Dilemmas

Yesterday a first time mom (aka:G1) came to the clinic in “labor”, but her contractions were abysmally short (25 sec) and moderate at best. The trouble was, they were frequent (q 1-2mins).

The women here believe that if labor starts they cannot drink water or their contractions will stop. They are right and wrong at the same time. Dehydration will cause muscle spasms and colicky contractions and even exasperate false labor, making it seem like she in labor when she’s not. But if a woman is in true labor, water will just help her muscles contract better.

This woman hadn’t taken any water all day, and could have been simply having painful Braxton-hicks contractions.

Not wanting to assume she was in dehydration-induced-false or early labor, I asked if I could do a vaginal exam to see if she was dilating. I told her what it would require; she seemed hesitant but willing.

Everything in me was saying she was in early labor and not to bother with the exam, but I’ve seen women here with contractions like this, deliver within the hour. I didn’t want to mess up.

Seconds into the exam, she refused to let me continue. So I stopped, never having found her cervix.

Now, I have had several pelvic exams in my many, many years; not one of them was painful -- uncomfortable but not painful. I’m told however, that in labor, exams are painful, and I always try to be considerate of my patients needs.

She needed me to stop, so I did.

Here is my dilemma. Based on the little I knew of what was happening cervically, and the small contractions she was having abdominally, she was in early labor and should go home.

I was told home was a 30 minute walk away. If she went home, she most likely wouldn’t return. In her head, I would have sent her away without help. If she stayed, a G1 like her could go on like this for hours and who knows days-- especially if she was refusing fluids.


We don’t have room to house women in early labor. We don’t have food for them and cannot accommodate the crowds of family members that come to visit. Or do we?

During prenatals, I encourage these women to come and deliver with us, but then send them away when they come. This must be confusing to them.... thus my dilemma.

Do I just let them labor here in the future, even if labor could be the next morning? But if I admit them, then I feel conflicted as to who will take care of them.

This is hard to admit, but we are not equipped to handle long labors. The translators/health workers haven’t grasped the idea of monitoring women in labor. I could go back and forth from the compound to the clinic all day, checking on her myself, but then she is taking a bed that we many times need for emergencies.

Plus, I’m not on-call at night. If I admit her, Margaret would be responsible for her throughout the night. I know she could handle it, but... is it fair to her to add this extra load of work?

Right now, I am the prenatal program. Everyone else rallies around me when there’s a problem, but when push comes to shove, it’s just me.

Margaret (bless her heart) delivers the babies that come in at night and allows me to be rested for prenatals in the morning. But that’s it. She takes no ownership of the preggos; she has too many other responsibilities to worry about and the clinic is much more than just the prenatal program.

It hurts my heart to send these women away in early labor when it’s clear they want to stay.

I know that birth is different all over the world. I know that what worked in the Philippines and what works in the States may not work here. I just can’t seem to get a grasp on what is appropriate for this culture and this stage in the clinic’s growth.

Pray for me... my heart is to admit them all now, and just let the cards fall where they may. But if I do, am I opening pandoras box?

A raw moment of truth ~

I was called early one morning for a birth, only to find a very pregnant woman, named Adich, writhing on the clinic floor. Her mother sat quietly beside her and smiled. They soon explained that she had never come for any prenatal care, and didn’t have a book. I asked if she was just interested in an evaluation or did she come to deliver. (Some women only want to confirm labor and then go home.)

She didn’t answer. Instead, she asked, “Is this the midwife that delivered the baby yesterday?” My translator nodded and told me her question. She looked at her mom and said, “Ok. I’ll stay then.” (What a sweet thing... my first referral.)

As I checked her in, I could tell she was trying to decide whether or not to trust me. Muscular arms and a green stripped bandana on her head, made her look hardened and strong. She preferred the floor to the bed, so we did most of our checks there.

Once she got settled, she asked, “Are you sure this is not a miscarriage?” I told her I was sure, then asked, “Why do you think this is a miscarriage?” (This was her first baby, so I wanted to hear what was going through her mind.) She said, “Well. I’ve been pregnant now for 9 months and this is the first time I’ve felt bad. It must be a miscarriage.”

Smiling at her logic and innocence, I assured her that this was what labor felt like and that she’d deliver soon. She just nodded and rolled on the floor some more.

A little while later, she made the comment: “My stomach feels rocky!” It was so honest and so innocent that it took me by surprise. Yes. Her stomach was “rocky” in more ways than one.

I asked her to walk around the clinic a bit since I had prenatals to do, and she agreed. She walked while the rest of the preggos in my line watched and chatted incessantly about her. She didn’t seem to hear or mind. Mostly, their comments were about me, however. “Look, the kowaja is going to deliver her baby. Look, the kowaja is listening to the baby’s heart. Look...” I ignored them and focused on Adich instead.

Finding a comfortable position in all that pain was hard for her, and occasionally, I’d encourage her to stand. She was reluctant, but complied. At one point, after standing up, her mother told her, “It hurts if you lie down. It hurts if you stand.”

What a statement! Does it get any truer than that?

She started pushing spontaneously perhaps a half an hour later, so I brought her into the clinic. She liked the kneeling position and did an amazing job pushing. Her mother supported her back and silently watched on.

As she pushed, she clung to me and trapped my knees between hers. It was needy and sweet and strong. I couldn’t have moved if I wanted to.

What this must have looked like to the others in the room, is a mystery to me. Three women connected in a powerful bond of energy, motion and force... and one little ‘woman’ on the way. It was raw and needy... and perhaps even a bit confusing, but I loved it.

When her little girl was born, relief flooded Adich’s face, and her gapped-tooth grin stole my heart. Afterward, no hint of the tough mamacita I met in labor, was left. Adich melted into a mother as she joyfully held her child to her chest. She’d done it! She was strong enough -- even for labor.

Oh, to watch a girl become a mother!

Amazing. Simply amazing.

Fat-tongue!

Some days, my prenatal lines goes by quickly and I find I have nothing to do after lunch. Sometimes I nap, but other times I help take patient histories at the clinic to speed up the line.

History taking is an art not a science here.

Often, you can ask a Dinka person what ails them and they will touch various parts of their bodies in response. This used to frustrate me and I’d insist they use their words, but these days I just smile and write down their various body parts.

Head means headache. Stomach means stomach ache. Back means backache. Easy, right?

Anyway, one day while taking histories, a boy was brought in by his mother; he seemed health enough, so I asked what was wrong. In frustrated anger, she spit out something about him having a ‘fat-tongue’.

Blinking in confusion, I asked, “Did he bite his tongue? Is there a sore?” My translator was relatively new at the time, and he couldn’t think of any other way to describe it.

No, there was no sore. No, he didn’t bite it. It was fat. That’s all.

Confused laughter and cyclical questioning persisted for at least another five minutes, until I was completely fed up. I asked my translator to tell in the simplest manner what a ‘fat-tongue’ meant, since I was new here and didn’t know.

Only then, equally frustrated, did he explain, “The mother cannot tell when the boy is lying. He has a fat-tongue!”

I laughed and shook my head in wonder, asking, “Does she expect the doctor to give him medicine for that?”

The boy, scowling in stubborn resentment, just stood there angrily while I wrote in his book. 

Chief complaint: mother cannot tell when child is lying; he has a fat tongue.

I should have followed up to find out what kind of medicines doctors give liars these days. Ha ha! If only it could be fixed so easily.

A gaggle of gigglers.

Achan is one of my precious prenatal ladies. Expecting her first, I was thrilled she came to the clinic in labor. Her contractions were confusing though-- short but frequent. Not a one of them lasted longer than 30 seconds and most were moderate at best. I thought she might be in early labor, but  since the contractions came every minute or so, that didn’t connect.

So, I did an internal exam.

Surprised as all get out, I found her already 9 cm dilated with an intact membrane. It wouldn’t be long. I told her that if she was able to walk around, she’d delivery faster -- perhaps even within the hour; she seemed happy to comply.

Twenty minutes into walking about, she started pushing spontaneously. It wasn’t long before she had to sit down with each contraction. She was so strong, so silent, and so serious.

Achan was doing well, but her baby wasn’t-- the heart tones were low. Every contraction, they dropped to the 80s and were slow to recover. I figured it was due to head compression, but I wasn’t ruling out cord trouble either. So, I got things ready for resuscitation-- just in case.

As she pushed, her mother yelled at her to confess who she slept with, but Achan paid no attention to her; she wouldn’t even look at her. Her mother insisted she confess or the baby wouldn’t be born, but Achan ignored her all the more. It was as if she knew it was just a game. I know her mother was doing it out of love, but I couldn’t bare to hear it.

(Let me stop and explain: Among the Dinka, it is commonly believed that women who cheat on their husbands have more difficult births. If a labor is extra long or hard, women are exhorted to confess their sins, so the baby will be born. I’m told it’s the midwife’s job to illicit this confession. It’s a cultural thing and this was not the first time I’ve seen it done.)

Fortunately, this confession blather didn’t last long, as she delivered soon after. Her boy popped out, screaming loud and clear with his cord trapped between his arms and chest. The trapped cord must have caused the low heart beat.

Relieved and exhausted, Achan started dozing off even before the placenta was delivered. Her mother tended to her boy with kisses and smiles and all talk of confessions were forgotten. It was time to celebrate.

As the rest of the family gathered close, Achan found her smile. Colorful dresses, beaming grins and continual laughter danced around the room. The older women kept grabbing my hands and lifting them to the heavens together with theirs, while rattling something off in Arabic. They were honoring me.

I repeated their words and they repeated mine -- then we’d giggle. It was fun. Oh so fun. We had no clue what the other was saying but it didn’t matter. It was a chance just to praise God and laugh. So, we did a lot of it. 

Look at those smiles! My precious gigglers!

It’s births like this that keeps me going. Achan showed me, once again, the faith these women have in their bodies. Her sisters and mothers showed me the joy a child brings to the family and were kind enough to include me in the celebration. I feel honored.

I’m so glad families are trusting me with their daughters, sisters and friends. So glad. Pray that even more come. Thanks.

I’ve been thinking...

When I first got here, only the most hair-raising complications came to deliver with me. That equated to about 5 births a month, and each one greyed me in some way. I couldn’t understand why the ‘normal’ births weren’t coming.

Why were they staying home?

Then it occurred to me, these women had no idea why I was here. How could they? I hadn’t told them. They assumed that they should all deliver at home unless there was a complication. Only then, would they come for help.

So, I started telling them they could deliver with me, even if there wasn’t an emergency. I told them that is why I was here. Some were shocked at the news, others clapped and still others laughed. Fortunately, a few took me up on the offer.

Now I have the occasional emergency, but most of the births are simple and fun. Also, I am catching roughly 15 babies a month. It’s not exorbitant, but it’s better.

However, this week as I looked out over my prenatal line-up, it occurred to me that only the sick ones were coming. Why? Do they think they have to be sick to see me? Every woman I saw, had MAJOR complications (pyelonephritis, raging STDs, preeclampsia, etc.). Where are all the somewhat healthy women? Do they exist?

At that moment, a light went off in my head. Of course! They must think they can only come if they are sick. It’s a clinic after all, right? How would they know any differently, if I haven’t told them?

I know. I know. By now you are probably thinking, du-uh! But I must confess, it honestly didn’t occur to me.

So this week, I started telling them to come even if they aren’t sick, so long as it is on the date I scheduled for them.

You wouldn’t believe the surprise and joy this news brought. One woman told me she was so happy to know she could come and have her baby checked regularly! She even asked, “Can I really come every month?” I smiled and nodded, equally happy. Sigh.

Why did it take me 9 months to figure this out? This means a lot more work initially, but if we catch these problems early, imagine all the headaches and pain we’ll prevent.

Please pray for me to have wisdom when dealing with their complaints. I see a lot more complications than I ever did in the Philippines. Also, pray for another long-term missionary to come help out. There is talk of possibly teaching traditional birth attendants and/or doing more teaching in the community.

Having another midwife would free me up to do those things without feeling guilty that the rest of the work is being neglected. Plus, I’m seeing a TON of women for prenatals. If all of them take me up on my offer to deliver here.... I’m in trouble! Happy trouble, but trouble nonetheless. Pray for long-term laborers. Thanks.

Sticky Shoulders!

Ayor was carried in to the clinic by two friends. It was late, but I was already there caring for another patient. She smelled of alcohol and urine, and most of her body was covered in dirt. Obviously exhausted, she lay on the bed and explained her labor had been very difficult.

During her pregnancy, she’d come for several prenatals where I taught not to push for too long. Fortunately, she listened. Apparently, her labor started two days before, but it only got bad that morning. Pushing at home for over four hours caused her labia and the baby’s head to swell. Not good.

Since this was her 6th child, I suspected some kind of malposition or cephalo-pelvic disproportion (CPD), so I did a vaginal exam. The head was large, but her pelvis seemed adequate. The problem was she wasn’t fully yet, but it wouldn’t be long.

Massaging the cervix away while she pushed (uncontrollably), it wasn’t long before the head crowned. It crowned for easily two to three pushes without any progress. Not normal for a P6 (aka: 6th time delivering). Did I have a shoulder dystocia on my hands?

I pushed the labia back over the head, but the body didn’t restitute; he was stuck. Just then, Dennis walked in and I asked him to do suprapubic pressure. Reaching in to manually rotate the shoulders wasn’t hard and the next push he was out -- to the relief of everyone one in the room!

Ayor was so glad to finally deliver. I was so glad she came. Praise God for babies that come out and breathe! I have to say... I love my job!

Do you sing?

When the winds of trouble find you, do you worship? When darkness crowds out faith, do you sing? When you are at the end of your strength, broken and beaten to a bloody mass, do you lift up songs of praise? Do you? Tell me... what do you do, when trials come?

In Acts 16, we read about two itinerant evangelists, named Paul and Silas, who do something very unusual when faced with trouble.

One day, while preaching in Philippi, they were harassed by a prophetic slave girl who followed them everywhere, proclaiming they were from God and teaching people how to be saved (Acts 16:16-18).

I say harassed because she wouldn’t shut up. Even though what she said was true, it was not coming from God, so Paul silenced her by casting out her evil spirit (vs 18). But instead of thanking him for this, those who owned her were furious. The girl’s prophesies made them lots of money, so they falsely accused our protagonists and had them arrested (vs. 19-21).

Long story short, Paul and Silas were stripped naked, beaten severely and chained up in the darkest part of the prison (vs 22-24). Now that’s what I call a tough day in ministry!

I don’t know about you, but if I were in their shoes, I think I would have felt sorry for myself. I probably would have bemoaned my fate and cried myself to sleep. Who knows, I may have even questioned God and demanded to know why! I’m not proud of this... I’m just being honest.

What about you? When faced with unjust beatings and dark prisons, how do you respond?

The Bible tells us that Paul and Silas didn’t cry or bemoan their fate. They did something much less predictable; they worshiped and prayed.

In Acts 16:25 we read: “About midnight Paul and Silas were praying and singing hymns to God, and the other prisoners were listening to them.” Do you get that? In their darkest hour, they sang and prayed for all the world to see.

They sang and God moved!

We are told that when they sang, the earth shook, the floors crumbled, the cell doors flew open and their chains were loosened (vs 26). Imagine that!

As a result of worshiping in dark times, Paul and Silas were set free -- literally. They were set free from their physical chains but most importantly they were set free from any spiritual and emotional chains. And if you read on, you’ll see how this act of joy brought many to salvation (vs 27-34).

Let’s remember this example and praise God when trials come. Let’s sing hymns when what we really want to do is cry. Let’s pray and worship instead... and watch what God will do! May all our prison cells and bruises vanish in song! Amen.

Labor of Love February 2011 ~ Newsletter

My latest newsletter: Labor of Love - February 2011 

Labor of Love February 2011




A little shout out to my good friend David L. Thank you so much for helping me figure this embedding thing out! Not sure why Google doc won't let me have the normal kind of embedding... but hey. It is what it is.

Blessings ~SW

Mastectomy!

Yesterday I participated in my first mastectomy!

(For those who have been following this blog for some time, you will probably guess who got the procedure. Yep. Mary!)

I first met Mary a few months back when she came in for a prenatal check. (Read her story here.) She explained that her right breast got really big after one of her births, and she had not been able to breastfeed from it since. As she sat on my consultation table, it sat beside her. It was big. It was cantaloupe-sized big.

Fast forward a few months, during which time I spoke about her case with the doctors. Tom seemed optimistic that he and a surgeon friend might be able to do the procedure when he (the surgeon) comes in May. But when Tom saw her breast this week, he said it would be easier than he thought. Why not do it now?

I couldn’t see any reason to wait; sure there were possible complications (pregnancy, no operating room, minimal staff, etc.), but doing the procedure now would give her time to heal before the birth.

When I shared this news with her, hope danced in her eyes. Twelve years is a long time to live with a dangling appendage.

Asking her to come back on Friday afternoon, Tom and I looked into what it would take and discussed the details. Tom was confident it would be a simple procedure, but didn’t down play the risks either. Using local anesthetics, we’d cut; if any bleeders occurred, we’d just ligate them and move on.

Nervous and excited, she returned yesterday afternoon. The clinic was (blissfully) quiet as we prepped the room and explained the procedure in detail (once again). She said she understood and was happy to do it now, adding that it was extra bothersome in the heat and it’s hard to sleep. (I can only imagine!)

I won’t bore you with the details. Suffice it to say, it was all about meticulous cutting, ligating arteries, and suturing everything back up. The hour it took to cut it off was long and grueling, but the blood loss was minimal.

When I showed her the removed portion, weighing in at 2.3 kg (or 5lbs), she smiled gleefully. I must admit, I didn’t expect such joy. But then again, if a part of my body had haunted me for 12 long years, I think I’d be ecstatic to see it go, too!

Long story short, we stitched her up and watched her through the night. We plan on daily wound dressings over the next few weeks and I’ll be sure to update you on the progress. Please pray for a quick recovery and that no infection sets in.  Thanks.

The breast before surgery.

The tissue after it was removed, weighing 2.3 kg.

To cut or not to cut?

Earlier this week, a man came in to get his finger chopped off... or so, he thought.

His right index was inflated to twice the size, and the skin surrounding it burst and peeled with infection. The tip of his bone, exposed and possibly gangrenous, smelled foul and caused him outrageous pain. It had been progressively getting worse. Wouldn’t I cut it off for him so he could go back to work?

As I cleaned his wound, I asked him how he got such a terrible infection.

-- “My wife bit me,” he announced grumpily. 
-- “What did you do to your wife to make her want to bite you?” I asked as the corners of my mouth twitched upward.
-- “She ran off for two days, leaving the small kid at home. When she came back I had to beat her,” he explained, “I had no choice.” He was asking for my sympathy but all I could do was laugh.
-- “And she bit you hard, huh?” He nodded and I laughed harder.
-- “It’s not good to have such young wives anymore,” he complained,  “they don’t let you beat them properly when you need to.”
-- Laughing outright and shaking my head, I chided, “You know, the Bible tells husbands to love their wives like God loves His church. You should not beat her anymore. It’s not good.”

My lecture fell on deaf ears because he chuckled at the thought. Imagine that! Puewff... You can’t stop beating your wives! How else will they obey you?

He was laughing at me for suggesting such nonsense, and I was laughing at him for having such a silly (but serious) infection.

It wasn’t long before the wound was cleaned, so I gave him antibiotics and sent him home. He would have to wait a few days to get his wish; there would be no amputations on command at our clinic (according to Dennis).

This week, he came once or twice for wound care, and I’m told it looked better; but he may have given up on our optimism and went elsewhere for his amputation, as I haven’t seen him in the last 3 days. Ha ha.

It’s the first time for me in two respects:
    It’s the first time someone has asked me to cut off their finger and...
    It’s the first time I’ve seen the benefit of having very young wives.

I guess if you are married of to a man too feeble to beat you, that can’t be too bad. Right?

Green Mango Eaters~

So all the locals -- Kenyans and Sudanese, I mean -- have been chomping away at the multitude of unripe mangoes popping up on trees. I wondered about these Green Mango Eaters, something had to be off in their heads to eat unripe fruit. In the States, unripe mangoes taste like flavorless, stringy blah.  I mean... come on! Why would you willingly eat that? If I eat a mango at all, I want it ripe.

But these guys kept insisting that green mangoes were good, so I thought I’d give it a go -- African Style. They eat them skin and all, like apples, so I decide to as well.

Sinking my teeth through the tender skin, I crunched away on all the crisp, semi-tart mango-ness. It was good. No. It was excellent! I’m happy to report, I’m now a green mango eater too!

Constructing Chaos!

Yesterday we closed the clinic for repairs; our floors, peppered with re-occurring potholes, needed to be fixed. This required digging up most of the main traffic areas, mixing new concrete and re-pouring. All our patients would need to be seen in the ‘observation’ room, and since it was Saturday, we expected just a few emergencies. We were wrong. 

The night before, a first time mom came in in very early labor. She didn’t want to go home, so Margaret let her stay. However, by morning she had progressed little, so I informed her of the coming chaos and recommended she go home to labor. She agreed.

By 8 am, all our Sudanese staff arrived. Instead of class, they were going to be doing small jobs around the clinic, translating and helping out. Organizing them in the various tasks proved challenging but in the end, things came together.

At 9 am, the construction crew was in full swing. The floors were dug up, and wheelbarrows of concrete chunks cluttered the halls. It was a mess. But hey.... we were getting new floors, so I was happy.

By 11 am my labor returned, but this time she was active. Walking the clinic grounds helped things progress even more, but the question on everyone’s mind was: Where were we going to deliver this baby? The observation room was full of patients; The clinic was full of dust.

By noon, she was ready to push, so I chased everyone out of the observation room and set up for the birth. She delivered a precious, bright-eyed, dimpled girl without the slightest noise. In the midst of chaos, she was utterly silent.

There was only one problem; her postpartum bleeding wouldn’t stop. I massaged her uterus to expel clots, but it was never a permanent fix. I gave oxytocin but it too was only temporary. I was sure it wasn’t caused by a vaginal tear (as she only had a few skin splits), but that meant it had to be incarcerated clots (when clots get stuck in the uterus preventing it from clamping down on itself) or retained placental fragments. If so, this required an internal manual exploration, a painful procedure I HATE doing. I wasn’t ready to jump to that, and instead watched and waited.

Meanwhile, more and more patients came. The clinic floor was poured and drying by then, and the Sudanese staff had all been dismissed except one, but the activities continued endlessly. It was barely lunch and I was already ready for bed. 

An hour went by and my patient continued to bleed big clots, so I told her I would have to do a manual exploration (reach inside her uterus and manually scrape out the contents) and asked her to cooperate. I had tried everything else. It was this or transferring her to Wau. She agreed. It was painful but worked well; her bleeding stopped immediately.

Then another labor came in! (Yes. You read that right. Another labor!) Normally, I would be game, but I was exhausted. I pushed on and checked her in.

My new labor had a history of ruptured membranes and contractions for over six weeks. She also reported many symptoms of sexually transmitted diseases and was treated each time. We were never sure if the membranes were actually ruptured... or the medicines were actually taken. It was all very confusing. (Two weeks ago earlier, I referred her to Wau because of the persistent ‘leaking’ waters, but she never went. Instead, she stopped coming back. I thought she delivered at home.)

She explained her labor started the night before and her membranes had ruptured (again) just an hour earlier. She and her baby both seemed fine, so I figured she was mistaken about her water breaking last month. I didn’t do a vaginal exam and opted to labor watch her instead. 

More patients came.

While I was busy with her, Dennis did a vacuum aspiration on a woman experiencing her 6th consecutive miscarriage, and treated a toddler for severe malaria. Margaret cleaned a man’s hand after being bitten by his wife. It was so infected, he was asking to have it cut off (I’ll tell his story another time!). But half way through dressing it, a young boy was rushed in after biting his tongue in half!

Madness.

Meanwhile, my second labor kept wanting to push but without success so I chose to do a vaginal exam. Immediately, I knew what was causing the delay. A butt just doesn’t dilate a cervix as fast as a head. Her baby was breech! (It was my first time identifying an tiny anus and butt cheeks during a vaginal exam. Exciting!)

Surprisingly, the fear I had of breeches was gone. Either that, or I was too tired and stressed to feel fear anymore.  Either way, since she was only 4 cm, I let her labor and got busy doing clinic laundry. (There have been so many births lately, we were out of clean underpads and cloths.)

Exhausted by now, I checked on my patient regularly but didn’t watch her like a hawk. She assured me, she’d call once she felt like pushing. However, when I got the call, I arrived to find her baby half way born and her friends yelling for her to PUSH-PUSH-PUSH!

Laughing, half at the lunacy of it all and half from sheer fatigue, I assisted the rest of the birth, delivering the head with ease. Her little girl required no help breathing and had an excellent apgar (AS 8/9). It was a sweet blessing after such a long day.

When my head finally hit my pillow, I laughed at the days events. I never thought births and breeches could be so chaotic and easy at the same time. Pray for me though. I’m tired -- so very, very tired. Exhausted even.

Also, pray for baby-breech. She developed a fever within 24 hrs of birth, indicating some kind of ascending infection (most likely because of the long history of ruptured membranes). We have treated her with antibiotics and are monitoring her closely. Thanks.

The Republic of Southern Sudan!

A country was born this week... right under my nose. Distracted with mamas and babies, I didn’t notice when Al Bashir (Sudan’s president) announced the referendum results. We were three days into this new country, Republic of Southern Sudan, when someone told me the good news!

According to the Sudanese Tribune, a remarkable 99% of voters opted for independence, leaving the North no choice but to let the South secede.  They will become officially separate in July 2011.

Happy Birthday Southern Sudan!

Click here to read an article on the results.

Miserable.

Yesterday evening, I found myself attending a lovely labor with no translator. She came in just as the clinic closed for the day. I explained communication would be limited since two health workers (aka:translators) left without warning this week, leaving us stranded on a few shifts. She said she didn’t mind and I was hopeful.

However, she had unique needs this birth; She was fearful. Her first two children both died at one month old. Coming to the clinic was her way of doing everything possible to make sure it didn’t happen again. I felt more like a lucky rabbits foot than a midwife, but I didn’t care. Her health and peace of mind mattered to me.

Nevertheless, superstition ruled the day; She wore bits of wood and a safety pin around her neck to ward off evil spirits. Believing that food and water would slow her contractions to a stop, she refused all nourishment, causing slow progress. At one point, I convinced her to take some water (so long as it was not cold!), but it didn’t have the nourishment she needed. 

Worn out, she refused to push even though she sat at fully for well over 2 hours. I think the fear of losing this child bounced around in her head while she labored. I think she fought help even though she desperately wanted it, because superstition and fear had their grip. 

I could see her struggle but felt powerless to help. How do you comfort such fear with no (understandable) words? Even through a translator, this birth would have been tough. Without one, it was a nightmare.

Against all odds and to the great relief of all those in the room, the baby came out-- a vernix glazed cherub, weighing in at 3.2 kg!

But her mother, vexed at the sight of her, insisted she was dying. “She is too cold! She is too blue! What is this pasty junk all over her face? Why is she crying! Quick, do something! Give her medicine. Now!”

I didn’t have to understand all her words to know what she was saying. She was having an immediate-postpartum-meltdown (or IPM for short). Bawling as loud as the cherub at her breast, she refused everything I gave her. She rejected my cheerful smiles and warm reassurances. She bristled at my soft tones and encouraging sounds. Nothing, I said or did, helped. 

Miserable.

She was miserable, thinking her baby was dying any minute. I was miserable watching her cry. I deeply desired to provide her with a safe, reassuring birth, yet failed. Miserably.

Her birth highlighted an interesting thought for me; Looking back at the hundreds of births I’ve attended so far, I’m startled to think that less then 10 of them where done in English. What does it feel like to have a laboring woman understand your words the moment they are uttered? I don’t remember. How amazing that must be! Sigh.

Lest I discourage any of you, let me say this: Her baby is perfectly healthy. They both recovered quickly and slept well last night. I discharged them this morning. Pray for Arop, the mom. Pray comfort and joy instead of the haunting fear of potential loss. Pray, also, for her little girl. May one day she sing praises to the Maker of heaven and earth! Amen.

The almost-twins.

Large, expressive eyes smiled playfully when I met her last November. A soldier living on base, Ayen was strong, lean and beautiful-- and very, very pregnant. Her belly was unusually large for her dates; Could she have twins? She had delivered twins once before, would she be up for a second round? Beaming, a toothy, yet tender smile, she explained: “One baby is a blessing, twins are a double blessing!” Her enthusiasm was infectious.

Unable to pin-point whether she had twins or not, she agreed to come back regularly. With time, we figured it would become clear, but it didn’t.

One month, the heart beat would be low, near the pelvis; The next month, it would be high, tucked up under her ribs. It was a quandary. And regardless of positioning, the fundal height kept soaring. I suspected twins because of all the tiny parts I could palpate, but... but... I wasn’t sure. The heartbeat was the same, meaning it could be just one baby. With no ultrasound, we had no way to confirm our suspicions. We’d have to wait.

Fast forward 3 months and several prenatal checks to this afternoon.

When she arrived, busting at the seams, my Twin-Alarm sounded in my head. Her fundal height was 40 cm (not outrageous for North American women but very uncommon here. In fact, the only other 40+ cm fundal height was on my twin delivery last year.), so I called for back-up. Margaret was happy to oblige.

Well on her way to fully, Ayen labored like a champ. She groaned and bit her lower lip in pain, twisting her mouth in a question mark with each contraction. It was child-like and sweet and so unexpected; I couldn’t help but smile in response. 

When it came time to push, she did it with gusto. In fact, a few pushes into it all and Niagra Falls exploded on the opposite wall and gushed down the bed legs, pooling on the floor. Startled, we jumped at the force of it all. The last birth with this much fluid was my twin birth. But then a normal sized head appeared, followed by a sea of more amniotic fluid.

That enormous belly sank to next to nothing once her boy emerged. Twins he was not. Instead, we got one healthy bambino surrounded by 3-babies-worth of amniotic fluid! Laughing at my miscalculation, I must confess I was a bit disappointed. I think she was too. Despite all the extra work twins can be, I think she really wanted her ‘double blessing’. Oh well.

... there you have it. The story of my almost-twins.

Rejoice with me! His birth is the 9th baby in 9 days. I like this season of baby-ness. It’s fun.

Comatose.

Last Friday, a young man in his twenties was carried into the clinic by family and friends. He was in a coma and had been that way for 4 days before coming. They diagnosed him with cerebral malaria and started him on medication. No one knew for sure if he’d make it through the night, but he did. 

He stayed on a constant flow of IV fluids and quinine while his family watched him around the clock. Two days went by, but he didn’t wake up. Three days went by and still nothing.

He is the one being held up by friends.

But today he finally woke up! 

Eight days in a coma is quite the miracle for me, especially in these parts. What a tremendous blessing to watch him regain strength. Watching the family’s relief and excitement at his improvement was fun, and this evening they took him home -- weak but greatly improved.

Missed it by minutes!

Nyankiir came in around eleven this morning. Since she was in early labor (short, moderate contractions), I chose not to do a vaginal exam and she chose to walk around a bit. Two sweet women followed her every step (she was in good hands), so I left her to it. 

Since I was teaching the Community Health Workers when she came in, something I/We do every Saturday, I returned to class intending to check on her in an hour. She knew to call if she needed to push or if her water broke; She promised she would.

An hour later, when I went to check on her, I found her kneeling in the dirt beside one of our buildings. Her mother kneeling in front of her, held a squawking little girl in her arms! I had missed the birth by minutes. Her birth brought the usual crowd and I shooed them away. Surprisingly, they listened and left us a tiny alcove of serenity.

My translator, quick on the draw, ran for gloves, scissors and a basin. I cut the cord and helped ease out the placenta, then together we walked back to the clinic. I asked her if the baby came too fast for her to call for help and she nodded. She explained that she was just going to poop and the baby came instead.

Smiling at her surprise, I told her that it was quite common. At first, I don’t think she believed me, but with time, she didn’t seem to mind either way. She only cared about the precious babe in her arms.

I’m going to have to be more vigilant now that I’m opting out on vaginal exams! I was sure she was in earlier labor. Next time, I’ll use the birth as an excuse to get out of class and stop trying to do so much at one time.

Side Note: Her birth was the third one today. Early this morning, Margaret (our illustrious Nurse-Midwife) delivered two babies within 30 minutes. That brings us to a grand total of seven births in the last five days. I’m so happy watching this program grow, but I know we could be doing a lot more. Pray for God’s very best to be lived out in this work and for us to find culturally sensitive ways to share the gospel. Thanks.

Quiet! Be Still!

 “Who is this? Even the wind and the waves obey him!” ~ Mark 4:41

I was reading in Mark recently and came across the story of Jesus calming the storm. (Mark 4:35-41) You know the story. Jesus was asleep in the stern of a boat after a long day of preaching and healing. A storm hits. The disciples, though seasoned fishermen, fight for their lives as the boat rocked and reared in the wind and the waves. Sure that death was imminent, they woke Jesus, and he spoke two small words. Instantly, the sky cleared and the waves calmed.

It says the disciples were 'terrified' when Jesus spoke 'Be still'.

Think about that. Why were they terrified? Wouldn’t ecstatic be a better response? Why doesn’t it say they were relieved? No. They were terrified. Only then did it occur to me that this happened early on in Jesus' ministry. The disciples were still just beginning to understand who Jesus really is/was.

They knew he was a healer. He healed lepers and blind men. They knew he was a teacher. He taught with authority and power. But though they may have suspected He was God, this was finally proof!

God spoke and creation obeyed; they were appropriately terrified. I think their understanding of Jesus radically changed that day, and though the storm was scary, their faith was bolstered.

Are you in the midst of a storm? Is it dark and scary? Are you wildly rowing those oars? Stop a minute and think. You are not alone. Jesus is on the boat! Let Him speak peace in the midst of this squall, and forever remember, He is God!

May our faith grow to the heights of His powers - Limitless!

AROM to the Rescue!

Crhisma is one of my prenatal girls. Expecting her second little one, she came as soon as her contractions got strong. They had started earlier that morning, giving her plenty of time to beat me to the clinic. Her contractions were strong and frequent, giving the impression it was time to push. But after trying to push a few times, I didn’t see progress, so I chose to do an exam. She was 5 cm but in a G2 (second time mom) that could mean anything.

She labored beautifully, choosing to alternate between walking and resting for several hours. The contractions stayed remarkably strong and regular, so I expected progress when I checked her again later that day (by her request). However, she had regressed to 4 cm and her cervix had become somewhat swollen. Even after, six hours of regular, painful contractions, there was no progress. I was confused.

Her cervix showed signs of softening (very good sign), so I chose to rupture her membranes to see if that might move things along. A warm bath of vernix stained waters gushed out in a wave,  surprising me a little. I wasn’t excited about the intense pain she would experience from this point on, but I, also, didn’t want her to get exhausted.

She chose to stand and walk furiously with each contraction, which fortunately kicked up a notch. She is the first woman I have ever seen actually walk DURING the height of a contraction. Normally, they walk between them and pause with the pain -- but not her. It was unique and powerful.

I prayed things would progress, as the possibility of transporting her weighed on my mind. As I watched the sun settle in the west, I wondered if this wasn’t a case of CPD. If so, could I get her to Wau in time? I prayed for wisdom and then sat back and watched her walk.

Remarkably, only 30 minutes after rupturing her membranes, she started pushing. I didn’t stop her. Instead, I set up the room in anticipation. So what if she was only 4 cm a few minutes ago. If she needed to push, perhaps it was time.

She pushed on her knees with my translator at her back. She pushed well-- focused and determined. She pushed joyfully and even laughed when she saw her precious boy emerge! Crhisma was thrilled with the birth, which is all that mattered to me.

Afterward, while holding her boy to her breast she smiled sweetly and told me in her limited English, “You give name. Christian name. You!” She was honoring me with the joy of giving her son an English (aka: Christian) name.

The friends in the room were surprised by this honor, and so was I. They smiled at me expectantly while I thought. Images of strength and beauty flooded my mind and the only name I could think of was Samson. So I told her, I wanted him to be called Samson. Would she mind? She shook her head and smiled. No, that would do fine!

The problem was (and this is a problem I keep forgetting when handing out names), Samson is difficult for Dinka speakers to say. The “S” sound comes out like a “F”. So, as she said his name, it sounded more like “Fanfon”! It was adorable.

She and her friends, happily whispered his name over and over to themselves in practice. Eventually, they mastered it and kissed him each time they said it. Sigh. It was so fun!

I really do love my job! How could I not, when you have little ‘Fanfons’ populating the world?

Hand Expressing Life!

Last week, a day and a half old baby was brought in with pneumonia secondary to meconium aspiration. (For those who don’t know, meconium is a baby’s first bowel movement. If lots of meconium is passed while still in utero, it increases the risk of the baby developing pneumonia if it is breathed in at birth.)

The tiny girl was seen by both Tom and Dennis, who started her on antibiotics. Her lungs were junky and her respirations were outrageously high (120-140s). It was hard to watch her fight for each breath and even harder to hear the clunk of each gasp. 

When I met her later that evening, I asked her mom if she had breastfed at all. She just shook her head and explained something about the doctors giving her oral rehydration fluid, but that was hours ago.

Confused, I dug a little more for clarification. This is what I was told: The mom had told the doctors she had no milk and they were unable to start an IV, so they resorted to oral rehydration solution.

I asked her if I could try and see if there was any milk and she agreed. I was able to hand express loads of the white gold and we fed her baby with a syringe. The little girl, licked and sucked weakly at the taste. It melted my heart!

Then, I taught the mom how to do it herself, working with her until she got the hang of it all. She was so happy to see milk and know she could be feeding her baby. In her mind, her baby was not sick so much as starving. (And she was right!)

Excited to see she was so willing to hand express, I left her to it and promised to check on her regularly. But before I left, I prayed her baby would live through the night. Her breathing was so bad... I wasn’t sure it would happen.

The next morning I rejoiced to see her baby eating well -- wanting to latch but still too weak-- and miracle of miracles, breathing so much better. It didn’t sound like the same baby! The antibiotics were very effective.

She stayed a total of three days. We discharged them while still hand expressing but the mom assured me she would continue as long as necessary. She said she was confident God would help her baby live, and so am I.

Would you believe this is my third attempt at teaching ‘hand-expression’ to a Dinka woman. She is the first one to be willing to do it. The others claimed it was too painful (aka: not worth it) and one said she felt like a cow.

Her willingness to do this simple thing, in my opinion, is what gave her baby a chance at life. I haven’t seen them this week, but I’m sure they have come back. I’ll have to ask the doctors... 

Hypertensive!

I have a girl coming for prenatals who has a fundal height of 21 cm at 30 weeks due to pregnancy induced hypertension (or possibly pre-eclampsia). Her belly has not grown since October when her blood pressure skyrocketed (as if overnight) to 185/130. (Previous it was in the 110/80 range.) Early December, we started her on BP meds but I guess she didn’t understand she had to stay on them permanently for them to be effective and didn’t return until yesterday.

Her fundal height and blood pressure combined, had me ready to refer her to Wau on the spot. But conferring with Dr. Tom, he pointed out the obvious. What could they do for her there that we cannot?

My brain stuttered as I realized how right he was. If she went to Wau, she would pay for all her meds, incur a huge bill and still deliver a small baby. Yes, she is at risk for convulsions and stroke, but we are aware of that. What’s more, God is aware of that! 

Quick! Somebody stop me from worrying like this all the time! S*i*g*h.

Pray for her please. She promises to come for weekly check-ups and to take her meds, and I promise to keep you posted.