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.
Showing posts with label Stillbirth. Show all posts
Showing posts with label Stillbirth. Show all posts
Sunday, January 29, 2012
Thursday, October 20, 2011
Stillbirth.
I’ve only seen Achan since mid-September for prenatals. She came the first time because malaria was burning through her body. However the first treatment was not effective... or she was exposed to enough mosquitoes to get it again just 3 weeks later.
Either way, she came in again last week, but this time the malaria was worse. She was vomiting and had been for days.
I stabilized her with IV meds then sent her home with orals, but her recovery was slow.
So when I saw her in my prenatal line, I was worried. Perhaps it was something worse than malaria, and I’d misdiagnosed her.
She said she wasn’t having contractions but felt really bad. So I asked Margaret to look into it.
Margaret checked her out and laughed at me for not doing it myself. She was definitely in labor she said, and was already 8 cm dilated.
Since my hands were full with prenatals, Margaret promised to keep an eye on her. But just as she was getting pushy, another woman came in to deliver.
So Margaret took over her care, and I turned my attention to the gap-toothed mama on my bed.
She was very active, and before I had a chance to do a vaginal exam, she was pushing.
Not 15 minutes later her girl was born!
She hemorrhaged which took several medicines and maneuvers to control, but eventually things calmed down and I transferred her to the recovery room, cleaned up, and went to see if Margaret needed my help with Achan.
I found Achan trying to push as a friend supported her back. Margaret kept insisting she needed to push harder and longer. I wasn’t sure how long they’d been at it.
Picking up the doppler, I found the heart tones with ease. They were steady at 120 bpm but dipped when she pushed to 90s. I suspected head compression since the head was passing under the pubic bone, and wasn’t initially concerned.
However, as she pushed the heart tones continued to drop. Margaret kept trying to get her to push harder; I suggested new positions.
Achan’s eyes flashed wildly in fear, so I comforted her with gentle words. The tension in the room thickened the air; emotions were high. So I prayed.
As I listened to the heart tones again, I whispered to Margaret that they were dropping still. They were in the 60’s and 70’s. The baby needed to get out quickly if we hoped to have any chance at resuscitating him.
Although Achan pushed her best, the baby was slow to come. Five minutes before he was born, I could no longer find the heart tones. They had dropped to the 50s; then were gone.
My hope was that he was just too far down in the birth canal to be found, but my gut told me otherwise.
He was born pale and limp.
Margaret cut his cord immediately, and I took him to resuscitate. Though his color was pale pink, his heart was completely stopped.
Tom came to give rescue breaths, while I pumped his tiny chest. This went on for several long minutes, as the room silently watched.
--Would the Kowajas get the baby to live?
After 10 minutes with no heartbeat, we pronounced him dead, wrapped him in a blanket, and handed his blue-tinged frame to his grandmother.
The grief in her eyes was too great to look at directly, and I furtively studied my shoes.
“Malesh mama. Malesh. (I’m sorry mama. Sorry.)” I said softly.
She nodded that she’d heard, reached for him, and sat down slowly on the edge of the bed.
I had to leave the room to breathe again --my chest, tight with grief, needed the sun, the air, the song birds. It gasped for it in panic, and I sobbed.
Fortunately, Nancy (a wonderful Christian woman here to help with the pastors) was near by and she let me blubber while she prayed.
Later the pastors and staff surrounded Achan and her family in mourning. We prayed and loved on them as best we could, and then they returned home.
This death was particularly hard for both Margaret and myself. Although I could see he was declining, there was no way we could get the baby out any faster. And once he was born, there was no clear reason as to why he died.
Please pray for Achan and her family as they grieve, and particularly Margaret. This death has rattled her severely. Thanks.
Either way, she came in again last week, but this time the malaria was worse. She was vomiting and had been for days.
I stabilized her with IV meds then sent her home with orals, but her recovery was slow.
So when I saw her in my prenatal line, I was worried. Perhaps it was something worse than malaria, and I’d misdiagnosed her.
She said she wasn’t having contractions but felt really bad. So I asked Margaret to look into it.
Margaret checked her out and laughed at me for not doing it myself. She was definitely in labor she said, and was already 8 cm dilated.
Since my hands were full with prenatals, Margaret promised to keep an eye on her. But just as she was getting pushy, another woman came in to deliver.
So Margaret took over her care, and I turned my attention to the gap-toothed mama on my bed.
She was very active, and before I had a chance to do a vaginal exam, she was pushing.
Not 15 minutes later her girl was born!
She hemorrhaged which took several medicines and maneuvers to control, but eventually things calmed down and I transferred her to the recovery room, cleaned up, and went to see if Margaret needed my help with Achan.
I found Achan trying to push as a friend supported her back. Margaret kept insisting she needed to push harder and longer. I wasn’t sure how long they’d been at it.
Picking up the doppler, I found the heart tones with ease. They were steady at 120 bpm but dipped when she pushed to 90s. I suspected head compression since the head was passing under the pubic bone, and wasn’t initially concerned.
However, as she pushed the heart tones continued to drop. Margaret kept trying to get her to push harder; I suggested new positions.
Achan’s eyes flashed wildly in fear, so I comforted her with gentle words. The tension in the room thickened the air; emotions were high. So I prayed.
As I listened to the heart tones again, I whispered to Margaret that they were dropping still. They were in the 60’s and 70’s. The baby needed to get out quickly if we hoped to have any chance at resuscitating him.
Although Achan pushed her best, the baby was slow to come. Five minutes before he was born, I could no longer find the heart tones. They had dropped to the 50s; then were gone.
My hope was that he was just too far down in the birth canal to be found, but my gut told me otherwise.
He was born pale and limp.
Margaret cut his cord immediately, and I took him to resuscitate. Though his color was pale pink, his heart was completely stopped.
Tom came to give rescue breaths, while I pumped his tiny chest. This went on for several long minutes, as the room silently watched.
--Would the Kowajas get the baby to live?
After 10 minutes with no heartbeat, we pronounced him dead, wrapped him in a blanket, and handed his blue-tinged frame to his grandmother.
The grief in her eyes was too great to look at directly, and I furtively studied my shoes.
“Malesh mama. Malesh. (I’m sorry mama. Sorry.)” I said softly.
She nodded that she’d heard, reached for him, and sat down slowly on the edge of the bed.
I had to leave the room to breathe again --my chest, tight with grief, needed the sun, the air, the song birds. It gasped for it in panic, and I sobbed.
Fortunately, Nancy (a wonderful Christian woman here to help with the pastors) was near by and she let me blubber while she prayed.
Later the pastors and staff surrounded Achan and her family in mourning. We prayed and loved on them as best we could, and then they returned home.
This death was particularly hard for both Margaret and myself. Although I could see he was declining, there was no way we could get the baby out any faster. And once he was born, there was no clear reason as to why he died.
Please pray for Achan and her family as they grieve, and particularly Margaret. This death has rattled her severely. Thanks.
Thursday, September 29, 2011
Stillness.
It was the monotonous way in which she spoke that told me something was wrong. There was no urgency or fear in her voice. There was no hope.
“My baby is not moving,” she announced to my translator flatly.
This I’ve heard before. Most often it’s nothing but an overly anxious mother in need of a little reassurance. So I didn’t react.
“Okay... so she’s worried about her baby, right?” I asked, trying to determine if her ‘not moving baby’ qualified her to jump to the front of the line. She had arrived late; there were 25 woman ahead of her. I didn’t want to play favorites if all she needed was reassurance.
“Is there anything else wrong?” I asked again, wanting to hear her voice as much as know the answer.
She answered in a slow cadence that unnerved me: “I was treated for malaria 4 days ago in the market. I think the medicines they gave me hurt my baby.”
She didn’t bother to look at me while she spoke. Instead she gazed off in the distance, trying to separate herself from something. What could it be?
It’s as if she was somewhere else and her words were spoken by another. Strange.
--What wasn’t she saying?
Although nothing she’d said up to this point would have normally given her priority in line, I asked her to get up from the floor and follow me inside.
My translator thought I was being silly. He didn’t say so, but his exasperation said it all. He seemed irritated that she was jumping the line.
I was breaking my own rules, but I didn’t care. My internal alarm was blaring. Something was wrong.
Once inside, I asked her to lie down on the bed and tell me her story from the beginning. While she spoke, I measured her fundal height, then searched and searched for heart tones.
In the same monotone voice as before, she explained that 4 days earlier she had had a high fever. She’d gone to the market pharmacy and was treated for malaria. They gave her an injection and then pills and sent her home.
Her belly was small (28 cm) and as hard as a rock.
--Was she in labor? Preterm?
She continued on with her story.
Two days later, she thought something was wrong so she went to the government hospital where she learned that her baby was dead. They gave her an IV drip and kept her for observation. But the next morning they told her she needed a cesarean and referred her to Wau.
She didn’t go.
Instead she went home, and later that night her labor started.
I interrupted her story at this point to confirm that I too believed her baby was dead. I could feel no movements and find no heartbeat.
She acknowledge my words with a slight nod as her eyes hardened with resolve. She knew it. She knew it long before she came for help. Her baby was dead.
I asked her about the contractions and was told that they were much stronger now. As I palpated them, I was surprised at their strength. But she didn’t seem to notice them at all.
Turning to my translator I whispered, “Please tell her I’d like to do a vaginal exam, then set up the room. I think she might be close.”
I quickly confirmed my suspicions. She was fully with an intact membrane bulging at a +2 station.
I explained that her baby was coming soon, and asked if she wanted anyone in the room with her. She asked for her friend, and a slender woman with a furrowed brow came in. She sat uncomfortably on a stool beside the bed and fidgeted with her nails.
Once everything was in place, she started pushing. Immediately the membranes bulged outwardly. Another push and they ruptured, spilling a burnt-brick fluid on the bed.
Two more pushes and he was born.
His tiny hands lay limp against his chest as I moved him about. His cord, swollen and red, looked very out of place. And his skin, though tanned, was starting to peel, confirming my suspicions.
He’d died several days before.
After cutting the cord, I asked if she wanted to see him. She again just nodded and I held his tiny frame up for her to inspect. She looked with interest but didn’t reach for him.
Then closing her eyes, she turned away --no longer able to look upon his stillness.
She spent the rest of the morning recovering from the birth with his tightly-wrapped body cuddled in her arms. Our pastors prayed for her and counseled her, then she slept some more.
She slept but didn’t cry. I discharged her later that day.
Please pray for them. Grief is always heavier than one expects. Pray that she would turn to Jesus and let Him lift this burden for her. Thanks.
Thursday, August 25, 2011
Retained Placenta
Anger (pronounced Ang-eer) was here a few months back. I remember her well because she delivered prematurely at 5 months. --That’s not something one forgets quickly.
At the time it came as a shock to me how she could be 5 months pregnant without a fundal height of any kind. Her whole history and situation was a puzzle. --It still is.
Afterward I treated her for STD’s and cautioned her to come regularly for prenatal check-ups if she conceived again.
Well she did conceive. And she did come.
This time we found fetal heart tones early in her second trimester and her belly was growing nicely. Both hopeful things would go better, we prayed expectantly.
But once again at 5 months gestation, she started bleeding.
When she arrived and I flipped through her book my heart stopped as flashbacks of her last stillbirth played through my brain.
Were we doomed to repeat it again?
Sure enough upon examination she was delivering prematurely. Her curled fetus came out with little difficulty, but the placenta was another matter.
Long story short, I was not able to get it out.
We tried drugs and procedures but they failed. We waited and prayed... but the little bugger wouldn’t come.
I was even ready to try and vacuum it out with our manual vacuum aspirator (MVA) but it broke in my hands. --Sigh.
And I ended up sending her to Wau for a D&C.
Please pray with me that we’d be able to learn what is causing her repeat stillbirths. Pray that her husband and his other wife -- and Anger -- would all come for more STDs treatments.
Thanks.
At the time it came as a shock to me how she could be 5 months pregnant without a fundal height of any kind. Her whole history and situation was a puzzle. --It still is.
Afterward I treated her for STD’s and cautioned her to come regularly for prenatal check-ups if she conceived again.
Well she did conceive. And she did come.
This time we found fetal heart tones early in her second trimester and her belly was growing nicely. Both hopeful things would go better, we prayed expectantly.
But once again at 5 months gestation, she started bleeding.
When she arrived and I flipped through her book my heart stopped as flashbacks of her last stillbirth played through my brain.
Were we doomed to repeat it again?
Sure enough upon examination she was delivering prematurely. Her curled fetus came out with little difficulty, but the placenta was another matter.
Long story short, I was not able to get it out.
We tried drugs and procedures but they failed. We waited and prayed... but the little bugger wouldn’t come.
I was even ready to try and vacuum it out with our manual vacuum aspirator (MVA) but it broke in my hands. --Sigh.
And I ended up sending her to Wau for a D&C.
Please pray with me that we’d be able to learn what is causing her repeat stillbirths. Pray that her husband and his other wife -- and Anger -- would all come for more STDs treatments.
Thanks.
Friday, March 25, 2011
Update: Stillbirth, Wounds
Her parents greeted me joyfully, and were relieved to hear she would recover well. It was a time of celebration. What a glorious answer to prayer!
Also, the young lady with the facial wound is healing, but it's not healing right. Would you please continue to pray that the sutures would hold, and she would one day be able to smile? She is coming diligently for wound dressing, but she is sad. Pray for her to know our Living Hope! Thanks.
Thursday, March 24, 2011
Three Witnesses.
(Caution: This story is about a miscarriage, some people might find it offensive. I hope not, but it's possible.)
The annoying chirp-chirp of the ambulance wailed as it came through the gate, but I barely noticed. It’s never for me. The cases brought by ambulance are always seen by Dennis, but this time I was called.
I was told a woman claiming she was five months pregnant, started bleeding this morning. Grabbing my watch and pen, I didn’t hurry, but I didn’t lolly-gag either. The number of times, I’ve been called for an “Emergency” because a woman was miscarrying, only to find out she wasn’t pregnant but menstruating... is too numerous to count. Honestly, I’ve become skeptical.
She was sure she was five months pregnant. Absolutely sure! But getting her information was challenging, since she was grunting in wild pain. She looked like she was in labor.
Duh! That’s why they called the midwife! (sarcasm implied)
The thing was: She had no belly! Not even a bump! Nothing.
All I could see was a thick abdominal scar where her last baby was taken. It was huge. It looked like they ripped her open and left it to heal on its own. It wasn’t the discrete bikini cut that you often see. This was a classical incision extending all the way across her abdomen.
I asked her about it.
In so much pain... and while pushing no less!.... she explained that she was here in January. At that time, I examined her and said there was no heartbeat (that’s 2 months ago!). We had discussed the possibility of her being only two months pregnant, since she didn’t have a belly then either.
Again, I asked about the scar.
She explained that this was her fifth pregnancy. The first two were alive, one ended badly in an emergency c-section, and her last was a miscarriage at two months. She was convinced she was five months pregnant.
How could I argue?
She was flaying around in so much pain, I honestly didn’t know what to think.
Was she just being hysterical? No. That didn’t fit. She looked like she was in labor.
If she was delivering prematurely at five months, wouldn’t I feel the fetus? If she was only three months pregnant, her pain was way out of proportion. What if it was an ectopic pregnancy? What if she was bleeding internally!?
Not finding heart tones, I decided to try to do a pregnancy test. It sounds silly now, but I couldn’t tell if she was even pregnant.
Every movement she made, looked as if she was in transition.... like she was ready to deliver any second. Something was off.
As she peed for the test, I sent my translator to get Dennis. He needed to weigh in on this case; I couldn’t figure it out at all.
They returned together, and I informed him of my confusion. I was waiting on the pregnancy test, while he went to check the abdomen for himself.
I didn’t watch what he was doing, but I’m guessing he just pressed on it firmly and SPLASH! I kid you not, amniotic fluid gushed out on the bed, and ran all over the floor!
What?
I was so surprised, I couldn’t move. Shocked into stupidity, I glanced over to see a small baby, only a few inches long, lying on the bed. The thin umbilical cord still attached; the placenta apparently still inside.
How on earth!
Like I said, it took me a few minutes to get a grip. But when I did, I found her in a lot less pain. The contractions had stopped, since the baby was out; there was little bleeding, but lots of water to clean up.
Picking up the umbilical cord, I hesitated. What do I do next?
I told her to please push, and we would see if the placenta would come out on it’s own. She pushed with all her strength, and out popped the tiniest placenta I’ve ever seen in my life!
Everything was in miniature.
As I laid him out on the bed, she asked if her three friends could come in and see. Her husband who had labored with her, was noticeably uncomfortable, and decided to take a breather. When he did, three women, all no taller than my shoulder, gathered around to inspect the child with me. She sat up to see as well.
The cookie-sized placenta was complete, and all the membranes could be accounted for. The cord, though thin and transparent, looked normal, and though his head was proportionately larger than his body, that too was normal for five months gestation.
She wanted to know his gender, so I picked him up and brought him close. We all agreed. It was a boy.
Pressing in close for a better look, her friends murmured among themselves, and sweetly consoled my patient. They were interested, sure, but more than anything, they were witnesses. They were there to see and testify as fact: They saw the baby. They examined his body. He was dead.
Watching them, it finally occurred to me why everyone comes to gawk here. This is not a private place. Labor is not private. Birth is not private. Death is certainly not private. Honestly, how could it be?
Here, nothing important is ever done alone. Life and death. Well, that’s just flat out important! Of course they will all come and see!
Sigh. Why did it take me so long to figure this out?
Anyway, back to my story.
The shoulder-high group of comforters all nodded approvingly at my excellent work! (Ha Ha! If they only knew I didn’t do a thing!) Nevertheless, they thanked me over and over again, lifting their hands to the sky, and praising God saying: “Inchalich Nalich! Thank you God!”
I joined them in their praises. How could I not? (Yes! Thank you God for covering my blundering assumptions and ignorance! Thank you! Thank you! Thank you! Thank you this was not an ectopic pregnancy!)
I asked them what they wanted to do with the child, and she made the comment: “Oh, don’t throw him in the trash. That is my baby.”
Horrified at such a thought, I told her of course we wouldn’t; I’d find a box to put him in so they could take him home. She smiled.
They wanted to stay the night to recover, so I moved her to the observation room, gave her the right meds, and made sure she was comfortable. Her friends all joined her, energetically recounting the day’s events.
Just before I left, I wrapped her baby in gauze and placed him in an old medicine container which had a lid. She nodded appreciatively. Then I prayed. I prayed she’d be able to carry her next child to term, and once again know the joy of holding a newborn in her arms.
They all thanked me again, and I left with the sound of comforting chatter reverberating through the halls. She would be fine.
Moral of the story.
If she looks like she’s labor, it’s probably labor. Forgo the pregnancy test!
If looky-loos come to gather, let them pass. Who else is going to testify?
Five months, means five months.... even if there is no belly!
And last but not least.... when in doubt, press on the abdomen really hard, and don’t be surprised if your shoes get wet!
Postscript:
Some of you might be wondering how I could be so calloused. I am talking about a stillbirth, aren’t I? That’s a good question. Frankly, death is no longer a surprise to me. Yes, I’m sad for the woman. She was sad as well. But mostly, she was just incredibly relieved to stop bleeding. She was grateful she lived. Grief looks differently over here. So if I’ve offended you, I’m sorry. I just can’t pretend to fear death anymore. I just can’t. I hope you understand.
The annoying chirp-chirp of the ambulance wailed as it came through the gate, but I barely noticed. It’s never for me. The cases brought by ambulance are always seen by Dennis, but this time I was called.
I was told a woman claiming she was five months pregnant, started bleeding this morning. Grabbing my watch and pen, I didn’t hurry, but I didn’t lolly-gag either. The number of times, I’ve been called for an “Emergency” because a woman was miscarrying, only to find out she wasn’t pregnant but menstruating... is too numerous to count. Honestly, I’ve become skeptical.
She was sure she was five months pregnant. Absolutely sure! But getting her information was challenging, since she was grunting in wild pain. She looked like she was in labor.
Duh! That’s why they called the midwife! (sarcasm implied)
The thing was: She had no belly! Not even a bump! Nothing.
All I could see was a thick abdominal scar where her last baby was taken. It was huge. It looked like they ripped her open and left it to heal on its own. It wasn’t the discrete bikini cut that you often see. This was a classical incision extending all the way across her abdomen.
I asked her about it.
In so much pain... and while pushing no less!.... she explained that she was here in January. At that time, I examined her and said there was no heartbeat (that’s 2 months ago!). We had discussed the possibility of her being only two months pregnant, since she didn’t have a belly then either.
Again, I asked about the scar.
She explained that this was her fifth pregnancy. The first two were alive, one ended badly in an emergency c-section, and her last was a miscarriage at two months. She was convinced she was five months pregnant.
How could I argue?
She was flaying around in so much pain, I honestly didn’t know what to think.
Was she just being hysterical? No. That didn’t fit. She looked like she was in labor.
If she was delivering prematurely at five months, wouldn’t I feel the fetus? If she was only three months pregnant, her pain was way out of proportion. What if it was an ectopic pregnancy? What if she was bleeding internally!?
Not finding heart tones, I decided to try to do a pregnancy test. It sounds silly now, but I couldn’t tell if she was even pregnant.
Every movement she made, looked as if she was in transition.... like she was ready to deliver any second. Something was off.
As she peed for the test, I sent my translator to get Dennis. He needed to weigh in on this case; I couldn’t figure it out at all.
They returned together, and I informed him of my confusion. I was waiting on the pregnancy test, while he went to check the abdomen for himself.
I didn’t watch what he was doing, but I’m guessing he just pressed on it firmly and SPLASH! I kid you not, amniotic fluid gushed out on the bed, and ran all over the floor!
What?
I was so surprised, I couldn’t move. Shocked into stupidity, I glanced over to see a small baby, only a few inches long, lying on the bed. The thin umbilical cord still attached; the placenta apparently still inside.
How on earth!
Like I said, it took me a few minutes to get a grip. But when I did, I found her in a lot less pain. The contractions had stopped, since the baby was out; there was little bleeding, but lots of water to clean up.
Picking up the umbilical cord, I hesitated. What do I do next?
I told her to please push, and we would see if the placenta would come out on it’s own. She pushed with all her strength, and out popped the tiniest placenta I’ve ever seen in my life!
Everything was in miniature.
As I laid him out on the bed, she asked if her three friends could come in and see. Her husband who had labored with her, was noticeably uncomfortable, and decided to take a breather. When he did, three women, all no taller than my shoulder, gathered around to inspect the child with me. She sat up to see as well.
The cookie-sized placenta was complete, and all the membranes could be accounted for. The cord, though thin and transparent, looked normal, and though his head was proportionately larger than his body, that too was normal for five months gestation.
She wanted to know his gender, so I picked him up and brought him close. We all agreed. It was a boy.
Pressing in close for a better look, her friends murmured among themselves, and sweetly consoled my patient. They were interested, sure, but more than anything, they were witnesses. They were there to see and testify as fact: They saw the baby. They examined his body. He was dead.
Watching them, it finally occurred to me why everyone comes to gawk here. This is not a private place. Labor is not private. Birth is not private. Death is certainly not private. Honestly, how could it be?
Here, nothing important is ever done alone. Life and death. Well, that’s just flat out important! Of course they will all come and see!
Sigh. Why did it take me so long to figure this out?
Anyway, back to my story.
The shoulder-high group of comforters all nodded approvingly at my excellent work! (Ha Ha! If they only knew I didn’t do a thing!) Nevertheless, they thanked me over and over again, lifting their hands to the sky, and praising God saying: “Inchalich Nalich! Thank you God!”
I joined them in their praises. How could I not? (Yes! Thank you God for covering my blundering assumptions and ignorance! Thank you! Thank you! Thank you! Thank you this was not an ectopic pregnancy!)
I asked them what they wanted to do with the child, and she made the comment: “Oh, don’t throw him in the trash. That is my baby.”
Horrified at such a thought, I told her of course we wouldn’t; I’d find a box to put him in so they could take him home. She smiled.
They wanted to stay the night to recover, so I moved her to the observation room, gave her the right meds, and made sure she was comfortable. Her friends all joined her, energetically recounting the day’s events.
Just before I left, I wrapped her baby in gauze and placed him in an old medicine container which had a lid. She nodded appreciatively. Then I prayed. I prayed she’d be able to carry her next child to term, and once again know the joy of holding a newborn in her arms.
They all thanked me again, and I left with the sound of comforting chatter reverberating through the halls. She would be fine.
Moral of the story.
If she looks like she’s labor, it’s probably labor. Forgo the pregnancy test!
If looky-loos come to gather, let them pass. Who else is going to testify?
Five months, means five months.... even if there is no belly!
And last but not least.... when in doubt, press on the abdomen really hard, and don’t be surprised if your shoes get wet!
Postscript:
Some of you might be wondering how I could be so calloused. I am talking about a stillbirth, aren’t I? That’s a good question. Frankly, death is no longer a surprise to me. Yes, I’m sad for the woman. She was sad as well. But mostly, she was just incredibly relieved to stop bleeding. She was grateful she lived. Grief looks differently over here. So if I’ve offended you, I’m sorry. I just can’t pretend to fear death anymore. I just can’t. I hope you understand.
Tuesday, March 22, 2011
When death moves in.
(Warning: this story is about death, grief, and a traumatic birth. It’s not light reading. Also, you might need to go for a cup of coffee, and empty your bladder before starting... it’s gonna be a long one.)
Sigh. Here goes.
I’ve decided to tell her story now. I don’t know how polished, or how well this is going to come out; but I’m now able to think about it and talk about it.... so I should be able to write about it.
She came in around noon with a note from a clinic in Thiet saying her baby was still alive. That immediately got my attention; it’s not everyday, I get a note from another clinic. Something must be wrong.
So, I took a deep breath, and asked them to start from the beginning.
This is the story I got.
Expecting her first child, Awende went into labor 4 days before. However, after a day of strong contractions, her water broke, revealing thick, green amniotic fluid. She continued to labor and push, and then labor and push some more, until her father had had enough. Even though they live far from town, they made the journey to Thiet, to seek help.
Once at the clinic, the health workers determined the baby was still alive, and gave her some IV fluids. By morning, she was on a bus to see us. Like I said, she arrived around noon.
She was young, but handling the pain very well... considering.
However, every time I asked her a question, her father answered instead. He seemed mad, like he was scolding her. I eventually asked him to sit outside, but it didn’t help. He just continued answering my questions even louder from behind the wall.
Confused, I invited him back in to the room, but this time watching his body language while ignoring his tone. His hands moved nervously as he talked; it occurred to me that he wasn’t mad. He was scared. How could I have missed that?
His graying face poorly hid his anxiety. Worry and fear etched his jaw, aging him. As he spoke, his voice boomed loudly-- loud enough to mask his dismay. Instantly, I loved him.
The heart of a father. Worried for his little girl, and tired of watching her hurt, he had come for help. It broke my heart to see-- so fresh and close to the surface-- but it moved me to action.
While we talked, her mom sat outside on the bench, wringing her hands quietly.
While examining Awende, I was relieved to find a steady, happy heartbeat. She seemed tired, but not exhausted. All her vitals were normal, so I did a vaginal exam.
What I found made my heart sulk.
She was fully and at +2 station; I couldn’t find any membranes, but I did find swollen testicles and a pointy right butt cheek.
Yes, you read that right. Her baby was breech.
I had a fully dilated first-time mom with a frank breech presentation on my hands, and the nearest operating room was 3 1/2 hours away.
~ Lord. What do I do?
For those who are not midwifery minded, let me explain. Breech births in first-time moms are the riskiest. Basic physiology of a newborn means that the buttock is significantly smaller than the head. The risk is that the baby’s bum won’t dilate her well enough for the larger (and unmolded) fetal head to be born. The baby’s head can get stuck, choking off his air. If so, he’ll die.
In the states, a woman in her condition would get a cesarean STAT, but we are not in the States. We are in the middle of nowhere-Southern-Sudan. What do you do then?
~ Lord. Is there time to transport her?
Knowing the risks is different than knowing the best option.
As I prayed and discussed her case with Dennis, I had peace. Yes, risks were involved, but for reasons I can’t quite explain, I wasn’t the least bit worried. (But... more on that later.)
Dennis agreed that it would be unlikely to find transportation in time for the birth, and that, so long as the family understood the risks of vaginal delivery, we could help them.
So, I gathered them together to explain.
“Your baby is in a dangerous position,” I began, “If your baby’s head gets stuck on the way out, there is a high risk he’ll need resuscitation.” They listened, clicking their tongues in understanding. “It’s even possible he will die,” I added. They grew silent.
“The best option is surgery. It’s the only way to ensure both of them survive.” Silence.
“However, if you deliver vaginally, Awende, you need to trust me, and do what I ask. Can you do that?” More clicks of the tongue.
“If your baby gets stuck, I’ll need to cut an episiotomy.” I added, “It will most likely require suturing afterward. Do you understand?” More clicks of the tongue.
Worried grooves knit the father’s brow together as he listened to everything I said. All the while, Awende searched the faces in the room-- one after the other. I don’t think she was listening.
“What would you like to do?” I asked, directing my question to the father. He was in charge. “We will stay and deliver here,” he said. It was final. This was a man used to speaking only once.
I reiterated that there were serious risks to vaginal delivery, but that if they chose to stay, we’d do everything we could to help them. He nodded. They all did.
As Awende’s labor continued, I spoke to her about the need to change her position regularly, what pushing would look like, and what would happen in an emergency. I also informed Margaret, and asked her for help. She would be there for resuscitation purposes, and in case things went bad.
Then we set up for the birth and waited.
Awende labored well. She grunted somewhat with contractions, changing her positions often, but didn’t push. I was hoping to wait until she was more than fully dilated, in an effort to let her body open naturally.
In my head, it was our best shot. So despite being fully and at a +2 station, she breathed through contractions for almost two hours.
However, the minute she started pushing, her baby’s heart tones went south. I changed her position quickly, but they never really recovered.
-- Was a cord problem the reason behind this breech?
Unable to find heart tones, I asked her to push hard, lest the baby die. I couldn’t figure out why they were faltering, the buttock was just barely visible.
Nevertheless, Awende pushed well, and in less than 5 minutes, the body was born. He came out in a Frank breech position, and I didn’t touch him until both legs popped free.
But as I supported his body, it occurred to me, neither arm was visible.
-- Sh*t! Lord, help me get these arms out! Please, Lord!
There was little room for me to maneuver, nevertheless, I reached in to free the right arm. It came out fairly easily. A minute ticked by.
I turned his body to get to the other arm, but he wouldn’t budge. I had no leeway.
-- Father God! Help this baby come out in time.
Cutting an episiotomy, Awende flinched and tried to pull away. No time to put in anesthesia. Her little boy was still pink and squirming a bit. There was hope.
Another minute passed-- or was it two.
He finally turned, and I was able to free the second arm. Okay. Deep breath. Now for the head. But it wouldn’t come. It was no longer flexed; he had extended it. The suprapubic pressure hadn’t worked to keep it flexed. I wanted to cry.
I remember distinctly looking at the clock. I had to focus to even see it. As I counted the minutes that the body had been out... I was surprised to see it was only five.
Five minutes had felt like forever.
“He’s stuck,” I worried out loud, “Margaret, the head isn’t coming. He’s dying on me.”
“Don’t say such things. Don’t say that, Stephanie. Keep pulling. You can do it.” She encouraged. I wanted so much to believe her, but I couldn’t see how-- at least not without breaking his neck.
As I struggled to free his head, I felt his body grow limp and cold.
“Margaret, you need to try. I can’t manage.”
We readjusted Awende’s position, and she took over. Meanwhile, I sent our translator to get Dennis. Praying out loud and begging God to help, I took over the suprapubic pressure. There was nothing to push upon. Strange.
What Dennis saw when he walked into the room, I can only imagine. I quickly briefed him on the situation while he gloved up. Then, he took over where Margaret left off. Only ten minutes had passed, but I could tell the baby was dying.
He was limp, pale, and unmoving. Even if we birthed the head this instance, he would not recover. Not without a miracle.
Dennis, manipulated and moved the baby this way and that. Nothing. Awende was so cooperative. She must have been frightened, and in so much pain, but she never showed it.
For well over five minutes Dennis worked on her, without success. I looked over once to see Margaret praying silently to herself -- head bowed in reverence. I’ve never seen her do that in an emergency before.
Stopping to take a breather and reassess, Dennis put the baby down, and told us to rest as well. The baby was obviously dead. We no longer needed to rush things.
He was right.
This is where my story gets fuzzy. I’m pretty sure Margaret went back to working on him again, because I remember watching her work out of the corner of my eye, when Dennis whispered the possibility of having to cut the baby out.
I wanted to vomit.
Lord, forgive me if this is my arrogance or presumption. Forgive me Lord if this is somehow my fault. Lord. We need a miracle. Please don’t make us cut this baby out!
I thought I was praying silently, but Dennis told me afterward that it was loud and clear for all the room to hear. He went back to working on her. A few minutes later, he was able to pull the head free.
Instantly, the room grew quiet as each of us milled about in stunned exhaustion. There was no celebration, just whispered thanks to God amidst the bloody rags and dead baby.
Twenty minutes. Twenty minutes between the body and the head. Twenty painful minutes.
Only then did I notice the family in the room. The father watched silently from the doorway. The mother stood motionless beside him. They had seen it all.
Pale and somber, they stared at their dead grandson. In that wave of silence, I wanted to scream. Anything to make it stop. Anything to keep my hands from shaking.
Taking her hand to comfort her, I said, “I’m so sorry, Awende.” She just looked at me in surprise, then looked at her dead son. She said nothing.
Turning from her to her parents, I again repeated: “I’m so sorry the baby died.” Our eyes connected, but there was no incrimination or accusation. Just sorrow. Silent sorrow.
We placed her boy in a basin. It didn’t feel right. He wasn’t a placenta, or a dirty rag, but there seemed no better place to put him.
He was beautiful. So beautiful. Perfectly formed but motionless.
After weighing him and wrapping him in a blanket, I asked Awende if she wanted to hold him. Surprised at my question, she refused, as if I had just suggested she kiss a snake. (I’ve yet to see a Dinka woman ask to hold her dead baby. It’s just not done here.) I then offered him to the parents, who also refused.
So, I laid my precious cargo on the bed, and covered his face.
Everything I warned might happen, happened. The problem was, when I was describing this worst-case scenario to the family, I didn’t really think it would happen-- at least not ALL of it. I was just quoting a paragraph from one of my midwifery textbooks. ‘These are the risks of breech birth in primigravidas...’
Cord compression. Entrapped arms. Episiotomy. Entrapped head. Death.
But the thing is... it happened. All of it.
I wish my story ended there, but it doesn’t.
After the placenta was born, I told Awende I needed to suture the episiotomy. She lay still as I examined the damage. She was so brave.
What I saw surprised me... but it shouldn’t have.
The episiotomy had extended deep into her rectal mucosa; she had a complete 4th degree tear two inches long.
Again, I started to pray.
I have no problem suturing, but this was the largest tear I’ve had to deal with to date. My mind stuttered to recall the stitches necessary for such a complicated tear, but eventually, it came back to me.
I prayed over each stitch I placed. What if it doesn’t heal right? Incontinence and sexual pain will haunt her for life.
-- Lord, please heal her completely.
Once I was finished, Awende ate some food, and then promptly fell asleep. I would have too after 4 days of labor.
Afterward, when I moved her to the postpartum room, I watched her father carry the dead child like a sac of potatoes. I even shuddered a bit when he lay the boy casually in the dirt to go back for something he’d forgotten. He wasn’t being disrespectful... it was just how things are done around here.
Nevertheless, I couldn’t help going over, scooping him up, and carrying him myself. Did I mention how beautiful he was?
As I did, I could hear the hinges of my cultural worldview creak. Tell me. How are you suppose to care for a dead child? Isn’t wrapping him in a blanket enough? So what if he’s on the floor, pushed under the bed. That way, he’s not under foot. Right?
In the hours, I spent with Awende afterward, I never once saw her wail or weep. Nothing. I asked my translator why she wasn’t crying. Was I missing something? He assured me she would cry once she got home.
Again my cultural worldview continued to creak under the strain. Aren’t you suppose to cry when babies die? As a mother -- a teenage mother at that-- aren’t you allowed the luxury of tears?
Bolts pinged off my cultural worldview; it was ready to blow!
The Kenyans I talked to after this difficult birth, all said the same thing. “You did everything you could.” “Think of all the babies that could have died, but didn’t because of you. You only lost one.” “Some babies die. Don’t be sad.”
I heard their words, but they didn’t compute. My brain was mis-firing. I saw how sad this death made them, but they weren’t shaken like I was. They weren’t sick and hiding in their rooms. In fact, they couldn’t figure out why I was taking it so hard. Did my reaction mean I somehow cared more? No. Clearly not.
All it proved to me, was my cultural paradigm was coming apart!
I hate to admit it. I hate to even write it down. But what haunts me most about this experience is not the trauma, pain, or death. What bothers me most is my own reaction -- or shall I say ‘non-reaction’.
Let me explain.
Somehow in the last 10 months, without my even noticing, I’ve grown used to dead babies.
Holding their limp, cold weight in my arms, putting them in a bowl to wait as I suture, wrapping them tight, and placing them with the rest of the bags on the floor. That’s what you do. Right?
When did that happen?
I knew coming to Africa would change me. I knew I’d see things that would break my heart. I knew that I’d hear things that would haunt me at night. But this... I never suspected.
No one told me I’d live with death.
He has moved in. He is a constant dinner guest-- uninvited but fed all the same. He hangs out in the open. I see him so often, I no longer try to excuse his presence. We’re almost on speaking terms. He’s here to stay, and somehow I’m okay with that.
Will there come a day when death is so familiar we laugh together? Play together? Sing?
In Africa, death is not relegated to the back rooms and mortuaries. He enters the front door. He comes and goes as he pleases... but he’s not being rude. He lives here.
In Africa, you live with death.
Please pray. Pray for Awende to heal completely, and for her to one day know the joy of holding a child in her arms. But please also pray for me. Pray that when my cultural worldview busts into pieces, a more godly one replaces it. As death moves in, may I find a way to live with him well.
Sigh. There you have it. It’s finally out.
Sigh. Here goes.
I’ve decided to tell her story now. I don’t know how polished, or how well this is going to come out; but I’m now able to think about it and talk about it.... so I should be able to write about it.
She came in around noon with a note from a clinic in Thiet saying her baby was still alive. That immediately got my attention; it’s not everyday, I get a note from another clinic. Something must be wrong.
So, I took a deep breath, and asked them to start from the beginning.
This is the story I got.
Expecting her first child, Awende went into labor 4 days before. However, after a day of strong contractions, her water broke, revealing thick, green amniotic fluid. She continued to labor and push, and then labor and push some more, until her father had had enough. Even though they live far from town, they made the journey to Thiet, to seek help.
Once at the clinic, the health workers determined the baby was still alive, and gave her some IV fluids. By morning, she was on a bus to see us. Like I said, she arrived around noon.
She was young, but handling the pain very well... considering.
However, every time I asked her a question, her father answered instead. He seemed mad, like he was scolding her. I eventually asked him to sit outside, but it didn’t help. He just continued answering my questions even louder from behind the wall.
Confused, I invited him back in to the room, but this time watching his body language while ignoring his tone. His hands moved nervously as he talked; it occurred to me that he wasn’t mad. He was scared. How could I have missed that?
His graying face poorly hid his anxiety. Worry and fear etched his jaw, aging him. As he spoke, his voice boomed loudly-- loud enough to mask his dismay. Instantly, I loved him.
The heart of a father. Worried for his little girl, and tired of watching her hurt, he had come for help. It broke my heart to see-- so fresh and close to the surface-- but it moved me to action.
While we talked, her mom sat outside on the bench, wringing her hands quietly.
While examining Awende, I was relieved to find a steady, happy heartbeat. She seemed tired, but not exhausted. All her vitals were normal, so I did a vaginal exam.
What I found made my heart sulk.
She was fully and at +2 station; I couldn’t find any membranes, but I did find swollen testicles and a pointy right butt cheek.
Yes, you read that right. Her baby was breech.
I had a fully dilated first-time mom with a frank breech presentation on my hands, and the nearest operating room was 3 1/2 hours away.
~ Lord. What do I do?
For those who are not midwifery minded, let me explain. Breech births in first-time moms are the riskiest. Basic physiology of a newborn means that the buttock is significantly smaller than the head. The risk is that the baby’s bum won’t dilate her well enough for the larger (and unmolded) fetal head to be born. The baby’s head can get stuck, choking off his air. If so, he’ll die.
In the states, a woman in her condition would get a cesarean STAT, but we are not in the States. We are in the middle of nowhere-Southern-Sudan. What do you do then?
~ Lord. Is there time to transport her?
Knowing the risks is different than knowing the best option.
As I prayed and discussed her case with Dennis, I had peace. Yes, risks were involved, but for reasons I can’t quite explain, I wasn’t the least bit worried. (But... more on that later.)
Dennis agreed that it would be unlikely to find transportation in time for the birth, and that, so long as the family understood the risks of vaginal delivery, we could help them.
So, I gathered them together to explain.
“Your baby is in a dangerous position,” I began, “If your baby’s head gets stuck on the way out, there is a high risk he’ll need resuscitation.” They listened, clicking their tongues in understanding. “It’s even possible he will die,” I added. They grew silent.
“The best option is surgery. It’s the only way to ensure both of them survive.” Silence.
“However, if you deliver vaginally, Awende, you need to trust me, and do what I ask. Can you do that?” More clicks of the tongue.
“If your baby gets stuck, I’ll need to cut an episiotomy.” I added, “It will most likely require suturing afterward. Do you understand?” More clicks of the tongue.
Worried grooves knit the father’s brow together as he listened to everything I said. All the while, Awende searched the faces in the room-- one after the other. I don’t think she was listening.
“What would you like to do?” I asked, directing my question to the father. He was in charge. “We will stay and deliver here,” he said. It was final. This was a man used to speaking only once.
I reiterated that there were serious risks to vaginal delivery, but that if they chose to stay, we’d do everything we could to help them. He nodded. They all did.
As Awende’s labor continued, I spoke to her about the need to change her position regularly, what pushing would look like, and what would happen in an emergency. I also informed Margaret, and asked her for help. She would be there for resuscitation purposes, and in case things went bad.
Then we set up for the birth and waited.
Awende labored well. She grunted somewhat with contractions, changing her positions often, but didn’t push. I was hoping to wait until she was more than fully dilated, in an effort to let her body open naturally.
In my head, it was our best shot. So despite being fully and at a +2 station, she breathed through contractions for almost two hours.
However, the minute she started pushing, her baby’s heart tones went south. I changed her position quickly, but they never really recovered.
-- Was a cord problem the reason behind this breech?
Unable to find heart tones, I asked her to push hard, lest the baby die. I couldn’t figure out why they were faltering, the buttock was just barely visible.
Nevertheless, Awende pushed well, and in less than 5 minutes, the body was born. He came out in a Frank breech position, and I didn’t touch him until both legs popped free.
But as I supported his body, it occurred to me, neither arm was visible.
-- Sh*t! Lord, help me get these arms out! Please, Lord!
There was little room for me to maneuver, nevertheless, I reached in to free the right arm. It came out fairly easily. A minute ticked by.
I turned his body to get to the other arm, but he wouldn’t budge. I had no leeway.
-- Father God! Help this baby come out in time.
Cutting an episiotomy, Awende flinched and tried to pull away. No time to put in anesthesia. Her little boy was still pink and squirming a bit. There was hope.
Another minute passed-- or was it two.
He finally turned, and I was able to free the second arm. Okay. Deep breath. Now for the head. But it wouldn’t come. It was no longer flexed; he had extended it. The suprapubic pressure hadn’t worked to keep it flexed. I wanted to cry.
I remember distinctly looking at the clock. I had to focus to even see it. As I counted the minutes that the body had been out... I was surprised to see it was only five.
Five minutes had felt like forever.
“He’s stuck,” I worried out loud, “Margaret, the head isn’t coming. He’s dying on me.”
“Don’t say such things. Don’t say that, Stephanie. Keep pulling. You can do it.” She encouraged. I wanted so much to believe her, but I couldn’t see how-- at least not without breaking his neck.
As I struggled to free his head, I felt his body grow limp and cold.
“Margaret, you need to try. I can’t manage.”
We readjusted Awende’s position, and she took over. Meanwhile, I sent our translator to get Dennis. Praying out loud and begging God to help, I took over the suprapubic pressure. There was nothing to push upon. Strange.
What Dennis saw when he walked into the room, I can only imagine. I quickly briefed him on the situation while he gloved up. Then, he took over where Margaret left off. Only ten minutes had passed, but I could tell the baby was dying.
He was limp, pale, and unmoving. Even if we birthed the head this instance, he would not recover. Not without a miracle.
Dennis, manipulated and moved the baby this way and that. Nothing. Awende was so cooperative. She must have been frightened, and in so much pain, but she never showed it.
For well over five minutes Dennis worked on her, without success. I looked over once to see Margaret praying silently to herself -- head bowed in reverence. I’ve never seen her do that in an emergency before.
Stopping to take a breather and reassess, Dennis put the baby down, and told us to rest as well. The baby was obviously dead. We no longer needed to rush things.
He was right.
This is where my story gets fuzzy. I’m pretty sure Margaret went back to working on him again, because I remember watching her work out of the corner of my eye, when Dennis whispered the possibility of having to cut the baby out.
I wanted to vomit.
Lord, forgive me if this is my arrogance or presumption. Forgive me Lord if this is somehow my fault. Lord. We need a miracle. Please don’t make us cut this baby out!
I thought I was praying silently, but Dennis told me afterward that it was loud and clear for all the room to hear. He went back to working on her. A few minutes later, he was able to pull the head free.
Instantly, the room grew quiet as each of us milled about in stunned exhaustion. There was no celebration, just whispered thanks to God amidst the bloody rags and dead baby.
Twenty minutes. Twenty minutes between the body and the head. Twenty painful minutes.
Only then did I notice the family in the room. The father watched silently from the doorway. The mother stood motionless beside him. They had seen it all.
Pale and somber, they stared at their dead grandson. In that wave of silence, I wanted to scream. Anything to make it stop. Anything to keep my hands from shaking.
Taking her hand to comfort her, I said, “I’m so sorry, Awende.” She just looked at me in surprise, then looked at her dead son. She said nothing.
Turning from her to her parents, I again repeated: “I’m so sorry the baby died.” Our eyes connected, but there was no incrimination or accusation. Just sorrow. Silent sorrow.
We placed her boy in a basin. It didn’t feel right. He wasn’t a placenta, or a dirty rag, but there seemed no better place to put him.
He was beautiful. So beautiful. Perfectly formed but motionless.
After weighing him and wrapping him in a blanket, I asked Awende if she wanted to hold him. Surprised at my question, she refused, as if I had just suggested she kiss a snake. (I’ve yet to see a Dinka woman ask to hold her dead baby. It’s just not done here.) I then offered him to the parents, who also refused.
So, I laid my precious cargo on the bed, and covered his face.
Everything I warned might happen, happened. The problem was, when I was describing this worst-case scenario to the family, I didn’t really think it would happen-- at least not ALL of it. I was just quoting a paragraph from one of my midwifery textbooks. ‘These are the risks of breech birth in primigravidas...’
Cord compression. Entrapped arms. Episiotomy. Entrapped head. Death.
But the thing is... it happened. All of it.
I wish my story ended there, but it doesn’t.
After the placenta was born, I told Awende I needed to suture the episiotomy. She lay still as I examined the damage. She was so brave.
What I saw surprised me... but it shouldn’t have.
The episiotomy had extended deep into her rectal mucosa; she had a complete 4th degree tear two inches long.
Again, I started to pray.
I have no problem suturing, but this was the largest tear I’ve had to deal with to date. My mind stuttered to recall the stitches necessary for such a complicated tear, but eventually, it came back to me.
I prayed over each stitch I placed. What if it doesn’t heal right? Incontinence and sexual pain will haunt her for life.
-- Lord, please heal her completely.
Once I was finished, Awende ate some food, and then promptly fell asleep. I would have too after 4 days of labor.
Afterward, when I moved her to the postpartum room, I watched her father carry the dead child like a sac of potatoes. I even shuddered a bit when he lay the boy casually in the dirt to go back for something he’d forgotten. He wasn’t being disrespectful... it was just how things are done around here.
Nevertheless, I couldn’t help going over, scooping him up, and carrying him myself. Did I mention how beautiful he was?
As I did, I could hear the hinges of my cultural worldview creak. Tell me. How are you suppose to care for a dead child? Isn’t wrapping him in a blanket enough? So what if he’s on the floor, pushed under the bed. That way, he’s not under foot. Right?
In the hours, I spent with Awende afterward, I never once saw her wail or weep. Nothing. I asked my translator why she wasn’t crying. Was I missing something? He assured me she would cry once she got home.
Again my cultural worldview continued to creak under the strain. Aren’t you suppose to cry when babies die? As a mother -- a teenage mother at that-- aren’t you allowed the luxury of tears?
Bolts pinged off my cultural worldview; it was ready to blow!
The Kenyans I talked to after this difficult birth, all said the same thing. “You did everything you could.” “Think of all the babies that could have died, but didn’t because of you. You only lost one.” “Some babies die. Don’t be sad.”
I heard their words, but they didn’t compute. My brain was mis-firing. I saw how sad this death made them, but they weren’t shaken like I was. They weren’t sick and hiding in their rooms. In fact, they couldn’t figure out why I was taking it so hard. Did my reaction mean I somehow cared more? No. Clearly not.
All it proved to me, was my cultural paradigm was coming apart!
I hate to admit it. I hate to even write it down. But what haunts me most about this experience is not the trauma, pain, or death. What bothers me most is my own reaction -- or shall I say ‘non-reaction’.
Let me explain.
Somehow in the last 10 months, without my even noticing, I’ve grown used to dead babies.
Holding their limp, cold weight in my arms, putting them in a bowl to wait as I suture, wrapping them tight, and placing them with the rest of the bags on the floor. That’s what you do. Right?
When did that happen?
I knew coming to Africa would change me. I knew I’d see things that would break my heart. I knew that I’d hear things that would haunt me at night. But this... I never suspected.
No one told me I’d live with death.
He has moved in. He is a constant dinner guest-- uninvited but fed all the same. He hangs out in the open. I see him so often, I no longer try to excuse his presence. We’re almost on speaking terms. He’s here to stay, and somehow I’m okay with that.
Will there come a day when death is so familiar we laugh together? Play together? Sing?
In Africa, death is not relegated to the back rooms and mortuaries. He enters the front door. He comes and goes as he pleases... but he’s not being rude. He lives here.
In Africa, you live with death.
Please pray. Pray for Awende to heal completely, and for her to one day know the joy of holding a child in her arms. But please also pray for me. Pray that when my cultural worldview busts into pieces, a more godly one replaces it. As death moves in, may I find a way to live with him well.
Sigh. There you have it. It’s finally out.
Wednesday, March 16, 2011
Choking on Grief.
Saturday, a young girl was brought to me in labor. Her story is hard to share. I want to write about it. In fact, I desperately want it out, but I can’t.
Each word sticks in my throat, choking back bile, grief, and shame. They fester in my stomach, making me sick. Oh, to vomit them up in readable paragraphs! What relief it would bring!
But I can’t seem to manage.
Telling her story makes it truer, somehow. I don’t want it to be true. I want to forget. So, I push my thoughts down with my words, only to gag that much more.
Choking on grief, what a nasty way to live.
Hopefully.... hopefully, I’ll be able to write her story down soon. I don’t know how long it will take me.
She lived. Her baby died.
He was such a beautiful baby... sigh. More bile. Gulp.
Her name is Awende.
Pray as the Lord leads.
Each word sticks in my throat, choking back bile, grief, and shame. They fester in my stomach, making me sick. Oh, to vomit them up in readable paragraphs! What relief it would bring!
But I can’t seem to manage.
Telling her story makes it truer, somehow. I don’t want it to be true. I want to forget. So, I push my thoughts down with my words, only to gag that much more.
Choking on grief, what a nasty way to live.
Hopefully.... hopefully, I’ll be able to write her story down soon. I don’t know how long it will take me.
She lived. Her baby died.
He was such a beautiful baby... sigh. More bile. Gulp.
Her name is Awende.
Pray as the Lord leads.
Thursday, December 2, 2010
Nyibol's Tears ~
(Warning: This story is hard to write. It might not be for everyone.)
This morning started early. I was called out of bed - dragon breath and duck puddy galore - to attend a lady in labor. The strain in my translators voice when he called, put urgency to my steps.
The robot drone in my brain issued orders: Dress. Do NOT stop for coffee. Do NOT brush teeth. Go directly to birth. Go.
I obeyed. But as I was going, I woke up Racheal (my roomie) for help. Last night, the health worker on shift was up all night with 9 admissions. (yes. 9 admission. A record, I think.) He was sure to be too tired to help me much. Would she come? She dressed and was out the door even before I was.
I also met Dr. Dave on the way, and invited him and Dr. Tom to join in. For some reason, I knew this one would need a few extra hands. Even if not, more the merrier. Right?
We all arrived in unison and were greeted by a sweet girl named Nyibol. She was expecting her first and was obviously in hard labor. I was happy to see her. I’m always happy to see my prenatal girls. And this one has been coming for months.
Month after month, as I measured her belly and listened to the toc-toc-toc of her baby’s heart, we bonded. She was looking forward to this day. So was I.
She squirmed in pain as I measured her belly for the last time. She winced, then smiled, when I palpated for the head. The contractions were on top of each other. I smiled back knowing it was close and then reached for the doppler.
Finding the baby’s back was easy... but I couldn’t find the heart. But then a contraction hit again. It was probably just the contractions... or the head was too low in the pelvis, I told myself.
I handed off the doppler to my assistant and put on gloves for a vaginal exam. I wanted to make sure she was fully before I asked her to push.
Immediately I could feel there was something amiss. Membranes. Fluid. Something sharp. Little things with bumps. She was fully dilated and her bag of waters was still in tact. But... I felt things in there that didn’t belong. Only after prodding a bit, did it occur to me that I was feeling a hand.
A hand? -- not good.
Hand presentations can cause obstructed labor. My mind raced back over the catalogue of articles and research I’ve done on this. What I remembered was not good. This was not good.
Only then did it occur to me, the hand wasn’t moving. “It should be moving,” I thought. I risked rupturing the membranes and pushed in deeper. What EXACTLY was I dealing with? I found something sharp and straight -- and very un-head-like.
I told the crew we had a hand presentation and possible fetal demise, de-gloved and grabbed for the doppler again. I was determined to find a heartbeat.
But I didn’t.
Nyibol, blissfully ignorant of my hurried whispers to the crew, labored on.
--“Honey, can you feel your baby moving?”
--“No.”
--“How long has it been? When did you feel your baby move last?”
--“I felt him move yesterday, before my labor began. But once it started, I didn’t feel him moving anymore.”
I then explained that she was close to delivering but that I wasn’t sure if her baby was alive. I told her the baby’s hand was in the way and I was going to have to push it out of the way. Did she understand?
It was a solemn few minutes as realization sank in. The room got crowded with question marks and whispers. “Do you understand what I’m saying, Nyibol?” I asked. She just nodded quietly.
Dr. Tom, eager to learn all he can about birth leaned in to say, “I’m so glad I’m not in charge. If I had to deal with a hand presentation right now...” And then shook his head.
Did that make me the expert? Am I in charge? Oh, Lord! Help me. Help me, please.
Not long after, her water broke and then the pushing. There was hair - lots of it. But the head was soft. Squishy. Swollen.
Hydrocephalus? No. Maybe. Oh! I don’t know.
The skull was broken. Shattered. Sharp edges poked out beneath the skin.
“Where is the face?” I wondered. “Where are the ears?” The head just kept coming. “Lord, does this baby have a face?” So much was so wrong.
Minutes stretched out to hours. Moments lasted forever. Even now, as I think back, the birth felt like a movie played in slow motion. Frame by frame, it flashes through my mind.
Eventually, I found his face. An ear. The head was born - swollen and hopelessly deformed. The shoulder. The chest. The hips. His body lay limp on the bed, arms flopping to one side. Skin peeling in places, exposing white flesh beneath.
He was dead.
And from the state of his peeling, he had been dead for at least a day -- maybe longer.
Niybol, relieved the pain had stopped, sank back on the bed, exhausted. She was too tired to wail but not too tired to weep. Tears streaked her face. She made no attempt to hide them.
She had done all she could to be healthy. She came regularly for check-ups. She even came to the clinic for delivery. The kowaja delivered her child. What more could she do? What went wrong?
“Do you want to hold your little boy?” I asked. “He’s beautiful. So perfect in so many ways.” She wouldn’t even look at him, let alone hold him. “Are you sure?” She just shook her head.
After examining him and wrapping him tight, she eventually took him in her arms. But she held him away from her and refused to look at him. More tears.
Her family came in, heads hung low, eyes downcast. What should they do with the baby? (Here they bury the baby immediately. There is no hub-bub, no fuss and certainly no casket.)
A man, tall but slouching, stepped forward to take care of it all. I took her boy and placed him in his arms. He held him like a box of breakables-- delicate and fancy -- and walked out.
Nyibol didn’t say another word the rest of the morning. She answered my questions with nods and slight shakes of her head. I monitored her for a few hours and she recovered with ease. She was able to sleep and eat something, but didn’t find her voice. Her tears spoke for her.
As I went to discharge her, she sat sullen and dejected. Quiet. Her family looked on. She couldn’t speak so I spoke for her instead. I spoke loud enough for everyone to hear.
“Nyibol, I want to tell you the story of your baby’s birth. Can I tell you what happened? What I saw?” She nodded and looked at me, eager to understand why. But she didn’t speak.
“When you arrived, your baby was already dead. He was most likely dead since yesterday when your labor started.” She didn’t move. She just looked at me, remembering. “When he was born, I could see no reason why he died. He had no deformities. He was perfect in almost every way.” She nodded, hearing if not believing.
“The cord was not wrapped around his neck. There was no sickness that I could see. But I did notice something strange about his umbilical cord. It was very red and very swollen near his belly. Perhaps that is what caused him to die.” She looked at me, eyes brimming with tears that she could no longer hold back. She silently nodded, glad to know all that I had to share.
I continued, “I want you to know, Nyibol, you did nothing wrong.” The tears started to flow. “I want you to understand that you should not feel guilty.” The tears flowed so hard, she had to turn her face to the wall. “Do you understand, Nyibol? This is not your fault. You did everything right. You got good prenatal care. You took care of yourself and your baby.”
She looked at me relieved and broken. Her whole chest sighed with each sob. “Do you hear me, Nyibol? You did nothing wrong.” I was speaking as much for her family as I was for her. “I want you to know that this is not the result of a curse. And if anyone tells you that this is your fault, remember what I’m saying. You tell them that your doctor said you did nothing wrong. You explain to them that the cord wasn’t normal.”
She leaned her head on mine and we wept. There was nothing left to say. Nothing left to do. So I prayed. Her family silently watched on. And then she left.
I grieve for her loss and pray. Pray with me. For He is no doubt collecting many tears tonight.
“You keep track of all my sorrows. You have collected all my tears in your bottle. You have recorded each one in your book.” Psalm 56:8
This morning started early. I was called out of bed - dragon breath and duck puddy galore - to attend a lady in labor. The strain in my translators voice when he called, put urgency to my steps.
The robot drone in my brain issued orders: Dress. Do NOT stop for coffee. Do NOT brush teeth. Go directly to birth. Go.
I obeyed. But as I was going, I woke up Racheal (my roomie) for help. Last night, the health worker on shift was up all night with 9 admissions. (yes. 9 admission. A record, I think.) He was sure to be too tired to help me much. Would she come? She dressed and was out the door even before I was.
I also met Dr. Dave on the way, and invited him and Dr. Tom to join in. For some reason, I knew this one would need a few extra hands. Even if not, more the merrier. Right?
We all arrived in unison and were greeted by a sweet girl named Nyibol. She was expecting her first and was obviously in hard labor. I was happy to see her. I’m always happy to see my prenatal girls. And this one has been coming for months.
Month after month, as I measured her belly and listened to the toc-toc-toc of her baby’s heart, we bonded. She was looking forward to this day. So was I.
She squirmed in pain as I measured her belly for the last time. She winced, then smiled, when I palpated for the head. The contractions were on top of each other. I smiled back knowing it was close and then reached for the doppler.
Finding the baby’s back was easy... but I couldn’t find the heart. But then a contraction hit again. It was probably just the contractions... or the head was too low in the pelvis, I told myself.
I handed off the doppler to my assistant and put on gloves for a vaginal exam. I wanted to make sure she was fully before I asked her to push.
Immediately I could feel there was something amiss. Membranes. Fluid. Something sharp. Little things with bumps. She was fully dilated and her bag of waters was still in tact. But... I felt things in there that didn’t belong. Only after prodding a bit, did it occur to me that I was feeling a hand.
A hand? -- not good.
Hand presentations can cause obstructed labor. My mind raced back over the catalogue of articles and research I’ve done on this. What I remembered was not good. This was not good.
Only then did it occur to me, the hand wasn’t moving. “It should be moving,” I thought. I risked rupturing the membranes and pushed in deeper. What EXACTLY was I dealing with? I found something sharp and straight -- and very un-head-like.
I told the crew we had a hand presentation and possible fetal demise, de-gloved and grabbed for the doppler again. I was determined to find a heartbeat.
But I didn’t.
Nyibol, blissfully ignorant of my hurried whispers to the crew, labored on.
--“Honey, can you feel your baby moving?”
--“No.”
--“How long has it been? When did you feel your baby move last?”
--“I felt him move yesterday, before my labor began. But once it started, I didn’t feel him moving anymore.”
I then explained that she was close to delivering but that I wasn’t sure if her baby was alive. I told her the baby’s hand was in the way and I was going to have to push it out of the way. Did she understand?
It was a solemn few minutes as realization sank in. The room got crowded with question marks and whispers. “Do you understand what I’m saying, Nyibol?” I asked. She just nodded quietly.
Dr. Tom, eager to learn all he can about birth leaned in to say, “I’m so glad I’m not in charge. If I had to deal with a hand presentation right now...” And then shook his head.
Did that make me the expert? Am I in charge? Oh, Lord! Help me. Help me, please.
Not long after, her water broke and then the pushing. There was hair - lots of it. But the head was soft. Squishy. Swollen.
Hydrocephalus? No. Maybe. Oh! I don’t know.
The skull was broken. Shattered. Sharp edges poked out beneath the skin.
“Where is the face?” I wondered. “Where are the ears?” The head just kept coming. “Lord, does this baby have a face?” So much was so wrong.
Minutes stretched out to hours. Moments lasted forever. Even now, as I think back, the birth felt like a movie played in slow motion. Frame by frame, it flashes through my mind.
Eventually, I found his face. An ear. The head was born - swollen and hopelessly deformed. The shoulder. The chest. The hips. His body lay limp on the bed, arms flopping to one side. Skin peeling in places, exposing white flesh beneath.
He was dead.
And from the state of his peeling, he had been dead for at least a day -- maybe longer.
Niybol, relieved the pain had stopped, sank back on the bed, exhausted. She was too tired to wail but not too tired to weep. Tears streaked her face. She made no attempt to hide them.
She had done all she could to be healthy. She came regularly for check-ups. She even came to the clinic for delivery. The kowaja delivered her child. What more could she do? What went wrong?
“Do you want to hold your little boy?” I asked. “He’s beautiful. So perfect in so many ways.” She wouldn’t even look at him, let alone hold him. “Are you sure?” She just shook her head.
After examining him and wrapping him tight, she eventually took him in her arms. But she held him away from her and refused to look at him. More tears.
Her family came in, heads hung low, eyes downcast. What should they do with the baby? (Here they bury the baby immediately. There is no hub-bub, no fuss and certainly no casket.)
A man, tall but slouching, stepped forward to take care of it all. I took her boy and placed him in his arms. He held him like a box of breakables-- delicate and fancy -- and walked out.
Nyibol didn’t say another word the rest of the morning. She answered my questions with nods and slight shakes of her head. I monitored her for a few hours and she recovered with ease. She was able to sleep and eat something, but didn’t find her voice. Her tears spoke for her.
As I went to discharge her, she sat sullen and dejected. Quiet. Her family looked on. She couldn’t speak so I spoke for her instead. I spoke loud enough for everyone to hear.
“Nyibol, I want to tell you the story of your baby’s birth. Can I tell you what happened? What I saw?” She nodded and looked at me, eager to understand why. But she didn’t speak.
“When you arrived, your baby was already dead. He was most likely dead since yesterday when your labor started.” She didn’t move. She just looked at me, remembering. “When he was born, I could see no reason why he died. He had no deformities. He was perfect in almost every way.” She nodded, hearing if not believing.
“The cord was not wrapped around his neck. There was no sickness that I could see. But I did notice something strange about his umbilical cord. It was very red and very swollen near his belly. Perhaps that is what caused him to die.” She looked at me, eyes brimming with tears that she could no longer hold back. She silently nodded, glad to know all that I had to share.
I continued, “I want you to know, Nyibol, you did nothing wrong.” The tears started to flow. “I want you to understand that you should not feel guilty.” The tears flowed so hard, she had to turn her face to the wall. “Do you understand, Nyibol? This is not your fault. You did everything right. You got good prenatal care. You took care of yourself and your baby.”
She looked at me relieved and broken. Her whole chest sighed with each sob. “Do you hear me, Nyibol? You did nothing wrong.” I was speaking as much for her family as I was for her. “I want you to know that this is not the result of a curse. And if anyone tells you that this is your fault, remember what I’m saying. You tell them that your doctor said you did nothing wrong. You explain to them that the cord wasn’t normal.”
She leaned her head on mine and we wept. There was nothing left to say. Nothing left to do. So I prayed. Her family silently watched on. And then she left.
I grieve for her loss and pray. Pray with me. For He is no doubt collecting many tears tonight.
“You keep track of all my sorrows. You have collected all my tears in your bottle. You have recorded each one in your book.” Psalm 56:8
Saturday, November 20, 2010
Silence in the womb.
*Caution: This story isn't for everyone. It's a story of death and heartache but needs to be told.
I was told in Midwifery school once, that after a birth... you’ll always know why the birth went the way it did. If there is bleeding or fetal distress... or even death, it is often only afterward that the cause is made clear.
We cannot see inside the womb but it doesn’t mean we are blind. A watchful and attentive midwife will know when things are not going well. There are signs. There are precautions to take.
When Achol came in on Tuesday last, she was tired. She had been up all night in labor but was otherwise doing well. But I couldn’t say the same for her child. Her waters had broke at home several hours before, pouring out slimy, thick, brown amniotic fluid. And as I listened to his heart beat... my warning alarm went off.
They would go up and down with and without contractions. I had to keep moving her around to find a position which didn’t cause the heart beat to drop. I immediately suspected a cord compression of some kind, but which kind? It didn’t appear to be a prolapsed cord. But I wasn’t ruling it out.
My heart bonded to her immediately and I have to admit, I smiled at her antics. This was her first pregnancy and as a teenager... she acted like it. (I’d guess her to be about 14-16 years old). As she moped about the clinic, she cried out loudly for God to “just let her die!” and for me “to give her a cesarean! Now!.”
I knew she was tired but I had to smile. She was just too adorable. I was strong with her though and warned her repeatedly that her baby wasn’t doing well. That she needed to listen carefully when I asked her to get in different positions. It was for her baby’s best. Sometimes she complied. Other times she didn’t.
As she labored that afternoon, some of her relatives explained a bit of her story. They said that her husband was a soldier. He wooed her and took her as a wife without paying the bride price. They ran away to Tonj together. And all was fine until six days earlier, he was killed in a car crash. She had just returned from his funeral. This was his only child.
It explained why her husband wasn’t there and her brother-in-law was. It also explained why she was so scared. Her family and friends lived very far away. She was alone in many ways.
She kept trying to push prematurely which caused some cervical swelling and a notable caput (swelling of the fetal head) to form. The thing was... each time she pushed prematurely her baby’s heart beat would drop. I begged her NOT to push. Everyone did.
In my head, I was pretty confident I was going to need to resuscitate this baby. I was prepared for it and so was the rest of the team. My hope (since I couldn’t get her the cesarean she needed) was to get her to breathe through her contractions until the very last moment and then push like mad.
She kept pushing each contraction so I did another vaginal exam. Finally, she was fully dilated and the heart tones were good, so I asked her to push. But as she pushed, the heart tones dropped. She moved in various positions and pushed. But since this was her first child, it took her time to figure out how to push exactly.
We worked feverishly to get the baby out. But I couldn’t get Achol to hurry. She had no sense of urgency. I don’t know if it was her age... or if my urgency was lost in translation. All I know is she dilly-dallied. (But as I look back at the chart she really only pushed about 45 minutes - which is short for a first time mom.)
Again, I found myself wishing for a vacuum extraction. Again, I did perineal stretching -- anything to get this baby out quickly. I had people searching for heart tones every few minutes. They were there for the first 15 minutes or so... then disappeared completely.
My hope was that the baby was just too low in the pelvis for us to hear them. But I wasn’t convinced. Ten minutes went by. I begged Achol to push with all her might. Another 10 minutes went by. Still no heartbeat found. I kept praying and with each passing minute I prayed even more.
It’s at this point I asked for the episiotomy scissors. I’ve never cut an episiotomy before. But the head was finally low enough for it to work. We hadn’t heard the heart in almost 30 minutes and the head was dusky.
I cut. She pushed. And he was born -- Limp, ashen and lifeless. Thick, sticky, meconium oozed from his mouth and nose. No breaths. Not even a grunt. No heart beat. Silence.
We started PPV and chest compressions but he didn’t respond. All the while, Achol watched in confusion. While resuscitating, I verbally walked her through what was going on. “Your baby isn’t breathing... we are giving him oxygen. Your baby’s heart isn’t beating. We are going to try to get it started.”
She seemed very confused and wildly looked from face to face in the room. Only after we gave up resuscitation efforts did she fully grasp her baby was dead. She wailed and mourned loudly, calling out to God. I cut the cord and she took him in her arms -- crying even louder than before. Desperate pleas of ‘Why!’ along with a warm, stream of tears filled the room... and the silence.
I didn’t have to speak Dinka to understand her words. They were universal. Part of me wonders if her brother and mother-in-law didn’t grieve even harder. They were equally devastated holding that beautiful boy in their arms. He was all that remained of their son... and brother.
Afterward, I had to suture the episiotomy (almost) against her will. She kept insisting I leave it but I couldn’t. I couldn’t leave her deformed. She didn’t know what she was asking. Fortunately, she slept through it. It was just too much to handle. Too much pain. Too much sorrow.
The boy was taken home to be buried and I kept her over night for observation. We ministered to her in every way we knew how. But I think the most effective person was Sabet (ministry director/Dinka man). He asked to hear her story and he listened. Later he explained to me that he wanted to see if she blamed herself. Her answer was heartbreaking.
She confessed that she broke her father’s heart by running away with her husband. She knew it was wrong but didn’t care. Now she felt cursed by God for disobeying her father. First her husband dies... now her son. “God is punishing me,” she said. “I am cursed.”
He shared with her the truth of God’s love and prayed for her. He also challenged her to return to her family... and seek forgiveness. I pray that she does. But even more, I pray she finds the forgiveness of our Heavenly Father and is forever changed by it and His love.
Please pray for her. Also, pray for me. I can’t help reliving the birth in my head and trying to manage it differently. What if I referred her to Wau the moment she got to the clinic? Would she have gone? Would it have made a difference? What if I had been clearer, earlier on, that her baby was at such a risk? Would she have been better prepared? Would the family have been less shocked?
Yes. I know. Had she been in the States, she would have had a cesarean the minute her meconium stained fluid and erratic heart tones first appeared. Was I foolish to even let her stay at the clinic? Should I have just referred her? It’s hard not to second guess. It’s hard not to feel responsible. Please pray for me too.
And yes. Once he was born, I immediately understood why he died. He had a remarkably short umbilical cord which was wrapped tightly around his neck. In essence, the minute she pushed, he was strangled.
I was told in Midwifery school once, that after a birth... you’ll always know why the birth went the way it did. If there is bleeding or fetal distress... or even death, it is often only afterward that the cause is made clear.
We cannot see inside the womb but it doesn’t mean we are blind. A watchful and attentive midwife will know when things are not going well. There are signs. There are precautions to take.
When Achol came in on Tuesday last, she was tired. She had been up all night in labor but was otherwise doing well. But I couldn’t say the same for her child. Her waters had broke at home several hours before, pouring out slimy, thick, brown amniotic fluid. And as I listened to his heart beat... my warning alarm went off.
They would go up and down with and without contractions. I had to keep moving her around to find a position which didn’t cause the heart beat to drop. I immediately suspected a cord compression of some kind, but which kind? It didn’t appear to be a prolapsed cord. But I wasn’t ruling it out.
My heart bonded to her immediately and I have to admit, I smiled at her antics. This was her first pregnancy and as a teenager... she acted like it. (I’d guess her to be about 14-16 years old). As she moped about the clinic, she cried out loudly for God to “just let her die!” and for me “to give her a cesarean! Now!.”
I knew she was tired but I had to smile. She was just too adorable. I was strong with her though and warned her repeatedly that her baby wasn’t doing well. That she needed to listen carefully when I asked her to get in different positions. It was for her baby’s best. Sometimes she complied. Other times she didn’t.
As she labored that afternoon, some of her relatives explained a bit of her story. They said that her husband was a soldier. He wooed her and took her as a wife without paying the bride price. They ran away to Tonj together. And all was fine until six days earlier, he was killed in a car crash. She had just returned from his funeral. This was his only child.
It explained why her husband wasn’t there and her brother-in-law was. It also explained why she was so scared. Her family and friends lived very far away. She was alone in many ways.
She kept trying to push prematurely which caused some cervical swelling and a notable caput (swelling of the fetal head) to form. The thing was... each time she pushed prematurely her baby’s heart beat would drop. I begged her NOT to push. Everyone did.
In my head, I was pretty confident I was going to need to resuscitate this baby. I was prepared for it and so was the rest of the team. My hope (since I couldn’t get her the cesarean she needed) was to get her to breathe through her contractions until the very last moment and then push like mad.
She kept pushing each contraction so I did another vaginal exam. Finally, she was fully dilated and the heart tones were good, so I asked her to push. But as she pushed, the heart tones dropped. She moved in various positions and pushed. But since this was her first child, it took her time to figure out how to push exactly.
We worked feverishly to get the baby out. But I couldn’t get Achol to hurry. She had no sense of urgency. I don’t know if it was her age... or if my urgency was lost in translation. All I know is she dilly-dallied. (But as I look back at the chart she really only pushed about 45 minutes - which is short for a first time mom.)
Again, I found myself wishing for a vacuum extraction. Again, I did perineal stretching -- anything to get this baby out quickly. I had people searching for heart tones every few minutes. They were there for the first 15 minutes or so... then disappeared completely.
My hope was that the baby was just too low in the pelvis for us to hear them. But I wasn’t convinced. Ten minutes went by. I begged Achol to push with all her might. Another 10 minutes went by. Still no heartbeat found. I kept praying and with each passing minute I prayed even more.
It’s at this point I asked for the episiotomy scissors. I’ve never cut an episiotomy before. But the head was finally low enough for it to work. We hadn’t heard the heart in almost 30 minutes and the head was dusky.
I cut. She pushed. And he was born -- Limp, ashen and lifeless. Thick, sticky, meconium oozed from his mouth and nose. No breaths. Not even a grunt. No heart beat. Silence.
We started PPV and chest compressions but he didn’t respond. All the while, Achol watched in confusion. While resuscitating, I verbally walked her through what was going on. “Your baby isn’t breathing... we are giving him oxygen. Your baby’s heart isn’t beating. We are going to try to get it started.”
She seemed very confused and wildly looked from face to face in the room. Only after we gave up resuscitation efforts did she fully grasp her baby was dead. She wailed and mourned loudly, calling out to God. I cut the cord and she took him in her arms -- crying even louder than before. Desperate pleas of ‘Why!’ along with a warm, stream of tears filled the room... and the silence.
I didn’t have to speak Dinka to understand her words. They were universal. Part of me wonders if her brother and mother-in-law didn’t grieve even harder. They were equally devastated holding that beautiful boy in their arms. He was all that remained of their son... and brother.
Afterward, I had to suture the episiotomy (almost) against her will. She kept insisting I leave it but I couldn’t. I couldn’t leave her deformed. She didn’t know what she was asking. Fortunately, she slept through it. It was just too much to handle. Too much pain. Too much sorrow.
The boy was taken home to be buried and I kept her over night for observation. We ministered to her in every way we knew how. But I think the most effective person was Sabet (ministry director/Dinka man). He asked to hear her story and he listened. Later he explained to me that he wanted to see if she blamed herself. Her answer was heartbreaking.
She confessed that she broke her father’s heart by running away with her husband. She knew it was wrong but didn’t care. Now she felt cursed by God for disobeying her father. First her husband dies... now her son. “God is punishing me,” she said. “I am cursed.”
He shared with her the truth of God’s love and prayed for her. He also challenged her to return to her family... and seek forgiveness. I pray that she does. But even more, I pray she finds the forgiveness of our Heavenly Father and is forever changed by it and His love.
Please pray for her. Also, pray for me. I can’t help reliving the birth in my head and trying to manage it differently. What if I referred her to Wau the moment she got to the clinic? Would she have gone? Would it have made a difference? What if I had been clearer, earlier on, that her baby was at such a risk? Would she have been better prepared? Would the family have been less shocked?
Yes. I know. Had she been in the States, she would have had a cesarean the minute her meconium stained fluid and erratic heart tones first appeared. Was I foolish to even let her stay at the clinic? Should I have just referred her? It’s hard not to second guess. It’s hard not to feel responsible. Please pray for me too.
And yes. Once he was born, I immediately understood why he died. He had a remarkably short umbilical cord which was wrapped tightly around his neck. In essence, the minute she pushed, he was strangled.
Friday, November 5, 2010
Death on a Tuesday ~
(This story is hard to write. It might be hard to read. Proceed cautiously.)
Mike our compound manager came to my door early Tuesday morning saying he’d got this call. Someone saw a pregnant woman being carried down the road on a home-made stretcher. They wanted us to pick them up. Would I come with him?
I quickly changed and ran out the door, wondering if I’d need gloves. Was she delivering on the road?
When we arrived, fifteen people rushed her to the truck and loaded her in. She was quiet but moaned each time we hit a bump on the road... which happened often.
Once back at the clinic, I tried to get her history. Name. Age. Number of pregnancies. Her name was Elizabeth. As it turned out, this was her 8th pregnancy but only two were still alive. Two died during delivery. The rest died at various ages for various reasons which she couldn’t explain. They just died.
Meanwhile, I measured her, took her vitals and searched and searched for the baby’s heart beat. Nothing. She calmly stated that her baby wasn’t moving anymore. I continued to search.
It was silent in there. Eerily silent. I couldn’t even hear placental sounds. Strange.
She went on to explain that her labor started the night before but after a few hours, lots of blood gushed out. Several hours after that, her water broke. At which point, her family and friends insisted she start pushing. She pushed all night. When the baby didn’t come, they finally decided to get help.
But by then it was too late for her child. When I explained her baby was likely dead, she turned her face to the wall. But she didn’t cry. In fact, she didn’t do anything. Her blood pressure was bottoming out from exhaustion and blood loss, so I pumped her full of fluids.
I asked her husband to explain again the sequence of events. How much blood did she lose? Did the water break first or the bleeding? How long exactly did she push?
I also did a vaginal exam to see what could be causing the problem. She assured me she had never pushed so long before. I couldn’t find anything significant. All I noticed was a very large caput (or swelling on the baby’s head) and a slightly contracted pelvis.
(For those midwives out there: She was fully, 0 station, caput at a +2 station. Her pelvis seemed somewhat platypelloid in shape but adequate. The baby’s head was extended but otherwise normal.)
Since her contractions had stopped completely, I started her on an oxytocin drip. I figured her uterus had just become exhausted. All that was needed, was a bit more oompf and the baby could be born. I barely opened the line, expecting the drugs to jump start things.
But nothing happened. Nada. Zip.
I opened the line completely and let the medicine storm in -- still nothing. Not even a twitch. This has never happened before. My magic solution failed. How was I going to get this baby out without a contraction?
I started talking about going to Wau. I told them that I would do everything in my power to help, but they might need to prepare to go for a cesarean. The husband, understanding the seriousness of the situation said, “I know that my baby is dead. Please, just save my wife. Do whatever you can.” I promised I would.
As I considered the situation, I realized I hadn’t tried EVERYTHING yet. I just wasn’t sure I was READY to try everything. My everything included some painful and unpleasant procedures.
I told them that since the Oxytocin wasn’t working. The only way I could think of pushing, was fundal pressure. (*Side note: I’ve never done fundal pressure before. It’s dangerous. A lot can go wrong.) I didn’t want to do it, since it’s outrageously painful but I couldn’t think of anything else.
So I explained what it was, and told them that I’d try to flex the baby’s head and turn it in a more favorable position while they pushed. My assistant and her husband would both need to help do fundal pressure.
She pushed. They pushed. I turned. Nothing. An hour went by.
And when I say an hour, I mean a full hour of sweat, pain and intermittent progress. One minute the head would descend and I’d think we were in the clear, the next, it would be all for naught.
With each push, my heart would sink and I’d pray harder. This is not the sort of thing I learned in school. I’d look up and see her face contorted in pain. I’d look at the men pushing with all their might and think, “This is crazy. She needs a cesarean. Get her to Wau. And fast!” But then, we’d all take a deep breath and try again. I could actually feel the skull shifting and crackling beneath the swelling. Not good.
I was so stressed, worried and scared by this point that I yelled at anyone who barged in the room. And yes, I had people barge in -- translators, patients, looky-loos! And when I had reached the very end of my strength and patience, a pregnant woman stormed in and threw herself dramatically to the floor. Apparently, she too was in labor. But I had NO time for her -- no compassion, no patience, nothing. My hand was elbow deep in the middle of a stillbirth. She was making it worse.
I screamed for her to leave, but it took 8 more looky-loos to fix the problem. I was on my last nerve. What madness had descended on me? I continued to pray.
But I was running out of ideas. I had only one plan -- fundal pressure the baby out. It wasn’t working. I have no vacuum extraction. I have no forceps. I was running out of options.
Only then, did I remember a procedure called internal version. I had studied how to do it in school. But since I have yet to do an external version, why did I think I could do an internal version? I didn’t. Would it even help THIS situation?
For those who don’t know. Internal version is when a baby is repositioned (usually) from a breech position to a cephalic (head down) position by reaching inside the uterus and turning the baby. It is most often done when dealing with multiple gestations, etc.
But this case was different. I had the baby in a cephalic position. I was thinking of turning it breech. What if I delivered the body and the head still wouldn’t come out? Was I just making things worse?
But I didn’t think about it long. I acted. Some would say foolishly. I pushed the baby out of the pelvis (into her uterus) and was instantly splashed with a gush of bloody amniotic fluid. The baby’s head had been sealing it off. Now it covered me.... and the floor and everything in between.
At the sight of it, my assistant nearly lost it. I had to ask him several times to mop it up. He froze in horror.... and disgust.
Meanwhile, my hand was floating inside her uterus. Let me say that again. My. Hand. Was. Floating. Inside. Her. Uterus. (Slight, freak out moment.)
Slowly, I started identifying parts and pieces. I felt a hand. I identified a foot. Oops, that’s the cord. Yep, that has to be the face. My patient looked calm. She didn’t seem to even notice what was happening. It was strange, warm and horribly fascinating.
My assistant was still trying to figure out what a mop is for, so I called for more help. Dennis and Margaret came in to find me covered in blood with my arm lost inside my patient. Dennis reconnected her IV line, while Margaret managed to get some of the chaos re-organized. It was good to have them there.
I firmly grasped both feet and turned the child breech. I delivered the feet and then the legs. The body came out with relative ease but the arms got trapped behind the head. It took me several minutes to get the arms un-trapped. I prayed earnestly for God to remind me of all the steps I learned in school. I sighed and ... maybe even laughed, when they finally did come out. You can’t imagine my relief. But the head still needed to be born.
At this point I was so passed the point of exhaustion my hands shook. I was stressed, covered in blood and sweating like mad. “Lord! Please help me get this head out!” Images of me decapitating the child in the effort flitted through my brain. “Lord, by your grace. Help me.”
It took me several more minutes of maneuvering, suprapubic pressure and a lot of pulling before the head was born. I wanted to celebrate but I couldn’t. My heart hurt too much.
This birth was anything but gentle. It was flat out traumatic. Horrifying even. And yet, we all rejoiced. The father rejoiced that his wife was saved. The mother rejoiced that her pain was over. I rejoiced that God had answered my plea.
But as I stood there, holding this beautiful boy in my hands I couldn’t help but shake in exhaustion. It had taken every ounce of me... and I wasn’t even the one in labor!
I, then, rushed off to get out of my blood-soaked scrubs and shower. I had to take a moment and pray. I needed to cry. My first stillbirth. It was awful. Terrible even.
When I returned, my assistant had cleaned up most of the blood. The mom was recovering well. She even smiled at me, then went right to sleep.
So there you have it. It’s not beautiful. In fact, it’s not far from nightmarish except for one thing. She lived.
Some of you might read this story in shock and horror. Rightfully so. I’m sure you can find much to criticize. I did many things wrong. But I’m not sure what I would have done differently -- except barred the looky-loos from the clinic. Ha ha!
Side note: The woman who barged in and threw herself at my feet in labor, delivered soon afterward with Margaret’s help. In fact, I don’t even think she realized I had a patient in my room... let alone my hand inside of her! Ha!
Update:
Both Elizabeth and her husband came in today for a check up. She is in pain from the fundal pressure but otherwise doing well. Please lift her up in prayer. Thanks.
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