November 12, 2021
Volume 2, Issue 3
The woman’s water breaks just moments after she steps into the clinic, pale pink serosanguinous fluid splattering onto the swept cement floor. I freeze, the blood pressure cuff I’d been sent to fetch clutched in my hands. The women crowding the short hallway make way as Esther, the midwife, barrels out of her office, pulling her thick black hair up into a headscarf. Paying no attention to me, she cajoles the woman towards the delivery room, speaking softly in Luganda.
My hands shake from adrenaline as I stuff my fingers back into used gloves, the pulled in fingers sticking on my sweaty hands. I’m only a first-year medical student, the extent of my knowledge of obstetrics garnered from growing up on a farm, rather than the dry classroom lectures on biochemistry and histology. I’ve always wanted to delivery a baby. Perhaps today will be my chance.
Taking a deep breath to calm my nerves, I follow them to the delivery room. The room is small and sparsely furnished–a sloped table covered by a plastic sheet and a set of cabinets stuffed with equipment and overlaid with a piece of plywood to form a makeshift table. Though a curtain flutters at the single high, barred window, the air in the room is stale and still.
“This is Fatima. She’s about 32 weeks along,” Esther says in English, shoving the woman’s bundle into my arms as she helps the patient onto the delivery table. “G6, P4, hasn’t had any prenatal care up to this point.”
I set the bundle on top of the cabinet, unable to take my eyes from the woman on the table. Her curly black hair is cut short, her eyes glassy, her thin chest rising and falling in quick, ragged breaths. It’s difficult to believe that this slender young woman has been pregnant six times and has four living children. She looks younger than me.
“Go ahead.” Esther’s voice is firm. “Examine her.”
I hesitate, then reach out to touch the woman’s effluvia-soaked skirt.
“OK?” I ask, miming lifting the skirt. The woman nods once, pressing her full lips together. She looks nothing like the women giving birth on TV, who grunt and scream and sweat and strain. Even with the hot Uganda sunlight streaming in through the window, this nameless woman is barely even sweating.
I push the skirt up over the woman’s thighs. Her pubic hair is matted with dark, clotted blood. I hesitate, ask permission once again, then probe inside the woman with two fingers. My fingertips brush against something hard and round.
“10 cm dilated,” I say, with more confidence than I feel, “and the crown is–”
There’s a ripple across the woman’s abdomen, and the baby’s skull becomes a relentless pressure against my fingertips. I withdraw quickly and the infant follows, sliding out to land in the puddle of amniotic fluid covering the plastic sheet. It squirms in my grasp, the slight body covered in membrane and fluids and a pale white fuzz. I don’t have the chance to marvel at the miracle of my first successful delivery, or to wonder at how quickly everything is happening. Esther places the scissors in my hands, shows me how to clamp and cut the cord. The she whisks the baby up in a towel and sets him–for it is a him–on top of the cabinet beside the woman’s bundle.
Fatima lies back in the bed, never turning towards her newborn child, never saying a word. I realize with a start that the woman is not the only one who has been silent.
“Is he OK,” I ask, hurrying to Esther’s side.
In answer, she removes the towel swaddling him. My breath catches in my throat. The head, which felt so huge in my hands just moments before, is miniscule compared to his body. But his microcephaly is not the only anomaly. One of his hands has no fingers, and there’s a large ventral hernia with visible viscera inside.
“What’s his APGAR score,” Esther asks, her voice quiet but determined.
I go through the mnemonic in my head, noting the feeble movements of his limbs, the bluish tinge to his extremities, the gasping, irregular jerks of his respirations.
I try to tell myself that it is not so bad. Ten is a perfect score, but anything above seven is considered adequate. Most infants will improve their score after five minutes.
Esther produces a long, thin wooden instrument from her miraculously still-white apron. It’s a pinard horn, which she’s been teaching me to use to listen for maternal and fetal heart sounds, rather than the stethoscope that hangs from my neck. She takes the trumpet and places the wide end on the infant’s heart, then presses her ear to the other end. The infant’s heartbeat is loud and fast, with an even louder whooshing sound between the first and second heart tones. Pressing one finger against his chest, I can feel his sternum vibrating with the force of it.
“Normal rate and rhythm,” I say, “but there’s a loud systolic murmur with thrill. I’d guess a ventriculoseptal defect?”
Esther nods. She doesn’t look surprised, but the corners of her lips pull inexorably downward. The infant still isn’t crying, though his features are all scrunched up, his blue-tinged lips pursed in a soundless wail. I blink back the tears burning in my eyes.
“Is he going to be OK?”
Behind me, the mother stirs on the delivery table, one hand clutching her stomach.
“Go ahead and deliver the afterbirth,” Esther says. Her voice is calm and reassuring. “I’ll work on the child.”
I turn back to the woman on the table, who still stares vacantly up at the corrugated roof, grimacing while my bloody gloves leave smears along the woman’s thighs. As I pry her legs apart, I can see the reddish-purple bulge of the placenta. Hesitantly, I place a bloody hand on her abdomen and press down on the hard knot of her uterus, massaging it. The woman doesn’t scream, though the muscles of her masseters bulge as her teeth grind together. Minutes–or perhaps just moments–later, the placenta spills out. Esther gathers it into a bucket then points to ragged tear in the flesh just below the opening of the vagina.
“Perineal tear,” she says, handing me a slim, curved suture needle, “only second degree, but you should sew it up.”
“Don’t I need anesthetic?” I ask, but Esther has already moved back to the swaddled infant.
Time slows as I fumble with the bloody, ragged edges of Fatima’s perineum. With every stitch, I expect her to scream in pain, but she just trembles, her fingers tightening on the sides of the bed. I place just three stitches, but each one seems to take a lifetime.
By the time I’m done, Esther and the infant are gone. I pull off my gloves–too bloody now to be reused–and hand Fatima a handful of extra-absorbent pads, which she shoves into the underwear neatly folded on top of the bundle. Then, still silent, she stands and pulls on the underwear. Her blood-stained skirt falls to the floor and she starts towards the door.
“Wait,” I grab her arm, pulling her back toward the table. “Esther will bring your son back in a minute. You rest.”
I point towards Esther’s office, where she retreated with the infant earlier, then make a rocking motion with my arms, wishing I knew enough Luganda to communicate. The woman just looks confused, then points to the bundle I’d set on the counter earlier. Glad for something to do, I hurry over and hand the neat white sheets to her. The woman nods then starts for the door again.
“Wait,” I repeat, but a hand touches her shoulder.
“Let her go,” Esther says, “she’s just going to the recovery room.”
I let Esther pull me away, frowning as I watch the woman’s mincing walk. She gave birth less than twenty minutes ago, just had her perineum repaired without anesthesia. How is she even walking?
“But she just…” I trail off, noticing Esther’s empty hands. “Is that where you brought her son? Is that why she can’t wait?”
Esther’s face is grave.
“Fatima knows that someone else may need the birthing room soon.”
My frown deepens to a scowl. I want to argue that Fatima needs that room, that she needs to rest and hold her baby. But at the thought of the baby, my throat goes dry.
“Where is he?”
Esther doesn’t reply, just takes my hand and leads me to her office. The baby is swaddled and placed amongst packed towels on her desk. His face is almost completely blue, the movements of his tiny fists jerky and irregular.
“APGAR?” she asks quietly.
“Two,” I reply in a hoarse whisper.
My hands shake as I take the trumpet and listen to his heart. The heart rate is slower now, the whooshing murmur so quiet I have to strain to hear it. As I listen, the heartbeat slows, fading away into nothingness.
I drop the trumpet to the ground and grab my stethoscope, listening at different points on his chest, trying frantically to hear lung sounds, heart sounds, anything. But the little body is still. Silent.
“We have to do CPR.”
I wrap my hands around his chest, pressing my thumbs against his sternum in a steady rhythm. I can see his intestines bulging into the thin membrane of his hernia with every compression. Esther pulls my hands away.
“There is nothing we can do.”
“No.” I grab for the body. “We have to–”
Esther lifts the infant from my grasp, cradling the unmoving blue body in her arms.
“The nearest hospital is an hour away,” she says softly. “Even if we could get him to a surgeon in time, even if Fatima could pay, it would not be enough.”
“He is gone.”
I stare down at my hands, unable to look at the bundle in Esther’s arms. “I don’t–I don’t understand.”
“You’re American. I wouldn’t expect you to.”
Though her tone is gentle, her words are as sharp as any scalpel. I bite my lip hard to prevent my retort. I’ve been in Ndejje for almost a month now. I’ve seen the cramped hovels where refugee families crowd together, read the statistics on HIV transmission, marital rape, and child mortality. I’m not like most Americans.
“What do you mean?” I ask, trying to keep the hurt from my voice.
Esther pulls the cloth over the unnamed boy’s face, sets him gently back down on the desk. “It is not yours to grieve.”
I want to argue, to scream and yell. I just watched a life slip away, literally listened to a child’s final breath. But then I remember the glazed look in Fatima’s eyes, the exhaustion and determination. The unwillingness to rest because someone else might need her spot.
Esther’s eyes soften. “Go home. We’ll resume your training tomorrow.”
Not trusting her voice, I nod and start for the door. Just as I’m about to step out into the hot Uganda sun, I glance back into the recovery room. Fatima is there, neatly tucking the last corner of her sheet onto the small twin bed she’s made up for herself. She crosses herself, mouths a prayer, then sinks onto the bed, her dark eyes glassy as she stares unblinking up at the ceiling.
After struggling with bipolar disorder, Natalie Dale, MD, took a leap of faith and left her neurology residency to focus on her life-long passion: writing. Since then, her short stories and essays have been published in Flash Fiction Magazine, Wyldblood, the READ White & Blue Anthology, Breath & Shadow, and the National Alliance on Mental Illness (NAMI) blog, among others. The first volume, Setting & Character, of her “Writer’s Guide to Medicine” series will be published on December 4th, 2021, by Ranunculus Press. In her spare time, Natalie organizes an elementary school reading program, runs a writing critique group, and plays violin in a community orchestra.