April 30, 2012

MSF OB-GYN Veronica Ades tells the story of successfully delivering a baby for a patient who had already lost her first two.

South Sudan 2012 © Lisa Jones

MSF OB-GYN Veronica Ades examines a patient.

 

Dr. Veronica Ades

 

Veronica Ades is an obstetrician-gynecologist on her first Doctors Without Borders/Médecins Sans Frontières (MSF) mission in Aweil, South Sudan.

Veronica is originally from New York City. She graduated from Wellesley College, and received her medical degree from the State University of New York at Downstate in Brooklyn, New York. She did her residency training in obstetrics and gynecology at the Albert Einstein College of Medicine in the Bronx, New York.

She is currently a fellow in reproductive infectious disease at the University of California, San Francisco. Veronica previously worked for one year at a rural district hospital in Uganda while doing research on malaria in pregnancy. Read her MSF Field Blog, "Love, Labor, Loss" here.

The woman came to us with no living children. She had been pregnant twice before, but both pregnancies resulted in stillbirths. In the first pregnancy, she had labored for days, and the baby died during labor, but delivered vaginally. In the second pregnancy, she had pushed and pushed, but the baby did not deliver. A C-section was done, but the baby died anyway.

I cannot imagine what that must feel like. In the United States, a stillbirth at term is a huge event. Privacy is paramount. A subtle sign is placed on the patient’s door so that the staff knows not to enter unnecessarily. A sympathetic nurse is chosen, one who will comfort the patient. Aggressive pain control is offered, because pain can only make grief worse. And the woman carries that loss with her for the rest of her life.

In South Sudan, it is unusual for a woman not to have lost at least one child. They die in childbirth, or they die later of malnutrition, malaria, infection, unexplained illness. I have seen women who have delivered seven children, only to have three of them die; or delivered four children but having only one living child. When a woman comes to us, the first question asked is “How many children have you had?” The second question is, “How many are alive?”

It may be a part of life here, but it would be hard to argue that these women suffer less. I truly cannot speak for them, nor know what they feel, whether they have different expectations or a more effective way of processing grief than we do. But in my opinion, grief is grief, and whether you acknowledge it or bury it, it is there and always will be. It is only how you process it that differs.

I have noticed that there is a lot of psychosomatic illness here. One would expect that, given how tough these women are, you wouldn’t have a lot of non-urgent medical problems; that people would only come in to the hospital for really serious things. But in only two weeks here, I have seen four or five cases of “hysteria,” in which women completely collapse and are unresponsive even to severe pain (rubbing the sternum, pinching, etc.), and when they awake, there is always a convoluted backstory involving family drama, traumatic experiences, and sadness.

Other women have “total body dolor” (a term I learned in the Bronx)—generalized body pain with no apparent source and no real description. Often, they will fully admit that they are having major emotional upheavals for one reason or another, and they will agree that the pain is probably related to the emotions. This is an astounding degree of self-awareness that I wouldn’t have expected. Often I give them Tylenol or ibuprofen and, depending on the severity of emotions, a mild sedative, and let them rest in the hospital for a day or so for TLC (tender loving care). Everybody needs a damn break sometimes.

So I think that the deaths of their infants do affect these women in one way or another. They are extremely stoic. I have never seen a woman who lost her baby (and I have already seen many) react with tears, or even a facial expression indicating sadness. It is really mind-blowing, because I would probably be inconsolable, and loudly emotional. But there is an incredible cultural factor at work here, I guess, and emotions don’t seem to be expressed on the face.

We examine the woman with two previous losses, and decide that her pelvis is terrible and no baby will fit through it alive. She should have a C-section. Although it means that she will be having her second C-section and will now require C-sections for any future deliveries, it also means she might finally have a living child.

Intraoperatively, I am glad I decided to do the C-section. Her pelvis is tiny, like many of the women here, and I have a hard time even getting my hand in there to lift out the baby’s head. The baby cries right away; it is a girl. I clamp the cord twice, and hand it over to the waiting nurse. The baby is cleaned off, examined, and wrapped in a towel. Katie, the Australian midwife, brings the baby to the mother’s face so that she can see her while we are finishing the C-section. The mother makes no expression, but tears roll down her face when she sees her healthy baby.

As the surgery ends and we take down the drapes, I try my few Dinka words on the woman.

Yin a pwal?” I ask. ("Are you OK?")

She nods once. No expression.

Meth a pwal?” ("Is the baby OK?")

She nods once. No expression.

I ask the nurse to ask her if she is happy.

Yin a mat po?” he translates.

She answers.

“She is happy,” says the translator. She still has no expression.

I take her at her word. It is sometimes a challenge for me to have so little emotional response from patients. I realize that I am accustomed to my own culture, and even Ugandan culture, which I have more experience with—both have a lot of reflexive smiling. When you make eye contact with a person, the first instinct is to smile.

I find it harder to connect here, where people make eye contact, but not a single muscle in their face twitches, and they feel no obligation to acknowledge the connection. I try to wrap my mind around it. What does it mean? How does it evolve? The South Sudanese staff that I work with have been very warm and friendly, with smiles and handshakes. Sometimes strangers respond to eye contact with smiles, but infrequently. Smiling is clearly not a cultural expectation. But most surprising of all is a patient you have just operated on, to whom you have given a very happy, very desired outcome. They have no obligation to smile, but it is hard for me to understand how anyone could suppress a smile at a time like that. I have come to learn not to expect it, and not to worry about it, but it is fascinating.