Concrete?

Call me crazy but concrete is not meant for vaginas. Yet tonight that is what I saw. My brain is having a hard time registering this information. I’m honestly baffled.

Let me explain.

Earlier tonight, Tom called for a consult saying one of my old patients was back complaining of something hard prolapsing from her vagina. He investigated and quickly determined he needed a second opinion and gathered the troops.

As I walked with him  toward the clinic (the rest followed a few minutes later) he told me that she was the girl that had the prolapsed hand that miscarried. I couldn’t tell if he was talking about the girl with the incompetent cervix or Biyana. But either way, I’d find out soon enough.

I walked in to see Biyana writhing in pain as one of our health workers finished giving her antibiotics intramuscularly.

Biyana? It’s not possible. I just saw her a few days ago. She was fine. She would have told me if there was something prolapsing then. What was going on?

Donning gloves, I investigated for myself.

Tom was right. A hard, white mass was protruding; it looked like a prolapsing cervix made of concrete.

What in the world?

After the others arrived, we tried to determine what it could be. Tom suggested it was some calcified foreign object possibly left in after her cesarean. I’m inclined to agree.

Perhaps a tampon of some kind? Maybe a strip of gauze?
    --But what if it is her cervix? No... that doesn’t make sense.

Tom reached in and said it’s long, round, and the length of a finger. He tried to remove it but failed. Dennis also examined her. He also failed to dislodge it.

Apparently, the object is firmly attached to the left vaginal wall. They cannot remove it without causing her a great deal of pain and possible bleeding.

Admittedly, I’m at a loss for words. How do we help?

I’m concerned this will have a negative effect on her getting her fistula repaired in a few months. Please pray for her. This is just one more challenge in an already difficult journey.

We’ve started her on antibiotics for an infection that has developed. But tomorrow we refer her (once again) to Wau.

Pray for wisdom for the doctors and healing for her body. Perhaps she’ll somehow get her fistula repaired early. Perhaps.

Pray for her. Thanks.

To understand her background better please read here, here, here and here. Thanks.

Biyana.

Biyana has a vesico-vaginal fistula that desperately needs repair. For over a year, she has not been able to urinate on her own. Instead, a constant acrid stench leaks from her body and clings to her clothes.

She cannot escape the shame. It haunts her day and night. 

The fistula formed after several days of obstructed labor ended in a cesarean. A few days after her surgery, she was discharged from the hospital --grateful to be alive but damaged.

Remarkably, despite her condition, she conceived again several months later.

When I met her for the first time, she was just starting her third trimester. But I didn’t know that at the time.

Since her baby was transverse, I measured her belly and guessed her to be only about 5 to 6 months gestation. But I was wrong.

A month or so after that, she returned in labor with ruptured membranes and a hand presentation.
It was hard trying to determine the best course of treatment --fistulas and hand presentations were new for me.

But after trying everything I/we could, I finally insisted her family get her the cesarean she needed. And they took her to Wau.

I later learned that she got the cesarean but never had her fistula repaired; they didn’t have the money for both surgeries.

At the time I was shocked to hear her baby had survived since I had assumed he was preterm. But her family said all was well, so I rejoiced with them.

A few months went by and I ran into her family and inquired after them both. They explained that the baby only lived two days. He died before she was discharged from the hospital.

She’s not yet 20 years old and yet she has lost two babies, had two cesareans, and is haunted by the stench of her own urine.

I pray for her regularly. I think of her all the time. I try to imagine the depths of her shame and loss... but I confess, I can’t.

My mind just can’t... 

So when a friend informed me of volunteer surgeons coming to do fistula repairs in Wau, I jumped at the opportunity.

It took me some time to get a hold of Biyana, but when I found her she was very interested in getting help. As we spoke over the possibilities, she explained that her husband left her after her second surgery. She hasn’t seen him in months.

She is hopeful at the opportunity but I can tell she seems skeptical. Nevertheless, she asked me over and over again, “Do not forget about me. Please help me. Remember me.”

Honestly, how can I forget? I can’t get her out of my mind... or heart.

When I contacted the surgeons though to set it up, I was told the fistula campaign was pushed to next Spring. They have more training and preparation work to do before they can pull it together. But they hope to be ready by February or March, and will start the procedures then. They promised to let me know if and when.

I know that it is many months off, but I feel the need to start praying now. Please pray for her to not grow weary while waiting... and for God to bring others like her our way. I know they must be out there. May He bring many more who need this help. May they get it.

Update: Helpless

(If you haven't read the previous story yet, read it here first.)

After insisting Biyana go to Wau, her family took her home. At the time, I worried they might let her die, but the following morning, I learned she caught the first bus to Wau!    
    --Hope.  Blessed hope!

Later on, I heard through the grapevine that she had made it through surgery, but the baby had died. This didn’t come as a surprise as his precious hand looked swollen when she had left.

However, this afternoon, the story changed again. I got news that the baby lived!

Yep, you read that right! Biyana is alive (Woohoo!), and her son is in her arms! (Hallelujah!) Please pray for them both to recover quickly. And pray that her fistula is somehow fixed! Thanks.

However, I’m not sure what has happened to Abuol. Her husband kept trying to find a private vehicle to take her to Wau, but failed. By mid-morning, I got tired of his dilly-dallying and told him to get her on a bus -- and fast!

Then I explained she was developing a fever and her baby was showing signs of dying. Only then did he seem to take me seriously. I think he hadn’t fully grasped the urgency before then. 

(Midwife note: The baby’s heart rate had no baseline. It was 112, 152, 124, 140, 112, 156, etc. I’m thinking a possible sinusoidal pattern.)

But when he did, he moved. He took the medicines and walked her gingerly out of the clinic to the bus station. But she didn’t get far, before she fell to the ground.

Too weak to walk, we drove her to the bus in our vehicle. But I warned Aboul not to show that she was sick, or else the bus drivers might charge her too much for her seat. Then I turned to Lucus (her husband), cautioning him to get her the surgery at all costs. He nodded blankly, promising to send word as soon as he could.

I cannot stop thinking of her. I don’t know how she is or what has happened. I promise to give an update if I do. Please pray for them both. Thanks.

Helpless.

Last night just as I prepared to put the cap on the end of a good day (happy prenatals, beautiful breech birth, etc.) in walked a labor, then another... and then two others followed.

What? Four labors all at the same time?

The first to come in was a G2 in early labor. She lived close by and opted to go home and labor until she became active. I told Sarah that she should catch this one (since it should be simple) and I’d supervise. The woman’s name was Victoria.

Then Adeng showed up. Adeng was a G1 (first time mom) who had been here earlier in the day for a prenatal. I had diagnosed her with STDs and warned her not to go into labor until the medicines were finished. She nodded in comprehension, forgetting that women don’t get to choose when they start labor. However, once she got home, the contractions started.

Now, she was back on my prenatal bed --in labor with STDs.

As I counted contractions, there was no denying the fact that labor was on its way. The progress was slow and steady, but she was good about moving around. Her family watched her like a hawk, hovering around her as she walked. This was her first, so the pressure to have her get the childbirth confession was strong; they wanted to be in the room all the time.

Then Aboul showed up.

She announced her arrival by throwing herself on the clinic porch with melodramatic flair. The crowds that had gathered laughed at her, but she ignored them and lay there silently until addressed.

When I got around to her, she explained that her water had been leaking continually for over 3 days. She had no contractions but was haunted by a constant lower abdominal pain that had compelled her to come for help.

Honestly, the continually leaking water worried me, so I checked her out. Her chart indicated that she’s been here only once before. At that time, I couldn’t tell if she was carrying twins or a very large term baby. Either way, it/they were breech.

When I checked her this time, she was already 2-3 cm dilated with ruptured membranes. The tiny buttock presenting, made me think she was carrying twins. But if that were the case, one of the babies was dead. I could find only one heartbeat.

I was still trying to figure out what to do with her, when Biyana came in.

Biyana as many of you may recall was here a few weeks ago with a vesico-vaginal fistula at 5 months pregnant. At that time, I had tried to assess it but it was too painful, so I referred her to Wau. (Read her story here.)

But yesterday, when she came back, it wasn’t about her fistula; she was bleeding.

My heart started to sag with the strain.

When I examined her, some bleeding was visible, but she wasn’t in labor. I tried to do a speculum exam, but she hit the roof in pain. Calling for Tom, we decided she was having an inevitable premature birth, and decided to sedate her.

Once the drugs took effect, I was able to place the speculum with ease. What I saw though... took my breath away.

A pool of dark red blood obscured it at first, but then it moved! Five white fingers flexed and twitched in unison. I was looking at a hand!          -- Sh#*!

Both Tom and Sarah bent low to inspect it for themselves. Could it be true? Her baby’s hand had prolapsed!

Because of the pain she experienced with the digital and speculum exams, I worried how she’d handle a vaginal delivery in the first place. Now we had no choice; she was dilating.

We observed her for some time, but eventually induced her. Her husband kept insisting there was no money to take her to Wau, and that it would be better to make the child come out.

However, the oxytocin did nothing but cause her uterus to form a tight, painless ball. I couldn’t do digital exams to monitor progress; she wouldn’t allow it. This went on for several confusing hours. 

In that time, Sarah caught Victoria’s baby. It was a fun birth. But I'll let her write about it on her blog. I'm sure she will soon.

Victoria and her little girl.

Adeng also progressed but not as quickly as her family wanted, so they opted to take her home. They promised to bring her back once it was time to deliver, then whisked her away.     --Sigh. I didn’t argue.

And Aboul... well Aboul slept the night at the clinic. We didn’t want her to go home, but we didn’t want to induce labor either. She needs a cesarean not induction. After loading her with antibiotics, she slept and promised to call her husband in the morning.

By 10 pm, we stopped trying to induce Biyana because it wasn’t working. Her baby was still doing famously --his little heart ticked like a drum-- but there were no signs that she was dilating. So we agreed to try again in the morning. 

Exhausted, both Sarah and I wrapped up the clinic. Aboul was sleeping, Biyana and her husband were well, and Adeng had gone home to labor. Victoria was recovering with her baby girl at her breast. So, we bid them all good night and went to sleep.

By sun up, Victoria was discharged, Aboul was rested, and Biyana reported no more pain or contractions.

But what would be our plan of attack?

I consulted with Tom, and we decided on watchful waiting. I’d focus on the prenatals accumulating out front, and deal with Aboul and Biyana later in the day.

By noon, I had finished with the prenatals, and I decided to try and induce Biyana again. But after several hours of oxytocin, nothing happened. The problem was, I couldn’t tell if she was dilating.

What happens if she cannot dilate? What then?

Finally, I bit the bullet and did a vaginal exam. It caused her tremendous pain, but I was finally able to get some answers.

She was still only 2-3 cm (no progress despite induction). Also, her baby’s entire right arm was prolapsed into her vaginal vault.

Yes. You read that right. A prolapsed arm that wiggled.

Despite my better judgment, I tried to replace the arm back through the cervix, but Biyana screamed and writhed in pain. Unable to watch her suffer anymore, I stopped.

What more could be done? We were out of options, so I informed her husband she HAD to go to Wau.

The baby was transverse. The cervix was not dilating. She needed surgery. She also needed her fistula fixed. Only after I explained the situation in detail for the third time, did he move. I repeated over and over again. “Your wife will die without surgery.” “She needs a cesarean or she will not live.” “Take her to Wau if you want her to live.”

Could I have been more clear?

I don’t mean to insinuate that he was calloused or dull. He is a husband that cares and is moved with love and compassion. He wanted to take her to Wau, but he kept insisting there was no money.

The look he gave me as he asked me to try again, will haunt me for the rest of my life. 

I can no longer muster hope.        

Finally accepting to go to Wau, her husband asked me to write an official referral for the doctors there. But as I was writing up the referral, my translator came running to get me.

“Come quick. The hand is coming out of her vagina,” he sputtered. 
“I know,” I spoke slowly, “There is nothing I can do. Tell them to go to Wau.”
“No. You don’t understand, Akuac, the HAND is out!” he insisted.
Frustrated and spent, I raised my voice, “No,” I hissed, “You are not listening. I have told them, there is nothing I can do. The baby is not coming out. It is only the hand. Go tell them they must find a way to get to Wau quickly.”

Turning back to the paperwork, I knew I had spoken too harsh, and I instantly felt bad. What did they want of me? Can I turn this child? Can I make him come out? Can I heal her wounds? Can I stop this pain?

I’m helpless -- heartbroken and helpless.

I have no ambulance (the government of Southern Sudan won’t give us the clearance papers). But even if I did, there is NO fuel in Sudan. Something has interrupted the fuel imports and the gas stations are empty.

How Biyana’s husband is going to find a bus, afford the exorbitant price for the seats..... and then afford the TWO surgeries she’ll need, I cannot begin to imagine. 

I knew in coming here, I’d see such things. I knew I’d experience these kinds of obstacles, but I didn’t know it would hurt so much. Overwhelmed and hopeless, I’m ready to run away. I’m ready to hide.

Lord, hide me in the shadow of Your wings! Hide me Lord from the pain and suffering I see. My heart can’t take any more.

My heart is not used to such suffering and pain. It’s leaking dry. Soon it will be a hollow heart-shaped shadow. What will I have to offer anyone then?

Oh, Lord. I’m tired. Please help me hope again. Please do a miracle for Biyana.

Pray.  Pray as He leads you.               --I’m out of words.

P.S. Some of you might be wondering... but what of Aboul. Well, she is waiting for her husband to come. She’s stable. Her water is still ruptured, but so far no infection has set in, and her labor has still not begun. We are waiting. She, too, needs to go to Wau. She needs a cesarean. Pray she can get it.

And what about Adeng?  Well, I suspect her family had her deliver at home. She never returned.

The Stench of Ignorance & Neglect.

Her name is Biyana, and she’s 18. Her first child was born naturally, but succumbed to the dreaded ‘one-day-diarrhea’ and died at a year and a half old.

Her second pregnancy brought on four days of excruciating labor pains which ended in a cesarean.     -- The baby didn’t make it.

The scar of that day, marked her body with a keloid an inch and a half wide -- from pelvis to umbilicus. She had a classical incision; and when I asked her why she had to have surgery, she couldn’t answer me.

-- “Didn’t you ask the doctors what happened?” I prodded. 
-- “No.”
-- “Didn’t they explain?”
-- “No,” she repeated with the twisted sucking sound made my Dinkas to indicated a ‘no’. 
-- “I see. So, when did this happen?”
-- “Last July.” 

I continued on with the rest of the prenatal as if such an obstetrical history was normal.
    -- Which, here is.

We discussed LMPs (last menstrual period) and fundal heights (how large her belly was growing for her dates), and I re-assured her that this baby was doing fine. She seemed excited and happy to be pregnant again, but something was off.

Although obviously clean, her clothes smelled strongly of urine. It was overwhelming, and attracting flies.

I waited until the prenatal was almost over before I asked her about it.
-- “Biyana. Did you shower today?”
-- “No. I didn’t.”
-- “Well... Right now, I can smell a lot of urine on your clothes. Do you have urine leaking from your vagina, by any chance?”

Looking at me in muted surprise, she clicked her tongue in response. “Yes.” Click.
-- “Really? Does it come out only when you carry heavy things, or is it all the time?”
-- “All the time,” she said flatly. The lack of emotion in her voice was frightening. 
-- “How long has that been happening?” I enquired.
-- “Since July. It started after my surgery.”

I started counting back months in my head. If it’s May now, that would mean... 10 months!
-- “Really?” I said calmly, trying to keep the desperation out of my voice, “You’ve had urine leaking from your vagina for 10 months?”

She must have thought me stupid for asking such a simple questions over and over again. But she answered me each time I asked.
-- “Yes,” she explained, “In fact, I haven’t urinated since the surgery.”

When my translator gave me this information, I made him repeat himself several times. I couldn’t be hearing what I was hearing. I just couldn’t!
-- “Wh... wha... what do you mean?” I stuttered, “Are you saying you have not urinated at all in 10 months?”
-- “Yes. It just comes out of me all by itself.”

Knowing full well I had some kind of vesico-vaginal fistula on my hands, I called Sarah in to watch and learn. I was fairly confident she hadn’t seen one before.

(For those who don’t know a vesico-vaginal fistula (VVF) is when the wall between the bladder and the vagina is compromised, allowing urine to pass through it unimpeded. If you are interested in learning more about it click here and here.)

Pictures taken from this website.

Then I asked Bisaya if she’d allow me to do a vaginal exam to see if I could identify the size of her hole. She agreed, but seemed a bit confused on the purpose.
    -- Did she think her incontinence was normal? I couldn’t tell.

But in the end, the exam caused more questions than it answered.

Instead of finding a small tear or thinning anterior wall, I encountered a large mass of scar tissue about 6 cm long and 3 cm wide. She writhed in pain as I attempted to feel around it.

Fortunately, I had my trusty translator James by my side and he was able to calm her down and explain what was happening and why. Once she relaxed, I was able to assess it better; but honestly, it had no idea what I was looking for.     --It was a mess in there.

Frankly, from the amount of pain my exam caused her, I’m amazed she even got pregnant. When I asked her if it was just as painful during sex, she clicked her tongue loudly in confirmation.

Wow.

We talked in depth about going to Wau for a GYN consult, the possibilities of a repair, and whether or not another cesarean might be indicated.

Right now, she is five month pregnant. However, if her pain is that intense during a vaginal exam, how much worse will it be for the birth?      --Lord! How can we help this girl?

She promised to discuss things with her family, but I’m not sure whether or not she’ll go to Wau. She did sound hopeful though. I think, I’m the first person to tell her there might be a solution to this curse. I think she had given up hoping for a way out of the smell of her stigma.

Oh, the stench of ignorance! Imagine not urinating for 10 months!        -- Just imagine.

Imagine not knowing there was a way to fix it.
      --It breaks my heart.

Please pray for Biyana. I will hopefully be seeing her in the coming months. Pray that one day, we’ll get a surgeon out here to repair fistulas in this community. Thanks.