Photos and Story by Khaula Jamil for MSF Pakistan
Somewhere in a remote village of Bajaur district (a former Federally Administered Tribal Area in Pakistan that borders Afghanistan) 27-year-old, Asiya, is waiting to give birth in her home on a cold December night.
She has a cup of hot tea and starts feeling the contractions. Since this is her sixth pregnancy, she is gripped with anxiety. With only one child alive, she lost all others to early neonatal deaths and still births. She hopes this one will make it so that he six-year-old son will finally have a sibling.
Something goes horribly wrong when the baby starts to come out but instead of the head or the feet, out comes a small hand! Panicked and frightened, her husband (a religious leader at a local mosque) rushed Asiya to the nearest medical center which was a two hour drive away.
When they reached the clinic, the doctor recognized that the baby was in a transverse position with a prolapsed hand and that this was beyond the clinic’s capabilities to handle. The couple was referred to MSF’s mother and child health unit in Timergara.
Asiya recalls the six hour painful journey to Timergara with her baby’s arm sticking out of her;
“I was 100 percent convinced my baby is dead that I am going to die also! I left everything up to God because I knew it was out of my control! I was so afraid that they were going to cut me up!”
Dr. Shumaila, the gynecologist who was on duty that night, said that she took a quick but calculated decision when Asiya arrived at the MCH at 7:00 am; “When I saw the patient, I did a quick assessment of the situation. The nurses had already started preparing for a C-section but I felt confident that I could deliver the baby normally. I took the patient’s consent and went in for an internal podalic version; a procedure in which I put my hand inside the vagina, grab the legs – rotate and then pull the baby out in a breech position. Thank God it went smoothly. The baby cried loudly so all was well!”
Since she joined MSF in Timergara, this is the third time Dr. Shumaila has delivered a baby in a transverse position with a prolapsed limb.
“This kind of situation usually arises when the women have not gone for proper pre-natal checkups to a hospital. Usually they go to a ‘dai’ (untrained midwife) at the time of delivery and when the ‘dai’ tries to induce a baby who is in a transverse position, the limb comes out first. Luckily, Asiya’s husband did not overthink and came to us directly or else we could have lost the baby.”
According to Dr. Shumaila, if they had waited for a c-section, by the time Asiya would be given anesthesia, the chances are the baby would have lost her heartbeat.
“Asiya was very cooperative. I could tell she had all but given up on the chances of her baby surviving so when I told her the baby was okay and that she needed to trust me I could see her get hopeful again.”
A few hours after delivering a healthy baby girl, Asiya could not be happier.
“I was certain I was going to die but the doctor was amazing and she delivered my baby normally! I can’t believe I didn’t need to have an operation. I’m the happiest woman in the world right now!”
After difficult births, all new born babies are sent to the DHQ Hospital’s New Born Unit for a full assessment by the pediatric doctors and specialists. Dr. Waqar Alam, the District Orthopedic Surgeon from MOH, checked Asiya’s baby and ordered an ultra sound of the arm.
“From what I can tell, there is clear trauma to the hand but there is no dislocation or fracture. We will know more after an ultra sound but are hopeful the baby will make a full recovery.”
(Patient’s name changed upon her request)
“Médecins Sans Frontières has provided an emergency medical assistance programme in Timergara District Headquarter Hospital since October 2010. This assistance includes support to the Maternal and Child Health (MCH) department, in the form of human resources, provision of medical and logistical supplies, as well as rehabilitation of the emergency operating theatre, recovery room and acute post-operative wards and full support to sterilization, hygiene and waste management. The hospital is meant to cater to the inhabitants of Lower Dir (where Timurgara is located), but patients also come from neighbouring districts, with the majority coming from Lower Dir, followed by Upper Dir and others within KPK as well as the Federally Administered Tribal Areas (FATA). All services are provided free of charge.
“Antenatal care in Pakistan is far from satisfactory. The reason being that majority of the population live in rural areas, with a high illiteracy rate, restricted health care facilities with an underlying synergistic background of anemia, malnutrition, infection and unregulated fertility. Consequently, a large majority of patients reach hospital too late with features of obstructed labour with grave consequences. Poor patient compliance to the advice given due to lack of understanding and education with a tendency to rely more on advice given by traditional birth attendants. Good intrapartum care can easily diagnose the condition. Prevalence of obstructed labour, an obstetrical disaster, is influenced by availability, quality and acceptance of maternity services in a community. The long term solution lies in prophylaxis i.e., provision of adequate antepartum and intrapartum care which could avert the preventable nature of obstructed labour.”