Do I start with the fact she was only 16 years old? Do I start with her scared eyes and obvious pain? Do I start with her partially blind grandmother who gnawed on her lower lip while telling me her story?
Seriously. Where do I start?
I think the best place to start is with the facts.
Age: 16 years old
G/P status: Primip (or first baby)
Village: Thiet (20 kilometers away)
Fundal Height: 31 cm, but irregularly shaped
Fetal Heart Tones: 204 bpm
LMP: sometime in June 2011
Gestational Age: roughly nine months
Vitals: BP normal but running a low grade fever
Complaints: (according to her family)
- Baby is stuck, head can be seen but won’t come out
- Contractions for over 30 hrs
- Pushing for over 14 hrs after her water broke
As I gathered these facts, two things stood out above all the rest. She was exhausted, and her bladder bulged painfully above her pubic bone --which was the likely cause of the obstructed birth. The only way to find out, would be to catheterize her.
Her exhaustion was due in part to her long labor, but it was compounded by the fact she was denied food and water during labor.
-- “Aluak, are you thirsty?”
-- “Yes. Very thirsty.”
-- “When was the last time you took water?”
-- “A day and a half ago....”
I had her sit up while I gave her water to drink, saying, “You need water in labor. It’s very important... I know some people tell you not to drink. But that is wrong. Very wrong. You need lots of water for your muscles to work right. Do you understand?”
I was saying it more for her family than for her. I don’t think she was at a point of understanding much of anything. Too much pain... for way too long...
As I continued to review her I noticed that her baby’s head could most definitely be seen. In fact, a large caput had formed, and it protruded conspicuously from her body.
What worried me most though were the heart tones. When I first heard them, I could not believe they were actually the baby’s; they were just too fast.
The baby was stressed out and in pain... and his tiny heart sped chaotically in protest.
Fetal heart tones should be no higher than 160 bpm. His was 204, 208, 212 bpm.
-- “Aluak, your baby is alive. But he is telling me he is not happy.”
She looked at me in confusion. So I went on.
-- “What I am saying is... your baby is not well. He might die. Do you understand?”
She continued to look at me blankly, so I turned to her mother.
-- “The baby is sick. Do you understand? The baby could possibly die....”
She locked eyes with me, nodded briefly, but said nothing.
While I started an IV, Margaret catheterized Aluak. She removed about 300 cc of urine which instantly gave some relief. But there was still the issue of the birth. Would she be able to deliver now that her bladder was out of the way? There was only one way to find out.
Once we re-hydrated her, we decided it would be best to augment her contractions (which were frequent but short). It didn’t take long for the medicine to work, and what with her bladder no longer holding things up, she was able to deliver naturally a few minutes later.
Her boy was born flat and we started resuscitating immediately. Margaret worked on him with speed and determination. He slowly recovered, and by 15 minutes postpartum, was stable. (His Apgars were 3/5/7.)
We kept him on oxygen until his respirations and heart rate lowered to a reasonable range. He did not seem particularly interested in crying which concerned me, however not long afterward, he started breastfeeding on his own, so I relaxed a bit.
He wasn’t my only concern however. Although Aluak lost little blood postpartum, she seemed to be leaking an unusual amount of urine. It was unlike anything I’d seen before. I fretted over it thinking it must be a fistula.... but did they form that quickly? I’m not sure.
All I know is I was doggedly determined to see her pee! This confused her and the rest of her family who incidentally wanted to take her home. Immediately!
-- “What? You can’t take her home now... it’s too soon,” I sputtered.
-- “But the baby is out. We take her home now,” one sister said in broken English.
-- “No. The baby is sick. She might have problems urinating, too. She must stay.”
-- “But we want take her home...”
-- “I don’t care what you want. It’s not time to go.”
This went on for awhile until I walked away in frustration, calling instructions over my shoulder for my interpreter, “Tell her to drink lots of water so she can urinate. And watch that baby closely.”
A little while later Albino, our compound manager, approached me about Aluak. “The family say they want to go home now,” he started.
-- “I know they want to go home... but the baby was born almost dead. They cannot go until the baby is healthy and she has urinated,” I explained.
-- “Oh. I did not know. Okay.”
-- “Don’t worry about them,” I continued, “I’ll go tell them again and check on the baby.”
As I went to get my stethoscope and thermometer to check vitals, her family approached me again about leaving.
-- “No. Aluak is not discharged. NO. You cannot take her yet,” I continued. I felt like a broken record. Why the hurry? Honestly.... what was so urgent that they had to go home?
Aluak sat up when I walked in. She had been sleeping. The poor thing looked exhausted, so I asked gently, “How are you feeling now, Aluak?”
-- “I’m okay. Just tired.”
-- “Have you urinated?”
-- “Can you try?”
She nodded that she would but seemed too tired to move. I couldn’t blame her. After 30 hours of labor, I think I’d be out for the count.
Turning my attention to the small mound of baby blankets, I fished the thermometer out of my pocket. It’d been over 30 minutes since his vitals were taken.
He looked like he was sleeping. But as I uncovered his chest, there were no movements. He was warm but disturbingly still.
-- “When did he stop breathing?” I asked somewhat foolishly. How would they know? They too had thought he had been sleeping.
No one answered my question. They just looked around the room at one another in surprise.
I quickly put on my stethoscope and placed it against his chest.
I rubbed his spine. I flicked the soles of his feet.
Turning to Aluak, I explained, “Your baby has died.”
But again she gave me the blank look of exhaustion, so I repeated myself.
-- “Aluak, I don’t know when... but your baby has stopped breathing.”
She said nothing, but the women huddled around us all started talking for her. Their voices --some soft, some harsh-- filled the room with confusion. So I stood up and went for a translator.
Albino came to help. He was surprised by the sudden death as well. Everyone was. But even with him there, the other women in the room wouldn’t stop talking.
-- Some days I’m glad I can’t understand all their words.
Fortunately, Albino was able to help me explain to Aluak that her baby had died peacefully. He was just too hurt after the difficult birth. She nodded that she understood but said nothing.
There was nothing to say.
Her tears spoke for her instead. They were tired tears --slow and weary-- which journeyed silently down her cheeks, then splashed in her lap. I sat with her while she cried, holding her hand and praying.
There were no words.
Now that the baby had died, they redoubled their efforts to take her home immediately. But I persistently refused. She needed to urinate before she could go. Plus, I was not about to send a 16 year old home to a distant village if she might have a vesico-vaginal fistula. Not a chance!
But with time she was able to void her bladder, and I sent her home as promised. Her little boy went with her, wrapped tightly in her arms.
So much of what happened to her could have been avoided if her family had known...
- to give her fluids in labor, not withhold them
- to allow her to eat during labor so she would not be exhausted
- to encourage her to urinate before pushing
- to not push until the head was visible
- to seek help early if pushing was not progressing properly
- or... better yet to make her deliver in a clinic instead of at home