Leopard Attack?

The other night a man in his 20's was brought in from the village. His head was sliced open, his right arm was punctured, and he was bleeding excessively.

As Dennis sutured his skull, I causally asked what had caused his wound, assuming it must have been another motor bike accident. But it wasn't.
-- “He was attacked by a leopard,” my translator explained in disbelief.
-- “A leopard? Really? Are they even around here?" I asked stupefied and scared. I had heard of hyenas... but leopards? Honestly... a leopard??
Once I got over my initial surprise, I said, “Tell me the story in detail. How did it happen?”

 By this time Dennis had already closed off most of the foot long wound on his head. A thick gauze bandage covered the man’s face leaving only right eye uncovered. He searched my face in fear but didn’t speak. So my translator asked his friends to relay the story, instead.

As they spoke, a half dozen people slowly inched into the room to hear as well.

He was fishing by a river in a far off village when he passed next to a large bush. He heard something and turned to see a leopard pounce on him, taking him to the ground. The beast swiped his head in the process cutting a wide, ragged wound from his left eye socket to the back of his skull. Then the animal turned quickly and sprang on him again. This time grabbing his arm he had raised it in his defense. Then without explanation the leopard left as quickly as he came.

Since he lives so far away, it took him all day to reach our clinic --all day with the muscles in his skull protruding and various holes in his body tied off with old rags.

I asked if I could take a few pictures and he nodded but still didn’t speak. After each picture, I flipped my camera around so he could see what we were doing. He had to lower the gauze to see them, but he did it readily and thanked me afterward.

I don’t know about you but if I had been twice attacked by a leopard, I would not have been so brave!

Dennis was able to sew the wounds closed leaving proper drainage to prevent infection. Please pray he heals both physically and psychologically from this attack. Thanks.

Update: Jan 29 2012
I saw him today and he's healing well. The wound on his head is not septic. Please continue to pray.

Update: Clubbed

Baby Yom is doing very well. His mother brought him in to be fitted for another set of casts for his clubbed feet. Admittedly he was not a fan of all the prodding, but he didn’t cry --instead he stuck his tongue out at me!

So cute!

Dr. Tom is pleased with how well his feet are turning back to normal. And although he has not reached full range of motion in all his joints, I’m seeing steady improvements.

Concrete?

Call me crazy but concrete is not meant for vaginas. Yet tonight that is what I saw. My brain is having a hard time registering this information. I’m honestly baffled.

Let me explain.

Earlier tonight, Tom called for a consult saying one of my old patients was back complaining of something hard prolapsing from her vagina. He investigated and quickly determined he needed a second opinion and gathered the troops.

As I walked with him  toward the clinic (the rest followed a few minutes later) he told me that she was the girl that had the prolapsed hand that miscarried. I couldn’t tell if he was talking about the girl with the incompetent cervix or Biyana. But either way, I’d find out soon enough.

I walked in to see Biyana writhing in pain as one of our health workers finished giving her antibiotics intramuscularly.

Biyana? It’s not possible. I just saw her a few days ago. She was fine. She would have told me if there was something prolapsing then. What was going on?

Donning gloves, I investigated for myself.

Tom was right. A hard, white mass was protruding; it looked like a prolapsing cervix made of concrete.

What in the world?

After the others arrived, we tried to determine what it could be. Tom suggested it was some calcified foreign object possibly left in after her cesarean. I’m inclined to agree.

Perhaps a tampon of some kind? Maybe a strip of gauze?
    --But what if it is her cervix? No... that doesn’t make sense.

Tom reached in and said it’s long, round, and the length of a finger. He tried to remove it but failed. Dennis also examined her. He also failed to dislodge it.

Apparently, the object is firmly attached to the left vaginal wall. They cannot remove it without causing her a great deal of pain and possible bleeding.

Admittedly, I’m at a loss for words. How do we help?

I’m concerned this will have a negative effect on her getting her fistula repaired in a few months. Please pray for her. This is just one more challenge in an already difficult journey.

We’ve started her on antibiotics for an infection that has developed. But tomorrow we refer her (once again) to Wau.

Pray for wisdom for the doctors and healing for her body. Perhaps she’ll somehow get her fistula repaired early. Perhaps.

Pray for her. Thanks.

To understand her background better please read here, here, here and here. Thanks.

Update: Helpless

(If you haven't read the previous story yet, read it here first.)

After insisting Biyana go to Wau, her family took her home. At the time, I worried they might let her die, but the following morning, I learned she caught the first bus to Wau!    
    --Hope.  Blessed hope!

Later on, I heard through the grapevine that she had made it through surgery, but the baby had died. This didn’t come as a surprise as his precious hand looked swollen when she had left.

However, this afternoon, the story changed again. I got news that the baby lived!

Yep, you read that right! Biyana is alive (Woohoo!), and her son is in her arms! (Hallelujah!) Please pray for them both to recover quickly. And pray that her fistula is somehow fixed! Thanks.

However, I’m not sure what has happened to Abuol. Her husband kept trying to find a private vehicle to take her to Wau, but failed. By mid-morning, I got tired of his dilly-dallying and told him to get her on a bus -- and fast!

Then I explained she was developing a fever and her baby was showing signs of dying. Only then did he seem to take me seriously. I think he hadn’t fully grasped the urgency before then. 

(Midwife note: The baby’s heart rate had no baseline. It was 112, 152, 124, 140, 112, 156, etc. I’m thinking a possible sinusoidal pattern.)

But when he did, he moved. He took the medicines and walked her gingerly out of the clinic to the bus station. But she didn’t get far, before she fell to the ground.

Too weak to walk, we drove her to the bus in our vehicle. But I warned Aboul not to show that she was sick, or else the bus drivers might charge her too much for her seat. Then I turned to Lucus (her husband), cautioning him to get her the surgery at all costs. He nodded blankly, promising to send word as soon as he could.

I cannot stop thinking of her. I don’t know how she is or what has happened. I promise to give an update if I do. Please pray for them both. Thanks.

Update on Holes & Incompetence.

On Monday, Ayen’s brother came to see me. Ayen as you may remember is the woman with the incompetence cervix we have been praying for. (Read her story here.)

He came just as he promised, to take me to her house. However, as a typical Monday, I was still swamped with obligations and asked him to return in a few hours.

Agreeing to come back at 4pm, he reassured me that her labor had not progressed. There was no bleeding but still lots of fetal movements and lower abdominal pain.

Woohoo! She has not delivered yet!

But here’s the thing.... that was on Monday. Today, a full five days later, he has not returned again. I don’t know any more than that. He promised to return but didn’t. Does that mean she was taken to Wau? Did she deliver? I have no idea. Please keep praying. Thanks.

Also, this week I got to see the young girl with the hole in her face. Her name is Arec. It has been almost two months since she first came in and we are now starting to see real improvement.

Yes, there is a terrible scar but now she’s in a lot less pain. She also has more range of motion and function. So, thank you so much for praying. Please continue as the Lord leads you.

The Stench of Ignorance & Neglect.

Her name is Biyana, and she’s 18. Her first child was born naturally, but succumbed to the dreaded ‘one-day-diarrhea’ and died at a year and a half old.

Her second pregnancy brought on four days of excruciating labor pains which ended in a cesarean.     -- The baby didn’t make it.

The scar of that day, marked her body with a keloid an inch and a half wide -- from pelvis to umbilicus. She had a classical incision; and when I asked her why she had to have surgery, she couldn’t answer me.

-- “Didn’t you ask the doctors what happened?” I prodded. 
-- “No.”
-- “Didn’t they explain?”
-- “No,” she repeated with the twisted sucking sound made my Dinkas to indicated a ‘no’. 
-- “I see. So, when did this happen?”
-- “Last July.” 

I continued on with the rest of the prenatal as if such an obstetrical history was normal.
    -- Which, here is.

We discussed LMPs (last menstrual period) and fundal heights (how large her belly was growing for her dates), and I re-assured her that this baby was doing fine. She seemed excited and happy to be pregnant again, but something was off.

Although obviously clean, her clothes smelled strongly of urine. It was overwhelming, and attracting flies.

I waited until the prenatal was almost over before I asked her about it.
-- “Biyana. Did you shower today?”
-- “No. I didn’t.”
-- “Well... Right now, I can smell a lot of urine on your clothes. Do you have urine leaking from your vagina, by any chance?”

Looking at me in muted surprise, she clicked her tongue in response. “Yes.” Click.
-- “Really? Does it come out only when you carry heavy things, or is it all the time?”
-- “All the time,” she said flatly. The lack of emotion in her voice was frightening. 
-- “How long has that been happening?” I enquired.
-- “Since July. It started after my surgery.”

I started counting back months in my head. If it’s May now, that would mean... 10 months!
-- “Really?” I said calmly, trying to keep the desperation out of my voice, “You’ve had urine leaking from your vagina for 10 months?”

She must have thought me stupid for asking such a simple questions over and over again. But she answered me each time I asked.
-- “Yes,” she explained, “In fact, I haven’t urinated since the surgery.”

When my translator gave me this information, I made him repeat himself several times. I couldn’t be hearing what I was hearing. I just couldn’t!
-- “Wh... wha... what do you mean?” I stuttered, “Are you saying you have not urinated at all in 10 months?”
-- “Yes. It just comes out of me all by itself.”

Knowing full well I had some kind of vesico-vaginal fistula on my hands, I called Sarah in to watch and learn. I was fairly confident she hadn’t seen one before.

(For those who don’t know a vesico-vaginal fistula (VVF) is when the wall between the bladder and the vagina is compromised, allowing urine to pass through it unimpeded. If you are interested in learning more about it click here and here.)

Pictures taken from this website.

Then I asked Bisaya if she’d allow me to do a vaginal exam to see if I could identify the size of her hole. She agreed, but seemed a bit confused on the purpose.
    -- Did she think her incontinence was normal? I couldn’t tell.

But in the end, the exam caused more questions than it answered.

Instead of finding a small tear or thinning anterior wall, I encountered a large mass of scar tissue about 6 cm long and 3 cm wide. She writhed in pain as I attempted to feel around it.

Fortunately, I had my trusty translator James by my side and he was able to calm her down and explain what was happening and why. Once she relaxed, I was able to assess it better; but honestly, it had no idea what I was looking for.     --It was a mess in there.

Frankly, from the amount of pain my exam caused her, I’m amazed she even got pregnant. When I asked her if it was just as painful during sex, she clicked her tongue loudly in confirmation.

Wow.

We talked in depth about going to Wau for a GYN consult, the possibilities of a repair, and whether or not another cesarean might be indicated.

Right now, she is five month pregnant. However, if her pain is that intense during a vaginal exam, how much worse will it be for the birth?      --Lord! How can we help this girl?

She promised to discuss things with her family, but I’m not sure whether or not she’ll go to Wau. She did sound hopeful though. I think, I’m the first person to tell her there might be a solution to this curse. I think she had given up hoping for a way out of the smell of her stigma.

Oh, the stench of ignorance! Imagine not urinating for 10 months!        -- Just imagine.

Imagine not knowing there was a way to fix it.
      --It breaks my heart.

Please pray for Biyana. I will hopefully be seeing her in the coming months. Pray that one day, we’ll get a surgeon out here to repair fistulas in this community. Thanks.

Incompetent.

I met Ayen for the first time 4 weeks ago. She had a terrible history of untreated STDs and two second trimester stillbirths. Since she was already in her 5th month, she decided to see how I could help keep this baby healthy.

Suspecting several STDs, we threw everything in our pharmacy at her blindly.

Insisting that her husband get the same treatment, she brought him in the next day, but hadn’t explained to him why. Once he learned he had STDS, he refused treatment. 

Frustrating even my translator with his obstinate refusal, my translator explained: “He is stubborn. You know, those from the village, they don’t want to take medicine. They argue.”

Since he wouldn’t get treatment, I asked her not to have sex with him until after the baby was born. They both agreed and I sent her home.

She returned weekly for check-ups, and, yesterday, I was thrilled to learn her infections were gone. So, I was a little surprised when she returned tonight in pain.

Even though there was no bleeding, she explained that it felt like she was miscarrying. The pain was constant; it reminded her of the other births. Despite not having any contractions, she knew something was wrong.

Was she just afraid? Or was there something amiss?

Since her infections were treated, the only other thing I could think of was an incompetent cervix. Leaning towards her being more fearful than incompetent, I asked if I could do a vaginal exam. I was just trying to rule it out, so I could send her home re-assured.

She agreed saying, “Do what you need. That is why I have come.”

During the exam, it took me a minute to get my bearings. Soft and squishy, her cervix was hard to find at first, but when I did, I jumped.                -- What the heck was that?!  

Sudden movement startled me.     -- It couldn’t be... No. It’s not possible! 

Since she was already dilated, I tried to assess without moving things around. I didn’t want to make it worse. However, while checking for effacement, I got poked.
    --Her baby was playing with my finger!

Tiny digits rubbed against my index finger, flittering and jabbing me through the membranes. Momentarily speechless, I stood there, equally amazed and horrified.

She had an incompetent cervix.

Calling for Tom to consult, I gathered all the facts in my head in preparation.

    --- 70% efffaced. 2 cm dilated. Membranes intact. Tiny fetal parts palpable.

He came in a hurry, only to listen and shake his head in resignation. There was nothing we could do for them --not at 26 weeks. They needed to go to Wau.

Part of me was hoping he’d swoop in and stitch her up right then and there. I mean, isn’t that how it’s done on t.v.? The doctor does a quick assessment, takes out some nylon suture and saves the day.

But his downcast eyes made it clear. It was too late.      -- Sigh.

As he left, I called Ayen’s family in the room. Her husband --the same man who a few weeks ago argued he wouldn’t get treatment-- sat before me again, but this time he wasn’t arguing. He was scared.

Pulling no punches, I explained the whys and the hows. “Ayen’s cervix is starting to open. If it opens any more your baby will be born, and die. He is too small to breath on his own.”

An hour later we were still discussing the options and possible consequences. I was able to convince her husband to get treatment for his infections, but he did so grudgingly. The village in him resisted getting the penicillin shot (since it was an injection). The villagers fear needles.

I encouraged them to go to Wau, but was honest that the hospital there would not be able to do much for their child. They would unlikely be able to care for one so small, and doing cerclage is contra-indicated so late in pregnancy.

They opted to take her home on strict bed rest, instead. Explaining what that might look like, I tried to keep things simple, but it was hard. I kept saying, ‘if this happens, then do this. But if that happens, then do that’. By the end, Makom (her husband) looked dejected and sad.

Before they left, I prayed for them to see God moving in the miraculous. I prayed this child would stay inside and live. I prayed that Makom would see God’s goodness and be transformed. I prayed for the hope to remain in Ayen’s heart.

Will you join me?

I have no idea what God has in store. But their baby is alive and definitely kicking. Oh, Lord! Help this child live! Amen. Please pray for Ayen, Makom... and their little Poke! Thanks.

Butt Surgery.

This week, Dennis and Tom performed surgery on a 5 month baby by removing a very large growth on her buttock.

When they told me they’d be removing this growth, and they wanted my assistance, I thought it’d be a few centimeters in diameter at most, but I was wrong.     --Way wrong!

Yom, being just 5 months old, had a tennis ball sized growth on her left buttock that had been growing progressively since her birth.

Understandably worried, her family brought her in to see what could be done; Tom and Dennis decided to remove it surgically.

Even though, I wasn’t much use to them, I was glad to watch the surgery. After sedating the tot, they infiltrated the area with lidocaine, cut, and tied off any bleeders.

It took just over an hour, but eventually, they were able to remove most of the scar tissue and close her up.

I can’t help wondering how such a growth can happen in the first place?

Knowing she was handling her surgery well, we laughed calling it a ‘Butt-ectomy’, and joked about her being the ‘youngest person to get liposuction’.
    -- I know. Corny, right?

Anyway, there is no doubt in my mind, this growth would have haunted her for the rest of her life if not removed. In Sudan, any unusual growths are thought to be demons or curses. To have them brings harassment and ostracism, I’m glad that Tom and Dennis could help her in this way.

Please pray that Yom would heal quickly and that it would not re-grow. Thanks.

Update: Culture Gap

Cinteth has come in twice since last Saturday. Each time, we’ve treated her with more powerful drugs. Each time, her uterus has failed to involute (aka: reduce in size postpartum). Each time, the infection has persisted.

(For those who are unfamiliar with her story, please read here first.)

Today, at 9 days postpartum and after seeing only a slight improvement on the infection front, we decided to do a MVA (Manual Vacuum Aspiration); perhaps there were placental parts trapped inside.

However, none of us were ready for what we found.

Instead of finding incarcerated clots or placental fragments, we found necrosis of the vaginal tissue lining the wall. Dennis had to debraid it.         --It was bad.

How such an injury could even happen is a mystery to us all.

The only thing that makes sense, is that she had several lacerations during the tramatic birth which subsequently got infected due to unhygenic conditions. I suspect the TBA helping her didn't use gloves and reached inside her in an attempt to deliver the child.

Cinteth’s improving, but not as quickly as we expected. Please pray that this infection doesn’t get worse. Pray she recovers completely and quickly. Thanks.

Even more Puzzling...

Today, Athong came in for a prenatal. (For those unfamiliar with her case, please read here first.)

Thrilled to see her in my prenatal line, I asked her quickly if her baby was doing well. She nodded excitedly and handed me her book.         --Hallelujah!

Since she hadn’t come the month before, I thought perhaps she had miscarried. I can’t tell you how relieved I was to see her. I kept thinking, “May this be the baby that lives, Lord!”

She positively glowed when I called her in to be checked. We exchanged pleasantries as she lay down and lifted up her shirt, exposing a perfectly round belly bump.             --Adorable.

Before I left on R&R, Athong had faithfully come for several weekly check-ups in order to get the full arsenal of our STD-fighting meds! She was eager to do whatever it took to keep this child.

Each visit, I expectantly searched for fetal heart tones but found none. I did find a growing belly, however, and so assumed either she was off on her dates or ... she’d miscarry very soon. We prayed it would be the former. but steeled ourselves for the latter, just in case.

So when she reported ‘no bleeding’ at all this morning, I was hopeful.

Already measuring 11 cms, her belly was firm but tender to the touch. She winced a bit while cautioning me to be careful; she didn’t want to lose the child.

Laughing lightheartedly, I continued to check her in.

My doppler picked up a number of blood vessels and whooshing sounds, but nothing resembling a heartbeat could be found.                         -- Not good.

Searching for much longer than I normally do, I sent for Dennis to consult. This was looking oddly familiar. As we waited for him to arrive, I reviewed all the basics with her again.

-- So, Athong. Tell me again when you think you got pregnant.
-- Well, it actually stopped bleeding in June of last year, but then it continued each month until February of this year. Then it stopped for good.
-- Oh, I see. So, you think you are only 3 months pregnant now. Right?
-- Yes.
-- But last time you told me that you got pregnant in December of last year.
-- No. I got pregnant in March.
-- Huh? So your last menses was in February and you got pregnant in March?
-- Yes.

Here’s the trouble: If she is only 3 months pregnant, why then this colossal belly-bump? What’s more.... why is it so hard? If she is 5 months pregnant, why can’t I hear the sweet toc-toc-toc of her child inside. Even at 3 months, there should be something... anything. But all I can hear is the soft wooshing of nothingness.

Palpating once again, I made mental notes: “It’s definitely a pelvic mass. Her ovaries are tender but not enlarged. Although no reported bleeding, her menses have been irregular. Plus there are no fetal heart tones. The fundus is growing (it grew 2 cms since last month), but it’s woody and hard. Could it be...?”

My brain trailed off as Dennis came in. Catching him up to speed, he nodded and palpated it all for himself.

Conclusion: She needed an ultrasound.

I can only think of three reasons for this state of being. One: she has a baby that is astute at hiding its heartbeat (unlikely); Two: she is only 2.5 months pregnant with large fibroids or some kind of uterine mass; Or three: she has a hydatidiform mole.

Personally, I suspect the hydatidiform mole. Horrified as I am to admit it, it just fits the symptoms best.

Unusual bleeding. HCG in her urine. Lots of nausea. Woody hard fundus. No fetal heartbeat.

Would someone please tell me I’m wrong? I would LOVE to be wrong.

I don’t want another hydatidiform mole. You all remember what happened with the last one. (If not, please read these stories. Story one. Story two.) Plus, she DESPERATELY wants a child.

Taking the news in stride, she nodded with possible INcomprehension as I explained the details over and over again.
-- “What you need is an ultrasound. We need to know what we are dealing with,” I said.
-- “No. I will go to the witch-doctor. I’m sure I have been cursed. The witch-doctor will fix it.”
-- “Actually... the witch-doctor will not be able to help. What you need is a picture on the inside which will tell us what is in there. Please don’t waste your money on a witch-doctor. Please get an ultrasound instead.” I almost begged. 
-- “Okay. I will go.”

Was she just telling me what I wanted to hear? I couldn’t tell. Please pray for her. If she has a hydatidiform mole and doesn’t seek help, she will start bleeding soon.

I’m very concerned for her.

Also... please pray that God would bless our clinic with an ultrasound machine. We need one desperately. It would be so great to not have to guess all the time.

Does anyone have one they want to donate to us? Does anyone have connections for a cheap retailer? I’m semi-desperate! ha ha.

Please pray for an ultrasound machine.... and a place for me to train how to use it. Thanks.

9-Month Fast~

When I first saw her, I had a hard time believing she was pregnant, let alone in labor. She was rail thin and gaunt. I asked if she had ever been to our clinic before... perhaps for a prenatal. (I doubted it, since I would have definitely remembered her face!) She said she hadn’t, but was seen once at another clinic in town. When pushed a bit further, her husband added she was treated for hypoglycemia at the government hospital the week before.

She didn’t look well... but that was just half of her problem.

Strong, relentless contractions peaked and passed, every few minutes; she was definitely in labor, but I couldn’t tell if she was term.

Her belly was abysmally small-- barely measuring 27 cm. She agreed she was only 8 months along, but that wasn’t the only reason it was small. She had been constantly sick this pregnancy.

Pushing to understand why, she explained she hadn’t stopped vomiting since she conceived. It was merciless. Food and water, alike, made her sick. It wasn’t hard to believe. She was positively emaciated.

This was her 9th pregnancy. I tried to guess her age, but her withered state made that difficult. I considered it a minute, but ended up just writing ’40 years old’ in her book. Did it matter? Probably not.

I was tempted to refer her to Wau... but she was already 9 cm dilated.

Instead, I set up for the birth, and prayed. I prayed hard. I’d either have a premie on my hands, or an SGA (small for gestational age) term baby. Either way, it didn’t change the fact, she’d deliver shortly.

Sitting beside her, her husband was just as delicate and frail. Decades of slouching caused him to fold himself into a neat envelope with ease, legs drawn in. Origami in the flesh. 

But when it came time to push, he was instantly at her side. Still slouching and a bit unsteady with age, he comforted her well.              --It was very encouraging.

She pushed like a pro, but her baby didn’t handle it well. Small, limp, and blue when he was born, he looked more like a floppy porcelain doll than a baby; I worried to move him.

Rubbing his back in an effort to make him cry, I cheered him on: “Come on ‘lil guy. I know it’s cold and scary out here... but breathing’s fun! Just try it.”
He must have liked my pep-talk, because he recovered nicely.

Boney and long and weighing just 2 kg (4.4 lbs), he reminded me a lot of his dad-- all arms and legs and a bit shaky. So, I wrapped him up tight, and handed him over. The father smiled as his lanky arms, awkward and unsure of how to hold someone so small, engulfed him.

It was love at first sight!

Later on, when I did a full exam on this lean, mean, sucking machine, I could see no major signs of prematurity. His reflexes were good, his testes had dropped, and even the creases on his itsy-bitsy feet were deep. His Ballard’s score (exam done to determine how premature/term a baby might be.) was high, placing him roughly at 36 weeks gestation.

Conclusion: 9 months of vomiting makes for one tiny person, but it doesn’t make him premature!

When I discharged them, they promised to return for check-ups, but I haven’t seen them yet. I hope all is well. Pray they both thrive after this 9-month fast! Thanks.

A day apart!

Today a woman was brought in by ambulance, sirens wailing and lights flashing. I was already at the clinic, and watched it approach from my window. As I peeked out in interest, I heard them say something about a woman in labor, but all I could see were her feet sticking out the ambulance door.

If she was coming by ambulance, it must be pretty serious. Right? Since I wasn’t sure how long it’d take them to get her through our narrow halls, I started setting up the room.

I barely had time to pull out my instruments when a VERY pregnant woman wobbled in, a bit off-balance. She walked timidly, like her feet couldn’t be trusted. I figured she was just lopsided with such a BIG belly, but there was some swelling in her legs as well.

Gingerly she lay on the bed. Everything she did was slow and steady. My translator was still outside, so I instructed her in my limited Dinka to lift up her dress so I could check on her baby.

Just then, my translator interrupted me:
-- “Wait. Here’s the baby!”
-- “What baby?” I asked stupidly, while pointing at her belly. “Do you mean this belly?”
-- “No. She gave birth yesterday. Here’s the baby,” he insisted, handing me a pea-sized person wrapped in an endless stream of clothes.

It took me a minute to find her face. She was tiny! I sent someone to get Margaret; this was going to be a doozie. What was I looking at if not a baby?

Aluong, my very-pregnant mama lay awkwardly on the bed, and slowly explained she gave birth yesterday afternoon, but the placenta wouldn’t come out. Huh? This belly was just her placenta? I wasn’t buying it.

So, I sent for her family. I needed to hear this story from every perspective. In my head, she obviously had twins. The question was... was the second one still alive.

When her mother came in, she explained the baby was born yesterday afternoon, but hadn’t nursed yet. They clamped and cut the umbilical cord, but it was sucked back into her body. (I could see no cord handing from her vagina.)

-- “Did you tie the cord on two sides and then cut in the middle?” I asked. I still didn’t have time to check heart tones. But if they had let the cord bleed, this baby might be dead.
-- “No. We tied it just once,” the mom explained, looking a bit confused I’d ask such a strange question.
-- “Aluong, can you feel a baby moving inside?”
-- “Yes.”
-- “Good.”
-- “But the placenta won’t come out,” her mother insisted.

I had to laugh. In my head the most important thing was delivering this next baby, not the placenta. But in her mind, she was more vexed the placenta hadn’t come out.

Margaret arrived just then, and I caught her up to speed. She took over checking on the pea-sized person. Since she hadn’t nursed in almost 24 hours, Margaret got her some sugar water and checked her vitals.

Her fundal height was 39 cm, the baby was cephalic (head down), and in a good position. I found heart tones easily, then started counting contractions. Whoever was inside was happy-- so was I!  There was no excessive bleeding, so I did a vaginal exam.

The membranes were bulging, and as I pressed deeper, I could feel the head. Everything was looking great. She would deliver very soon.

We got everything set up for the birth, made sure the other baby was doing well, and then I ruptured the membranes. I had to do it twice. The first time I got a slightly bloody fluid. The second time, the waters were clear and fresh. They gushed out in one salty wave, making the room jump back a bit.

The head settled into the pelvis nicely, and she instantly needed to push. Heart tones were solid, so we just sat back, and watched this little patch of miracle peak out at us intermittantly. Three solid pushes and she was out! 

Her chubby cheeks cried astonished whoops of wonder as a tidal wave of salty waters burst behind her, and trickled to the floor in rivulets. She lay on the bed like some beach beauty, announcing her arrival. We laughed!

Her size and the fact Aluong’s belly drooped anti-climatically reassured me that there were only twins, and not triplets. (Yes, I had my doubts.)

After the cord was cut and the placenta was born, we discussed her obstetrical history a bit more in detail. She explained this was her second pregnancy. Her first was born dead at 8 months. She claimed she got in a fight and her baby died.

As for this pregnancy, her first baby was born almost a full day before her second. Their weights weren’t too different, but their appearances were striking. The first was thin, frail and weighed only 2.3 kg (5lbs). The second would have made sumo wrestlers jealous in her chunky folds and lusciousness, but she only weighed 3kg (6.6lbs).

Nevertheless, they were a delight to behold!

I taught Aluong how to breastfeed them both, since this was her first time; she was a natural. Both babies sucked vigorously, and they were all discharged a few hours ago.

There you have it... another almost twins story! Ha ha!

Oh, for those who like to know about such details, let me tell you about the placenta! It was super cool. They were two separate placentas (completely unattached). Both had remarkably short cords (less than 10 inches), but they appeared healthy. There were a few blood clots trapped between the amnion and chorion, and the smaller placenta (for baby number 1) looked as if it had partially detached (abruption?), since it had an extensive black clot over one edge.

Also, the membranes of the first (smaller) placenta had two areas where they had ruptured. The placentas were ONLY connected by these membranes. I’m thinking they may have shared the chorion? What do you all think? Check out these pictures. You can decide for yourself.

All I know is, had they shared a placenta, the second baby would not have survived after they cut the first’s cord. I’m thinking fraternal twins. What do y’all think? I think I can rule out twin-to-twin transfusion as an explanation of the size discrepancy. Right? Perhaps the blob on the smaller placenta caused her to get less of the oxygen and nutrients.

So praise God with me that both girls lived! They are beautiful!

Twins, born a day apart, used to be things I only read about in books! Is this really my life? I have to say, I love it. I really do! It’s hard at times, but I really do love all this craziness.

What a grand adventure He has laid before me!

Thank you for following me around in these adventures! Thank you for encouraging me so persistently, and praying so diligently! You help me in so many unspeakable ways! Thank you!

Hydatidiform Mercy.

(Updated Information at the end)

A week after Awen’s hydatidiform mole was removed, she came in for a check up. She had almost no bleeding and her hemoglobin was on the rise. She was doing well, and promised to come regularly for reviews. 

She promised not to get pregnant for as long as possible, so that the tissues would be less likely to reoccur. I was looking good; I was hopeful.

However, today she came back. She looked so dejected and morose, I almost didn’t recognize her.

Dread. That’s it. Dread. She looked like a woman awaiting the firing squad. She looked like death had visited her and rattled her chain.

Dread.

Downcast eyes hid her fear, as she explained the bleeding started again two days ago. It kept coming. No clots. Could I help?

My heart sank.

Her uterus (that had involuted nicely last visit) was palpable again. Rubbing it firmly, no clots were expelled, but it didn’t look good. Her clothes were stained with blood- both fresh and old.

Oh, no.

It’s been about a month since her procedure. That’s not too soon for a menstruation, but this was too much blood if so. What was going on? The only thing that made sense was if her hydatidiform mole had re-grown.

To be sure, I did a pregnancy test.

If the abnormal tissues had started growing again, she’d have excessive amounts of HCG (Human Chorionic Gonadotropin) hormones in her system, giving a positive pregnancy test.

I held my breath as the first line -- and then the second line appeared.     --It was positive.

I wanted to swear.

I conferred with Dennis, and he agreed. She needed more care than we could provide. Doing another manual vacuum aspiration (MVA) could cause her uterine scarring or possibly perforate it. It wasn’t safe. She needed a D&C or a hysterectomy.

Trying to explain this to her family wasn’t easy.

-- “Can’t you just give her some drugs to make her stop bleeding?” they asked.

-- “No. It doesn’t work that way. This problem cannot be fixed with pills. She needs surgery and soon.” 

Shaking their heads in dejection, they said they’d take her home, and discuss it with her husband.

At the thought... my heart shrieked ‘Noooooooo!’ but it didn’t reach my lips.

The problem is: I’ve met her husband. He’s a scary, monster of a man. He left her here for three days, with no money and practically no food, after her last procedure. When he arrived, he told her she was not sick, and was just pretending.

When I told him that she almost died and was very sick, he argued with me in loud octaves that shook the walls.

This belligerent beast of a man reminded me of a pirate; one of his eyes, white with scarring, stared vacantly at me during his tirade. He scared me at a level that I’ve rarely experienced, so I quickly got Dennis involved. 

At that time, she told me that he was a hard husband to live with. She was at his mercy, and he was not a merciful man.

So when her family chose to take her home, my heart screamed itself hoarse. It’s screaming still.

He doesn’t strike me as a man willing to spend money to keep this wife alive when he could just buy a newer one that wouldn’t be sick all the time.

I’ll be shocked if he makes any effort to keep her alive.

Her family took her home before I got a chance to say goodbye, but I did pray for her.

Without surgery or at least a D&C, I’m not sure she’ll live.

Please pray for her. I’m sick. I’m sick thinking her life might be in her husband’s hands. Yes, I know ultimately she is in God’s hands. I know this in my every fiber and cell!

Honestly, her death might be God’s mercy toward her. It might be better for her to die than live another month with such a hard man.

I don’t know how to pray.

Lord, You know! Please, show mercy -- however that might be best! Amen.

March 29, 2011 ~
She and her husband came in today for another review. Thank you so much for praying! The husband was a completely different person. He was worried, and willing to take her to Wau. They left this morning, and promised to come back after the procedure. Praise the Lord!!!

Also, a few wonderful nursing friends reminded me that we could start her on Methotrexate or actinomycin D to prevent it from regrowing. Does anyone know how I can get my hands on some?