A Perfect Mess.

Maguet said she was in labor but didn’t look active.
    --They rarely do.

As my helper readied the room, I tried to count contractions and ask her questions. She had never come for a prenatal, and I needed a few facts.

But getting her to talk was an exercise in futility. She just flat out couldn’t.

Only then did I see the first contraction. Saying it was strong just doesn’t cut it --intense to the nth degree --powerful the the power of ten. Okay. So they were strong!
    --How could she be so calm?

As I stood by her side trying to measure their intensity, a sudden rush of wet warmth gushed down my legs and hit the floor with a audible splash!
    -- Had someone emptied a bucket on me?

Maguet and I locked eyes in surprise, then looked down in unison. Black, murky fluid stained our clothes as if we had waded knee deep in a lake of amniotic fluid.

My first response was to laugh; but Maguet was a bit more hesitant. She looked embarrassed. Or was it horrified? Eventually she realized I was not mad and laughed timidly along with me.

I didn’t have heart tones; I had not measured her fundal height; and I still did not even know her gestation... but she wanted to push.

Did I have time to change? --Unlikely.

My warm, sticky pant legs clung to my skin, growing colder by the minute. My shoes squished loudly at every step. Eek.

I really wanted to go get changed... and perhaps take a long shower with bleach.
    --Could I risk it?

The midwife in me worried the murky fluids could mean a compromised baby. Heck, I still didn’t know if the baby was alive! However, the non-midwife in me was thoroughly disgusted and ready to run for a decontamination shower.

What is the protocol when a total stranger expels ink-flecked slime all over you?

My translator didn’t know what to do or where to stand. The horror on his face was evident. I had to tell him more than once to get the mop.

Only when I rolled up my pant legs and started moving her into position for the birth, did he push past his disgust and prepare for the birth.

He ran for the mop. I slipped a pad under her. She got in the squatting position.

Ten minutes later her little girl was born.

The baby came out with another splash of blood and water coating me in a second layer of grime. But I didn’t have time to notice.

Green-gray meconium coated the baby and sputtered from her lips. I suctioned her mouth and dried her off before handing her over to her mom. Then I took a long look at myself. A mess.

A. Cold. Sticky. Wet. Mess.

What a bad week for the water to stop working at the clinic!

Once the baby was stabilized and breastfeeding well, I ran off to the compound for a quick shower. A bar of soap never looked so great!

Her baby was initially fine, but by the second day she developed an infection --most likely due to meconium aspiration but also possibly due to untreated STDs.

We have her on antibiotics now. Please pray she recovers quickly. Thanks.

Resuscitation.

Abuk came to see me on Monday. She was terribly sick and had been that way for a week and a half. But she lived so far away, she wasn’t able to come earlier.

She was expecting her second child and was term. She could deliver any day.

I diagnosed her with malaria and dysentery and gave her the medicines, praying she would not start labor until they were finished.

But that didn’t happen.

At first light, she was back in the clinic and pushing. And would you believe it... she was fully! 

Listening to her baby’s heartbeat waver and peak irregularly, I knew we had a problem. He was showing signs of severe compromise with erratic variables and late decelerations.

I called for Sarah and Margaret. I wanted as many hands available as possible. Images of Nyiriak’s birth crowded my thoughts.        

--Lord, please don’t let me have two babies die in a row. Please!

It wasn’t long before her precious boy was born.

He came out covered in thick meconium. Limp, cyanotic and with just the slightest will to live, he didn’t do much but lay there listlessly.

--Lord, help this baby to breathe!

With both Sarah and Margaret right there, we were able to work on him quickly. Sarah got the oxygen machine set up and flowing; Margaret breathed for him and stimulated him like mad; and I tried to stay focused on Abuk.

She delivered her placenta before he was fully recovered. Although we got him breathing, we couldn’t keep him warm.

So I asked Abuk to do Kangaroo care. She complied at first, but eventually decided it was too much trouble.

Confused I tried to explain to her that it was important for her baby to live. But she didn’t seem to care.

Was she just too tired?

Fortunately, her brother volunteered to do it for her baby instead. He stripped off his shirt in haste and happily took the tot in his arms. It was so amazing to watch!

So few Dinka men help in such matters. What a delight to see this exception!

Once her boy’s temperature stabilized, she was able to breastfeed without any difficulties. We watched them both the rest of the day, and discharged them with strict instructions to return if anything went wrong.

In my heart, I was ecstatic. Finally a baby that would live. The resuscitation worked!

However, the next afternoon she returned saying her baby had a fever. Sure enough, he was showing signs of neonatal sepsis which was probably due to meconium aspiration.

We admitted him for treatment and observation. And I started praying hard.

But I found out the next morning that Abuk had discharged herself in the middle of the night. I was told that she said she didn’t see her baby getting better so she refused to stay.

I haven’t seen them since.

Admittedly, I’m disappointed. I wish I could have found a way to communicate to her that this baby was going to live... he just needed the right medicines and time.

Please pray for Abuk, her son, and the rest of her family. Pray that this boy might thrive despite not getting the rest of the medicines he needed. Thanks.

My Girl Friday~

Santos is one of our translators. He’s only been working for us a few months, but I like his attitude and work ethic. He’s polite, helpful, and teachable. Mostly, he works in the pharmacy.

He’s been telling me about his pregnant wife, and eagerly awaiting the delivery. It’s his first.

He wasn’t sure if she’d deliver at the clinic or not. I encouraged him to do what he thought was best, and reminded him that we were here for them.

His wife, Mary, started labor last night and by early morning was looking very active. Santos insisted she come to deliver with us, even though she was resistant.

I didn’t do a vaginal exam right off, preferring to watch and wait. But by the time I needed to start doing prenatals, I couldn’t guess where she was anymore. She seemed to be in intense pain, but the contractions where short and sweet.

The exam showed her to be well effaced and roughly 8cm. Since I knew I could do a few prenatals as she dilated, I moved her to the laboring room. Fortunately, her mother arrived around then, and was happy to take over as main doula.

Even though her progress was steady, everyone seemed overly concerned about how long she was taking. I kept reassuring Santos, her mother and every other person within ear shot, that first moms take time to open properly. Give it time. They ignored me, shaking their heads in disapproval.

When it came time to push, I called Santos in the room to translate. He told me later, that his being there was breaking some cultural taboo, but the only other option was having a different male co-worker translate instead. It was the lesser of two evils, but it bothered him.

In spite my own reassurances, I was a bit perplexed at how narrow her pelvis felt, and how slow the progress was going. What if things didn’t go well? Sigh. I pushed aside my concerns and encouraged her to push when she had a contraction. Both she and the baby were doing great.  

When the head was visible for the first time, Santos looked at me quizzically and asked: “Will she open for the baby?” It took me a minute to figure out what he was asking, but when I did I had to laugh.

Here was a husband and father-in-the-making, watching a baby-sized head trying to knock its way through something the size of a quarter. No wonder he looked confused and .... skeptical!

I assured him, she’d open up. Unconvinced, he just stood there nervously fidgeting with the doppler and (probably) wishing he was anywhere but there!

Making him translate for me was asking a lot, now that I think of it. He had never assisted before in the birthroom. He was unfamiliar with the sights, sounds and procedures. But then again, it was either him or one of his buddies.

Once Mary got her on the birth stool, there was significant progress in her pushing. But... her pushes were so intense; she didn’t (or couldn't) stop for anything. I kept asking her to breathe every now and again, but she didn't seem to hear. 

After the head was born, out popped a blue-tinged rag doll, floppy and covered in brown goo.
                 ~ What? She was fine a minute ago. What happened?

The 'doll' blinked at me, but made no other sign of life. I wiped her clean, suctioned the gunk out of her mouth and nose, but nothing. Floppy stillness.

She wasn’t dead, but she sure wasn’t trying to live!
                 ~ C'mon baby breathe!

My internal alarm sounded, as I rubbed her spine raw. She made no signs of pain. Santos was asking me why his girl didn’t look right: “Why isn’t she crying?” Ignoring him, I called for help: “Margaret, my baby won’t breathe!” She was there in a flash.

Minutes rolled by like hours, as we cleared her airways and gave oxygen. Every now and again, she’d gasp.
              ~ What happened? Just a few minutes before, her heart was a steady rhythm.

Now as I listened to her heart race in her chest, I imagined formula-one cars roaring their engines. No. Jet planes. Her heart beat was 170, but she wasn’t breathing. Limp. Cold. Ashen. Gasping.

Once Santos understood something was wrong, he was useless as an interpreter. He couldn’t focus. How could he? His little girl lay like a stained dish rag. I had to call in my other translator.

I cut the cord so Margaret could work on her better. It took a full five minutes for her color to go from light-blue to dusky. It took another five minutes for her to gasp every now and again. By 15 minutes, her color and breathing stabilized somewhat, but she was glacial.

While Margaret resuscitated, I delivered the placenta and tried to get Mary and Santos to remain calm. Mary was uncooperative and didn’t listen to any of my instructions. Santos held back fear-stained tears, choking out a questioning, ‘Why won’t she cry?’ every now and again.

Long story very short, she started breathing and we got her temperature up. She improved, but then developed a fever a few hours later. I suspect she aspirated some of the meconium (brown goo), so we started her on treatment for MAS (meconium aspiration syndrome).

Please, please pray for them all. Pray for Mary as she is trying to get her baby girl to breastfeed. It’s not going well. Pray for Santos, he’s so worried. Pray for their baby to respond well to the medications, and figure out how to breastfeed.  Thanks.

They named her Friday. No joke. Pray for my girl Friday!

Update: March 20, 2011
So little Friday didn't want to breastfeed at all that first night. We expressed colostrum and gave it to her with a syringe, along with sugar water. Her fever came down with antibiotics, and the next day she was able to breastfeed well. We discharged them yesterday afternoon. Santos was tired but happy.
Thank you so so much for your prayers!
            ~ SW

Hand Expressing Life!

Last week, a day and a half old baby was brought in with pneumonia secondary to meconium aspiration. (For those who don’t know, meconium is a baby’s first bowel movement. If lots of meconium is passed while still in utero, it increases the risk of the baby developing pneumonia if it is breathed in at birth.)

The tiny girl was seen by both Tom and Dennis, who started her on antibiotics. Her lungs were junky and her respirations were outrageously high (120-140s). It was hard to watch her fight for each breath and even harder to hear the clunk of each gasp. 

When I met her later that evening, I asked her mom if she had breastfed at all. She just shook her head and explained something about the doctors giving her oral rehydration fluid, but that was hours ago.

Confused, I dug a little more for clarification. This is what I was told: The mom had told the doctors she had no milk and they were unable to start an IV, so they resorted to oral rehydration solution.

I asked her if I could try and see if there was any milk and she agreed. I was able to hand express loads of the white gold and we fed her baby with a syringe. The little girl, licked and sucked weakly at the taste. It melted my heart!

Then, I taught the mom how to do it herself, working with her until she got the hang of it all. She was so happy to see milk and know she could be feeding her baby. In her mind, her baby was not sick so much as starving. (And she was right!)

Excited to see she was so willing to hand express, I left her to it and promised to check on her regularly. But before I left, I prayed her baby would live through the night. Her breathing was so bad... I wasn’t sure it would happen.

The next morning I rejoiced to see her baby eating well -- wanting to latch but still too weak-- and miracle of miracles, breathing so much better. It didn’t sound like the same baby! The antibiotics were very effective.

She stayed a total of three days. We discharged them while still hand expressing but the mom assured me she would continue as long as necessary. She said she was confident God would help her baby live, and so am I.

Would you believe this is my third attempt at teaching ‘hand-expression’ to a Dinka woman. She is the first one to be willing to do it. The others claimed it was too painful (aka: not worth it) and one said she felt like a cow.

Her willingness to do this simple thing, in my opinion, is what gave her baby a chance at life. I haven’t seen them this week, but I’m sure they have come back. I’ll have to ask the doctors...