Saturday, October 22, 2011

Deep Transverse Arrest


Nunu’s first birth ended in a cesarean. She was in labor for several days by the time she got to Wau. The doctors explained the baby was transverse and performed a cesarean. The baby lived just two hours.

The evidence of her loss came in the form of a copper streak an inch wide which sprouted from her pelvis and pushed raggedly past her belly button --a classical cesarean scar. Tiny dots ran along each side like a fence post; it must of hurt to get those sutures removed. 

She had been coming to our clinic for several months before I met her. Up until then, Margaret or Sarah had done her checks.

I clearly remember meeting her that day for two reasons. One, she discussed her case in English. And two, she really didn’t like what I had to say.

At that time, her baby was breech. I told her it wouldn’t be safe for her to deliver anywhere but a big hospital. There were just too many risk factors.

She argued with me, saying that she wanted to talk to Margaret. When I called her in for a consult, Nunu broke down in tears and wept on her shoulder. She categorically refused to consider going to Wau.

Then together we explained the risks. She needed to prepare for surgery and consider going to Wau even to labor. She shook her head in refusal, flashed tear-filled eyes my way, then took her book and hurried off.

Fast forward another month or so, to earlier this week.

She arrived mud splattered and soaked to the bone in the middle of a storm. She was in active labor.

One look at her file and I was concerned. Why had she not listened?

I told her that since there was no way we could get her to Wau that night, we’d let her have a ‘trial of labor’, but ultimately if there was no progress she’d still have to go. 

She listened... but didn’t at the same time. Her jaw was set in refusal.

Since she was already 8 cm dilated with an intact membrane, I let her labor on her own. Progress was slow, but I remained hopeful.

But then again, I didn’t have many options. We couldn’t drive her in the middle of the night. The storm only made things worse. Plus... she wouldn’t even consider it.

Margaret took over her care that night. She explained that although she was well past fully, Nunu was not pushing right. Perhaps she didn’t know how or couldn’t.

I assessed her again and found the head to be at a zero station and slightly swollen. Her pelvic outlet seemed more than adequate. But he did palpate to be big.

Margaret continued to explain to them the need for a cesarean while letting her try and push a bit longer. Fetal heart tones were fine, and Nunu was determined.

But after a few more hours of no progress, Margaret told them she’d need to leave first thing in the morning for Wau. She went to get some sleep and left them to discuss it amongst themselves.

The translator working that night said Nunu’s mother was upset we were ‘giving up’ by going to sleep and took her home. Nunu and her family left in a hurry around 2:30 am.

When I woke for my shift, I expected to be greeted by a baby or a transport. But the clinic was empty. I couldn’t understand why they left.

There was little I could do but pray. So I prayed and prayed. In fact, I could do little else.

Had she gone home and delivered? Did they take her to another clinic? What happened?

I worked through my worry by doing prenatal after prenatal. I finished just after lunch then went to a staff meeting. By 4 pm, I was called away early because she’d returned.

Fourteen hours had passed since she’d been checked. Fourteen long hours...

I asked her what they’d been doing all this time but they were silent. I pressed them only to learn they’d simply gone home. They didn’t call a TBA. They didn’t go elsewhere in town. They simply went home and did nothing.

Digging deeper, I also learned her contractions stopped shortly before dawn.

However when I lifted her dress to check her baby, my heart jumped in my mouth. I couldn’t believe my own eyes. Bandl’s Ring had developed.

Bandl's Ring.
(For those who don’t know, Bandl’s Ring is when the upper uterine segment separates from the lower uterine segment, forming a band around the belly. It is a sign of severe neglect of an obstructed labor and proceeds uterine rupture.)

I asked if I could take a picture and told her that she needed to go to Wau immediately. She agreed to both. They realized she was dying and had gathered the money. They’d come back to ask to use our ambulance.

Thankful for this change in heart, I set the wheels in motion. The drivers had to be called, the ambulance needed to be fueled, and I needed to write her doctors a referral.

Although her blood pressure was stable, Nunu was deteriorating fast. Her baby was alive but  had developed a sinusoidal heart rate pattern. This is a serious indication of imminent death, and I told her so.

(For those who don’t know, a sinusoidal heart rate pattern goes high and then low and then high and then low again. There is never a stable baseline but it typically stays within a normal range and is a sign of severe fetal compromise.)

-- “Nunu, if you don’t get this surgery soon both you and your baby can die.”
-- “I understand.”
-- “I’m not saying this to scare you. I just need to know... Do you know Jesus?”
-- “Yes. I am a believer,” she said then turned away.

Fortunately, it didn’t take us long to get her on the road. But I had my doubts.

She’d be arriving at the end of the day. Most doctors aren’t working late night shifts I’m told. Plus, the last woman we referred for a cesarean was told to wait another 8 hours after arriving because her baby had died. That girl eventually got surgery, but died minutes later. Would Nunu have a similar experience?

Dark thoughts nipped at my heels. Yappity dogs. Fierce hounds. My only retreat was prayer.

Lord, may Nunu live. May her child somehow survive. You knit this precious one in her womb, now please bring him out. I’m begging for a miracle.

I woke the next morning to learn she’d not had the cesarean. At first I was nauseated, but again I prayed. There must have been a good reason.

Later that day, I learned that by the time she’d arrived the baby was dead and she was semi-conscious. She was too unstable for anesthesia and was pale. The doctors didn’t want to perform a surgery just to have her die on their table.

Plus, they wanted her family to donate blood. She couldn’t have the surgery until they had 2 or 3 units of blood standing by.

When I learned of this new rule I didn’t respond well. They were doing nothing! Why were they doing nothing? But again God reminded me that they must have good reasons and I prayed.

Lord, I’m tired of sending people to Wau for help and they never get it. I’m tired of hearing they have no blood there and that’s why this girl or that girl must die. Please, Papa, do a miracle!

I later learned that she has my blood type and volunteered to donate. But my going there was not an option. Instead we helped organize her family members in the area and got them there.

But it was all for naught. She died later that night, never having woken from her coma.

I understand why the doctors in Wau didn’t take her into surgery. I understand their need for blood. I even understand their anger with us. They thought we were wrong to keep her so long or allow the trial of labor.

What I don’t understand are Nunu’s choices. Why did she argue when we told her to deliver in Wau? Why did she come after a day of active labor in a rain storm? Why did she abscond in the night when we wanted to refer? Why did her family let her get so bad before taking action? Why didn’t she plan ahead and set aside the money? Why didn’t she listen?

I don’t ask these question in judgment. I ask them in genuine confusion. Why?

Perhaps with time, I’ll better understand the social and economic limitations of the women here. Perhaps with experience, I’ll be able to better help them maneuver any obstacles. Perhaps with time, fewer women will die. Perhaps.

Perhaps not.

Nunu’s death burdens me. Please pray for her family. She was well loved and known in this community. Her funeral is tomorrow.