Sunday, November 29, 2009

Over Cooked

So, last June (ish), when working with our CHW (Community Health Worker) students in Gasmala - doing the 'Under 5 clinic' (where we weigh babies to see if they are growing at a good rate or getting malnourished) and Antenatal (seeing and assessing pregnant mothers to see if every thing is going as it should using really basic skills) I encountered a lady named Mary for the first time.

She was laying on my bed (we were working out of my tent in Gasmala) with her belly in the air ready to be assessed, and as soon as the CHW touched her, she cried out in pain. So I tried - same thing. She was supposed to be about 5-6 months pregnant, but sure didn't look it, had a lot of pain all on her right side, no abnormal bleeding or anything like that (I'm gunna down play the nasty terms for you non medical folks), and had been seen by other people in our Doro clinic months previously. So, not being an expert (or really, knowledgeable at all, besides what we get in our nursing training)I went out in search of Barb, my coworker and the CHW's teacher, who was doing the same thing in another tukul.

When I told her about our lady she was SURE that she'd seen her before and told her to go to the clinic to be seen by Dr.Emily (who was with us at the time). So, together we went back over to see her - sure enough, same woman. So, after a 'conference' with Mary and her husband, we stressed that she needed to go to the clinic b/c her pain was NOT normal, and we didn't have the necessary ability to assess her further in the village (not that the clinic has much more mind you!). So, with faith that she would take our concern to heart, we let her go.

The next time, about a month or two later when doing follow up 'clinics' in the village, I had Mary again. Same story. This time she HAD been to the clinic and she reported to us that they found nothing abnormal. Huh. That's odd considering her intense abdominal pain... Again, she was guarding to the point where I was uncomfortable probing deeper then surface in order to assess her. According to my measurement, she wasn't hardly 6 months along (still), and she hadn't gained any weight at all in the past two months. By this time, in my head, I'm starting to doubt if she is even really pregnant but had some sort of tumor/growth or something going on that, to her, is presenting as a pregnancy. So by this time it's August - I was just about to go home to Canada for about a month, and she was "due" to deliver, according to LMP math, next month. After stressing AGAIN that she NOT deliver in the village - since we really didn't know what was up with that abdominal pain, we set her off again.

A whole month or more later, when I got back from home and we are in Gasmala again seeing kids and prego moms, Mary walks into my tent again! "Still no baby?" I say to her... "oh, Kata... no - when is it going to come!?" So, she lays down for us to assess her again, this time she is at least measuring at about 8 months, and has gained weight. So, on the with assessment (as much as we could do, she was STILL having that R sided abd pain)... the CHW pulls out or fetalscope (the wooden cone shaped thing you've seen in the movies) to assess for a fetal heartbeat and I'm thinking - yeah, the likelihood of that is like zero to none... and low and behold... "here is it" he says. "What!?" I say, and promptly get out of my chair convinced that I'm going to hear the placental rhythm... "Well, I'll be..." There is was - strong and fast... a Baby. Not only that, but the head was engaged - this baby was gettin' ready to meet the world! So, we tell her, it shouldn't be too long - maybe a few weeks, and out she went.

I continued to see Mary when I was out in Gasmala every week - she is actually James' (my Mabaan Dad) neice and lives close. And week after week, she'd walk by with that big belly and I'd say, "Mary - still!?" and she'd say "oh, Kata, when!?"

So, about two weeks ago now - mid november, I stopped to talk with her and had James there to help me with Mabaan. As I asked her questions I found out that she'd been having back pain for about 4 days, and the baby had stopped moving. So, even though James asked me to assess her right there (I had nothing with me!), I told her to get to the clinic as soon as she could (which was going to be the day after tomorrow).

Saturday evening (the day she was to come) rolled around and still no Mary. Where was she? Finally at about 5pm Masir, one of the clinic CHW's came to get me - she'd arrived. When I got up to the clinic with Scottie (who is working in the clinic for about 5 months), Mary tells me that she left Gasmala that morning and because she was having so much back pain, it took her all day to get here - the walk usually takes about 1 hour - 1 1/2 hours. She'd walked alone, and brought no food or belongings with her, even though I'd told her to prepare to stay in the Doro area for a few days when she came (just in case). So, Scottie and I started over - going through all the details with her and previous assessments. She told us that her water broke (but not fully, really only leaking) about 4 days ago, and at that time her body started contracting as if the baby was going to come. But, after a day or so it stopped and hadn't started again - and the baby had stopped moving. She had no other fluids or fever, or complications, other then the bad back pain. And, as I'd feared, when we pulled our Doppler out to find the baby's heartbeat, there was nothing. Scottie and I just looked at each other. We knew there was nothing we could do about it that night, we needed to talk to Dr.Rob, Sandy, and Sarah (who all knew lots more then we did), and we needed to tell her to stay in Doro and come to the clinic when it was open again on Monday - unless something started happening. How long until a body started to expel a dead baby? I didn't know. But, with no fever, we felt fine to leave her for the time being (we gave her meds to cover our bases for infections, and pain). "But Kata, I want to go home tomorrow" she said to me with pleading eyes... "Mary, you really can't - there is something wrong and we don't know what. If you go home, the problem will get bigger. You need to stay and come to the clinc on Monday." "OK."

Monday morning rolls around, and b/c Sandy said she was my patient, I was up there waiting for her - Sarah was going to assess her, and I wanted to learn AND wanted to be a familiar face for Mary. We waited - then I went out to search for her. I went to the place she was staying and asked after her. "We don't know where she is - she went back to Gasmala yesterday." What!? Seriously. After all our efforts and trying to help her, I felt like she'd thrown it back in our faces. How do you make people care about their own health... and why are we bending over backward when they don't!? For the love. I felt like she'd made a fool of me, b/c I asked the clinic to make exceptions for her. I got on the phone and called James. I was ticked, and he knew it. He assured me he'd send her back - he was rather frustrated as well. So, later that night, who walks into our compound? Mary was back - tired, but moving easier then the day before. I asked her why she went back, and her answer was "I was hungry". I'm still not sure what I think about that - I don't think that's the whole story, but anyway, nothing could be done right then. I told her to come to the clinic the next morning first thing, and we'd see her. So she left to stay the night with James' relatives in Doro (a different place then the time before). We weren't about to make more exceptions for her & see her right then, since it didn't seem like she was too concerned about herself. She'd have to wait until morning.

So, now it's Tuesday morning - my flight for Nairobi is the next morning, and finally she is THERE at the clinic waiting for us when it opens. Sarah reviews the history, asks more questions, and the does her assessment. THIS time, through the doppler come the strong pulsating sound of the baby's heart. Praise the Lord! We have NO idea where that heart beat was 36 hour previous, but we could NOT find it! So, with that bit of good news, Sarah calls Dr.Rob to find out what he thinks since now, Mary is about 10-11 months along in her pregnancy... yep you read that right. She was supposed to deliver in September, and it was November 24th. The answer came, "Induce her!" So, Sarah pulled out the text books, and we readied an IV and the meds while reading up on how one goes about inducing someone in the bush - this was to be the first induced delivery in our Doro clinic. I went back in to tell her the good news. After MONTHS of making a good home for this baby, she was SO happy to find out that she would mostly likely be having it that day! Finally! :)

I stayed with her most of the day - again she'd come with no family, and Mabaan women always deliver with help from family and friends... I didn't want her to be alone with Kawaja's she didn't know. So, about 6 hours later, a rather hilarious, but I'm sure horrible, phase of transition labor started where she kept moving from the bed to the floor saying: "Kata... I need to go out side... let me go out side..." - "no Mary, you can't, you have to stay here where we can help you..." (2 minutes later) "Kata, I need to go outside." "Why Mary?" "Kata, please." "Mary, you really need to say." (a minute later), "Kata, take me outside, I need to go to the bathroom", "Mary you can't, if you go to the bathroom outside the baby will come, and then what will happen?" (2 minutes later) "Kata, I need to go outside", "Mary you need to stay here..." (I realize that this sounds rather cruel to those of you who haven't been around a woman in labor... but trust me, she was fine - she didn't have to poo like she thought, it was the baby's head, and if she went outside and started pushing that baby would have come out and we'd have been up the creek to help her if there was a complication). WE finally got her to lie down, and she complained that she was hot and wanted to go out side b/c there was wind out there - "I'll bring the wind in here!" I told her, and started fanning her with the curtain... that kept her calm for about 10 minutes... praise the Lord. Then she got up once more, slid to the floor, got in a squatting position, and made eye contact with me. I raised my eyebrows, and she responded with one nodd and click of her tongue... It was time. I communicated with the rest of our team (Sandy, Amy, and Scottie) as well as two of James' relatives (at least there were two Mabaan women there, even if they hardly knew Mary), and everyone got into place. Since Mary was squatting (the best position in my very inexperienced opinion), there was only room for Sandy's hands, the rest of us stood watching and ready with tools and towels. I watched Mary's face, as still, even with the two Mabaan ladies there, she looked to me as being her support person (can you imagine!).

Mary pushed maybe two or three times, and Sandy barely had enough warning to catch the beautiful and perfect baby girl that came out crying! :) Mary had tears streaming down her face - it was finally over, and my eyes were welling up with tears, with pride over my friend who'd been through so much in her life, and endured SUCH a long pregnancy. The baby was here, and Praise be to the Lord of Hosts who'd brought this strange pregnancy to such a beautiful end, and with no big complications (she bled more then she should have, but Sandy go that under control with some great prompting and directions from Dr.Rob via Satellite phone in Nairobi).

With Mary laying down in bed once more, and the baby at her side, we all breathed a sigh of relief that it was over, but none of us more happy than Mary. Eventually her family started to show up and meet the newest edition to the clan - they showed up with food and clean clothes and smiles - it was such a familiar routine but in a completely different context - the only thing missing was the bouquets of flowers.

Twelve hours later I went up to check on my new favorite mother/daughter duo... the baby's skin was darker (the pink from yesterday giving way to the beautiful dark color she will end up being), wrinkly, and dry - which is apparently common and indicative of babies who have been "Over cooked" such as this one! She is beautiful, and Mary looked much better after some rest :) I have to be honest with you and say that I do hope they name the baby Kata - that would be quite an honor. But, no matter what they name that gorgeous little one, she is SO precious in the eyes of Jesus, as is her mother... and I can hardly tell you what a privilege and honor it was to be alongside this woman as she brought her into this world. As I watched the Lord give this woman a gift - her daughter, I felt a similar overwhelming feeling as the reality of my own gift from the Lord sunk in... As much as I am a Kawaja, and will always be one :) these people have opened their lives and hearts to me, they have allowed me to walk with them through tough times, labor pains, hunger, joys, and blessings. I am, and will always be, I expect, utterly amazed at the gift that that is from the Lord. May He be glorified in these relationships, and May, by His Severe Grace and Mercy, He the Lord and Savior of this new little life.