Tuesday, April 5, 2011

Twins: Waiting to push?

Mary was expecting twins. We were able to confirm it a few months back with two little heads, two different heartbeats and a mega-large fundal height. Not having an ultrasound machine, we were as confident as we could be that there were two... but I’m never one-hundred percent certain.

Since her estimated due date was in May, I was a bit concerned when she came in this week. Her belly was large, but if we were right on the EDD, then she was preterm.

However when I did the vaginal exam, it was too late to stop contractions (not that we have the medicines for that anyway, ha ha!). She was 9 cm and stretchy. The babies were happy. Both appeared to be cephalic (head down), but then again... I wasn’t positive.

Since their heads were small (another sign of prematurity), I informed the rest of the staff we had a possible preterm twin delivery on our hands that could go any minute.

Setting up the room, I sent my translator to send all my prenatal ladies home. Mary was the second labor to arrive in less than an hour that particular morning; Margaret and I were maxed out.

The preggos understood immediately, and wished us luck for the births. So sweet.

As, Mary walked about the clinic, I prayed. I wasn’t feeling the stress of twins like I did last year. I felt at ease. Monitoring them regularly, I tried to stay as ‘hands off’ as possible.

After about an hour, Mary started pushing. She wasn’t doing it very well; it looked strained and artificial. So, I asked her if she had an urge to push at all. She didn’t. So, I asked her to push only when she had an urge.         -- ha ha. But that time never came.

One hour flowed into two. Two hours flowed in to four. By four hours, I was nervous. What was wrong? Was there some kind of compound presentation? Could they be interlocked? Why hadn’t she delivered yet?

I did another vaginal exam.

She was fully with the head at a +2 station, so I encouraged her to push. Pushing should have been simple. It should have been straight forward and quick, but it wasn’t. She pushed externally but couldn’t figure out how to do so internally.

It was odd.

Could it be possible she didn’t know how? I tried to instruct her how to push, but she categorically refused. Round and round we went. I explained how to push and why. She would pretend to push then give up.

Mind you it had been close to 5 hours since she arrive. It had been at least four hours since she was fully. The babies where small; her pelvis was more than adequate. All she had to do was push, and the birth would be over.

But instead, she delayed.

Why she preferred the hours of contractions to pushing, is still a mystery to me.

Begging her to push, I explained that I needed to make sure there wasn’t a major problem, but she ignored me. I was racing the clock.

As I watched the sun settle lower on the horizon, I honestly worried. What if something was seriously wrong, and I couldn’t get her to Wau in time.

Nervous. Uneasy. Confused.

Tired of begging fruitlessly, I left the room in frustration. I needed a minute alone to pray. Was there an emergency, Lord? Or was I just being impatient?

Did we have a “labor problem” or a “midwife problem”? Which was it?

Another hour went by.

Finally, I had had enough. If she was still unwilling to push, then she needed to go to Wau. Only then did she get serious. I hated having to threaten her with Wau, but I was genuinely concerned. I told her that she had the option of pushing, letting me use the vacuum extractor, or going to Wau.

Unwilling to push, or go to Wau. She chose the vacuum.

Surprised she’d choose the vacuum over pushing, I didn’t argue. Instead, I did another vaginal exam. Not only was she fully, but the head was at a +4 station. All she had to do was push once or twice and her babies would be born.

“Won’t you just push once, Mary?” I asked pleadingly.
“No. I don’t want to,” she said and stiffly lay down on the bed.

Grudgingly, I put the vacuum in place. I didn’t want to use it. I wanted her to push. But... that wasn’t going to happen.

The next contraction, I pulled. She pretended to push. The baby was born!

Mary screamed uncontrollably as the baby emerged. Strange. She continued to scream long after the baby was out. Bizarre.

Her precious little girl screamed with her, as I wiped her down. She was perfect... and term. (I guess we were wrong on the due dates! ha.) It was so easy... so simple. Sigh. 

We waited a few minutes, then double clamped the cord. One baby down. One baby to go.

I ruptured the second baby’s membranes, and fluid slowly leaked out. Reaching in to guide things along, I was expecting a head, but got a sweet, little buttock instead.

Mary continued to push, a bit more effectively this time, but screamed once again. One boney butt emerged, followed by belly and then arms. Then the head slipped out with ease.

They were born 10 minutes apart.

Once the placenta was born, it was pretty obvious that they were identical. Even though they had separate placentas (two distinct sets of cotyledons), they shared a chorion. (But I don’t think they shared the amnion.)

Plus, they weighed almost the same. The first was 2.1 kg while the second was 2 kg, exactly.

Afterward, we had a nice time hugging on the babies. There was laughter and joy as the family gathered around to celebrate these two perfect little ladies.

It was so great... once she pushed. Ha!

Placenta Pictures:
For those of you out there that love this sort of thing... and yes, I know you are out there! I cannot be the only one. Here is her placenta. Cool huh?!

Funny side note:
Afterward, we took tons of pictures. In almost all of them, Mary was shirtless. I tried getting pictures that were more discrete (for this blog), but it was an exercise in futility. Toplessness is not shameful here.

At one point, I instructed my translator to have her hold the baby up higher, so as to hide her breasts. He cocked his head to the side and asked why.
-- “Well. In America, it’s not proper to show a woman’s breasts.”
-- “Don’t the men in America know what breasts look like?” he asked innocently.
-- “Yes. I know it’s silly to you, but the men in America ... well, it’s just best not to show them.”
-- “Okay,” he laughed, a bit confused. I couldn’t help laughing with him.

Culture. Culture is a powerful thing.

And perhaps there are too few men reading this blog to care if breasts are in every photo, but out of respect for you all with Western cultural backgrounds, I don't. I hope you realized how hard it is to get a ‘decent picture’ around here. Ha Ha!

I don’t know what is attractive to Dinka men, but it’s certainly not breasts.

Oh Sudan!