Fieldset
My First Kiss

Midwife Mara shares a patient story that isn't quite as romantic as it sounds...

The compound in Agok really is a luxurious place compared to other MSF projects. We have running water, lights, and showers.

The amenities are something not to be taken lightly, some even refer to this project as “Agok Paradise.” But after so many months living inside the compound even a change of scenery from paradise is welcomed.

The sister project

The past week I was sent via Land Cruiser to collect a woman with pre-eclampsia from our partner project in Mayom.

Mayom is a newer MSF project that just celebrated its one year anniversary of successfully delivering care to a population in great need. The services in Mayom are basic health services and the project is much smaller than Agok. When a patient's case becomes complicated and it looks like they may need surgery or more medical intervention, they are transferred to Agok.

About four months ago I travelled along the same road to visit another NGO with some of my colleagues. The road was a lunar landscape of red dust cracking in the hot sun.

Incredible mud

With the rainy season arriving in the past few weeks, it rains almost every afternoon. The clouds build throughout the day until late afternoon when the sky grows dark and the rain pelts the tin roof of the maternity department.

Cattle crossing. © Mara Evans

The sound is deafening and I find myself yelling things at the top of my lungs that would be absurd in any other situation, like - “PLEASE I NEED A URINE CATHETER!!!” just to be heard. The rain has transformed the countryside. Long-horned cattle supervised by small boys with long sticks graze on bright green grass. Streams have appeared and men stretch across the shallow muddy currents with handmade fishing nets.

The biggest difference in the trip however, is the road. The mud here is incredible. It is a thick and sticky glue that will stick to your shoes layer by layer until you find yourself walking around with something that looks like 12 pound moonboots.

Stuck. © Mara Evans 

The muddy road is carved deep with ruts of vehicles spinning their wheels looking for firm ground. Our drivers are skilled at reading the messy road fishtailing to the left side, four wheeling to the right side, and venturing off road to find a passable way.

The kiss

While we are making our way towards Mayom, two vehicles from Mayom are headed towards us until we meet at some point in the middle. This type of movement is referred to as a “kiss” and is frequently used to transfer patients, medications, or supplies from one MSF project to another.

After about two hours of trudging down the road up ahead we spot a two vehicle convoy, white Land Cruisers flying MSF flags. It’s our colleagues from Mayom. We pull over at the side of the road and the drivers position the cars back to back.

Patients waiting patiently for vehicles. © Mara Evans 

The patients from Mayom are helped into our vehicles and we wish the Mayom team luck with their difficult travel back.

A risky condition

The pregnant woman I’ve come for is nine months pregnant with her third baby. Her blood pressures have been high and there is protein in her urine. These are two signs of pre-eclampsia, a serious condition in pregnancy which can lead to seizures.

One medication which can decrease the risk of seizures is Magnesium Sulfate. At home this medication is carefully controlled through an IV drip. Out here we give Magnesium by IM injection.

The woman is overdue for her injection, before we start our return journey I give the dose as she is lying on a mattress in the back of the vehicle.

As the clouds darken and build, the trip isn’t as smooth on the way home. Twice one of our vehicles get stuck in the mud. Twice the drivers use long cables, gunning their engine, wheels spinning to pull the stuck vehicle free.

The kiss. © Mara Evans 

Many large trucks are also stranded in the mud nearby. One large truck is filled with armed SPLA soldiers who shout and gesture helpful advice on how to avoid the worst parts. As we near the homestretch, the threatening clouds burst causing everyone to run for cover.

Motorcycles are laid on their sides in the middle of the road, abandoned by their drivers. Donkeys are left facing the storm on their own, their cargo and cart their only soaking companions.  Medically, the trip goes well and with both of us dripping wet, I admit the patient to the maternity department.

Twins

Soon she spontaneously is in labor and the baby she is carrying is actually twins. The first twin is coming head first and makes his appearance around 11pm. The second twin is breech, I wait 15 minutes for him to come down and when it becomes difficult to hear his heartbeat I perform a breech extraction.

Wearing long gloves, I gently, but firmly, take hold of one of his little legs through the amniotic sac and guide the leg down towards the real world.

The amniotic sac ruptures and amniotic fluid rushes out.

Meconium, or baby poop, is frequently seen in breech deliveries and although it can be a sign of distress in a baby coming head first, it is common in breech births.

The second leg soon follows with the help of the mother pushing. Next the buttocks and baby’s lower abdomen emerge up until the umbilicus.

By vaginal exam it is noted both of the baby’s undelivered arms are raised above his head. Two arms and the diameter of a head is usually too wide to pass through the pelvis at one time and delivery is obstructed.

Lovset’s maneuver was performed by grasping the infant’s hips and gently turning the baby to face directly to the right. This allows the baby’s right shoulder to come under the pubic bone. The arm was delivered by grasping the arm gently and bending at the elbow to guide the arm through the pelvis and out.

The procedure was repeated for the left arm by turning the baby 180 degrees to the left, to free the baby’s left arm from inside the pelvis. With only the baby’s head remaining inside, the baby’s back was towards the ceiling and the baby was once again facing the mother’s spine.

To deliver the head I lifted the baby’s hips up and over the mother’s pubic bone for Bracht’s maneuver. Like a well-supported back flip in slow motion, baby’s back was placed on his mother’s abdomen. During this maneuver the baby’s head slowly turned underneath the pubic bone.

Healthy boys

The chin was first visible, then the mouth, and finally nose and eyes as the baby made his entrance into the world with a robust cry!

The babies are now almost two-weeks-old and doing well. The mama is healthy and no longer needs medicine for her blood pressure.

On the last kiss movement that took place, I was again asked to ride along to receive another pregnant lady from Mayom. The ride out wasn’t as long this time because I had company—the mother and her twin boys were going home.