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.

Placenta Previa?

Two days ago, Adhieu started having contractions in her sleep. She thought it was unusual since she was only 6 months along, but there was nothing she could do about it. She lived too far away to get immediate help. She’d have to wait until light.

But as the sun peeked up the next morning, the bleeding started. Lots and lots of bleeding. She bled heavily until noon.

She said her baby kicked like mad during that time, but then suddenly stopped.

That was a day ago.

She knew something was wrong, but it took time to get the family involved. Someone needed to bring her to town. She couldn’t go alone. Who would come?

Eventually it was decided her father would accompany her.

By the time she arrived, her clothes and legs were crusted in dirt-stained blood. A large flap of membranes hung from her introitus but she was no longer in labor.
    --Was this placenta previa?

(For those who don’t know, placenta previa is when the placenta presents first, causing painless bleeding. It can be life threatening for both mother and child, depending on the blood loss.)

There were no heart tones to be found. No movement. Nothing. Her baby was dead.
        --Could she have had an abruption?

(For those who don’t know, an abruption is when the placenta detaches from the uterine wall prematurely. This is very painful and presents with bright bleeding. An abruption can be complete or partial. It is almost always life threatening for the baby unless delivered quickly.)

She wasn’t surprised when I told her baby was dead. And she didn’t cry, either. Instead she looked unblinkingly off in the distance, hardening her jaw. Resolved.

A quick speculum exam revealed a 2-inch chunck of placenta plugging up her cervix like a cork. Thick membranes dangled down the canal, but the bleeding had stopped. She was 2 cm dilated and had no contractions.

Ideally, she would have gone to Wau for a c-section, but I intuitively knew this was NOT an option.

Had you asked me how I knew this, I would have been hard pressed to give you an answer. And yet when Tom asked me to send them anyway, I gawffed, “That’s not going to happen. They don’t have the means.”

He insisted on it though, expounding on the potential danger of her bleeding to death if it was a previa, etc.
-- “If contractions start, her cervix can open and she can hemorrhage... maternal mortality.... too dangerous... must transport....” He lectured pedantically. He wanted us to warn them of the risk of her dying. Just in case.

I listened to his words --I even agreed with them-- but I knew they’d never go.

Her clothes were too worn. Her body was too lean. And neither of them wore shoes. Plus her only companion was a frail father with clouded pupils and trembling hands.

But the biggest clue was the fact it took her a day and a half to get to us.

No one with any sort of means waits a day and a half to seek treatment with this much blood loss. No one. 

I respected Tom’s wishes though and talked to them about transporting. The discussion was disheartening short.

Conclusion: They had no money. His goats were back in Thiet. It would take time to arrange their sale --perhaps two days.

I listened and nodded, then induced her.

I had peace about this induction. Her bleeding was almost nil, and she was a multigravida. If the medicines worked... she’d deliver quickly and this would all be over.

Then no goats would need to be sold.

By God’s grace, the induction was effective and she delivered 2 hours later with very minimal bleeding.

Her baby weighed just 800 grams, but he was perfectly formed. Tiny ears. Delicate fingers. Two thin eyebrows neatly knit atop unseeing eyes.

He never opened his eyes to this world... but I believe he’s seeing something much more beautiful now!

Please pray for Adhieu as she grieves this loss. It was not her first. Pray that it is her last. Thanks.

Stillness.

Caution: This story is not for everyone. It’s about a stillbirth. I know that such stories are hard to read at times, however these are the realities of my work here.

It was the monotonous way in which she spoke that told me something was wrong. There was no urgency or fear in her voice. There was no hope.

“My baby is not moving,” she announced to my translator flatly.

This I’ve heard before. Most often it’s nothing but an overly anxious mother in need of a little reassurance. So I didn’t react.

“Okay... so she’s worried about her baby, right?” I asked, trying to determine if her ‘not moving baby’ qualified her to jump to the front of the line. She had arrived late; there were 25 woman ahead of her. I didn’t want to play favorites if all she needed was reassurance.

“Is there anything else wrong?” I asked again, wanting to hear her voice as much as know the answer. 

She answered in a slow cadence that unnerved me: “I was treated for malaria 4 days ago in the market. I think the medicines they gave me hurt my baby.”

She didn’t bother to look at me while she spoke. Instead she gazed off in the distance, trying to separate herself from something. What could it be?

It’s as if she was somewhere else and her words were spoken by another. Strange.
    --What wasn’t she saying?

Although nothing she’d said up to this point would have normally given her priority in line, I asked her to get up from the floor and follow me inside.

My translator thought I was being silly. He didn’t say so, but his exasperation said it all. He seemed irritated that she was jumping the line.

I was breaking my own rules, but I didn’t care. My internal alarm was blaring. Something was wrong.

Once inside, I asked her to lie down on the bed and tell me her story from the beginning. While she spoke, I measured her fundal height, then searched and searched for heart tones.

In the same monotone voice as before, she explained that 4 days earlier she had had a high fever. She’d gone to the market pharmacy and was treated for malaria. They gave her an injection and then pills and sent her home.

Her belly was small (28 cm) and as hard as a rock.
    --Was she in labor? Preterm?

She continued on with her story.
Two days later, she thought something was wrong so she went to the government hospital where she learned that her baby was dead. They gave her an IV drip and kept her for observation. But the next morning they told her she needed a cesarean and referred her to Wau.

She didn’t go.

Instead she went home, and later that night her labor started.

I interrupted her story at this point to confirm that I too believed her baby was dead. I could feel no movements and find no heartbeat.

She acknowledge my words with a slight nod as her eyes hardened with resolve. She knew it. She knew it long before she came for help. Her baby was dead.

I asked her about the contractions and was told that they were much stronger now. As I palpated them, I was surprised at their strength. But she didn’t seem to notice them at all.

Turning to my translator I whispered, “Please tell her I’d like to do a vaginal exam, then set up the room. I think she might be close.”

I quickly confirmed my suspicions. She was fully with an intact membrane bulging at a +2 station.

I explained that her baby was coming soon, and asked if she wanted anyone in the room with her. She asked for her friend, and a slender woman with a furrowed brow came in. She sat uncomfortably on a stool beside the bed and fidgeted with her nails.

Once everything was in place, she started pushing. Immediately the membranes bulged outwardly. Another push and they ruptured, spilling a burnt-brick fluid on the bed.

Two more pushes and he was born.

His tiny hands lay limp against his chest as I moved him about. His cord, swollen and red, looked very out of place. And his skin, though tanned, was starting to peel, confirming my suspicions.

He’d died several days before.

After cutting the cord, I asked if she wanted to see him. She again just nodded and I held his tiny frame up for her to inspect. She looked with interest but didn’t reach for him.

Then closing her eyes, she turned away --no longer able to look upon his stillness.

She spent the rest of the morning recovering from the birth with his tightly-wrapped body cuddled in her arms. Our pastors prayed for her and counseled her, then she slept some more.

She slept but didn’t cry. I discharged her later that day.

Please pray for them. Grief is always heavier than one expects. Pray that she would turn to Jesus and let Him lift this burden for her. Thanks.

Third Trimester Malaria

On Sunday, Aguak arrived in a lot of pain. Even though she complained of everything BUT malaria, I knew she had it.

She was burning up. She was writhing in pain. She was pregnant.

I admitted her and started her on IV medications because she couldn’t keep anything down. At one point she said she had only been sick a day at most, but her symptoms seemed too severe.

Malaria will cause contractions, and she kept insisting she was in labor. I assured her that once her fever came down and the medicines took effect, her ‘labor’ would stop.

While the quinine slowly dripped into her system, I assessed her baby. This was her first pregnancy, and she was well into her third trimester. Perhaps she WAS in labor.

As I measured her belly and listened for the heartbeat, I was disturbed by the silence. Even though she insisted in a half-dazed malarial rant that the baby was alive since it was moving, I didn’t believe her.

I could feel no movements. I could hear no beating heart.

That was two days ago.

Last night as her medicines had finally worked their magic, she was well enough to understand her child was dead. She took it bravely but it was hard news nonetheless.

Normally, I’d be willing to induce her. But she is still so weak. I’m worried she won’t be able to handle the induction.

After informing the family of the death of the child and potential dangers it poses --the baby decomposing and causing her to get septic or her developing disseminated intravascular coagulation-- I asked them to take her to Wau.

At first I was hopeful. They have the money and even took her home this morning. But then they came back again this evening.

Apparently, despite all their searching they were not able to find a ride to Wau. They seem to be unwilling to go on the bus (I can’t figure out why) and private transportation is too expensive.

Perhaps they will go tomorrow. Please pray that they do.

Pray for Aguak and her child. May mercy, grace, love and peace surround them all during this difficult time. Thanks.

Four in twenty-four!

(Warning: this is a long story. You might want to get a cup of tea before starting. Oh, and it gets a bit complicated in the middle, feel free to take notes!)

To tell this story right, I have to explain that the day started at midnight with a knock on my door.
-- “Akuac, there is a woman in labor. She says the contractions started at 8pm, but water has come out.”

Gabriel, my translator for the night, looked as tired as I felt, but he didn’t complain. We marched off together toward the clinic. On the way, it occurred to me that Sarah (short-term missionary nurse) might want in on this, too. So, I sent Gabriel to wake her up also.

Sarah came quickly, and together we checked Adong in. Since she was in early labor, I decided to not do a vaginal exam and just let her labor through the night. This was her first baby and I wanted her to rest up for the hard work ahead.

Even though birth wasn’t imminent, Sarah wanted to do the hourly checks with me, explaining that she wanted to see what an unmedicated labor looked like; all her experience with labor has been with epidurals back in the States.

Ignoring the fact we’d be exhausted by morning, we got up hourly to monitor her progress.

I must confess, I enjoy night labors. The sleepy silence of darkness muffles the otherwise harsh tones of birth -- especially, here in Sudan.  And this night didn’t disappoint. It brought rain.

Dancing on and off all night, the rains chased the bugs away and inspired the frogs to sing. Plus, the wet drizzly curtain muted voices and footsteps alike, replacing them with an orchestra of sounds.

Drip-drip-drip. Cro-AK. Buzzz. Whimper. Ping-ping-drip-pang. CRO-AK. Bizzzzzzzz. Groan.

By first light, Adong wanted to push but didn’t seem ready. So, I did a vaginal exam. She was a good 5 cms and handling things well; so, I sent her walking instead. She happily complied.

I then sent Sarah for a nap --and tried to get one myself-- but it was hard. By 8 am, God woke me with a start. I grab some strong coffee and headed off to devotions.

However, within minutes I was called out of devotions for another labor. Another first time mom, Awang was looking active. She explained that her labor started the night before, but the rains had kept her from coming. 

Fortunately, she was already 8 cm dilated, so I sent her to walk around the compound as well. It was fun looking off the back porch and seeing two waddling ducks turning circles and squatting. It made me smile.

Guessing we’d have a few hours, I jumped right in to doing prenatals. However, one of my prenatal ladies had a serious problem. I couldn’t find her baby’s heartbeat. Even though, I searched every inch of her abdomen in a desperate hope, I never found it.

Eventually, I asked:
-- Can you feel your baby moving?
-- No. I haven’t felt him move in a month.
-- From the size of your belly, you are seven moons now. Is that right?
-- Yes. Seven moons.
-- Have you had any bleeding recently?
-- Oh. Yes. I’ve had bleeding for two months straight...

Alarms going off in my head, I poked and prodded some more. Was this another hydatidiform mole? (Unlikely. Her belly would feel different. Harder.) Fibroids or poly-hydraminos? (Neither made sense with the facts, but I wanted to rule them out, nevertheless.)

Eventually, I was clear. I had an intrauterine fetal demise (IUFD) on my hands. Her baby’s head was clearly palpable --as were his limbs-- but I couldn’t find a heartbeat. I couldn’t even hear her placenta.

Again, wishing for an ultrasound machine, I explained that I thought her baby was dead, and that she’d need to be induced soon before she became septic. It took a few minutes for my words to sink in. But even then, I’m not sure they fully did.

In the end, she refused to believe me and went home. I encouraged her to go to Wau for an ultrasound, warned her of the risks, and encouraged her to come back if she changed her mind.

It’s the first time a woman has refused to believe me about something so important; it was hard watching her go without help. But I didn’t get to dwell on it for long because Adong started pushing.

Adong with her family gathered around.

Rushing in to the prenatal room, Adong explained that the head was coming out. We scrambled to set up the room while she pushed. A few minutes later, a handsome vernix coated boy emerged! What a sight!

However, as I was waiting for her placenta, one of our health workers barged in saying that Aweng was pushing in the observation room now, too.

--“Come quick, you can see the head!”
-- “I cannot deliver the baby over there (other sick patients in the room, no equipment, lots of looky-lous), make her come to the wound care room to deliver.”

He ran off to do as I asked, and I looked over at Sarah and shrugged. Sarah had never delivered a baby before, I couldn’t send her. And plus, she had only seen two births so far here at the clinic. I would be unreasonable to ask her to do it.

The now breathless health worker was back in less than a minute explaining she was refusing to come. So I de-gloved and went to get her, leaving Sarah in charge of the placenta.

Once I got to the observation room, I found 10 people gathered at the door, Aweng lying on her back in the lithotomy position, pushing with all her strength. The sick man in the bed next to her watched unashamedly in interest.

-- “Aweng, you cannot deliver here. Please get up after your next contraction and come with us.”
-- “No. I cannot walk,” she insisted while pushing again. Fortunately, she was a first time mom so I knew that she could in fact move; the baby would not fall out as she walked.
-- “Yes, you can. I will help you,” I explained while forcing her to her feet.

Aweng with her precious boy by her side.

Although confused, she complied and together we walked hand in hand to the ‘second birthing room’.

-- “Sarah,” I called across the wall once I got there, “has the placenta come out yet?”
-- “Nope. Still waiting.”
-- “Okay. You take that, and I’ll try to get set up here.”

Aweng, determined and gutsy, pushed like a pro and in just a few minutes delivered a gorgeous little boy! He came out about the same time as Adong’s placenta in the other room.

However, after Aweng’s birth she wouldn’t stop bleeding. After loosing well over 500 ccs, I decided to do a cherry pop and help the placenta out with a little traction. It was delivered completely but the bleeding persisted.

When both oxytocin and fundal massage didn’t work, I decided to do an internal manual exploration. I hate doing them, but I think she hated having it done even more. However, once completed, her bleeding stopped nicely.

Once the dust settled, Sarah and I took lunch and then I finished up the remaining prenatals. I remember Sarah saying, “I just hope no other labors come in tonight; I’m tired.”

Nodding in exhausted agreement, I laughed and told her, “I should not have kept us both up all night. Serves me right that I’m this tired. Next time, I’ll know better.”

However, after lunch a new labor came in. I taught Sarah how to do a vaginal exam and suggested she be the main midwife.

I wanted Sarah to have an easy birth for her first. And since Mary was expecting her forth, I assumed all would go rather quickly. But I was wrong.

Sarah walking with Mary.

I sat at the clinic to supervise, trying not to get in Sarah’s way. Mary’s contractions were originally every 2 minutes but with time they slowed down. Sarah was starting to fade; we both were. That’s when the fourth labor arrived.

When I saw it was another first time mom, I smiled wryly at the cruelty of the situation. Would that mean we’d be up all night again?

Her name was Yar, and she was perhaps 18 years old.

Fortunately, she was already 7 cm dilated with solid contractions. Her friend, Debora, had delivered with me earlier this year and had encouraged her to come in. Together they labored on the floor in the other room while Sarah and I worked to help Mary’s baby descend.

After 4 hours of doing walking and nipple stimulation without results, I decided to rupture Mary’s membranes. After another hour Mary was fully but the head wasn’t coming down. I decided to take over for Sarah and do a vacuum extraction. It worked, but progress was still tediously slow.

In the midst of using the vacuum for the third time, my hand covered in blood, and Mary looking completely spent, Yar insisted on pushing, too.                  -- What? Again??

I was too tired to think straight. So, I sent my translator to get Dr. Tom for help. I couldn’t put Sarah in charge of either birth at the moment.         -- What a gong show!

Mary with her boy after the birth.

Mary, pushed while I pulled with the vacuum. Santino her husband stood by her side sweating bullets. Meanwhile, Yar and her friend Debora kept calling for me over the wall. “Akac, ba ten! Meth benbe! (Akac, come. Baby coming!)

If I hadn’t been so tired, I would have laughed at the deja vu scenario. Hadn’t we seen this already today? Didn’t I have two labors push and deliver within minutes of each other earlier this morning? It felt like I was trapped in some kind of birthing vortex and I was going under.

Tom arrived in time to help Yar calm down, and see that Mary had finally delivered her child --A boy!

The shape of her son’s head immediately explained the delay. He had the funnel shaped head that you often see in first time moms. Apparently, this little guy had quite the squeeze on the way out! 

Laughing in relief, I wiped him down and went to put him on Mary’s abdomen. But when I looked at her, I realized she had fainted! What? I tried to wake her, but she didn’t respond to words or pain.

-- “Tom!” I yelled, “My patient is acting strange. She looks semi-conscious.”

He was there in a flash, trying to wake her and assess the situation. He worried it might be malaria still (despite having treated her successfully last week for it), and started her on IV quinine. Within a few minutes, she woke up and delivered her placenta.

Meanwhile, I went to check on Yar who was still pushing. I wanted Sarah to catch at least one of these births. 

-- “Sarah, Yar will deliver soon. Do you still want to catch a baby today?”
-- “I do.”
-- “Then get over here and glove up. This will be your birth now.”

She hustled over with gloves and I walked her though the basic steps of delivering. But honestly, I think I was a bit of a basket case by then. I don’t even know what I told her, I think I said, “Just call when you need me. I’ll be right back.” and left the room. (What a terrible supervisor! I know! Right?!)

I just needed a minute to make sure Mary wasn’t bleeding too much. Fortunately, I found her sitting up and smiling at her dimpled boy. We laughed together and praised God for helping her through it all, and she started breastfeeding.

But then I heard Sarah calling, “Stee-pphhannnn--iieeee!!!” and I went running. Yar’s baby was out, and Sarah was wiping his mocha brown body down with a towel --another boy!

Yar with her son after the birth.

The rest of the night consisted of cleaning up and helping to control bleeding and establish breastfeeding. Both Mary and Yar, stayed the night and I discharged them the next morning.

What a day!

In the end, it was a first in a lot of ways. It was Sarah’s first time seeing a woman labor naturally; it was my first time supervising. It was Sarah’s first time catching a baby, and it was my first time catching three babies in a day!

So praise God for firsts -- First time moms and first time midwives! 

Oh, Sudan! Never a dull moment.

Three Witnesses.

(Caution: This story is about a miscarriage, some people might find it offensive. I hope not, but it's possible.)

The annoying chirp-chirp of the ambulance wailed as it came through the gate, but I barely noticed. It’s never for me. The cases brought by ambulance are always seen by Dennis, but this time I was called.

I was told a woman claiming she was five months pregnant, started bleeding this morning. Grabbing my watch and pen, I didn’t hurry, but I didn’t lolly-gag either. The number of times, I’ve been called for an “Emergency” because a woman was miscarrying, only to find out she wasn’t pregnant but menstruating... is too numerous to count. Honestly, I’ve become skeptical.

She was sure she was five months pregnant. Absolutely sure! But getting her information was challenging, since she was grunting in wild pain. She looked like she was in labor.

Duh! That’s why they called the midwife! (sarcasm implied)

The thing was: She had no belly! Not even a bump! Nothing.

All I could see was a thick abdominal scar where her last baby was taken. It was huge. It looked like they ripped her open and left it to heal on its own. It wasn’t the discrete bikini cut that you often see. This was a classical incision extending all the way across her abdomen.

I asked her about it.

In so much pain... and while pushing no less!.... she explained that she was here in January. At that time, I examined her and said there was no heartbeat (that’s 2 months ago!). We had discussed the possibility of her being only two months pregnant, since she didn’t have a belly then either.

Again, I asked about the scar.

She explained that this was her fifth pregnancy. The first two were alive, one ended badly in an emergency c-section, and her last was a miscarriage at two months. She was convinced she was five months pregnant.

How could I argue?

She was flaying around in so much pain, I honestly didn’t know what to think.

Was she just being hysterical? No. That didn’t fit. She looked like she was in labor.

If she was delivering prematurely at five months, wouldn’t I feel the fetus? If she was only three months pregnant, her pain was way out of proportion. What if it was an ectopic pregnancy? What if she was bleeding internally!?

Not finding heart tones, I decided to try to do a pregnancy test. It sounds silly now, but I couldn’t tell if she was even pregnant.

Every movement she made, looked as if she was in transition.... like she was ready to deliver any second. Something was off.

As she peed for the test, I sent my translator to get Dennis. He needed to weigh in on this case; I couldn’t figure it out at all.

They returned together, and I informed him of my confusion. I was waiting on the pregnancy test, while he went to check the abdomen for himself.

I didn’t watch what he was doing, but I’m guessing he just pressed on it firmly and SPLASH! I kid you not, amniotic fluid gushed out on the bed, and ran all over the floor!

What?

I was so surprised, I couldn’t move. Shocked into stupidity, I glanced over to see a small baby, only a few inches long, lying on the bed. The thin umbilical cord still attached; the placenta apparently still inside.

How on earth!

Like I said, it took me a few minutes to get a grip. But when I did, I found her in a lot less pain. The contractions had stopped, since the baby was out; there was little bleeding, but lots of water to clean up.

Picking up the umbilical cord, I hesitated. What do I do next?

I told her to please push, and we would see if the placenta would come out on it’s own. She pushed with all her strength, and out popped the tiniest placenta I’ve ever seen in my life!

Everything was in miniature.

As I laid him out on the bed, she asked if her three friends could come in and see. Her husband who had labored with her, was noticeably uncomfortable, and decided to take a breather. When he did, three women, all no taller than my shoulder, gathered around to inspect the child with me. She sat up to see as well.

The cookie-sized placenta was complete, and all the membranes could be accounted for. The cord, though thin and transparent, looked normal, and though his head was proportionately larger than his body, that too was normal for five months gestation.

She wanted to know his gender, so I picked him up and brought him close. We all agreed. It was a boy.

Pressing in close for a better look, her friends murmured among themselves, and sweetly consoled my patient. They were interested, sure, but more than anything, they were witnesses. They were there to see and testify as fact: They saw the baby. They examined his body. He was dead.

Watching them, it finally occurred to me why everyone comes to gawk here. This is not a private place. Labor is not private. Birth is not private. Death is certainly not private. Honestly, how could it be?

Here, nothing important is ever done alone. Life and death. Well, that’s just flat out important! Of course they will all come and see!

Sigh. Why did it take me so long to figure this out? 

Anyway, back to my story.

The shoulder-high group of comforters all nodded approvingly at my excellent work! (Ha Ha! If they only knew I didn’t do a thing!) Nevertheless, they thanked me over and over again, lifting their hands to the sky, and praising God saying: “Inchalich Nalich! Thank you God!”

I joined them in their praises. How could I not? (Yes! Thank you God for covering my blundering assumptions and ignorance! Thank you! Thank you! Thank you! Thank you this was not an ectopic pregnancy!)

I asked them what they wanted to do with the child, and she made the comment: “Oh, don’t throw him in the trash. That is my baby.”

Horrified at such a thought, I told her of course we wouldn’t; I’d find a box to put him in so they could take him home. She smiled.

They wanted to stay the night to recover, so I moved her to the observation room, gave her the right meds, and made sure she was comfortable. Her friends all joined her, energetically recounting the day’s events.

Just before I left, I wrapped her baby in gauze and placed him in an old medicine container which had a lid. She nodded appreciatively. Then I prayed. I prayed she’d be able to carry her next child to term, and once again know the joy of holding a newborn in her arms.

They all thanked me again, and I left with the sound of comforting chatter reverberating through the halls. She would be fine.

Moral of the story.

If she looks like she’s labor, it’s probably labor. Forgo the pregnancy test!
If looky-loos come to gather, let them pass. Who else is going to testify?
Five months, means five months.... even if there is no belly!
And last but not least.... when in doubt, press on the abdomen really hard, and don’t be surprised if your shoes get wet!

Postscript:
Some of you might be wondering how I could be so calloused. I am talking about a stillbirth, aren’t I? That’s a good question. Frankly, death is no longer a surprise to me. Yes, I’m sad for the woman. She was sad as well. But mostly, she was just incredibly relieved to stop bleeding. She was grateful she lived. Grief looks differently over here. So if I’ve offended you, I’m sorry. I just can’t pretend to fear death anymore. I just can’t. I hope you understand.

Hydatidiform Mole~

Awen came for a prenatal yesterday morning, saying she’d been bleeding non-stop for 9 days. She was pale and worried and scared -- she had a right to be.

As I measured her belly and reviewed her vitals, the best conclusion I could come up with was a missed abortion and/or intrauterine fetal demise (IUFD).

For those who don’t know, a missed abortion is when a child dies in utero before 20 weeks gestation, (whereas a IUFD is after the 20 week mark), and the child is not expelled.

She had no idea when she got pregnant, but I thought she might be more than 20 weeks since her fundal height was 20 cm and she reported fetal movements before the bleeding began. If so, she had an intrauterine fetal demise (IUFD) which wasn’t being expelled.

The abdominal mass was alternately soft and mushy, then hard and rigid. There were no heart tones and no clots passed, and the bleeding was strange-- slightly foul smelling, and thin.

I conferred with Dennis and he agreed that the best course of action would be to induce her, lest the pregnancy become septic. I asked her if she had family to help her through this, but she didn’t. She spoke, however, of a sister in town who could help her with food, and she’d send word for her husband to come.

Once, the prenatals were through, I started her on an oxytocin drip. I titrated the dosage, bumping it up regularly to help the contractions take off. A few hours into it, I did a vaginal exam. She was completely closed, so I bumped it up some more.

Four hours later, she was still only 1 1/2 cm dilated, 50% effaced. I wasn’t sure if this was normal as I’ve never done it before. The books never said how long such things would take. But Dennis had done this numerous times before, so he was my reference.

However, several hours later, she started passing large clots. I called Dennis in because clots in ‘labor’ don’t make sense. He assured me it wasn’t normal and suggested we were wrong about the gestation age.

I agreed. Perhaps we were dealing with an early pregnancy (missed abortion) after all, and/or incarcerated clots. We were guessing, but they were our best guesses.

Dennis decided to do a manual vacuum aspiration (MVA) to remove the missed abortion and clots and I happily handed her case over. Margaret was taking over the shift, so I left them to it.

About an hour later, I was called to help them again; Tom was called as well. When we arrived, the room was full of IV fluids, bowls of blood and a pile of clots mixed with strange looking tissue that Dennis had removed during the procedure.

He had called us because she wouldn’t stop bleeding. He had completed the MVA and removed as much  tissue as he could get, but he couldn’t get the bleeding to stop. He also wanted us to weigh in on the tissues extracted.

The white, vesicled tissue was distinct and immediately apparent; what he removed was not a fetus but a hydatidiform mole. (For those who don’t know, a H. Mole is a rare mass or growth that forms in the uterus. It develops early in pregnancy, as a tissue that is suppose to become the placenta, goes rogue. What develops is a grape-like vesicle tissue that is NOT a baby but still produces pregnancy hormones.)

We discussed how to manage her case as she lay there bleeding. What should we do to stop the bleeding? To look at the amount of blood lost and the amount that kept pouring out, I was shocked Awen was even conscious! Afterward, we conservatively estimated her to have lost 3000cc. That’s about half a person's blood volume!

She was going into shock despite massive fluid replacement, but was still coherent. A miracle!

After discussing her case, I suggested I do an internal manual extraction of clots, since the MVA was not getting it out. Frankly, there was too much blood to even see the cervix. How Dennis was able to do it at all was/is a mystery.

An internal manual exploration is not something you normally do for miscarriages, but if you recall I did it on a incomplete abortion last year and it worked. I explained my reasoning to Dennis and he agreed.

So, I donned gloves and explained what and why to Awen; she agreed, and I reached in to extract what I could. It was painful-- there is no doubt. But once the clots were removed from her vaginal vault, I was able to extract a large piece of vesicles and tissue trapped in her cervix.

Instantly, her bleeding stopped as her uterus clamped down, and the room heaved a collective sigh of relief.

Wow.

Of the four of us in the room, only Dennis had ever seen a hydatidiform mole before -- just once. What a miracle we were able to get it out, keep her alive and stop the bleeding! What excellent team work!

She has been resting all day and is still dizzy for all the blood loss, but that is to be expected.
Pray for a full recovery and that this mole wouldn’t reoccur her next pregnancy. Thanks!

Pre-eclampsia Update:

My precious pre-eclamptic patient, Pour, came in today for a check-up. I’m always happy to see her and greeted her with a big smile. She smiled back and sat down slowly. My translator had just stepped out, so I asked her to lie down, so I could check her baby.

She shook her head sadly and said there was no more baby to check. My Dinka’s limited, but I somehow understood all her words. I instantly wanted to cry, (but culturally, crying is not an option), so I blinked back tears and waited for my translator to return.

My heart sank as she explained she’d delivered her baby 4 days before. She only had two hours of very intense contractions and her baby was born. He breathed twice and then died. She also explained that he was term but thin and had ‘burns’ all over his body.

I’ve seen one other macerated baby (a baby who dies in utero and starts to decompose) before and as the skin starts to peel, it does look like the child has been burned. It doesn’t make sense that a macerated baby would breathe, but I didn’t tell her that. If he was macerated, he’d probably died a day or so before the birth.

Her blood pressure was still high and her body ached. I wanted to wrap my arms around her and bawl; but again, such antics are not socially acceptable. Instead, I taught her more about pre-eclampsia and why her baby probably died. I also prayed for her to have peace about her child and to know Jesus’ comfort and joy in this hard time.

Should I have induced her last week? She wasn’t term (I’d have to check, but I think she was only 34 weeks last week), and her fundal height was only 22 cm.

I don’t know.

She’ll keep coming back each week for follow-up checks. Pray for her blood pressure to stabilize and her body to recover quickly. Thanks.

Waiting to die...

Preparing the vehicle to transport her.

I have a story but I don’t want to tell it. I’m afraid if I write it down, it will somehow become real to me. It is true though and that’s why I don’t want to tell it. But the not telling is starting to make me sick. So here goes...

Monica was a regular prenatal patient. Each time she came, I stressed the importance of delivering with us. She also knew not to push longer than two hours at home for I taught it many times. But as a 19 year old Dinka girl expecting her first child, she was at the mercy of her family when it came to how she’d deliver... not her midwife.

When her labor started, her family chose to keep her at home calling for a TBA (Traditional Birth Attendant) to watch her through the night. By morning, even though she was fully dilated, the TBA wasn’t able to get the baby to come down. She pushed for hours causing the baby’s head to swell as well as her labia. The TBA did all she could but eventually gave up.

Precious time lost.

But instead of coming to us next, they gathered their money and took her to a witch doctor, where (I’m told) he massaged herbs on her belly and proclaimed that ‘Now, the knots were untied and the baby could be born.’ Realizing he had nothing left to offer, they finally brought her to us.

More time lost.

When she arrived, I estimated she had been fully dilated for at least 6 hours, possibly longer. Her contractions were still strong but there was absolutely no progress. She lay exhausted, writhing in silent pain as her family explained all they had done. 

As I did a vaginal exam, I knew immediately she required a cesarean. There were too many signs of obstructed labor. This couldn’t be fixed by binding her belly. This wouldn’t progress if I stretched her and forced her to push. This appeared to be a case of deep transverse arrest (when the fetal head gets stuck in the mid-pelvis, restricting the mechanisms of labor). So I told her family she needed a cesarean. They didn’t seem surprised.

Fortunately, both Monica and child where doing fairly well. All we had to do was get her to Wau and they could be saved. There was just one catch, night was falling. Buses don’t travel at night. However, even if it were broad daylight, they’d be out of luck. With all the voting this week, the buses were booked solid. Even if the family paid twice the fare, there were no seats available. So I went to Sabet and asked if we could drive her.

He was happy to comply but we had to find our diver first. It’s dangerous to drive at night but sometimes if he is in the right mood, and you ask him nicely he will take that risk. We sent people to find him.

More waiting.

The family paced the floor while she writhed in pain. I went back to Sabet an hour later asking if we found our driver. He explained he couldn’t locate him and that we’d have to wait until morning. But even then, they wouldn’t leave at first light since the truck would need to be fueled first.

Meanwhile, the family told me they had arranged for a motor bike to take her home. What? I was confused. “How will she get to Wau if they went home?” I asked naively. Only then did it occur to me that they were giving me an out. They wanted to take her home to die.

The last time I had this conversation I kept telling the family that the patient (a multigravida with  IUFD and potential placenta abruptio. Her story here. And here.) needed to get to Wau or she’d die any minute, thinking that pressuring them would get her there faster. It didn’t. It just made them insist she go home and die there instead. The family gave up because I painted such a dark picture.

So this time, I played my cards differently. I reminded them that Sabet had promised transportation at sun-up. All they had to do was get through the night and we’d drive them to Wau. I explained that both she and the baby were alive and they shouldn’t give up hope.

They were glad for the news. But it meant more waiting.

My stomach churned as I considered how long she’d have to endure. Already, she had suffered so much. I couldn’t help but marvel at how she handled the pain. But her silence wasn’t courageous resolve for her eyes betrayed her. They darted from face to face in panic. Fear had it’s grip on her. So I prayed.

I prayed she would be able to handle the pain, that the contractions would stop, or that miraculously the baby would be born. I prayed that if not, she’d make it to Wau and both would be saved. I entrusted her to God and went to sleep. The on-duty health worker would check on her in the night and alert me if there was a problem.

Tossing and turning all night, I got up early to check on her. I needed to be reassured. I arrived as the health worker was unsuccessfully trying to find heart tones. It was apparent Monica hadn’t slept at all.

I shooed away the onlookers as I searched for heart tones myself. Nothing. Her abdomen was taut and tender to the touch. How long had she been like this? The health worker explained he never checked on her in the night. What? I wanted to scream it but didn’t want to cause a scene.

“What do you mean you never checked on her? You were suppose to check her every two hours. I left very clear instructions.” He stammered something about not having been told, refusing to look me in the eye.

I was kicking myself for not waking the guard to let me out of the compound that night to check on her. I should have been more persistent. I shouldn’t have trusted our health worker with something so important. I was mad at him... myself... and the situation.

She was in shock. Her blood pressure was bottoming out. It wasn’t good. On top of it all, her baby was dead. I couldn’t find a heartbeat anywhere. I called for Dennis to help me get an IV started as her veins were collapsed. He got it on the third try. Then I went to wake Sabet.

I explained that the baby had died in the night and the laboring mom couldn’t wait any longer. She was in shock. We needed to go now or she’d be dead too. He immediately got on it, saying he didn’t realized she was at such a risk. An hour later they were on the road.

In my head I imagined they’d drive up to the hospital, rush her through the doors and take her directly to surgery. She’d be saved.                       But I was wrong.

Our driver returned in good spirits saying she got ‘a picture taken of her baby on the inside’ (ultrasound?) and it was still alive. (Really the baby was alive? How?) He added that the ‘doctor lady’ said Monica would be observed for another 8 hours. If she didn’t deliver in that time then they’d do a c-section that night. (What? She is being made to wait another 8 hours! $#@%$#!) I wanted to scream.

I bit my tongue instead and smiled as he gave me this ‘great news’. My gratitude was genuine. I was thankful he was willing to go, for Sabet’s generosity in sending the vehicle, for the family’s continued hope. I trusted that the doctors in Wau knew what they were doing. I trusted God with her life. It didn’t make sense to wait. She had waited long enough but it wasn’t up to me. (By the time she arrived in Wau, she was fully for over 24 hour.)

So I waited and prayed. More time lost.

The next day I learned that she got the cesarean after failing to progress in Wau. She waited 7 hours before they took her in. The baby was born dead (not a surprise) and an hour post-op, she joined him. I don’t know why.

I think it was all the waiting. 

Her death surprised me -- not because dying in childbirth isn’t possible but because it was completely avoidable. I know it’s foolish to play the ‘what if’ game but I can’t help it.

What if she came to the clinic earlier?
What if they hadn’t wasted time pushing so long?
What if they bypassed the witch doctor?
What if they arrived before sunset?
What if our driver was found and took her to Wau that night?
What if the hospital rushed her to surgery immediately?
What if... What if....

Death on a Tuesday ~

(This story is hard to write. It might be hard to read. Proceed cautiously.)

Mike our compound manager came to my door early Tuesday morning saying he’d got this call. Someone saw a pregnant woman being carried down the road on a home-made stretcher. They wanted us to pick them up. Would I come with him?

I quickly changed and ran out the door, wondering if I’d need gloves. Was she delivering on the road? 

When we arrived, fifteen people rushed her to the truck and loaded her in. She was quiet but moaned each time we hit a bump on the road... which happened often.

Once back at the clinic, I tried to get her history. Name. Age. Number of pregnancies. Her name was Elizabeth. As it turned out, this was her 8th pregnancy but only two were still alive. Two died during delivery. The rest died at various ages for various reasons which she couldn’t explain. They just died.

Meanwhile, I measured her, took her vitals and searched and searched for the baby’s heart beat. Nothing. She calmly stated that her baby wasn’t moving anymore. I continued to search. 

It was silent in there. Eerily silent. I couldn’t even hear placental sounds. Strange.

She went on to explain that her labor started the night before but after a few hours, lots of blood gushed out. Several hours after that, her water broke. At which point, her family and friends insisted she start pushing. She pushed all night. When the baby didn’t come, they finally decided to get help.

But by then it was too late for her child. When I explained her baby was likely dead, she turned her face to the wall. But she didn’t cry. In fact, she didn’t do anything. Her blood pressure was bottoming out from exhaustion and blood loss, so I pumped her full of fluids.

I asked her husband to explain again the sequence of events. How much blood did she lose? Did the water break first or the bleeding? How long exactly did she push?

I also did a vaginal exam to see what could be causing the problem. She assured me she had never pushed so long before. I couldn’t find anything significant. All I noticed was a very large caput (or swelling on the baby’s head) and a slightly contracted pelvis.
(For those midwives out there: She was fully, 0 station, caput at a +2 station. Her pelvis seemed somewhat platypelloid in shape but adequate. The baby’s head was extended but otherwise normal.)

Since her contractions had stopped completely, I started her on an oxytocin drip. I figured her uterus had just become exhausted. All that was needed, was a bit more oompf and the baby could be born. I barely opened the line, expecting the drugs to jump start things.

But nothing happened. Nada. Zip.

I opened the line completely and let the medicine storm in -- still nothing. Not even a twitch. This has never happened before. My magic solution failed. How was I going to get this baby out without a contraction?

I started talking about going to Wau. I told them that I would do everything in my power to help, but they might need to prepare to go for a cesarean. The husband, understanding the seriousness of the situation said, “I know that my baby is dead. Please, just save my wife. Do whatever you can.” I promised I would.

As I considered the situation, I realized I hadn’t tried EVERYTHING yet. I just wasn’t sure I was READY to try everything.  My everything included some painful and unpleasant procedures.

I told them that since the Oxytocin wasn’t working. The only way I could think of pushing, was fundal pressure. (*Side note: I’ve never done fundal pressure before. It’s dangerous. A lot can go wrong.) I didn’t want to do it, since it’s outrageously painful but I couldn’t think of anything else.

So I explained what it was, and told them that I’d try to flex the baby’s head and turn it in a more favorable position while they pushed. My assistant and her husband would both need to help do fundal pressure.

She pushed. They pushed. I turned. Nothing. An hour went by.

And when I say an hour, I mean a full hour of sweat, pain and intermittent progress. One minute the head would descend and I’d think we were in the clear, the next, it would be all for naught.

With each push, my heart would sink and I’d pray harder. This is not the sort of thing I learned in school. I’d look up and see her face contorted in pain. I’d look at the men pushing with all their might and think, “This is crazy. She needs a cesarean. Get her to Wau. And fast!” But then, we’d all take a deep breath and try again. I could actually feel the skull shifting and crackling beneath the swelling. Not good.

I was so stressed, worried and scared by this point that I yelled at anyone who barged in the room. And yes, I had people barge in -- translators, patients, looky-loos! And when I had reached the very end of my strength and patience, a pregnant woman stormed in and threw herself dramatically to the floor. Apparently, she too was in labor. But I had NO time for her -- no compassion, no patience, nothing. My hand was elbow deep in the middle of a stillbirth. She was making it worse.

I screamed for her to leave, but it took 8 more looky-loos to fix the problem. I was on my last nerve. What madness had descended on me? I continued to pray.

But I was running out of ideas. I had only one plan -- fundal pressure the baby out. It wasn’t working. I have no vacuum extraction. I have no forceps. I was running out of options.

Only then, did I remember a procedure called internal version. I had studied how to do it in school. But since I have yet to do an external version, why did I think I could do an internal version? I didn’t. Would it even help THIS situation?

For those who don’t know. Internal version is when a baby is repositioned (usually) from a breech position to a cephalic (head down) position by reaching inside the uterus and turning the baby. It is most often done when dealing with multiple gestations, etc.

But this case was different. I had the baby in a cephalic position. I was thinking of turning it breech. What if I delivered the body and the head still wouldn’t come out? Was I just making things worse?

But I didn’t think about it long. I acted. Some would say foolishly. I pushed the baby out of the pelvis (into her uterus) and was instantly splashed with a gush of bloody amniotic fluid. The baby’s head had been sealing it off. Now it covered me....  and the floor and everything in between.

At the sight of it, my assistant nearly lost it. I had to ask him several times to mop it up. He froze in horror.... and disgust.

Meanwhile, my hand was floating inside her uterus. Let me say that again. My. Hand. Was. Floating. Inside. Her. Uterus. (Slight, freak out moment.)

Slowly, I started identifying parts and pieces. I felt a hand. I identified a foot. Oops, that’s the cord. Yep, that has to be the face. My patient looked calm. She didn’t seem to even notice what was happening. It was strange, warm and horribly fascinating.

My assistant was still trying to figure out what a mop is for, so I called for more help. Dennis and Margaret came in to find me covered in blood with my arm lost inside my patient. Dennis reconnected her IV line, while Margaret managed to get some of the chaos re-organized. It was good to have them there.

I firmly grasped both feet and turned the child breech. I delivered the feet and then the legs. The body came out with relative ease but the arms got trapped behind the head. It took me several minutes to get the arms un-trapped. I prayed earnestly for God to remind me of all the steps I learned in school. I sighed and ... maybe even laughed, when they finally did come out. You can’t imagine my relief. But the head still needed to be born.

At this point I was so passed the point of exhaustion my hands shook. I was stressed, covered in blood and sweating like mad. “Lord! Please help me get this head out!” Images of me decapitating the child in the effort flitted through my brain. “Lord, by your grace. Help me.”

It took me several more minutes of maneuvering, suprapubic pressure and a lot of pulling before the head was born. I wanted to celebrate but I couldn’t. My heart hurt too much.

This birth was anything but gentle. It was flat out traumatic. Horrifying even. And yet, we all rejoiced. The father rejoiced that his wife was saved. The mother rejoiced that her pain was over. I rejoiced that God had answered my plea.

But as I stood there, holding this beautiful boy in my hands I couldn’t help but shake in exhaustion. It had taken every ounce of me... and I wasn’t even the one in labor!

I, then, rushed off to get out of my blood-soaked scrubs and shower. I had to take a moment and pray. I needed to cry. My first stillbirth. It was awful. Terrible even.

When I returned, my assistant had cleaned up most of the blood. The mom was recovering well. She even smiled at me, then went right to sleep.

So there you have it. It’s not beautiful. In fact, it’s not far from nightmarish except for one thing. She lived.

Some of you might read this story in shock and horror. Rightfully so. I’m sure you can find much to criticize. I did many things wrong. But I’m not sure what I would have done differently -- except barred the looky-loos from the clinic. Ha ha!

Side note: The woman who barged in and threw herself at my feet in labor, delivered soon afterward with Margaret’s help. In fact, I don’t even think she realized I had a patient in my room... let alone my hand inside of her! Ha!

Update: 
Both Elizabeth and her husband came in today for a check up. She is in pain from the fundal pressure but otherwise doing well. Please lift her up in prayer. Thanks.

Reasonable Tradition?

I don't know how to begin my story, so I’ll start in the middle. Earlier I wrote how a woman was in “labor” with a stillbirth after severe bleeding for a day and a half. (read her story below: VASA PREVIA.)

You prayed. I prayed. Here’s what happened next.

Well, She had been at our clinic all morning, stable and ready to go to Wau once the family got the money. They found the money but then needed to get bus tickets or a car. They went to look for it and some more money. I waited patiently for the family to return with the good news...  and take her to Wau. They didn't come. Then I waited a little less patiently. I even got loud.

What's going on? Don’t you know she's sick? Why aren't you doing anything?
They just looked around confused. She looked fine to them... what's the big deal? So what if she’s barely able to sit up and urinating blood so dark it’s purple? She doesn't look that bad! I wanted to beat something... someone. They had given up.

But part of me doesn't blame them. They tried to raise funds and got enough to get her surgery but when they went to buy a bus ticket to Wau, the driver extorted them for more.

A ticket that should cost 30 pounds would cost THEM 150 a person because she was desperate. Yes. You read that right. They'd have to pay five times as much... double even... because a care taker must go as well. Pay 300 pounds and we'll take ya! I understand why they gave up. Three hundred pounds is more than most people make in a month.

But I don't understand why the bus driver would do that. Here a woman's life is in the balance. They saw only dollar signs! AAAAhhhhhhhgGGGG! I was so angry I could have spit!

Fine so the bus option was out. But the good news was they had enough money for the hospital stay. We were driving to Wau the following morning and would take them with us. All she had to do was stay alive through the night. I was prepared to do everything possible to make that happen.

It’s at this point that I decided to induce her. Perhaps if we could just deliver the baby, the bleeding could be controlled. Perhaps, by God’s grace, she wouldn’t have any further bleeding. It was a risk but one I was willing to take.

Just as her contractions picked up, they started talking about taking her home. What? But if she goes home, she might hemorrhage even more and a blood clotting disorder can happen. (This is called DIC -- disseminated intravascular coagulation). If it happens, she'll not be able to clot her own blood and bleed out quickly. It's dangerous. It’s better she deliver at the clinic where we have life saving measures available. But the family kept insisting. They wanted to take her home.

I begged them to stay until Sabet came back from his trip. He had been away all day with the car. (That's why we couldn't take them to Wau ourselves). He was due home at 5pm. They agreed to stay... but were anxious.

However, as God would have it, Sabet got delayed. And with each passing hour, they insisted louder. I told them they were free to go whenever they wanted. I couldn’t make them stay. But I kept praying they’d stay. I felt like a prison guard keeping her hostage. She wanted to go. Why? I wondered. To die? Eventually after waiting 3 additional hours, I unhooked her IVs (she had two) and let them carry her away.

As she was unable to walk, we drove them home. And as they loaded in the car, her brothers assured me they'd be back tomorrow morning to go into Wau with our truck. Just then Sabet arrived. But it was too late to convince them to stay.

They drove off and my stomach sank. Ten hours I kept her stable and alive. The induction was working and she was already 4-5 cm dilated. *When I did the last vaginal exam, I felt only placenta. My best guess is placenta previa but one that was completely detached. (I say this because she had absolutely no pain.)

So to answer all your questions, I don't know if she lived. All I know is she left our clinic alive. We called numerous times the following day but no one answered. That morning on the way into Wau, we drove by their house but it was empty. The locals I asked all think she was taken to the witch doctor. I don't know if she lived. I wish I knew. It eats me alive to think they chose to take her home than spend the night at the clinic. But that is the case.

I asked Sabet why they'd insist on taking her home when we could keep her stable and transport her to the hospital the following day. He explained that the Bongo tribe (of which she is a part) do a number of rituals on a dying person. It's VERY important for them to make sure all the rituals are observed. They would not have had the chance to do them at the clinic.

So in the end, tradition won out over reason. And in this case, it may have cost a life.

*(midwife disclaimer): I know I'm not suppose to do a vaginal exam when there is bleeding. It was a judgment call. Once I knew there wasn't a chance I was going to get her to the hospital, I needed to know what I was dealing with. Please understand. And if necessary, forgive.

Vasa Previa?

A mom is at our clinic right now in very serious condition. She had painless vaginal bleeding after ROM (rupture of membranes) a day and a half ago. By the time she got to us, her pulse was through the roof and her blood pressure non-existent. She was in shock.

We got her stabilized and after several liters of IV fluids, found her blood pressure. But it's pretty low still. But her baby is dead. There are no fetal movements and I can't find a heart beat. What's worse... I can't even find a placental sound.

My best guess right now is vasa previa or placenta previa.

The problem is... she is not responding to induction methods. My hope was to get the baby out quickly so we could control the bleeding. But we are hesitant to insist on induction since her risk of DIC (disseminated intravascular coagulation -- a blood clotting disorder that can happen after hemorrhage of this type) is very possible.

Her family is doing a mad scramble for funds so they can get her to Wau (nearest hospital). But it's taking forever. I'm frustrated because we asked them to start looking for money hours ago but they just sat there. I don't think they believe me when I say she can go downhill very quickly.

They've found some money... but need more. But they also need transportation there. Lord, please provide us with an ambulance. We desperately need one. Sigh.

Pray she lives even though her baby hasn't. Pray. Pray! PRAY!!!