Mara Evans blogs from a maternity ward in South Sudan

MaraProfile picThe day was hot and quiet. Ward rounds had finished and the local midwife and I were waiting on a woman’s seventh baby. The other midwife had just examined our labouring patient and told me she was dilating well at seven centimetres. Generally, when a person is giving birth to their seventh baby things can happen quite fast, so we were prepared for the woman to tell us when she needed to push.

Women labour next to each other in the maternity department, and mostly prefer to lay down while they do. I attempt to encourage women to walk about, as this can help with labour, but my pantomime actions are apparently hilarious, and usually not considered seriously.

ViewfromwindowAgokWhen it is time to push or be examined the women walk toward the back of our department where we have two delivery tables in a smaller room. The tables are separated by a curtain for some privacy, but sometimes it’s hard to be discreet when you’re having a baby.  Most of the time women time it just right as they make their way to the delivery room. Every once in a while we have a baby born in the bed and there’s a mad dash to set up a portable screen and bring a delivery kit.

One woman recently delivered twins, the first in the bed in front of a small gathering of people.  Then she walked to the back to deliver the second twin. After birth, a woman will get down off of the delivery table, arrange her dress, and walk back to her bed.

Our labouring patient soon gives us the sign that she is ready to deliver her baby. The sign can vary from a caretaker frantically motioning for a midwife to come, or it might be the other mothers in the ward pointing towards the delivery room where a woman has disappeared.  Today the mother calmly stands up from her bed, looks at us and walks to the back. This is when the story takes an interesting turn, because her examination is not what I expect at all.

The woman’s labia are smoothly fused together. Where there should be a passage way for a baby to exit, there is only an opening at the very bottom, about an inch (2.5cm) across. This is female genital mutilation (FGM).

I am able to partially examine the woman and can feel the baby’s head is very low, probably she is fully dilated. I ask the midwife I am working with if he thinks there is anything unusual about this woman’s anatomy.  He is a new and dedicated midwife learning more every day.  He tells me he thought this might just be how the woman was born. I think back to when I was a new midwife student silently praying to the anatomy gods to help me just locate a woman’s cervix. There is not a lot of FGM in this area and probably, like me, this midwife has never seen FGM before.

Blog_pic_1I call Erika, the other international midwife, for back up. We put our minds together, recalling articles we’ve read and consulting the ever-present MSF guidelines. The woman is now pushing and I quickly explain my recommendations to her. She agrees and I inject lidocaine to numb the area. First cleaning the tissue with iodine, then using sterile scissors, I extend the small opening anteriorly to resemble her original anatomy.

I worried there would be a lot of bleeding from the scissors, but the tissue is almost completely scar tissue with very few blood vessels. The baby is very near now and I use suture to separately stitch closed each side of the new labia.  It is MSF policy not to reinfibulate or re-sew any kind of mutilation.

The baby girl is born fat cheeks and pink lips scrunched up in protest. Her chubby hands are balled into tiny fists and, quietly squinting, she looks around the delivery room, unsure about this new world she’s entered. I ask the mother about how she had delivered her previous six babies and if they needed any help coming out. Through a translator she tells me the other children were born at home into the hands of community midwives who at each of the six births would use a razor blade to make an adequate opening for birth. Afterwards they used regular thread from the market to once again fuse the labia almost completely together.

I finish stitching each labial side to stop the bleeding and the woman thanks me in Arabic.  She gathers her long flowing wrap which she puts over her dress and walks back to her bed.  My assistant tells me upon discharge the patient will most likely find a community midwife to perform a different kind of repair for the seventh time.

Mara Evans is a midwife with Medecins Sans Frontieres.

Patient consent obtained.