OB-GYN Veronica Ades tries to save a pregnant woman’s life in South Sudan, while struggling with her own feelings about motherhood.

Note: You can read more details about Veronica's experience on her blog here.

Veronica Ades, MD, MPH is a board-certified obstetrician-gynecologist. She attended medical school at the State University of New York at Downstate in Brooklyn, NY, and obtained residency training in obstetrics and gynecology at the Albert Einstein School of Medicine in the Bronx, NY. After residency, she obtained a Master’s degree in Public Health with a concentration in Quantitative Methods at the Harvard School of Public Health. Dr. Ades then completed a three-year fellowship in Reproductive Infectious Disease at the University of California, San Francisco, in which she lived and worked in rural Uganda, and  conducted research on placental malaria in HIV-infected and –uninfected women. Dr. Ades also completed a Certificate in Comparative Effectiveness at the NYU School of Medicine. Dr. Ades has worked with Médecins Sans Frontières/Doctors Without Borders on assignments in Aweil, South Sudan in 2012 and 2016 and in Irbid, Jordan in 2013. Dr. Ades is currently an Assistant Professor of Obstetrics and Gynecology and Director of Global Women’s Health at the New York University School of Medicine (NYUMC). Her clinical work is at the New York Harbor VA and at Gouverneur Health. At NYUMC, Dr. Ades has created an educational and research partnership with Korle Bu Teaching Hospital in Accra, Ghana. She is also the Director of the EMPOWER Clinic for Survivors of Sex Trafficking and Sexual Violence at Gouverneur Health on the Lower East Side. Dr. Ades’ main research focus is on post-sexual trauma gynecologic care. She runs the Empower Lab at the College of Global Public Health at NYU, where she has active research projects on sexual and gender-based violence, intimate partner violence, military sexual trauma, and global women’s health.

This story originally aired on Sept. 8, 2017, in an episode titled “Identification.”

Story Transcript

About a year ago, I found myself in South Sudan.  It was two or three o’clock in the morning and this was actually my third straight night awake -- three days, three nights.  I was in the hospital.  I was standing over a patient’s bed, and I was holding this freezing bag of blood.  And I was squeezing it and I was just trying to press the blood into her veins as fast as possible.  And I was thinking, I will not let this woman die. 

To understand why I was there, I have to give you some background.  So I am an OB-GYN, or obstetrician-gynecologist.  So I deliver babies, I take care of pregnant women, I do C-sections.  My whole life I knew that I would have an interesting career that I was passionate about and that I would pursue wholeheartedly. 

But even though I spent most of my life or my time delivering babies, I wasn’t actually super sure that I wanted to have them.  It seemed conventional, limited.  It seemed like it derailed your career.  And I really hated it when people would say these condescending things to me like, “Well, you won’t care so much about your career when you have children.”  If that’s the case, then maybe I don't want them.  I don't know that that was true, but I just didn’t like the prospect of being so limited by my biology. 

So I went to medical school, I did training in OB-GYN, my residency, and then I ended up doing a lot of global health work and that’s how I ended up working with Doctors Without Borders, which is known by its French acronym MSF. 

This was my third mission with MSF.  We were in a town called Aweil in South Sudan, which is in northern Bahr el-Ghazal, if anybody is familiar with that state.  We were in South Sudan because there was a need. 

So South Sudan used to be part of Sudan, if you're not familiar with the geography.  It’s the newest country in the world.  Sudan was at chronic civil war for fifty years and finally, in 2011, there was a referendum, a peaceful referendum that split the country into Sudan and South Sudan. 

That did not end the war so the fighting continued in South Sudan.  So after fifty years, the country has really been decimated.  There's almost no infrastructure at all, almost no educational system, almost no healthcare system, almost no government.  And that means that the most vulnerable populations, which are pregnant women and children, are the most likely to die.  In fact, they were dying in very high numbers in this area. 

So MSF came in and they went into the Ministry of Health Hospital.  They were invited and they took over these wards because the hospital needed help.  There were very few trained personnel there. 

So this was my third mission with MSF and I was the OB-GYN.  There are expats and there are local workers, so I was the only expat OB-GYN.  I was actually the only surgeon.  There were expat midwives, there were internal medicine doctors, pediatricians, logisticians, administrators, and then there were local midwives and nurses but there were no surgeons.  So that meant that if anybody needed a C-section, I had to be there.  And if anybody needed, had an obstetric emergency, it was all me.  That is how I ended up being awake for three days and three nights straight because there were so many emergencies and so many C-sections.  I actually ended up being four days straight. 

So there I was and I had just come out of a C-section.  I had delivered a woman’s twelfth child, because that’s how it tends to go in South Sudan.  She was okay and I was looking forward to getting to sleep.  The nurse came to talk to me and she said, “I have a patient I want you to evaluate.”  It was one of the local nurses. 

To be honest, I was kind of irritated.  They were supposed to call the midwife before me and I was in a surgery, so if it’s urgent, you really shouldn’t be waiting for me.  And besides that, I’m so tired.  I’m so tired, I don’t even feel tired, which is the most dangerous kind of tired so I did not want to see this patient.  But how can I go home if there's somebody potentially in need? 

So I said, “Okay.  What’s wrong with her?” 

And she said, “Well, her hemoglobin level is two.”  Okay, some people understand what that means.  Two. 

So hemoglobin is the concentration of red blood cells in your blood.  And normal for a woman is about thirteen, for pregnant women it could get down to about ten or eleven.  At seven, we transfuse, because you're at-risk of dying.  And at two, almost anybody would be dead, except South Sudanese women for some reason. 

I have seen people actually walk in with this hemoglobin level and be like, “I don’t feel great.”  And then we transfuse them to like four, which is still dead-level, and they go home because we don’t have that much blood.  So I was like, okay.  I guess like she could be really sick, but she could be fine, but let me go see her. 

So I go over to see her and she's lying on her side in the fetal position and she's apparently sleeping.  So I actually just kind of looked at her first.  She's very emaciated, but every pregnant woman and child in South Sudan is emaciated.  And her belly looks a little small.  The staff is telling me she's full term but, to me, it looks like about thirty weeks, maybe seven months. 

So I turn her on her back and I realize that she's gasping for air.  [makes gasping sound] Like that.  So oh my God.  Okay, this is bad.  This is not one of those just-walk-in-and-transfuse-it’s-fine.  She's sick. 

So I have to figure out is this acute or chronic?  If it’s acute, she's losing blood and then that’s the reason that she's so anemic.  If she's losing blood, where is it going?  Well, usually, unless they were stabbed or something, it was vaginal bleeding.  So I asked the staff is she having any vaginal bleeding?  They said no. 

So okay, it could be chronic.  I've seen people with this before, but they don’t usually look like this.  She looks really sick for chronic.  Everybody has severe malnutrition in South Sudan.  They have multiple consecutive pregnancies.  Life is really hard there.  So it’s possible, but then what’s making her so sick? 

There is one thing that could be causing her to have severe acute anemia that would make her so sick but we wouldn’t see the bleeding, and that’s placental abruption.  That’s where the placenta tears off the uterus a little bit and bleeds but it can get trapped behind the placenta and so we don’t see the bleeding come out. 

The staff has actually told me that the baby is dead and so an abruption would be consistent with that, so I need to do an ultrasound to see if that’s the case.  They bring over the ultrasound and I do it and I think I see some fluid.  Not a hundred percent sure but it looks like there's fluid.  And is it behind the placenta or is it by the liver?  It’s really hard to tell on ultrasound.  But either way, it would be bad and that I need to get this baby out because it really could be what’s causing her to be so sick. 

So I do a vaginal exam to see if she's dilated and actually she's fully dilated ten centimeters.  She's ready to deliver. 

So one of the nurses actually scoops her up.  Most people in South Sudan are over six feet tall.  They're like six-foot-five. This particular tribe is the Dinka tribe, they're very tall, so they scoop her up.  She's tiny.  This nurse, a male nurse - most of the nurses and midwives are men there - scoops her up and carries her tiny body over to the maternity ward. 

The maternity ward is four maternity beds all lined up next to each other.  There's no privacy in South Sudan.  There's not even an expectation of privacy.  And they have footrests and so we put her legs up there, but she's so weak that she can’t even hold her legs up.  So I have the nurses hold up her legs and we have her push.  And because she's so weak, we help her by pulling with a vacuum. 

The baby comes out really easily.  It is dead.  And the placenta comes out easily.  But as soon as it comes out, I realize that her uterus isn’t contracting.  That’s called uterine atony, and the uterus needs to go from about this to this in seconds.  If it doesn’t, the blood vessels are wide open and they're just pouring out blood.  A woman can lose her entire blood volume in a matter of minutes.  It’s actually the number one cause of death around the world for pregnant women. 

So what I do is… sorry, it’s about to get very vaginal.  I put one hand into the vagina and I massage her uterus and I put the other hand on top of her abdomen and I massage.  It’s called a bimanual massage.  It’s actually one of the most life-saving techniques you can do.  It’s actually pretty simple.  But it tamponades the uterus until you can get medications on board and get it to contract. 

So I’m massaging and starting to call for medications.  So we can give one dose every five minutes of various medications, so I’m calling for them.  Then I realize this is bad.  She has no blood, almost, and she doesn’t have much to lose.  This is an emergency.  I should be directing this as a most senior person in the room. 

So I ask the expat midwife, Cecile, to come and do the bimanual massage.  So she does.  She takes over.  And so I’m timing the medications and thinking about all the coordination. 

The blood arrives and they hang the first bag of blood, and her mother comes in the room.  The patient’s mother.  So I briefly turn to her and I use a Dinka interpreter to tell her that I’m very sorry but the baby is dead and your daughter is very sick and we’re just working on helping her.  So she says, “I knew that the baby was dead.  I’m not worried about the baby, just please save my daughter.” 

So we keep working, we give medications and we’re transfusing the blood, and that’s how I end up just standing over her, holding this freezing bag of blood and I realize that she's getting very cold and actually hypothermic.  It’s because the blood is so cold and we haven't had time to warm it up properly. 

So I turn to the blood bank guy and I say, “Is there any way to warm up this blood?”  And he goes, very South Sudan, just put it in your armpit. 

So I didn’t do that.  We just wrapped her in wool blankets and that tinfoil blanket that they give to marathoners that helps keep you warm.  What are you going to do, right? 

So we’re squeezing the blood in and Cecile is massaging her and we’re giving medications and we get to the limit of our medications.  We've given everything that we could give.  At this point, the only thing that we can do is a hysterectomy, but she is not going to survive that surgery.  So we’re at our last resort and, just as a temporizing measure, we put in a balloon into her uterus. 

So Cecile prepares the balloon and that should give us a tamponade and hopefully give us time.  But as she goes to insert the balloon, she can’t get it in because the uterus has contracted.  Finally.  So we’re relieved that the bleeding has stopped and we can finally take a minute to figure out what’s going on, because we haven't even been able to think about it.  We've been so busy just trying to save her life. 

So the local midwives are actually great and they are now taking care of her and we can leave her with them for a couple of minutes.  We step outside and just take a breath and say what is going on.  So it didn’t seem like abruption.  There wasn’t any blood behind the placenta.  It could be preeclampsia, which is high blood pressure in pregnancy, but her blood pressure is not high.  But maybe she's so sick that now it’s back down to normal, which is low.  I don't know.  We’ll put that on our list. 

It could be sepsis, it could be HELLP syndrome, it could be Kala-Azar, it could be tuberculosis, it could be so many things.  That’s what’s hard in South Sudan.  They don’t have prenatal care so I don't know what was wrong with her or if there were problems in the pregnancy.  And they have so many diseases that I have never seen before that I didn’t train to see and wouldn’t know how to recognize.  So we just needed to try to figure it out and we have to figure it out fast, because whatever is hurting her could still be going on.

So we ask for a bunch of labs, and you can’t get that much South Sudan.  It’s not like here.  So we just fill out whatever we can that we think will help and we give the list to the midwives.  We come back to check on her and she actually seems better.  The first unit has gone in, she's not gasping anymore.  She's quiet and calm.  She's still weak.  And the second unit is going to start so we’re relieved that we've kind of gotten through this period. 

I realized that if I’m going to take care of her in the morning, it’s probably 3:00 or 4:00 at this point, I need to get some rest.  So we give strict instructions to the local midwives they're going to hover over her and they're going to call us for anything, and they’re going to get this second unit running and draw the blood.  

So Cecile and I take the car back to the living compound.  It felt like as soon as I lay down, Cecile was knocking on my door.  She is pounding and she's saying, “Veronica, she's very sick.  We have to go.” 

So I throw some clothes on, we go running to the car and this white MSF SUV is just careening through these really, really bumpy roads just to get us there faster.  As soon as the car, like pretty much before the car stops, we throw the doors open and we’re racing to Labor and Delivery.  What’s going on? 

We get to maternity ward and she's there, and she's dead.  I couldn’t believe it.  I was not going to let her die and I failed.  Everyone is standing around and it’s just happened right now.  They're just stunned and the staff are just standing there staring at her.  And her tiny body is still wrapped in these wool blankets and this tinfoil, and her mother is standing at her head in shock.  What happened? 

The staff can’t really figure it out.  They say that the second unit went in and she actually started to feel better.  She started talking normally.  She wasn’t slurring her words anymore.  She said her chest pain and shortness of breath were gone.  She actually wanted to sit up and she was talking to her mother.  They made her lie down to rest but she looked okay.  Then all of a sudden, her oxygen saturation went from a hundred percent to nine percent to zero and she died. 

I don't know what this means and I don't know what she has but I know I’m about to cry.  I don’t cry very much anymore.  I've seen a lot and I've a little bit lost my ability to cry, especially in front of other people.  I kind of wish I had it more.  But I’m realizing I’m about to cry and I don’t want them to see me cry.  So I step out of the room and I cry. 

And Cecile follows me and I see that she's crying too.  And one of the local midwives, who’s just the most sensitive soul I've ever met, is also very upset.  We gather ourselves together and we go back in.  Cecile has to go see a woman who’s delivering twins and I go back to see this patient. 

She's still there, still wrapped in those blankets, and her mother is there still.  But now she's crying and that is really striking because women in South Sudan almost never cry.  I actually don’t think I've ever seen anyone cry, and I've seen them been through horrible things, losing babies, hysterectomy, major surgery, complications.  They're incredibly stoic.  And I don't know if it’s the environment or how hard their lives are or just cultural, but you don’t see them cry.  So the fact that her mother is crying…

She's not just crying, the tears are just pouring down from her eyes and then they're pooling on her prominent cheekbones, and then they're just cascading down.  It’s like a waterfall.  As soon as she sees me, she looks right at me and she starts speaking in Dinka.  I don't understand so I call an interpreter over who says, “She's saying that she will never blame you because she saw how hard you worked to save her daughter, and she knows that you tried.” 

And I started crying and I said, “Tell her that I did everything, everything that I could and it wasn’t enough, and I’m sorry.” 

Sometimes you do your best and it’s not enough.  That mission was really hard.  I lost another patient that I really cared about and I got sick.  I lost ten pounds and ended up actually getting medevac-ed at the end of my mission. 

When I got back to New York, MSF has you meet with a therapist to process the experience and make sure you're okay, and it’s great.  So I sat down with Dorothy, the therapist, and she said, “Tell me about your mission.” 

So I said, “You know what?  It was really hard.  I had these interpersonal conflicts that you always have when you're working and living with people twenty-four-seven.  They're very stressful and I think it made the physical toll of it harder and the maternal deaths harder.” 

So we talked through the interpersonal conflicts.  She was really supportive.  And then she said, “Tell me about the maternal deaths,” and I just burst into tears.  

I cried for an hour in her office.  I thought I was okay.  I always think I’m okay.  I've seen maternal death before.  I've seen several and I know how it goes.  I know how they sink a hook into your heart when you work that hard to save them and when they die, it brings you down.  I know that you need to just mourn and you need to give it time and eventually put it in this box that you carry around with you forever, but you're okay. 

But I was not okay yet.  In fact, I was depressed for a good month after I got back, but I didn’t realize it until I was in Dorothy’s office. 

So I told her about this death and the other one that broke my heart.  She listened and she said, “What are you thinking about when you reflect on these experiences?  I mean, it’s sad, but why did it feel so personal?” 

I thought about it and I realized that in both of the cases where the patient died, the patient’s mother was there watching her own daughter die giving birth.  I thought about my own mother who loves me so fiercely, like more than anything I've ever seen in my life.  And I think about what, if that was me and my mother had to watch me die giving birth, I can’t even handle it. 

Dorothy points out that I spent a lot of my life taking care of pregnant women and helping them deliver their babies safely and that I've made a lot of sacrifices to do it, and this fire in my belly is really a profound anger that women have to die in childbirth. 

So Dorothy says, “What does motherhood mean to you?”  The question goes so deep I can’t even answer her for a few minutes. 

I realize that I have been thinking about motherhood all wrong.  Motherhood is love.  It’s fierceness.  It’s sacrificing yourself for your child.  Motherhood is taking care of someone else.  It’s putting their needs before yours.  Motherhood is powerful in this way I had never appreciated before. 

In many ways, my own career, taking care of others, is a form of motherhood.  I don’t feel anymore like it’s this biological need that will limit my life and my destiny.  Motherhood is something that I could be really good at, something that I’m kind of already doing.  Motherhood is part of me. 

Thank you.