A Very Different Birth.

A few months after arriving in South Sudan, a woman came in with antepartum bleeding. Her baby was dead, could I help her?

I hemmed and hawed, but eventually said I would try.

Her birth was the very hardest of my life --shaking me to my core --teaching me things I never wanted to learn.

I can still vividly remember sobbing hot tears into a staff member’s lap as she helplessly tried to understand my grief. She prayed. I thanked her, then walked back into the room where my helper quietly mopped up the pooled blood. 

Elizabeth had delivered. Finally.

But in that time, I somehow morphed into a different midwife --one that pulls babies out by their feet. I wasn’t sure I ever wanted to become such a midwife... but there was no going back.

Her birth changed me. 

Something else happened that morning. Something surprising. I came to love Elizabeth and her husband, Michael, with an intensity I find hard to explain. It rolls over me in waves, filling my lungs, making it hard to breathe.

So when I saw Elizabeth back in my prenatal line a few months ago I instantly recognized her. Love does not forget. Then I turned and saw Michael sitting beside her. He stood to shake my hand, bouncing as he proudly announced she was four months pregnant.

Could it be true? Was she really expecting another baby? Whoohooo!

She came faithfully to each prenatal visit with Michael always at her side. To date, he is the only husband who has come to every check-up.

Anyway. Long story short. Her due date drew near.

Then a few weeks back she started having contractions. Even though she was in early labor, I admitted her for observation, and watched her through the night. But her contractions stopped as suddenly as they started, and by morning they were ready to go home.

It was a false alarm. 

However, a week later she was back with more contractions. This time they were dilating her better, but barely. It was slow going.

Fortunately, it was a Sunday morning and the clinic was quiet. Since I was in no hurry, I watched, waited, and prayed; but her labor never progressed.
    --What was the hold up?

Eventually after waiting fourteen hours without any significant progress, it was time to take action. I started her on oxytocin, and she went from 4 cm to fully in about an hour.

As she labored, I listened in with the doppler. Each time the static warble found heart tones, she smiled. The steady toc-toc-toc of her baby’s heart, wrinkled her face in a toothy, contagious grin.

We were making new memories. Memories that didn’t involve silent wombs. Memories that were noisy with life --her baby’s life!

When it came time to push, Michael supported her from behind, and she got on her knees.

The pushing was slow for a G7 (or woman delivering her 7th child). Really slow.
     --Which explains a lot. 

As she grunted, pushed, and sweat, I silently prayed. 
    -- Lord, however you work this birth... please let the baby live.

I confess, the toc-toc-toc reassured me more than I let on.

Hard as I tried, I couldn’t shake the echo of that fateful morning from my thoughts. Here I was... in the very spot I pulled her last baby from her body.
    --Would this baby die, too?

Deep breath.

She continued to push, but the head would not descend. Finally, I had had enough of waiting, and I got out the vacuum. It took one tiny tug and another strong push, and she was born!

At the sound of her plaintive gasps, the room filled with laughter, and her parent’s eyes danced with joy.

She was alive!

It was a very different birth --one that ended in tears of joy rather than sorrow. Thank you Jesus! And thank you all for praying for her. He answered our prayers!

Elizabeth, Michael, and baby girl at 3 day check-up.

Head Strong!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Would you know it? It worked!

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

The following one, he was born!

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

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

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

Chubbiest of All the Land.

Amouk arrived in the morning with a fountain of gushing amniotic fluid each contraction; it pooled on the floor -- a puddle but not quite a lake.

Splish-Splash

Expecting her 7th child, she looked like she was carrying twins by the way her belly hung. It was a mountain beside her lake.

When I checked her, she was 4 cms dilated with abysmally short contractions. But with a G7, you can never guess how quickly labor might go. So I admitted her and watched.

She spent the morning trying to augment her contractions with nipple stimulation and walking. And I knocked off prenatal after prenatal from the line. There were at least 35 prenatals to see.

Each time I checked her baby’s heart tones, she would comment on the fact there might be two inside. What did I think?

I told her that I honestly didn’t know. I felt and heard only one baby, but she was the size of two babies... maybe even three!

We’d laugh each time and she’d go back to waddling around the clinic. I’d go back to my prenatal ladies.

When the very last prenatal was seen, I brought her back in for another vaginal exam. It had been hours (8 hours to be precise), and she was looking no closer to delivering. What was wrong?

Her second vaginal exam showed her to have made no progress whatsoever. She was still 4 cm and 50% effaced.

Hum...

But by this time, her helper had changed. It was no longer her mother but a young lady named Martha. When Martha saw me she laughed excitedly and asked if I remembered her. When I said I didn’t and that I was sorry, she laughed again.

“But you delivered my baby last year! I’m Martha,” she exclaimed, “I named my son Stephen after you!”

And together we slapped hands in excitement and caught up on how my namesake had been doing. Martha was Amouk‘s niece and had no doubt encouraged her aunt to deliver with me.

So back to my story. When I told Amouk that she was not progressing and that I wanted to augment her labor with an IV drip, her only concern was whether or not she’d get home before dark.

Hum...

It was about 4 pm already and it gets dark around 7:30 pm. Would she deliver before dark? I couldn’t say. But we induced/augmented anyway.

However once the oxytocin was running, her contractions kicked up a notch. In fact, just 30 minutes later she was asking to push.

Not sure if she was exaggerating things or actually ready, I did another vaginal exam. Not only had she dilated to 9 cms, but his head had dropped 2 stations. It was a go!

I let her push a few times but she wasn’t making progress so I asked her to hold off pushing until she was fully dilated.

Another 30 minutes later she started pushing with earnest. Although fully, her baby’s head wasn’t coming.

She pushed and pushed. The head molded and molded. I could see it crinkling up inside; but it would not come.

Hum...

After 40 minutes of this, I tried the vacuum. And even then... he wouldn’t come. No doubt we were dealing with a bigger baby than normal.

However, with time his head started to crown and he eventually emerged.

Roughly the size of a mac truck, he squealed and complained as I wiped him down. Rolls of stocky legs and chubby arms, he flayed his arms in excitement.

He was HUGE!

If I hadn’t watched him come out, I would have sworn he was a 3-month old! And would you believe it, he is officially the biggest baby I have ever delivered!

10.3 lbs (or 4.7 kg) of kissable cuteness!

Twins he was not, but he could have been!

Afterward, Amouk laughed in relief while her mother --eyes greyed with age and cateracts-- took my hands and lifted them to the heavens --this is how the midwife is honored in this culture-- and together we praised God for His goodness in giving us a healthy baby!

Inchelich Nalich! Praise God! Inchelich Yesu! Thank you Jesus!

A Community Affair.

Long labors here in Sudan often mean serious injury or death. Those most at risk are the first time moms. Knowing this crucial fact, I often try to convince women to come for help early in labor. Some might even accuse me of sounding like a broken record, but I don’t care.

I don’t care, because every once in a while someone listens; every once and a while, it makes a huge difference. One of those ‘whiles’ was this week.

Her name is Nyaruom, and if we were right on her dates, she was roughly 40-42 weeks pregnant. Her perfectly round face glowed in health, matching her perfectly round belly.

When I saw her on Sunday morning, she looked to be in early labor. Her contractions were moderate but irregular. Although painful, she seemed to handle them well. Initially, her mother wanted to take her home to deliver. But when I warned them to come back if her labor had trouble, she changed her mind. They would stay.

Smiling, I gave the labor to Sarah. It seemed like a good one to learn on. Plus, I had delivered a baby just a few hours earlier; I didn’t want to be greedy. Ha ha. And since it was Sunday afternoon it was a perfect time to teach.

Sarah jumped at the opportunity. She hadn’t delivered a baby in days, because each time there was an opportunity, she either got called too late (arrived after the baby was out) or the labor I gave her turned out to be super complicated.

Well, little did we know that this birth would be complicated, too!

I won’t try to write out all the details of that chaotic day and a half of labor watch, but I will try to give you some of the highlights.

Sunday mid-morning: Nyaruoum arrived in labor with an entourage. She decides to stay and deliver at the clinic. No vaginal exam done.

Sunday afternoon: Her mother got antsy at the slow progress and asked me to do an exam. Vaginal exam: 2 cms, 60% effaced. I tell them they can go home if they like but to come back if the contractions get stronger and longer. But they choose to stay saying the house is too far away. 

Sunday night: Nyaroum is loud and uncooperative with each contraction. I plan to give her some pain meds and a sedative if she is not due to deliver soon so she won’t get exhausted. Her vaginal exam shows her to be 3 cms, 80%. She has progressed only 1 cm in about 9 hours, but refuses to let me give her any pain medicines.

Monday morning early: She slept on and off through the night (as did Sarah and I), all is normal. But her contractions were not going anywhere. I suggested we augment her labor. They jumped at the offer, chiding me for not doing it earlier. Immediately her contractions improve.

Monday noon: another labor arrives and delivers. Read her story here.

Monday early afternoon: With the oxytocin, Nyaroum is even louder and more uncooperative. I figured things are dilating, but her next vaginal exam showed her to have only progressed another centimeter. I decide to rupture her membranes and be more aggressive with the augmentation.

Monday evening: A beautiful boy is born after some serious management (perineal stretching, vacuum, oxytocin) to the relief of everyone in the clinic! Sarah does a great job describing this labor in her blog. Read it here and enjoy.

In total, Nyaroum was in labor for 48 hrs -- 32 of which were at the clinic! Although not a record, it was certainly note-worthy.

Well done Nyaroum! And great job labor watching Sarah! If I had to be the solo midwife on this labor, I don’t think I would have made it. Thank you Jesus for babies that come out! Thank you for oxytocin! Thank you for vacuums!

Cultural side note: a labor is not just a family affair here; it’s a community affair. How do I know this? Well, after the birth, the strangest people kept congratulating me.    
        --Me? Why would they congratulate me?

The first one to congratulate me was Mario, one of our translators. The minute he got on shift, he already knew about her and was thrilled to see she’d delivered. He told me he was impressed and shook my hand vigorously. He was so impressed, in fact, that later that night he knocked on my door to ask me how I learned the skills necessary to make a baby come out like this one.

Confused at first by how much of a fuss he was making about it, I told him about my schooling, then went to sleep.

The next morning, two other translators (Santos and Peter) --who had listened to Nyaroum screaming the previous day-- were pleasantly surprised to learn she’d delivered. They shook my hand and one even slapped me on the back. Why were they so impressed? What was different about this birth that they were making such a big deal about it?          -- Hum....?

Then again. Not long after, the woman who cooks at the compound (Elizabeth) inquired what had happened. Did she know them? No. She had just heard her screaming all day and had to know. Was the baby born? When I told her that all went well, she praised God excitedly.
    -- Interesting.

As I thought about it, it occurred to me that very few people thought this baby was going to be born naturally. The community was watching with bated breath to see what would happen. Would the Kowaja know what to do? Would Nyaroum need a cesarean? This was a birth the whole community had been waiting for.

Her birth was hard. There is just no getting around it. It was challenging on so many levels. But I shudder to think what would have happened if she hadn’t come for help. I think she would have stayed in labor for 3 or 4 days easily before her family finally took her to Wau. I think she would have delivered a dead baby or a seriously compromised one, if she had delivered at all.

Such labors are a fact of life here. The whole community knows it only too well. But now... they  know there’s another way. That is why I’ve been congratulated.

Pray that this birth gets the community talking in a positive way, and other first-time moms come to deliver too. Thanks.

Is it one of us?

Abak, the midwife, her wounded bird friend.

Abak came in pushing. She was pushing so hard, the translator on duty ran to call me, and breathlessly announced, I should hurry. I grabbed my stuff and ran. I didn’t want to miss it.

But when I got there, not only was she NOT pushing, but she seemed calm and collected. I had to laugh.

Nevertheless, this was her 4th child. It was sure to be soon. Heck, I could see a little patch of membranes ready to burst as she pushed. That’s always a good sign, right?     -- Not always.

Smiling, I went through the regular check-in scenario and set up the room.

In her mid-thirties, Abak was small and slender. She’d come a number of times for prenatals, and I was looking forward to her birth.

Between pushes, I learned that her labor had started the night before. No water or blood had come out, and all was great.         -- or was it?

As she pushed first in the supine position, then kneeling, then on the birth stool... I began to suspect there was a problem. Why was it taking so long?

Only then did I think to ask: “Have you been pushing like this at home?”
-- “Yes, the baby won’t come.”
-- “When did you start pushing?”
-- “After the water broke.” That didn’t make sense since, I could see the membranes bulging and she had just told me the water hadn’t come out yet.
-- “When was that exactly?”
-- “Last night around 8 pm.”
-- “Oh...”

Mind you, it’s 3 pm on a Sunday afternoon.

Since her story was all jumbled with mis-information and assumptions, I asked her to start again.  She explained her labor actually started on Saturday morning. When her water ‘broke’ that night, she attempted to deliver alone and began pushing.

She had delivered all her other babies without assistance, and assumed this one would be the same. However, it had been 7 years since her last birth; perhaps she had forgotten how.

As she finished explaining, I started counting backwards. It was almost four pm now, and if she’d been pushing since dark the night before... the sun sets around 7pm... that means roughly 18 to 20 hours of ineffective pushing... humm... not good.

“Poor thing! Why didn’t she come earlier?” I thought to myself. I didn’t bother asking her though; I already knew the answer. It would be someone ‘important’ in her family that had insisted she stay home. I’d heard it before.

Honestly, I didn’t know if I should be more impressed or horrified. Eighteen hours! That’s a record in my book!

Only then, did I do a vaginal exam. I wanted to rule out a compound presentation or some kind of cephalopelvic disproportion (aka: baby too big for the pelvis). I, also, wanted to rupture the bulging membranes. Perhaps that would speed things along.

Her pelvis felt more than adequate, and I could see no major reason for the delay. The fetal head did appear to be somewhat military in presentation and a bit posterior. With her permission, I attempted to flex the fetal head and ‘dial’ it to a better position.

She pushed well, but even still, there was little progress. Obviously worried, the young girl assisting her, couldn’t sit still. She moved about like a wounded bird. I was glad when she left the room.

Humm...  What to do? What to do? Lord, what is needed most right now for this baby to make its way into the world? Do I need to move her in a better position? Do I need to manually assist? How do I get this baby out?

As I prayed, my translator kept looking at me funny. I’ve been praying out loud over my patients for so long, I’ve forgotten how strange it must seem to those less familiar with my ways. Once he figured out I wasn't talking him but God, he just smiled and watched from a distance.

Doesn’t everyone talk to God during deliveries? It can’t be just me!

Anyway... back to my story.

The brother-in-law kept poking his head in the room, monitoring the progress. I couldn’t blame him. Eighteen hours of pushing! I’d be worried too. I think coming for my help was a last ditch effort on their part. It was as if they were saying, “Why not see what the Kowaja can do?” Perhaps not.

But they did seem a bit hopeless.

At one point, Abak said: “If I die, Sudan will not fall into the sea.” My translator explained it was the Dinka way of saying, ‘my life is small in the grand scheme of things, just let me die’.

I told her that today was NOT her day to die, and reminded her to stay strong. Her baby was doing great, and despite the encroaching exhaustion, her vitals were stable.

Finally, after an hour of putting her in every position imaginable, I got out the vacuum extractor. I told her what it was, and how it worked. She nodded, “Okay, I’m ready.”

Once in place, she pushed and I pulled. I barely had to tug, when the head crowned and rest of her baby’s wrinkled body followed.

What? So easily? It surprised us all, at how quickly it worked.

Abak couldn’t stop laughing in relief, and although tired, she sat up and grinned at this tiny trouble maker. She continued to laugh in disbelief as I laid her on her chest. 

This wrinkled, no-neck self, howled her hellos as I rubbed her clean. If the gestational dates were correct, this little one was a bit over-cooked, arriving past her alloted 42 weeks.

Meconium stained vernix covered most her body. That coupled with the fact, her feet were peeling and her nails long, indicated someone forgot to set the timer on the oven. She wasn’t the prettiest baby in the world (just then!), but she was the most celebrated!

At her first cry, the brother-in-law again poked his head in the room. Relieved beyond words, he asked, “Is it one of us or one of you?”

My translator explained that this is how Dinkas ask if it’s a boy or a girl.

“It’s one of us! It’s one of us!” (Since it was girls saying it, it meant it was a ‘girl’.)

He smiled and immediately went to share the good news.

Meanwhile, Abak continued to laugh between periodic naps. She almost slept through the placenta delivery. Calling her tired, may have been an understatement.

My translator said, at one point, she mumbled to herself: “This is why I told them to let me come.”

I couldn’t help but smile.

Yes. It was a good day. A very good day.

They named her Lat, which means ‘Sunday’. Perhaps she’ll get a better name later on, but this way they can keep track of her age... at least for the first couple months. Ha!

Thank God for vacuum extractors!

Rejoice with me that baby Lat was born after such a long labor, but please pray for the fever she developed right afterward. We treated her with medicines and discharged her the next morning. At that time, she was breastfeeding well but colicky. Pray it passes quickly. Thanks!

Hardly Simple. Simply Hard.

Sunday night Mary came in with solid contractions, but they started two hours before. She seemed like she was handling them well, so I didn’t do a vaginal exam. If she was early, I’d have to send her home. I didn’t want to send her home. But it wasn’t my call; it was Margaret’s, as she works nights.

Knowing she wouldn’t deliver right away, I handed her over to Margaret early. Margaret did the vaginal exam, and she was only 2 centimeters. However, Mary categorically refused to go home, so, Margaret labored with her all night. I’m told she was vocal and uncooperative, making it tough for anyone to sleep.

At 7 am (when I’m back on shift), another labor came in looking active and they called me to help. Mary and Margaret were in a battle of the wits. Mary was fully but unprepared (I think mentally) to push. Margaret was fed up with her screaming and stubborn antics (or so I’m told), and kept insisting she push-push-push.

I wanted to take over, but the new labor was very active. I was torn. Where to go? Who to help first?

The new labor’s name was Yom and this was her third baby. She didn’t want an exam, and I didn’t want to do one. So I opted to monitor her while stepping back and forth between each birth.

Mary kept screaming and calling for God to just let her die; Yom silently squatted on the floor and rocked a bit with each contraction. The difference was dramatic and perhaps even more marked by their proximity.

Yom’s membranes ruptured spontaneously a few minutes after admission, and she needed to push almost immediately. She pushed, and I scurried to set up the room while her husband watched from a chair in the corner. He is the first husband I’ve seen ‘support’ his wife in labor in AGES! I was happy to have him there.

She pushed silently and a gorgeous, vernix laced baby boy bounced into the world. His whiteness concerned the father, but I assured him that the ‘white stuff’ comes off. He laughed when I promised him he didn’t have a kowaja but a Sudanese!

When Mary, in the next room, heard Yom had delivered within minutes, she got mad... and motivated. Margaret tells me she started pushing properly, all of the sudden.

Once Yom was breastfeeding and her bleeding was controlled, I went to help with Mary’s birth. Margaret was using our newly donated vacuum extractors (Thank you Ann-Jule!!!), but was having little success. Fortunately, Mary was close and so we stopped with the vacuum extractor and taught her how to push a bit better.

A couple serious pushes later and her boy slipped on to the scene. Mary’s mother sat exhausted but pleased in the corner of the room. What a relief!

Margaret gathered her things and stumbled off to bed, and I took over. Mary, had a slow recovery and after the placenta was born continued to bleed like mad.

I rubbed her fundus and massaged out clots repeatedly, but her uterus just wouldn’t firm up. Was it incarcerated clots? Were membranes or placental parts retained? I didn’t want to do an internal manual exploration at all, but I couldn’t see any other option. 

Needless to say, she was uncooperative (a theme for her birth I guess, but understandably so... ). But the instant I finished, her bleeding stopped, as if I’d turned off a faucet.

They recovered together, most of the morning, and were discharged later that day. Yom, skipped off with her husband as if she were off to the fair, but Mary was another story.

Mary and Margaret after the birth.

She was sullen and sore, perhaps even disappointed in herself, or us. I’m not sure. It was a hard birth for her. Before she left, I told her that her birth was tough - there was no doubt about it! She nodded slowly in response. I added that sometimes births are easy, and that just because this one was hard, it doesn’t mean the next one will be, too.

She softened when I said that and nodded some more. She believed me. Pray for her. May God bless her with a speedy recovery, and the next time may she have an easier go at it all!

Side note: Mary’s birth was my 200th catch. Yep. I’m one of those geeks that keeps track. Ha ha. I’ve attended a total of 358 births, the last 70 were here in Sudan. What a blessing to be a midwife!