Slowly, slowly, the monkey comes out of the bush

As of today, we have a little more than a week left before we head back to Dakar and the airport to get on our way home. I really feel like Ive been here for months, and even though it also feels like its ending very soon, I am ready to come home. Glorified camping and rogue midwifery are exhausting and losing a little bit of their charm. Im also ready to get back to MY routines, MY space, MY things, hot showers when I want them and (bless it) familiar food. Im ready. So hello last week in Africa: bring it on.

I spent Friday night and all of Saturday in one of the clinics waiting on a second timer to have her baby. I was expecting it to be relatively straight forward, and it was anything but. We had first seen this mama on Friday morning while observing prenatals at the clinic. She was about 3 centimeters dilated, having basically no contractions, her cervix was maybe 60 percent effaced and felt a little sleevelike, like the babys head wasnt well applied. (Some baby-having 101: to have a baby, your cervix needs to thin out AND open up. When youre not in labor, a womans cervix is long, firm and closed. As her labor progresses, with the help of a well applied head to the cervix, it shortens and thins which is called effacement, and it opens up which is called dilation). I had a hard time locating the heart tones, which is often indicative of a "malpresentation" and she felt very full of baby --especially large for the women weve seen here. The clinics dont assign due dates here unless a woman has had an early ultrasound, because often the women dont know when they got pregnant or when their last period was, so without an ultrasound, they only date a pregnancy by how she measures at her prenatal visits. More baby-having 101: the midwifes rule of thumb is that, from the time when the pregnancy rises out of the pelvis, the pregnancy is going to grow about a centimeter a week on average, measured from the top of the pubic bone to the top of the uterus. At 20 weeks gestation, the pregnancy should be at the belly button, or about 20 centimeters on a measuring tape. At term, the top of the fundus should measure about 40 cm, for 40 weeks gestation (this is a big oversimplification) give or take a couple centimeters. Anything within 2-3 centimeters is considered within the range of normal, but if a woman is measuring consistenly ahead of or behind where youd expect her to be for her "dates" (based on her date of conception or last period), thats something to look at. So, here in Africa, it is probably usually fine for the clinics to "date" the women and pregnancies they see by how the woman is measuring because the majority of pregnancies are healthy and straightforward even without the HOLY and SANCTIFIED monitoring of a midwife or doctor, but its misleading and problematic. First, its hard because they dont see these women often. Maybe 2 or 3 times on average through the entire pregnancy, so its hard to monitor growth with such a small sample siz of measurements. And also because they can say "she is measuring 26 centimeters" and that *probably* means shes about 26 weeks pregnant, but what if shes only 20 weeks pregnant? Or what if shes really 31 weeks pregnant? So shes 26 centimeters against *WHAT*? Like I said, even without prenatal care, most pregnancies are going to go off without a hitch, but the ones that are having issues arent going to be caught without good dates. So...

Anyway, this mama felt big and her kid seemeed like he was in there kinda funny, so I made a note of it on the chart and thought to myself that she felt like maybe just had a lot of fluid or maybe it really was a pretty big kid in there. The mama was just resting and waiting for labor to kick in. I figured it was daytime and her baby was probably not in an ideal position so maybe shed take the day to rest, the baby would turn and labor would start boiling when things got quiet after dark --we are mammals after all. (I also sort of thought, just send her home! But thats not how it works here.)

After dinner, Tara and I went back to the clinic to spend the night and wait for her baby. Before we went to bed, she was still not contracting much and had only dilated to 4cm and while I was a little surprised so little was happening, I also accepted that maybe this was just how she does it. The next morning, having lost half my body weight in fluid loss to the mosquitos over night, we checked on her, saw no change and went home to breakfast and wait for a call. An hour later, the matrone called us back. We fairly raced back the clinic but hadnt missed anything. The mama was now 7 centimeters dilated, with a slightly bulging bag and a more regular labor pattern. Sweet! So about an hour later, she was mostly complete with a bit of a cervical lip to the right and behind the babys head, but the head was definitely lower. Not long after, she got a little pushy and so she did that for a while. And then she rested. And then she pushed and then she rested. The lip seemed stretchy and like the babys head could come right past it, but I couldnt seem to work with the mama to get her to push the head past the lip. For 6 hours, she pushed and slept on and off. This is A VERY LONG TIME. I would not have stayed at home with this situation. But this is Africa. The baby sounded GREAT the whole time, and I figured the mom was exhausted from having been in the clinic for so long. She walked, she lay on her side, she pushed, she slept. We gave her an IV of dextrose to give her some energy and make sure she was hydrated. Nothing helped. The kid didnt budge. Around 2pm, after shed been donig this for almost 4 hours, I did a more vigorous exam to try to see if I could find anything to explain what was happening. Palpation was really hard on this woman for some reason, so I couldnt get great information on the babys position that way, though the location of heart tones gave me some good info and I knew the baby was head down. However, this time, the bag was a little more forgiving and I could clearly feel the babys sutures (newborns skull bones are not yet fused in order to accomodate the molding that needs to happen to navigate the bones of the pelvis. The spaces between the skull bones are called sutures and can be felt with our fingers and give a lot of valuable information regarding the babys position) and sure enought I could feel the kid was coming into the pelvis super cock-eyed! Dammnit! I told this to the matrone who felt it too and then made the mama drink "Gris Gris" which the matrone mimed to me would help the baby turn.

In the meantime, a woman arrived at the clinic at 8 centimeters, particulate meconium in the bag of waters when it was ruptured (indicating possible fetal distress), and a prolapsed urethra (weve been seeing a LOT of this and are having a hard time explaining it). When she finally gave birth, she dumped a bunch of blood and I ran around helping Tara stop the hemorrhage. We actually ran out of supplies due to these two births. It was crazy and exhausting.

So after all that chaos, two hours had passed with my monitoring my mamas fetal heart tones and her vital signs between gushes of blood on the other side of the curtain, but leaving her mostly alone to rest and hope the Gris Gris worked. However, with everything settled, nothing had changed and the poor mama was wiped out. I agreed when the matrones suggested the mama needed to be transported and 30 minutes later, through a sea of gathered family and much shouting (I can never decide if theyre just excited or talking passionately about something or if theyre actually ANGRY), off she went to the hospital. I havent heard anything for sure but...here goes:

The rumor going around is that she got to the hospital and gave birth to TWINS. I very possibly, in fact probably, missed TWINS. Ive been beating myself up over it, but I really am not sure how I was supposed to know, even though now in retrospect there are a few things that could have tipped me off, if Id been looking for it. Argh. Another learning experience and Im very curious to know if the rumor has any foundation. Ill update you as I know more.


In the meantime, a new week has begun which means a new partnership with another group member and we are on call tonight. Pregnant, in other words, for more stories waiting to be born. Stay tuned.

xoxox L