Tuesday, March 22, 2011

When death moves in.

(Warning: this story is about death, grief, and a traumatic birth. It’s not light reading. Also, you might need to go for a cup of coffee, and empty your bladder before starting... it’s gonna be a long one.)

Sigh. Here goes.

I’ve decided to tell her story now. I don’t know how polished, or how well this is going to come out; but I’m now able to think about it and talk about it.... so I should be able to write about it.

She came in around noon with a note from a clinic in Thiet saying her baby was still alive. That immediately got my attention; it’s not everyday, I get a note from another clinic. Something must be wrong.

So, I took a deep breath, and asked them to start from the beginning. 

This is the story I got.

Expecting her first child, Awende went into labor 4 days before. However, after a day of strong contractions, her water broke, revealing thick, green amniotic fluid. She continued to labor and push, and then labor and push some more, until her father had had enough. Even though they live far from town, they made the journey to Thiet, to seek help. 

Once at the clinic, the health workers determined the baby was still alive, and gave her some IV fluids. By morning, she was on a bus to see us. Like I said, she arrived around noon.

She was young, but handling the pain very well... considering.

However, every time I asked her a question, her father answered instead. He seemed mad, like he was scolding her. I eventually asked him to sit outside, but it didn’t help. He just continued answering my questions even louder from behind the wall.

Confused, I invited him back in to the room, but this time watching his body language while ignoring his tone. His hands moved nervously as he talked; it occurred to me that he wasn’t mad. He was scared. How could I have missed that?

His graying face poorly hid his anxiety. Worry and fear etched his jaw, aging him. As he spoke, his voice boomed loudly-- loud enough to mask his dismay. Instantly, I loved him.

The heart of a father. Worried for his little girl, and tired of watching her hurt, he had come for help. It broke my heart to see-- so fresh and close to the surface-- but it moved me to action.

While we talked, her mom sat outside on the bench, wringing her hands quietly.

While examining Awende, I was relieved to find a steady, happy heartbeat. She seemed tired, but not exhausted. All her vitals were normal, so I did a vaginal exam.

What I found made my heart sulk.

She was fully and at +2 station; I couldn’t find any membranes, but I did find swollen testicles and a pointy right butt cheek.

Yes, you read that right. Her baby was breech.

I had a fully dilated first-time mom with a frank breech presentation on my hands, and the nearest operating room was 3 1/2 hours away.
        ~ Lord. What do I do?

For those who are not midwifery minded, let me explain. Breech births in first-time moms are the riskiest. Basic physiology of a newborn means that the buttock is significantly smaller than the head. The risk is that the baby’s bum won’t dilate her well enough for the larger (and unmolded) fetal head to be born. The baby’s head can get stuck, choking off his air. If so, he’ll die.

In the states, a woman in her condition would get a cesarean STAT, but we are not in the States. We are in the middle of nowhere-Southern-Sudan. What do you do then?
        ~ Lord. Is there time to transport her? 

Knowing the risks is different than knowing the best option.

As I prayed and discussed her case with Dennis, I had peace. Yes, risks were involved, but for reasons I can’t quite explain, I wasn’t the least bit worried. (But... more on that later.)

Dennis agreed that it would be unlikely to find transportation in time for the birth, and that, so long as the family understood the risks of vaginal delivery, we could help them.

So, I gathered them together to explain.

“Your baby is in a dangerous position,” I began, “If your baby’s head gets stuck on the way out, there is a high risk he’ll need resuscitation.” They listened, clicking their tongues in understanding. “It’s even possible he will die,” I added. They grew silent.

“The best option is surgery. It’s the only way to ensure  both of them survive.” Silence.

“However, if you deliver vaginally, Awende, you need to trust me, and do what I ask. Can you do that?” More clicks of the tongue.

“If your baby gets stuck, I’ll need to cut an episiotomy.” I added, “It will most likely require suturing afterward. Do you understand?” More clicks of the tongue.

Worried grooves knit the father’s brow together as he listened to everything I said. All the while, Awende searched the faces in the room-- one after the other. I don’t think she was listening.

“What would you like to do?” I asked, directing my question to the father. He was in charge. “We will stay and deliver here,” he said. It was final. This was a man used to speaking only once.

I reiterated that there were serious risks to vaginal delivery, but that if they chose to stay, we’d do everything we could to help them. He nodded. They all did.

As Awende’s labor continued, I spoke to her about the need to change her position regularly, what pushing would look like, and what would happen in an emergency. I also informed Margaret, and asked her for help. She would be there for resuscitation purposes, and in case things went bad.

Then we set up for the birth and waited.

Awende labored well. She grunted somewhat with contractions, changing her positions often, but  didn’t push. I was hoping to wait until she was more than fully dilated, in an effort to let her body open naturally.

In my head, it was our best shot. So despite being fully and at a +2 station, she breathed through contractions for almost two hours.

However, the minute she started pushing, her baby’s heart tones went south. I changed her position quickly, but they never really recovered.
    -- Was a cord problem the reason behind this breech?

Unable to find heart tones, I asked her to push hard, lest the baby die. I couldn’t figure out why they were faltering, the buttock was just barely visible.

Nevertheless, Awende pushed well, and in less than 5 minutes, the body was born. He came out in a Frank breech position, and I didn’t touch him until both legs popped free.

But as I supported his body, it occurred to me, neither arm was visible.
    -- Sh*t! Lord, help me get these arms out! Please, Lord!

There was little room for me to maneuver, nevertheless, I reached in to free the right arm. It came out fairly easily. A minute ticked by.

I turned his body to get to the other arm, but he wouldn’t budge. I had no leeway.
    -- Father God! Help this baby come out in time.

Cutting an episiotomy, Awende flinched and tried to pull away. No time to put in anesthesia. Her little boy was still pink and squirming a bit. There was hope.

Another minute passed-- or was it two.

He finally turned, and I was able to free the second arm. Okay. Deep breath. Now for the head. But it wouldn’t come. It was no longer flexed; he had extended it. The suprapubic pressure hadn’t worked to keep it flexed. I wanted to cry.

I remember distinctly looking at the clock. I had to focus to even see it. As I counted the minutes that the body had been out... I was surprised to see it was only five.

Five minutes had felt like forever.

“He’s stuck,” I worried out loud, “Margaret, the head isn’t coming. He’s dying on me.”
“Don’t say such things. Don’t say that, Stephanie. Keep pulling. You can do it.” She encouraged. I wanted so much to believe her, but I couldn’t see how-- at least not without breaking his neck.

As I struggled to free his head, I felt his body grow limp and cold.
“Margaret, you need to try. I can’t manage.”

We readjusted Awende’s position, and she took over. Meanwhile, I sent our translator to get Dennis. Praying out loud and begging God to help, I took over the suprapubic pressure. There was nothing to push upon. Strange.

What Dennis saw when he walked into the room, I can only imagine. I quickly briefed him on the situation while he gloved up. Then, he took over where Margaret left off. Only ten minutes had passed, but I could tell the baby was dying.

He was limp, pale, and unmoving. Even if we birthed the head this instance, he would not recover. Not without a miracle.

Dennis, manipulated and moved the baby this way and that. Nothing. Awende was so cooperative. She must have been frightened, and in so much pain, but she never showed it.

For well over five minutes Dennis worked on her, without success. I looked over once to see Margaret praying silently to herself -- head bowed in reverence. I’ve never seen her do that in an emergency before.

Stopping to take a breather and reassess, Dennis put the baby down, and told us to rest as well. The baby was obviously dead. We no longer needed to rush things.

He was right. 

This is where my story gets fuzzy. I’m pretty sure Margaret went back to working on him again, because I remember watching her work out of the corner of my eye, when Dennis whispered the possibility of having to cut the baby out.

I wanted to vomit.

Lord, forgive me if this is my arrogance or presumption. Forgive me Lord if this is somehow my fault. Lord. We need a miracle. Please don’t make us cut this baby out!

I thought I was praying silently, but Dennis told me afterward that it was loud and clear for all the room to hear. He went back to working on her. A few minutes later, he was able to pull the head free.

Instantly, the room grew quiet as each of us milled about in stunned exhaustion. There was no celebration, just whispered thanks to God amidst the bloody rags and dead baby.

Twenty minutes. Twenty minutes between the body and the head. Twenty painful minutes.

Only then did I notice the family in the room. The father watched silently from the doorway. The mother stood motionless beside him. They had seen it all.

Pale and somber, they stared at their dead grandson. In that wave of silence, I wanted to scream. Anything to make it stop. Anything to keep my hands from shaking.

Taking her hand to comfort her, I said, “I’m so sorry, Awende.” She just looked at me in surprise, then looked at her dead son. She said nothing.

Turning from her to her parents, I again repeated: “I’m so sorry the baby died.” Our eyes connected, but there was no incrimination or accusation. Just sorrow. Silent sorrow.

We placed her boy in a basin. It didn’t feel right. He wasn’t a placenta, or a dirty rag, but there seemed no better place to put him.

He was beautiful. So beautiful. Perfectly formed but motionless.

After weighing him and wrapping him in a blanket, I asked Awende if she wanted to hold him. Surprised at my question, she refused, as if I had just suggested she kiss a snake. (I’ve yet to see a Dinka woman ask to hold her dead baby. It’s just not done here.) I then offered him to the parents, who also refused.

So, I laid my precious cargo on the bed, and covered his face.

Everything I warned might happen, happened. The problem was, when I was describing this worst-case scenario to the family, I didn’t really think it would happen-- at least not ALL of it. I was just quoting a paragraph from one of my midwifery textbooks. ‘These are the risks of breech birth in primigravidas...’

Cord compression. Entrapped arms. Episiotomy. Entrapped head. Death.

But the thing is... it happened. All of it.

I wish my story ended there, but it doesn’t.

After the placenta was born, I told Awende I needed to suture the episiotomy. She lay still as I examined the damage. She was so brave.

What I saw surprised me... but it shouldn’t have.

The episiotomy had extended deep into her rectal mucosa; she had a complete 4th degree tear two inches long.

Again, I started to pray.

I have no problem suturing, but this was the largest tear I’ve had to deal with to date. My mind stuttered to recall the stitches necessary for such a complicated tear, but eventually, it came back to me.

I prayed over each stitch I placed. What if it doesn’t heal right? Incontinence and sexual pain will haunt her for life.
    -- Lord, please heal her completely.

Once I was finished, Awende ate some food, and then promptly fell asleep. I would have too after 4 days of labor.

Afterward, when I moved her to the postpartum room, I watched her father carry the dead child like a sac of potatoes. I even shuddered a bit when he lay the boy casually in the dirt to go back for something he’d forgotten. He wasn’t being disrespectful... it was just how things are done around here.

Nevertheless, I couldn’t help going over, scooping him up, and carrying him myself. Did I mention how beautiful he was?

As I did, I could hear the hinges of my cultural worldview creak. Tell me. How are you suppose to care for a dead child? Isn’t wrapping him in a blanket enough? So what if he’s on the floor, pushed under the bed. That way, he’s not under foot. Right?

In the hours, I spent with Awende afterward, I never once saw her wail or weep. Nothing. I asked my translator why she wasn’t crying. Was I missing something? He assured me she would cry once she got home.

Again my cultural worldview continued to creak under the strain. Aren’t you suppose to cry when  babies die? As a mother -- a teenage mother at that-- aren’t you allowed the luxury of tears?

Bolts pinged off my cultural worldview; it was ready to blow!

The Kenyans I talked to after this difficult birth, all said the same thing. “You did everything you could.” “Think of all the babies that could have died, but didn’t because of you. You only lost one.” “Some babies die. Don’t be sad.”

I heard their words, but they didn’t compute. My brain was mis-firing. I saw how sad this death made them, but they weren’t shaken like I was. They weren’t sick and hiding in their rooms. In fact, they couldn’t figure out why I was taking it so hard. Did my reaction mean I somehow cared more? No. Clearly not.

All it proved to me, was my cultural paradigm was coming apart!

I hate to admit it. I hate to even write it down. But what haunts me most about this experience is not the trauma, pain, or death. What bothers me most is my own reaction -- or shall I say ‘non-reaction’.

Let me explain.

Somehow in the last 10 months, without my even noticing, I’ve grown used to dead babies.

Holding their limp, cold weight in my arms, putting them in a bowl to wait as I suture, wrapping them tight, and placing them with the rest of the bags on the floor. That’s what you do. Right?

When did that happen?

I knew coming to Africa would change me. I knew I’d see things that would break my heart. I knew that I’d hear things that would haunt me at night. But this... I never suspected.

No one told me I’d live with death.

He has moved in. He is a constant dinner guest-- uninvited but fed all the same. He hangs out in the open. I see him so often, I no longer try to excuse his presence. We’re almost on speaking terms. He’s here to stay, and somehow I’m okay with that.

Will there come a day when death is so familiar we laugh together? Play together? Sing?

In Africa, death is not relegated to the back rooms and mortuaries. He enters the front door. He comes and goes as he pleases... but he’s not being rude. He lives here.

In Africa, you live with death.

Please pray. Pray for Awende to heal completely, and for her to one day know the joy of holding a child in her arms. But please also pray for me. Pray that when my cultural worldview busts into  pieces, a more godly one replaces it. As death moves in, may I find a way to live with him well. 

Sigh. There you have it. It’s finally out.