Friday, January 6, 2012

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.