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 miscarriage. Show all posts
Showing posts with label miscarriage. Show all posts
Sunday, January 29, 2012
Wednesday, March 2, 2011
Hydatidiform Mole~
As I measured her belly and reviewed her vitals, the best conclusion I could come up with was a missed abortion and/or intrauterine fetal demise (IUFD).
For those who don’t know, a missed abortion is when a child dies in utero before 20 weeks gestation, (whereas a IUFD is after the 20 week mark), and the child is not expelled.
She had no idea when she got pregnant, but I thought she might be more than 20 weeks since her fundal height was 20 cm and she reported fetal movements before the bleeding began. If so, she had an intrauterine fetal demise (IUFD) which wasn’t being expelled.
The abdominal mass was alternately soft and mushy, then hard and rigid. There were no heart tones and no clots passed, and the bleeding was strange-- slightly foul smelling, and thin.
I conferred with Dennis and he agreed that the best course of action would be to induce her, lest the pregnancy become septic. I asked her if she had family to help her through this, but she didn’t. She spoke, however, of a sister in town who could help her with food, and she’d send word for her husband to come.
Once, the prenatals were through, I started her on an oxytocin drip. I titrated the dosage, bumping it up regularly to help the contractions take off. A few hours into it, I did a vaginal exam. She was completely closed, so I bumped it up some more.
Four hours later, she was still only 1 1/2 cm dilated, 50% effaced. I wasn’t sure if this was normal as I’ve never done it before. The books never said how long such things would take. But Dennis had done this numerous times before, so he was my reference.
However, several hours later, she started passing large clots. I called Dennis in because clots in ‘labor’ don’t make sense. He assured me it wasn’t normal and suggested we were wrong about the gestation age.
I agreed. Perhaps we were dealing with an early pregnancy (missed abortion) after all, and/or incarcerated clots. We were guessing, but they were our best guesses.
Dennis decided to do a manual vacuum aspiration (MVA) to remove the missed abortion and clots and I happily handed her case over. Margaret was taking over the shift, so I left them to it.
About an hour later, I was called to help them again; Tom was called as well. When we arrived, the room was full of IV fluids, bowls of blood and a pile of clots mixed with strange looking tissue that Dennis had removed during the procedure.
He had called us because she wouldn’t stop bleeding. He had completed the MVA and removed as much tissue as he could get, but he couldn’t get the bleeding to stop. He also wanted us to weigh in on the tissues extracted.
The white, vesicled tissue was distinct and immediately apparent; what he removed was not a fetus but a hydatidiform mole. (For those who don’t know, a H. Mole is a rare mass or growth that forms in the uterus. It develops early in pregnancy, as a tissue that is suppose to become the placenta, goes rogue. What develops is a grape-like vesicle tissue that is NOT a baby but still produces pregnancy hormones.)
We discussed how to manage her case as she lay there bleeding. What should we do to stop the bleeding? To look at the amount of blood lost and the amount that kept pouring out, I was shocked Awen was even conscious! Afterward, we conservatively estimated her to have lost 3000cc. That’s about half a person's blood volume!
She was going into shock despite massive fluid replacement, but was still coherent. A miracle!
After discussing her case, I suggested I do an internal manual extraction of clots, since the MVA was not getting it out. Frankly, there was too much blood to even see the cervix. How Dennis was able to do it at all was/is a mystery.
An internal manual exploration is not something you normally do for miscarriages, but if you recall I did it on a incomplete abortion last year and it worked. I explained my reasoning to Dennis and he agreed.
So, I donned gloves and explained what and why to Awen; she agreed, and I reached in to extract what I could. It was painful-- there is no doubt. But once the clots were removed from her vaginal vault, I was able to extract a large piece of vesicles and tissue trapped in her cervix.
Instantly, her bleeding stopped as her uterus clamped down, and the room heaved a collective sigh of relief.
Wow.
Of the four of us in the room, only Dennis had ever seen a hydatidiform mole before -- just once. What a miracle we were able to get it out, keep her alive and stop the bleeding! What excellent team work!
She has been resting all day and is still dizzy for all the blood loss, but that is to be expected.
Pray for a full recovery and that this mole wouldn’t reoccur her next pregnancy. Thanks!
Monday, November 22, 2010
Update: "... to save a life."
Today the girl I referred to Wau for the threatened abortion/stillbirth at 5 months came in for a follow up visit. I was SO relieved to see her again. So relieved.
When I saw her last, part of me wondered if she’d even go to Wau. The other part of me wondered if she’d live. I’m glad that both happened and that she is fine... well sort of.
She explained that she was able to get on the bus to Wau and stayed 3 days at the hospital before the baby died and they induced her. She delivered there and stayed 4 days postpartum before being discharged. That was two days ago.
She came in today because she wasn’t well. She had severe lower right quadrant pain (appendicitis?) as well as some supra-pubic pain (pelvic inflammatory disease?). I’m hoping it was just the PID and covered her with every antibiotic we had on the shelf! I also explained all the signs of an appendicitis. She promised to go back to Wau if they start happening.
So rejoice with me this small victory. Yes, she lost her child but she is recovering.
If you want to read her story you'll find it below on "... to save a life."
When I saw her last, part of me wondered if she’d even go to Wau. The other part of me wondered if she’d live. I’m glad that both happened and that she is fine... well sort of.
She explained that she was able to get on the bus to Wau and stayed 3 days at the hospital before the baby died and they induced her. She delivered there and stayed 4 days postpartum before being discharged. That was two days ago.
She came in today because she wasn’t well. She had severe lower right quadrant pain (appendicitis?) as well as some supra-pubic pain (pelvic inflammatory disease?). I’m hoping it was just the PID and covered her with every antibiotic we had on the shelf! I also explained all the signs of an appendicitis. She promised to go back to Wau if they start happening.
So rejoice with me this small victory. Yes, she lost her child but she is recovering.
If you want to read her story you'll find it below on "... to save a life."
Sunday, November 21, 2010
No-Man’s Land of grief
If each story of each woman that came through my door could be summed up in a tight little paragraph for all the world to read, would they read it? What if the story got complicated and long? What if it wasn’t as interesting as the last one? Would it then be less worthy of the telling?
This week three women came through my door. They had similar stories - all tragic. Some are more tragic than the next. But can heartbreak be measured? Can you qualify that one woman had reason to mourn more than the other, just because she might die?
The challenge I faced this week was how I was to cope with all the death, loss, grief and pain I saw. I kept trying to shut out the pain and sear my heart numb. And when I thought I had succeeded, God would slice it open again in a new area, and gently whisper, “Feel this pain, child. Let it break your heart. It breaks Mine.”
“If you deaden the pain or shut it out, you might survive a little while. But ultimately you will lose your tears, your compassion and start thinking this is normal. It is not.”
So as I write you these women’s stories... know that I only got a glimpse of their pain. I will show you that glimpse. Please don’t dismiss it. Let it break your heart and move you to prayer.
A silent grief ~
Alual has been coming to our clinic for months. She miscarried her last child to an unknown and untreated STD. So during this pregnancy we treated her with all that we could. But our strongest stuff wasn’t working. I don’t know if her husband was treated or not. But I do know she wasn’t sharing her bed with him anymore - now that she was with child.
I loved seeing her in my prenatal line. She was always so happy and round and red. (She wore the same dress each time - a red, cotton dress with white spots.) Her name actually means “red cow.”
Well, this week she came into the clinic complaining of lower abdominal pain but no contractions. So I sent her home to rest. She was only 6 months along, perhaps what she was feeling were the innocuous Braxton-Hicks contractions.
The next morning, however, she returned holding a cold but breathing little girl in her arms. I was horrified.
She had delivered at home unassisted several hours before. Her child was glacial but breathing strong. As a team, we worked hard to get her body temperature up (kangaroo care, hot-water bottles, heat lamp) and started an IV. She only weighed 750 grams. Her heart beat was so strong I could see it beneath her rib cage. Clack-CLACK. Clack-CLACK. There was just one problem. It kept beating slower and slower.
We resuscitated and monitored her for hours. She made some great improvements but we couldn’t keep her heart going. Eventually we explained to Alual that there was nothing left we could do. She asked to take her home to die.
I cried... but she didn’t. She calmly wrapped her baby in her arms and went home. She wasn’t bitter or angry. She was sad but this wasn’t the worst thing she’d lived through. She’d go on.
A raw hopeful grief~
The very next day, another of my regulars came in holding a child in her arms. She, too, delivered prematurely in the middle of the night. Her little boy weighed only 1600g and was estimated to be about 32 weeks gestation. He was alive but fighting to remain so. His lungs lacked the surfactant it needed to fully expand and when we listened closely it sounded like a door slamming shut each time. Gasp-KLUNK. Gasp. KLUNK. But he was a fighter.
We started an IV and talked to the family about getting him to Wau. Perhaps they could do what we couldn’t. I didn’t have much hope but... they were willing to try. And I was not going to steal their hope. It was early enough in the day for them to get a bus to Wau and they hurried off, IV still running.
But this mom, she was young. This was her first child. And as she prepared to go to Wau, she wept uncontrollably. The reality of her child’s fate sinking in, must have finally touched her heart. I wanted to weep but I couldn’t. I didn’t want to feel her pain. It was too fresh. Too raw.
A grief unspoken~
And again, the following day another woman came in. Except this time her baby was already dead and she was not far behind. She was carried in by her family. The smell alone screamed of infection and death.
I came late on the scene but I was told she had a retained placenta that was offensive and possibly gangrenous. Margaret got it out but she kept ‘bleeding’ a thin, white, foul liquid from her uterus.
Her family explained that she had delivered a full-term, macerated baby earlier that day. It was black and decomposing which explained the smell and her condition. She claimed that it had only been one day that she hadn’t felt the baby moving but I doubt it. A baby takes weeks to decompose like that.
In addition to the severe uterine infection and continuous flow of fluid, she had a ragged 4th degree vaginal tear. But it had been too many hours since the birth to suture and heck... what do I know about suturing a 4th degree tear?! I don’t. My heart dropped when I saw the size of it.
Fortunately, she didn’t have a fistula (that I could find) and was stable. We treated her with several antibiotics and kept her over night. The following morning, her family was able to gather the money needed and took her to Wau. Or at least... I hope they did.
She, too, was young. She, too, delivered her first child. But she had no tears to shed. She had to stay alive to cry. Perhaps, she’ll live. Perhaps, not. I pray she does and is able to one day mourn her loss.
So there you have it -- a glimpse at my week.
For those of you who tend to worry, let me reassure you. I am not carrying these women’s burdens. I am sharing their pain with you. I weep for them and pray you will too.
Pray for me. Pray that I would learn to live in this no-man’s land -- that place between the joys of birth and the anguish of death. Pray that despite the sadness and overwhelming pain I see here, I would not be a casualty of this war but instead victorious... and able to lead others into new life.
This week three women came through my door. They had similar stories - all tragic. Some are more tragic than the next. But can heartbreak be measured? Can you qualify that one woman had reason to mourn more than the other, just because she might die?
The challenge I faced this week was how I was to cope with all the death, loss, grief and pain I saw. I kept trying to shut out the pain and sear my heart numb. And when I thought I had succeeded, God would slice it open again in a new area, and gently whisper, “Feel this pain, child. Let it break your heart. It breaks Mine.”
“If you deaden the pain or shut it out, you might survive a little while. But ultimately you will lose your tears, your compassion and start thinking this is normal. It is not.”
So as I write you these women’s stories... know that I only got a glimpse of their pain. I will show you that glimpse. Please don’t dismiss it. Let it break your heart and move you to prayer.
A silent grief ~
Alual has been coming to our clinic for months. She miscarried her last child to an unknown and untreated STD. So during this pregnancy we treated her with all that we could. But our strongest stuff wasn’t working. I don’t know if her husband was treated or not. But I do know she wasn’t sharing her bed with him anymore - now that she was with child. I loved seeing her in my prenatal line. She was always so happy and round and red. (She wore the same dress each time - a red, cotton dress with white spots.) Her name actually means “red cow.”
Well, this week she came into the clinic complaining of lower abdominal pain but no contractions. So I sent her home to rest. She was only 6 months along, perhaps what she was feeling were the innocuous Braxton-Hicks contractions.
The next morning, however, she returned holding a cold but breathing little girl in her arms. I was horrified.
She had delivered at home unassisted several hours before. Her child was glacial but breathing strong. As a team, we worked hard to get her body temperature up (kangaroo care, hot-water bottles, heat lamp) and started an IV. She only weighed 750 grams. Her heart beat was so strong I could see it beneath her rib cage. Clack-CLACK. Clack-CLACK. There was just one problem. It kept beating slower and slower.
We resuscitated and monitored her for hours. She made some great improvements but we couldn’t keep her heart going. Eventually we explained to Alual that there was nothing left we could do. She asked to take her home to die.
I cried... but she didn’t. She calmly wrapped her baby in her arms and went home. She wasn’t bitter or angry. She was sad but this wasn’t the worst thing she’d lived through. She’d go on.
A raw hopeful grief~
The very next day, another of my regulars came in holding a child in her arms. She, too, delivered prematurely in the middle of the night. Her little boy weighed only 1600g and was estimated to be about 32 weeks gestation. He was alive but fighting to remain so. His lungs lacked the surfactant it needed to fully expand and when we listened closely it sounded like a door slamming shut each time. Gasp-KLUNK. Gasp. KLUNK. But he was a fighter.
We started an IV and talked to the family about getting him to Wau. Perhaps they could do what we couldn’t. I didn’t have much hope but... they were willing to try. And I was not going to steal their hope. It was early enough in the day for them to get a bus to Wau and they hurried off, IV still running.
But this mom, she was young. This was her first child. And as she prepared to go to Wau, she wept uncontrollably. The reality of her child’s fate sinking in, must have finally touched her heart. I wanted to weep but I couldn’t. I didn’t want to feel her pain. It was too fresh. Too raw.
A grief unspoken~
And again, the following day another woman came in. Except this time her baby was already dead and she was not far behind. She was carried in by her family. The smell alone screamed of infection and death.
I came late on the scene but I was told she had a retained placenta that was offensive and possibly gangrenous. Margaret got it out but she kept ‘bleeding’ a thin, white, foul liquid from her uterus.
Her family explained that she had delivered a full-term, macerated baby earlier that day. It was black and decomposing which explained the smell and her condition. She claimed that it had only been one day that she hadn’t felt the baby moving but I doubt it. A baby takes weeks to decompose like that.
In addition to the severe uterine infection and continuous flow of fluid, she had a ragged 4th degree vaginal tear. But it had been too many hours since the birth to suture and heck... what do I know about suturing a 4th degree tear?! I don’t. My heart dropped when I saw the size of it.
Fortunately, she didn’t have a fistula (that I could find) and was stable. We treated her with several antibiotics and kept her over night. The following morning, her family was able to gather the money needed and took her to Wau. Or at least... I hope they did.
She, too, was young. She, too, delivered her first child. But she had no tears to shed. She had to stay alive to cry. Perhaps, she’ll live. Perhaps, not. I pray she does and is able to one day mourn her loss.
So there you have it -- a glimpse at my week.
For those of you who tend to worry, let me reassure you. I am not carrying these women’s burdens. I am sharing their pain with you. I weep for them and pray you will too.
Pray for me. Pray that I would learn to live in this no-man’s land -- that place between the joys of birth and the anguish of death. Pray that despite the sadness and overwhelming pain I see here, I would not be a casualty of this war but instead victorious... and able to lead others into new life.
Sunday, November 7, 2010
... to save a life.
A young woman came in this morning because she was 5 months pregnant and miscarrying. She had lots of bleeding and abdominal pain since last night. When I saw the amount of bleeding, I assumed the child was already dead. But he wasn't.
I could hear his heart ticking away at lightening speed. Tic-tic-tic-tic-tic-tic-tic-tic-tic-tic-tic! The rate was high of course (160-170s) but he was alive. She told me her water broke a full week before. It didn't look good. But he was still alive.
I told her family that she needed to get help at Wau, that we didn't have the means to help her. But her mother said... "I understand we should go to Wau. But it's better if the pregnancy ends now." Only then did it occur to me that perhaps this woman had tried to abort this child. I tried to ask if anything had been put inside the woman to stop the pregnancy? Did anyone give her special herbs to drink? They assured me that they hadn't. I want to believe them. Most of me does.
Understanding that she needed the care in Wau, the family rallied and found money. But before she left, I had to warn her not to let the bus driver know she was sick. In the past, the drivers refused to take sick patients or charged them 300 pounds (a months salary) to take them. Extortion.
When I explained this to the women they grew somber, immediately understanding the situation. It broke my heart to have to warn her not to groan in pain on the bus for fear they'd kick her off. But I did. I told them she'd have to change her clothes and hide the blood as well. They complied.
It's wrong to lie. It's wrong to deceive. And I told them so. But I think it's even more wrong to charge 100 times the bus fare to sick patients. I look forward to having an ambulance. I really do.
Pray she gets on that bus and is able to get the care she desperately needs. Thanks.
I could hear his heart ticking away at lightening speed. Tic-tic-tic-tic-tic-tic-tic-tic-tic-tic-tic! The rate was high of course (160-170s) but he was alive. She told me her water broke a full week before. It didn't look good. But he was still alive.
I told her family that she needed to get help at Wau, that we didn't have the means to help her. But her mother said... "I understand we should go to Wau. But it's better if the pregnancy ends now." Only then did it occur to me that perhaps this woman had tried to abort this child. I tried to ask if anything had been put inside the woman to stop the pregnancy? Did anyone give her special herbs to drink? They assured me that they hadn't. I want to believe them. Most of me does.
Understanding that she needed the care in Wau, the family rallied and found money. But before she left, I had to warn her not to let the bus driver know she was sick. In the past, the drivers refused to take sick patients or charged them 300 pounds (a months salary) to take them. Extortion.
When I explained this to the women they grew somber, immediately understanding the situation. It broke my heart to have to warn her not to groan in pain on the bus for fear they'd kick her off. But I did. I told them she'd have to change her clothes and hide the blood as well. They complied.
It's wrong to lie. It's wrong to deceive. And I told them so. But I think it's even more wrong to charge 100 times the bus fare to sick patients. I look forward to having an ambulance. I really do.
Pray she gets on that bus and is able to get the care she desperately needs. Thanks.
Saturday, October 16, 2010
Manual Vacuum Aspiration ~
Today I saw my first manual vacuum aspiration (MVA) performed. It was hard to watch but gently performed. Dennis was instructing me how to use it, since, it will be my responsibility to do it in the future. I’m not looking forward to it.
For those who don’t know, an MVA is used when a woman has an incomplete abortion (aka: miscarriage). It is different from a D&C (Dilitation and Curettage) which is performed (at least in the states) under anestesia.
As its name describes, it uses a vacuum seal to draw the products of conception from the uterus through a thin tube inserted via the cervix.
I’m happy to learn this new skill and to provide such a needed service to these women... but I’m also sad. I never suspected that my work here would involve so many miscarriages.
In the Philippines, we NEVER saw or dealt with miscarriages. Once in awhile we had a patient that had a miscarriage, but the minute it occurred we transferred care to the hospital. But here, WE are the hospital.
Having this skill saves our women lives as well as the cost of going to Wau. It costs (I’m told) as much to have a D&C as it does a C-section. We of course, provide it for free.
For those who don’t know, an MVA is used when a woman has an incomplete abortion (aka: miscarriage). It is different from a D&C (Dilitation and Curettage) which is performed (at least in the states) under anestesia.
As its name describes, it uses a vacuum seal to draw the products of conception from the uterus through a thin tube inserted via the cervix.
I’m happy to learn this new skill and to provide such a needed service to these women... but I’m also sad. I never suspected that my work here would involve so many miscarriages.
In the Philippines, we NEVER saw or dealt with miscarriages. Once in awhile we had a patient that had a miscarriage, but the minute it occurred we transferred care to the hospital. But here, WE are the hospital.
Having this skill saves our women lives as well as the cost of going to Wau. It costs (I’m told) as much to have a D&C as it does a C-section. We of course, provide it for free.
Monday, October 4, 2010
Mulling over a miscarriage.
Right before I left on break (Yes, almost a month ago.) I had a patient come in with a history of heavy bleeding and clots with what turned out to be an incomplete abortion (aka: miscarriage).
I was so rattled and yet ... impressed by the encounter, that I’m only now able to write about it. I’ve had a month to think it over and ... well, I’m still unsettled. But at least now, I’m ready to write it down.
She came alone and toward the end of the day - almost as if saying she had better things to do that day. She sat still and quietly explained that she was bleeding big clots. She was miscarrying but something was wrong. She said the bleeding started four days before and didn’t want to stop. That is why she came.
She was thin in the way years of working fields and nursing babies make you thin. And she was strong. Long muscles defined by endless grinding and sweeping and caring for kids. But it was her eyes that did me in. They were no-nonsense-black and piercingly serious.
I explained to her that I needed to do a speculum exam to see what was going on. She agreed and that’s when I saw the extent of the miscarriage. Fortunately there were no signs of infection, so I called Dennis in to see if using the manual aspiration vacuum would be appropriate. He said that it wouldn’t (I forget the reason why now.) and recommended I send her to Wau.
Here’s the thing. Women like her (no family support group with her, tattered clothes and worked-to-the-bone thin) don’t tend to have money to go to Wau. I’m tired of referring women to Wau that cannot realistically go. I feel like I’m failing them. I’m not doing all I can do.
So I told her we had too options. One, she could go to Wau and get a D&C because to do nothing would lead to sepsis and further problems. Or two, I could try and do an internal manual exploration to get the rest of the fetus out. BUT that an internal exploration is EXTREMELY painful and I would prefer she go to the hospital.
She explained that she had no money and she wanted me to do an internal exploration. My heart skipped a beat.
Any woman who has had this procedure can tell you it’s worse than the pain of birth. I’ve had to do it a few times (right after a birth) and each time the woman crawled the walls and screamed my ears bloody in pain. My heart shrinks in despair every time I have to do it.
For those who don’t know, an internal exploration requires I reach a gloved hand inside and manually remove the fetus, placenta or membranes from the uterus allowing for it to clamp down and stop bleeding.
It’s a lifesaving measure in preventing postpartum hemorrhage... but this is the first time I considered doing it for a miscarriage. Would it even work? Is the benefit worth the pain? What if I do nothing? What if she goes septic and dies?
I had my translator explain over and over again what it required and how painful it was going to be. I asked her to be strong and try not to pull away. I made sure she understood and again asked her permission to do it. Was she sure?
I was stalling. I flat out didn’t want to cause her the pain. But I wanted her to live more. So I did it.
Here’s the thing. She never once flinched. Nor did she make a sound. She lay still and stoic - shockingly so.
As I removed the fetus from the cervix, I discovered half of it was still inside the uterus. I had to manually dilate her cervix to get it out. This must have been blindingly painful but you would never have been able to tell by her reaction. She was motionless and... resolute.
Once I finished, I asked her if she wanted to see her child. She only hesitated a moment then gathered herself together and sat up. She looked long and hard then said “Thank you”.
I apologized over and over again for the pain I caused her and told her how brave she was. I warned her of signs of infection and instructed her on how to care for herself. I was almost certain I got it all out but she needed to come back for a check up in a day or so, etc. She listened carefully to each instruction while quietly gathering herself together.
Again I found myself apologizing for the pain I caused her and telling her how sorry I am that she lost her child. Only then did she speak.
“Please don’t be sad.” She said. “I am not sad. I am glad that you did it. Now I know that I will not die. Thank you.”
Even now, as I think of her I want to cry. Here is a woman who has not had an easy life. Yet when she loses a child, and suffers severe pain... she ends up comforting her midwife.
My world feels a little upside down.
I was so rattled and yet ... impressed by the encounter, that I’m only now able to write about it. I’ve had a month to think it over and ... well, I’m still unsettled. But at least now, I’m ready to write it down.
She came alone and toward the end of the day - almost as if saying she had better things to do that day. She sat still and quietly explained that she was bleeding big clots. She was miscarrying but something was wrong. She said the bleeding started four days before and didn’t want to stop. That is why she came.
She was thin in the way years of working fields and nursing babies make you thin. And she was strong. Long muscles defined by endless grinding and sweeping and caring for kids. But it was her eyes that did me in. They were no-nonsense-black and piercingly serious.
I explained to her that I needed to do a speculum exam to see what was going on. She agreed and that’s when I saw the extent of the miscarriage. Fortunately there were no signs of infection, so I called Dennis in to see if using the manual aspiration vacuum would be appropriate. He said that it wouldn’t (I forget the reason why now.) and recommended I send her to Wau.
Here’s the thing. Women like her (no family support group with her, tattered clothes and worked-to-the-bone thin) don’t tend to have money to go to Wau. I’m tired of referring women to Wau that cannot realistically go. I feel like I’m failing them. I’m not doing all I can do.
So I told her we had too options. One, she could go to Wau and get a D&C because to do nothing would lead to sepsis and further problems. Or two, I could try and do an internal manual exploration to get the rest of the fetus out. BUT that an internal exploration is EXTREMELY painful and I would prefer she go to the hospital.
She explained that she had no money and she wanted me to do an internal exploration. My heart skipped a beat.
Any woman who has had this procedure can tell you it’s worse than the pain of birth. I’ve had to do it a few times (right after a birth) and each time the woman crawled the walls and screamed my ears bloody in pain. My heart shrinks in despair every time I have to do it.
For those who don’t know, an internal exploration requires I reach a gloved hand inside and manually remove the fetus, placenta or membranes from the uterus allowing for it to clamp down and stop bleeding.
It’s a lifesaving measure in preventing postpartum hemorrhage... but this is the first time I considered doing it for a miscarriage. Would it even work? Is the benefit worth the pain? What if I do nothing? What if she goes septic and dies?
I had my translator explain over and over again what it required and how painful it was going to be. I asked her to be strong and try not to pull away. I made sure she understood and again asked her permission to do it. Was she sure?
I was stalling. I flat out didn’t want to cause her the pain. But I wanted her to live more. So I did it.
Here’s the thing. She never once flinched. Nor did she make a sound. She lay still and stoic - shockingly so.
As I removed the fetus from the cervix, I discovered half of it was still inside the uterus. I had to manually dilate her cervix to get it out. This must have been blindingly painful but you would never have been able to tell by her reaction. She was motionless and... resolute.
Once I finished, I asked her if she wanted to see her child. She only hesitated a moment then gathered herself together and sat up. She looked long and hard then said “Thank you”.
I apologized over and over again for the pain I caused her and told her how brave she was. I warned her of signs of infection and instructed her on how to care for herself. I was almost certain I got it all out but she needed to come back for a check up in a day or so, etc. She listened carefully to each instruction while quietly gathering herself together.
Again I found myself apologizing for the pain I caused her and telling her how sorry I am that she lost her child. Only then did she speak.
“Please don’t be sad.” She said. “I am not sad. I am glad that you did it. Now I know that I will not die. Thank you.”
Even now, as I think of her I want to cry. Here is a woman who has not had an easy life. Yet when she loses a child, and suffers severe pain... she ends up comforting her midwife.
My world feels a little upside down.
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