Rosalia… one and ninety nine… cost… quite a story

Rosalia is 35 years-old and arrived in Cavango in the early morning hours with her husband after three jarring hours on the back of a motorbike (both of them) over 30km of dirt, in the dark, from a simple village of about 1000 people that bears one of my favorite village names, Chumbangombe (shoombongaumbee). Chumbangombe sits on top of a small mountain and has a beautiful view of a large river valley and we love driving through this village on our way to Cavango and admiring the view.

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I took monthly clinics to this village in the past and got to know the area and its people pretty well. Chumbangombe has no water source apart from a river, which is a long, grueling walk from the village, down into the valley and back up. No one has electricity or plumbing. The village is known to be among the poorest of the 50-60 extremely simple villages that are within a “day’s walk” of Cavango.

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Rosalia was nine months into her eighth pregnancy (five survived), and she had experienced 24hr of severe, painless bleeding, which had stopped prior to her trip. Her blood count was 3 (normal 12). Thus, in one day she had lost 75% of her blood volume! She reported that she’d had no prenatal visits and had survived a Cesarean in 2014, followed by the normal births of three healthy children.

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With ultrasound, we found the baby alive and diagnosed the cause of Rosalia’s bleeding, a condition called “placenta previa”, which occurs in about 4/1000 pregnancies. In previa, the placenta is positioned low in the uterus where it might, at delivery, prevent the descent of the baby through the opening of the uterus (cervix), depending on how much of the cervix is blocked by the placenta (difficult to quantify via ultrasound). If you have ever seen a placenta, you know that it is a membrane-covered sack, full of blood vessels, delivering oxygen and nutrients to the unborn baby. If the membrane is damaged/torn by the growing baby pushing on the placenta, with the help of gravity because of its low position, it can catastrophically bleed, taking the life of the baby and/or mother. The only known treatment for placenta previa is a Cesarean and there is no medical literature to support an attempt at a vaginal delivery. Eduardo and I can both perform this procedure, but we have neither the instruments nor the infrastructure in Cavango to safely perform a Cesarean. Being well prepared for this and other surgical procedures is costly and we haven’t yet arrived at this point in Cavango. Some day!

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We recognized the risk in attempting a Cesarean, the risk in waiting and the risk in transporting Rosalia in such an unstable condition, and we knew she would likely not survive without a Cesarean. In light of no further bleeding, her cervix almost closed (2cm), and no labor, we decided to continue to stabilize her and put her on the next MAF flight to Lubango, acknowledging that the initiation of labor could cause catastrophic bleeding. We could then, more safely, transport her to our colleagues in Lubango for this procedure, as they wouldn’t be able to perform the operation immediately, anyway, with her current blood volume status. We gave her four units of blood over four days as we waited for our next scheduled MAF flight. With no further blood loss, her Hb rose to 9. The situation looked good…

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On the night before our scheduled MAF flight, however, Rosalia told us that she was having slight labor pains and she had enough experience to know. Her cervix had not dilated, though, through the night, and her bleeding was controlled, so we continued with our planned transport… but… about an hour before her departure for the airstrip, along with her mild, intermittent labor pain, she began hemorrhaging again… significantly. We could not transport her with this hemorrhaging – two hours by car, two hours by air and then another hour through the airport in Lubango and to CEML (hospital) – so we cancelled the transport.

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Over the next 24hr, Rosalia lost the equivalent of her total blood volume. Because Rosalia has a rare blood type which permits her to be the recipient of all of the various blood types, we solicited blood from her husband and everyone working at the hospital, as well. Many people donated throughout the day and night, including Eduardo, Jocelyn, their son, Mariano, myself and others on our hospital staff. We kept up with the blood lost, barely, maintaining a blood count (hemoglobin) around 6.

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As night approached, we talked again about performing an ill-equipped Cesarean with our limited experience and instruments, but the deciding factor was that we couldn’t take her to surgery with such a low blood volume. At about 6p, we checked her cervix and it was the same, and we discussed a four-hour car ride to Huambo, the closest city hospital with Cesarean capabilities, but my experience there has been that nothing is (ever) done urgently and the patient, no matter their condition, is given a bed and no exam or treatment occurs until the following day (maybe).

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Even with this history, because she wasn’t dilating and we thought we had time (and whether she could survive a vaginal delivery remained questionable), we made contact with Huambo and they said they would prepare for her arrival. Eduardo volunteered to take her, knowing he would be gone most of the night, We prepared the car, endeavoring to prepare for any possibility during the four-hour jaunt and, just to be sure, we checked her cervix before her departure… and… her cervix was now 8cm! She could now not travel, as we, obviously, did not want her to deliver on the way. Our options were gone. We would have to see if she could survive a high-risk delivery here. We explained the situation to Rosalia and her husband and prayed for her.

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So, after about 12hr of labor and continued brisk bleeding and replacement, Rosalia’s contractions were increasing and her cervix was responding, but her bleeding was also increasing. More blood replacement… We helped move labor along with medication. Then, about 1am, her cervix was fully dilated and she began pushing, but her membranes (“sack of water”) were bulging against the cervix, preventing the baby’s descent. We ruptured her membranes, her “water” poured out and, just a few minutes later, Rosalia delivered a lifeless, markedly premature baby girl, who wasn’t developed because of the deformed placenta, and wasn’t able to survive her mother’s severe anemia.

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We tried, unsuccessfully, to resuscitate the little baby girl and we were disappointed that the undeveloped baby didn’t survive this whole ordeal, yet we were thrilled that Rosalia had survived such a condition through delivery. We thought we were finished… but… Rosalia’s placenta wouldn’t deliver and was adhered to her previous Cesarean scar and this adherence wouldn’t allow descent or manual removal. And she continued to bleed!

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Postpartum hemorrhage (of all things!) is a common complication of this condition of a “stuck” placenta, called “placenta accreta” because the uterus can’t squeeze down on itself and compress bleeding vessels. Rosalia continued to bleed profusely. We used further medication and other (painful) measures to help contract Rosalia’s uterus to diminish the hemorrhaging and saw some success over an hour or two. She received three more units of blood during the rest of the night, the placenta remained fixed, but the bleeding almost stopped (!) so, in the early morning, we (again) solicited help from MAF to provide emergent transport to Lubango, believing she would now survive the transport. As always, our MAF colleagues readily agreed and quickly mobilized for the two-hour flight to an airstrip an hour from us.

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One of our visitors, Greg, who is here to carve out an airstrip a mile from the hospital, offered to transport Rosalia to the airstrip to meet the plane, so that we could attend to the rest of our hospital patients. Rosalia was still receiving a last unit of blood so we sent one of our registration workers to help manage her two IV sites (everyone here learns and participates in all facets of nursing care). The transport was a tough two hours for Rosalia, and for Greg (first time driving this “road”), over about fifteen miles of mud, water, ruts, holes and roots but they made it without a hiccup (such as a flat tire, more bleeding, etc) and MAF picked her up and delivered her to Lubango, where she underwent a successful hysterectomy (with more blood loss and replacement) and will likely survive.

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Of course, we had many other severe cases to attend to throughout the day and night and the effort by our staff was tremendous. I was so pleased and sensed our Father’s immense pleasure in all we did!

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The resources used, human and financial, on this one patient, were exponentially greater than what we normally would spend on treating any other critical patient over a 24hr period.  One and ninety nine…

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Epilogue… At our weekly staff meeting this morning I asked all of our workers what characterized a person who followed another. We listed the obvious answers, that the follower walked in the steps of their leader, did what their leader did, said what the leader said, shared the leader’s priorities, learned from the leader, etc

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I explained that the primary characteristic of Jesus’ life (many in the room would claim to follow Jesus) … was not… going to church services, being a church “member”, being a good citizen, knowing all the answers, being “nice”, “liked” or having a good reputation, avoiding offense/conflict, following rules, being a “moral” person, not drinking or smoking, having it “all together” (or looking like you do), being a “leader”, worshipping or praying all day… The One we follow served those He loved… and gave His effort, strength, sleep, status, blood and life… to benefit others… The primary characteristic of the life of Jesus, the One we follow, is love – the prioritization of the beloved. There is no such thing as love without cost to oneself, demonstrated profoundly and repeatedly in the One we follow…

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I shared my immense pleasure in our whole staff, many sacrificing blood, sleep and food throughout the day and night to help this hurting woman/neighbor/stranger. I encouraged them to think again of the One they claim to follow and cited Jesus’ reference to His stated life’s calling and thus, as His followers, our highest calling – that of giving away our lives, sleep, blood, effort… for the benefit of others. “There is no greater love than to lay down one’s life for one’s friends.”

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Vision, vision, vision… I shared with my dear friends that this is what we desire to see as the primary characteristic of our service in Cavango… and we had demonstrated this week that we, as a Jesus-following hospital staff, were well on our way to resembling the One we follow, who gave away His life… and more… for us…

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I also cited His reference to the value He places on the one of ninety nine who is lost/hurting/in need…

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The meeting lasted two hours, with much interaction, and the excitement and pleasure in a deserved “well done” was tangible…

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