A Breech of Trust.

Two weeks ago one of my prenatal ladies came to the clinic in labor. I had followed her pregnancy for several months, and during that time we’d developed a sense of trust  --or so I thought.

When she arrived, she was 6 to 7 centimeters dilated with consistent contractions. Since it was her 5th child, I expected things to go quickly.

However, there were a few concerns.

Abdominally, her baby appeared to be breech. But when I tried to confirm vaginally, I had more questions than answers. The membranes wouldn’t allow for a clear diagnosis, and I was unwilling to rupture them to find out.

During her prenatals, she had never palpated breech before, so it came as a surprise. I questioned my suspicions though, saying that perhaps the heart-tones were high because the head was not engaged. Maybe what I felt in the fundus was just a really boney butt. So I noted it in her charted and waited.

Time would tell.

I re-examined her 6 hours later and she had not progressed at all. Moreover, the presenting parts were still unengaged despite increasingly effective contractions. This worried me.

Even though I had oxytocin at my disposal, and theoretically I could rupture her membranes, I hesitated to push things along. I could not rationalize the risks.

With the baby still unengaged, such actions could lead to cord compression... or worse. Cord prolapse. Maybe we just needed more time.

So I waited... and prayed.

Another 4 hours went by and she got more and more active. Outwardly, her contractions indicated birth was close and I considered doing another vaginal exam to reassure everyone. But I hesitated... what if there had been no progress? What if the head was still high? But if so, wouldn’t it be better to know?

This internal debate went on for sometime, but eventually, I caved in and did one.

The news wasn’t good; she had not budged at all. After close to 10 hours of stronger and longer contractions, she had dilated just one extra centimeter... but even that was iffy.

What was the hold up? Why wouldn’t the baby descend?

Over dinner, I casually mentioned her case to Dr. Tom, suggesting we might need a cesarean. I told him my hesitations and concerns, and together we agreed to stop her labor if she did not show significant progress within the next few hours. That way she could get some sleep and her family could start preparing money for a transport.

But an hour later her water broke.

I was pleased that things had progressed to this point, but did not do another vaginal exam. I figured that as long as the heart tones were good and moving lower on her abdomen we were golden.

Looking back, I regret that choice. I regret it a lot.

An hour later my shift ended and Margaret took over. Since the water had broken, I figured she’d deliver shortly and didn’t think to tell Margaret my suspicions.

That too, I regret.

Exhausted from the long labor watch, I turned in early. But by 3 a.m. there was a knock at the door. Groggily, I asked what the problem was.
-- “Margaret says she needs your help,” our health worker said quietly.
-- “Is there a new labor?” I asked.
-- “No. Same woman.”
-- “I’ll be there in two minutes.”
While my body changed into scrubs, my brain struggled to connect the dots. I had assumed she’d delivered hours before.

I was wrong.

I arrived to find her pushing and got hopeful, but it didn’t last long. I quickly realized that Margaret had decided to break her waters a few hours before (apparently the first rupture sealed off again or hadn’t happened at all). However, when that didn’t bring the baby down, she augmented with oxytocin. 

After she explained the various measures she’d taken to spur on her labor, she told me why she had called for help. “I just did a vaginal exam, Steph. She’s fully, but I’m not sure if it’s the baby’s foot or arm.”

I asked her a number of questions, probing here and there. Then I put on gloves. If she was presenting a shoulder or a hand, we couldn’t let her push. So I stopped the oxytocin and asked her to breathe through her contractions.

A quick exam told me a lot. I measured her to still be about 8 cm dilated. And although there seemed to be more than enough room for a baby, the fetal parts were high. With the membranes out of the way, I could feel a squishy butt and what appeared to be toes. But honestly, the baby was just too high to get a good read on it.

Only then did I tell Margaret my suspicions. As I related the subtle warning signs I had observed, she seemed irritated. Why hadn’t I told her this hours ago?

I apologized. There was no good excuse.... except I honestly thought she’d already delivered and my suspicions were groundless.

Once it was decided to transport her for a cesarean, we worked quickly to inform the family and stop her contractions. The baby was alive, but the variables in his heart-rate worried me.

Sunlight was just a few hours off, so Margaret worked with the family to get money prepared for a transport. And I went back to sleep.

Just before 7 a.m., there was another knock at the door. It was louder this time. I opened the door to find Margaret’s lips pressed thin with disappointment.
-- “Is everything okay, Margaret? Is the baby alive?” I asked with an urgency I couldn’t suppress.
-- “There’s another labor. She just arrived,” she started to explain. “The woman from last night... well, I don’t know what happened. I’m still figuring out the details...”
-- “What do you mean?” I asked in confusion. “Did her family get the money for a transport?”
-- “They got some money... but when they could not find it all, they brought in a TBA (traditional birth attendant) to deliver the baby....”
-- “They did WHAT?” My mind jolted awake instantly. What was she saying?
-- “I don’t have the whole story yet... all I know is I went to check on her a few minutes ago and a TBA was there... I’ll explain later.”

I thanked her, closed my door, and then took a deep breath. I couldn’t worry about that just now. I had another labor to take care of.

When I got to the clinic, the other mama was active. Although she was not one of my prenatal ladies, she had heard good things about the clinic and wanted to see for herself. The friend that brought her used to work for us. I was happy they trusted us enough to come.

She delivered an hour later on her knees.

The peacefulness of her birth stood in stark contrast to the turmoil in my heart. I kept having to force my thoughts back on the woman before me. I couldn’t stop thinking about what was happening in the next room.

My mind raced round and round. “What was happening in there? Was the baby already born? What did Margaret mean that a TBA had come to help? Were they transporting still?”

By the time my labor had delivered and we got things cleaned up, the clinic was bustling. A line of women waited patiently outside on benches. The day had begun.

I didn’t hear the full story until late that afternoon when Margaret and I had time to connect again. The story she told doused my heart with indignation, then set it on fire.

Picking up were she left off that morning, she explained, “The woman’s husband didn’t go for money. He went for a TBA. Apparently, she arrived around 4 or 5 this morning, and the clinic worker just let her in...”
-- “Our health worker didn’t stop her?” I asked incredulously.
-- “No. He couldn’t explain why... but he gave her gloves,” she paused a moment then went on, “As you know, when we left last night, her contractions were stalled and she was sleeping (because of the medicines we gave her), so I can’t figure out how she pushed.”
-- “Yeah... how could the TBA get her to push if she was so drugged?”
-- “I don’t know... I don’t know. All I know is that when I went to check on her this morning, the baby was dead and she was covered in blood.”
-- “What did the TBA do?”
-- “The health worker said she reached inside vaginally and tried to pull the baby out.”
-- “Why didn’t he stop her?” I demanded with more indignation in my voice than I intended. 
-- “He did not say. I don’t know...” she continued defeatedly. “But when I found her she was still wearing the bloody gloves and was trying to deliver your labor as well...”

Since neither of us were there, it’s hard to know for sure. I’m left to my imagination as to what really happened. What I suspect is that her husband assumed we were just not good enough midwives to get the baby out. He figured another one would do better.

But instead of fixing the problem, this woman made things worse. By trying to force the baby out (which failed), she killed him.

I suspect some kind of cord compression combined with fundal pressure.

We had spent 20 hours laboring with her to avoid this very thing. We’d given her our best. We’d done everything to keep that baby alive. And yet it was all for naught.

Her baby died... and she still had to have a cesarean.

I’ve thought about her labor a lot over the past few weeks, playing the what-if game in my head. I’ve gone over it again and again but to no avail. I have, however, made a few cultural observations.

The Sudanese seem to believe that:
-- the death of the baby is an acceptable, although disappointing risk of birth.
-- cesareans are to be avoided at all costs (not always for financial reasons).
-- cesareans should only be done to save the mother’s life, if the baby lives then good. 
-- women have little to no say in their health care choices.

Many other lessons can be extrapolated, of course. And if I had it to do all over again, I’d do it much differently.

Suffice it to say... I’ve learned many lessons --the greatest of which is trust.

Trust is essential.

Prayer Project: Scoliosis

Sarah came for her first prenatal a few months ago. She stood out from all the other ladies though because she brought her own chair.

Born with congenital malformations and scoliosis, making walking impossible, she stands at roughly 4 feet tall and gets around in a wheel chair.

Early on we discussed the need for an elective cesarean, and she completely understood. Her family had already started saving money for her to deliver in Wau.

I was glad for this insight, but even more so when I heard a surgeon was coming on staff. I discussed her case with Dr. Mike shortly after he arrived, and he reviewed her in person this week. He says she would be an excellent candidate for surgery here.

It's hard to tell with her shorter-than-usual abdomen, but I'd venture to say she's 7 months pregnant (or roughly 30 weeks gestation). I know that means her due date is two months out, but I feel the need to cover her in prayer now.

Will you join me?

Please pray for her to carry her baby to term, and deliver without any complications --whether that's here or in Wau. Also pray that she would not be fearful. Every time I see her she seems more withdrawn and afraid. 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.

Update: Helpless

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

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

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

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

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

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

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

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

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

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

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

6 days and 6 nights.

Transporting her with our truck. Family looking on.

Nyibol came into the clinic in very active labor on Monday. I was so sure she was going to deliver, I set up the room for it while checking her in. Contraction after contraction moved across her abdomen in a lovely wave. I remembering thinking, “She’s going to deliver any minute.”

Of course... I couldn’t be sure until I did a vaginal exam. But she refused one and said she was going home to deliver. huh? I encouraged her to stay. Why come all this way, if you didn’t want my help? But she grabbed her things and rushed home.

This is fairly common here. Often, women come to ‘verify’ with me if labor has started and then go home to give birth. I don’t stop them but it breaks my heart. I figure there is something socially I’m still not clueing in on... perhaps I’ll understand better in time.

Well... this morning Nyibol came back still in labor!

She explained that she’d now been in labor 6 days. Her water broke 3 days ago (after seeing me Monday morning) and it was originally clear but then became brown. Her baby was alive (Thank God!) but she was exhausted. She hadn’t eaten in three days. Nor had she urinated.

As a result she had a painfully distended bladder which was likely one of the factors in her lack of labor progress. We removed 800-1000 cc of urine with a straight catheter and did a vaginal exam. She was fully but the baby’s head was swollen (3 cm caput). Her pelvis seemed adequate but the contractions had stopped last night.

As we started the IV fluids to induce her, she explained that her family had done fundal pressure and she had been pushing for days. But the oxytocin wasn’t working. We turned up the drip as fast as was safe but it didn’t produced even a twitch of a contraction. 

There was nothing left for us to do but transport. It was too late. I truly believe she could have delivered vaginally if she had stayed at the clinic.         Perhaps not.

The family was able to find money for a cesarean and the ministry truck was free so we took her to Wau. This afternoon she was taken into surgery.

So rejoice with me. This is a victory. A life saved -- two even. I’m just sorry it came at such a price.

Imagine, 6 days of pain... 6 nights of sleeplessness!

Update~
So I got some of my facts wrong. She got to Wau this afternoon but... when they checked her in, they discovered that her baby had died on the way. So she didn't get the cesarean right away, they have waited until this evening to do it. She is likely on her way to surgery right now. Please pray for her, her family and this precious child lost.