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!