a bit long and hard on the heart, be warned

From almost a week ago, because it is such a long entry I decided to wait on the more recent updates, hopefully I can post those tomorrow.

8/11/2013

from the village of Ngolahun

I thought that I heard someone outside my window in the cool, misty predawn light, but I quickly dismissed it.  After I used the chamber pot and got back into bed under the mosquito net, I lay in a half sleep imagining that someone was in labor and we were being called to the birth.  Not 5 minutes later Jitta leaned  her head against the window to our room and called to me

“I am going to a birth at the clinic.”

“Great” was my groggy response “shall I join you?”

“Yes, please come” was her reply as I was already slipping out from under the net. 

I spent a few minutes getting dressed, teeth brushed and coffee in hand (they prepare our coffee the night before and leave it in a thermos so it is ready whenever we wake up, genius).  Maybe 10 minutes after my mattress musings I was on the road with Jitta up to the clinic.  Just before we arrived one of the TBAs came out and spoke to JItta in Mende, she looked to me

“The baby has already been born” her face disappointed, “ and he is having trouble breathing”.

I dumped my coffee and started running the rest of the way.  I am by far the most trained and experienced medical professional for many miles around (and you all know I am still far from an MDs level of training), and I was feeling the weight of that just then.  When we arrived in the labor room the Maternal Child Health Aid, Jospehine, was doing PPV (giving breaths with the ambu bag) on a good size baby who was limp and grey.  I was putting my gloves in as I walked up and she handed the bag and mask to me and I took over.  He had been born a few minutes before and while his heartbeat was strong he had not yet taken a real breath.  He had occasional agonal gasps, but was otherwise limp and unresponsive to stimulation.

The irony here is that just yesterday we spent the entire day teaching neonatal resuscitation to Josephine, an MCH aid from a neighboring village and a few TBAs.  It is the Helping Babies Breathe, developed by the American Academy of Pediatrics for training and use in low resource areas. The reason that Josephine even had the ambu bag with which to provide the PPV (positive pressure ventilation) was because we had given it to her for use in the clinic the day before.  They were getting to see a real life demo only 12 hours later, a situation that had never before been seen in this newly built clinic.

After 30 minutes the baby was still not making any real respiratory effort and despite maintaining a strong heartbeat I decided that it didn’t make sense for me to continue breathing for him, even if he did make it at this point I did not think he would be neurologically intact.  I discontinued the PPV and watched him, his heart rate slowed after a few minutes and I thought that he was passing, and then things turned around, he was maintaining his color and his heartbeat retuned to its steady baseline.  I am not sure how this was all happening because I could not hear any significant breath sounds with the stethoscope.  So we laid him on his mother’s chest, bundled them up and I told her that it was up to the baby and god at this point (the response in Mende to most things is Praise God "nkaiguoma", so i felt it was appropriate).  He was still completely limp, but he was maintaining his color and his heartbeat was strong.  I did not think that he was going to make it but everyone else in the room was hopeful, so I too hoped.

After returning home and having a good cry and an even better breakfast, Katmoon began “planting” (braiding) my hair.  This was a plan for the day, little did I know that it would take 9 hours! Throughout the day we got news from the TBAs who came by that the baby was slowly improving.  He was sneezing, he was coughing, at one point Jitta went up and came back delighted to show us a picture of the baby’s hand clasped around her finger. I asked if he had nursed and she said no but that they were trying to get him some colostrum.

We sat on the front porch, listening to music, receiving guests and visitors who were delighted that I was braiding my hair “like a Mende woman”, and talking.  Jitta and Katmoon starting telling me stories from the war. Jitta showed me her scar from a bullet wound on her forearm and told me how the man in front of her hiding with her during an ambush was shot and killed, his brains all over her body…but she was smart and she knew how to hide. They told me how Katmoon is not Jittas sister by blood; that Jitta’s mom had found her during the war, as a baby, abandoned and she had taken her in and raised her as her own.  Katmoon does not even know what village she is from, who her people are, how old she actually is. It is a hard thing for her, but she laughs easily and often.  It was a rare sunny afternoon and at some point we had to move from the front porch to the back yard for shade.  There are two moss cover cement pads under the tree in the back.  I thought maybe they were old wells, or graves, we walk by them many times per day to use the latrine, Jitta turns to me and says

“do you know what these graves are? One is the father of the woman who owns this house, and the other is a mass grave, 16 people are buried there, killed during the war.  One day in this village the rebels killed over 150 people, there were too many to bury so they made mass graves.”

As hard as all this was to hear there was also a lot of laughter and joking, there was a lot of gratitude for their luck in surviving and staying together.  I felt so honored that they were comfortable sharing these stories with me and the tears welled up more then a few times with my own gratitude at their survival.

The “planting” was finally done just before dinner and immediately after, I grabbed Jitta and we headed up the road to the clinic to check on the baby.  When I walked into the postpartum room the mom was sitting up in bed eating and chatting with some of the TBAs, the baby was all bundled up, on his side, lying in the bed. One look at him and I knew things were not great.  I asked for the stethoscope as I slipped on my gloves and Josephine handed him to me.  There was silence when I put the stethoscope to his chest.  No more decisions to make, he was gone. I handed the stethoscope to Josephine so that she could hear and confirm.

After that things got hard, as you would expect.  At fist they didn’t want to tell the woman, that is not their way, it is too early after the birth.  I disagreed with them politely but said that it is not my place to tell tem how to manage this situation. I stepped out of the room to the back porch and watch darkness take away the cerulean blue light of evening.

  20 plus woman stuffed in to that room when I walked back in and all of a sudden another 20 were on the front porch.  News travels fast and support had arrived, family and TBAs.  Josephine walked in to the room and sobbed openly in front of the mother before running out, it was her first demise.  Here I could help.  I know her pain and she speaks English.  I followed her into her room in the clinic and sat next to her on the bed and rubbed her back.  I talked with her about how hard this work is and how strong we must be, but that sadness and tears are good to, they help us heal.  I con

gratulated her for her good work.  After a while Jitta and I headed home so that the woman’s family and friends could help her. 

 

Her husband came to our house with 10 men and boys in tow, we expressed our sadness and regret, greeting everyone individually. I told them we did what we could.  He said that he knew and had a lot of appreciation.  Of course I was feeling guilty that I was sitting on the porch getting my hair done all day while that baby was dying. Not that there was anything that I could do.  It is I am sure for the best that he did not make it but it doesn’t make it easier, not really.  I can only imagine that he had been deprived of oxygen for a fair amount of time while he was being born, and even in America I cannot imagine that he would have some out of this “intact” neurologically, he was so very depressed at birth.  But if I had been called to the birth earlier, maybe there was something I could have done.  If I had not brushed my teeth and stopped to grab a cup of coffee, maybe? My brain tells me this is twisted logic, but my heart is still in knots.  There is no escaping the harsh realities of life here, even amongst the beauty and smiles.