Aluak’s story.

Where do I start?

Do I start with the fact she was only 16 years old? Do I start with her scared eyes and obvious pain? Do I start with her partially blind grandmother who gnawed on her lower lip while telling me her story?

Seriously. Where do I start?

I think the best place to start is with the facts.

Age: 16 years old
G/P status: Primip (or first baby)
Village: Thiet (20 kilometers away)
Fundal Height: 31 cm, but irregularly shaped
Position: ROA
Fetal Heart Tones: 204 bpm
LMP: sometime in June 2011
Gestational Age: roughly nine months
Vitals: BP normal but running a low grade fever

Complaints: (according to her family)

• Baby is stuck, head can be seen but won’t come out
• Contractions for over 30 hrs
• Pushing for over 14 hrs after her water broke

As I gathered these facts, two things stood out above all the rest. She was exhausted, and her bladder bulged painfully above her pubic bone --which was the likely cause of the obstructed birth. The only way to find out, would be to catheterize her.

Her exhaustion was due in part to her long labor, but it was compounded by the fact she was denied food and water during labor.

-- “Aluak, are you thirsty?”
-- “Yes. Very thirsty.”
-- “When was the last time you took water?”
-- “A day and a half ago....”

I had her sit up while I gave her water to drink, saying, “You need water in labor. It’s very important... I know some people tell you not to drink. But that is wrong. Very wrong. You need lots of water for your muscles to work right. Do you understand?”

I was saying it more for her family than for her. I don’t think she was at a point of understanding much of anything. Too much pain... for way too long...

As I continued to review her I noticed that her baby’s head could most definitely be seen. In fact, a large caput had formed, and it protruded conspicuously from her body.

What worried me most though were the heart tones. When I first heard them, I could not believe they were actually the baby’s; they were just too fast.

The baby was stressed out and in pain... and his tiny heart sped chaotically in protest.

Fetal heart tones should be no higher than 160 bpm. His was 204, 208, 212 bpm.

-- “Aluak, your baby is alive. But he is telling me he is not happy.”
She looked at me in confusion. So I went on.
-- “What I am saying is... your baby is not well. He might die. Do you understand?”
She continued to look at me blankly, so I turned to her mother.
-- “The baby is sick. Do you understand? The baby could possibly die....”
She locked eyes with me, nodded briefly, but said nothing.

While I started an IV, Margaret catheterized Aluak. She removed about 300 cc of urine which instantly gave some relief. But there was still the issue of the birth. Would she be able to deliver now that her bladder was out of the way? There was only one way to find out.

Once we re-hydrated her, we decided it would be best to augment her contractions (which were frequent but short). It didn’t take long for the medicine to work, and what with her bladder no longer holding things up, she was able to deliver naturally a few minutes later.

Her boy was born flat and we started resuscitating immediately. Margaret worked on him with speed and determination. He slowly recovered, and by 15 minutes postpartum, was stable. (His Apgars were 3/5/7.)

We kept him on oxygen until his respirations and heart rate lowered to a reasonable range. He did not seem particularly interested in crying which concerned me, however not long afterward,  he started breastfeeding on his own, so I relaxed a bit.

He wasn’t my only concern however. Although Aluak lost little blood postpartum, she seemed to be leaking an unusual amount of urine. It was unlike anything I’d seen before. I fretted over it thinking it must be a fistula.... but did they form that quickly? I’m not sure.

All I know is I was doggedly determined to see her pee! This confused her and the rest of her family who incidentally wanted to take her home. Immediately!

-- “What? You can’t take her home now... it’s too soon,” I sputtered.
-- “But the baby is out. We take her home now,” one sister said in broken English.
-- “No. The baby is sick. She might have problems urinating, too. She must stay.”
-- “But we want take her home...”
-- “I don’t care what you want. It’s not time to go.”

This went on for awhile until I walked away in frustration, calling instructions over my shoulder for my interpreter, “Tell her to drink lots of water so she can urinate. And watch that baby closely.”

A little while later Albino, our compound manager, approached me about Aluak. “The family say they want to go home now,” he started.
-- “I know they want to go home... but the baby was born almost dead. They cannot go until the baby is healthy and she has urinated,” I explained.
-- “Oh. I did not know. Okay.”
-- “Don’t worry about them,” I continued, “I’ll go tell them again and check on the baby.”

As I went to get my stethoscope and thermometer to check vitals, her family approached me again about leaving.
-- “No. Aluak is not discharged. NO. You cannot take her yet,” I continued. I felt like a broken record. Why the hurry? Honestly.... what was so urgent that they had to go home?

Aluak sat up when I walked in. She had been sleeping. The poor thing looked exhausted, so I asked gently, “How are you feeling now, Aluak?”
-- “I’m okay. Just tired.”
-- “Have you urinated?”
-- “No.”
-- “Can you try?”
She nodded that she would but seemed too tired to move. I couldn’t blame her. After 30 hours of labor, I think I’d be out for the count.

Turning my attention to the small mound of baby blankets, I fished the thermometer out of my pocket. It’d been over 30 minutes since his vitals were taken.

He looked like he was sleeping. But as I uncovered his chest, there were no movements. He was warm but disturbingly still.

-- “When did he stop breathing?” I asked somewhat foolishly. How would they know? They too had thought he had been sleeping.

No one answered my question. They just looked around the room at one another in surprise.

I quickly put on my stethoscope and placed it against his chest.
        --Nothing.

I rubbed his spine. I flicked the soles of his feet.
         --Nothing.

Turning to Aluak, I explained, “Your baby has died.”
But again she gave me the blank look of exhaustion, so I repeated myself.
-- “Aluak, I don’t know when... but your baby has stopped breathing.”

She said nothing, but the women huddled around us all started talking for her. Their voices --some soft, some harsh-- filled the room with confusion. So I stood up and went for a translator.

Albino came to help. He was surprised by the sudden death as well. Everyone was. But even with him there, the other women in the room wouldn’t stop talking.
    -- Some days I’m glad I can’t understand all their words.

Fortunately, Albino was able to help me explain to Aluak that her baby had died peacefully. He was just too hurt after the difficult birth. She nodded that she understood but said nothing.

There was nothing to say.

Her tears spoke for her instead. They were tired tears --slow and weary-- which journeyed silently down her cheeks, then splashed in her lap. I sat with her while she cried, holding her hand and praying.

There were no words.

Now that the baby had died, they redoubled their efforts to take her home immediately. But I persistently refused. She needed to urinate before she could go. Plus, I was not about to send a 16 year old home to a distant village if she might have a vesico-vaginal fistula. Not a chance!

But with time she was able to void her bladder, and I sent her home as promised. Her little boy went with her, wrapped tightly in her arms.

So much of what happened to her could have been avoided if her family had known... 

• to give her fluids in labor, not withhold them
• to allow her to eat during labor so she would not be exhausted
• to encourage her to urinate before pushing
• to not push until the head was visible
• to seek help early if pushing was not progressing properly
• or... better yet to make her deliver in a clinic instead of at home

I talked to her about these things. I tried to explain, but I'm not sure she was in a place to learn. Please pray for her. Sixteen is just too young to learn these lessons --just too young. Thanks.

Baby Season!

Adeng after the birth. Her son is in my arms.

Today is the first day in about a week that I’ve not been labor watching... or baby catching... or  running around counting heart tones on every preggo in sight!

I'm happy but thankful for the reprieve.

Am I tired?     --Most definitely.  
But am I fried?    --Not even close.

There has been a joy surrounding these births that can only be the Lord. These women are coming in answer to my heart’s cry! I couldn’t be happier.

Last night Margaret and I delivered three more babies --two boys and a girl. Each birth was unique and special.

The first one to deliver, Adeng, had been quietly laboring for three days (two of which she spent in the clinic) before she pushed her baby out!

She had two doulas with her --a close friend who never left her side and an aunt who quietly sat back and cheered.

Her husband came to check on her regularly. Young and proud, he watched everything closely (especially how I treated his wife!) but didn’t stay long each time.

But despite the sleepless nights, we were able to stave off exhaustion, and when it came time to push she gave it her all. She was so in-tuned to her body! What a delight to watch.

When he finally made his way out with that last gentle push, the room erupted in praise. Laughing in relief, I looked up at Adeng only to see the most radiant smile shining back at me. She then started crying for joy, and thanking us over and over in her limited English.

Her sweet friend clung to her neck and cried tears of joy as well, and for some time everyone in the room was overcome.

We wept. We giggled. We praised God for His goodness!

My necklace and sweet Giver. 

(Fun side note: Earlier that day, this friend had pulled me aside to give me a gift. Quickly taking a brightly beaded necklace from her pocket, she slipped it over my head saying, “Now you are Sudan!” with an admiring grin of satisfaction. We slapped hands in thanks and she shyly stole away before I could make too much of it. What a honor!)

The second baby born that night was to Ajok! She, too, was a superstar. But unlike Adeng, she came in ready to push.

She was a solid 7 cm dilated when she arrived but with very good contractions. So I encouraged her to walk.

Wordlessly she got up and marched the clinic grounds. Her friends followed close at hand encouraging her to endure.

Ajok breastfeeding her son.

At one point I found her kneeling in the dirt out front --her friends squatting before her. I thought she might be pushing so I went to investigate. As it turns out, her friends were just rubbing her belly with spit as a blessing!

Not 10 minutes later her son was born!

She went from 7 cm to baby out in 20 minutes!

The last labor to deliver was Hala. She, too, had an entourage of well-wishers and friends; they’d been following her around all afternoon.

Although I could not understand all they were saying, I could tell that they were annoying her immensely. She kept trying to hide from them, but they wouldn’t leave her side. They followed her like a gaggle of geese --quacking and clacking about.

Only 15 years old, she acted her age and pouted with the pain. Every now and again, she indulged in some self-pity, but it never lasted very long.

Her enormous belly poked straight out like an arrow as she waddled about, and every where she went her geese followed.

I caught her peeking during both of the other births and smiled at how jealous she looked.

In fact, after Ajok’s 20 minute birthing spree, I found Hala lurking in the hallway slacked-jawed and a bit horrified... or was it indignant.

Smiling I caught her eye and she stormed off to pout by herself. Her unspoken question ringing loudly as she left was, “When will it be MY turn?”

Although I suspected her to be fully, the baby’s head was still molding and she needed to labor-down. So I encouraged her to keep moving.

She walked, stomped, sulked, then eventually slept.

I laughed as her family questioned me about her progress.
-- “Are you sure she’ll deliver tonight?”
-- “Yes. Tonight. And soon.”
-- “But she’s sleeping...”
-- “Don’t worry. The baby is coming tonight.”

Her gaggle eventually went home to their families, leaving behind her closest friend. And she slept on. Frankly, I was excited to see her sleeping; it was the ‘calm before the storm’.

Since my shift was up, I handed her over to Margaret and tried to get some sleep. I was on-call as back-up, of course, but I was getting punchy from fatigue. I needed sleep.

Fortunately, I was able to get an hour or so before they called for re-enforcements. I arrived to find her pushing but not very effectively.

Although it was 1 AM, her gaggle had returned and were calling instructions through the window. But this time they brought the men.

-- “Shove a cloth in her mouth so she can push longer!” suggested her husband.
-- “Make her kneel!” cried another.
-- “Confess, Hala, so you can deliver!” encouraged a third.

She ignored them all and pushed again and again. Progress was slow, but with time she found her groove and a chubby girl made her debut.

Hala's precious little girl.

The crowd outside cheered! Hala was amazing!

Later that night when I crawled into bed, my body ached with the joys of the day, but I was happy. So many blessings! So many sweet answers to prayer!

Thank you for praying for us -- please keep it up. Baby season is just beginning!

Head Strong!

Aleu arrived on foot but in obvious pain; her friends had to hold her upright. Sweating and shaking with each contraction I wasn’t sure if she was in labor or having convulsions from malaria. Either way, it looked urgent.

But since I was mid-prenatal I let Margaret take care of her. I’d check on her when I could.

Five minutes later, I prayed for my prenatal and pointed her toward the pharmacy. I could hear excited voices in the next cubicle (achem... I mean room), and I decided it offer my help.

I walked in to find a very pregnant girl on her back frantically trying to push. Eyes jumping in confusion, her face was a mask of fear and pain. I stayed back and watched.

It seemed that Margaret was trying to do a vaginal exam. She did so despite Aleu's pushing and called over her shoulder at me: “She’s fully. Are you ready to take her?” 

Not wanting to seem too eager, I nodded and smiled. Touching Aleu on the arm, I assured her everything was alright but that I needed her to come with me.

“Can you stop pushing for a minute and move to the other room?” I asked quietly.
She nodded and slowly sat up. At the sound of my Dinka she seemed to melt. A good sign.

Once I got her into my room, I had her start pushing. She complied but couldn’t figure out how. After a few fruitless contractions, it finally dawned on me that she may have been doing this already at home.
-- “Has she been pushing at home?” I asked the room.
-- “Yes,” my translator explained softly. Apparently this was explained before I took over.

Duh, of course she’d been pushing at home. She showed all the signs. Frightened. Exhausted. Caput on the baby’s head. Vaginal swelling.

Only then did I take a step back and ask a few extra questions. How long? When did the water break? Was there any blood? How many babies has she had?

Normally I have all this information before pushing, but this was Aleu’s first time to our clinic. She hadn’t received any antenatal care at all.

But the story she told was not new. It’s one I’ve heard over and over again. Aleu’s first child died during delivery after 3 days of pushing. This was her second child.

She went into labor the previous evening, her water broke around 2 am, and she’d been pushing ever since. That was 11 hours earlier.

Knowing this information, I did my own vaginal exam and reassessed her pelvic outlet. Her ischial spines were prominent leaving less room for the baby’s head to maneuver. It’d be a tight squeeze.

No longer willing to dilly-dally, I got out the vacuum. It’s my go-to tool every time ‘one of these’ labors comes in --labors where the damage is already done --labors where the baby is still alive but the mother is exhausted.

But even with the vacuum and her pushing with all her might the head wouldn’t budge. In the States she would have been a very good candidate for a cesarean. I’ve rarely seen such a small outlet. 

Nevertheless, we persisted and prayed. The vacuum popped off a number of times but we kept putting it back on, each time hoping that the baby would come the next push.

Finally, frustrated that we were getting nowhere and fast, I placed the vacuum once again. I was determined to pull harder than the previous times. I put my back into it.

Yes, it was foolish. Yes, a cesarean would have been a better choice. You’ll get no argument here.    
-- I will say this however. I prayed. I prayed hard. And I pulled.

Would you know it? It worked!

The head slid lower and Aleu’s eyes widened in surprise. She could feel the difference and was eager to push once again. The next contraction the head was almost crowning.

The following one, he was born!

He had massive molding on his skull, plenty of caput (or swelling) and one large scrape from the vacuum. But he was alive!

I was horrified to learn the vacuum caused him damage but I seemed to be the only one to feel that way. Everyone else was amazed and thrilled he’d come out alive! So I dropped it and rejoiced with them.

Thank you Jesus for vacuums! Thank you Jesus for babies that come out! Thank you Jesus for everyday miracles!         
             -- I’ve seen my fair share!