The tenacity of love: 23-week breech birth
By Kristine Lauria, CPM, of Médecins Sans Frontières. Kristine is currently working in a refugee camp in South Sudan, serving a population of around 100,000 people. Her clinic takes in all of the complex and/or complicated maternity cases: preterm, breech, multiples, high-risk pregnancies, etc. There is one general surgeon on call to do cesarean sections, otherwise Kristine and the other staff manage all of the births.
I woke up just before 5am the last day of November and went to make myself some coffee and watch the sun come up over the refugee camp here in South Sudan. As luck would have it, I had just finished making my coffee when my radio went off. The midwife on night duty said he needed me. So my coffee and I went down to see what was up.
Most of my stories start with, "I walked into the birth room and there was a patient on the table..." This story is no different. I greeted the midwife and he proceeded to tell me that this 18 year old was about 23 weeks pregnant, she had malaria and a UTI but also had been bleeding and I could see a lot of clots that had already come out. I asked if her cervix was open and the midwife said it was not.
This patient had been pregnant once before but it had ended in miscarriage at about 2 months. After doing an ultrasound and determining there was healthy baby but a low-lying placenta, I figured the bleeding must be from the placenta. I observed that the patient was having contractions. I told the midwife I thought she was clearly in labor, he didn't think so. Not too much later I decided to check her cervix because she was having increasingly more contractions and making more noise. Preterm labor is usually not long and at 23 weeks, the cervix doesn't even need to completely dilate.
When I checked her, she was 6cm with the amniotic sac intact. I listened and heard the baby's heartbeat, strong and steady. She was not in preterm labor due to anything being wrong with the baby. This was disheartening because it is always easier when there has been a demise rather than another cause for the pregnancy loss -- in this case, malaria and UTI. I had seen a few 22 and 23 week babies in Afghanistan come out still alive and proceed to live for an hour or so. It is such a helpless feeling to not be able to do anything for them. I dreaded having to see this again.
We have mid-term losses all the time here and usually the baby has died and that is what precipitates labor. In these cases, the baby is not taken to the morgue like a term stillbirth would be, but rather placed in the bucket with the placenta and disposed of with other biohazard. That is always hard for me but that is how it is done.
Morning shift change happened and a new set of staff came in. I was still with the patient in the birth room. I wanted to stay with her because of the bleeding and needed to be there in case of a hemorrhage. I knew the labor would not take long. I checked to see if she had any cervical change and felt a bulging water bag and broke it so we could just have this baby. The mother was ready to be done. Right after, a little, tiny red foot presented and then another and then the little body slipped down and out into my hands. What was interesting was that as small as she was, she could have come out any way quite easily. But the baby still maneuvered the pelvis the exact same way one would see with a term breech baby. This tiny little thing began to cry, a fairly loud cry considering her size. Her eyes were still fused but she had a voice. I gave her to her mother who was very happy to receive her. We had explained to her in advance that her baby could not survive at this gestation, so she knew this and understood
She lie on the birth table after the placenta was out. I told the staff she could stay there as long as she wanted with her baby until she was gone. I asked the staff to explained to the mother that we didn't know how long the baby would survive. I stayed in maternity another 30 minutes before going back to shower and get ready for the day. The baby was still alive.
By the time I got back to the unit, almost an hour later, the mother was out of the birth room and in a bed. And there, nestled in her arms, was her tiny little girl, still alive, still moving around, still determined to get the most out of her time with us.
Hours went by, the baby lived on. At one point when I went to check on her, her mother was feeding her colostrum. Her nipple was far too large for the tiny mouth but the baby's mouth was open and the mother was expressing drops of colostrum into her mouth. It was so touching to watch this young mother nurture this tiny little thing. I marveled at her and talked to her just as I did the other newborns in the ward. It made her mother smile.
I made sure to instruct the staff to watch for signs of the baby's passing. The mother could go home when she wanted after the baby had died, she was already discharged. Then I told them, "Under no circumstances is this baby to go into the placenta bucket!" They heartily agreed with me. I told them, "This baby is alive and this mother has cared for her and she will go to the morgue when it is time." And I told them if they had an issue with it, they could radio me and I would come down and prepare the baby and take her to the morgue myself.
Late in the afternoon when I went to check in on the unit, the baby was still alive but now she was taking breaths far less frequently. It wouldn't be long. I left to have dinner. When I came in later that evening to check in with the night shift, the bed was empty and I knew that little soul had finally left us.
I walked into the birth room and on the neonatal table lie a small pile of flowered cloth. In the cloth I knew was the baby. I kept her in the cloth because the family had left her with us like that so I figured they wanted her that way. I took out the white paper we use for sterilization of instruments and wrapped her up and taped it down and wrote the date and mothers name on the outside. I took the tiny bundle -- barely 2 pounds -- and walked to the morgue.
On my way back to maternity, I thought of the tenacity of this tiny soul, how much she wanted to be here, how, against all odds, with no oxygen supplementation, no medical care of any kind, in the middle of a refugee camp in South Sudan, she survived for almost 10 hours purely on her mother's love.