Eid Mubarrak

Patuma sat on the bench outside labor ward Thursday afternoon along with other women waiting for ultrasound scans. As I motioned her inside the scanning room I noted that the midwife had written “multiple gestation??” on the line for her most recent prenatal visit. Like most other pregnant Malawian women, Patuma was thin and sinewy but as she lifted her dress the size of her belly was so impressive, and her skin over it so taught, that it seemed almost as though a balloon had appendaged itself to her front. When I asked, Patuma said she was only eight months pregnant and that this was her fifth pregnancy. She had 5 living children, two from the previous pregnancy.

Unable to palpate much, I rolled the transducer over the gel on her belly and peered through the window it provided - definitely multiple gestation. I moved slowly in irregular circles making sure not to count the same head twice. Hesitant to tell the mother until my finding was confirmed – I called in the medical intern. He agreed - triplets. I told Patuma she had three babies; she remained quiet and looked mildly shocked. I measured each head, abdomen, and femur to approximate the estimated gestational age and size. This process took me a while as I tried to sort out the kicking rolling bodies and ensure that this leg belonged to this head. I moved back and forth over her belly and Patuma sighed under its weight. According to my scan the babies seemed to be about 32 weeks and all weighed less than two kilograms. Patuma could not remember the specific date of her last period (which would enable a more accurate calculation of the gestation) but from my experience with the women at Bottom, as they approach term, their babies’ measurements fall away from the standard indices, so it was possible that Patuma was already 35 weeks (37 weeks is considered term).

Friday morning only a few women lay on beds in the labor ward when I arrived. On the high risk side of the ward Patuma sat quietly on one bed and across from her lay another woman crying with pain. Patuma was now draining amniotic fluid and apparently in early labor though no one had thought to give her Dexamethasone (a steroid injection shown to accelerate fetal lung maturity, given when women go into preterm labor). The other woman had arrived ten days previously complaining that her current and fifth pregnancy, was overdue (pregnancies passing 42 weeks gestation carry a much higher risk of stillbirth). Although not noted, the midwife added that she had been draining amniotic fluid since admission. Glancing over her chart I saw that she had had several vaginal exams and that no one had started antibiotics. An induction had been ordered Wednesday and the first dose of medicine had been inserted, however no one had documented hearing the baby’s heart since early Wednesday. I considered these two women and felt a wave of anger and despair wash over me. I placed my fetoscope on her belly. Silence. I moved it. Silence. I brought the ultrasound machine in and found the heart, no movement. I called the medical intern. He watched the still heart. He contemplated the reason the baby died and told the mother. I wanted to walk out, go home, and crawl under the covers. Instead, Lonnie, the nursing student with Patuma asked me to come help her make an assessment.

Patuma, though quiet and not appearing to have strong contractions, complained that she needed to push. I told her to go ahead and as she lifted her chitengi I saw a head with dark wet curls emerging. Lonnie rushed to grab a delivery pack and returned in time to catch the first baby boy at 9:20. I brought the ultrasound machine to her bedside and checked the other babies. I found two heads down and a third head in the fundus! Three little hearts beat reassuringly. Patuma said she felt some relief, although still uncomfortable; she could breathe a bit better and looked forward to eating. I examined her and felt the next head almost out of reach. Her contractions spaced out. I began stimulating her nipples (this releases oxytocin, the hormone that causes uterine contractions) and scanned the three heartbeats every few minutes. She worked and waited and now and then would loose confidence. She said, “I have already gone through so much and after this next one there will still be another, I can’t do this.” I told the student but did not tell her she still had three babies inside.

After about 40 minutes of anxious watching, assessing, encouraging, stimulating nipples, and silent praying, I felt the next head settle into her pelvis and we ruptured the membranes. At 10:30 the second little boy arrived. Again we dried her bed, I scanned and examined her. She laughed lightly and told Lonnie we would each have to take a baby home because she had only wanted one. When we asked about her husband’s reaction she said he hadn’t said much but she was not worried because he is usually able to provide for the children. At 11:25 I caught the third boy. As I gave the little one some oxygen, the student examined Patuma and said she could not feel the next baby. I repeated the exam and felt a hand and a foot floating high inside. I called Chikoti, one of the experienced clinical officers, and asked him to put on gloves. He instructed me to rupture the membranes, reach inside, and grab the feet. After explaining the situation to Patuma, I reached in, broke the bag and found a single foot, which I pulled down to where it was visible. Chikoti then helped bring it the rest of the way and as a small crowd of students encouraged Patuma, I assisted her little girl out. 11:55am. At the resuscitare I gave the girl some oxygen, examined her, weighed her and placed her among her brothers. They weighed 1.8kg, 1.6kg, 1.4kg, and 1.5kgs.

The nursing matron helped make the bed and dress Patuma, and then called the newspaper. Shortly thereafter a female journalist arrived at her bedside. I stood directly across with the other woman who still labored with her dead baby. No curtain hung in-between. Patuma and the journalist chatted and laughed softly. The other woman cried, “I’m sorry. I’m sorry. Please take me for a c-section,” moving from her back to her knees, pushing, straining, crying, pleading. I felt the head low in her vagina; her cervix was completely dilated. Her contractions were weak and infrequent but no one wanted to give her pitocin for fear of rupturing her uterus. I stimulated her nipples. We brought over the vacuum to assist, but the pressure gauge would not work and we could not maintain enough suction. At 4:15pm I called Chikoti he said he would come. A screen was located and placed between Patuma and the other woman. I walked to the nursery to see the quadruplets and to restore some joy, then exhausted I left.
This morning I stopped by Bottom to see the babies; they looked pink and peaceful in their single cart. Patuma was all smiles.