MAKING A DIFFERENCE

I arrived at labour ward yesterday ay 7.15am. By 7.45am. I had attended 2 births, performing vacuum extraction for fetal distress on one and resuscitating both babies. Thats how it is in the morning. The night staff are tired after their long 15 hour shift. Those that are unlucky enough to need attention between 5.30 and 7.30am. will be at risk. I never quite know what may have happened during the night which makes it difficult take over in the morning. How long has she been pushing? Are these signs of fetal distress recent or is this baby in its final stages of coping?
Was this woman with a previous c/section really in labour all night with a baby that is just too big to come down or should I wait a little longer and risk a uterine rupture? It is very often difficult to make the right decision so I try to watch her closely and hope that Tarek or one of the "real" doctors will be along soon to discuss the case. Protocol is to call for the clinical officer.It sometimes works, most are now quite willing to listen to me, but so many of them have so little experience I find it difficult to refer to them. The charge midwife called to say she would be late as her transport had not arrived. As the most senior midwife I took charge. Assessing the women, organizing the students, trying to ensure that they are suitably supervised ( difficult with just 2 other trained staff!) Then there is the ward round. At 8.30am. the obstetricians plus a whole host of CO's, students and others, patrol from bed to bed discussing each woman, taking the opportunity to teach the students or make decisions on difficult cases. I insist on maintaining as much intimacy and privacy as possible for the labouring women.This is a huge task. The curtains that should hang between the beds to give just a pretence of privacy are either broken or torn, many are just not there. Up to 20 persons trying to fit round the bed..most of them male.. make it almost impossible, but we try. Covering the women with their colourful cloths (chitenges) putting ourselves physically between her and the crowd, we achieve something. Yesterday was full of problems. Everyday we receive many women referred from other centres. By the time they reach us at Bwaila they have already passed through the health centre and maybe a local hospital. After waiting for transport between each centre these "emergencies"arrive on labour ward. We were just finishing the "round"
" Ruptured uterus" I heard them cry, as they wheeled in this poor, shocked, traumatised woman. Without waiting I went to the bedside. Luck was on her side as all the medical staff were still on the ward. The decision was made for immediate c/section and hysterectomy. I knew we should move fast. But "fast" is not, evidently, part of the Malawian vocabulary! IV line, urinary catheter..she was bleeding from the urethra..not a good sign, Consent signed, take blood for laboratory, she would most certainly need a transfusion. I got hold of the trolley and started pushing her down the corridor towards theatre, administring her IV antibiotic on the way. Later I heard that one of the CO's had gone to theatre to inform them and shouted loudly that they had better get on and stop laughing and talking there was a ruptured uterus on its way! It is so unusual and so pleasing to hear that someone understood the emergency.
The operation was quickly underway and whilst I stood waiting to receive the baby I realized that we had not listened for fetal heart sounds. I remember reading in her referral notes that they were not sure if it could be heard. What the heck! What difference would it make? We couldn't move any faster and we were saving the mothers life. I commented to the surgeon. "I dont know if the baby is still alive but I doubt it" It was not an easy c/section, intense hemorrage made things difficult. The baby was well down in the pelvis, stuck in the bony outlet for how long? Completely stuck for enough time to cause her uterus to rupture in its intent to push it out. I pushed upwards on the head whilst the surgeon tried to pull through the abdominal opening. It took a while, I thought it would never come, but then I felt it come loose and the baby was delivered.
" Its alive! " the surgeon exclaimed as the baby made a small noise. I knew it was now up to me. This baby deserved chance! I must do a good job on resuscitating. As I inflated its little lungs with oxygen and sucked the liquor and mucous from its nose and mouth I really prayed for this little one to make it, to find the strength to live. And it did! Small gasps at first then stronger and it started crying. Turning a lovely shade of pinky brown I knew it was on its way. Boy or girl ? they asked me. Its a girl. Of course it would be! Everyone knows that girls are stronger, real fighters! You may laugh, we all laughed in theatre but its true, the girl babies do fight harder ( comments welcome!) The outcome of that story will keep me going for a week. You see it made me realize that it can be done in Malawi, it can be done in Bwaila. It justs needs the whole team to work together, to move fast, to really believe that the way they work that what they do WILL and DOES make a difference. That it is in their power to save lives not once or twice but many times. Before I left theatre with that baby and put it into the outstretched hands of the guardian I thanked them all, the doctors and nurses and theatre staff and told them what a wonderful job they had done. Later I used this example in my workshop to illustrate once more that what we do and how we act can make a difference. They need to be told. I think that they often think that what ever they do nothing will change.I dont believe it ...not yet...please.. not ever.
Befoer I left today I went to post natal ward. There I found her. A strong looking woman lying on her side with her little girl suckling at her breast. I wonder if she realizes how lucky she is to be alive and to have a live baby?

I've bought my car! Its blue, its little and its nippy! Its a four wheel drive and much higher off the ground, just right for my vivits to the villages. Next week I shall try it out as I go to visit my twins and my miracle baby. Now I have another miracle baby.... I hope I will have many more.

Some of you have asked how you can help my mums and babies how you can get involved. I refer you to my friend Carol who is supervising my sponsorship and continues to raise money for Bwaila hospital. SOS Malawi carolarad2000@yahoo.com I'm sure she will be pleased to hear from you.