Saturday, May 28, 2011

Four in twenty-four!

(Warning: this is a long story. You might want to get a cup of tea before starting. Oh, and it gets a bit complicated in the middle, feel free to take notes!)

To tell this story right, I have to explain that the day started at midnight with a knock on my door.
-- “Akuac, there is a woman in labor. She says the contractions started at 8pm, but water has come out.”

Gabriel, my translator for the night, looked as tired as I felt, but he didn’t complain. We marched off together toward the clinic. On the way, it occurred to me that Sarah (short-term missionary nurse) might want in on this, too. So, I sent Gabriel to wake her up also.

Sarah came quickly, and together we checked Adong in. Since she was in early labor, I decided to not do a vaginal exam and just let her labor through the night. This was her first baby and I wanted her to rest up for the hard work ahead.

Even though birth wasn’t imminent, Sarah wanted to do the hourly checks with me, explaining that she wanted to see what an unmedicated labor looked like; all her experience with labor has been with epidurals back in the States.

Ignoring the fact we’d be exhausted by morning, we got up hourly to monitor her progress.

I must confess, I enjoy night labors. The sleepy silence of darkness muffles the otherwise harsh tones of birth -- especially, here in Sudan.  And this night didn’t disappoint. It brought rain.

Dancing on and off all night, the rains chased the bugs away and inspired the frogs to sing. Plus, the wet drizzly curtain muted voices and footsteps alike, replacing them with an orchestra of sounds.

Drip-drip-drip. Cro-AK. Buzzz. Whimper. Ping-ping-drip-pang. CRO-AK. Bizzzzzzzz. Groan.

By first light, Adong wanted to push but didn’t seem ready. So, I did a vaginal exam. She was a good 5 cms and handling things well; so, I sent her walking instead. She happily complied.

I then sent Sarah for a nap --and tried to get one myself-- but it was hard. By 8 am, God woke me with a start. I grab some strong coffee and headed off to devotions.

However, within minutes I was called out of devotions for another labor. Another first time mom, Awang was looking active. She explained that her labor started the night before, but the rains had kept her from coming. 

Fortunately, she was already 8 cm dilated, so I sent her to walk around the compound as well. It was fun looking off the back porch and seeing two waddling ducks turning circles and squatting. It made me smile.

Guessing we’d have a few hours, I jumped right in to doing prenatals. However, one of my prenatal ladies had a serious problem. I couldn’t find her baby’s heartbeat. Even though, I searched every inch of her abdomen in a desperate hope, I never found it.

Eventually, I asked:
-- Can you feel your baby moving?
-- No. I haven’t felt him move in a month.
-- From the size of your belly, you are seven moons now. Is that right?
-- Yes. Seven moons.
-- Have you had any bleeding recently?
-- Oh. Yes. I’ve had bleeding for two months straight...

Alarms going off in my head, I poked and prodded some more. Was this another hydatidiform mole? (Unlikely. Her belly would feel different. Harder.) Fibroids or poly-hydraminos? (Neither made sense with the facts, but I wanted to rule them out, nevertheless.)

Eventually, I was clear. I had an intrauterine fetal demise (IUFD) on my hands. Her baby’s head was clearly palpable --as were his limbs-- but I couldn’t find a heartbeat. I couldn’t even hear her placenta.

Again, wishing for an ultrasound machine, I explained that I thought her baby was dead, and that she’d need to be induced soon before she became septic. It took a few minutes for my words to sink in. But even then, I’m not sure they fully did.

In the end, she refused to believe me and went home. I encouraged her to go to Wau for an ultrasound, warned her of the risks, and encouraged her to come back if she changed her mind.

It’s the first time a woman has refused to believe me about something so important; it was hard watching her go without help. But I didn’t get to dwell on it for long because Adong started pushing.

Adong with her family gathered around.
Rushing in to the prenatal room, Adong explained that the head was coming out. We scrambled to set up the room while she pushed. A few minutes later, a handsome vernix coated boy emerged! What a sight!

However, as I was waiting for her placenta, one of our health workers barged in saying that Aweng was pushing in the observation room now, too.

--“Come quick, you can see the head!”
-- “I cannot deliver the baby over there (other sick patients in the room, no equipment, lots of looky-lous), make her come to the wound care room to deliver.”

He ran off to do as I asked, and I looked over at Sarah and shrugged. Sarah had never delivered a baby before, I couldn’t send her. And plus, she had only seen two births so far here at the clinic. I would be unreasonable to ask her to do it.

The now breathless health worker was back in less than a minute explaining she was refusing to come. So I de-gloved and went to get her, leaving Sarah in charge of the placenta.

Once I got to the observation room, I found 10 people gathered at the door, Aweng lying on her back in the lithotomy position, pushing with all her strength. The sick man in the bed next to her watched unashamedly in interest.

-- “Aweng, you cannot deliver here. Please get up after your next contraction and come with us.”
-- “No. I cannot walk,” she insisted while pushing again. Fortunately, she was a first time mom so I knew that she could in fact move; the baby would not fall out as she walked.
-- “Yes, you can. I will help you,” I explained while forcing her to her feet.

Aweng with her precious boy by her side.
Although confused, she complied and together we walked hand in hand to the ‘second birthing room’.

-- “Sarah,” I called across the wall once I got there, “has the placenta come out yet?”
-- “Nope. Still waiting.”
-- “Okay. You take that, and I’ll try to get set up here.”

Aweng, determined and gutsy, pushed like a pro and in just a few minutes delivered a gorgeous little boy! He came out about the same time as Adong’s placenta in the other room.

However, after Aweng’s birth she wouldn’t stop bleeding. After loosing well over 500 ccs, I decided to do a cherry pop and help the placenta out with a little traction. It was delivered completely but the bleeding persisted.

When both oxytocin and fundal massage didn’t work, I decided to do an internal manual exploration. I hate doing them, but I think she hated having it done even more. However, once completed, her bleeding stopped nicely.

Once the dust settled, Sarah and I took lunch and then I finished up the remaining prenatals. I remember Sarah saying, “I just hope no other labors come in tonight; I’m tired.”

Nodding in exhausted agreement, I laughed and told her, “I should not have kept us both up all night. Serves me right that I’m this tired. Next time, I’ll know better.”

However, after lunch a new labor came in. I taught Sarah how to do a vaginal exam and suggested she be the main midwife.

I wanted Sarah to have an easy birth for her first. And since Mary was expecting her forth, I assumed all would go rather quickly. But I was wrong.

Sarah walking with Mary.
I sat at the clinic to supervise, trying not to get in Sarah’s way. Mary’s contractions were originally every 2 minutes but with time they slowed down. Sarah was starting to fade; we both were. That’s when the fourth labor arrived.

When I saw it was another first time mom, I smiled wryly at the cruelty of the situation. Would that mean we’d be up all night again?

Her name was Yar, and she was perhaps 18 years old.

Fortunately, she was already 7 cm dilated with solid contractions. Her friend, Debora, had delivered with me earlier this year and had encouraged her to come in. Together they labored on the floor in the other room while Sarah and I worked to help Mary’s baby descend.

After 4 hours of doing walking and nipple stimulation without results, I decided to rupture Mary’s membranes. After another hour Mary was fully but the head wasn’t coming down. I decided to take over for Sarah and do a vacuum extraction. It worked, but progress was still tediously slow.

In the midst of using the vacuum for the third time, my hand covered in blood, and Mary looking completely spent, Yar insisted on pushing, too.                  -- What? Again??

I was too tired to think straight. So, I sent my translator to get Dr. Tom for help. I couldn’t put Sarah in charge of either birth at the moment.         -- What a gong show!

Mary with her boy after the birth.
Mary, pushed while I pulled with the vacuum. Santino her husband stood by her side sweating bullets. Meanwhile, Yar and her friend Debora kept calling for me over the wall. “Akac, ba ten! Meth benbe! (Akac, come. Baby coming!)

If I hadn’t been so tired, I would have laughed at the deja vu scenario. Hadn’t we seen this already today? Didn’t I have two labors push and deliver within minutes of each other earlier this morning? It felt like I was trapped in some kind of birthing vortex and I was going under.

Tom arrived in time to help Yar calm down, and see that Mary had finally delivered her child --A boy!

The shape of her son’s head immediately explained the delay. He had the funnel shaped head that you often see in first time moms. Apparently, this little guy had quite the squeeze on the way out! 

Laughing in relief, I wiped him down and went to put him on Mary’s abdomen. But when I looked at her, I realized she had fainted! What? I tried to wake her, but she didn’t respond to words or pain.

-- “Tom!” I yelled, “My patient is acting strange. She looks semi-conscious.”

He was there in a flash, trying to wake her and assess the situation. He worried it might be malaria still (despite having treated her successfully last week for it), and started her on IV quinine. Within a few minutes, she woke up and delivered her placenta.

Meanwhile, I went to check on Yar who was still pushing. I wanted Sarah to catch at least one of these births. 

-- “Sarah, Yar will deliver soon. Do you still want to catch a baby today?”
-- “I do.”
-- “Then get over here and glove up. This will be your birth now.”

She hustled over with gloves and I walked her though the basic steps of delivering. But honestly, I think I was a bit of a basket case by then. I don’t even know what I told her, I think I said, “Just call when you need me. I’ll be right back.” and left the room. (What a terrible supervisor! I know! Right?!)

I just needed a minute to make sure Mary wasn’t bleeding too much. Fortunately, I found her sitting up and smiling at her dimpled boy. We laughed together and praised God for helping her through it all, and she started breastfeeding.

But then I heard Sarah calling, “Stee-pphhannnn--iieeee!!!” and I went running. Yar’s baby was out, and Sarah was wiping his mocha brown body down with a towel --another boy!

Yar with her son after the birth.
The rest of the night consisted of cleaning up and helping to control bleeding and establish breastfeeding. Both Mary and Yar, stayed the night and I discharged them the next morning.

What a day!

In the end, it was a first in a lot of ways. It was Sarah’s first time seeing a woman labor naturally; it was my first time supervising. It was Sarah’s first time catching a baby, and it was my first time catching three babies in a day!

So praise God for firsts -- First time moms and first time midwives! 

Oh, Sudan! Never a dull moment.