Loss

For all the drama that transpires within the walls of the labor ward there is also lightness. Mornings are always good. I love walking in to the smiles and greetings of the midwives. They welcome me with incredible warmth everyday and everyday renew my desire to be present. I feel I belong when I hear my name, as they pronounce, it nestled in the midst of Chichewa spoken with kindness - even though the context is often lost on me. The labor ward is a world to itself, so many stories, blessings, and tragedies. Birth is never routine.

The day started with the ward half full, I attended two births both uncomplicated and fast. The beds filled, each one holding a laboring woman, rows of pregnant bellies and colorful chitengies stretched on green and black mattresses. I was about to place an IV when one of the midwives who was attending a delivery herself called my attention to a woman laboring on her plastic sheet on the floor. The woman lay on her back under an enormous belly and her bag of waters bulged expectantly between her legs. Quickly I changed gloves and reached her in time to welcome a little girl (her fifth girl) into the world. I dried her, clamped and cut her cord, wrapped her, and placed her next to her mother whose belly had hardly diminished in size. At that point the mother said that she had been told that she might have twins but that the suspicion was never confirmed. So, I reached up gently and felt a foot, at that moment confirming her twin gestation. We slowly moved her to the nearest bed, temporarily displacing the woman lying there, and with the coaching of another midwife I attended the breech delivery. Amazing. Each labor and birth is unique, every birth is raw, often it is beautiful and it is always astonishing. I watched feet and legs descend, followed by belly, shoulders, arms, and head, then I placed the screaming boy (her third boy) on his mother’s belly. Within minutes the mother was off to the shower and soon stood smiling at the door holding arms open to embrace the weight and life that only minutes before she had carried within. I was flying, the first twin delivery and first breech delivery for me all in one, made even more miraculous by the fact that the cord of the first twin had a true knot in it. Very rarely a baby’s swimming movements will tie a knot in its umbilical cord, usually resulting in the death of the baby. But this little girl met the world with open lungs and eyes, very much awake and alive in spite of the ominous knot that followed inches behind.

A few hours later another birth brought me to the opposite end of the emotional spectrum. A nineteen year-old, with her first pregnancy and a very small belly, lay in the bed closest to the nurses’ station. At the time I approached her, she had been laboring for many hours and pushing much longer than usual. At that moment all the other midwives were occupied. I walked up to her, touched her belly, and listened to the fetal heart. My own heart raced as I heard a slow steady beat around 70 (a fetus’ heart beat should be between 110 and 160 beats a minute). The baby’s head was low but not descending further even though the veins on the mother’s neck protruded as she pushed and strained with each contraction. Another nurse called the clinical officer on duty, and with his coaching I extracted the baby by vacuum (the vacuum is a small suction cap that is placed on the baby’s head, the clinician gentle pulls as the mother pushes to expedite the birth). A baby girl was born limp in a wash of meconium but after a little suctioning and stimulation she perked up. A few minutes later I cut the cord and placed her in the warmer besides her mother’s bed while I set out to suture the small tear in the mom’s perineum. When I finished, about thirty minutes later (I’m still slow with suturing), I noticed that the baby was gasping occasionally but still breathing and pink. I showed her to the mother and took her to the nursery. In the time it took me to walk down the hall, the baby became quite pale and the heart rate dropped significantly. I started resuscitation with a bag and mask, oxygen, and chest compressions but the heart rate hovered around 60 and the gasping breaths continued. I asked someone to call the clinical officer and together we continued the same simple resuscitation measures for another 45 minutes. By then the baby was a dusky gray, limp, and the heart rate faint at 40 beats a minute. There was no one else. There was no medication to give. No ventilation machine. No pediatrician to call.

Without any improvement the clinical officer took over while I went to get the mother. I brought her to see her dying child. She went to get her mother and then we stopped the resuscitation, took off the oxygen and handed the gasping child to her mother. The young mother looked more shocked than sad holding her daughter loosely in her arms, shifting her gaze from her baby to her own mother. This first born girl who was pink and wiggling an hour before now lay pale and gasping on her mother’s lap. This is not how it was suppose to be. The clinical officer left. I asked the nursery nurse to ask the mother and grandmother if they had any questions. The mother said she had none. The grandmother, looking sad and angry, said she had none, she said saw us try to help the baby, and she said that perhaps this child was not meant to survive.

I know that no matter what they said or what expressions they wore, the death of this baby girl will beget incredible grief. I know that the loss will exist always, stitched painfully and permanently into their hearts. And, I know that the attempts to rationalize the death are really just attempts to put a more acceptable mask over the face of blatant injustice.

I tearfully said “Pepani” (I’m sorry) and then managed to hold in the sobs only until I reached the vehicle waiting for me outside. If only I had not left the baby alone for that period of time. If only I had started the resuscitation sooner. If only there was someone else present. Maybe the child still had a good chance to live. Maybe I should have continued the resuscitation. I don’t know. I do know that what I did was not enough. I know that baby’s chances had she been born in the US would have been much better. This child might have had a chance for a full life but she died leaving only unfulfilled hopes and grief behind.

Dr Kaponda was home when I arrived; she offered comfort and empathy, telling me the story of the first baby that had died under her watch during her years as a clinician. I will return to the labor ward willingly on Monday. I want to go back. I want to be here, but it breaks my heart to think that I contributed to the death of this child. The vision of grandmother, mother, and daughter will live forever in my mind’s eye.