Friday, August 12, 2011

Natural Childbirth

The uterus was not my usual territory. It took a minute of gentle exploring to sort things out. I found the little scrunched face. I scrunched my own eyes closed, like the copycat game you play with babies. Instinct was to pull my hands out of the mess, but I resisted. I couldn’t open my eyes again though; I worked by Braille. I pulled. My hand slipped off. Gripping the tiny head more firmly, I felt the chilling wrongness I'd expected.

A surgeon's duty throughout training is to learn what feels like what. Every new texture and sensation is recorded deliberately somewhere in white matter. The fingers and brain teach and learn together: This is the smooth inflamed inner wall of mature abscess; this is dense, scarred adhesion; this is liver parenchyma; this is thickened appendix; this floppy one’s normal. The hands have to know: Can I pinch between these inflamed organs and separate them? Or, will they burst between thumb and finger, spilling disaster?

My hand only knew the auspicious firmness of healthy baby heads. My brain was recoiling, as this head was not that. Recoiling because this new texture, of a soft, yet swollen, collapsing ball, dense, but not firm, confirmed tragedy off the charts - an unfamiliar brand of tragedy for a surgeon accustomed to deaths nearer the other end of life expectancy. Death before birth was too much. I couldn’t look.

Worse yet, I couldn’t extract the baby.

He was a home birth, like 99% of South Sudanese deliveries.

Good luck, or science and public policy, had spoiled me. I’d taken for granted the public health moon-landing which brought us from Nature’s criminal childbirth statistics to the expectation of perfection for every mother and child.

In South Sudan, childbirth is a one-in-ten risk of death to the child, and one in a hundred for Mom. I’d forgotten - and it’s just been a few generations since American settlers faced the same statistics.







The baby boy I was delivering had come, at home, arm-first. Tribe midwives, doulas, friends, and family all failed in bringing forth anything but the little arm. Three days later, when Mom arrived by emergency air shuttle, the arm was a grotesque eggplant, dislocated but still connected to his shoulder by skin. Dead skin. His mother’s vagina was dying too, by my guess - that was the urgency, in fact. I’d seen plenty of obstetric fistulas. (Stories for another day.)

I’d made a C-section incision and gone through the usual steps, plus a three-inch incision in Mom’s bladder on accident. Her urethra was crushed closed with her swollen child’s arm and she hadn’t voided her bladder in three days. I confused the massive bladder for uterus and made a nice cut that demanded repair before getting back to the business of delivering a dead baby boy.

When I finally had head in hand, I pulled, slipped off, pulled, slipped again, etc. In a humid hundred-degree inflatable operating theatre, I was sweating through my cloth cap and gown.

I hadn’t looked at the little corpse in minutes. Having a one-year-old girl of my own at home, this was unbearable.

Esther?

Yes?

Grab his arm with both hands and push it back up the birth canal. Try to squeeze some of the fluid out of the arm as you go.

Working together, my eyes still closed, we loosened him up. He came free all of a sudden. Trying not to appear stunned to my new medical colleagues, I looked at the ceiling and passed him immediately to Esther, the Kenyan midwife who knew these terrors too well. I opened my eyes again, and began the pleasant simple business of sewing, fixing, repairing, restoring. Concluding a case. Getting her off the table. Curing. Healing. Saving. Helping - a little, maybe. Who knows.



South Sudan - Mabior's Scholarship

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