Handing-Over.

When I got back to Tonj to pack my things, I met Annie. She is one of the Kenyan nurse-midwife hired to replace me. That first night I didn’t have much time to talk, but by morning I was bursting with things to say.

It was handing-over time.

But how do I tell her two years worth of lessons in three days? How do I show her all the birthing positions and Dinka preferences? How do I explain the superstitions in such a way that she’d understand?

How?

But I was soon to learn that Annie was as keen to learn as I was to teach.

What a blessing!

That first morning as I walked Annie through the prenatal system and explained the medicines used, I rambled on and on about the beliefs and practices I’d seen over the years.

I wanted so much for her to learn and accept the Dinka’s traditions. Knowing that the biggest hurdle she’d encounter would be the Dinka birthing positions, I started there.

-- “The women here have many birthing preferences,” I started to explain, “If you respect them, they will flock to deliver with you. If you don’t, they’ll disappear.”
She nodded pleasantly in response, then asked, “What are these preferences?”
-- “Well... to start, they give birth on their knees...” I paused to watch her face, knowing full-well that such an idea can be strange for most African-trained nurses.
-- “Their knees!” she half laughed, half gauffed, “Why do they do that?”

Annie and Margaret during devotions.

I explained the whys and hows, even falling to the floor to show her the crouch-squat myself. She smiled while I spoke, shaking her head in disbelief.

-- “Okay,” she finally agreed, “but I have never delivered a baby like that... how do you do it?”
Relieved that she was at least willing, I explained the hows and what-nots involved.

She listened attentively, but I could see it was well past her comfort zone. Finally, I added, “Perhaps we’ll have a birth together before I leave. If so, call for me and I’ll show you what I mean.”

She readily agreed and I continued her orientation. There was so much to tell her... and so little time.

I prayed we’d have a birth together for two reasons. One, I desperately wanted to show her how easy it was to deliver a baby in that position. And two, I selfishly desired one last birth in South Sudan.

Our chance came the following night, when I heard a slight knock at my door. It was Annie.
-- “A mama has come in labor,” she started. “I know it’s late, but I’d love if you’d show me how things are done.”
To hear her speak in such a way melted my heart. I could see that she genuinely wanted to work in a culturally sensitive way. Smiling, I agreed to come right over.

My scrubs were packed so I slipped into my jeans and headed over.

Sure it was 1 a.m. and I was tired from my constant packing, but I could think of no place I’d rather be.

Blessed by her eagerness, I talked Annie through the birthing customs as we labor watched. Describing a kneeling birth is harder than I thought. It’s truly a watch-what-I-do kind of thing.

So as the laboring mama progressed from 8 cm to fully, I taught Annie the questions to ask and how to set up the room.

Our labor, Ajak, was expecting her 8th child. Her first seven were all delivered at home, but this time she had decided to deliver with us. I was honored by this choice as it revealed the depth of trust we’d developed in the community over the years.

Her friend, a woman I’d seen many times before, acted as her doula. She never left her side, encouraging Dinka style with sharp comments and disapproving clicks of her tongue.

Ajak’s labor was slow to progress, and her doula-friend disapproved. She kept clicking her tongue impatiently, and speaking gruff remarks. After the third negative comment, I had had enough and I turned to her and asked, “Why are you so upset?”

She looked at me in confusion, so I continued on. “Right now, Ajak is having a normal labor. Everything is okay. I need you to know that so you do not worry... or make her worry.”

I smiled politely while I spoke, but my words were sharp. “Please, if you stay in this room, be happy with your words... I don’t want her to think things are wrong when they are not.”

Her doula friend smiled in agreement, explaining she was tired. Looking around the room, we all laughed with her, and agreed that three o-clock in the morning was rough.

Annie silently took it all in. No doubt watching Ajak labor on the floor was new to her, but she embraced it.

I loved her for this.

We talked softly as Ajak moved about. After several hours, she was finally ready to push. So I asked her, “How do you want to deliver --on the bed or on the floor?”
She looked up at me in surprise, eyes flashing in relief and respect. But she didn’t answer. I could see she was hesitant to speak, so I asked again.
-- “Ajak, do you prefer to give birth on your back or kneeling?”
-- “Kneeling,” she whispered with a smile. Her whole body relaxed at the thought.

I smiled with her, then glanced in Annie’s direction.
    --Excellent!

When it came time to push, Ajak started crawling the room in pain and complaining her hips ached. So I applied pressure and massaged where I could. Eventually she fell to her hands and knees and rocked a bit.

It was close.

Annie sat in the corner of the room wide-eyed in wonder. She looked hesitant and nervous, but hid it well. Ajak was silent but active --very active.

Suddenly there was a noticeable change in her grunts. It was time.

Since she was already on the floor, I slipped a pad under her and seconds later her little girl was in my hands.

I had Ajak sit down on the pad to wait for the placenta, as our translator milled about handing me things.

Her girl was healthy and strong; she yelped sporadically as I wiped her off. Trying to keep her warm, I covered her tiny frame and waited.

As we waited I continued to teach Annie the Dinka birthing traditions (as there are as many for after the birth as there are during).

With time, the placenta was born and we cut the cord. Weighing her and wrapping her tightly in a blanket, I handed her over to Ajak's doula-friend.

She started complaining that she had spittle in her mouth, but then caught herself. Apologizing, she stopped half way through and smiled at me. “I won’t be negative anymore,” she told me with a smile that reached her eyes, “because I see that with you I don’t have to worry.”

What a blessing!

I continued to teach Annie the ropes while Ajak breastfed on the floor. At one point, she looked up at me glowing and said, “I’m so happy.”

I smiled back and told her I was happy too --so very happy!

I’m happy I got to be a part of one last birth before I left. I’m happy I got to show Annie the typical birthing style as well. But more than anything, I’m happy Ajak got to deliver in a way that made her happy.

Lord, bless Annie and Axilla (the other midwife that came a bit later on). Help them to love the women well. Teach them how to be culturally sensitive to the Dinka traditions. Bless them, Lord. And use them powerfully for Your glory. Amen.

Ajak was my 230th birth in South Sudan. I’m going to miss them.

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.

Speed Birthing.

Prayer night had just ended, and I was settling in for the night when I heard a timid knock at my door and went to answer it.

-- “Moses needs you,” our new guard whispered. Moses, one of our health workers, was working the night shift.
-- “Is there a labor?” I asked.
-- “Yes. Mother in labor,” he continued quietly.

When a health worker is too busy to come himself.... there’s an emergency. When he’s calling ME... there’s a birthing emergency.

I didn’t bother changing into scrubs. If it was a birth, I’d never get there in time if I did. So I grabbed my watch, a pen, and slipped on my flip-flops.

I didn’t run though. I find that running in flip-flops in the middle of the night can be hazardous to my toes. Plus, you’ve got to take your time in scorpion season. You’ve just gotta!

I arrived a minute later to find a mother pushing so hard she trembled.
    -- No wonder he sent the guard to get me!

Moses was moving faster than normal to get the room set up, but it had only been a few minutes since she arrived. It still wasn’t prepared.

As I watched silently off to one side for her contraction to fade, I took note of her body language.  She was having this baby; and she was having it fast!

Jaws clenched in determination, she continued to push on the edge of the bed. And just as the contraction peaked, a clear jet of waters jumped across the room, splattering four feet away.

Moses was still gathering the basics, so I asked her her name.
-- “My name is Adut,” she grunted between contractions.
-- “Adut, where’s your booklet?”
-- “At home. Forgot it.”
-- “Do you have a file with us?” I continued. I’ve started keeping records at the clinic, for just such occasions.
-- “No. You did not give me a file....”

Humm... that’s odd. Her face was ober familiar. I was almost sure I had a file on her.

-- “Give me your full name... I’m going to look it up.”

She gave it to me through clenched teeth, and in between purple pushes. But then it occurred to me, I’d never have time to look it up anyway.

Instead I slipped a pad under her butt, and started looking for heart tones. They were low (100s, 90s), but that’s normal right before the birth, due to head compression.

All I knew about her was that she had been here before (because her face was so familiar), her name was Adut, and she really wanted to push.

So I let her.

-- “Push hard, Adut. You can do it!” I coaxed. The head was already started to peak out.
A friend supported her head while I supported her perineum, and Moses stood to one side, handing me things.

Three minutes later her precious boy was born!

She delivered exactly 6 minutes after arriving at the clinic! And it wasn’t another five minutes after that when her placenta plopped into my hands. It had an additional lobe, so I took the time to show it to Moses so he could learn. 

As I inspected it, Adut cocked her head slightly in disgust, but Moses came in closer for a better view. It’s not everyday a Dinka man is willing to get so close to a placenta. Kudos to his teachable spirit!

-- “Adut, your placenta is healthy. I’m just looking at it to see if it’s all there,” I explained.
She nodded she’d heard me... but the look of disgust didn’t fade.

Another five minutes later, she was breastfeeding her munchkin and asking to go home.

-- “Normally I ask you to stay for a few hours for observation. Can you stay the night and go home tomorrow?” I asked a little pleadingly.
-- “No. There is no one else to care for my kids at home. I cannot stay.”

I had suspected as much. Frankly, the fact she came at all was a miracle. She had stayed at home until the very last minute. And now that the baby was out she needed to hurry home... and soon.

Her bleeding was very slight. So I promised her she could go home early if no clots came.

They didn’t.

And an hour postpartum she was cleaned, dressed, and prayed for. I discharged her with a few mild warnings, and she was off.

She walked out without the slightest hint of pain in her gait. Her friend walked beside carrying her little boy in her arms.

Humm.... I’m still not sure what to think. All I know is the women around her are STRONG!

Feverish.

Ajer showed up at 3:30 pm saying she was having a bit of bleeding on and off and was worried. She insisted there were no contractions, but as I checked her I noticed several mild ones in short succession.

“But Ajer... that is a contraction right there,” I argued, “Isn’t that painful?”
“Yes, but I’ve been having those for a few days now...,” she explained.
“Oh...”

When I touched her belly to palpate position, I was surprised by how hot she felt --even for such a blistering summer day. It could be simple dehydration... or it could be something worse.

“Have you had any fevers recently?” I queried, trying to pinpoint her diagnosis.
“Yes. I had one last night, but it went away this morning.”

This felt like more than simple dehydration, so I got out my thermometer. She was burning up with a temperature of 38.0 C.

Her baby’s heart tones were also high (168, 172). Not good. Perhaps the fever was causing the contractions, but I doubted it was the other way around.

She was sick... but with what?

She tested negative for malaria and complained of no other symptoms except contractions.
    --Humm....

The vaginal exam showed she was dilating; but with such mild contractions, I didn’t expect her to deliver any time soon. (For any midwives out there: she was 2 cm, 80%, 0 station, IBOW.)

So I started her on prophylactic malaria medicines and antibiotics --just in case-- then hung some IV fluids. The minute I hydrated her though, her contractions picked up speed.... and strength.

I had barely finished giving her IV antibiotics when she started getting grunty. Her fever soared higher (38.8 C), and her baby’s heart tones raced even faster (176).
    -- What was going on?

She felt something come out from between her legs, and I looked down to see water.
    -- Humm.... strange that she’d have rupture at 2 cm. Very strange, but okay.

I started counting contractions and measuring their strength. They were strong now, lasting 45 seconds... and happening like clock-work every 2 minutes.
    -- Seriously.... something was up.

Then she started pushing.

“Ajer... please don’t push. You are only 2 cm dilated. It’s not time now.”
“But I’m not doing it on purpose,” she promised. “I just can’t help it.”
“Please don’t push...” I continued. “Don’t...”

Then I looked down.

Her bag of waters was bulging, and the baby’s head was right behind.

“It’s coming,” she half grunted, half pushed.
        --Yes. It most definitely was.

My helper moved lightening fast to prepare the room for the birth, and I slipped a pad under her butt. The next push he was born.

She went from 2 cm to baby out in 43 minutes with a fever of 38.8 C!

Unfortunately my story does not end there. Even before the placenta was born, she started dumping blood. And by the time I got it out (15 minutes postpartum), she had lost over 1500 cc. Fortunately, oxytocin helped stop the bleeding, and she slept through the night.

This morning everything looked normal and I was about to discharge her when she reminded me about the tear.
    -- The tear? Which tear...? She didn’t tear during the birth.

She went on to remind me of how she got a severe 4th degree vaginal tear after her last birth at home. She came to us initially for help, but we referred her to Wau for an operation. She went but never got it fixed; she didn’t have the money.

However a few months later she got pregnant again, and was told she could not get the surgery until after she delivered.

As she explained, I remembered running into her in town a few weeks back. Yes, of course I remembered her. We had discussed the option of her getting surgery with our surgeon instead.

Dr. Mike reviewed her and said she was a good candidate for surgery; he wants to schedule her back for the beginning of April.
         --What a blessing!

It’s strange that she neglected to say anything during prenatals, or even during the birth. But I’m glad she reminded me of it this morning!

Her previous tear helps explains the unusual fever and lightening fast birth though. It helps explains a lot.

Praise God she got to us in time for a safe birth and quick antibiotics for both her and her new son! Thank God that she can now get the surgery in town! Please pray for them to heal quickly, and for her to have a successful surgery. Thanks.

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.

A Perfect Mess.

Maguet said she was in labor but didn’t look active.
    --They rarely do.

As my helper readied the room, I tried to count contractions and ask her questions. She had never come for a prenatal, and I needed a few facts.

But getting her to talk was an exercise in futility. She just flat out couldn’t.

Only then did I see the first contraction. Saying it was strong just doesn’t cut it --intense to the nth degree --powerful the the power of ten. Okay. So they were strong!
    --How could she be so calm?

As I stood by her side trying to measure their intensity, a sudden rush of wet warmth gushed down my legs and hit the floor with a audible splash!
    -- Had someone emptied a bucket on me?

Maguet and I locked eyes in surprise, then looked down in unison. Black, murky fluid stained our clothes as if we had waded knee deep in a lake of amniotic fluid.

My first response was to laugh; but Maguet was a bit more hesitant. She looked embarrassed. Or was it horrified? Eventually she realized I was not mad and laughed timidly along with me.

I didn’t have heart tones; I had not measured her fundal height; and I still did not even know her gestation... but she wanted to push.

Did I have time to change? --Unlikely.

My warm, sticky pant legs clung to my skin, growing colder by the minute. My shoes squished loudly at every step. Eek.

I really wanted to go get changed... and perhaps take a long shower with bleach.
    --Could I risk it?

The midwife in me worried the murky fluids could mean a compromised baby. Heck, I still didn’t know if the baby was alive! However, the non-midwife in me was thoroughly disgusted and ready to run for a decontamination shower.

What is the protocol when a total stranger expels ink-flecked slime all over you?

My translator didn’t know what to do or where to stand. The horror on his face was evident. I had to tell him more than once to get the mop.

Only when I rolled up my pant legs and started moving her into position for the birth, did he push past his disgust and prepare for the birth.

He ran for the mop. I slipped a pad under her. She got in the squatting position.

Ten minutes later her little girl was born.

The baby came out with another splash of blood and water coating me in a second layer of grime. But I didn’t have time to notice.

Green-gray meconium coated the baby and sputtered from her lips. I suctioned her mouth and dried her off before handing her over to her mom. Then I took a long look at myself. A mess.

A. Cold. Sticky. Wet. Mess.

What a bad week for the water to stop working at the clinic!

Once the baby was stabilized and breastfeeding well, I ran off to the compound for a quick shower. A bar of soap never looked so great!

Her baby was initially fine, but by the second day she developed an infection --most likely due to meconium aspiration but also possibly due to untreated STDs.

We have her on antibiotics now. Please pray she recovers quickly. Thanks.

Crying it out!

Athieng was hard to read.

Her contractions said one thing (i.e. “We’ve got a long way to go.”). But her response to those contractions said another (i.e “Quick, catch this baby. It’s coming out right now!”)

Which was it?

Originally I waited and watched trying to avoid a vaginal exam, but eventually I caved in after another half hour of confusion.

She was only 3 cm dilated.

Normally I would have insisted she go home, but she didn’t look like she was coping well.

Tears. Sobs. Whines. Whimpers.

This was not the typical Dinka labor. Usually the women I serve are restrained to the point of stoicism.

She was different; she actually looked and acted like she was in labor. It was refreshing.

I told her it would be many hours before she delivered and that it was best if she went home to labor. However if she’d be more comfortable at the clinic, of course she could stay.

Shaking off the pain, mustering a half-smile, then wiping streams of tears from her eyes, she finally said that she preferred to labor at home. So I prayed for her and sent her on her way.

I half expected her to stay home, but she surprised me by coming back 6 hours later. But this time she was active. But as the hours progressed, so did her tears. 

At the start of each contraction the flood waters would open, gush across her face, then drip off her chin. Yet the moment the contraction faded, she’d wipe her face, sniffle a bit, then go back to pacing the clinic grounds.

These were no ordinary tear drops; these were brewing geysers, raging tidal waves, gushing rivers.

In all my years, I’ve never seen a coping mechanism quite like this one. However, it makes the most sense. I mean... why not cry?

Before I go on, there is something you should know about me. I’m a cry-er. Some would even say a cry-baby.
            --Heaven knows I’ve been called worse.

So when I saw her crying, I instantly understood.

You see, I cry when I’m happy. I cry when I’m sad. I cry when I’m stressed, pissed, depressed, blessed. I just cry.

I loved that she did, too.

Long story short, her crying eventually came to an end. The contractions led to her water breaking, which led to frantic pushing, which led to more crying. But this time it was her son making the noise!
    --What a beautiful sound it was!

Personally, I think I’m going to be much like her in labor. I’m sure I’ll do my fair share of blubbering, sobbing, and crying. I mean, why not?

It just feels good to cry it out sometimes. Right?

Anyway. I’m happy to report that the word is out. Women are coming to deliver with us quite regularly. Last month we had 40 births. I wonder what this new year will bring.

Thank you for praying that they would trust us enough to come. Now please pray that those that come, would see Jesus in our actions and words. Thanks.

A Traditional Sudanese Birth?

Akul first came for help two weeks ago. She was sure it was labor; but her contractions were unconvincing.

Although obviously painful, her contractions lasted no more than 15 seconds and weren’t bringing any progress.

Since it was her fifth pregnancy I admitted her for observation; and for the next 5 hours we watched and waited. But nothing happened.

Now, I’ll be the first to admit I’m cautious when it comes to Braxton-Hicks contractions. I used to educate women on them, reminding them that it wasn’t labor until there was progress, etc. But after a year and a half of malaria cases, I don’t like to risk it anymore.

Why? Because I cannot tell the difference between Malaria-Labor and Braxton-Hicks contractions.

Yes. It might only be Braxton-Hicks contractions. But what if it’s not? What if she has chronic malaria and the pregnancy is masking the symptoms? What if the paracheck gave a false-negative? What if...?

So when I have a woman like Akul --in pain with regular but short contractions-- I treat for malaria if I haven’t seen any progress for several hours.

This was the case for Akul; so I gave her the first line treatment and sent her home. When I didn’t see her the next day, I figured the medicine worked, or she’d delivered at home.
    --Follow-up on patients here isn’t as easy as you might think.

I didn’t see her for two weeks. Then two days ago, she returned with the same symptoms. In the course of her evaluation it became clear she did not take her medicines properly.

We were right back to square one.

More pain. More spastic-y contractions. More worrisome watching.

But since her symptoms were worse this time, I started her on IV medicines and kept her for the night. By morning she hadn’t dilated even a centimeter.

I gave her a new course of treatment and sent her home, warning that her labor could start at anytime and she’d need to come back if her water broke... or the pain got stronger.

She returned 12 hours later saying her water broke.

I wanted to believe she was in labor... but all I felt was irritation. Stupid malaria. Stupid, stupid malaria.

Grumbling under my breathe about the evils of this debilitating parasite, I watched her suffer under its torment.
    --Childbirth is painful enough without adding this nasty plague!

But when I re-evaluated her, she hadn’t dilated at all. However, her water had most assuredly broken. I wasn’t sure if she was in labor... but I figured it’d come soon enough.

I told her as much, then gave her the option of staying the night again or going home. She wanted to stay.

I didn’t argue. Even if she didn’t progress, at least she’d be close.

However her labor surprised me.

Her contractions got strong rather quickly, shaking her body like a ship in a storm. They went from being every 20 minutes to every 8 minutes in under an hour. 

Another hour went by and she was pacing --pacing and moaning rhythmically.

It was close.

Her husband, a man who had faithfully sat by her side each step of the way, watched us pace together but made no comment.

His dark, lanky frame stood in shadows and watched. In the black of night, the only thing visible was the reflection of the clinic lights in his eyes.

Less than an hour later, Akul was asking to push. No... she was NOT asking; she was grunting, moaning, jerking, clenching, and whimpering.

It was time.

I asked her if she wanted to deliver on the birth bed or on the floor.
-- “The floor,” she whispered.
-- “Okay. Once this contraction is over,” I said as a strong wave of pain rushed over her, “we’ll help you get positioned on the floor.”

Nodding, she answered with another whimper. 

Once set up, I invited her husband to join us. He had been sitting silently on the bench outside.
-- “Tell him that he can come in if he wants to...” I told my translator, “He doesn’t have to come in... but if he wants to, he should come now.”

My translator called for him over the thin wall, and he noiselessly entered and sat down.

Turning my attention to Akul, I said, “Only push when you have a contraction. Okay?”

She nodded determinedly but said nothing.

Her husband sat in the corner, firmly grasping his knees to his body in an effort to stay on the stool. It was a tight squeeze for his long legs.

After a few minutes, he spoke his first words.
-- “How do women deliver on a bed?” he questioned innocently.

It was child-like in tone. And I could see his mind whirling as he considered the plastic-covered birth bed in front of him. It had a hole at one end and a movable flap at the other. Very confusing.

He wasn’t asking me, but my translator, so I didn’t butt in until the conversation was over. I had understood a bit of it and asked my translator to help me understand it all.

-- “He cannot imagine how the woman earlier delivered on the bed,” explained my translator.  (The previous labor delivered just an hour before and he had heard all the commotion. That labor had insisted on delivering on the bed.) My translator continued: “He wants to understand how it’s possible to deliver in such a way.”
-- “Did you tell him?” I asked, but then couldn’t wait for the answer.

She was pushing.

She delivered in the supported squat position a few minutes later. As her boy slipped out, a piercing screech filled the room --and then silence.

It was done.

Slimy and beautiful in every way, he complained as I wiped him down and placed him in her waiting arms. For several long minutes, we sat in silence enjoying the calm after the storm.

As we sat, I couldn’t help but think about his question. It was a good one. Very practical.

“How do women deliver on a bed?”

I’m willing to bet there are a large number of non-Dinka men (and women for that matter) out there wondering the very opposite question.

It could be equally asked: “How do women deliver on their knees?”

Ahh! Culture! Thou art a tenacious beast! You cling to our preconceptions like barnacles; you beat about our heads like waves; your flotsam and jetsam clutters our minds. How do we escape unscathed?

Underneath what we are really asking is, "What is the right way to give birth?"

There are just no answers, are there? There are just opinions colored by what is most familiar, comfortable, and common place.
           --Oh, the traditions we hold so dear! 

I’m happy to report that Akul had a traditional Dinka birth.

She delivered in a supported squat with her husband’s knees in her back while malarial parasites raced through her veins.

Afterward Akul glowed with satisfaction, saying “I’m so happy. Ana chi pou mieth. I’m so very happy.”

Yes, Akul. So am I.    --So very happy!

Please pray for them. Pray her chronic malaria goes away quickly. Pray for health and love and joy and peace.

I invited them to church on Sunday, please pray that they come. Thanks.

Primip Breech!

Last year a first-time mom was brought to me after several long days of labor. Exhausted and scared, she lay on the bed for an evaluation. But it was soon clear what was wrong.

Her baby was breech.

Now I’ve delivered my share of breech babies but this was the first time I had to deal with a primip breech (meaning one for a first-time mom).

In any industrialized nation, a primip breech would be an immediate (or scheduled) cesarean as the risk of the baby dying is quite high.

The worry is that the larger fetal head will not mold enough to be born after the smaller buttock is born. The head would then get stuck, leading to suffocation.

Although I’m sure we all know someone who knows someone who had a successful breech birth the first time around, more often than not, the birth can go wrong (or be mishandled) and the baby can die.

But I digress.

My point is that the young girl last year came to me fully dilated with her baby’s buttock already protruding from between her legs. We had no time to transport, so we informed the family of the risk of vaginal birth then prayed like mad.

The birth went horribly wrong. Everything that could have gone wrong, did. Everything. And her baby died. (Read her story here.)

Afterward I asked God to never give me another primip breech, and to always help me diagnose them early so I can get them the cesareans they need... and deserve. 

I grieved that birth for many months. I was haunted by regrets. “If only I had done this instead of that... if only I had insisted on a transport... If only I had reacted better... faster... smarter. If only...”

In fact, I was still grieving it when I went to Switzerland to visit two midwifery classmates last Spring, and we talked about it in detail. One of them also introduced me to a midwife friend who had read about this tragic birth and wanted to encourage me.

Long story short, this midwife poured out sweet comfort coupled with years of wisdom. What is more... she taught me what to do if it ever happened again.

I listened to her words carefully, praying that it never would, but thankful to have options if it did.

Well, it did happen again. It happened last night.

This time, however, I handled the birth differently.

As I readied the room for the birth, her words rang out in my mind: “Make sure you go slow. Allow for the woman’s body to dilate properly. Don’t ever take your cupped hand away from the perineum. Once the buttock starts coming out, push the buttock back in with counter-pressure. Push hard. Make sure the baby does not unfold... that way the arms won’t fly up over the head and get trapped.”

Nyibol, my labor, wanted to push like mad and didn’t like the counter-pressure. She asked over and over for me to “just let her push harder”. But I was determined not to let this baby get stuck. So I explained my reasons again and again, insisting she breathe through her contractions as long as possible and to push only when she couldn’t help it.

She needed to go slow.

Tom came to assist, but since he wasn't needed right away, decided to sleep in the other room. Having him there was a huge comfort.

Meanwhile, Nyibol pushed on. And I supported the perineum.  

The Swiss midwife’s words continued to echo in my head, “Make sure you never take your hand away. Not for one second. The baby must not unfold. Only remove your hand when most of the body is born... then deliver the baby like a normal breech.”

My hands cramped. My forearms ached. But it didn’t matter. The baby was doing well.

Plus, Nyibol was making good progress.

I called Tom in to assist once the body was mostly delivered, and he applied suprapubic pressure as the shoulders were born. I had to reach in to release the baby’s right arm, but the left came out on its own.

The following push the head was born!

Nothing went wrong. None of the emergencies happened. Amazing.

The difference between this primip breech and the last was night and day.

Night... and day.

Thank you Jesus for this healthy little girl. Thank you that she is alive. Thank you for sending me wise midwifery friends who taught me this simple technique. Thank You! Thank You! Thank You!

Nyibol did not get an episiotomy; she did not even tear. Her baby had decent APGAR scores (6/8), needed no resuscitation, and transitioned well.

Night and day.

I share this story with you so that if any midwives out there find yourselves in a surprise breech in a primip, you might remember... cup the perineum. Never let the baby’s body unfold. Basically, make your hands like a second-perineum so the baby stays in a compact position. This will dilate her body most effectively, permitting enough room for the head to emerge without delay.

I realize this is the OPPOSITE of what almost every textbook says on the issue of breech delivery. And for that, I would be remiss not to comment. I agree with the textbooks. Hands off a breech. Never pull on the body.

Never. Never. Ever.

What I am suggesting is that you PUSH on the body --not pull. Give counter-pressure as the baby descends. Provide a place (aka your cupped hands) for the baby’s butt to pivot naturally as it passes over the perineum.

I did not "touch" the baby (and never pulled on her) after her legs and trunk were born. I only assisted in the birth of one arm, so the head could emerge.

I hope that makes sense. If not... let me know.

Thanks for praying for these women. Thanks for praying for me. I could never do this without your love, encouragements, and prayers.

Placenta Previa?

Two days ago, Adhieu started having contractions in her sleep. She thought it was unusual since she was only 6 months along, but there was nothing she could do about it. She lived too far away to get immediate help. She’d have to wait until light.

But as the sun peeked up the next morning, the bleeding started. Lots and lots of bleeding. She bled heavily until noon.

She said her baby kicked like mad during that time, but then suddenly stopped.

That was a day ago.

She knew something was wrong, but it took time to get the family involved. Someone needed to bring her to town. She couldn’t go alone. Who would come?

Eventually it was decided her father would accompany her.

By the time she arrived, her clothes and legs were crusted in dirt-stained blood. A large flap of membranes hung from her introitus but she was no longer in labor.
    --Was this placenta previa?

(For those who don’t know, placenta previa is when the placenta presents first, causing painless bleeding. It can be life threatening for both mother and child, depending on the blood loss.)

There were no heart tones to be found. No movement. Nothing. Her baby was dead.
        --Could she have had an abruption?

(For those who don’t know, an abruption is when the placenta detaches from the uterine wall prematurely. This is very painful and presents with bright bleeding. An abruption can be complete or partial. It is almost always life threatening for the baby unless delivered quickly.)

She wasn’t surprised when I told her baby was dead. And she didn’t cry, either. Instead she looked unblinkingly off in the distance, hardening her jaw. Resolved.

A quick speculum exam revealed a 2-inch chunck of placenta plugging up her cervix like a cork. Thick membranes dangled down the canal, but the bleeding had stopped. She was 2 cm dilated and had no contractions.

Ideally, she would have gone to Wau for a c-section, but I intuitively knew this was NOT an option.

Had you asked me how I knew this, I would have been hard pressed to give you an answer. And yet when Tom asked me to send them anyway, I gawffed, “That’s not going to happen. They don’t have the means.”

He insisted on it though, expounding on the potential danger of her bleeding to death if it was a previa, etc.
-- “If contractions start, her cervix can open and she can hemorrhage... maternal mortality.... too dangerous... must transport....” He lectured pedantically. He wanted us to warn them of the risk of her dying. Just in case.

I listened to his words --I even agreed with them-- but I knew they’d never go.

Her clothes were too worn. Her body was too lean. And neither of them wore shoes. Plus her only companion was a frail father with clouded pupils and trembling hands.

But the biggest clue was the fact it took her a day and a half to get to us.

No one with any sort of means waits a day and a half to seek treatment with this much blood loss. No one. 

I respected Tom’s wishes though and talked to them about transporting. The discussion was disheartening short.

Conclusion: They had no money. His goats were back in Thiet. It would take time to arrange their sale --perhaps two days.

I listened and nodded, then induced her.

I had peace about this induction. Her bleeding was almost nil, and she was a multigravida. If the medicines worked... she’d deliver quickly and this would all be over.

Then no goats would need to be sold.

By God’s grace, the induction was effective and she delivered 2 hours later with very minimal bleeding.

Her baby weighed just 800 grams, but he was perfectly formed. Tiny ears. Delicate fingers. Two thin eyebrows neatly knit atop unseeing eyes.

He never opened his eyes to this world... but I believe he’s seeing something much more beautiful now!

Please pray for Adhieu as she grieves this loss. It was not her first. Pray that it is her last. Thanks.

Clubbed Breech.

Sunday was a blissful day of rest. After church I napped and read. It was nice not to have any labors to watch or babies to catch for a few hours.

However just before dusk drew an orange cloak across the sky, Tom told me about a woman with premature rupture of membranes who had just arrived. He’d checked on her, but she wasn’t having any contractions yet. What did I want him to do?

Since I was making dinner (and didn’t want to check her myself) we discussed her case briefly and decided to let her go home to labor. She didn’t live far.

Two hours later she was back.

Since Tom was the one who saw her originally he offered to take care of things again. But as I stood there hesitating on whether or not to go help. God pushed me to go.

I changed out of my pajamas, slipped on my shoes, and wandered over.

Akoot was in obvious pain.

As she lay on the bed writhing, she explained the contractions came fast and hard once she got home.

I measured her belly and counted heart tones. She looked small for a term pregnancy. Could she be preterm?

-- “How many months pregnant are you, Akoot?” I asked calmly.
-- “I’m eight.”
-- “Does that include your first month?” I asked knowing that most women don’t count it here.
-- “No. I’m nine months if you count the first month.”
-- “Okay... but your belly is small,” I pointed out between contractions. “Are you sure you’re really nine months?”

(For those midwives out there. She was measuring only 27 cm. And her baby’s heart rate was erratic --lots of variability but within normal range.)

I was about to do a vaginal exam... but quickly realized I didn’t have time. Thick membranes bulged between her legs, revealing a vernix stained fluid beneath.

Birth was imminent.

Instead I called Tom in to assist. If this baby was preterm, I wanted his help to resuscitate.

Tom took a seat in the corner while I told Akoot my concerns.
-- “Akoot, it looks like your baby is coming soon. But I think he might be too small...” She listened carefully to each word.
-- I continued, “If he is very small he might have a hard time breathing. Do you understand?”

I always hesitate in times like these. How much do I explain beforehand? Will telling the mother my doubts cause more fear than necessary? Should I refrain?

In the end, I usually always tell them. Hard truths take time to seep in. But mostly, it’s what I’d want. I’d want to know of problems earlier rather than later.

-- She listened, nodded that she understood, then explained, “I’ve been sick for one month. Very sick.”
-- “What have you been sick with?”
-- “Bloody diarrhea. Chest pain. Fatigue.”
-- “One month?” I asked again, “Why did you wait so long to come for help?”

Flipping through her prenatal book I saw various entries of where she’d sought treatments for various complaints. She’d been treated for a number of ailments, the latest being dysentery. But she’d only had that for 4 days.

In fact, Tom gave her very effective drugs for it earlier in the day.

Pushing her sicknesses aside, I turned my focus to her baby. Whatever the reason, he’d be born very soon.

Looking back at the bulging membranes, I was disturbed to note they had turned from white to black. Not good. Could this be blood?

No time to worry about that. Everything was set up for the birth, so I encouraged Akoot to push.

At first I thought the membrane-covered object was his head... but I was wrong.

Admittedly, I was surprised to see a tiny butt emerge instead. He was coming out breech. And he was in the caul (aka: born in the membrane sac).

When I broke open the membranes, I realized that what I had confused for blood was actually meconium, and I wiped it away.

This breech birth was different however. His legs were jammed tightly against his face, and I couldn’t release them.
    -- Strange. 

Akoot continued to push and I called over the wall for Tom to come help.

Something was holding up the delivery of the legs though. So I reached up to draw then out. They wouldn’t budge.

So I pulled harder.

Eventually they came free but then hung awkwardly to the left of his body. Stiff as boards.

Both arms were tucked up close to his head. So, I reached in to release the right one first. It came on the first try. But the left arm wouldn’t bend.
         -- Strange.

I ended up having to deliver his head before his left arm.
        -- Very strange.

Once he was born it became clear he was not preterm. But there were other problems to consider.

His feet were severely clubbed and his knees were locked in straight line. His hips were unbending causing his feet to fall naturally at his chin. When I tried to move them his back arched in pain.

Later we realized his fingers were formed but clenched in boxing fists, impossible to open.

Seeing the confusion on our faces, Akoot tried to understand what was wrong.
-- “Is my baby alive?” she asked eagerly.
-- “Yes. Yes. Your baby is breathing well. And the good news is he is not preterm,” I started.

She nodded and searched my face.
-- I continued, “But there are some unusual things about his legs and hands. You will understand more later. Please don’t worry... I’ll explain it after the placenta is out.”
-- “His legs are bad?” she asked.
-- “Don’t worry. Your baby is doing well. You’ll understand more later.”
 She nodded gravely then delivered her placenta.

This is the first time I’ve delivered a baby with clubbing. I wasn’t sure what to say.

I asked her about possible teratogens that may have caused this and she mentioned a fight she had with a family member at 6 months pregnant.
-- “No. That is not the cause. This does not happen at 6 months,” I told her. “This happens before 3 months.”
-- “Oh... well, at 3 months I got injected (vaccinated) by the traveling medical people...”
-- “Do you know what they injected you with?” I asked.
-- “No. They did not tell me.”

Could vaccinations have caused this? I don’t know. I suspect not.

I also asked her if any of her other babies came out breech, and she gawfed.
-- “Ehh..? My baby came out breech?” She asked incredulously.
-- “Yes,” I laughed, “He was born breech. Have any of the others come out this way?”
Shaking her head in disbelief, she looked to her friend for confirmation. They discussed it rapidly in Dinka.

Turning to my translator, I asked him what they were saying.
-- “She says no baby has come out butt first like this. First time.”

She was obviously surprised --almost even more surprised by the birthing position than the clubbing.
-- “Why is she so surprised?” I asked him.

They discussed it with fierce animation, interspersed with laughter, then he turned to me and said, “She says that in the village if her baby had come out with the butt like this they would have forced him back inside and given her lots of alcohol to drink...”
-- “What? .... I mean why?” I stumbled over my questions but smiled at the thought.
-- “They say babies die when born like this one. She is amazed her baby is alive...” he explained.

Only then did it all make sense. Yes. With all the troubles this breech gave me, I think he could very well have died if he wasn’t born at the clinic. He was not an easy birth. And he needed a bit of resuscitation right at the beginning.

When I told Akoot this she nodded enthusiastically, then looked down at her child in wonder.

Over the next day or so, Tom and I helped Akoot understand his problems, start physical therapy, and establish breastfeeding. It was essential to me that Akoot bond as well as she could with him.  

He took some time to breastfeed properly but I am happy to report they are both doing well and were discharged this morning.



Tom decided to put casts on his legs to turn his feet outward. Seeing such a tiny tot with casts like this is new to me. It makes me smile.

Please pray for them. I think he might have signs of down’s syndrome as well. Thanks.

The Fantastic Five!

 (Warning: long but fun stories... grab a cup of coffee and get comfortable. It’s gonna take awhile.)       

I arrived in Sudan after a long but uneventful flight to find Margaret elbow deep in a twin birth. Her wry smile couldn’t hide the frazzled look underneath.

-- “Have you been busy, Margaret?” I asked already sure of the answer.
-- “Yes, it’s been crazy. I’ve delivered 6 babies in the last week. Two sets of twins, two preterm and oh... by the way, the first set of twins were preterm and both died.”

She went on to explain some of the strange cases that had filled her days then asked, “Where are all these women coming from?”

I smiled knowingly. I knew Christmas would be a busy time. It’s simple math.

Just count back 9 months and you’ll see what I mean. 

November, October.... skip a few.... July, June... keep going... May and April, then March!

March was a big month for South Sudan. Men journeyed here from far and wide to vote on the referendum. Every vote counted. A country’s future was at stake!

But while they were here... they made sure they did their part to populate this great country!  

Thus the birthing surge.

So when I got the call the following morning that a woman was in labor, I smiled and marched over to the clinic. I walked in to find a huge smile on a very familiar face! 

Rebecca used to work for us as a translator but quit shortly after getting pregnant. She has a happy laugh and playful spirit, and now she was in labor!  

Rebecca and her son.

Although she was still very early, she insisted on staying at the clinic. I didn’t argue. If she was happy to labor here, I was happy to have her.

But morning melted into afternoon which faded into dusk, before her contractions picked up any speed. But by nightfall her labor was well under way. And by 1 a.m. she was fully.

But pushing wasn’t going well. She had pushed for an hour with very slow progress.

-- “You need to push harder than that, Rebecca, if you want your baby to come out,” I urged.
-- “I’m pushing... but I’m afraid,” she finally confessed.
-- “What makes you afraid?” I asked.
-- “I’m too small down there. My baby won’t come out,” she stated flatly. 
-- “... but you’ve seen how this works. You know your body can open, don’t you?
-- “Yes. I know. I’ve seen it. But... I’m too small,” she argued, “I’m just too small.” 
-- “You are not too small, my dear. Just push and you will see. Just push harder,” I pleaded.

Another hour went by.

As the minutes ticked past, I worried. How long should I let this go on before I get tough with her? Was the vacuum in order?

I chased away each worry with the facts. The baby was doing well. She was still strong. There was progress.

Even though it was slower than I liked, nevertheless, there was progress.

It’s moments like these that I wouldn’t mind having a midwife of my own.... You know, someone to remind me to be patient. Someone to speak encouraging words in my ear. “Don’t push her until she’s ready. Trust the process. Know when NOT to interfere...”

So I prayed about it and God assured me things would be fine. So I sat on my hands and waited.

Then all of the sudden, her pushing changed and she gave it her all; within minutes her boy was in my hands!

After the birth, Rebecca fell asleep as soon as she could with her boy snuggled close to her chest.

Equally tired, I tried to follow her example. But sleep evaded me for several more hours. By 5 am I finally dozed off.

Two hours later there was a loud knock at my door.
-- “Ma’m Akuac. There is a woman in labor.”
-- “Is she pushing?” I asked scratching the sleep from my eyes. (I always ask this so I know how fast to get dressed.)
-- “No, but her contractions are very fast...” he explained.
-- “Okay. I’ll be there in a minute.”

I arrived to find her squatting in the middle of the room.... pushing.

Glancing quickly at her book, I learned her name.
-- “Yar, do you need to push?” I asked.
-- “Yes. Yes. Baby is coming...” Her hurried voice was all I needed to hear. 

I signaled for my translator to get the room ready for the birth while I did a quick vaginal exam. Sure enough, not only was she was fully, she was at a +3 station.

Yar and her daughter.

She paused long enough for me to get a pad under her butt. Then her mother came in to help hold her shoulders down while she pushed in a semi-squat.

This is a typical birthing position for the women here. It provides counter pressure for them to push against.

And boy did she push!

She pushed so hard that when her baby finally crossed the finish line, it stormed the judges, stole the gold medallion, and ran off with it!

Honestly had I turned away for a second, her baby would have hit the ground hard enough to bruise.
        -- Impressive!

Once she was cleaned up and ready to transfer to the postpartum room, my translator informed me there was another labor waiting outside.

She’d been there awhile in fact. Over an hour.

I invited her inside with an apologetic smile, and she smiled back. Her name was Mary and she was expecting her 7th baby. 

She was calm and relaxed, so it came as a surprise that she was already 9 cm dilated. But since she wasn’t quite ready to push, I asked her to walk a bit. She happily complied.

Meanwhile another woman showed up in labor.

I asked Tom to check her in because I was feeling spread a little too thin. He screened her but found her to be having braxton-hicks contractions and sent her home.

A few minutes later, Mary started getting grunty and waddled back into the clinic. She tried to urinate in the chamber pot (aka: big wooded bucket with a toilet seat), but got nothing.

Then she started pushing while still on the pot.

All of a sudden her eyes flew wide and I instantly knew it was time. The problem was... my translator was off getting tea.

I tried to get her to a better position --as the chamber pot isn’t ideal for maneuvering-- but she couldn’t move. So instead I reached low and steadied her baby’s head as it eased out. Her little girl was born with one push!

Having no where else to place the tot, I slip her into her mother’s waiting arms and we laughed.                        --Priceless.

When my translator arrived with the tea a few minutes later. He couldn’t believe he’d missed the birth. He was only gone a few minutes!

Apologizing nervously, he kept asking what I needed and what he should do.

He’s new to the whole birth scene and had never seen a woman give birth on the toilet before. It was my first toilet birth as well.
           --I confess. I liked the easy clean up!

Mary got off the toilet to deliver her placenta, then sat down on the floor to breastfeed. As I was charting and monitoring her blood loss, one of the compound workers interrupted to say another labor was on her way.

Apparently this woman’s family had called for the ambulance. They had just gone to pick her up and I could hear the sirens wailing off in the distance. So we scrambled to set up the next room for her birth.

Mary smiled knowingly as I excused myself to go help.

Mary with her daughter.

The next labor stepped out of the ambulance gingerly. She moaned non-stop as we walked her to the birth room, peppering her with questions.

How long had she been in labor? Had the water come out? Had she been pushing at home? How many babies did she have.... oh, and by the way... what was her name?

-- “Akuch. My name is Akuch,” she whispered between contractions.
-- “Okay. How long have you been pushing?
-- “Five hours.”
-- “You’ve been pushing for 5 hours at home?” I repeated incredulously.
-- “Yes,” she moaned. Another contraction hit.

We soon learned that she was expecting her 5th child, had been in labor since dawn but started  pushing from the very first contraction. She couldn’t explain why. No water had come out.

All her vitals were normal except she was in obvious distress. Was it fear?

After assessing her and finding her dilated to only 5 cm, I reassured her all was fine. With time I  convinced her to walk around a bit, strictly forbidding her to push.

She promised she wouldn’t and wandered off with her sister. 

By this time Mary --the previous birth-- had moved to the postpartum room and we cleaned up the main birth room.

I was about to go rest as well when one of the translators rushed in to tell me Akuch was pushing outside.

He’s the excitable kind but rarely wrong, so I went to check on her.

I found Akuch surrounded by three family members, all trying to hold her upright as she strained to push her baby out.

-- “Akuch, please stop. You are not ready to give birth,” I argued.
She trembled and grunted in response.

My translator informed me her water broke, and I looked down to see a  steady flow of fluid running down her leg. As another contraction rolled across her body, she fell to her knees and pushed like mad.

-- “Akuch. Don’t push. Don’t push...” But my words were white noise in her transitional state.

After her contraction faded, I picked her up out of the dirt and walked her back to the clinic.
         --Could she really be fully after only 15 minutes?

Akuch and her daughter.

She lay down on the bed for me to get a better look...  and lo and behold the head was visible! We had just enough time to put an under pad beneath her before her little girl was born.

As I wiped her baby off, several family members smiled at us through the screened window; a few more peaked past the sheet we use as a door.
           --Wow! ... I mean wozers! I mean gosh-golly-gee...

Four babies before lunch. Now that’s a record!

Tom kindly offered to take over any other births that might come in so I could get some shut eye, but naps don’t come easily to me these days. I tried and tried to sleep but I couldn’t.

By 2 pm I headed back to the clinic only to find another big-bellied mamacita pacing the grounds. Her name was Agum.

-- “Tom, do we have another labor,” I asked not wanting to know the answer.
-- “Yep, but she’s only 3 cm dilated. Don’t ya worry ‘bout her,” he quipped, “I got her covered.”

Covered? I didn’t doubt him for a second, but he looked pretty busy. He kept bouncing back and forth between a very sick man with malaria (who incidentally bit him in the butt while he inserted an IV) and another patient with massive road-rash from a recent motor accident.

Since I was more or less rested by this point, I assured him I’d look after Agum.

As the sun dipped low on the horizon, Agum got a bit more active. Her contractions were regular but unimpressively short. Was she progressing? I couldn’t tell.

Nevertheless, a few hours later she was sweating profusely.
    --Could she be in transition?

Not wanting to do a vaginal exam, I waited and watched. Her contractions were still very short.

At one point, I left to grab a cup of coffee; my lack of sleep was starting to take its toll. When I returned, I crossed a friend of hers in the hall. She motioned frantically for me to go inside but didn’t say a word.

Agum holding her son.

I entered to find Agum lying on her side, soaked from the waist down. Her water had broken.

Knowing the drill, I readied the room and checked for progress. I was considering doing a vaginal exam, but didn’t need to. The head was visible.

She pushed with her next contraction and out slid a very handsome boy with a very happy cry.
        --Woohoo!

After dinner, I didn’t linger long. Tom promised to look out for any labors or births in the night --Bless his heart!-- and I hit my bed like a rock.

There was in fact another labor that night... but Tom delivered her. I’m told she gave birth around 2 am. I was called to come if I wanted to, but I declined. I had nothing left to prove.

Five babies in one day! That’s a record for this midwife.

I wonder how many babies will be born this month...

Please pray for strong hands and deep sleep... when we can get it! Thanks.

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.

Achol’s Journey.

She walked 5 hours over dusty roads in the heat of the day. She walked carrying a blue plastic bag which held a change of clothes, but no food. She walked in active labor.

40 kilometers.

She arrived after the noise of the day had settled to a low hum with only the bleating goats left to complain at her late arrival.

As I entered the birth room, she flashed a familiar smile my way. I recognized her square jaw and sparkling eyes immediately and we slapped hands in greetings.

It was Achol!

Achol had come for several prenatal checks over the last few months. Her gentle demeanor impressed me, but I never dreamed she’d come to deliver. She lived too far away... or so I thought.

I was happy to be wrong --for there she sat on my prenatal bed with contractions every two minutes.

But she was so calm I was having a hard time believing she was in labor. So I asked if I could do an exam. She agreed with a smile.

When I told her she was fully, her smile deepened touching the corners of her eyes.

It was time!

In fact, the only thing keeping the baby inside was her bag of waters. Did she want me to brake it?

Nodding excitedly, she consented and out gushed a warm wave of amniotic sea. Almost immediately the head dropped lower and she started pushing.

But the funny thing was... she wanted to keep walking.

So I stood aside and watched as she slowly pace the birth room floor. During each contraction she’d bare down for a few seconds then chuckle softly at the pain.

It was mesmerizing.

Pacing then pushing then pacing again, she let her baby settle even lower in her pelvis. But eventually she got tired and eased herself onto the bed with a sigh.

But that didn’t stop her from pushing.

Within minutes a fuzzy head emerged like a winter’s sunrise --calm and quiet and warming to the bone.

When I announced it was a boy, her eyes lit up the room and she asked to hold him. Long joyful minutes passed while she whispered softly in his ear and laughed. I couldn’t help but laugh with her.  
     --A son!

Her birth was different... but for the longest time I couldn’t figure out why. What had made her birth so different? Was it the joy and trust? No. Was it the intimacy and laughter? No. Those were amazing but not new.

What was it?

Then I looked around the room and it hit me; she was alone.

Not one friend had sneaked into the room during pushing. No one had asked to hold the child. No one had screamed for her to push.

Where was her cheer squad?

When I asked her, she smiled softly and explained that she had had no time to inform them when she got to town. Since she knew she was close, she didn’t want to risk delivering unassisted, therefore she didn’t stop to tell them the news.

But that meant she had no one to goo and gaw over her precious jewel. But more importantly... that mean there was no one to feed her.

Fortunately her family lived just a few minutes away, so we arranged for our health worker to go tell them for her.

He was there and back in a flash, and her family soon followed... bringing with them even more laughter and love!

Thank you Jesus for allowing me the honor of seeing such miracles on a daily basis. Birth... I’m awed at its beauty and mystified by its power. It is one miracle I hope to never fully understand.