IUGR or Pre-term?

This morning one of my prenatal girls proudly brought in her precious little girl for me to meet. She was beaming! When I looked beneath the blankets though, my breath caught in my throat. She was tiny! So small in fact, I had to touch her briefly to make sure she was alive.

“When was your baby born, honey?” She certainly didn’t look like she just gave birth. She was too rested and relaxed.
“Last Sunday.” She said with a smile.
“Oh, you had her yesterday?” I offered.
“No. The Sunday before.” I must have looked confused, so she repeated herself. “You know, a week ago.”

I had to marvel at this little package of estrogen. Could she really be a week old, already?
“She is so small. Why didn’t you come before now?” I asked.
“Oh... we have a tradition in our culture. You cannot take babies out of the home for several days. If it’s a girl you must wait 4 days. But if it’s a boy then you wait only 3 days.”
“I see. Can I do a exam on your baby to see how old she is?”
“Of course you can. I’m here for a check-up anyway.”

I smiled and held back my concern. She certainly didn’t act like she was fighting to live... but she was so small. When I got her on the scale, flash backs of last weeks premature births blasted through my brain. In fact, the second premature baby weighed more than she did! She only weighed 1500 grams (3.3 lbs!).

But as I checked her out... all her vitals were stable and she seemed healthy in every way. So I did a Ballard’s Score on her. This is a test done on newborns to help determine if they are premature and, if so, how much. It tests reflexes, neurological development and physical maturity attributes. It’s only meant to give a general range but it can help differentiate between a small but term baby and a premature newborn.

When I checked her reflexes, postures and muscle tone, she passed with flying colors. Her neurological development was spot on. In fact, I didn’t see anything amiss except her size. At the end of the exam, it was clear to me I was dealing with a severely IUGR baby and not a preterm one.

For those who don’t know, IUGR stands for Intra-uterine Growth Restriction. It means the baby was unable to develop and grow at a normal rate in utero. Something hindered her. It could have been from placental insufficiency or maternal life-style (alcohol, drugs, cigarettes). It is also caused by poor nutrition and illness (chronic or infectious).

I’m not sure what caused hers... but it’s the most severe case I’ve seen to date.

Fortunately, she is fine and eating fairly well. I asked her mom to bring her in regularly so we can monitor her growth. She said she’ll come. I have a feeling she will.

Retained Placenta.

Today one of my patients came in with her newborn boy. She delivered at home 6 days ago and “things weren’t quite right”.

When I uncovered her boy, he was tiny. My heart sank. Another preterm baby? Really LORD? Really??? But it was clear. He weighed exactly one kilo. But he was alive. I figure he was probably 7-8 months along but IUGR (Intrauterine Growth Retardation). He was breathing fine. His vitals were normal... except he was a bit on the cold side and lethargic.

But here’s the thing. This was her first baby. She had no husband and one kind (but exhausted) friend helping her. She didn’t know much about babies and as a result thought breastfeeding only 3 times a day was perfectly reasonable. (FYI: It’s not. Newborns need to breastfeed every 1-3 hrs minimum depending on their size and suck potential. :- ) I stressed the need for better feeding and she said no problem. Then we moved on to her.

She then explained that her placenta didn’t come out for 24 hours after her baby. When it did finally come, only half of it was there. The other half fell out all black and smelly just yesterday (5 days postpartum).

I was horrified.

When I did a speculum exam to find out more, it was not good. I’ll spare you the details. Suffice it to say, she needed a D & C quickly.

Part of me was hopeful to use our new Manual vacuum extraction machine. Dennis is going to teach me how to use it. But when I asked him if this would be a time to use it, he told me no. That once infection has set in, the risk of uterine perforation is too high. She needed a D & C.

My heart sank with the news. How is this little girl going to get the money to get to Wau? How is she going to afford a D & C? How?

When I explained the news to her and her friend... she just listened with her eyes averted. When I mentioned going to Wau... she just cuddled her baby closer and looked down. Her friend listened with tears rimming her eyes. They were scared.

They put on a brave face. One standing strong. The other in denial. But I didn’t detect much hope.

Here’s the thing. Had she come the day of her birth I could have gotten her placenta out any number of ways. Had she come on day one, two or three postpartum, perhaps it would have been possible to use the vacuum aspiration. But by waiting until sepsis set in, my hands were tied. My window of opportunity had passed. I had no choice but to refer her.

Perhaps I’m in a pessimistic mood, but I don’t think she’ll go. I think she’ll stay at home and die, along with her precious son.

Forgive me Lord. I don’t know what else to think. Save her. Make her whole again. By your strength and love, touch them. Heal them. Amen. Please pray with me.

Surprise! Surprise!

Last week.... sorry so late in blogging.... a classmate caught "surprise twins"!

The story goes that this young lady came in fully and pushing... she made it to the bed and shortly thereafter birthed her first little girl. But something was amiss.... the mother's fundal height was 37 (considered large in this country) but the little girl was small (only 5 lbs). They noticed the fundus was still pretty large and so they checked for heart tones and what do you know another little one was still inside!

No one knew she was carrying twins. She had never had an ultrasound (not routinely done for cost reasons). Her sister was born a few minutes later. Both of them were born head first (PTL!) which is perfect because we have not done the lesson on breech deliveries yet. The second twin was IUGR (or growth restricted) due to a smaller umbilical cord and only weighed a little more than 3 lbs.

The mother didn't do so well in the postpartum period. She went into shock due to the blood loss and was transported to the hospital after vomiting several times. She had to have a blood transfusion and yet she couldn't take her twins with her! They were so small they would run the risk of getting ill. But God is an amazing provider! The classmate who caught the babies is a breastfeeding mother herself and she and her husband loved on these twins for about a week while their mother recuperated. She took them to see their mother everyday and helped them to establish solid breastfeeding patterns! They sure can eat!

But my classmate was definitely tired at the end of it all.... tandem feedings, midnight feedings, three babies at her breast continually (for she still breast feeds her youngest!) and an assignment to complete on top of it all! She just gave the babies back last night! Please pray that they will grow up strong and that their family can afford two of everything when they only planned for one!

The first little girl is named Shweety (but we called her Bean Sprout) weighed 5 lbs at birth
The second tiny girl is named Cutie (but we called her Sweet Pea) weighed 3 lbs at birth