QUIET TIMES KEEPING BUSY

I can't really believe it has been so long since I last wrote to you all. Did you think I had forgotten you?Its nearly Easter and school holidays. I am hoping to take a few days off to go away to the lake with Lucas.Labour ward has been remarkably quiet this past month. This means that we have been attending around 25 births a day instead of the usual 40 and above. In many ways that is good as it gives the midwives a chance to rest and breathe but as we have around 10 midwifery students on the ward doing their practical placement it some times feels as if they are fighting for deliveries! We also have 4 midwives who are in training for obstetric emergencies they are also desperate to gain experience. I wonder how many vacuum extractions have been done just so they could learn? All these students need close supervision and bedside teaching so it has been a pleasure for me to spend time with them, to share my knowledge and experience. I am continuously reminded as to how much I enjoy clinical teaching.This morning I was contemplating the decreased number of births in the month of March and wondering what could possibly be the cause? Remembering back to this time last year this was not the case. I wondered if it could be a much needed drop in birth rate? the greater use of condoms? increased education in birth control? Are things beginning to change? But then as I thought more I realized that we are still in the rainy season and the month of March has been particularly wet. Roads and bridges have been washed away. Many villages have been unreachable. Access to the more remote areas is now only by foot or ox cart. So I began to wonder, could this be the reason that the hospital has been so quiet? I hope not. What would this mean? The reality of the situation began to dawn on me. If the villages are inaccessible and the rain has prevented the women from coming to receive our care, who has been attending them? Where have these babies been born? What has been the outcome? These questions are almost impossible to answer. Most of the births and deaths that occur in the rural areas, unless they have been referred to a health facility, will never be registered. So we will never know how many have been born and how many have died.
Two weeks ago I was called from labour ward to nursery twice in one day. I was introduced to an old ( or at least she looked old) woman cradling a small baby in her arms. Her daughter had died in childbirth and she had no money or means to buy formula milk to feed the child. I was able to reassure her that through our feeding program to aid the orphans from Bwaila nursery we would be able to support her. She took her tins of milk and we promised to visit her the following week. The second call was a grandmother with twins of nearly one year old. These babies had been born in our hospital, prematurely and been cared for in our nursery. All was well until her 20 year old, unmarried, mother died suddenly. The grandmother could not look after the twins so came back to the only place where she had found care and attention. We were also able to help her, at least for a while. March is a particularly difficult time of the year for the poor people of Malawi as some of the maize is not ready to harvest and the rains are causing crop damage. This is the time that many are starving. There are so many people who need help the task is overwhelming.
Luiza was brought in to labour ward one morning, on a trolley, from an outlying health centre. Her baby had been born at home, in her village, assisted by a TBA. (traditional birth attendant) The birth had taken place without incident but the placenta was still inside her uterus. She had been bleeding profusely. When I first saw her I thought she was dead. She was so thin and gaunt I wondered how she could possibly be alive. My immediate reaction was to wonder how on earth could she have carried a baby to full term? Why had she stayed in her village to birth her baby when she was so obviously seriously sick and how was it she had not found help earlier? But those were questions for later, first we had to resuscitate her, but even if we did, would she really live more than a few hours? We started to care for her. We decided not to remove the placenta, at this time, as she was not bleeding more importantly we needed to stabilize her condition. I took blood samples and sent then to the laboratory. We slowly rehydrated her and awaited blood to arrive for transfusion. It didn't come. Eventually I was told that the centrifuge machine was not working so the blood could not be matched. The samples should be taken to the central hospital in the ambulance. By now it was almost lunch time and lunch time is sacred. Not an ambulance was to found and no driver answering his phone. Leaving Luiza with my colleagues I got in my car and drove the 5 kms. to fetch blood. I was lucky to find a technician in the laboratory who could process the samples and supply the blood. It also helped to mention that my good friend and neighbour, Bibiana, is a quality control supervisor in that department! I rushed back with a bag of blood (only 1 bag not 2) and started the transfusion. Slowly Luiza started to regain consciousness and began to talk to her guardians. I cared for her the rest of the afternoon. Later I was able to successfully remove the placenta with no further bleeding. When I left that evening the 2nd bag of blood that I had been promised had still not arrived. I phoned to check.'Yes they would send it'Her baby was small 1.9kg but strong and healthy. I went to nursery to get formula milk as Luiza was still critically ill and could not breast feed. I couldn’t stop thinking of her that evening wondering how it was possible and what were the beliefs and customs that allowed that young woman not to seek help for her illness. Yes she was HIV positive but testing and treatment is readily available, free of charge and often very successful. Despite our care and attention I didn’t think that Luiza would last the night. The best I hoped for was that my fellow midwives would care for her well in her last hours.Luiza was still alive the following day but still critically ill. The blood that was promised arrived at 9am. Whilst it was still transfusing Luiza died. Her baby was taken to be cared for by her family. That is the best we can hope for as so many are abandoned to be cared for in orphanages.
Do you remember the story of Laureen? Or maybe I didn’t tell you? She was the 2nd child of a educated mum. Her grandmother was also present at her birth as she is a midwife in Zomba. What should have been an easy 2nd birth turned into an emergency when Laureen, who weighed over 4kgs. got her shoulders stuck. The head was born with a huge effort and then no more. It didn’t matter how much her Mum pushed or I pulled she wouldn’t come. I quickly performed the appropiate manouvers for a shoulder distocia but she was truly stuck. I managed to get her Mum into another position and tried again. Eventually I got her out but in the process I managed to break her right arm. Well you can imagine how bad I felt? OK, so I had saved her life but I had BROKEN her arm! In the following days I managed to get her arm x-rayed and seen by an orthopaedic specialist who assured me all would be well and she would heal perfectly. I'm not sure I believed him at the time, but he was proved right and Laureen is now 6 months old bonnie and beautiful with no sign of the trauma she experienced at birth. Last Sunday I was invited to her baptism, I even bought her a frilly dress to wear. I was the only white face in a congregation of over 300 but what the heck!
So, as usual, its ups and downs, good and bad, happy and sad.Last night I read love described as 'agony and ecstasy'That just about sums it up.