture the episiotomy (almost) against her will. She kept insisting I leave it but I couldn’t. I couldn’t leave her deformed. She didn’t know what she was asking. Fortunately, she slept through it. It was just too much to handle. Too much pain. Too much sorrow.

The boy was taken home to be buried and I kept her over night for observation. We ministered to her in every way we knew how. But I think the most effective person was Sabet (ministry director/Dinka man). He asked to hear her story and he listened. Later he explained to me that he wanted to see if she blamed herself. Her answer was heartbreaking.

She confessed that she broke her father’s heart by running away with her husband. She knew it was wrong but didn’t care. Now she felt cursed by God for disobeying her father. First her husband dies... now her son. “God is punishing me,” she said. “I am cursed.”

He shared with her the truth of God’s love and prayed for her. He also challenged her to return to her family... and seek forgiveness. I pray that she does. But even more, I pray she finds the forgiveness of our Heavenly Father and is forever changed by it and His love.

Please pray for her. Also, pray for me. I can’t help reliving the birth in my head and trying to manage it differently. What if I referred her to Wau the moment she got to the clinic? Would she have gone? Would it have made a difference? What if I had been clearer, earlier on, that her baby was at such a risk? Would she have been better prepared? Would the family have been less shocked?

Yes. I know. Had she been in the States, she would have had a cesarean the minute her meconium stained fluid and erratic heart tones first appeared. Was I foolish to even let her stay at the clinic? Should I have just referred her? It’s hard not to second guess. It’s hard not to feel responsible. Please pray for me too.

And yes. Once he was born, I immediately understood why he died. He had a remarkably short umbilical cord which was wrapped tightly around his neck. In essence, the minute she pushed, he was strangled.