2.1 equals 1.1

Yesterday a young girl came for help. Reported to be early in her third trimester, she complained of malaria symptoms. Fever. Chills. Pain.

Margaret saw her and called Dr. Tom to help evaluate. I’m told she was severely pale so they asked our new lab technician, Caroline, to check her hemoglobin.

She had a hb reading of 2.1 g/dl.
    --Yes. You read that right. A hemoglobin of 2.1

(For those who don’t know, that reading is crazy low! Normal hb in pregnancy is 11-12 g/dl if you are moderately healthy.)

She needed a blood transfusion.

Remarkably, her baby was still alive. I was told Margaret and Tom were preparing to refer her to Wau for a transfusion while starting aggressive treatment of the cause --malaria.

Since church was starting soon, I decided to visit her after church. But once service ended, Margaret approached me saying she’d delivered.

What? I thought she wasn’t having contractions. When did she deliver?

Apparently in an effort to save her life, her body expelled the child spontaneously. He was born alive but severely preterm weighing just 1.1 kg (or 2.4 lbs).

Once I heard the news I went to check on him. He was breathing well but starting to show signs of distress. His mother looked sad and exhausted.

She explained that all her family was far away or in prison. There was no one left to help her get to Wau for the blood she needs.

Sigh.

With time Dennis was able to start an IV on this precious munchkin and we gave formula through an NG tube. He looked like he wanted to live.

After doing a Ballard’s score (a rating to help determine the gestational age of a newborn), we guess him to be around 31-32 weeks gestation. This explains his ability to breath well but not his size. I believe him to be small for gestational age (SGA) as well. Long term anemia will do that in a pregnancy.

Please pray for them. Her name is Ayen. She is family-less, severely anemic, with a tiny preterm baby. Please pray for God to keep them both healthy and alive. Thanks.

Deep Transverse Arrest

 

Nunu’s first birth ended in a cesarean. She was in labor for several days by the time she got to Wau. The doctors explained the baby was transverse and performed a cesarean. The baby lived just two hours.

The evidence of her loss came in the form of a copper streak an inch wide which sprouted from her pelvis and pushed raggedly past her belly button --a classical cesarean scar. Tiny dots ran along each side like a fence post; it must of hurt to get those sutures removed. 

She had been coming to our clinic for several months before I met her. Up until then, Margaret or Sarah had done her checks.

I clearly remember meeting her that day for two reasons. One, she discussed her case in English. And two, she really didn’t like what I had to say.

At that time, her baby was breech. I told her it wouldn’t be safe for her to deliver anywhere but a big hospital. There were just too many risk factors.

She argued with me, saying that she wanted to talk to Margaret. When I called her in for a consult, Nunu broke down in tears and wept on her shoulder. She categorically refused to consider going to Wau.

Then together we explained the risks. She needed to prepare for surgery and consider going to Wau even to labor. She shook her head in refusal, flashed tear-filled eyes my way, then took her book and hurried off.

Fast forward another month or so, to earlier this week.

She arrived mud splattered and soaked to the bone in the middle of a storm. She was in active labor.

One look at her file and I was concerned. Why had she not listened?

I told her that since there was no way we could get her to Wau that night, we’d let her have a ‘trial of labor’, but ultimately if there was no progress she’d still have to go. 

She listened... but didn’t at the same time. Her jaw was set in refusal.

Since she was already 8 cm dilated with an intact membrane, I let her labor on her own. Progress was slow, but I remained hopeful.

But then again, I didn’t have many options. We couldn’t drive her in the middle of the night. The storm only made things worse. Plus... she wouldn’t even consider it.

Margaret took over her care that night. She explained that although she was well past fully, Nunu was not pushing right. Perhaps she didn’t know how or couldn’t.

I assessed her again and found the head to be at a zero station and slightly swollen. Her pelvic outlet seemed more than adequate. But he did palpate to be big.

Margaret continued to explain to them the need for a cesarean while letting her try and push a bit longer. Fetal heart tones were fine, and Nunu was determined.

But after a few more hours of no progress, Margaret told them she’d need to leave first thing in the morning for Wau. She went to get some sleep and left them to discuss it amongst themselves.

The translator working that night said Nunu’s mother was upset we were ‘giving up’ by going to sleep and took her home. Nunu and her family left in a hurry around 2:30 am.

When I woke for my shift, I expected to be greeted by a baby or a transport. But the clinic was empty. I couldn’t understand why they left.

There was little I could do but pray. So I prayed and prayed. In fact, I could do little else.

Had she gone home and delivered? Did they take her to another clinic? What happened?

I worked through my worry by doing prenatal after prenatal. I finished just after lunch then went to a staff meeting. By 4 pm, I was called away early because she’d returned.

Fourteen hours had passed since she’d been checked. Fourteen long hours...

I asked her what they’d been doing all this time but they were silent. I pressed them only to learn they’d simply gone home. They didn’t call a TBA. They didn’t go elsewhere in town. They simply went home and did nothing.

Digging deeper, I also learned her contractions stopped shortly before dawn.

However when I lifted her dress to check her baby, my heart jumped in my mouth. I couldn’t believe my own eyes. Bandl’s Ring had developed.

Bandl's Ring.

(For those who don’t know, Bandl’s Ring is when the upper uterine segment separates from the lower uterine segment, forming a band around the belly. It is a sign of severe neglect of an obstructed labor and proceeds uterine rupture.)

I asked if I could take a picture and told her that she needed to go to Wau immediately. She agreed to both. They realized she was dying and had gathered the money. They’d come back to ask to use our ambulance.

Thankful for this change in heart, I set the wheels in motion. The drivers had to be called, the ambulance needed to be fueled, and I needed to write her doctors a referral.

Although her blood pressure was stable, Nunu was deteriorating fast. Her baby was alive but  had developed a sinusoidal heart rate pattern. This is a serious indication of imminent death, and I told her so.

(For those who don’t know, a sinusoidal heart rate pattern goes high and then low and then high and then low again. There is never a stable baseline but it typically stays within a normal range and is a sign of severe fetal compromise.)

-- “Nunu, if you don’t get this surgery soon both you and your baby can die.”
-- “I understand.”
-- “I’m not saying this to scare you. I just need to know... Do you know Jesus?”
-- “Yes. I am a believer,” she said then turned away.

Fortunately, it didn’t take us long to get her on the road. But I had my doubts.

She’d be arriving at the end of the day. Most doctors aren’t working late night shifts I’m told. Plus, the last woman we referred for a cesarean was told to wait another 8 hours after arriving because her baby had died. That girl eventually got surgery, but died minutes later. Would Nunu have a similar experience?

Dark thoughts nipped at my heels. Yappity dogs. Fierce hounds. My only retreat was prayer.

Lord, may Nunu live. May her child somehow survive. You knit this precious one in her womb, now please bring him out. I’m begging for a miracle.

I woke the next morning to learn she’d not had the cesarean. At first I was nauseated, but again I prayed. There must have been a good reason.

Later that day, I learned that by the time she’d arrived the baby was dead and she was semi-conscious. She was too unstable for anesthesia and was pale. The doctors didn’t want to perform a surgery just to have her die on their table.

Plus, they wanted her family to donate blood. She couldn’t have the surgery until they had 2 or 3 units of blood standing by.

When I learned of this new rule I didn’t respond well. They were doing nothing! Why were they doing nothing? But again God reminded me that they must have good reasons and I prayed.

Lord, I’m tired of sending people to Wau for help and they never get it. I’m tired of hearing they have no blood there and that’s why this girl or that girl must die. Please, Papa, do a miracle!

I later learned that she has my blood type and volunteered to donate. But my going there was not an option. Instead we helped organize her family members in the area and got them there.

But it was all for naught. She died later that night, never having woken from her coma.

I understand why the doctors in Wau didn’t take her into surgery. I understand their need for blood. I even understand their anger with us. They thought we were wrong to keep her so long or allow the trial of labor.



What I don’t understand are Nunu’s choices. Why did she argue when we told her to deliver in Wau? Why did she come after a day of active labor in a rain storm? Why did she abscond in the night when we wanted to refer? Why did her family let her get so bad before taking action? Why didn’t she plan ahead and set aside the money? Why didn’t she listen?

I don’t ask these question in judgment. I ask them in genuine confusion. Why?

Perhaps with time, I’ll better understand the social and economic limitations of the women here. Perhaps with experience, I’ll be able to better help them maneuver any obstacles. Perhaps with time, fewer women will die. Perhaps.

Perhaps not.

Nunu’s death burdens me. Please pray for her family. She was well loved and known in this community. Her funeral is tomorrow.

Two Liters Too Few.

Her precious children.

Angueth came in barely conscious. But by the time I was called, my translator had little time to do much more than learn her name and get her to lie down on the bed. It was a busy night.

So I busied myself with fundal heights and heart tones while he asked her more questions.

“Ask her how long she’s been sick like this,” I instructed my translator.
She responded but I couldn’t understand her words. She was slurring them.
“Is she drunk?” I asked again, confused and not a little worried, “Or has she had a stroke?”

The man who brought her in, didn’t know so he asked her daughter. There was a brief discussion,  during which it became clear that this man wasn’t her husband. He may have been a neighbor or a random stranger. But he wasn’t family.

“The girl says she doesn’t drink,” I was informed.

Angueth was barely hanging on at this point. Every few minutes she’d slip from consciousness and I’d try to pull her back.

Limp and cold, her extremities were swollen and her mucosa was white. She was severely anemic. I screened her for malaria symptoms.

She’d had all the major symptoms for some time, but she’d not been able to talk right for three days.

“This is outside of my scope of practice,” I explained to my translator, “Please get Dennis. I need his help.”

He grabbed the flashlight and left in a hurry, leaving me with Angueth, the Good Samaritan and a handful of kids.

Three to be precise.

Her eldest looked to be about 10 years old; the other two were both under 5. And all three sat quietly on the bench in the hall.

I continued checking her vitals while I waited.

Search as I might, I found no heart tones and eventually gave up. She looked to be about 7-8 months pregnant.

“My lower abdomen hurts,” she mumbled softly while rubbing the spot.
“Is it a contraction?” I asked in Dinka.
“Yes, it hurts. It hurts.”

Although I could not see or feel any contractions, I suspected her body might be delivering in an effort to save her life. So I did a vaginal exam.

Sure enough she was dilating. She was already 5-6 cm along.

Dennis arrived and I filled him in. He assured me that she hadn’t had a stroke but was in the late stage of severe anemia. Surprisingly her blood pressure was stable. So we started her on antimalarials and admitted her for labor.

Late as it was, there was no hope of getting her to Wau for a transfusion. Plus the Good Samaritan had quietly slipped away, and we had no way of contacting her family.

When I told her that she was very sick and was delivering early, she wasn’t surprised. But when I told her that her baby was no longer alive it took her a while to come to terms.

“So my baby is coming?” she asked, bubbles forming at her mouth.
“Yes,” I said looking at her full in the face. Her eyes searched mine in an effort to understand.
“When he comes. Will he be alive or dead?” she continued on.
“Your baby will be dead.”
Whimpering softly in response, she closed her eyes.

I think she wanted to say more, but the effort to speak was too great. Staying conscious was a hard enough.

Margaret took over her care in the night. She told me that Angueth’s labor progressed naturally, and a few hours later she delivered a girl. She was dead but hadn't been for long. Fortunately, Angueth lost only the slightest amount of blood, and her blood pressure remained stable throughout.

The following morning when I went to check on her, I was surprised to find her fast asleep. But when I tried to rouse her, she was completely unresponsive.

Although she’d been assessed shortly before by our night staff, it was clear the vitals were off. So I took them again. And sure enough, I was right.

She was unconscious and in shock.

With cold extremities, high pulse, and blood pressure bottoming out, I called for re-enforcements. First I called Tom, who listened to her chest for the sound of heart failure in the form of fluid build up. But eventually announced that it was out of our hands, saying she needed a blood transfusion.

Yes. That was clear.

Then I called Dennis, who helped me elevate her legs and suggested I give her Hemosele (a blood replacement IV fluid) to see if her blood pressure might at least stabilize. It was 68/42.

Blissfully unaware of the seriousness of the situation, two of her three children napped on our porch while the eldest went to get porridge.

When she returned I asked her to find an uncle or an aunt. Anyone. I told her that I needed to speak to them urgently. Could she do that for me?

Eager to help, she smiled sweetly and left right away. And I returned to her mother. I continued to monitor her vitals, but the fluids didn’t help.

Her blood pressure continued to plummet, and her breathing became more rapid and hoarse. A choking rattle filled the room as I watched... and counted. She was up to 60 respirations a minute.

A few minutes later, she passed away, shedding two tears without waking. They streamed down her cheeks and onto the bed.

Then the rattled ceased.

At the sight of her tear-stained face, I couldn’t hold back my own. And I mourned for this stranger as if she were my sister, grateful no one was there to watch.

A few hours later, Albino was able to track down her brother and uncle. They hadn’t even heard she was ill. Apparently her husband left some time ago. She lived alone.

Her family gathered around and I told them the story of her death. They were sad but thankful to have a few answers. Then one of our guards walked her children home while the rest of us placed her in the ambulance.

Rigor mortis had already set in.

As I helped lift her body into the vehicle, I had to step over two shovels and a pick.
    --How long will it take them to dig her grave?

Lord, please teach us how to do blood transfusions and send us the equipment. I’m tired of watching these women die for the lack of two liters of blood. Better still... Lord, send them to us for prenatals.

And if by some miracle any reader out there knows how to do transfusions and can teach us what kind of equipment we need, I want to chat! Write me in the comment section.

I’m praying that God will send us the equipment and the expertise to do transfusions. Will you pray with me?

Blood.

“Adut went to Wau and died,” Albino informed me.
"Adut?" I asked.
"The woman who needed the transfusion," he explained.
Albino is our compound manager and was the one who arranged for their transport.
He continued, “They were bringing her body back for the funeral, and their truck broke down. They want to use our ambulance again.”
“She died?” I asked incredulously.
“Yes. She died in Wau. They are stuck on the way back...”
“Did she get the transfusion?” I asked suspiciously. “Because had she gotten it... it’s unlikely she would have died.”
“I don’t know. I didn’t ask them,” he explained quietly.
“And what is going to become of the baby? Is there a wet-nurse in the family?” I persisted.
“I don’t know... I didn’t ask,” he repeated.
“Please ask them. I have to know...” I said, thinking to myself that I’d take the baby before they let her starve.

Mothers who die in or shortly after childbirth are trouble for the family. I’ve heard of more than one child left to die. I told this to Albino who nodded knowingly and told me he’d find out for sure.

That was two days ago.

Today Albino knocked on my door inviting me to go speak to the family. He remembered my offer to help if the family couldn’t (or wouldn’t) do it and wanted me to join him for a visit.

Eager to get the details of her care in Wau, I went with him. Sam, a Kenyan pastor on staff, joined us.

When we entered their bamboo gate, three men sat somberly beside a tukel and several sets of female eyes peered out at us from inside. Everyone was hiding from the mid-morning sun which was hotter than normal for the season.

The men didn’t rise to greet us, nor did they smile; the pall of mourning was heavy. They did shake our hands, however, and gesture to three empty plastic chairs. We sat down.

A long, respectful minute ticked by before Albino spoke. He told them we were sorry for her death and asked for details of their time in Wau. What had happened?

After a long discussion in Dinka, he turned to me to explain:
“She never got the blood,” he started, “They try to buy but there was no blood to buy. So, many got the test to see if they can give. They not have right blood.”

He paused to ask a few more questions, nodded as the husband explained, then continued:
“She had O+ blood. One man, he had same blood. But this man, he refuse to give. So she die.”

As he explained, my brain raced with this new information. I have O+ blood. I could have donated. Had I known, I would have given it happily. Why would that ‘man’ not give his blood? Why would he withhold what could so easily cure?

Albino then kindly asked them about the baby. I needed to know the child was well. In response, they brought her out of the tukel.

She was sleeping the deep sleep of baby-bliss. She knew nothing of the burial mound just 15 feet away --a mound topped with all of Adut’s worldly possessions. A worn out mattress. A green plastic basin. A cooking pot. Several dresses. A shovel.

As I looked from the child to the mound, I wondered what I’d leave behind if I were to die today. But I was quickly pulled from my reverie when Albino said my name.

“Stephanie,” he started, “they are giving the baby milk from market.”
“What kind of milk?” I asked. “Could I see it?”
They brought me a canister of baby formula and I asked them how they were giving it. What kind of water were they using? Were they giving it with a bottle or a cup? How many scoops were they using for the fluid?

Their answers were spot on; everything was being given correctly, and I was told that Adut’s mother (the grandmother) was now sole caregiver of the child.

As I looked at her thin, strong arms and grave but determined expression, I was comforted to see she was still young; she could be no more than 40 years old. There wasn’t a gray hair on her head, and only the slightest of crows-feet nestled in the corner of her eyes. The child would be well cared for and loved.

Albino suggested we pray before going, but I wasn’t ready. I wanted to teach them on how to prevent this from happening again. They agreed to hear me out and the newly formed crowd followed us to a shade tree outside their yard. 

We sat in a circle and I prayed silently to myself before I began; I didn’t want to mess this up. I don’t remember all that I said, but it was a lot.

I explained the role of good antenatal care in preventing such sicknesses and the importance of delivering at clinics. They listened with rapt attention, eyes never leaving my face. I had a captive audience and was grateful for it. Perhaps this information will prevent any more women from dying in their family.

The women sat a bit further back but were equally attentive. They didn’t fidget or cough. They hung on every word.
        --Lord, may all these women live!

After some time, I finished and Albino asked Sam to share the gospel. Sam spoke on the a verse in Isaiah that calls men grass (Is 40:6), reminding us all how fleeting and short life is. He encouraged them to place their faith in Jesus. Then Albino shared again.

I don’t know what he said but the crowd listened carefully.

Then the patriarch spoke. I never asked his name, but I don’t think I’ll ever forget his face. His dark blue jalibia stood out sharply against is cole-black skin. His piercing ebony eyes gazed fixedly on mine as he spoke. In them I saw pain and grief but no condescension.

His questions were honest --his pain real.

He spoke about the difficulty of being a patriarch, but he didn’t complain. Instead he explained how in the village when his daughter got sick, he had to take her to the witch-doctor first.

He lamented the social pressure he was under that forbid him from going to the hospital first. He added that in the village, when someone gets sick they must first find out if it’s a curse. So he took her to the witch-doctor.

Only when she didn’t improve did the witch-doctor allow them to bring her to the hospital. That’s when they came. But when they learned she needed new blood he finally understood. But by then it was too late. They weren’t able to get the blood.

“... had I known she just needed blood, I would have brought her earlier,” he explained, “But I was told she was cursed.”

My heart ached more and more with each sentence he spoke. Albino translated his words but the grief on his face needed no translation.

“Why is God letting all my children die?” he asked us. “It must be because He is far and does not know our troubles. He must not care...”

I listened carefully, thankful for his candor. Here was a man who really did want to understand. When he finished I asked for permission to answer his questions. Even though I spoke directly to him, everyone in the circle listened attentively.

Then I shared the gospel. I spoke about how his daughter was cursed, but not in the sense the witch-doctor suggested. She was cursed by sin. We all are. I explained that death was the consequence of sin, but that God had provided a way for forgiveness.

He listened carefully. Respectfully. They all did.

I gave them the clearest gospel message I could and we invited them to church. Afterward they thanked us for sharing this information with them. They had never heard these things before.

We prayed for them and left, shaking each one’s hand in respect.

As sad as her death is, I pray that it will be the start of new life for the rest of her family. Please pray with me that the seeds shared would find good soil and bring much fruit. Thanks.

Also pray for us to find a way to do blood transfusions. This is now the 3rd maternal mortality I know about that could have been cured with a simple transfusion.

Update: Blood Transfusion?

A few weeks ago, I wrote about an 18 year old pregnant woman who had a hemoglobin of 4.4 after a case of severe malaria. We attempted to do a direct blood transfusion to improve her condition. (Read her story here.) But we failed. We just aren't set up for this kind of thing.

In fact, after several hours and many 'learning curve' situations, we were only able to infuse about 30-40 ccs of blood. She spent the night at the clinic and we discharged her to Wau the next day, so she could get a transfusion there.

Well. Today I learned she died.

I was surprised to think a grown woman could die for something so preventable, let alone a pregnant one. What happened? What went wrong? Didn't she go to Wau? Didn't she get the blood transfused?

One of our translators, Wilson, (who happens to be her cousin) told me the rest of her story today. She was too weak to travel so he (Wilson) went to Wau instead and inquired if there was any blood available. He was told they had no B+ blood but if someone came in to donate they'd do the transfusion. He came back, told his family the news and together they stopped trying.

She died two days later. (Three days after our attempt at a transfusion.)

I asked him why the two men (that we cross matched to her in our lab), didn't just go and give their blood; They still had plenty. He looked at me confused and said, "But they had no blood. Don't you remember? We couldn't get any from them."

Instantly my heart sank. Yes, I remembered. But I remembered it much differently than he did. We couldn't get blood from them because we didn't have the correct materials -- not because they were out of blood. (!#$%!@!)

I asked him if he remembered learning in class that a person has over 5 liters of blood in their body on average. He nodded and said he remembered. "Well, if a person has 5 liters, don't you think that they can give much more than 30 ccs?" He just cocked his head to the side and looked at me sadly. He didn't appear to understand.

"Wilson, your friends still had blood to give. She could have gotten the transfusion with their blood." I struggled to keep the incrimination out of my voice. He explained that the 'Fathers' decided that they shouldn't give anymore since they had tried and failed...

I tried to teach him more about how blood transfusions are (normally) done and how much can be given. I didn't want him to feel bad, just to know so this didn't happen again. But I cut my lecture short, seeing he wasn't listening.

He was tired. He was sad. He had done all he could... all he thought best in fact. So, I shut up and started lecturing myself instead. "He did everything he knew to do... He was trying by going to Wau, by talking to the 'Fathers'. He was fighting for her life and failed... just like we did."

The conversation moved on but my heart sank further down. What more could I say? I failed.

I failed to explain to them that a person cannot 'run out of blood'. I've failed because... this isn't the first time I've heard this excuse. I just never thought it could hurt anyone.

Generally when someone says they have 'no blood', I ignore them. I don't try to explain to them that it's impossible to live without blood, that we have liters and liters of the stuff... yada yada. I just move on with a prenatal or check-up or whatever. But now I see the damage this ignorance can do.

Another face of maternal mortality. Another needless death. Lord please don't ever let this happen again. May her death teach me to teach them better. May I never forget this lesson. Amen.

Blood Transfusion?

Dr. Tom took over all the deliveries and prenatals while I was away. He delivered two babies and referred a woman with twins (one that died in utero) to Wau for a cesarean in the two weeks I was gone. I'm sure he saw a lot of prenatals as well.

One of those prenatal girls came in sick (initially testing negative for malaria) and was treated with a course of antibiotics. At that time, her hemoglobin was an 8. Anemic. In pregnancy, it shouldn't drop below a 12 or else even a slight amount of blood loss can cause her to go into shock. And a moderate hemorrhage, might kill her.

When I got back from my trip, I was told she had returned, still sick, and tested positive for malaria. She was treated, however in the week it went undiagnosed, her hemaglobin dropped to a 4.4!

Not good at all.

She needed a blood transfusion but we don't have the equipment for that. Dr. Tom looked up direct transfusions in his medical books and brain stormed the idea with Dennis and Caleb. They were all game to get her the blood she needed.

They started testing all her relatives for crossmatches and found two donors that would work. This was only made possible by George tirelessly working to screen them all in the lab. It was a lot of work.

The question was, could we actually pull it off before the blood coagulated? Nobody really knew. They tried a number of ways, using a variety of instruments and techniques, but none of them were working.

It was harvesting the blood that was the most difficult. 

Hours later we finally got a bit transfused without it coagulating -- but only about 30 ml. That's not enough to bring her around. It helped of course but she's not out of the woods. Our only option was to send her to Wau and hope that she goes.

The good news in all of this is we fine tuned our techniques and now know what works and what doesn't. And even though 30 ml is not anywhere near enough for an adult woman, it's plenty for a young child who might be suffering from anemia.

This gives us options we didn't have before. I'm excited.

Let's start praying for blood bank and transfusion section in this clinic! Anyone in?

Also pray with me that this girl is able to stay healthy and deliver well. Thanks.