TEACHING OR FACILITATING

As time flies by and each week passes I find it increasingly difficult to find the right moment to sit down and write to you all. Everyday there are stories to tell as I become more and more involved in the different aspects of African life and health care.

It has been a week full of teaching. I find myself particularly involved with the clinical teaching on labour ward passing from bed to bed observing and questioning, trying to make the students think about their practise in a new way. To see the woman as an individual with a story to tell quite unique and special and therefore to be treated as such. Sometimes its difficult to stand back and let them attend, even whilst I am supervising. Inexpert and clumsy, results in torn perineums or less sensitive handling of mother and baby as they perform their tasks but I guess thats just part of teaching. and learning. Its a priveledge to be with them to be part of their training, to maybe have some influence. I hope that my words will be remembered and my example sufficient to aid them to be better more caring and knowledgeable midwives in the future.
But not all the students are receptive and many have a dangerous overconfidence after just a short time on labour ward. Then there are the students that are more concerned about filling in their papers for x number of vacuum extractions, twins or breech deliveries and can be found attending these births totally or inadequately supervised. I returned from workshop on Tuesday to the cries of a woman in bed 2. Behind the curtains I found a very newly trained CO supervising a student midwife with a vacuum extraction. I had been aware earlier that she was "on the look out" for vacuum extractions. Things didnt seem to be going well. The whole scene was chaos and the woman out of control. On enquiring as to the whereabouts of the fetal stethescope to check the baby's condition I found that they didnt have one. They hadn't seen it as and important part of thier equipment! I could not let this continue and pushed past to examine the lady. I found that the conditions were not favourable for this sort of intervention and told them to stop untill I called a senior clinician. I ran to operating theatre where I found him having lunch. Fortunately he was finishing and came straight away. ( Luch hour in Malawi is sacred and even an emergency will not be attended to untill after lunch!) He attempted to extract the baby but soon decided it was not possible. I hurried her to theatre where the baby was born by a difficult c/section. I stayed to recussitate a very floppy baby then transferred him to nursery. Today the baby has been discharged from nursery and is with his mother. He is one of the lucky ones. I dont understand this behaviour. I cannot condone this behaviour. But it exists and it continues. The workshops are going well. I am called the ' facilitator' Its the new word instead of teacher. I rather like it! I have now finished the first session which consisted of 4 groups. 35 midwives attended in total. Feedback has been good so far and I am encouraged. Next week I will introduce a new topic as we start to analize our individual practices and attitudes.

Pilirani and the twins Edward and Alex are still doing well. They now weigh in at 3.700 and 3.050 kgs. respectively. The harvest has begun. The maize is picked and being ground into flour. This week she did not complain of hunger. The boys are hungry babies and growing fast. They are still taking 2 formula feeds a day and I continue to supply them with milk powder. I have however advised her to try stop these supplements now that both mother and babies are stronger.
Grace spent 5 days in hospital with little Angela whilst they treated a chest infection with antibiotics. I was disappointed to find that when I visited on Monday she had already been discharged without doing the cardiac scan. This happens often. If she has a cardiac complaint it will not be investigated untill next time she is admitted with the next infection or failure to thrive.
It is frustrating but it is Malawi. I hope that she will start to grow and gain weight and that it wont be necessary.

It is not uncommon for me to attend 5 to 7 births in one 9 hour shift. Some are quick and straight forward but many long and complicated requiring the maximum of my skills.
Just 2 examples this week...1. A referred case with prolonged dilatation phase. Aparently she would be unable to deliver due to an abnormal cervix. I was told to try a vaginal birth but it was unlikely. After much care she pushed out a healthy boy and avoided a c/section.
.... 2. It was her 5th pregnancy and she still didnt have a living child. She had been admitted during the night and was well in labour. I started caring for her at 7.30am. At 8.30am. the doctors do there "round" The orders were clear.. " This lady will be c/sectioned immediately " It was not for me to question this decision which was made in the interest of mother and child but I do question as to whether a c/section is really the safest option, not only here in Bwaila but in any part of the world? I started to prepare her for theatre. IV infusion, urinary catheter, consent form etc. She started pushing, what could I do? Ten minutes later she birthed a healthy bouncing baby boy! She was so happy and so was I! I'm not sure if the boss knows yet but I'm sure not going to tell her!!