Sunday, February 13, 2011

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.