Saturday, January 15, 2011

Waiting to die...

Preparing the vehicle to transport her.
I have a story but I don’t want to tell it. I’m afraid if I write it down, it will somehow become real to me. It is true though and that’s why I don’t want to tell it. But the not telling is starting to make me sick. So here goes...

Monica was a regular prenatal patient. Each time she came, I stressed the importance of delivering with us. She also knew not to push longer than two hours at home for I taught it many times. But as a 19 year old Dinka girl expecting her first child, she was at the mercy of her family when it came to how she’d deliver... not her midwife.

When her labor started, her family chose to keep her at home calling for a TBA (Traditional Birth Attendant) to watch her through the night. By morning, even though she was fully dilated, the TBA wasn’t able to get the baby to come down. She pushed for hours causing the baby’s head to swell as well as her labia. The TBA did all she could but eventually gave up.

Precious time lost.

But instead of coming to us next, they gathered their money and took her to a witch doctor, where (I’m told) he massaged herbs on her belly and proclaimed that ‘Now, the knots were untied and the baby could be born.’ Realizing he had nothing left to offer, they finally brought her to us.

More time lost.

When she arrived, I estimated she had been fully dilated for at least 6 hours, possibly longer. Her contractions were still strong but there was absolutely no progress. She lay exhausted, writhing in silent pain as her family explained all they had done. 

As I did a vaginal exam, I knew immediately she required a cesarean. There were too many signs of obstructed labor. This couldn’t be fixed by binding her belly. This wouldn’t progress if I stretched her and forced her to push. This appeared to be a case of deep transverse arrest (when the fetal head gets stuck in the mid-pelvis, restricting the mechanisms of labor). So I told her family she needed a cesarean. They didn’t seem surprised.

Fortunately, both Monica and child where doing fairly well. All we had to do was get her to Wau and they could be saved. There was just one catch, night was falling. Buses don’t travel at night. However, even if it were broad daylight, they’d be out of luck. With all the voting this week, the buses were booked solid. Even if the family paid twice the fare, there were no seats available. So I went to Sabet and asked if we could drive her.

He was happy to comply but we had to find our diver first. It’s dangerous to drive at night but sometimes if he is in the right mood, and you ask him nicely he will take that risk. We sent people to find him.

More waiting.

The family paced the floor while she writhed in pain. I went back to Sabet an hour later asking if we found our driver. He explained he couldn’t locate him and that we’d have to wait until morning. But even then, they wouldn’t leave at first light since the truck would need to be fueled first.

Meanwhile, the family told me they had arranged for a motor bike to take her home. What? I was confused. “How will she get to Wau if they went home?” I asked naively. Only then did it occur to me that they were giving me an out. They wanted to take her home to die.

The last time I had this conversation I kept telling the family that the patient (a multigravida with  IUFD and potential placenta abruptio. Her story here. And here.) needed to get to Wau or she’d die any minute, thinking that pressuring them would get her there faster. It didn’t. It just made them insist she go home and die there instead. The family gave up because I painted such a dark picture.

So this time, I played my cards differently. I reminded them that Sabet had promised transportation at sun-up. All they had to do was get through the night and we’d drive them to Wau. I explained that both she and the baby were alive and they shouldn’t give up hope.

They were glad for the news. But it meant more waiting.

My stomach churned as I considered how long she’d have to endure. Already, she had suffered so much. I couldn’t help but marvel at how she handled the pain. But her silence wasn’t courageous resolve for her eyes betrayed her. They darted from face to face in panic. Fear had it’s grip on her. So I prayed.

I prayed she would be able to handle the pain, that the contractions would stop, or that miraculously the baby would be born. I prayed that if not, she’d make it to Wau and both would be saved. I entrusted her to God and went to sleep. The on-duty health worker would check on her in the night and alert me if there was a problem.

Tossing and turning all night, I got up early to check on her. I needed to be reassured. I arrived as the health worker was unsuccessfully trying to find heart tones. It was apparent Monica hadn’t slept at all.

I shooed away the onlookers as I searched for heart tones myself. Nothing. Her abdomen was taut and tender to the touch. How long had she been like this? The health worker explained he never checked on her in the night. What? I wanted to scream it but didn’t want to cause a scene.

“What do you mean you never checked on her? You were suppose to check her every two hours. I left very clear instructions.” He stammered something about not having been told, refusing to look me in the eye.

I was kicking myself for not waking the guard to let me out of the compound that night to check on her. I should have been more persistent. I shouldn’t have trusted our health worker with something so important. I was mad at him... myself... and the situation.

She was in shock. Her blood pressure was bottoming out. It wasn’t good. On top of it all, her baby was dead. I couldn’t find a heartbeat anywhere. I called for Dennis to help me get an IV started as her veins were collapsed. He got it on the third try. Then I went to wake Sabet.

I explained that the baby had died in the night and the laboring mom couldn’t wait any longer. She was in shock. We needed to go now or she’d be dead too. He immediately got on it, saying he didn’t realized she was at such a risk. An hour later they were on the road.

In my head I imagined they’d drive up to the hospital, rush her through the doors and take her directly to surgery. She’d be saved.                       But I was wrong.

Our driver returned in good spirits saying she got ‘a picture taken of her baby on the inside’ (ultrasound?) and it was still alive. (Really the baby was alive? How?) He added that the ‘doctor lady’ said Monica would be observed for another 8 hours. If she didn’t deliver in that time then they’d do a c-section that night. (What? She is being made to wait another 8 hours! $#@%$#!) I wanted to scream.

I bit my tongue instead and smiled as he gave me this ‘great news’. My gratitude was genuine. I was thankful he was willing to go, for Sabet’s generosity in sending the vehicle, for the family’s continued hope. I trusted that the doctors in Wau knew what they were doing. I trusted God with her life. It didn’t make sense to wait. She had waited long enough but it wasn’t up to me. (By the time she arrived in Wau, she was fully for over 24 hour.)

So I waited and prayed. More time lost.

The next day I learned that she got the cesarean after failing to progress in Wau. She waited 7 hours before they took her in. The baby was born dead (not a surprise) and an hour post-op, she joined him. I don’t know why.

I think it was all the waiting. 

Her death surprised me -- not because dying in childbirth isn’t possible but because it was completely avoidable. I know it’s foolish to play the ‘what if’ game but I can’t help it.

What if she came to the clinic earlier?
What if they hadn’t wasted time pushing so long?
What if they bypassed the witch doctor?
What if they arrived before sunset?
What if our driver was found and took her to Wau that night?
What if the hospital rushed her to surgery immediately?
What if... What if....