Sunday, January 29, 2012

Of Death and Blood.

Yesterday was a difficult day. After the grieving mother was carried off by her family, the crowd thinned enough for me to see Ajulla. She stood quietly beside the clinic entrance, looking scared and in pain.

At first I thought it was the fierceness of the woman’s grief, but as I approached her water broke. The suddenness of it surprised us all, especially Ajulla. Her eyes widened in astonishment as she looked around her as if saying, “Is this normal?”

Her belly looked suspiciously small for a term pregnancy, but I couldn’t be sure with her dress. As I walked her slowly inside for a check-up, I peppered her with questions.

When did the contractions start? Has any blood come out? How many months are you now? Have you been coming for check-ups?

She tried to answer our questions but was too confused. Once we got her on the bed, I understood everything without a word.

Two tiny black legs hung from between her legs. Her baby was dead and coming out breech.

As we waited for her birth to proceed naturally, I asked her the rest of her questions. She did not appear the least bit surprised when I told her she was delivering preterm. She actually looked relieved.

It took us only a few minutes to get the baby out, but the placenta was a challenge. I could not pull on it for fear it would tear.

With time she delivered half of it, but a large portion remained inside. She was not hemorrhaging so I did not go in after it. Instead I waited and prayed.

About an hour after the birth, her placenta was born. Ragged like hash, it fell apart in my hands.

Just as I moved her to the observation room, another woman arrived covered in blood. She knelt in the dust wearing nothing but a bloodied sheet.

-- “Are you pregnant?” I asked.
-- “Yes.” she said. The crowd gathered in to get a better look.
-- “How far along are you?”
-- “I’m 4 months...”

The crowd was getting larger, so I lifted her to her feet and together we walked inside. The prenatal women waiting to be seen, watched quietly. They would have to wait again.

Hers was less of a birth and more of a miscarriage (or incomplete abortion). Even though she claimed to be four months pregnant, her body told me otherwise. Tom had to perform a D&C to stop the bleeding, but she recovered well.

So much grief! So much loss! So much blood!

Lord, thank you for bringing these women to us. May the work we do glorify you regardless of the results. Bless them with health and heal them from their grief. Strengthen us so we can serve you faithfully. Amen.

A Grief Observed.

Yesterday morning I heard wailing coming from the clinic, and I knew. I knew from the strength of the piercing cries and the intensity of their sound that it had to be about the boy. The little cherub that I had prayed for the night before --the tiny toddler with pneumonia-- must have died.

He was very sick, struggling for every breath. We had put him on oxygen until we ran out of fuel to run the machine. But even when he was on it, he struggled.

His mother had come two days before, got medicine, and was told to return the next morning bright and early. Instead she stayed home, only coming late that night once the convulsions started.

She was frantic, wanting to take him to the witch doctor since our medicines were not working as fast as she liked.

Dr. Tom was not sure he’d make it through the night. But he did.

However by sunrise the shallow rasps coming from his chest finally stopped. He was dead.

When Tom pronounced him, the mother let out a guttural shriek that carried some distance in the dawn silence. It shook me from my bed.

When I arrived to check on another patient a few minutes later, I found her still shrieking and wailing sharply every few seconds. She punctuated her grief by throwing herself again and again on the ground --arms flailing --feet pounding.

Her family and friends sat quietly by and watched. Silenced by her grief, they did nothing to calm her.

Each wail eventually faded to a sob, then slowly she would stand again. Once standing, she would start to pace which eventually led to another wail more pitiful than the one before; and she would throw herself to the ground. Pounding. Stomping. Beating.

No one approached. No one comforted. No one joined in.

It was a difficult grief to watch --too fresh --too real. But eventually there were no more screeches to be uttered, and she quieted to a steady sob, prostrated in the dirt.

Only then did her family gather her up from the dust and walk her home. A friend followed with her child wrapped tightly in his arms.

The wails may have stopped, but the grief was just beginning. Please pray for her. I don’t know her name. But God does. Thanks.

Saturday, January 28, 2012

Leopard Attack?

The other night a man in his 20's was brought in from the village. His head was sliced open, his right arm was punctured, and he was bleeding excessively.

As Dennis sutured his skull, I causally asked what had caused his wound, assuming it must have been another motor bike accident. But it wasn't.
-- “He was attacked by a leopard,” my translator explained in disbelief.
-- “A leopard? Really? Are they even around here?" I asked stupefied and scared. I had heard of hyenas... but leopards? Honestly... a leopard??
Once I got over my initial surprise, I said, “Tell me the story in detail. How did it happen?”

 By this time Dennis had already closed off most of the foot long wound on his head. A thick gauze bandage covered the man’s face leaving only right eye uncovered. He searched my face in fear but didn’t speak. So my translator asked his friends to relay the story, instead.

As they spoke, a half dozen people slowly inched into the room to hear as well.

He was fishing by a river in a far off village when he passed next to a large bush. He heard something and turned to see a leopard pounce on him, taking him to the ground. The beast swiped his head in the process cutting a wide, ragged wound from his left eye socket to the back of his skull. Then the animal turned quickly and sprang on him again. This time grabbing his arm he had raised it in his defense. Then without explanation the leopard left as quickly as he came.

Since he lives so far away, it took him all day to reach our clinic --all day with the muscles in his skull protruding and various holes in his body tied off with old rags.

I asked if I could take a few pictures and he nodded but still didn’t speak. After each picture, I flipped my camera around so he could see what we were doing. He had to lower the gauze to see them, but he did it readily and thanked me afterward.

I don’t know about you but if I had been twice attacked by a leopard, I would not have been so brave!

Dennis was able to sew the wounds closed leaving proper drainage to prevent infection. Please pray he heals both physically and psychologically from this attack. Thanks.

Update: Jan 29 2012
I saw him today and he's healing well. The wound on his head is not septic. Please continue to pray.

A Perfect Mess.

Maguet said she was in labor but didn’t look active.
    --They rarely do.

As my helper readied the room, I tried to count contractions and ask her questions. She had never come for a prenatal, and I needed a few facts.

But getting her to talk was an exercise in futility. She just flat out couldn’t.

Only then did I see the first contraction. Saying it was strong just doesn’t cut it --intense to the nth degree --powerful the the power of ten. Okay. So they were strong!
    --How could she be so calm?

As I stood by her side trying to measure their intensity, a sudden rush of wet warmth gushed down my legs and hit the floor with a audible splash!
    -- Had someone emptied a bucket on me?

Maguet and I locked eyes in surprise, then looked down in unison. Black, murky fluid stained our clothes as if we had waded knee deep in a lake of amniotic fluid.

My first response was to laugh; but Maguet was a bit more hesitant. She looked embarrassed. Or was it horrified? Eventually she realized I was not mad and laughed timidly along with me.

I didn’t have heart tones; I had not measured her fundal height; and I still did not even know her gestation... but she wanted to push.

Did I have time to change? --Unlikely.

My warm, sticky pant legs clung to my skin, growing colder by the minute. My shoes squished loudly at every step. Eek.

I really wanted to go get changed... and perhaps take a long shower with bleach.
    --Could I risk it?

The midwife in me worried the murky fluids could mean a compromised baby. Heck, I still didn’t know if the baby was alive! However, the non-midwife in me was thoroughly disgusted and ready to run for a decontamination shower.

What is the protocol when a total stranger expels ink-flecked slime all over you?

My translator didn’t know what to do or where to stand. The horror on his face was evident. I had to tell him more than once to get the mop.

Only when I rolled up my pant legs and started moving her into position for the birth, did he push past his disgust and prepare for the birth.

He ran for the mop. I slipped a pad under her. She got in the squatting position.

Ten minutes later her little girl was born.

The baby came out with another splash of blood and water coating me in a second layer of grime. But I didn’t have time to notice.

Green-gray meconium coated the baby and sputtered from her lips. I suctioned her mouth and dried her off before handing her over to her mom. Then I took a long look at myself. A mess.

A. Cold. Sticky. Wet. Mess.

What a bad week for the water to stop working at the clinic!

Once the baby was stabilized and breastfeeding well, I ran off to the compound for a quick shower. A bar of soap never looked so great!

Her baby was initially fine, but by the second day she developed an infection --most likely due to meconium aspiration but also possibly due to untreated STDs.

We have her on antibiotics now. Please pray she recovers quickly. Thanks.

Labor of Love January 2012

Labor of Love January 2012

Friday, January 27, 2012

Update: Clubbed

Baby Yom is doing very well. His mother brought him in to be fitted for another set of casts for his clubbed feet. Admittedly he was not a fan of all the prodding, but he didn’t cry --instead he stuck his tongue out at me!

So cute!

Dr. Tom is pleased with how well his feet are turning back to normal. And although he has not reached full range of motion in all his joints, I’m seeing steady improvements.

Wednesday, January 25, 2012

Surgeon in the House.

Dr. Mike is a general surgeon from Florida who has come to serve this community for the next 3 months. His happy manners and quick wit have already made him quite popular; and I’m confident his many skills will make him even more so in the coming months.

He will be working at the government hospital since we don’t have space in our clinic. Plus, the government hospital has a tiled room designed for just such surgeries.

The staff has been organizing the equipment and setting up the room for the last few days. Yesterday they did their first surgery --a hernia repair on a 7 year old boy. I’m told things went very well.

It sure is nice to have a surgeon in the house!

Tuesday, January 24, 2012

Friendly Farewell.

Achan and me after her birth last August.

Achan delivered a few months back. She blessed me to no end during her birth with her serious promise of friendship.... if I could just stop her pain! When she delivered a few minutes later, she decided we’d be friends for life! (Read her story here.)

What an honor!

I’ve seen her a number of times since then. Each time she has greeted me loudly, while repeating over and over again the only English words she knows.

My friend! My friend! My friend!

I can’t help but just love her to pieces.

Well today, she came to say goodbye. Apparently, she must return to the village and can no longer come to visit.

She brought her doe-eyed daughter with her, and proudly handed her over for me to snuggle. Then through a translator and while continually repeating “My friend! My friend! My friend!” she told me that she named her baby after me.

When I expressed my happy surprise she explained, “Her name is Akuac Kowaja!”

You might recall that my Dinka name is ‘Akuac’ which means ‘White cow with black spots and uneven horns’.
          -- Yep, I'm a Jersey cow.

However, you may not know that ‘Kowaja’ is the term used for anyone who is not Sudanese. Technically it means ‘foreigner’ but it is also the term most often used for ‘white person’.

She is the first baby named ‘Kowaja’ that I’ve met!

I was happy to see my friend one last time and hope that we’ll get to meet again soon!

A Transport.

Last night, Judo, a 22 year primigravida was carried into the clinic by her family. Exhausted she fluttered in and out of sleep as I checked her vitals.

She is from the Luo tribe; and since no one else in her family could speak any Dinka, she pushed past her fatigue to explain her long and difficult labor herself.

Her contractions had started two days before. Everything looked good until her water broke and she started pushing. She pushed and pushed for over six hours, but her baby would not come. Eventually her contractions just faded away. 

She had not had a contraction since dawn --roughly 16 hours earlier.

Gesturing toward the wrinkled woman at the foot of her bed, she explained “My grandmother was my midwife. She said she could see the baby’s head, but it went back inside.”

I looked back and forth from her grandmother’s worried face to her oblong belly while trying to process her words.

What? She was in labor? She didn’t look like she was in labor. Could they have been mistaken? Perhaps she had malaria-labor and just dreamed up the fact the head was poking out?   

I needed more facts.

A quick vaginal exam explained everything. Not only was she fully dilated, but the presenting parts were at a +2 station. Her pelvic outlet seemed adequate despite her low pubic arch, but the real problem was the swelling.

It took me a long, breathless minute before I realized the squishy mass of swollen flesh was her baby’s head. It was so edematous I could not find any suture lines. None at all.

Not good.

All the signs pointed to deep transverse arrest due to cephalopelvic disproportion (or CPD).

She needed a cesarean.

The good news was an American surgeon just came on staff last week. The bad news was we are not ready to start doing cesareans yet.

After discussing her case with the rest of the staff, we decided to transport her to Wau instead of risking an ill prepared surgery.

When we explained the situation to her family, they didn’t hesitate. They quickly gathered the necessary funds and an hour later she was en route.

I’m happy to say that this was the fastest transport we have ever organized. Originally when I heard that she’d be transported, I assumed we’d have to wait until sun up like before. But I was wrong. Apparently, we have a new driver who can go at all hours of the day and night.

What a blessing!

Today I am genuinely grateful for cesareans, ambulances, and willing drivers. By now, Judo and her baby should be recovering from surgery. Pray that it was successful and that they heal quickly. Thanks.

And also pray for our new surgeon and the many families he will bless in the coming months. I’m told that he is doing a hernia repair today. Exciting!

More about him later.

Tuesday, January 17, 2012


I have stories --lots and lots of stories-- but I can’t write. When I try to write, my mind races in circles silently screaming --arguing --raging, but nevertheless perversely mute.

Oh, to be able to write them down!

In all honesty, I don’t trust myself. I’m afraid once written, my words will grow into loathsome monsters that will shock, horrify... disappoint.

So I’m silent.

Please bare with me. I have many stories. Really, I do. But how can I write them when my words are mute, and my thoughts are monsters?

Please pray for me to master these monsters. Thanks.

“For though we live in the world we do not wage war as the world does... We demolish arguments and every pretension that sets itself up against the knowledge of God, and we take captive every thought to make it obedient to Christ.”
        2 Corinthians 10:4-5

Wednesday, January 11, 2012


Now with the Christmas birthing rush behind us, we are back to only 2-3 births a week.           --Sigh

I miss having so many babies to catch, but I'm not complaining; I don't have time!


Well, the rest of the staff got back this weekend and we are open again for consultations.

Margaret and I (along with our very tired translators) have done just over 100 prenatals in the last 3 days.

Yesterday was our busiest day. We had 40 prenatals and a labor.

The labor, Elizebeth, spoke excellent English and was older than the average G1 at 25 years old. Her progress was slow, but she was able to cope well with the pain.

When it came time to push, her gap-toothed mother stood by her side and cheered. She delivered a healthy little girl over an intact perineum after only 15 minutes of pushing!

What a superstar!

Also, I heard that in a few weeks another doctor will be joining our staff for awhile. He is a surgeon and will focus on surgical cases. 

Perhaps he'll be able to help us with a cesarean or two while he's here. I pray that he won't HAVE to... but it'll be nice to have his skills if needed. Right?

Saturday, January 7, 2012

200 Reasons Why.


I'm one of those midwives that keeps statistics. I write birth stories. I keep logs.

I do it so I can remember. I do it so I can learn. But mostly I do it because it's fun.

Today as I was writing down the ridiculously short birth story from this morning, I realized I'd passed a milestone.

Yep, today I caught my 200th Sudanese baby!

It was a brilliant birth. The mother went into labor at 5 am, arrived at the clinic shortly before 7 am, and delivered at precisely 7:02 am. 

I am glad she made it in time!

Side Note:
It's my 200th catch in Sudan, my 315th catch in total, and the 488th birth I've attended. But who's counting? :- )

Friday, January 6, 2012

Crying it out!

Athieng was hard to read.

Her contractions said one thing (i.e. “We’ve got a long way to go.”). But her response to those contractions said another (i.e “Quick, catch this baby. It’s coming out right now!”)

Which was it?

Originally I waited and watched trying to avoid a vaginal exam, but eventually I caved in after another half hour of confusion.

She was only 3 cm dilated.

Normally I would have insisted she go home, but she didn’t look like she was coping well.

Tears. Sobs. Whines. Whimpers.

This was not the typical Dinka labor. Usually the women I serve are restrained to the point of stoicism.

She was different; she actually looked and acted like she was in labor. It was refreshing.

I told her it would be many hours before she delivered and that it was best if she went home to labor. However if she’d be more comfortable at the clinic, of course she could stay.

Shaking off the pain, mustering a half-smile, then wiping streams of tears from her eyes, she finally said that she preferred to labor at home. So I prayed for her and sent her on her way.

I half expected her to stay home, but she surprised me by coming back 6 hours later. But this time she was active. But as the hours progressed, so did her tears. 

At the start of each contraction the flood waters would open, gush across her face, then drip off her chin. Yet the moment the contraction faded, she’d wipe her face, sniffle a bit, then go back to pacing the clinic grounds.

These were no ordinary tear drops; these were brewing geysers, raging tidal waves, gushing rivers.

In all my years, I’ve never seen a coping mechanism quite like this one. However, it makes the most sense. I mean... why not cry?

Before I go on, there is something you should know about me. I’m a cry-er. Some would even say a cry-baby.
            --Heaven knows I’ve been called worse.

So when I saw her crying, I instantly understood.

You see, I cry when I’m happy. I cry when I’m sad. I cry when I’m stressed, pissed, depressed, blessed. I just cry.

I loved that she did, too.

Long story short, her crying eventually came to an end. The contractions led to her water breaking, which led to frantic pushing, which led to more crying. But this time it was her son making the noise!
    --What a beautiful sound it was!

Personally, I think I’m going to be much like her in labor. I’m sure I’ll do my fair share of blubbering, sobbing, and crying. I mean, why not?

It just feels good to cry it out sometimes. Right?

Anyway. I’m happy to report that the word is out. Women are coming to deliver with us quite regularly. Last month we had 40 births. I wonder what this new year will bring.

Thank you for praying that they would trust us enough to come. Now please pray that those that come, would see Jesus in our actions and words. Thanks.

A Traditional Sudanese Birth?

Akul first came for help two weeks ago. She was sure it was labor; but her contractions were unconvincing.

Although obviously painful, her contractions lasted no more than 15 seconds and weren’t bringing any progress.

Since it was her fifth pregnancy I admitted her for observation; and for the next 5 hours we watched and waited. But nothing happened.

Now, I’ll be the first to admit I’m cautious when it comes to Braxton-Hicks contractions. I used to educate women on them, reminding them that it wasn’t labor until there was progress, etc. But after a year and a half of malaria cases, I don’t like to risk it anymore.

Why? Because I cannot tell the difference between Malaria-Labor and Braxton-Hicks contractions.

Yes. It might only be Braxton-Hicks contractions. But what if it’s not? What if she has chronic malaria and the pregnancy is masking the symptoms? What if the paracheck gave a false-negative? What if...?

So when I have a woman like Akul --in pain with regular but short contractions-- I treat for malaria if I haven’t seen any progress for several hours.

This was the case for Akul; so I gave her the first line treatment and sent her home. When I didn’t see her the next day, I figured the medicine worked, or she’d delivered at home.
    --Follow-up on patients here isn’t as easy as you might think.

I didn’t see her for two weeks. Then two days ago, she returned with the same symptoms. In the course of her evaluation it became clear she did not take her medicines properly.

We were right back to square one.

More pain. More spastic-y contractions. More worrisome watching.

But since her symptoms were worse this time, I started her on IV medicines and kept her for the night. By morning she hadn’t dilated even a centimeter.

I gave her a new course of treatment and sent her home, warning that her labor could start at anytime and she’d need to come back if her water broke... or the pain got stronger.

She returned 12 hours later saying her water broke.

I wanted to believe she was in labor... but all I felt was irritation. Stupid malaria. Stupid, stupid malaria.

Grumbling under my breathe about the evils of this debilitating parasite, I watched her suffer under its torment.
    --Childbirth is painful enough without adding this nasty plague!

But when I re-evaluated her, she hadn’t dilated at all. However, her water had most assuredly broken. I wasn’t sure if she was in labor... but I figured it’d come soon enough.

I told her as much, then gave her the option of staying the night again or going home. She wanted to stay.

I didn’t argue. Even if she didn’t progress, at least she’d be close.

However her labor surprised me.

Her contractions got strong rather quickly, shaking her body like a ship in a storm. They went from being every 20 minutes to every 8 minutes in under an hour. 

Another hour went by and she was pacing --pacing and moaning rhythmically.

It was close.

Her husband, a man who had faithfully sat by her side each step of the way, watched us pace together but made no comment.

His dark, lanky frame stood in shadows and watched. In the black of night, the only thing visible was the reflection of the clinic lights in his eyes.

Less than an hour later, Akul was asking to push. No... she was NOT asking; she was grunting, moaning, jerking, clenching, and whimpering.

It was time.

I asked her if she wanted to deliver on the birth bed or on the floor.
-- “The floor,” she whispered.
-- “Okay. Once this contraction is over,” I said as a strong wave of pain rushed over her, “we’ll help you get positioned on the floor.”

Nodding, she answered with another whimper. 

Once set up, I invited her husband to join us. He had been sitting silently on the bench outside.
-- “Tell him that he can come in if he wants to...” I told my translator, “He doesn’t have to come in... but if he wants to, he should come now.”

My translator called for him over the thin wall, and he noiselessly entered and sat down.

Turning my attention to Akul, I said, “Only push when you have a contraction. Okay?”

She nodded determinedly but said nothing.

Her husband sat in the corner, firmly grasping his knees to his body in an effort to stay on the stool. It was a tight squeeze for his long legs.

After a few minutes, he spoke his first words.
-- “How do women deliver on a bed?” he questioned innocently.

It was child-like in tone. And I could see his mind whirling as he considered the plastic-covered birth bed in front of him. It had a hole at one end and a movable flap at the other. Very confusing.

He wasn’t asking me, but my translator, so I didn’t butt in until the conversation was over. I had understood a bit of it and asked my translator to help me understand it all.

-- “He cannot imagine how the woman earlier delivered on the bed,” explained my translator.  (The previous labor delivered just an hour before and he had heard all the commotion. That labor had insisted on delivering on the bed.) My translator continued: “He wants to understand how it’s possible to deliver in such a way.”
-- “Did you tell him?” I asked, but then couldn’t wait for the answer.

She was pushing.

She delivered in the supported squat position a few minutes later. As her boy slipped out, a piercing screech filled the room --and then silence.

It was done.

Slimy and beautiful in every way, he complained as I wiped him down and placed him in her waiting arms. For several long minutes, we sat in silence enjoying the calm after the storm.

As we sat, I couldn’t help but think about his question. It was a good one. Very practical.

“How do women deliver on a bed?”

I’m willing to bet there are a large number of non-Dinka men (and women for that matter) out there wondering the very opposite question.

It could be equally asked: “How do women deliver on their knees?”

Ahh! Culture! Thou art a tenacious beast! You cling to our preconceptions like barnacles; you beat about our heads like waves; your flotsam and jetsam clutters our minds. How do we escape unscathed?

Underneath what we are really asking is, "What is the right way to give birth?"

There are just no answers, are there? There are just opinions colored by what is most familiar, comfortable, and common place.
           --Oh, the traditions we hold so dear! 

I’m happy to report that Akul had a traditional Dinka birth.

She delivered in a supported squat with her husband’s knees in her back while malarial parasites raced through her veins.

Afterward Akul glowed with satisfaction, saying “I’m so happy. Ana chi pou mieth. I’m so very happy.”

Yes, Akul. So am I.    --So very happy!

Please pray for them. Pray her chronic malaria goes away quickly. Pray for health and love and joy and peace.

I invited them to church on Sunday, please pray that they come. Thanks.

Tuesday, January 3, 2012

Primip Breech!

Last year a first-time mom was brought to me after several long days of labor. Exhausted and scared, she lay on the bed for an evaluation. But it was soon clear what was wrong.

Her baby was breech.

Now I’ve delivered my share of breech babies but this was the first time I had to deal with a primip breech (meaning one for a first-time mom).

In any industrialized nation, a primip breech would be an immediate (or scheduled) cesarean as the risk of the baby dying is quite high.

The worry is that the larger fetal head will not mold enough to be born after the smaller buttock is born. The head would then get stuck, leading to suffocation.

Although I’m sure we all know someone who knows someone who had a successful breech birth the first time around, more often than not, the birth can go wrong (or be mishandled) and the baby can die.

But I digress.

My point is that the young girl last year came to me fully dilated with her baby’s buttock already protruding from between her legs. We had no time to transport, so we informed the family of the risk of vaginal birth then prayed like mad.

The birth went horribly wrong. Everything that could have gone wrong, did. Everything. And her baby died. (Read her story here.)

Afterward I asked God to never give me another primip breech, and to always help me diagnose them early so I can get them the cesareans they need... and deserve. 

I grieved that birth for many months. I was haunted by regrets. “If only I had done this instead of that... if only I had insisted on a transport... If only I had reacted better... faster... smarter. If only...”

In fact, I was still grieving it when I went to Switzerland to visit two midwifery classmates last Spring, and we talked about it in detail. One of them also introduced me to a midwife friend who had read about this tragic birth and wanted to encourage me.

Long story short, this midwife poured out sweet comfort coupled with years of wisdom. What is more... she taught me what to do if it ever happened again.

I listened to her words carefully, praying that it never would, but thankful to have options if it did.

Well, it did happen again. It happened last night.

This time, however, I handled the birth differently.

As I readied the room for the birth, her words rang out in my mind: “Make sure you go slow. Allow for the woman’s body to dilate properly. Don’t ever take your cupped hand away from the perineum. Once the buttock starts coming out, push the buttock back in with counter-pressure. Push hard. Make sure the baby does not unfold... that way the arms won’t fly up over the head and get trapped.”

Nyibol, my labor, wanted to push like mad and didn’t like the counter-pressure. She asked over and over for me to “just let her push harder”. But I was determined not to let this baby get stuck. So I explained my reasons again and again, insisting she breathe through her contractions as long as possible and to push only when she couldn’t help it.

She needed to go slow.

Tom came to assist, but since he wasn't needed right away, decided to sleep in the other room. Having him there was a huge comfort.

Meanwhile, Nyibol pushed on. And I supported the perineum.  

The Swiss midwife’s words continued to echo in my head, “Make sure you never take your hand away. Not for one second. The baby must not unfold. Only remove your hand when most of the body is born... then deliver the baby like a normal breech.”

My hands cramped. My forearms ached. But it didn’t matter. The baby was doing well.

Plus, Nyibol was making good progress.

I called Tom in to assist once the body was mostly delivered, and he applied suprapubic pressure as the shoulders were born. I had to reach in to release the baby’s right arm, but the left came out on its own.

The following push the head was born!

Nothing went wrong. None of the emergencies happened. Amazing.

The difference between this primip breech and the last was night and day.

Night... and day.

Thank you Jesus for this healthy little girl. Thank you that she is alive. Thank you for sending me wise midwifery friends who taught me this simple technique. Thank You! Thank You! Thank You!

Nyibol did not get an episiotomy; she did not even tear. Her baby had decent APGAR scores (6/8), needed no resuscitation, and transitioned well.

Night and day.

I share this story with you so that if any midwives out there find yourselves in a surprise breech in a primip, you might remember... cup the perineum. Never let the baby’s body unfold. Basically, make your hands like a second-perineum so the baby stays in a compact position. This will dilate her body most effectively, permitting enough room for the head to emerge without delay.

I realize this is the OPPOSITE of what almost every textbook says on the issue of breech delivery. And for that, I would be remiss not to comment. I agree with the textbooks. Hands off a breech. Never pull on the body.

Never. Never. Ever.

What I am suggesting is that you PUSH on the body --not pull. Give counter-pressure as the baby descends. Provide a place (aka your cupped hands) for the baby’s butt to pivot naturally as it passes over the perineum.

I did not "touch" the baby (and never pulled on her) after her legs and trunk were born. I only assisted in the birth of one arm, so the head could emerge.

I hope that makes sense. If not... let me know.

Thanks for praying for these women. Thanks for praying for me. I could never do this without your love, encouragements, and prayers.

Monday, January 2, 2012

Placenta Previa?

Two days ago, Adhieu started having contractions in her sleep. She thought it was unusual since she was only 6 months along, but there was nothing she could do about it. She lived too far away to get immediate help. She’d have to wait until light.

But as the sun peeked up the next morning, the bleeding started. Lots and lots of bleeding. She bled heavily until noon.

She said her baby kicked like mad during that time, but then suddenly stopped.

That was a day ago.

She knew something was wrong, but it took time to get the family involved. Someone needed to bring her to town. She couldn’t go alone. Who would come?

Eventually it was decided her father would accompany her.

By the time she arrived, her clothes and legs were crusted in dirt-stained blood. A large flap of membranes hung from her introitus but she was no longer in labor.
    --Was this placenta previa?

(For those who don’t know, placenta previa is when the placenta presents first, causing painless bleeding. It can be life threatening for both mother and child, depending on the blood loss.)

There were no heart tones to be found. No movement. Nothing. Her baby was dead.
        --Could she have had an abruption?

(For those who don’t know, an abruption is when the placenta detaches from the uterine wall prematurely. This is very painful and presents with bright bleeding. An abruption can be complete or partial. It is almost always life threatening for the baby unless delivered quickly.)

She wasn’t surprised when I told her baby was dead. And she didn’t cry, either. Instead she looked unblinkingly off in the distance, hardening her jaw. Resolved.

A quick speculum exam revealed a 2-inch chunck of placenta plugging up her cervix like a cork. Thick membranes dangled down the canal, but the bleeding had stopped. She was 2 cm dilated and had no contractions.

Ideally, she would have gone to Wau for a c-section, but I intuitively knew this was NOT an option.

Had you asked me how I knew this, I would have been hard pressed to give you an answer. And yet when Tom asked me to send them anyway, I gawffed, “That’s not going to happen. They don’t have the means.”

He insisted on it though, expounding on the potential danger of her bleeding to death if it was a previa, etc.
-- “If contractions start, her cervix can open and she can hemorrhage... maternal mortality.... too dangerous... must transport....” He lectured pedantically. He wanted us to warn them of the risk of her dying. Just in case.

I listened to his words --I even agreed with them-- but I knew they’d never go.

Her clothes were too worn. Her body was too lean. And neither of them wore shoes. Plus her only companion was a frail father with clouded pupils and trembling hands.

But the biggest clue was the fact it took her a day and a half to get to us.

No one with any sort of means waits a day and a half to seek treatment with this much blood loss. No one. 

I respected Tom’s wishes though and talked to them about transporting. The discussion was disheartening short.

Conclusion: They had no money. His goats were back in Thiet. It would take time to arrange their sale --perhaps two days.

I listened and nodded, then induced her.

I had peace about this induction. Her bleeding was almost nil, and she was a multigravida. If the medicines worked... she’d deliver quickly and this would all be over.

Then no goats would need to be sold.

By God’s grace, the induction was effective and she delivered 2 hours later with very minimal bleeding.

Her baby weighed just 800 grams, but he was perfectly formed. Tiny ears. Delicate fingers. Two thin eyebrows neatly knit atop unseeing eyes.

He never opened his eyes to this world... but I believe he’s seeing something much more beautiful now!

Please pray for Adhieu as she grieves this loss. It was not her first. Pray that it is her last. Thanks.