Tuesday, March 29, 2011

Is it one of us?

Abak, the midwife, her wounded bird friend.
Abak came in pushing. She was pushing so hard, the translator on duty ran to call me, and breathlessly announced, I should hurry. I grabbed my stuff and ran. I didn’t want to miss it.

But when I got there, not only was she NOT pushing, but she seemed calm and collected. I had to laugh.

Nevertheless, this was her 4th child. It was sure to be soon. Heck, I could see a little patch of membranes ready to burst as she pushed. That’s always a good sign, right?     -- Not always.

Smiling, I went through the regular check-in scenario and set up the room.

In her mid-thirties, Abak was small and slender. She’d come a number of times for prenatals, and I was looking forward to her birth.

Between pushes, I learned that her labor had started the night before. No water or blood had come out, and all was great.         -- or was it?

As she pushed first in the supine position, then kneeling, then on the birth stool... I began to suspect there was a problem. Why was it taking so long?

Only then did I think to ask: “Have you been pushing like this at home?”
-- “Yes, the baby won’t come.”
-- “When did you start pushing?”
-- “After the water broke.” That didn’t make sense since, I could see the membranes bulging and she had just told me the water hadn’t come out yet.
-- “When was that exactly?”
-- “Last night around 8 pm.”
-- “Oh...”

Mind you, it’s 3 pm on a Sunday afternoon.

Since her story was all jumbled with mis-information and assumptions, I asked her to start again.  She explained her labor actually started on Saturday morning. When her water ‘broke’ that night, she attempted to deliver alone and began pushing.

She had delivered all her other babies without assistance, and assumed this one would be the same. However, it had been 7 years since her last birth; perhaps she had forgotten how.

As she finished explaining, I started counting backwards. It was almost four pm now, and if she’d been pushing since dark the night before... the sun sets around 7pm... that means roughly 18 to 20 hours of ineffective pushing... humm... not good.

“Poor thing! Why didn’t she come earlier?” I thought to myself. I didn’t bother asking her though; I already knew the answer. It would be someone ‘important’ in her family that had insisted she stay home. I’d heard it before.

Honestly, I didn’t know if I should be more impressed or horrified. Eighteen hours! That’s a record in my book!

Only then, did I do a vaginal exam. I wanted to rule out a compound presentation or some kind of cephalopelvic disproportion (aka: baby too big for the pelvis). I, also, wanted to rupture the bulging membranes. Perhaps that would speed things along.

Her pelvis felt more than adequate, and I could see no major reason for the delay. The fetal head did appear to be somewhat military in presentation and a bit posterior. With her permission, I attempted to flex the fetal head and ‘dial’ it to a better position.

She pushed well, but even still, there was little progress. Obviously worried, the young girl assisting her, couldn’t sit still. She moved about like a wounded bird. I was glad when she left the room.

Humm...  What to do? What to do? Lord, what is needed most right now for this baby to make its way into the world? Do I need to move her in a better position? Do I need to manually assist? How do I get this baby out?

As I prayed, my translator kept looking at me funny. I’ve been praying out loud over my patients for so long, I’ve forgotten how strange it must seem to those less familiar with my ways. Once he figured out I wasn't talking him but God, he just smiled and watched from a distance.

Doesn’t everyone talk to God during deliveries? It can’t be just me!

Anyway... back to my story.

The brother-in-law kept poking his head in the room, monitoring the progress. I couldn’t blame him. Eighteen hours of pushing! I’d be worried too. I think coming for my help was a last ditch effort on their part. It was as if they were saying, “Why not see what the Kowaja can do?” Perhaps not.

But they did seem a bit hopeless.

At one point, Abak said: “If I die, Sudan will not fall into the sea.” My translator explained it was the Dinka way of saying, ‘my life is small in the grand scheme of things, just let me die’.

I told her that today was NOT her day to die, and reminded her to stay strong. Her baby was doing great, and despite the encroaching exhaustion, her vitals were stable.

Finally, after an hour of putting her in every position imaginable, I got out the vacuum extractor. I told her what it was, and how it worked. She nodded, “Okay, I’m ready.”

Once in place, she pushed and I pulled. I barely had to tug, when the head crowned and rest of her baby’s wrinkled body followed.

What? So easily? It surprised us all, at how quickly it worked.

Abak couldn’t stop laughing in relief, and although tired, she sat up and grinned at this tiny trouble maker. She continued to laugh in disbelief as I laid her on her chest. 

This wrinkled, no-neck self, howled her hellos as I rubbed her clean. If the gestational dates were correct, this little one was a bit over-cooked, arriving past her alloted 42 weeks.

Meconium stained vernix covered most her body. That coupled with the fact, her feet were peeling and her nails long, indicated someone forgot to set the timer on the oven. She wasn’t the prettiest baby in the world (just then!), but she was the most celebrated!

At her first cry, the brother-in-law again poked his head in the room. Relieved beyond words, he asked, “Is it one of us or one of you?”

My translator explained that this is how Dinkas ask if it’s a boy or a girl.

“It’s one of us! It’s one of us!” (Since it was girls saying it, it meant it was a ‘girl’.)

He smiled and immediately went to share the good news.

Meanwhile, Abak continued to laugh between periodic naps. She almost slept through the placenta delivery. Calling her tired, may have been an understatement.

My translator said, at one point, she mumbled to herself: “This is why I told them to let me come.”

I couldn’t help but smile.

Yes. It was a good day. A very good day.

They named her Lat, which means ‘Sunday’. Perhaps she’ll get a better name later on, but this way they can keep track of her age... at least for the first couple months. Ha!

Thank God for vacuum extractors!

Rejoice with me that baby Lat was born after such a long labor, but please pray for the fever she developed right afterward. We treated her with medicines and discharged her the next morning. At that time, she was breastfeeding well but colicky. Pray it passes quickly. Thanks!

Monday, March 28, 2011

9-Month Fast~

When I first saw her, I had a hard time believing she was pregnant, let alone in labor. She was rail thin and gaunt. I asked if she had ever been to our clinic before... perhaps for a prenatal. (I doubted it, since I would have definitely remembered her face!) She said she hadn’t, but was seen once at another clinic in town. When pushed a bit further, her husband added she was treated for hypoglycemia at the government hospital the week before.

She didn’t look well... but that was just half of her problem.

Strong, relentless contractions peaked and passed, every few minutes; she was definitely in labor, but I couldn’t tell if she was term.

Her belly was abysmally small-- barely measuring 27 cm. She agreed she was only 8 months along, but that wasn’t the only reason it was small. She had been constantly sick this pregnancy.

Pushing to understand why, she explained she hadn’t stopped vomiting since she conceived. It was merciless. Food and water, alike, made her sick. It wasn’t hard to believe. She was positively emaciated.

This was her 9th pregnancy. I tried to guess her age, but her withered state made that difficult. I considered it a minute, but ended up just writing ’40 years old’ in her book. Did it matter? Probably not.

I was tempted to refer her to Wau... but she was already 9 cm dilated.

Instead, I set up for the birth, and prayed. I prayed hard. I’d either have a premie on my hands, or an SGA (small for gestational age) term baby. Either way, it didn’t change the fact, she’d deliver shortly.

Sitting beside her, her husband was just as delicate and frail. Decades of slouching caused him to fold himself into a neat envelope with ease, legs drawn in. Origami in the flesh. 

But when it came time to push, he was instantly at her side. Still slouching and a bit unsteady with age, he comforted her well.              --It was very encouraging.

She pushed like a pro, but her baby didn’t handle it well. Small, limp, and blue when he was born, he looked more like a floppy porcelain doll than a baby; I worried to move him.

Rubbing his back in an effort to make him cry, I cheered him on: “Come on ‘lil guy. I know it’s cold and scary out here... but breathing’s fun! Just try it.”
He must have liked my pep-talk, because he recovered nicely.

Boney and long and weighing just 2 kg (4.4 lbs), he reminded me a lot of his dad-- all arms and legs and a bit shaky. So, I wrapped him up tight, and handed him over. The father smiled as his lanky arms, awkward and unsure of how to hold someone so small, engulfed him.

It was love at first sight!

Later on, when I did a full exam on this lean, mean, sucking machine, I could see no major signs of prematurity. His reflexes were good, his testes had dropped, and even the creases on his itsy-bitsy feet were deep. His Ballard’s score (exam done to determine how premature/term a baby might be.) was high, placing him roughly at 36 weeks gestation.

Conclusion: 9 months of vomiting makes for one tiny person, but it doesn’t make him premature!

When I discharged them, they promised to return for check-ups, but I haven’t seen them yet. I hope all is well. Pray they both thrive after this 9-month fast! Thanks.

Sunday, March 27, 2011

3 lbs of life!

Yesterday, just as the twin birth was coming to an end, I met two sorrowful faces in the hall. They rattled on and on in Dinka, and gestured toward a bundle one held in her arms. My translator was off working elsewhere, so, I  unwrapped the stained sheet to find a very small and very cold baby. 

She was obviously preterm. 

The woman holding her was old, wrinkled, and withered. Was she the mom? I couldn’t tell.

Once my translator arrived, I learned that the mother of the child died a few minutes after birth due to a massive hemorrhage. She had delivered at home, unassisted-- except by family.

Despite her prematurity, she was breathing well. Her vitals were normal, except for her temperature. She was 34.3 degrees (94 degrees Fahrenheit). I had to take it twice before I believed it.

The woman holding the child was the grand-mother, and she looked every bit the part. Thin, sagging, and with puffs of gray about the edges, she must have been 60 plus. (Mind you, that is NOT old in the States, but here, it’s ancient!)

She had already tied the band of cloth around her middle in mourning. (This, I’m told is done after a death to signify mourning.) It was her little girl that had died in those desperate bloody minutes after birth. She was sorrow edged in despair, and slightly splattered in hopelessness. So, I prayed for her. 

As I examined the baby, I wasn’t surprised to see she weighed only 1.4 kg (3lbs). She was thin and had frail bones. I almost feared moving her. (When I did a Ballard’s Score, she was only 30-32 wks gestation, or roughly 7 months.)

Since she was so cold, glacial really, I continued to monitor her while the grand-mother did kangaroo care. Fortunately, in the span of only 45 mins, her temperature stabilized.

She, also, sucked enthusiastically at the sugar-water we gave her by syringe. This was a baby who wanted to live. I kept telling them that, but they didn’t seem convinced.

When I told them, all they had to do was find a wet-nurse or get formula, and the baby would live, they argued with me.

I think they decided to bring the baby to the clinic to die. I really do. Every time I told them she would live, so long as they kept her warm and fed her properly, they’d shake their heads in disbelief. I was confused.

I called Sabet in for help. Was I misunderstanding? Did they want this baby to die? If so, give her to me! I’ll keep her.

He laughed at the impracticability of such a suggestion while trying to reason with the women. They were hopeless. They could see no way of helping her. They knew no one who could give this baby milk. They had no money for formula. (A month’s supply of formula costs roughly $12 or two and a half days salary.)

They refused to go home. The grand-mother explained that she didn’t want to be there to watch her child’s burial. (I couldn’t figure out why, but I didn’t try to, either). She asked to stay at the clinic, and seemed to indicate that she’d stay until the baby died.

The problem was, the baby wanted to live. She had no infection, no signs of distress, and now her temperature was stable. All she needed was food to live. Wouldn’t they go talk to their family about feeding her?         -- No. We’ll stay here until she dies.

I went back to Sabet. I wanted to take the child from them and strap her to my chest. I wanted to feed her myself and help her live. Why were they giving up so easily?

Part of me understands that grief played a role in it. Another part of me imagined their confusion. I’m sure they have never seen a baby so small and frail, live before. They must have thought I was crazy for suggesting she would.

After Sabet spoke to them for the second time, he agreed that the women were planning on letting her die. So, he promised to get them formula if they would just feed her. They agreed.

Explaining the details of how to mix formula correctly took time, but I think they got it. They also promised to bring the baby back for check-ups. I’ll let you know how it goes.

Please pray for them all. Pray that this little girl gets the food she needs to not only survive but to thrive! Pray that as she grows, the family would see what a precious miracle she really is! God has put air in her lungs and life in her body; He has a beautiful plan for her life! May she one day grow to know His love! Thanks.

By the way, they named her ‘Akec’, which means ‘born to a dead mother’. 

Postscript:
During our conversations, I found out the the woman who died was apparently very sick all throughout her pregnancy. The family said she had 'yellow fever', but everyone claims that; it’s rarely the case. The symptoms they described were stomach pains, swelling, and green eyes. I think she may have been anemic, due to some underlying chronic liver problem. That is the best explanation I can come up with for her hemorrhage, and subsequent death. But then again, I’m guessing. They said the woman who died was seen only once, and that was at a different clinic. They told her she didn’t need medicine, and sent her away. Pray that the women of this community would all come for prenatal care, deliver at the clinic, and seek postpartum care. Pray that one day the name ‘Akec’ would never be given again. Thanks.

Saturday, March 26, 2011

A day apart!

Today a woman was brought in by ambulance, sirens wailing and lights flashing. I was already at the clinic, and watched it approach from my window. As I peeked out in interest, I heard them say something about a woman in labor, but all I could see were her feet sticking out the ambulance door.

If she was coming by ambulance, it must be pretty serious. Right? Since I wasn’t sure how long it’d take them to get her through our narrow halls, I started setting up the room.

I barely had time to pull out my instruments when a VERY pregnant woman wobbled in, a bit off-balance. She walked timidly, like her feet couldn’t be trusted. I figured she was just lopsided with such a BIG belly, but there was some swelling in her legs as well.

Gingerly she lay on the bed. Everything she did was slow and steady. My translator was still outside, so I instructed her in my limited Dinka to lift up her dress so I could check on her baby.

Just then, my translator interrupted me:
-- “Wait. Here’s the baby!”
-- “What baby?” I asked stupidly, while pointing at her belly. “Do you mean this belly?”
-- “No. She gave birth yesterday. Here’s the baby,” he insisted, handing me a pea-sized person wrapped in an endless stream of clothes.

It took me a minute to find her face. She was tiny! I sent someone to get Margaret; this was going to be a doozie. What was I looking at if not a baby?

Aluong, my very-pregnant mama lay awkwardly on the bed, and slowly explained she gave birth yesterday afternoon, but the placenta wouldn’t come out. Huh? This belly was just her placenta? I wasn’t buying it.

So, I sent for her family. I needed to hear this story from every perspective. In my head, she obviously had twins. The question was... was the second one still alive.

When her mother came in, she explained the baby was born yesterday afternoon, but hadn’t nursed yet. They clamped and cut the umbilical cord, but it was sucked back into her body. (I could see no cord handing from her vagina.)

-- “Did you tie the cord on two sides and then cut in the middle?” I asked. I still didn’t have time to check heart tones. But if they had let the cord bleed, this baby might be dead.
-- “No. We tied it just once,” the mom explained, looking a bit confused I’d ask such a strange question.
-- “Aluong, can you feel a baby moving inside?”
-- “Yes.”
-- “Good.”
-- “But the placenta won’t come out,” her mother insisted.

I had to laugh. In my head the most important thing was delivering this next baby, not the placenta. But in her mind, she was more vexed the placenta hadn’t come out.

Margaret arrived just then, and I caught her up to speed. She took over checking on the pea-sized person. Since she hadn’t nursed in almost 24 hours, Margaret got her some sugar water and checked her vitals.

Her fundal height was 39 cm, the baby was cephalic (head down), and in a good position. I found heart tones easily, then started counting contractions. Whoever was inside was happy-- so was I!  There was no excessive bleeding, so I did a vaginal exam.

The membranes were bulging, and as I pressed deeper, I could feel the head. Everything was looking great. She would deliver very soon.

We got everything set up for the birth, made sure the other baby was doing well, and then I ruptured the membranes. I had to do it twice. The first time I got a slightly bloody fluid. The second time, the waters were clear and fresh. They gushed out in one salty wave, making the room jump back a bit.

The head settled into the pelvis nicely, and she instantly needed to push. Heart tones were solid, so we just sat back, and watched this little patch of miracle peak out at us intermittantly. Three solid pushes and she was out! 

Her chubby cheeks cried astonished whoops of wonder as a tidal wave of salty waters burst behind her, and trickled to the floor in rivulets. She lay on the bed like some beach beauty, announcing her arrival. We laughed!

Her size and the fact Aluong’s belly drooped anti-climatically reassured me that there were only twins, and not triplets. (Yes, I had my doubts.)

After the cord was cut and the placenta was born, we discussed her obstetrical history a bit more in detail. She explained this was her second pregnancy. Her first was born dead at 8 months. She claimed she got in a fight and her baby died.

As for this pregnancy, her first baby was born almost a full day before her second. Their weights weren’t too different, but their appearances were striking. The first was thin, frail and weighed only 2.3 kg (5lbs). The second would have made sumo wrestlers jealous in her chunky folds and lusciousness, but she only weighed 3kg (6.6lbs).

Nevertheless, they were a delight to behold!

I taught Aluong how to breastfeed them both, since this was her first time; she was a natural. Both babies sucked vigorously, and they were all discharged a few hours ago.

There you have it... another almost twins story! Ha ha!

Oh, for those who like to know about such details, let me tell you about the placenta! It was super cool. They were two separate placentas (completely unattached). Both had remarkably short cords (less than 10 inches), but they appeared healthy. There were a few blood clots trapped between the amnion and chorion, and the smaller placenta (for baby number 1) looked as if it had partially detached (abruption?), since it had an extensive black clot over one edge.

Also, the membranes of the first (smaller) placenta had two areas where they had ruptured. The placentas were ONLY connected by these membranes. I’m thinking they may have shared the chorion? What do you all think? Check out these pictures. You can decide for yourself.

All I know is, had they shared a placenta, the second baby would not have survived after they cut the first’s cord. I’m thinking fraternal twins. What do y’all think? I think I can rule out twin-to-twin transfusion as an explanation of the size discrepancy. Right? Perhaps the blob on the smaller placenta caused her to get less of the oxygen and nutrients.

So praise God with me that both girls lived! They are beautiful!

Twins, born a day apart, used to be things I only read about in books! Is this really my life? I have to say, I love it. I really do! It’s hard at times, but I really do love all this craziness.

What a grand adventure He has laid before me!

Thank you for following me around in these adventures! Thank you for encouraging me so persistently, and praying so diligently! You help me in so many unspeakable ways! Thank you!

Hydatidiform Mercy.

(Updated Information at the end)

A week after Awen’s hydatidiform mole was removed, she came in for a check up. She had almost no bleeding and her hemoglobin was on the rise. She was doing well, and promised to come regularly for reviews. 

She promised not to get pregnant for as long as possible, so that the tissues would be less likely to reoccur. I was looking good; I was hopeful.

However, today she came back. She looked so dejected and morose, I almost didn’t recognize her.

Dread. That’s it. Dread. She looked like a woman awaiting the firing squad. She looked like death had visited her and rattled her chain.

Dread.

Downcast eyes hid her fear, as she explained the bleeding started again two days ago. It kept coming. No clots. Could I help?

My heart sank.

Her uterus (that had involuted nicely last visit) was palpable again. Rubbing it firmly, no clots were expelled, but it didn’t look good. Her clothes were stained with blood- both fresh and old.

Oh, no.

It’s been about a month since her procedure. That’s not too soon for a menstruation, but this was too much blood if so. What was going on? The only thing that made sense was if her hydatidiform mole had re-grown.

To be sure, I did a pregnancy test.

If the abnormal tissues had started growing again, she’d have excessive amounts of HCG (Human Chorionic Gonadotropin) hormones in her system, giving a positive pregnancy test.

I held my breath as the first line -- and then the second line appeared.     --It was positive.

I wanted to swear.

I conferred with Dennis, and he agreed. She needed more care than we could provide. Doing another manual vacuum aspiration (MVA) could cause her uterine scarring or possibly perforate it. It wasn’t safe. She needed a D&C or a hysterectomy.

Trying to explain this to her family wasn’t easy.

-- “Can’t you just give her some drugs to make her stop bleeding?” they asked.

-- “No. It doesn’t work that way. This problem cannot be fixed with pills. She needs surgery and soon.” 

Shaking their heads in dejection, they said they’d take her home, and discuss it with her husband.

At the thought... my heart shrieked ‘Noooooooo!’ but it didn’t reach my lips.

The problem is: I’ve met her husband. He’s a scary, monster of a man. He left her here for three days, with no money and practically no food, after her last procedure. When he arrived, he told her she was not sick, and was just pretending.

When I told him that she almost died and was very sick, he argued with me in loud octaves that shook the walls.

This belligerent beast of a man reminded me of a pirate; one of his eyes, white with scarring, stared vacantly at me during his tirade. He scared me at a level that I’ve rarely experienced, so I quickly got Dennis involved. 

At that time, she told me that he was a hard husband to live with. She was at his mercy, and he was not a merciful man.

So when her family chose to take her home, my heart screamed itself hoarse. It’s screaming still.

He doesn’t strike me as a man willing to spend money to keep this wife alive when he could just buy a newer one that wouldn’t be sick all the time.

I’ll be shocked if he makes any effort to keep her alive.

Her family took her home before I got a chance to say goodbye, but I did pray for her.

Without surgery or at least a D&C, I’m not sure she’ll live.

Please pray for her. I’m sick. I’m sick thinking her life might be in her husband’s hands. Yes, I know ultimately she is in God’s hands. I know this in my every fiber and cell!

Honestly, her death might be God’s mercy toward her. It might be better for her to die than live another month with such a hard man.

I don’t know how to pray.

Lord, You know! Please, show mercy -- however that might be best! Amen.

March 29, 2011 ~
She and her husband came in today for another review. Thank you so much for praying! The husband was a completely different person. He was worried, and willing to take her to Wau. They left this morning, and promised to come back after the procedure. Praise the Lord!!!

Also, a few wonderful nursing friends reminded me that we could start her on Methotrexate or actinomycin D to prevent it from regrowing. Does anyone know how I can get my hands on some?

Friday, March 25, 2011

Update: Stillbirth, Wounds

Awende came in a day or so back. In fact, she came in the morning after I wrote the blog about her. I was so glad to see her and so thankful she was well, I could barely contain my joy! I checked on the healing of her tear and I'm glad to say all is healing nicely. No fistula! No incontinence! Alleluia!

Her parents greeted me joyfully, and were relieved to hear she would recover well. It was a time of celebration. What a glorious answer to prayer!

Also, the young lady with the facial wound is healing, but it's not healing right. Would you please continue to pray that the sutures would hold, and she would one day be able to smile? She is coming diligently for wound dressing, but she is sad. Pray for her to know our Living Hope! Thanks.

Thursday, March 24, 2011

Three Witnesses.

(Caution: This story is about a miscarriage, some people might find it offensive. I hope not, but it's possible.)

The annoying chirp-chirp of the ambulance wailed as it came through the gate, but I barely noticed. It’s never for me. The cases brought by ambulance are always seen by Dennis, but this time I was called.

I was told a woman claiming she was five months pregnant, started bleeding this morning. Grabbing my watch and pen, I didn’t hurry, but I didn’t lolly-gag either. The number of times, I’ve been called for an “Emergency” because a woman was miscarrying, only to find out she wasn’t pregnant but menstruating... is too numerous to count. Honestly, I’ve become skeptical.

She was sure she was five months pregnant. Absolutely sure! But getting her information was challenging, since she was grunting in wild pain. She looked like she was in labor.

Duh! That’s why they called the midwife! (sarcasm implied)

The thing was: She had no belly! Not even a bump! Nothing.

All I could see was a thick abdominal scar where her last baby was taken. It was huge. It looked like they ripped her open and left it to heal on its own. It wasn’t the discrete bikini cut that you often see. This was a classical incision extending all the way across her abdomen.

I asked her about it.

In so much pain... and while pushing no less!.... she explained that she was here in January. At that time, I examined her and said there was no heartbeat (that’s 2 months ago!). We had discussed the possibility of her being only two months pregnant, since she didn’t have a belly then either.

Again, I asked about the scar.

She explained that this was her fifth pregnancy. The first two were alive, one ended badly in an emergency c-section, and her last was a miscarriage at two months. She was convinced she was five months pregnant.

How could I argue?

She was flaying around in so much pain, I honestly didn’t know what to think.

Was she just being hysterical? No. That didn’t fit. She looked like she was in labor.

If she was delivering prematurely at five months, wouldn’t I feel the fetus? If she was only three months pregnant, her pain was way out of proportion. What if it was an ectopic pregnancy? What if she was bleeding internally!?

Not finding heart tones, I decided to try to do a pregnancy test. It sounds silly now, but I couldn’t tell if she was even pregnant.

Every movement she made, looked as if she was in transition.... like she was ready to deliver any second. Something was off.

As she peed for the test, I sent my translator to get Dennis. He needed to weigh in on this case; I couldn’t figure it out at all.

They returned together, and I informed him of my confusion. I was waiting on the pregnancy test, while he went to check the abdomen for himself.

I didn’t watch what he was doing, but I’m guessing he just pressed on it firmly and SPLASH! I kid you not, amniotic fluid gushed out on the bed, and ran all over the floor!

What?

I was so surprised, I couldn’t move. Shocked into stupidity, I glanced over to see a small baby, only a few inches long, lying on the bed. The thin umbilical cord still attached; the placenta apparently still inside.

How on earth!

Like I said, it took me a few minutes to get a grip. But when I did, I found her in a lot less pain. The contractions had stopped, since the baby was out; there was little bleeding, but lots of water to clean up.

Picking up the umbilical cord, I hesitated. What do I do next?

I told her to please push, and we would see if the placenta would come out on it’s own. She pushed with all her strength, and out popped the tiniest placenta I’ve ever seen in my life!

Everything was in miniature.

As I laid him out on the bed, she asked if her three friends could come in and see. Her husband who had labored with her, was noticeably uncomfortable, and decided to take a breather. When he did, three women, all no taller than my shoulder, gathered around to inspect the child with me. She sat up to see as well.

The cookie-sized placenta was complete, and all the membranes could be accounted for. The cord, though thin and transparent, looked normal, and though his head was proportionately larger than his body, that too was normal for five months gestation.

She wanted to know his gender, so I picked him up and brought him close. We all agreed. It was a boy.

Pressing in close for a better look, her friends murmured among themselves, and sweetly consoled my patient. They were interested, sure, but more than anything, they were witnesses. They were there to see and testify as fact: They saw the baby. They examined his body. He was dead.

Watching them, it finally occurred to me why everyone comes to gawk here. This is not a private place. Labor is not private. Birth is not private. Death is certainly not private. Honestly, how could it be?

Here, nothing important is ever done alone. Life and death. Well, that’s just flat out important! Of course they will all come and see!

Sigh. Why did it take me so long to figure this out? 

Anyway, back to my story.

The shoulder-high group of comforters all nodded approvingly at my excellent work! (Ha Ha! If they only knew I didn’t do a thing!) Nevertheless, they thanked me over and over again, lifting their hands to the sky, and praising God saying: “Inchalich Nalich! Thank you God!

I joined them in their praises. How could I not? (Yes! Thank you God for covering my blundering assumptions and ignorance! Thank you! Thank you! Thank you! Thank you this was not an ectopic pregnancy!)

I asked them what they wanted to do with the child, and she made the comment: “Oh, don’t throw him in the trash. That is my baby.”

Horrified at such a thought, I told her of course we wouldn’t; I’d find a box to put him in so they could take him home. She smiled.

They wanted to stay the night to recover, so I moved her to the observation room, gave her the right meds, and made sure she was comfortable. Her friends all joined her, energetically recounting the day’s events.

Just before I left, I wrapped her baby in gauze and placed him in an old medicine container which had a lid. She nodded appreciatively. Then I prayed. I prayed she’d be able to carry her next child to term, and once again know the joy of holding a newborn in her arms.

They all thanked me again, and I left with the sound of comforting chatter reverberating through the halls. She would be fine.

Moral of the story.

If she looks like she’s labor, it’s probably labor. Forgo the pregnancy test!
If looky-loos come to gather, let them pass. Who else is going to testify?
Five months, means five months.... even if there is no belly!
And last but not least.... when in doubt, press on the abdomen really hard, and don’t be surprised if your shoes get wet!

Postscript:
Some of you might be wondering how I could be so calloused. I am talking about a stillbirth, aren’t I? That’s a good question. Frankly, death is no longer a surprise to me. Yes, I’m sad for the woman. She was sad as well. But mostly, she was just incredibly relieved to stop bleeding. She was grateful she lived. Grief looks differently over here. So if I’ve offended you, I’m sorry. I just can’t pretend to fear death anymore. I just can’t. I hope you understand.

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.

Sunday, March 20, 2011

Labor of Love March 2011 ~ Newsletter

My latest newsletter. Click on this link or read below.

Labor of Love March 2011

Saturday, March 19, 2011

The hole.

(Warning: story contains pictures that are graphic and disturbing. Caution.)

When I first glanced her direction, I couldn’t help doing a double-take. Resisting the urge to stare, I quickly itemized the concerns in my head.

Swollen face. Oozing sore. Bandages covered in dirt. Obvious pain. Sadness.

“What was wrong?” I wondered to myself, but I didn’t press it. She was Dennis’ patient. I had enough to do that morning. So, I finished consulting with Dennis about a prenatal concern (which was my reason for barging in on his consultation in the first place), and got back to my belly measuring. Dennis returned to the sullen and swollen patient before him.

I thought nothing more of her, until I needed another consult about an hour or so later. But this time, I found Dennis in the wound care room.

He warned me before coming in: “Prepare yourself Stephanie. I don’t want you to get sick.” That just piqued my curiosity more. What was he doing in there?

Even though, blood, pus, and fluids don’t bother me at all, once inside, I was glad for the word of caution. What I saw made me stare in horror-tinged curiosity.

The right half of a girl’s face lay open and exposed. It was the girl from the consultation room, but this time, the bandages were off and the wound was debraided.

Half of her lips and almost all of her right cheek were gone. White, pristine teeth sparkled through, and I watched in fascination as she ran her tongue casually across them. It was something out of a horror film.

She was so young and beautiful; how did this happen?

The story went that she had an abscess in her cheek which was lanced and drained by someone in the village. That was only 3 days before. In that short time, the infection took over, eating its way through her face until all that remained was teeth.

Hard to believe and even harder to look at, I watched Dennis put in the first suture. Drawing the would-be lips together to form the inside of her mouth, he steadily worked to give her some tiny resemblance of normalcy.

I couldn’t stay and watch, even though I would have happily done so-- I had too many prenatals waiting for me. So, I left him and Margaret to the work they do best, and went back to work.

I happened to come in just as he finished. Naively, I had expected her wound to be closed. But when I saw the raw, fleshy, gaping hole, it finally dawned on me-- she had no skin left to suture.

Pray for her. She’s in a lot of pain. Dennis mentioned her needing a skin graft. She’ll be coming for daily wound dressings. Thanks.

Friday, March 18, 2011

A Puzzle.

Athong on her first prenatal.
This week brought many new and strange cases to my door. Cases ranging from possible placental abruptio, to ectopic pregnancy, to placenta previa. None of which, could I properly diagnose (no ultrasound machine), so I quickly referred them to Wau.

Why my brain goes to all these worst-case scenarios eludes me. I must be tired. Perhaps, they were just having normal bleeding.... but when is bleeding and sharp pain ever normal in pregnancy? My point.

Plus, I had to tell, not one but three women, that their babies had died in utero. Definitely low points this week. 

But of all the women, who lay on my prenatal bed, one stands out. Her name is Athong.

(For the midwifery minded out there, she is a G6 P3 L0 A2. Not good.)

Her first baby died during delivery after a 3 hour shoulder dystocia. (Yes. Read that again. 3 hours.) Her second baby was born prematurely (at 6 months), and died a few hours after the birth. Her third baby also died within hours of his premature birth (also at 6 months). The fourth baby miscarried at 3 months. The fifth miscarried at 2 months.

She was now on my bed telling me she was 5 months pregnant... or maybe less. There was no baby bump and no fetal heart tones, so I ordered a pregnancy test. Honestly, I was leaning toward her NOT even being pregnant.

When it came back positive, I got hopeful.

What her history screamed to me was an incompetent cervix due to her traumatic first delivery. But that would only explain the two premature births, not the two miscarriages. Sigh.

Differential diagnosis made me think syphilis or some other kind of STD; but perhaps she had a Rh-negative blood type and became sensitized somehow. Wouldn’t that explain her history better?

She was a puzzle-- a sad puzzle where each piece brought tears and dashed hopes.

Fortunately, our lab can test for blood typing and syphilis, so I sent her for an evaluation. Her blood was Rh-positive and she didn’t have syphilis. (Both results pointed toward incompetent cervix.)

I asked if I could do a speculum exam to see if her cervix had any noticeable tearing or scarring. She agreed happily, saying, “Whatever you need! I will live here at the clinic if you tell me to, so long as this baby lives!” We laughed jovially. There was hope in her voice.

During the exam, I didn’t see any tears, but I did see extensive signs of STDs, which explained the last two miscarriages.

What that means is, if she is really 3 months pregnant now, then there’s time to do a cervical cerclage to help her maintain this pregnancy. Whoohooo!

(For those who don’t know, cerclage is when you sow the cervix closed to reinforce the pregnancy, until it’s term. The sutures are removed in the third trimester, so labor can progress naturally.)

I don’t know how to do this procedure, but I’m told Dr. Tom does. All we have to do is treat her STDs, make sure the pregnancy is viable, stitch her closed, then watch her like a hawk.

When I explained this possibility to her, she jokingly promised: “If you help me have this baby, and it’s a girl, I will name her Akuac! And if it’s a boy, I’ll still name him Akuac!”

We laughed heartily at the idea of a boy walking around named after a female cow, but I’m pretty sure she’s serious. Ha!

I warned her that I was not guaranteeing her anything. I was only promising to do everything possible to help, and pray like mad!

Will you join me? 

May this baby be the one that lives!

My Girl Friday~

Santos is one of our translators. He’s only been working for us a few months, but I like his attitude and work ethic. He’s polite, helpful, and teachable. Mostly, he works in the pharmacy.

He’s been telling me about his pregnant wife, and eagerly awaiting the delivery. It’s his first.

He wasn’t sure if she’d deliver at the clinic or not. I encouraged him to do what he thought was best, and reminded him that we were here for them.

His wife, Mary, started labor last night and by early morning was looking very active. Santos insisted she come to deliver with us, even though she was resistant.

I didn’t do a vaginal exam right off, preferring to watch and wait. But by the time I needed to start doing prenatals, I couldn’t guess where she was anymore. She seemed to be in intense pain, but the contractions where short and sweet.

The exam showed her to be well effaced and roughly 8cm. Since I knew I could do a few prenatals as she dilated, I moved her to the laboring room. Fortunately, her mother arrived around then, and was happy to take over as main doula.

Even though her progress was steady, everyone seemed overly concerned about how long she was taking. I kept reassuring Santos, her mother and every other person within ear shot, that first moms take time to open properly. Give it time. They ignored me, shaking their heads in disapproval.

When it came time to push, I called Santos in the room to translate. He told me later, that his being there was breaking some cultural taboo, but the only other option was having a different male co-worker translate instead. It was the lesser of two evils, but it bothered him.

In spite my own reassurances, I was a bit perplexed at how narrow her pelvis felt, and how slow the progress was going. What if things didn’t go well? Sigh. I pushed aside my concerns and encouraged her to push when she had a contraction. Both she and the baby were doing great.  

When the head was visible for the first time, Santos looked at me quizzically and asked: “Will she open for the baby?” It took me a minute to figure out what he was asking, but when I did I had to laugh.

Here was a husband and father-in-the-making, watching a baby-sized head trying to knock its way through something the size of a quarter. No wonder he looked confused and .... skeptical!

I assured him, she’d open up. Unconvinced, he just stood there nervously fidgeting with the doppler and (probably) wishing he was anywhere but there!

Making him translate for me was asking a lot, now that I think of it. He had never assisted before in the birthroom. He was unfamiliar with the sights, sounds and procedures. But then again, it was either him or one of his buddies.

Once Mary got her on the birth stool, there was significant progress in her pushing. But... her pushes were so intense; she didn’t (or couldn't) stop for anything. I kept asking her to breathe every now and again, but she didn't seem to hear. 

After the head was born, out popped a blue-tinged rag doll, floppy and covered in brown goo.
                 ~ What? She was fine a minute ago. What happened?

The 'doll' blinked at me, but made no other sign of life. I wiped her clean, suctioned the gunk out of her mouth and nose, but nothing. Floppy stillness.

She wasn’t dead, but she sure wasn’t trying to live!
                 ~ C'mon baby breathe!

My internal alarm sounded, as I rubbed her spine raw. She made no signs of pain. Santos was asking me why his girl didn’t look right: “Why isn’t she crying?” Ignoring him, I called for help: “Margaret, my baby won’t breathe!” She was there in a flash.

Minutes rolled by like hours, as we cleared her airways and gave oxygen. Every now and again, she’d gasp.
              ~ What happened? Just a few minutes before, her heart was a steady rhythm.

Now as I listened to her heart race in her chest, I imagined formula-one cars roaring their engines. No. Jet planes. Her heart beat was 170, but she wasn’t breathing. Limp. Cold. Ashen. Gasping.

Once Santos understood something was wrong, he was useless as an interpreter. He couldn’t focus. How could he? His little girl lay like a stained dish rag. I had to call in my other translator.

I cut the cord so Margaret could work on her better. It took a full five minutes for her color to go from light-blue to dusky. It took another five minutes for her to gasp every now and again. By 15 minutes, her color and breathing stabilized somewhat, but she was glacial.

While Margaret resuscitated, I delivered the placenta and tried to get Mary and Santos to remain calm. Mary was uncooperative and didn’t listen to any of my instructions. Santos held back fear-stained tears, choking out a questioning, ‘Why won’t she cry?’ every now and again.

Long story very short, she started breathing and we got her temperature up. She improved, but then developed a fever a few hours later. I suspect she aspirated some of the meconium (brown goo), so we started her on treatment for MAS (meconium aspiration syndrome).

Please, please pray for them all. Pray for Mary as she is trying to get her baby girl to breastfeed. It’s not going well. Pray for Santos, he’s so worried. Pray for their baby to respond well to the medications, and figure out how to breastfeed.  Thanks.

They named her Friday. No joke. Pray for my girl Friday!

Update: March 20, 2011
So little Friday didn't want to breastfeed at all that first night. We expressed colostrum and gave it to her with a syringe, along with sugar water. Her fever came down with antibiotics, and the next day she was able to breastfeed well. We discharged them yesterday afternoon. Santos was tired but happy.
Thank you so so much for your prayers!
            ~ SW

Wednesday, March 16, 2011

Choking on Grief.

Saturday, a young girl was brought to me in labor. Her story is hard to share. I want to write about it. In fact, I desperately want it out, but I can’t.

Each word sticks in my throat, choking back bile, grief, and shame. They fester in my stomach, making me sick. Oh, to vomit them up in readable paragraphs! What relief it would bring!

But I can’t seem to manage.

Telling her story makes it truer, somehow.  I don’t want it to be true. I want to forget. So, I push my thoughts down with my words, only to gag that much more.  

Choking on grief, what a nasty way to live.

Hopefully.... hopefully, I’ll be able to write her story down soon. I don’t know how long it will take me.

She lived. Her baby died.

He was such a beautiful baby... sigh. More bile. Gulp.

Her name is Awende.

Pray as the Lord leads.

Burned.

So many little babes have been burned lately. They are so small and in so much pain, it's hard to bear their screams. This little girl was burned when boiling water (or alcohol) fell on her. It's estimated that 26% of her body was scalded in a matter of seconds.

Pray for her, she is in constant pain. She comes daily for wound dressings, and these pictures show her after a great deal of healing has already occurred.


There is another boy, about her same age, with an estimated 30% of his body burned in a similar fashion. Oh, it hurts just to look at them!

Sunday Smiles!

This weekend, I had the task of teaching Sunday school. Anyone who knows me well, would say teaching kiddos is one of my joys (not tasks), but I must confess, it's a lot harder cross-culturally. I often dread it and worry that the kids aren't hearing the gospel as well as they should.

Wouldn't it be better in their own language?

Nevertheless, by faith that God will somehow make this rock speak, I teach.

This Sunday I taught on Jesus being the Sheep-Gate (but I compared Him to the cattle camps). The kids instantly understood. I added the teaching on Jesus being the Good-Shepherd (but compared Him to a cattle herder instead). Their eyes lit up in sweet comprehension.

They got it! They really grasped what I was saying. It made the morning fun and easy. We sang songs, prayed and played.

Afterward, all I could do was praise God repeatedly for allowing me to share these truths with the kids. Many of them professed faith in Christ (but they do that over and over here. ha ha). Nevertheless, I hope that all of them truly understood and believed.

He is our Good Shepherd. His sheep know His voice and follow him. He is the Sheep-Gate. No one goes to the Father, except by Him. (Check out John 10:1-18)

Sunday, March 13, 2011

Goat-midwife

We have goats. Did I ever tell you that? We have goats, chickens, a dog and a whole mess of cats hanging around the compound. It’s Old McDonald’s farm with a meow-meow here and a woof-woof there, here a baa, there a chirp e-i-e-i-o.

The funniest part is, at any given time, most of them are pregnant. It’s epidemic.

Lately, it’s been our goat that has been walking a little lower than usual. Her sagging belly and engorged udders have been expanding at such a steady rate, I imagined her exploding and leaving entrails strung up in the nearest tree.

Fortunately, she reached the end of her gestation before exploding, and delivered beside the clinic a few days ago. I’m told one of the patients saw her delivering and went to help out.

The “Goat-midwife” explained in a steady stream of Dinka how she pulled the kid free, but I didn’t understand (no translator) until she pantomimed it for me. She was very proud of her accomplishment, and had a right to be.

A handful of gawkers (me included) came to admire this black and white beauty covered in goat slime. We couldn’t help ooh-ing at how perfect she was.

The placenta was already eaten, but the umbilical cord was still attached. It dangled from the wobbly legged wee one’s belly. So cute!

The Goat-midwife stepped up to the task of getting the kid back to the compound. Picking up said slime-covered miniature, she taunted the mother goat to follow her, stopping and baa-ing every few steps.

The mother goat knew she needed to follow and didn’t hesitate but a moment. She circled the Goat-midwife, loudly protesting. At one point, I thought the midwife might get a horn jabbed in her thigh, but she seemed to know what she was doing.

In less than a minute, both mama and kid were happily resting in the chicken coop.

Woohoo! Way to go goat!



Is it silly to rejoice even when a goat gives birth? Probably, but I can’t help it.

Weird question: would it be better to call her a midgoat? Or does goat-midwife make more sense? ha ha.

Tuberculosis of the Spine.

Last summer, I went to ask Dennis a question while he was treating a young girl. At first sight of her, I forgot my question momentarily and just stared. It was rude, I’m sure, but I’d never seen anything like her.

She was very sick, and she knew it.

Enlarged lymph nodes on her neck restricted her breathing, and large nob protruded from her back at a right angle, causing her to bend unnaturally forward. Plus, she was emaciated; a shell of skin with no substance.

Thin, weak and hunched over, she looked more like a wheezing hermit crab than a little girl.

Equally curious and horrified, I asked what was wrong with her. Dennis showed me her back and neck while explaining she had tuberculosis of the spine.

Fortunately, a Catholic charity in town runs a clinic that tests for HIV and tuberculosis. Dennis referred her to them for treatment.

Over these last few months, I’ve thought and prayed for her often. She was too small to be so sick. The image of her face and hump wouldn’t leave me alone. So, when she came in this week for some minor aches and pains, I was overjoyed!

I didn’t recognize her at first; her mother had to point out the nob on her back and I had to review her book before I connected the waif of last year as the girl before me.

She was vibrant and healthy, even dancing to music while waiting in line. I couldn’t believe how drastically she had changed!

Sure, the hunch is still there (I’m told her back will never grow normally again), but the vacant stare of death is gone. She smiled so sweetly during her examination, moving her neck with ease as I examined her lymph nodes (which are still enlarged but improved). I loved it.

Just thought you would all like to know her story. Pray for her as the Lord leads. Thanks.

Answer to prayer!

I’m happy to introduce you to Veronica. She has been helping me in the antenatal room for the last few weeks as my translator. She is a gifted linguist and a very bright young lady. The preggos are SO happy to have a female translator and so am I!

What a brilliant answer to prayer!

She can only work half days since she has two children at home. I don’t know how long exactly she’ll be able to work with us, but for the meantime, I’m counting my blessings.

Thank you for praying. Please pray more skilled, dedicated, female translators into this ministry. We need them. Thanks.

Joy comes.

When Apiu came in she looked defeated. I couldn’t put my finger on it, but it felt like she was mourning something.        
    Strange.

She explained that her labor had started the night before, but she wasn’t tired. However, she hadn’t eaten anything all morning. Perhaps she was just hungry.        
    I wasn’t convinced.

I sent her husband for tea and porridge; he seemed willing but exhausted, like his legs were made of lead. Grief haunted his steps.        
    Or was it despair? 

What weren’t they telling me?

Worry and fear lurked in the halls and hung on the door frame. I bumped into them every time I entered the room. Unwelcome guests. Bullish intruders. 

Heart tones were solid, and I told her so. She just nodded sadly. Her vitals were good, and I told her so. Again, she nodded, but that was it.        
    What was I missing?

Looking through her chart, I was surprised she even came at all. During her last prenatal, she had assured me she lived too far away, and would be having her baby at home.    
    So, what changed her mind?

Her chart also indicated that this was her second child. So, normally things should go smoothly.
    Why was she fighting it then?

All my comforting words were ignored. All my reassurances were spurned until finally I stopped to pray. She thanked me, but her words sank like heavy stones and clunked on the floor.
    Hum.

After an hour of this, I finally asked her what she needed since she didn’t want anything I had offered. Her response took me by surprise.

She said to my translator: “You tell my midwife she needs to take better care of me. My first baby died during delivery.”
    Ah-ha! I was attending a funeral, not a birth. Of course!

Apparently, the story we got during prenatals was wrong. She explained that the first child died after a very difficult labor where she pushed for hours.

Telling me didn’t stop the dread from oozing out her every pore, however, knowing helped me tremendously. As I listened to her recount her first birth in detail, she relaxed. When I consoled, she received it.

It’s at this point, things started to change. It’s as if she wanted to mourn the first before she could celebrate the second. So, we mourned until she had had enough.

Another hour or so went by, but I didn’t notice. She was working with her body, listening to its signals. I didn’t interfere. She walked when she needed; she slept when she wanted. All the while, the tiny passenger inside toc-toc-toc-ed away steadily.
    All was well.

When it came time to push, things bogged down again. She couldn’t figure out what a push felt like. She pretended to push with her body, but did nothing internally.

The only thing that helped was getting her on the birth stool where she delivered her little girl within minutes.
    Lovely. 

Would you believe, her baby came out sleeping!? Yep, she was practically snoring for the first and second apgar scores.
    Hilarious!

Apiu’s face positively glowed as she watched her girl sleep on the floor. While waiting for the placenta, I scanned the room for Fear and Worry, but they were long gone. The corners of the room whispered praise; the walls practically cheered ‘Hallelujah!’

With this baby, she regained honor in her husband’s eyes and status in everyone else’s. Her grief vanished at the sound of her child’s first cry! Joy came at last.  

“Weeping may last in the night, but joy comes in the morning!” Psalm 30:5

Wednesday, March 9, 2011

Speaking in Tongues!

Each Wednesday, the staff on the compound gather around a bonfire to pray and worship. It’s our midweek service of sorts, and I love it.

Some weeks, I’m too tired to pray, but I’m never too tired to listen. Regardless of what’s going on in my heart, this ministry, or Sudan in general, it’s always nice to take an hour to re-focus on what truly matters -- worshiping the King!

Last week, as I listened to the voices around me, I couldn’t help but think of the day of Pentecost when the Spirit of the Lord descended upon the disciples. On that day, a mighty wind blew, and it looked as if fire dipped down from heaven, as the young believers were anointed in God’s Spirit. And through Him, they declared the wonders of God in many foreign tongues. It was a beautiful outpouring of the Spirit. (Acts 2:1-13)

Well, sitting around our bonfire, I hear echos of that day. Foreign tongues utter praises and supplications continually. One minute it’s in Arabic; the next it’s in English. Kiswahili is then followed up with a song in Dinka. Then it’s back to Luo.

I love it.

I don’t understand all the words, but I wholeheartedly concur with the Spirit. It’s beautiful and melodic; it’s worship in God’s many, glorious languages -- everyone speaking in tongues!

Is this what it’ll sound like in heaven?

Sunday, March 6, 2011

A Masterpiece~

She arrived as the sun settled for the day, streaming pinks and oranges across the clouded sky. One look and I knew she’d go quickly. The fact that she couldn’t sit down, coupled with the slow lean against the wall, whispered just how close she really was to delivering.

In long, fluid movements, her body masterfully danced to ancient rhythms, and another contraction flitted across her belly.

She’d birthed before... many times in fact, but this time she was choosing to birth with me. I couldn’t suppress the smile this brought to my heart, as I walked her into the clinic.

While checking heart tones and counting contractions, everything fell into place.  She settled in by making a nest on the floor, and I took my stool in the corner of the room.

I explained to my translator that she’d go quickly, and he should set up for the birth. He didn’t believe me, saying she was too composed and even able to walk on her own. I didn’t argue. I just smiled, wordlessly watching this masterpiece unfold.

A few minutes later, I realized I had forgotten my notebook back in my room. (It’s where I ‘chart’ the birth and frankly, I flounder without it.) However, to get it meant leaving her for five minutes. I wasn’t sure I should; it was that close. Weighing the pros and cons, I finally succumbed to tradition and hurried off.

Speed walking there and back, I couldn’t shake the urgency in my gut. My translator just laughed as I hustled passed him. However, when I returned, she was still laboring on the floor. Relieved, I found my seat and continued to watch quietly.

It was beautiful, languid and sweet.

Shifting her weight from one leg to the other, she crouched and then kneeled. Watching for the slightest shift and movement, I knew when she pushed that once.

When she did, a climatic splash clapped as a sea of salty water spilled across the floor. Our eyes connected and I moved. Wordlessly, I slipped the underpad beneath her body, then gloved up.

Seconds later, she mumbled something, but I had no idea what. (My translator was off chatting up his friend.) Her friend, however, pointed at her, indicating I should hurry.

Kneeling in front of her, I bent low to get a closer look; the head was already out! She was holding him in with her hands, so I placed my hands on hers, and together we delivered him.

Easy. Slow. Beautiful.



His cries brought my translator running, but there was nothing that needed to be said. So we just laughed and started to clean up the mess.

The rest of the birth went just as smoothly; placenta and postpartum melted together in a steady stream of laughter, as her friend relayed the story of her birth to two late comers.

When she finished telling her version, I pantomimed the birth from my perspective, re-enacting the one push, the splash and the baby’s birth. We couldn’t stop laughing!

A good day. A beautiful birth.

When I discharged her the following day, she thanked me over and over again. Through my translator, she thanked God that I had come, and prayed that I would be here for years and years.

I packed her kind words neatly in my heart. Every now and again when things get tough, I take them out. They remind me why I’m here -- to bless these women and show them the Love that changed my life. Jesus.

Thank you for praying for me. Tomorrow, the clinic staff plans to sit down and discuss the new building/clinic floor plan. Pray for wisdom and vision for us all. Pray the new clinic is completed soon. Thanks.

Saturday, March 5, 2011

Poverty.

Poverty is relative.

Week after week, women file through my doors. Some are meticulously dressed with detailed henna tattoos and large nose rings. Others wear dirt caked underslips for dresses and smell of stale urine; calloused knees are the only things more used then their clothes. It’s very diverse, but I like it that way.

Mis-matched flip flops make no difference to me; I’m just happy they come.

Sometimes, those with the nice clothes try to skip the line by pulling in favors with the translators. I ignore them and put them back in line, recognizing there is some kind of rich-vs-poor pecking order here, but I chose to live outside of it. 

However, the only reason I can live outside of it is, I’m rich. (I’m not by American standards of course... Heck, the IRS wonders why I even filed this year!)

But to them, I’m stinkin’ rich. I wear a different scrub set every day. Imagine that, seven outfits! (Never mind I have countless others they never see.)

Plus, I’m fat or should I say... proudly plump. Let’s face it, it’s been a while since I skipped a meal. So, Yes. Comparatively, I’m rich. In fact, I’m filthy rich.

Like I said, poverty is relative.
mis-matched flip flops of a patient

However, this week, I overheard (and understood even though it was in Dinka) one of my translators asking a very poor and thus dirty pregnant woman if she owned any soap. He asked her twice, before I could stop him.

“What are you asking her that for?” I interrupted. He looked down like a two year old holding a bag of stolen cookies. “Are you asking her so you can give her some soap?” I continued bitingly. Again, he made no comment and continued to take her blood pressure in silence. “That was rude. You should not ask them such things. You should only ask them what I ask you to translate. Do you understand?” He nodded, but made no effort to apologize. In his mind, he had the right to insult her filth since he was clean.

It made my blood boil... but not for very long.

The reality is, poverty will always be an issue. The sheer fact of having or not having puts a person in a special ‘status’. It’s not just here. I’ve seen this on Fremont street in downtown Vegas while ministering to drugged-out homeless people. I’ve been guilty of it myself.

However, God tells us that we are to consider others as greater than ourselves. We are to esteem others and show them how valuable they are to us, and by doing so, to show them the love of God.

Did Jesus’ blood only flow for the rich and the clean?