I have had some small successes since my initial heart-wrenching days in Aweil, South Sudan. So today I am in better spirits.
Two nights ago at 3 AM I did a C-section on a woman with heavy vaginal bleeding because of a placenta previa. Placenta previa occurs when the placenta attached to the uterine wall grows too low over the cervix. As labor begins and the cervix dilates, bleeding ensues. Vaginal delivery in these cases often results in the death of the mother due to hemorrhage, and death of the infant due to a lack of oxygen as the placenta bleeds and shears from the uterus and cervix.
This woman’s red blood cell count, or hemoglobin, was 5.4 g/dL but no one is impressed around here until it is less than 2. But to put this in perspective, normal hemoglobin is 12 to 13, and most western women would pass out if it were less than about 8 g/dL. But the women we see in Aweil are chronically anemic from frequent pregnancies, inadequate nutrition, and often malaria as well (as this patient had). They tolerate so much.
We called for a unit of emergency blood, inserted a bladder catheter for continuous drainage, and whisked her to the OT (operating theatre). As I took the scalpel in hand, I heard her softly saying prayers behind the surgical drape. Through a torn and bloody placenta, I delivered a robust, screaming baby boy. Fortunately mom’s uterus contracted immediately, so she did not lose more than the usual amount of blood during the surgery. When I saw this woman just five hours post-op, her hemoglobin was 7.2. She had just finished nursing her baby, was up cleaning her bed, and was asking for the catheter to be removed. These women are tough!
This morning I did a vacuum-assisted vaginal delivery on woman having her eighth baby. She'd been pushing for one and a half hours. She was exhausted and when she saw me she asked for a Cesarean section. I assessed her pelvis and contractions and felt confident that the baby could deliver vaginally. So I applied a small cup to the baby’s head, which was low by now, and suction was added. I gently pulled as the mother pushed with her next contraction and out came the 3.7 kg boy with a big head. The woman herself must have weight about 110 lbs. She got off the delivery table, walked to the postpartum room, and started eating breakfast while nursing her newborn. It was routine to her. As I said, tough women!
One aspect of life in South Sudan that I have repeatedly witnessed and for which I have felt a deep reverence is an acquiescence to the natural order of things, a strong connection to instincts. We in the U.S. have become so far removed from the natural that we are uncomfortable with it. It is no longer innate for us, as it is for them. In every postpartum bed—except those where the baby has died (and there are too many of them)—mom and baby are laying side by side, skin to skin. Usually the mother's breast is bare and the baby is naked. The baby nurses at will, rooting and finding the mother's accessible, nourishing, comforting breast.
And the postpartum mothers, sisters, and grandmothers support one another on the maternity ward. As I enter to make my rounds, they alert me to a problem in another bed. They teach a first-time mom how to get the baby to latch in breastfeeding. They feed a mom who is too weak from malaria and/or anemia.
I contrast that to my two experiences of childbirth, in my private hospital room. I appreciate that my husband was there and acknowledge that he was as supportive as he could have been. But there is something about the community of women that is affirming and comforting, especially at a time like that. I remember that after giving birth to my first daughter and putting her to the breast for a few minutes, both she and I fell asleep. I was awoken by an RN interrogating me about when I last nursed and berating me to check the clock and offer my newborn the breast every 2 hours.
Later that morning, my husband and I took the elevator to another floor for a "breastfeeding class," activating the alarm because we had not waited for the nurse to disable it and accompany us. I had the most technologically advanced maternity care available to me and I am thankful for the clean, state-of-the art facilities. But missing was the solidarity of women that is ever-present at Aweil State Hospital.
I feel grateful that these women let me into their circle for a short period of time. They are amused as I delight in their beautiful newborns. They allow me a seat on their bed as I hold and coo at their babies for a while before resuming my rounds.
I wish many things for these women—better nutrition, a more hygienic environment, accessible health care, improved diagnostic capabilities and more treatment options when things go wrong. But despite all they lack, they have something very valuable that we in the developed world have lost long ago and are not likely to recover.