Of Death and Blood.

Yesterday was a difficult day. After the grieving mother was carried off by her family, the crowd thinned enough for me to see Ajulla. She stood quietly beside the clinic entrance, looking scared and in pain.

At first I thought it was the fierceness of the woman’s grief, but as I approached her water broke. The suddenness of it surprised us all, especially Ajulla. Her eyes widened in astonishment as she looked around her as if saying, “Is this normal?”

Her belly looked suspiciously small for a term pregnancy, but I couldn’t be sure with her dress. As I walked her slowly inside for a check-up, I peppered her with questions.

When did the contractions start? Has any blood come out? How many months are you now? Have you been coming for check-ups?

She tried to answer our questions but was too confused. Once we got her on the bed, I understood everything without a word.

Two tiny black legs hung from between her legs. Her baby was dead and coming out breech.

As we waited for her birth to proceed naturally, I asked her the rest of her questions. She did not appear the least bit surprised when I told her she was delivering preterm. She actually looked relieved.

It took us only a few minutes to get the baby out, but the placenta was a challenge. I could not pull on it for fear it would tear.

With time she delivered half of it, but a large portion remained inside. She was not hemorrhaging so I did not go in after it. Instead I waited and prayed.

About an hour after the birth, her placenta was born. Ragged like hash, it fell apart in my hands.

Just as I moved her to the observation room, another woman arrived covered in blood. She knelt in the dust wearing nothing but a bloodied sheet.

-- “Are you pregnant?” I asked.
-- “Yes.” she said. The crowd gathered in to get a better look.
-- “How far along are you?”
-- “I’m 4 months...”

The crowd was getting larger, so I lifted her to her feet and together we walked inside. The prenatal women waiting to be seen, watched quietly. They would have to wait again.

Hers was less of a birth and more of a miscarriage (or incomplete abortion). Even though she claimed to be four months pregnant, her body told me otherwise. Tom had to perform a D&C to stop the bleeding, but she recovered well.

So much grief! So much loss! So much blood!

Lord, thank you for bringing these women to us. May the work we do glorify you regardless of the results. Bless them with health and heal them from their grief. Strengthen us so we can serve you faithfully. Amen.

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.

Premature.

After lunch, I was quickly called back to the clinic because a woman had delivered prematurely and her placenta was ‘stuck’ inside. My translator looked worried and so I rushed. I told the rest of the staff (who had started lunch a bit later due to other emergencies) about it and they agreed to come soon.

However, Jessica (volunteer/Nurse) hurried after me, eager to learn as much as she could. I wasn’t told anything more than that the baby was preterm and the mom had a ‘stuck’ placenta.

The last time this happened the placenta was sitting in the vaginal vault and needed the slightest tug to come out. Today was a much different case.

When I walked into the room, the mom was covered in blood and motionless on the bed. A family member was holding her baby, wrapped in a blanket and gasping for air. The baby girl only breathed every 15 seconds or so and her heart rate was a cool 60 bpm. (It should have been in the 130 range). She was dying.

I started to resuscitate and Jessica was quick to help with chest compressions. The Ambu-bag we had was much to large (due to her prematurity). She had lots of secretions and was pale.

Caleb and Maggie came in shortly afterward. Caleb took over my job in resuscitation and Maggie helped me assess the mom.

All the while, I kept calling out for more information. When was the baby born? How long has she been bleeding? How much blood has she lost? How long was her labor? How many babies has she had? Which ones of them are alive? Has this happened before?

The story unfolded for me question by question as I continued to assess the young girl. This was her forth pregnancy. Each of her babies were born premature. Each of them died.

I remember looking over to the table where Caleb and Jessica worked tirelessly on the baby girl. She wasn’t breathing spontaneously. Her heart rate would jump from 30 to 100 depending on resuscitation efforts. It didn’t look good.

Meanwhile, Maggie was getting an IV started as we could see the young mom was in hypovolemic shock. Her blood pressure was bottoming out. Her pulse was through the roof. She had been bleeding non-stop since birth (which was 3 1/2 hrs earlier).

I could see her heart beating in her chest. I didn’t need to take a pulse to count it.

When I evaluated her placenta, it was partially detached (the reason for all the bleeding). What’s more, is it was very determined to stay that way. I had to do a number of maneuvers to knock it loose. But when it came out, all the membranes were still inside.

My only option then was to do a manual exploration for the membranes. This is not comfortable but it was the only way I could be sure the membranes wouldn’t continue to cause bleeding. Fortunately it worked. Her bleeding stopped.

A second IV line was started, as we flooded her with fluids. She got 5 liters before her blood pressure even remotely stabilized. She was pale as a sheet, desperately needing the one thing we couldn’t give her; blood. 

The baby died but she didn’t. I think the baby could have survived if she was born in the clinic. But even then, I’m not sure. Maggie tells me that babies born that early here rarely survive.

The young mom, turned her head from me in sorrow when I told her but she didn’t cry. So I cried for her. I cannot begin to fathom her pain. Four time pregnant. Four time heartbroken.

The only reason I can think of her premature labor is an incompetent cervix. I told her how to fix this problem next time she gets pregnant. But I’m not sure she believed me. I think she’s lost hope of every having a baby live.

Pray for her. She’s in desperate need of blood but her family doesn’t have the resources to get her to the hospital for treatment. I think she will recover. It might take months without the blood but it’s still possible.