A RARE BIRTH AT TSMP

The morning of Jan. 24, 2010 began like any other at the Teso Safe Motherhood Project (TSMP) clinic in Soroti, Uganda, for Midwife Alice Esabu, but it would end unexpectedly. At 5:20 p.m., Immaculate Ariso, 22-year-old mother of one small child at home, entered the clinic doubled over with labor pains. An hour and a half later, she and midwife Alice would have a very great surprise.

In Alice's own words:
"As we received Immaculate, she walked in alone, without anybody escorting her. She appeared so much in labor pains! I greeted her and asked for her antenatal card, which she held in her hands already. I read through the card, seeing that she was full term. I asked when her labor started. She replied, 'It started at 5 a.m. of this morning.'

When I asked her to go with me to the labor suite for examinations, she complained that the contractions were constant. I requested her to allow me to palpate the abdomen when she feels the contractions subside, but she kept saying, 'Nurse, these pains are just constant!' The abdomen looked big compared to the skinny mother, and indeed the contractions seemed to be constant! Finally I was able to palpate, but only briefly because she just couldn't settle enough to allow me to palpate carefully.

I needed to do a cervical exam, but she just couldn't allow me because of the constant pain. So, I set up my delivery equipment. At 6:30 p.m., the membranes ruptured with lots of clear fluid. At 6:40 p.m. a baby girl was born, head first. The cord was too short to hand her up to her mother. As I held her,  I saw how large the abdomen still was, and for the first time I said to myself, 'Yes, these are twins!'

I asked Caro (the other midwife on duty) to hold the baby, but the mother said she felt like pushing again. I asked Caro to prepare for the next baby, who was born just five minutes later, also head-first presentation. Both babies were alive and kicking.

I noticed the cords were tied together in two knots and realized then they had been in the same sac! They were the rarest type of identical twins – ones who share the same amniotic sac. Incredibly, the knots in the cord had not tightened. If they had pulled tight, the babies likely would not have survived.  

The mother lost a lot of blood when she delivered the placenta, and I had to respond quickly to avoid a potential hemorrhage. We were just grateful she had come to TSMP to give birth and hadn’t stayed in the camps. Postpartum hemorrhage is a frequent complication in twin pregnancies, and in the camps she could easily have lost her life to the bleeding, and then who would care for these babies?

Both the girls were nursing well, and I was happy! Immaculate and her babies stayed at the birth center until the following afternoon, and I was able to advise her and her husband on the care needed for the babies and herself, especially the good nutrition needed to feed two healthy baby girls!"

Alice Esabu,
Enrolled Comprehensive Nurse
Midwife at TSMP

WHY THIS BIRTH IS MIRACULOUS:
More about Monoamniotic Twins

Monoamniotic twins are identical twins who share the same amniotic sac in utero. They are the rarest type of twin, occurring only in about one out of every 35,000 to 60,000 pregnancies.

There are two types of twins – fraternal and identical. Fraternal twins are twins who result from two eggs being fertilized by two sperm. They are like any siblings. They share 50 percent of their genetic information. Identical twins result when one egg fertilized by one sperm splits into two. Identical twins share 100 percent of their genetic material, and therefore are always the same gender. Identical twins occur in about one out of every 250 pregnancies, and the incidence is the same regardless of race. (In developed countries, the rate of fraternal twins has been on the rise, largely due to fertility treatments, but identical twins do not result from fertility treatment.). Most identical twins are not monoamniotic (or sharing the same amniotic sac). Only five percent of all identical twins are monoamniotic.

High-Risk Pregnancy

All twin pregnancies carry more risks to the mother and babies than a pregnancy with a single baby. However, in the case of monoamniotic twins, the risks are even greater. The mortality rate for this type of twin is 50 to 60 percent! The most common complication is entangled umbilical cords, which threaten to rob one or both babies of vital oxygen and nutrients. In nearly all cases of monoamniotic twins, there is some degree of cord entanglement –however, it’s when the entanglements become tightened and compression of the umbilical cords result that the situation becomes life-threatening.

In the United States, mothers carrying monoamniotic twins are often diagnosed early in pregnancy, and their pregnancies are followed very closely. These mothers are seen by obstetricians and a perinatologist (or someone who specializes in high-risk pregnancies).Beginning at 26 weeks of pregnancy, mothers carrying these rare twins are put on twice-weekly monitoring of fetal heart rate and movement. After the 28th week, many mothers are hospitalized so they can receive 24/7 monitoring. Full-term pregnancy is considered unsafe by most medical professionals, as the risk of cord entanglement and compression becomes too great after 34 weeks. All monoamniotic twins in the United States are delivered by cesarean section, some as early as 32 weeks, but no later than 36 weeks. However, it is common for this type of twin to experience life-threatening complications as early as 26 weeks and need to be delivered immediately.

There are several concerns with delivering monoamniotic twins vaginally. One fear is that entangled cords will have become so short that the babies could get stuck in the birth canal. Also, the entangled cords can compress at the time of birth, further complicating the delivery. Lastly, as with all twins, both babies may not be in head down position. One or both could be breech.

Of course, our patients in Uganda do not have access to the high-tech care that is available in the United States. Without the use of an ultrasound machine, it is impossible to diagnose monoamniotic twins. Only with this technology are we able to look into the mother’s womb to see that the twins are sharing one sac. Also, our patients, who are the poorest of the poor living in squalid camps, could not hope to afford 24/7 hospitalization even if it were available in northern Uganda, which it is not. Immaculate was a very fortunate young mother to have carried both twins full-term without complications and to have given birth without complications.

Most especially because of the high-risk of hemorrhage associated with twin births, she was very wise to have arrived at TSMP seeking the help of our trained staff. All in all, the birth Alice attended on January 24 was nothing short of miraculous!

LONG-TIME VOLUNTEER RETURNS TO UGANDA WITH IMA

Volunteer midwife Marion Toepke McLean, CNM, has gone to work in Soroti, Uganda, with the Teso Safe Motherhood Project. She will spend January, February, and some of March at the clinic there. Marion has been a practicing midwife in the U.S. since 1971 but also offers extensive experience with IMA in the developing world. Marion first volunteered with IMA and traveled to Afghanistan in 2006, where she traveled around the rural province of Bamiyan teaching midwives and doctors IUD insertion techniques. In 2007, she traveled to Soroti for the first time to help our then fledgling maternity program. Today, she returns to our health clinic where the birth center is now well established. This time she will be able to share her expertise in family planning with Joyce Aedeke who is in charge of Teso Safe Motherhood’s new expanded family planning program. Marion will send us regular updates about news from the clinic, and we are looking forward to sharing them with you. 

Click here to read A Difficult Breech Birth written by Marion McLean about IMA’s lifesaving work in Uganda and published in the latest edition of Midwifery Today.

MIDWIFERY TODAY SHOWCASES IMA IN LATEST PUBLICATION 

A Difficult Breech Birth
"Jennifer Braun, Colorado midwife and director of International Midwife Assistance and the Teso Safe Motherhood Clinic, was at her desk in the clinic in Soroti, Uganda, one morning, focused on paperwork . . . Two babies had already been born that day, and a third mom who had birthed the night before was still there with her baby. Midwives Alice Esabu and Bernadette Okello were busy with their care. The moms who had come for prenatals waited patiently outside. Glancing up, Jennifer watched as a woman in labor came through the door. She noted that the mother was bearing down as she came past the desk. Some time passed, then she heard Berna yell, 'Get Jennifer!' She ran back to find the woman with a breech baby delivered to the umbilicus . . ."Click here to read the rest of the article!

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