24 hours in the life of an expat midwife in South Sudan

I wanted to chronicle a 24 hour period of time in my life and work here. I chose midnight starting on Thanksgiving Day. I am always on call but I don’t get too many calls at night usually because the staff can manage most things but they are required to call me for others. I have a radio that comes everywhere with me, including the shower. At night it is next to my head so I am sure not to sleep through maternity calling me.

At about 2:00am, I was called and the midwife said it was an emergency. I ran down and found a woman on the delivery table and blood all around. It was a placenta previa that had started to bleed. The baby was about 34 weeks gestation. We did all the preparation for a C-section, which included putting in 2 IV cannulas, a Foley catheter, sending a type and cross match to the lab along with a request for a hemoglobin level and of course, calling the surgical team. We also sent family members of the patient down to the lab to donate blood. We don’t have a large blood bank here and family of anyone needing blood always need to present at the lab to see if they qualify. The baby was born and sent to the NICU and the mother received a much needed transfusion – her hemoglobin was 4.3. At this writing, the mother is doing well will discharge tomorrow. The baby was very sick and lived for 4 days and then died.

I went back to bed around 3:30am. I received an emergency radio call around 5:00am and I ran back down to maternity. There was a mother that had just birthed and the baby was not breathing and a midwife was resuscitating him with no luck. So I started to do the Ambu bag and we stimulated him and eventually he came around slowly. The heart rate had been fine before birth and the pushing phase had not been long so we are not sure why he was so slow to start.

In the morning, a 17-year-old primip we had induced the day before was finally in active labor. She had been referred to us because of suspected pre-eclampsia and when we did an ultrasound we saw the baby had died. We induced because her blood pressure was high and she had swelling and protein and the baby needed to come out. The staff doesn’t like attending IUFD births, who would? I don’t mind because it is all part and parcel of being a midwife and you have to take the good with the bad. So once she was pushing, I took her into the birth room and helped her as she push out her stillborn baby. He hadn’t been dead much more that 24 hours. There was absolutely zero amniotic fluid, just some meconium, so I could be fairly certain the cause of death was due to cord compression from having no fluid. The birth went smoothly and the mother was back on the ward to recover.

Just prior to noon, I got a heads-up from another project that a patient was being flown in if I would accept her at our facility. It was a G4P3 term, with polyhydramnios and suspected hydrocephalus of the baby who had been in labor for 3 days. Of course I green lighted it. I headed to the airstrip, a 10 minute drive away, and waited while the plane arrived. The flight had made the patient have more contractions and the pilots were very nervous and glad to hand her over because they said they, “didn’t know what to do”. I told them that was okay, I couldn’t fly a plane!

We got the patient to the maternity and examined her, she was 8cm dilated. The ultrasound revealed a term fetus with a very large head and obvious accumulating fluid. The mother told me how tired she was and how she thought the baby was just not going to come out. I listened to her. I called the surgeon and it just happened that a patient who was due to get a foot amputated had just been bumped due to other health issues putting him at risk with anesthesia. They could take my patient to OT straightaway. I saw the relief of the mother as the surgeon explained what he would do.

I went with the patient into surgery to receive the baby. I wasn’t sure what condition he would be in although he was clearly strong because he had survived the long, obstructed labor. The surgery went smoothly and the surgeon worked hard to get that very large head out of the normal size incision. Once out, they clamped and cut the cord and handed him over to me. I took him to the table under the warming lights – he was a super heavy boy, the majority of the weight being the head. I stimulated him a bit and his heart rate came to normal and I gave him a few puffs with the Ambu bag and he started moving all of his limbs and was breathing on his own. I wrapped him in the surgical towel and then brought him across to the maternity. I weighed him, he was 4.2kg. His head was massive and there was molding off to the side, so it gave his head a more lopsided appearance. I wrapped him in the cloth his aunt had waiting. I did no further exam, no cord care, no vitamin K, no eye ointment, I just wrapped him up to keep him warm and handed him to his aunt. I had the staff explain to her that he should remain wrapped because he was so cold. He hadn’t cried this whole time and I doubted that he could. There was so much pressure on his brain from the fluid, I think much of it couldn’t function properly. Clearly his brain stem was fine because all things involuntary, like breathing, were working. I wasn’t sure how long he would live but it wouldn’t be days.

Not too much later, his mother came out of OT and was put in our recovery bed. I set her baby next to her. She looked at him and cuddled him. We had told her beforehand what she might expect. She understood. I instructed the whole staff that the baby should not be unwrapped. People here are very curious and there is literally NO privacy on the ward and other patients knew something was up with the baby, so I wanted him kept wrapped so he could just be a baby and not a zoo exhibit; he and his mother deserved that much. If he stopped breathing there was a DNR, we were doing only palliative care for him. He was in no pain or distress. I did not want staff rushing him over to the NICU if he stopped breathing, there was no point. They all understood.

That evening, we had pizza for dinner, and I thought of how everyone back home would be celebrating Thanksgiving Day and eating copious amounts of delicious food. I wasn’t missing it but I was missing my mother. I spent last Thanksgiving Day with her – the first one in decades. If the pandemic had a positive side, it was that I got to spend a lot of time with my mom, which included every holiday and her birthday and mine! It was an unexpected silver lining and those memories carry me through the hard times.

Later I would be called in when a 16-year-old primip came in in labor. They wanted me to do an ultrasound because they couldn’t find a heartbeat with the doppler. The ultrasound revealed the baby had died. Our second IUFD of the day, almost identical to the first one. She was well advanced in labor and I sat with her as she pushed her baby out, slack and still.

When I left the ward that evening, the little hydrocephalic baby was nestled in next to his mother where he would be for the rest of his life. Some time that night, he slipped away quietly. The next morning when I came in, he was no longer there and I knew.

As my 24 hours came to a close, I was roused near midnight from a deep sleep by the radio calling me into maternity. As I arrived, I followed a trail of blood from the waiting area into the ward and through the door to the birth room. One of the midwives was there with a women who had been assaulted by her husband. She had a laceration next to her cervix and that was where all the blood was coming from. The midwife had the bleeding under control and basically just wanted my support in doing the interview for SGBV (sexual and gender based violence), which is quite lengthy. Medically she was now stable and we put her inpatient so she could rest. I told the midwife we would wait and do the interview first thing in the morning when the SGVB midwife specialist was in. The fact that there is a midwife specifically dedicated to SGBV in this project, speaks volumes as to just how commonplace SGBV is here.

Aside from all the highlights here, there were the other things I do in the normal course of the day, like ward rounds with the midwives, making sure things run smoothly and we have what we need to keep the maternity going. There are 10 beds and all were full and we had to find an overflow place for patients and then decide who would go to that overflow. We are discharging patients a little sooner that we might normally because of lack of space. It is my job to help figure out all the little work-arounds so we can still have space for any new patients that may suddenly appear.

At some point that night I did make it back to bed as Thanksgiving Day came to a close. I was truly thankful for how blessed I am in my life, so much so that I am able to come to places like this and help others. It is truly meaningful and rewarding work for me and I feel fortunate to have all of the experiences I do because they help me grow.

That night, I slept until 6:00am and then got up and started a new day. I didn’t know what the day would have in store but I did know there would probably not be many dull moments.

***For more photos from the field, you can follow me on IG @globalmidwife64 ***