It’s Friday night and the expat team is winding down. Most of the team works regular hours, but I am on call 24/7 in case of any complications in Maternity. Since it’s the weekend, people are relaxing and staying up later than they normally would during the week. By 11:30, the party is winding down, and just a few people are left talking on the sofas. My phone rings, and one of the local midwives tells me he has a patient he is concerned about.
“Dr. Veronica, I have a patient here. She has three previous stillbirths, and she is here complaining of vomiting. She is also worried about the baby. The fetal heart rate is 170.”
With three previous stillbirths, I have to worry about several things:
Is her pelvis too small to fit a fetus? She could have started labor with each one, but have been unable to pass the baby. If so, she would need a C-section.
Does she have some kind of genetic problem that causes her blood to clot abnormally? That could cause stillbirths, and there would be very little I could do in this setting.
Does she just have incredibly bad luck in a setting with extremely poor access to obstetric care? Maybe the three previous stillbirths were unrelated. So many women here have stillbirths or neonatal deaths, and there is no consistent reason.
Regardless, I have to do everything I can to ensure that this child survives. Having lost the previous three children, this woman must be desperate to have one survive. I review some of the vital signs with the midwife and ask him to check her temperature again to make sure she doesn’t have an infection that could be causing the vomiting and the high heart rate.
When I arrive on the labor ward, the interpreter and the midwife help me evaluate the woman. She looks weak and tired, and I am not surprised that she was recently vomiting. The midwife tells me that her cervix is 3 centimeters dilated but still thick, and she is having some contractions, but does not seem to be in real labor. Her pelvis feels adequate – sufficiently roomy to deliver a fetus.
I bring the ultrasound over to evaluate the fetus. It has good fluid and is measuring at full term. I discuss the plan with the midwife. I tell him to give her some IV fluid and resuscitate her. It’s possible that she just has gastroenteritis and the dehydration is causing her to have false contractions. If so, they will go away when she feels better. I can understand her concerns about the three previous stillbirths, but since the fetus looks good and she will be staying in the hospital, we can decide how to manage that tomorrow. I tell him to monitor the fetal heart rate every two hours, just to be very careful. He agrees.
Back at base, I mull over her case. What could have caused her stillbirths? How can I prevent this one? Doing a C-section for her isn’t the greatest option – most of the women here live several hours’ walk from the nearest health center, and having one C-section would make the next pregnancy much more complicated and potentially endanger her now and in the future. I have to consider the woman herself, not just the fetus. Nonetheless, I am very sympathetic to how devastating three prior stillbirths must be, especially here in South Sudan where it is extremely important for women to produce children, and most women have six, eight, or ten children. She might even be at risk of being abandoned by her husband if she cannot produce a healthy baby. Here, a pregnancy after multiple poor outcomes is referred to as a “precious baby.” I know all babies are precious, but I can certainly understand the term.
In the U.S., a woman who has had even just one stillbirth would have an extensive workup, and in her next pregnancy, she would have regular fetal monitoring and her labor would be induced before her due date to prevent it from happening again. I decide that this woman should be induced as well. My measurements for this fetus showed that the fetal size was equivalent to 38 weeks and 6 days, and the fetal thighbone – probably the most accurate at this point - was measuring 42 weeks, so this baby can come out without concern for being preterm. I know that the mother will be relieved to be delivered.
When I arrive on Maternity the next day, Roisin, the expat midwife on her first MSF mission, has seen her on rounds and relays to me that she is asking for a C-section. I am sure that this is the only way the woman can imagine her baby is going to get out safely. I find an interpreter and go to see her. I sit down on her bed next to her, and I ask her more extensive questions about her prior losses.
“What happened in her other pregnancies?”
The interpreter confers with her. “The water was leaking, and then she went to the hospital and she had labor, and the babies were dead.”
“How long was the water leaking?”
“Sometimes three days, sometimes five days.”
“Was the baby dead before labor, or after labor started?”
“Was she sick during the delivery, or was she OK?”
“She was OK.”
“Was it the same for each delivery?”
“Yes, the same each time.”
To me, it sounds like she broke her water before the onset of labor, which can often happen in a normal pregnancy. Labor did not start, but she did not have easy access to a health center. Infection set in, and the baby died each time, and by the time she did seek care and go into labor, it was already dead. This is a terribly sad story, but it is also good news for her now. From what I can tell, it is a non-recurring cause of stillbirth – meaning that it will not necessarily occur again. It is a coincidence that it happened to her three times in a row, but it does not mean anything is wrong with her. Her pelvis is not too small, she does not have a blood clotting disorder, and nothing else is wrong with her. If we induce her labor, she will in all likelihood have a healthy normal baby via vaginal delivery.
I explain to her that three to five days of leaking water is too long, and I explain my theory of what happened in her previous pregnancies. I also explain that she probably wants very much for this baby to survive, and I do, too. I tell her that there is a medicine I can give her that will make her labor come now, before her water breaks, and it should cause her to deliver within the next day. I tell her that since she has pushed three babies before, I think she will be good at pushing.
The interpreter relays this to her. She looks unfazed. “She says this is OK. Pushing will not be a problem.”
I smile and offer my hand and she takes it, and we share the mutual, warm South Sudanese handshake, so deep it feels like a hug.
Because she is not in labor, I want to use an induction agent that will both soften her cervix and cause contractions. Misoprostol is an excellent medication for this. It is temperature-stable – great for hot climates like this (109°F/42.7°C as I am talking to her), and very effective. I don’t want to give too high of a dose, as it can cause excessive contractions. The pill we have here is 200 mcg, but I only want to give 20-25 mcg at a time. I dissolve it in a bottle of water, and teach the nursing staff to give her 60cc of the liquid every two hours. They have never done this before, and they are amused and fascinated, and maybe a little skeptical.
Twelve hours later, Roisin tells me she is only starting to feel some cramping, which is fine. They are continuing to monitor her, and she is doing well. By the next day, she has delivered. When I come in, the staff immediately approaches me to ask about liquid misoprostol. Is it in MSF protocols? (It is.) Can they use it in the future? (They can.)
I go with the interpreter to visit the mother. I ask if the baby is OK, and she nods, but doesn’t smile. I ask if she is feeling well, and she says she is feeling well, but doesn’t smile. I ask if she is happy or sad. The interpreter repeats the question, and she breaks into a large grin.
“She is very happy.”
She shows me the baby, and now she is all smiles. It is a girl. I tell her that she should use family planning for two years before having the next child so that she can take care of this child. She nods and says that she will. (The Ministry of Health sends a family planning team around to the postpartum ward every day to place implants and offer other family planning options. This is a huge improvement over my last mission here four years ago, when options were limited.)
“You need to make sure she is strong so she can grow up to be the President of South Sudan.”
The interpreter repeats this and she and her mother both laugh and agree. Her mother says something, and the interpreter relays it.
“She says maybe she will even grow up to be a doctor like you.”
We laugh, and I thank her. I hold out my hand to the patient, and we shake hands, like a hug.
This blog post appeared on Everyday Emergency, the MSF podcast
Also available on Pocket Casts and Podcast Addict