Heads or Tails?

Mondays always seem to bring the strangest cases, and this week was no exception. When I arrived at the clinic a G2 was in active labor. She kept insisting that she wasn’t sure if it was labor or not though.

“Perhaps it’s malaria,” she said then knelt as if to push her baby out.
After a quick (guilty) glance at the crowd waiting for prenatals, I chuckled to myself and set up the room for her birth.

When I did a vaginal exam, she was fully at a +2 station with her membranes intact. I told her that it was time to deliver and encouraged her to push when she was ready.

She wasn’t.

Instead we waited expectantly until I realized she needed some space and sent her for a walk. Meanwhile I finished taking vitals on my prenatal ladies and did my health teaching.

Thirty-odd preggos listened politely as I rattled on about the importance of monthly check-ups and delivering at the clinic. It’s a message many of them have heard before; but I don’t care. It’s a matter of life and death for some of them, so I don’t mind repeating myself over and over.

Half-way through however, my labor called me. I arrived to see her pushing well, and soon after she delivered a beautiful baby boy.

Once the dust settled, I cleaned her up and moved her to our observation room, promising to check on her regularly.



Turning my attention back to the preggos, the morning flew by. I was able to see the majority of them before lunch (with Margaret’s help of course!). But those that remained had strange complaints, so I gulped down my soup and hurried back.

I didn’t want them to wait too long. I never do.

My first patient after lunch was one of those strange complaints though. She was reporting leaking water for 2 days. Normally this is not something that I would ignore for so long, but I didn’t have a choice. Malaria trumps leaking water in my book and I’d seen almost a steady stream of malaria cases all morning.

Plus, there is no difference in Dinka for the words ‘water’ or ‘mucus’ in the vagina. In the past I’ve rushed a woman inside with this complaint thinking she had premature rupture of membranes only to learn she has a little extra discharge. Nothing more.

So when I finally got around to assessing her, I spotted the contractions with ease. They were every 10 minutes, but they were regular.         --Not good.

Her fundal height was only 28 cm and we had assessed her to be only 33 weeks pregnant. Plus her baby felt like it was breech by palpation and the fetal heart-tones were high in the abdomen.

This was too soon; and I told her so.

Did I have a preterm breech birth on my hands or a simple case of malaria-labor? I couldn’t tell.

When I reached inside during her vaginal exam, I was perplexed to feel itsy-bitsy parts.    
        --Could that be a foot?

As I explored a bit I discovered a soft smoochy bag which told me her baby was definitely male, and I smiled.        
        --Yep. This baby was footling breech. And he was all boy!

But since she was only 4 cm dilated I didn’t mess around in there for very long. I told her that she was most definitely in labor and that the baby was coming out breech.

She took the information in stride and decided to walk around to augment her contractions a bit. I told her about nipple stimulation and she promised to do it. Then I turned my attention to the rest of the girls.

I finished them within an hour then went to find her again. She had spent the time exercising just as I asked. And as a result, her labor was well underway with strong contractions every 2 minutes.

Plus she was showing me all the signs of transition. She was sweating profusely, grunting and baring down with contractions, and starting to tremble from the pain.

But it had only been an hour. She couldn’t be fully already. Could she?

So I discharged my first labor, sending them off with prayers and then waited on my second one.

But 15 minutes later I was convinced she was close and did another vaginal exam to be sure.

Lo and behold she was fully! And while I was in there, I couldn’t resist tickling his toes. They were so tiny.

I called for Margaret and told her what we were up against, and she helped to prep the room. Once we were ready, we suggested she start pushing.

Again I did the same breech guarding maneuver I was taught last Spring and it worked like a charm. The foot and then buttock pivoted on my hands, delivering with ease. Then the rest of his body came out without a hitch. It was seamless and beautiful!

When I wiped him down and suctioned his mouth, I was relieved to see that he was term --just small for gestation (SGA).

He weighed 2.4 kg and had the sweetest dimples!

The rest of the day, he and his mama bonded beautifully as her family came to lavish love on their newest member.

Before I discharged them they informed me that his name would be ‘Doctor’ in my honor. (Yes, they think I’m a doctor here.) I laughed and tried to convince them that Nathaniel would be a better choice.

But they couldn’t pronounce it and insisted ‘Doctor’ it would be!

At the end of this perfect day, I looked back in my notes and learned that this breech birth was the 5th one I’ve done this year and my 2nd footling.

I share this only to point out that this breech was by far the most rewarding. The fear I had during my first breech was burdensome and vexing. Even though it ended well, it didn’t go as smoothly as I would have hoped.

However, this birth was different in a good way. This birth was delightfully routine. I honestly didn’t think that a breech birth could ever feel routine. But I confess it’s nice that it does.

Have I told you all lately... I LOVE being a midwife!
      --Cuz I do! I really do.

Thank you so much for praying for these women to have safe deliveries. Please pray for me to grow into a culturally sensitive midwife with the skills that will bless them the most. Thanks.

Easy as 1 - 2 - 3!

 My alarm sounded, pulling me from a fuzzy dream of distant lands. It was time to greet the day, but I wasn’t ready. Turning in my bed, I hit the snooze once, then twice trying to return to my dream.

Knock-knock-knock.

Someone was at my door. Startled but awake, I rushed to answer it.

I was greeted by an even sleepier Margaret ready to brief me on a labor that had just arrived. My labor-watch shift was starting.        

Apparently a not-too-active G2 had just arrived; I had time for coffee.

I dressed in the dark, blindly finding scrubs that matched then heated water for coffee. I figured even if she wasn’t active now, G2’s (Aka: Gravida 2 or woman expecting her second child) are unpredictable. I needed to be ready.

The blue light of dawn was just starting to roll across the sky, but the clinic was already buzzing.       

“It’s gonna be a busy one,” I thought to myself as I pushed pass the patients sleeping on the clinic front porch. They too were rubbing sleep from their eyes.

Settling into the birth room, I got things arranged and started sipping my coffee. I was just about to go look for my patient when I heard urgent voices and a rustling at my door.

Turning I found a young girl in orange being hurried along by three others. They dropped her at my feet, then started talking over each other.

Moaning and pushing with determination and grit, I recognized her as the G1 (aka: first time mom) that had come each morning for the last two days convinced it was time.     -- It wasn’t.



However now it really was! Not only was she in labor but she was close.                   --So close.

Long story short she delivered a few minutes later. A boy!

I had them cleaned up and resting by the time most of my prenatal ladies had arrived. But it had been well over an hour and I had yet to meet my G2. She was off somewhere in the wings.

I tracked her down near the mango tree.

Her contractions looked effective and thoroughly painful, but she was progressing slowly. So I got her settled and prayed for her, promising to check on her regularly throughout the morning.

Fortunately, there were only 13 prenatals to do (instead of the regular 30 +).

By 11:30 am I’d already seen the majority of them, but one late-comer was now saying she too was in labor. As I was assessing her outside, my G2 called frantically for help.

Running, I found her vomiting bile (a good sign of progress) and ready to push. She made big eyes at me indicating it was time. Whoohoo!



A few minutes and several high-pitched sound effects later, out popped baby boy number two!

His mouth opened wide for a breath... then never closed! Wailing and pouting in protest as I dried him off. I couldn’t help but laugh. His lips were huge and gloriously kissable.

I nick-named him Lips on the spot. (His is the mugshot at the top of this post!)

His birth was beautiful and celebrated by all her friends. Together we laughed at his comical mouth and I clicked off a few pictures of his kissable lips!

It was certainly a wonderful day!    

Once the dust settled, I learned that the woman outside WAS in fact in labor and she was ‘mine if I wanted her’.

Smiling at the thought of another baby I told Margaret I’d take her off her hands; then I had lunch. 

Once back at the clinic, I learned that my new labor was a G3 (aka: expecting her third baby) with a sad obstetrical history. Flipping through her chart I saw my hand writing and I instantly remembered her.

Her first baby died during a traumatic three-day birth. She insisted she PUSHED for 3 days! Her second birth was also difficult and left the child paralyzed on his left side. I’m not sure if his paralysis is from birth trauma or not but I suspected so. 

“What if her pelvis is deformed?” I wondered.

I decided to evaluate her myself and called her in.

Sweating and grunting, she moved slowly but silently toward the prenatal bed. Instantly I knew we were in the final stretch and hurried to ready the room.

Within minutes she was desperately trying NOT to push but was obviously READY.



She opted for the kneeling position... and yep, you guessed it. A few minutes later out rolled a precious little boy!

He was a tight squeeze --his shoulders and hips snagged on the way out-- but in the end all went according to plan.                                --Thank You Jesus!

Three beautiful boys in 8 hours!

Once again I’m awed by the strength of these women! They make giving birth look as easy as 1 - 2 - 3!

Culture side note:
When one of the husband’s arrived to meet his son, he asked me if his wife “confessed”. Smirking to myself knowingly, I lied and told him that I asked his wife during the pushing stage if she had slept around.

--“She didn’t confess so the baby must be yours,” I lied. “Plus just look at that head of his,” I said pointing at the funnel-shaped alien's neonate’s head, “It looks just like yours!”

Reassured, he smiled but refused to believe that his boy’s misshaped noggin looked anything like his. Nevertheless we laughed.

Yes. Perhaps one day if the fancy suits me I’ll start drilling my labors with questions of faithfulness while pushing. Then and only then, will I be a real Sudanese midwife!


Ha!

Later on my translator told me that TBAs (Traditional Birth Attendants) in the villages have a ‘code of silence’ when it comes to this childbirth confessional thing.

And apparently some husbands are on to them.

If the husband suspects the TBA is hiding anything from him, he can take her to court and make her swear by oath his wife's faithfulness!

Yep. I can see it now.

“I, Stephanie Williams, so solemnly swear that Mr. Dinka Dude’s wife did not have an affair. She gave birth to his child because during the pushing stages of birth, she did not confess to being unfaithful.”

Where do I sign up?

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.