Wednesday, December 1, 2010

"Crazy Mondays"

Tersa and her little girl.
(Long story... but hopefully worth the read.) ~

Mondays are always our busiest days. Loads of patients -sick since Friday- sneeze, cough, cry or vomit  their way to the front of the line. And prenatals that could have come at anytime, choose THIS day to get checked out. All the hustle and bustle makes things seem more urgent... more important. I think they like the show.

But to see it all, you have to get there early.

Tersa came in earlier than most however since she was in labor. When I first saw her, she was squirming in pain and clinging to my translator so tight he couldn’t move. It was endearing really. But since the contractions came every minute or so... it was impossible for him to do anything but stand there looking scared (and slightly annoyed). 

I took his place and comforted her through the pain. It was clear, she was close to delivering. Since this was her first child, I talked to her about how to push WITH contractions and not to do purple pushing. (Here they believe you have to PUSH-PUSH-PUSH at the very end whether you have a contraction or not. This wreaks havoc on perineums and babies alike. The first gets torn to shreds and the second gets less oxygen and becomes ‘depressed’).

So when Tersa started pushing, she had some ‘un-learning’ to do. She caught on quickly and a beautiful little girl was born just a few minutes later. She amazed us all with her strength and silence. Simple. Sweet. Beautiful. Strong.

For me the most memorable moment was when I placed her little girl in her arms. I looked from her little girl, to her and then to her mom who was standing beside her rejoicing. Three generations of resilient, beautiful women.

Sigh. Time to rest. Right?

Wrong. This Monday had just begun. I still had 20-some-odd ladies to care for prenatally. They patiently waited outside during the birth and smiled in solidarity when she shuffled passed to the postpartum room. But as this Monday would have it, I only got to three of them, when another labor came inching in. I apologized but knew I’d have to send them home.

They didn’t make a fuss when they saw the labor. She was almost too tired to walk. It was going to be a long one.

Her name was Amijima and she was expecting her 6th child. She had a basketball shaped belly that hung low, sad tired eyes and a solemnity that worried me to the bone. Something was wrong.

The TBA with her kept trying to help --bringing out supplies, instructing her and flittering about nervously. She had a sweet spirit and was Amijima’s friend, so I didn’t chase her from the room. But I was tempted a few times.

My heart sank as they told me her story. Her contractions started 4 days ago but hard labor had been torturing her non-stop for 2 days.  Her water also broke 2 days ago and was sticky brown. They did all they could but the baby wouldn’t come. The night before, they went to their local clinic in Thiet (a town 26 miles away). She was given an IV and then referred to us at first light. It took them all morning to reach us by car.

When I examined her abdominally something was amiss. Her baby was posterior/oblique -- and not budging. But most of all, her abdominal muscles were so lax, that even when lying flat, her belly stuck straight out -- unnaturally so.

(Midwives: think OP but with the head jammed in the maternal right iliac region. Vaginally the fetal head was felt only on the maternal right side, but at a -1 station. She was already 9 cm despite the fact, nothing was dilating her.)

I conferred with Margaret. How were we going to get this baby out? What could we do that hadn’t already been done? What was causing this problem? We vacillated back and forth and finally decided on me working vaginally to reposition the fetal head while she worked abdominally to do a modified version of external version.

What I discovered during this maneuver was very useful. It turns out, the head was extended and in a brow presentation. I was able to flex it and things somewhat improved. The head came down to at least a zero station and it was a little less oblique. But the baby still wouldn’t come.

I should note, the baby was still alive. Thankfully. But the meconium staining and high/low heart tones told me he hasn’t doing well. We were ready for resuscitation and kept praying that he’d have a chance to get that far.

Amijima was exhausted and only wanted to lie flat on her back. I could’t blame her. But I knew the baby needed to turn anteriorly. So, I put her in the hands-knees position and tied her belly tight. (Her lax abdominal muscles, I suspected as being the culprit for the malpresentation.) She didn’t like it and kept asking me to take off the belly binder. I kept explaining how it was helping and why it was important. She was almost to her limit. So was I.

“Will this baby come, Lord? Should I refer her?” I prayed.

He didn’t tell me to send her away. So I kept praying, encouraging and asking God for a miracle. And that is exactly what He did. In just 30 minutes of binding her belly and getting on her knees, she was able to deliver her little boy!

Margaret delivered him while I resuscitated. He was severely compromised and we worked on him for some time before he came around. (His Apgar score was 5/7/8. He had thick meconium aspiration and his breathing was so strained, it completely drowned out his heartbeat. Loud.)

We celebrated of course, but it was half-hearted. This precious boy was not handling the whole breathing thing like we hoped. He developed a high fever almost immediately (very unusual and indicative of some kind of intra-uterine infection) and his lungs screamed at me through the stethoscope. It actually hurt to hear... and watch. He was not well.

We treated him soon after with strong antibiotics (the perk of having doctors right there!) and watch him overnight. While they rested, I told Amijima that I was so glad we were able to help her. “You came in time. Thank you for coming early enough for us to help. Had you stayed at home even one day longer, you and your baby may not have done so well.” I said.

She nodded in weary agreement and explained, “Today, when I arrived. I thought to myself, “This is the day that I die.” I am glad I have not died. I am thankful my baby is alive, too.”

It is to His glory that we were able to help her. Neither of us had a clue what we were doing. Neither of us thought the baby was going to come out. She spent 4 days in pain -- convinced that each day might be her last. But God moved. He answered our prayers!

The next day: Since they live so far away, she asked to be discharged. I didn’t want to but she promised to give him his medicine properly and seek care at the clinic in Thiet. Dr. Tom says he only has a 50% chance of surviving (in his experience), even with the medicine.

Amijima and her little boy.
So pray with me. Pray that this boy one day is able to hear the story of his birth, remember how loved he is and how gracious God is for preserving his life. God must have a great purpose for this boy. Pray the medicine we gave them will work and for the family to recognize this as the miracle it is.

Post note: Margaret told me that after the baby was born, she went outside for something and saw Amijima’s father weeping. Men don’t cry here often. She asked him why he was weeping since she delivered and they were both alive. He said, “Because she didn’t die. My daughter didn’t die. I’m just so relieved.”

Frankly. So am I.