Thursday, March 22, 2012

A Breech of Trust.

Two weeks ago one of my prenatal ladies came to the clinic in labor. I had followed her pregnancy for several months, and during that time we’d developed a sense of trust  --or so I thought.

When she arrived, she was 6 to 7 centimeters dilated with consistent contractions. Since it was her 5th child, I expected things to go quickly.

However, there were a few concerns.

Abdominally, her baby appeared to be breech. But when I tried to confirm vaginally, I had more questions than answers. The membranes wouldn’t allow for a clear diagnosis, and I was unwilling to rupture them to find out.

During her prenatals, she had never palpated breech before, so it came as a surprise. I questioned my suspicions though, saying that perhaps the heart-tones were high because the head was not engaged. Maybe what I felt in the fundus was just a really boney butt. So I noted it in her charted and waited.

Time would tell.

I re-examined her 6 hours later and she had not progressed at all. Moreover, the presenting parts were still unengaged despite increasingly effective contractions. This worried me.

Even though I had oxytocin at my disposal, and theoretically I could rupture her membranes, I hesitated to push things along. I could not rationalize the risks.

With the baby still unengaged, such actions could lead to cord compression... or worse. Cord prolapse. Maybe we just needed more time.

So I waited... and prayed.

Another 4 hours went by and she got more and more active. Outwardly, her contractions indicated birth was close and I considered doing another vaginal exam to reassure everyone. But I hesitated... what if there had been no progress? What if the head was still high? But if so, wouldn’t it be better to know?

This internal debate went on for sometime, but eventually, I caved in and did one.

The news wasn’t good; she had not budged at all. After close to 10 hours of stronger and longer contractions, she had dilated just one extra centimeter... but even that was iffy.

What was the hold up? Why wouldn’t the baby descend?

Over dinner, I casually mentioned her case to Dr. Tom, suggesting we might need a cesarean. I told him my hesitations and concerns, and together we agreed to stop her labor if she did not show significant progress within the next few hours. That way she could get some sleep and her family could start preparing money for a transport.

But an hour later her water broke.

I was pleased that things had progressed to this point, but did not do another vaginal exam. I figured that as long as the heart tones were good and moving lower on her abdomen we were golden.

Looking back, I regret that choice. I regret it a lot.

An hour later my shift ended and Margaret took over. Since the water had broken, I figured she’d deliver shortly and didn’t think to tell Margaret my suspicions.

That too, I regret.

Exhausted from the long labor watch, I turned in early. But by 3 a.m. there was a knock at the door. Groggily, I asked what the problem was.
-- “Margaret says she needs your help,” our health worker said quietly.
-- “Is there a new labor?” I asked.
-- “No. Same woman.”
-- “I’ll be there in two minutes.”
While my body changed into scrubs, my brain struggled to connect the dots. I had assumed she’d delivered hours before.

I was wrong.

I arrived to find her pushing and got hopeful, but it didn’t last long. I quickly realized that Margaret had decided to break her waters a few hours before (apparently the first rupture sealed off again or hadn’t happened at all). However, when that didn’t bring the baby down, she augmented with oxytocin. 

After she explained the various measures she’d taken to spur on her labor, she told me why she had called for help. “I just did a vaginal exam, Steph. She’s fully, but I’m not sure if it’s the baby’s foot or arm.”

I asked her a number of questions, probing here and there. Then I put on gloves. If she was presenting a shoulder or a hand, we couldn’t let her push. So I stopped the oxytocin and asked her to breathe through her contractions.

A quick exam told me a lot. I measured her to still be about 8 cm dilated. And although there seemed to be more than enough room for a baby, the fetal parts were high. With the membranes out of the way, I could feel a squishy butt and what appeared to be toes. But honestly, the baby was just too high to get a good read on it.

Only then did I tell Margaret my suspicions. As I related the subtle warning signs I had observed, she seemed irritated. Why hadn’t I told her this hours ago?

I apologized. There was no good excuse.... except I honestly thought she’d already delivered and my suspicions were groundless.

Once it was decided to transport her for a cesarean, we worked quickly to inform the family and stop her contractions. The baby was alive, but the variables in his heart-rate worried me.

Sunlight was just a few hours off, so Margaret worked with the family to get money prepared for a transport. And I went back to sleep.

Just before 7 a.m., there was another knock at the door. It was louder this time. I opened the door to find Margaret’s lips pressed thin with disappointment.
-- “Is everything okay, Margaret? Is the baby alive?” I asked with an urgency I couldn’t suppress.
-- “There’s another labor. She just arrived,” she started to explain. “The woman from last night... well, I don’t know what happened. I’m still figuring out the details...”
-- “What do you mean?” I asked in confusion. “Did her family get the money for a transport?”
-- “They got some money... but when they could not find it all, they brought in a TBA (traditional birth attendant) to deliver the baby....”
-- “They did WHAT?” My mind jolted awake instantly. What was she saying?
-- “I don’t have the whole story yet... all I know is I went to check on her a few minutes ago and a TBA was there... I’ll explain later.”

I thanked her, closed my door, and then took a deep breath. I couldn’t worry about that just now. I had another labor to take care of.

When I got to the clinic, the other mama was active. Although she was not one of my prenatal ladies, she had heard good things about the clinic and wanted to see for herself. The friend that brought her used to work for us. I was happy they trusted us enough to come.

She delivered an hour later on her knees.

The peacefulness of her birth stood in stark contrast to the turmoil in my heart. I kept having to force my thoughts back on the woman before me. I couldn’t stop thinking about what was happening in the next room.

My mind raced round and round. “What was happening in there? Was the baby already born? What did Margaret mean that a TBA had come to help? Were they transporting still?”

By the time my labor had delivered and we got things cleaned up, the clinic was bustling. A line of women waited patiently outside on benches. The day had begun.

I didn’t hear the full story until late that afternoon when Margaret and I had time to connect again. The story she told doused my heart with indignation, then set it on fire.

Picking up were she left off that morning, she explained, “The woman’s husband didn’t go for money. He went for a TBA. Apparently, she arrived around 4 or 5 this morning, and the clinic worker just let her in...”
-- “Our health worker didn’t stop her?” I asked incredulously.
-- “No. He couldn’t explain why... but he gave her gloves,” she paused a moment then went on, “As you know, when we left last night, her contractions were stalled and she was sleeping (because of the medicines we gave her), so I can’t figure out how she pushed.”
-- “Yeah... how could the TBA get her to push if she was so drugged?”
-- “I don’t know... I don’t know. All I know is that when I went to check on her this morning, the baby was dead and she was covered in blood.”
-- “What did the TBA do?”
-- “The health worker said she reached inside vaginally and tried to pull the baby out.”
-- “Why didn’t he stop her?” I demanded with more indignation in my voice than I intended. 
-- “He did not say. I don’t know...” she continued defeatedly. “But when I found her she was still wearing the bloody gloves and was trying to deliver your labor as well...”

Since neither of us were there, it’s hard to know for sure. I’m left to my imagination as to what really happened. What I suspect is that her husband assumed we were just not good enough midwives to get the baby out. He figured another one would do better.

But instead of fixing the problem, this woman made things worse. By trying to force the baby out (which failed), she killed him.

I suspect some kind of cord compression combined with fundal pressure.

We had spent 20 hours laboring with her to avoid this very thing. We’d given her our best. We’d done everything to keep that baby alive. And yet it was all for naught.

Her baby died... and she still had to have a cesarean.

I’ve thought about her labor a lot over the past few weeks, playing the what-if game in my head. I’ve gone over it again and again but to no avail. I have, however, made a few cultural observations.

The Sudanese seem to believe that:
-- the death of the baby is an acceptable, although disappointing risk of birth.
-- cesareans are to be avoided at all costs (not always for financial reasons).
-- cesareans should only be done to save the mother’s life, if the baby lives then good. 
-- women have little to no say in their health care choices.

Many other lessons can be extrapolated, of course. And if I had it to do all over again, I’d do it much differently.

Suffice it to say... I’ve learned many lessons --the greatest of which is trust.

Trust is essential.