We have 14 beds on labour ward at Bwaila hospital. It is the traditional ' nightingale ward ' which allows little or no privacy for the labouring women as more often than not the curtains hanging round each bed ar either torn broken or not present. The beds are about 1.5m apart which does not allow much freedom of movement for the woman or the midwife. However this ' layout ' does have its advantages as it allows the understaffed midwives to, at least, be aware of what is going on in most of the ward. If you can't see them you can hear them. " Nursey! nursey! nursey! " they cry to attract our attention., very often when the babies head is emerging, so all we can do is run to catch the little one coming out. However it doesn't always work. I should tell you of the birth on night duty, I wasn't present. The woman cried out alerting the staff that the baby had been born. The midwife approached the bed with her equipment but there was no sign of the baby. On closer inspection the newborn was found dangling by the umbilical cord over the side of the bed! Both mother and baby are fine.....now!
We are attending around 40 to 50 births a day so, as you can imagine, it is not unusual to find that we have no spare beds. Labouring women will stand beside the bed of a recently delivered mother just waiting for her to get up and go to the shower so she can claim her bed! ( It reminds me of people waiting in restaurant queues for the next available table. Trying to judge if the diners on table one, who are taking coffee, will then ask for a liquor after or just go straight for the bill and what a relief when you see them putting on their coats and getting up to go!) No spare beds means that women will birth on the floor. This can be an advantage as she will rarely lie down but be in whatever position she finds most comfortable but the disadvantages are that the cement floors are extremely dirty, hardly ideal for receiving a newborn and most midwives would not get down on the floor to assist. And so it was on Monday morning when I arrived. " A full house! " I was told. I enquired as to where I should start? Who was pushing? Any problems? I was asked to attend bed 8. " She was fully dilated at 6am. but we've been so busy we told her she would have to wait " And she had! As I went to her bed I passed a woman crouching on ' all fours' on the floor. She was moaning loudly, obviously in advanced labour, but as there was no bed and I had another to attend I left her on the floor. It was her first baby and the head was low. I got her out of bed and onto the birthing stool. " Can I push now" she enquired and was happy and relieved that she didn't have to wait any longer, that she had someone to care for her and so she started pushing. Ten minutes later, with much encouragement I started to see the head, the fetal heart was fine and she was doing well. I had been looking over regularly at the woman on the floor to see how she was doing and shouting words of encouragement. " We'll have a bed soon, don't worry " I dont expect she understood me but then again my words were not only for her, but for the other midwives standing around. Its a dangerous time to give birth as the night nurses have finished and the day staff have not yet started. " Can someone attend that woman please I begged" Too late! The cleaner shouted out " Baby born!" Still no one seemed to move, so I left my young first timer and rushed to her side. The baby had been born by the breech ( bum first) and was hanging by its head while she stayed on all fours position. This is a great position for normal births but absolutely NOT for breeches. I got on the floor and quickly managed to help the head to be born, it was not easy, even with my experience in attending in all sorts of positions. The baby needed immediate resuscitation which I did. Still no movement from my colleagues! " Please will someone get her onto a bed " I cried. " Can you check if there is a twin as the baby is quite small. " I asked. It took about 10 minutes to get another woman off to the shower and wash the bed. In that time I continued to work on the baby all the time asking for them to hurry up and please check if there was a twin. By the time she was on the bed and being attended by 2 students the baby was breathing spontaneously so I left her with oxygen and approached the bed. They had confirmed a 2nd twin but still had not listened for the fetal heart or determined the presentation. I continue to be amazed by the total lack of a sense of urgency amoung my fellow midwives. I could not bear it, so I just took over. "She has one nearly dead baby by god we're going to save this one " I exclaimed. They had not heard a heart beat! I examined her, determined a head presentation, ruptured the membranes, applied a vacuum extraction and as she pushed I pulled that baby out. It was not difficult but it was urgent. The baby's condition was poor so I left the students to attend to the woman and resuscitated the 2nd little girl. Both babies responded well and are now in nursery. The students working in Nursery have taken a special interest in them and I have visited them everyday since. I am happy to say that they are doing well. Both are breast feeding, they have lost weight and are being treated with antibiotics but after the first 24hours on oxygen are now maintaining well. I was able to take them some of the clothes and blankets that Katy brought over given by very generous donations. I hope to continue to follow their progress when they are discharged.
Just to finish I should tell you of our visitors to labour ward this week. We have received a large group of senior midwives, tutors, matrons, clinical instructors etc.from all the different university training centres in Malawi. They are on a 3 week goverment course funded by an NGO specifically to revise and refresh their practical knowledge so has to improve their teaching both in the classroom and in the clinical situation. Part of their updating is to look at different birthing positions, freedom of movement in labour, spontaneous pushing and instinctive birthing behaviour. They had been told that in Bwaila maternity unit we are already practising this type of care. Hallelujuh ! Its just what I have been teaching and trying to implement, but how much better that it now comes from official ministry sources and encouraged by their own people. I have had the opportunity to work with these midwives this week and we have had more vertical births than ever. Women were seen crouching, standing, moving around and generally off the bed. Yesterday I was able to demonstrate how to attend the delivery of twins with the woman sitting on the birthing stool.
I am happy and extremely encouraged.
Thursday, 25 September 2008
Thursday, 18 September 2008
HORRIBLE AND HAPPY
I was glad to be back on labour ward on Monday. I spent the weekend missing my girls and feeling a bit sorry for myself.
It was as busy as ever and we had a new set of student midwives who had started whilst I was away. Their time is to be spent attending high risk women so this is a very important part of their clinical training.
These midwives will soon be out on their own in the district health centres and hospitals so I am quick to point out to them the district referrals that we receive so as they can become aware of the dangers of waiting to long before sending these women to us. We had an especially busy morning on Tuesday when we received up to 10 referred cases. I was appalled to find one woman, labouring her 5th child, who had been pushing "since yesterday"
Her whole lower regions were swollen beyond recognition. I quickly and easily diagnosed a posterior prestentation ( the baby looks up instead of down) a huge full bladder that obstructed the descent of the babys head and severe fetal distress. Examing her I felt sure that we could assist a vaginal delivery, though difficult. I made a quick decision that the childs life was already compromised that a c/section would take at least 30 minutes to get the baby out and that her other 4 children needed a fit healthy mother. She has more chance of this with a vaginal delivery. Any operative procedure carries a very high risk for the mothers here in Malawi. From haemorrage, underlying conditions such as Hepatitis or HIV,severe and chronic anaemia and sepsis due to little personal hygiene, no clean or running water, not to mention the deplorable state of the operating theatres and the sometimes very inexperienced clinicians. I referred to the clinician on duty and the senior midwife. Neither were too sure but I have now built up a good relationship with them all. They trust me and will refer to me in many difficult situations where decisions have to be made. So we worked together and the baby was born with the assistance of a vacuum extraction. Leaving the clinician to care for the mother I rushed the little one to the resuscitaire and commenced profound resuscitation. I did not feel confident that my efforts would be successful but at least I could try. The baby responded slowly so I continued to work on him. When I had achieved spontaneous breathing , though still with difficulty I transferred him to the nursery. I handed him over to the nursery nurses telling them that I was not hopeful that he would survive. It was a long hard morning. I had intended to leave at 3pm having worked non stop since 7.15 am but just had to help sort out 2 other situations before I left. Sometime around midday a young woman having her 1st baby arrived. A very late referral for prolonged labour. We could only find a slow heart beat. My Norweigian midwife colleague called me to assist a vacuum extraction, she felt sure the baby would come with a little help. She was not successful with her first pull so asked me to take over. The baby would not come even though it was very close. I felt that there was some other reason for this difficulty.. it didn't make sense.. I tried to find the babys heart beat before continuing but it was not to be found. When a baby has died in the uterus it is much more difficult to birth. Babies also play a part in facilitating their own birth. My colleague agreed that she had probably been hearing the mothers pulse. This we confirmed on ultra sound scan. Sadly we explained to her that her baby had died, she had been pushing too long.We decided to leave her a while to see if she could birth with less violence as now there was no hurry to get the baby out. I gave her some sedation so she could rest and would feel less pain.At 3pm she was still no closer to birthing her dead child. I enquired of the clinician on duty as to when she would come to assist the woman. She was the only clinician left on duty. Where the others had gone I dont know . She had to do an urgent c/section and possibly another after. I could not go home and leave this woman. It was likely that she could not be attended for several hours. Her uterus was still contracting.she was still being forced by her own body to push her child out. I called to another midwife and a student to assist me. A c/section in these circumstances would be unforgivable. The only other option is to destoy the baby. I had to try. I pulled and she pushed
my fellow midwives encouraged her to use all her strength. I sweated and manipulated untill at last the little one came. What a relief ! Not nice, not at all pleasant, never to be done in your rich and well developed world where clean and safe operating theatres are the norm. Where anesthetics and anaesthetists are readily available but the best option here. Today she was discharged home, without a baby but alive and well and with the possibility of other pregnancys, of other babies...I hope.
I eventually left at 4pm!
Arriving on Wednesday morning I was greeted by a call from a fellow midwife who was having problems. I don't know how long the woman had been pushing but the baby was not coming. I could see a large part of the fetal skull so suggested an episiotomy (cut in the perineum) might be helpful. This she did . The head was born and the shoulders got stuck. Following the correct manouvers of which I have now had plenty of practice the baby was born. I immediatley realized that this baby was severely distressed so quickly carried his floppy body over to the resuscitaire. I found a slow heart beat but nothing else. It was 7.15am. I had just arrived. Hardly time to put on my apron and I found myself resuscitating a nearly dead baby. As I stood there doing all I could. Giving my best . Inflating his little lungs suctioning the mucous from his throat, I began to wonder when this would all stop? How much longer would the rich world let this carry on? Its not as if they don't try .....millions of dollars are being poured into Malawi so why is it not working? Why am I still finding these hopeless situations daily? The baby was pink, the chest was rising I was inflating his little lungs the heart was beating strongly but he just would not breath. I could see that his pupils were already dilated, he was already brain damaged the respiratory centres in his brain were not functioning but I carried on. At 7.40am the students started to arrive. I had been breathing for him for 25 minutes but he still showed no signs of improvement. How long do I carry on? Can I really stop? When? I asked a student to take over, we would continue a while longer. I went to look at the mothers file and give her the news that her baby would not survive. The labour graph told me that niether she nor the baby had not been attended since 12midnight, when she was found to be 8cms dilated. That means she would have expected to give birth between 2 and 4 am. the baby was born at 7.15 am! I went back and told the student to cease resuscitation. It was nearly an hour since the birth. The baby was making a few gasping sounds so I left him under the warm heater with an oxygen supply. The doctors and clinicians came to make their grand "round" It was commented by a white visiting doctor as to "why had that baby been left there and abandoned? " I just cried. My Malawian midwife colleague held in her arms andgave me a big hug and reminded me we can only do so much, we can only do our best, we cant do more. The baby died in nursery during the afternoon. Later I went back to check the labour graph and found that the times had been changed that the graph had been manipulated. It is not the first time that I have witnessed this but this is still too big for me to confront.
Most afternoons I call by nursery to see 'my' babies. I found the woman I had attended the day before sitting on the floor with her baby in her arms. I asked the staff how he was as I had expected him to die. " Improving" they assured me. I knelt on the floor and the mother started talking to me. "What is she saying?" I asked.
" She says she has no milk for him" I gently squeezed her breast and out came those precious drops of calostrum which I put onto his lips. He began to respond so I squeezed out more. Bringing the baby close to the breast I carefully put her nipple into his mouth. He sucked! There was no hesitation, he latched on beautifully and wouldn't let go! His mum gave me a huge smile and the students working in nursery looked on in amazement. I still wonder if he will be brain damaged and if so, how severely but at the present he is happily sucking away at his happy mum's breast.
Yes that will keep me going for a while!
It was as busy as ever and we had a new set of student midwives who had started whilst I was away. Their time is to be spent attending high risk women so this is a very important part of their clinical training.
These midwives will soon be out on their own in the district health centres and hospitals so I am quick to point out to them the district referrals that we receive so as they can become aware of the dangers of waiting to long before sending these women to us. We had an especially busy morning on Tuesday when we received up to 10 referred cases. I was appalled to find one woman, labouring her 5th child, who had been pushing "since yesterday"
Her whole lower regions were swollen beyond recognition. I quickly and easily diagnosed a posterior prestentation ( the baby looks up instead of down) a huge full bladder that obstructed the descent of the babys head and severe fetal distress. Examing her I felt sure that we could assist a vaginal delivery, though difficult. I made a quick decision that the childs life was already compromised that a c/section would take at least 30 minutes to get the baby out and that her other 4 children needed a fit healthy mother. She has more chance of this with a vaginal delivery. Any operative procedure carries a very high risk for the mothers here in Malawi. From haemorrage, underlying conditions such as Hepatitis or HIV,severe and chronic anaemia and sepsis due to little personal hygiene, no clean or running water, not to mention the deplorable state of the operating theatres and the sometimes very inexperienced clinicians. I referred to the clinician on duty and the senior midwife. Neither were too sure but I have now built up a good relationship with them all. They trust me and will refer to me in many difficult situations where decisions have to be made. So we worked together and the baby was born with the assistance of a vacuum extraction. Leaving the clinician to care for the mother I rushed the little one to the resuscitaire and commenced profound resuscitation. I did not feel confident that my efforts would be successful but at least I could try. The baby responded slowly so I continued to work on him. When I had achieved spontaneous breathing , though still with difficulty I transferred him to the nursery. I handed him over to the nursery nurses telling them that I was not hopeful that he would survive. It was a long hard morning. I had intended to leave at 3pm having worked non stop since 7.15 am but just had to help sort out 2 other situations before I left. Sometime around midday a young woman having her 1st baby arrived. A very late referral for prolonged labour. We could only find a slow heart beat. My Norweigian midwife colleague called me to assist a vacuum extraction, she felt sure the baby would come with a little help. She was not successful with her first pull so asked me to take over. The baby would not come even though it was very close. I felt that there was some other reason for this difficulty.. it didn't make sense.. I tried to find the babys heart beat before continuing but it was not to be found. When a baby has died in the uterus it is much more difficult to birth. Babies also play a part in facilitating their own birth. My colleague agreed that she had probably been hearing the mothers pulse. This we confirmed on ultra sound scan. Sadly we explained to her that her baby had died, she had been pushing too long.We decided to leave her a while to see if she could birth with less violence as now there was no hurry to get the baby out. I gave her some sedation so she could rest and would feel less pain.At 3pm she was still no closer to birthing her dead child. I enquired of the clinician on duty as to when she would come to assist the woman. She was the only clinician left on duty. Where the others had gone I dont know . She had to do an urgent c/section and possibly another after. I could not go home and leave this woman. It was likely that she could not be attended for several hours. Her uterus was still contracting.she was still being forced by her own body to push her child out. I called to another midwife and a student to assist me. A c/section in these circumstances would be unforgivable. The only other option is to destoy the baby. I had to try. I pulled and she pushed
my fellow midwives encouraged her to use all her strength. I sweated and manipulated untill at last the little one came. What a relief ! Not nice, not at all pleasant, never to be done in your rich and well developed world where clean and safe operating theatres are the norm. Where anesthetics and anaesthetists are readily available but the best option here. Today she was discharged home, without a baby but alive and well and with the possibility of other pregnancys, of other babies...I hope.
I eventually left at 4pm!
Arriving on Wednesday morning I was greeted by a call from a fellow midwife who was having problems. I don't know how long the woman had been pushing but the baby was not coming. I could see a large part of the fetal skull so suggested an episiotomy (cut in the perineum) might be helpful. This she did . The head was born and the shoulders got stuck. Following the correct manouvers of which I have now had plenty of practice the baby was born. I immediatley realized that this baby was severely distressed so quickly carried his floppy body over to the resuscitaire. I found a slow heart beat but nothing else. It was 7.15am. I had just arrived. Hardly time to put on my apron and I found myself resuscitating a nearly dead baby. As I stood there doing all I could. Giving my best . Inflating his little lungs suctioning the mucous from his throat, I began to wonder when this would all stop? How much longer would the rich world let this carry on? Its not as if they don't try .....millions of dollars are being poured into Malawi so why is it not working? Why am I still finding these hopeless situations daily? The baby was pink, the chest was rising I was inflating his little lungs the heart was beating strongly but he just would not breath. I could see that his pupils were already dilated, he was already brain damaged the respiratory centres in his brain were not functioning but I carried on. At 7.40am the students started to arrive. I had been breathing for him for 25 minutes but he still showed no signs of improvement. How long do I carry on? Can I really stop? When? I asked a student to take over, we would continue a while longer. I went to look at the mothers file and give her the news that her baby would not survive. The labour graph told me that niether she nor the baby had not been attended since 12midnight, when she was found to be 8cms dilated. That means she would have expected to give birth between 2 and 4 am. the baby was born at 7.15 am! I went back and told the student to cease resuscitation. It was nearly an hour since the birth. The baby was making a few gasping sounds so I left him under the warm heater with an oxygen supply. The doctors and clinicians came to make their grand "round" It was commented by a white visiting doctor as to "why had that baby been left there and abandoned? " I just cried. My Malawian midwife colleague held in her arms andgave me a big hug and reminded me we can only do so much, we can only do our best, we cant do more. The baby died in nursery during the afternoon. Later I went back to check the labour graph and found that the times had been changed that the graph had been manipulated. It is not the first time that I have witnessed this but this is still too big for me to confront.
Most afternoons I call by nursery to see 'my' babies. I found the woman I had attended the day before sitting on the floor with her baby in her arms. I asked the staff how he was as I had expected him to die. " Improving" they assured me. I knelt on the floor and the mother started talking to me. "What is she saying?" I asked.
" She says she has no milk for him" I gently squeezed her breast and out came those precious drops of calostrum which I put onto his lips. He began to respond so I squeezed out more. Bringing the baby close to the breast I carefully put her nipple into his mouth. He sucked! There was no hesitation, he latched on beautifully and wouldn't let go! His mum gave me a huge smile and the students working in nursery looked on in amazement. I still wonder if he will be brain damaged and if so, how severely but at the present he is happily sucking away at his happy mum's breast.
Yes that will keep me going for a while!
Friday, 12 September 2008
MY GIRLS IN MALAWI
I have just returned form leaving my two girls, Katy and Fiona at the airport. I am sad.
They have been with me for 9 days and we were able to take a short trip to the lake and the game park and thus introduce them to a little of Malawi, of Africa.
It has been a wonderful time for me. I have enjoy their company, their love and their interest in everything.
During the first few days I was able to take them to Bwaila hospital to show them where I am working and the conditions under which the poor women of Lilongwe are being attended. They were both amazed and saddened to experience, first hand, some of the things they have been following in my blog and our regular phone calls. They were particularly interested in our nursery and the tiny babies that are being cared for. Just 900 grams and very premature it was difficult for the girls to hear that these babies have very little chance of surviving as both the facilities, the equipment and the medical expertise are not available.
Katy had been busy collecting money, clothing and toys, crayons, books and note pads for the past months. The response to her call was wonderful making it possible for her to bring not only a large number of these things but also more expensive items such as a doppler for listening to fetal heart rate, and weighing scales much needed by the Traditional Birth Attendents in the villages. We were able to visit an orphanage, a small mission clinic by the lake, two TBA's as well as distributing to the many women and babies "camped out" in the grounds of Bwaila hospital.
We visited my twins in the village and also one of my "miracle babies" These were both wonderfully enriching experiences for the girls who were able to appreciate true Malawian village life. We we received by the head man of the village which was a great honour.
We were entertained to homemade doughnuts sitting inside a cool mud hut and much time was spent blowing up and playing with balloons with the numerous children many of whom had never seen nor touched a balloon. We warned them that it may pop making a loud noise but it still suprised them!
The twins were looking big ! They are now nearly 8 months old. Unfortunatly they were suffering from vomiting and diarrhoea so we took them all, in my small jeep, to the clinic and left Pilirani with money for medicine and transport home. It was quite a squash... 6 adults and 2 babies ...but nobody seemed to mind!
The girls soon became aware that wherever we went there was poverty and need. They were able to give small gifts to the children as we travelled and were rewarded with dancing, with obvious joy and huge smiles. But they too soon found that there was never enough to give. Where they thought there were just 2 or 3 children, suddenly, out of nowhere, dozens of little ones appeared. At times it was very frustrating. They too felt the conflict and confusion of bargaining for every small wooden carving or craft that they wanted to buy. How much to pay ? Was it enough ? Maybe they could pay more? Should they pay more?
I am looking forward to going back to labour ward tomorrow after a week off. I know it continues to be very busy and there are many new students. I feel strong and positive. There is much to do...
They have been with me for 9 days and we were able to take a short trip to the lake and the game park and thus introduce them to a little of Malawi, of Africa.
It has been a wonderful time for me. I have enjoy their company, their love and their interest in everything.
During the first few days I was able to take them to Bwaila hospital to show them where I am working and the conditions under which the poor women of Lilongwe are being attended. They were both amazed and saddened to experience, first hand, some of the things they have been following in my blog and our regular phone calls. They were particularly interested in our nursery and the tiny babies that are being cared for. Just 900 grams and very premature it was difficult for the girls to hear that these babies have very little chance of surviving as both the facilities, the equipment and the medical expertise are not available.
Katy had been busy collecting money, clothing and toys, crayons, books and note pads for the past months. The response to her call was wonderful making it possible for her to bring not only a large number of these things but also more expensive items such as a doppler for listening to fetal heart rate, and weighing scales much needed by the Traditional Birth Attendents in the villages. We were able to visit an orphanage, a small mission clinic by the lake, two TBA's as well as distributing to the many women and babies "camped out" in the grounds of Bwaila hospital.
We visited my twins in the village and also one of my "miracle babies" These were both wonderfully enriching experiences for the girls who were able to appreciate true Malawian village life. We we received by the head man of the village which was a great honour.
We were entertained to homemade doughnuts sitting inside a cool mud hut and much time was spent blowing up and playing with balloons with the numerous children many of whom had never seen nor touched a balloon. We warned them that it may pop making a loud noise but it still suprised them!
The twins were looking big ! They are now nearly 8 months old. Unfortunatly they were suffering from vomiting and diarrhoea so we took them all, in my small jeep, to the clinic and left Pilirani with money for medicine and transport home. It was quite a squash... 6 adults and 2 babies ...but nobody seemed to mind!
The girls soon became aware that wherever we went there was poverty and need. They were able to give small gifts to the children as we travelled and were rewarded with dancing, with obvious joy and huge smiles. But they too soon found that there was never enough to give. Where they thought there were just 2 or 3 children, suddenly, out of nowhere, dozens of little ones appeared. At times it was very frustrating. They too felt the conflict and confusion of bargaining for every small wooden carving or craft that they wanted to buy. How much to pay ? Was it enough ? Maybe they could pay more? Should they pay more?
I am looking forward to going back to labour ward tomorrow after a week off. I know it continues to be very busy and there are many new students. I feel strong and positive. There is much to do...
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