Blood Loss.

They aren't smiling... but they were happy. At least I think they were...

Apiu is one of my prenatal girls. Although she lives far away, she decided to move to town her last month of pregnancy. She explained that she had had 3 days of heavy bleeding after her last child and was worried it would happen again.

So when her labor started yesterday morning, she slowly made her way to us. She arrived quite active and delivered two hours later on her knees.

Her precious girl looks just like her. Same sparkling eyes. Same playful mouth.

Although she had some initial bleeding postpartum, I controlled it with fundal massage and oxytocin.

But just when I thought it was over, she started bleeding again. Clots. Heavy clots. 

So I decided on intravenous oxytocin to keep things firm and had her breastfeed. This improved things dramatically and I figured we were through the roughest patch.

Once stabilized, I moved her to the postpartum room to rest. She’d only lost about 600 cc by this point and she wasn’t dizzy.

But during her recovery (roughly 2 1/5 hrs postpartum), she started bleeding again. Heavy, thick clots.

I got there to find her lying on the floor COVERED in blood. Several large blood clots lay beside her. And she was dizzy. Too dizzy to even sit.

In all my time here in Sudan, this is the first case quite like this. She’d lost at least another 600-800 cc by this point.

Something was keeping her uterus from clamping down on itself, leaving me with few options. There was just one thing left to do -a manual exploration.

(For those who don’t know, this procedure requires me reaching inside the woman’s uterus with my gloved hand and systematically removing anything remaining inside, i.e. placental parts, sequestered clots, etc.)

I hate doing this, but I couldn’t let her bleed to death either. So I readied the room, started more IV fluids, then reached inside her body.

Her screams brought looky-loos (of course), but it couldn’t be helped. She needed to stop bleeding. This was the only way left to do it.

I quickly removed several large clots, then massaged her uterus shut.

Painful? Yes. Anyone who has ever had this procedure knows it’s crazy painful. Some say it’s worse than giving birth.

Effective? Yes. It stopped her bleeding almost immediately.

It took me some time to convince Apiu that I didn’t hate her... and that I wasn’t an evil person determined to cause her endless pain. But I’m not sure she believed me.

“I didn’t want to hurt you, Apiu. I just didn’t want you to bleed to death, either. Can you understand that?” I asked pleadingly.

She just stared at me with hardened eyes. So I continued.

“If I had let you continue to bleed, you would have needed a blood transfusion,” I explained. “This was the only way I know how to help you stay alive...”

More hardened stares coupled with whimpers, but then a slight nod of her head.

Once the pain subsided and the bleeding finally stopped, I think she forgave me. But I’m not sure. She looked at me with fear-tinged suspicion the rest of the night.

But did I care? Not really... I did what I did to save her life. She might not get that now, but I do.

We kept Apiu overnight for observation, but by morning she was strong enough to be discharged. Please pray she regains her strength quickly. Thanks.

Afterward, all I could think of were my midwifery teachers in the Philippines who taught me this procedure. If they could see me now...

To all my teachers at Newlife School of Midwifery: I love you and thank you from the bottom of my heart! This women is well because of the countless hours you spent teaching me. I love and appreciate you ladies so much!

Lord, bless the faithful midwives who worked so hard to teach me these skills. Bless them for their dedication and patience. Help them remember when they are tired and frustrated that their service is quite literally saving lives half way around the world! May they never forget that. Amen.

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.

Hardly Simple. Simply Hard.

Sunday night Mary came in with solid contractions, but they started two hours before. She seemed like she was handling them well, so I didn’t do a vaginal exam. If she was early, I’d have to send her home. I didn’t want to send her home. But it wasn’t my call; it was Margaret’s, as she works nights.

Knowing she wouldn’t deliver right away, I handed her over to Margaret early. Margaret did the vaginal exam, and she was only 2 centimeters. However, Mary categorically refused to go home, so, Margaret labored with her all night. I’m told she was vocal and uncooperative, making it tough for anyone to sleep.

At 7 am (when I’m back on shift), another labor came in looking active and they called me to help. Mary and Margaret were in a battle of the wits. Mary was fully but unprepared (I think mentally) to push. Margaret was fed up with her screaming and stubborn antics (or so I’m told), and kept insisting she push-push-push.

I wanted to take over, but the new labor was very active. I was torn. Where to go? Who to help first?

The new labor’s name was Yom and this was her third baby. She didn’t want an exam, and I didn’t want to do one. So I opted to monitor her while stepping back and forth between each birth.

Mary kept screaming and calling for God to just let her die; Yom silently squatted on the floor and rocked a bit with each contraction. The difference was dramatic and perhaps even more marked by their proximity.

Yom’s membranes ruptured spontaneously a few minutes after admission, and she needed to push almost immediately. She pushed, and I scurried to set up the room while her husband watched from a chair in the corner. He is the first husband I’ve seen ‘support’ his wife in labor in AGES! I was happy to have him there.

She pushed silently and a gorgeous, vernix laced baby boy bounced into the world. His whiteness concerned the father, but I assured him that the ‘white stuff’ comes off. He laughed when I promised him he didn’t have a kowaja but a Sudanese!

When Mary, in the next room, heard Yom had delivered within minutes, she got mad... and motivated. Margaret tells me she started pushing properly, all of the sudden.

Once Yom was breastfeeding and her bleeding was controlled, I went to help with Mary’s birth. Margaret was using our newly donated vacuum extractors (Thank you Ann-Jule!!!), but was having little success. Fortunately, Mary was close and so we stopped with the vacuum extractor and taught her how to push a bit better.

A couple serious pushes later and her boy slipped on to the scene. Mary’s mother sat exhausted but pleased in the corner of the room. What a relief!

Margaret gathered her things and stumbled off to bed, and I took over. Mary, had a slow recovery and after the placenta was born continued to bleed like mad.

I rubbed her fundus and massaged out clots repeatedly, but her uterus just wouldn’t firm up. Was it incarcerated clots? Were membranes or placental parts retained? I didn’t want to do an internal manual exploration at all, but I couldn’t see any other option. 

Needless to say, she was uncooperative (a theme for her birth I guess, but understandably so... ). But the instant I finished, her bleeding stopped, as if I’d turned off a faucet.

They recovered together, most of the morning, and were discharged later that day. Yom, skipped off with her husband as if she were off to the fair, but Mary was another story.

Mary and Margaret after the birth.

She was sullen and sore, perhaps even disappointed in herself, or us. I’m not sure. It was a hard birth for her. Before she left, I told her that her birth was tough - there was no doubt about it! She nodded slowly in response. I added that sometimes births are easy, and that just because this one was hard, it doesn’t mean the next one will be, too.

She softened when I said that and nodded some more. She believed me. Pray for her. May God bless her with a speedy recovery, and the next time may she have an easier go at it all!

Side note: Mary’s birth was my 200th catch. Yep. I’m one of those geeks that keeps track. Ha ha. I’ve attended a total of 358 births, the last 70 were here in Sudan. What a blessing to be a midwife!

Mulling over a miscarriage.

Right before I left on break (Yes, almost a month ago.) I had a patient come in with a history of heavy bleeding and clots with what turned out to be an incomplete abortion (aka: miscarriage).

I was so rattled and yet ... impressed by the encounter, that I’m only now able to write about it. I’ve had a month to think it over and ... well, I’m still unsettled. But at least now, I’m ready to write it down.

She came alone and toward the end of the day - almost as if saying she had better things to do that day. She sat still and quietly explained that she was bleeding big clots. She was miscarrying but something was wrong. She said the bleeding started four days before and didn’t want to stop. That is why she came.

She was thin in the way years of working fields and nursing babies make you thin. And she was strong. Long muscles defined by endless grinding and sweeping and caring for kids. But it was her eyes that did me in. They were no-nonsense-black and piercingly serious.

I explained to her that I needed to do a speculum exam to see what was going on. She agreed and that’s when I saw the extent of the miscarriage. Fortunately there were no signs of infection, so I called Dennis in to see if using the manual aspiration vacuum would be appropriate. He said that it wouldn’t (I forget the reason why now.) and recommended I send her to Wau.

Here’s the thing. Women like her (no family support group with her, tattered clothes and worked-to-the-bone thin) don’t tend to have money to go to Wau. I’m tired of referring women to Wau that cannot realistically go. I feel like I’m failing them. I’m not doing all I can do.

So I told her we had too options. One, she could go to Wau and get a D&C because to do nothing would lead to sepsis and further problems. Or two, I could try and do an internal manual exploration to get the rest of the fetus out. BUT that an internal exploration is EXTREMELY painful and I would prefer she go to the hospital.

She explained that she had no money and she wanted me to do an internal exploration. My heart skipped a beat.

Any woman who has had this procedure can tell you it’s worse than the pain of birth. I’ve had to do it a few times (right after a birth) and each time the woman crawled the walls and screamed my ears bloody in pain. My heart shrinks in despair every time I have to do it.

For those who don’t know, an internal exploration requires I reach a gloved hand inside and manually remove the fetus, placenta or membranes from the uterus allowing for it to clamp down and stop bleeding.

It’s a lifesaving measure in preventing postpartum hemorrhage... but this is the first time I considered doing it for a miscarriage. Would it even work? Is the benefit worth the pain? What if I do nothing? What if she goes septic and dies?

I had my translator explain over and over again what it required and how painful it was going to be. I asked her to be strong and try not to pull away. I made sure she understood and again asked her permission to do it. Was she sure?

I was stalling. I flat out didn’t want to cause her the pain. But I wanted her to live more. So I did it.
Here’s the thing. She never once flinched. Nor did she make a sound. She lay still and stoic - shockingly so.

As I removed the fetus from the cervix, I discovered half of it was still inside the uterus. I had to manually dilate her cervix to get it out. This must have been blindingly painful but you would never have been able to tell by her reaction. She was motionless and... resolute.

Once I finished, I asked her if she wanted to see her child. She only hesitated a moment then gathered herself together and sat up. She looked long and hard then said “Thank you”.

I apologized over and over again for the pain I caused her and told her how brave she was. I warned her of signs of infection and instructed her on how to care for herself. I was almost certain I got it all out but she needed to come back for a check up in a day or so, etc. She listened carefully to each instruction while quietly gathering herself together.

Again I found myself apologizing for the pain I caused her and telling her how sorry I am that she lost her child. Only then did she speak.

“Please don’t be sad.” She said. “I am not sad. I am glad that you did it. Now I know that I will not die. Thank you.”

Even now, as I think of her I want to cry. Here is a woman who has not had an easy life. Yet when she loses a child, and suffers severe pain... she ends up comforting her midwife.

My world feels a little upside down.