Wednesday, June 1, 2011

Helpless.

Last night just as I prepared to put the cap on the end of a good day (happy prenatals, beautiful breech birth, etc.) in walked a labor, then another... and then two others followed.

What? Four labors all at the same time?

The first to come in was a G2 in early labor. She lived close by and opted to go home and labor until she became active. I told Sarah that she should catch this one (since it should be simple) and I’d supervise. The woman’s name was Victoria.

Then Adeng showed up. Adeng was a G1 (first time mom) who had been here earlier in the day for a prenatal. I had diagnosed her with STDs and warned her not to go into labor until the medicines were finished. She nodded in comprehension, forgetting that women don’t get to choose when they start labor. However, once she got home, the contractions started.

Now, she was back on my prenatal bed --in labor with STDs.

As I counted contractions, there was no denying the fact that labor was on its way. The progress was slow and steady, but she was good about moving around. Her family watched her like a hawk, hovering around her as she walked. This was her first, so the pressure to have her get the childbirth confession was strong; they wanted to be in the room all the time.

Then Aboul showed up.

She announced her arrival by throwing herself on the clinic porch with melodramatic flair. The crowds that had gathered laughed at her, but she ignored them and lay there silently until addressed.

When I got around to her, she explained that her water had been leaking continually for over 3 days. She had no contractions but was haunted by a constant lower abdominal pain that had compelled her to come for help.

Honestly, the continually leaking water worried me, so I checked her out. Her chart indicated that she’s been here only once before. At that time, I couldn’t tell if she was carrying twins or a very large term baby. Either way, it/they were breech.

When I checked her this time, she was already 2-3 cm dilated with ruptured membranes. The tiny buttock presenting, made me think she was carrying twins. But if that were the case, one of the babies was dead. I could find only one heartbeat.

I was still trying to figure out what to do with her, when Biyana came in.

Biyana as many of you may recall was here a few weeks ago with a vesico-vaginal fistula at 5 months pregnant. At that time, I had tried to assess it but it was too painful, so I referred her to Wau. (Read her story here.)

But yesterday, when she came back, it wasn’t about her fistula; she was bleeding.

My heart started to sag with the strain.

When I examined her, some bleeding was visible, but she wasn’t in labor. I tried to do a speculum exam, but she hit the roof in pain. Calling for Tom, we decided she was having an inevitable premature birth, and decided to sedate her.

Once the drugs took effect, I was able to place the speculum with ease. What I saw though... took my breath away.

A pool of dark red blood obscured it at first, but then it moved! Five white fingers flexed and twitched in unison. I was looking at a hand!          -- Sh#*!

Both Tom and Sarah bent low to inspect it for themselves. Could it be true? Her baby’s hand had prolapsed!

Because of the pain she experienced with the digital and speculum exams, I worried how she’d handle a vaginal delivery in the first place. Now we had no choice; she was dilating.

We observed her for some time, but eventually induced her. Her husband kept insisting there was no money to take her to Wau, and that it would be better to make the child come out.

However, the oxytocin did nothing but cause her uterus to form a tight, painless ball. I couldn’t do digital exams to monitor progress; she wouldn’t allow it. This went on for several confusing hours. 

In that time, Sarah caught Victoria’s baby. It was a fun birth. But I'll let her write about it on her blog. I'm sure she will soon.
Victoria and her little girl.

Adeng also progressed but not as quickly as her family wanted, so they opted to take her home. They promised to bring her back once it was time to deliver, then whisked her away.     --Sigh. I didn’t argue.

And Aboul... well Aboul slept the night at the clinic. We didn’t want her to go home, but we didn’t want to induce labor either. She needs a cesarean not induction. After loading her with antibiotics, she slept and promised to call her husband in the morning.

By 10 pm, we stopped trying to induce Biyana because it wasn’t working. Her baby was still doing famously --his little heart ticked like a drum-- but there were no signs that she was dilating. So we agreed to try again in the morning. 

Exhausted, both Sarah and I wrapped up the clinic. Aboul was sleeping, Biyana and her husband were well, and Adeng had gone home to labor. Victoria was recovering with her baby girl at her breast. So, we bid them all good night and went to sleep.

By sun up, Victoria was discharged, Aboul was rested, and Biyana reported no more pain or contractions.

But what would be our plan of attack?

I consulted with Tom, and we decided on watchful waiting. I’d focus on the prenatals accumulating out front, and deal with Aboul and Biyana later in the day.

By noon, I had finished with the prenatals, and I decided to try and induce Biyana again. But after several hours of oxytocin, nothing happened. The problem was, I couldn’t tell if she was dilating.

What happens if she cannot dilate? What then?

Finally, I bit the bullet and did a vaginal exam. It caused her tremendous pain, but I was finally able to get some answers.

She was still only 2-3 cm (no progress despite induction). Also, her baby’s entire right arm was prolapsed into her vaginal vault.

Yes. You read that right. A prolapsed arm that wiggled.

Despite my better judgment, I tried to replace the arm back through the cervix, but Biyana screamed and writhed in pain. Unable to watch her suffer anymore, I stopped.

What more could be done? We were out of options, so I informed her husband she HAD to go to Wau.

The baby was transverse. The cervix was not dilating. She needed surgery. She also needed her fistula fixed. Only after I explained the situation in detail for the third time, did he move. I repeated over and over again. “Your wife will die without surgery.” “She needs a cesarean or she will not live.” “Take her to Wau if you want her to live.”

Could I have been more clear?

I don’t mean to insinuate that he was calloused or dull. He is a husband that cares and is moved with love and compassion. He wanted to take her to Wau, but he kept insisting there was no money.

The look he gave me as he asked me to try again, will haunt me for the rest of my life. 

I can no longer muster hope.        

Finally accepting to go to Wau, her husband asked me to write an official referral for the doctors there. But as I was writing up the referral, my translator came running to get me.

“Come quick. The hand is coming out of her vagina,” he sputtered. 
“I know,” I spoke slowly, “There is nothing I can do. Tell them to go to Wau.”
“No. You don’t understand, Akuac, the HAND is out!” he insisted.
Frustrated and spent, I raised my voice, “No,” I hissed, “You are not listening. I have told them, there is nothing I can do. The baby is not coming out. It is only the hand. Go tell them they must find a way to get to Wau quickly.”

Turning back to the paperwork, I knew I had spoken too harsh, and I instantly felt bad. What did they want of me? Can I turn this child? Can I make him come out? Can I heal her wounds? Can I stop this pain?

I’m helpless -- heartbroken and helpless.

I have no ambulance (the government of Southern Sudan won’t give us the clearance papers). But even if I did, there is NO fuel in Sudan. Something has interrupted the fuel imports and the gas stations are empty.

How Biyana’s husband is going to find a bus, afford the exorbitant price for the seats..... and then afford the TWO surgeries she’ll need, I cannot begin to imagine. 

I knew in coming here, I’d see such things. I knew I’d experience these kinds of obstacles, but I didn’t know it would hurt so much. Overwhelmed and hopeless, I’m ready to run away. I’m ready to hide.

Lord, hide me in the shadow of Your wings! Hide me Lord from the pain and suffering I see. My heart can’t take any more.

My heart is not used to such suffering and pain. It’s leaking dry. Soon it will be a hollow heart-shaped shadow. What will I have to offer anyone then?

Oh, Lord. I’m tired. Please help me hope again. Please do a miracle for Biyana.

Pray.  Pray as He leads you.               --I’m out of words.

P.S. Some of you might be wondering... but what of Aboul. Well, she is waiting for her husband to come. She’s stable. Her water is still ruptured, but so far no infection has set in, and her labor has still not begun. We are waiting. She, too, needs to go to Wau. She needs a cesarean. Pray she can get it.

And what about Adeng?  Well, I suspect her family had her deliver at home. She never returned.