SOMETIMES A STRUGGLE

The back-up generator broke down and the power went off on Sunday morning from eleven am. until nine pm.
The on call anesthetist just didn’t show up for duty
….but life went on at Bwaila.
These sort of situations are unimaginable in the developed countries but not with us here at Bwaila, one of the busiest maternity units in the whole of Southern Africa.
So what happened?
38 babies were born during that time.
6 mothers were transferred to the new referral unit it the central hospital for emergency c/sections and 2 babies died. Fortunately we didn’t lose any of our mothers.
I arrived on labour ward on Monday morning unaware, at that time, of the difficulties that had been faced by our staff the previous day and night. The only evidence was the half burnt candles still present around the ward. Many babies will have been born by the light of those few candles and many will have been born in darkness. I was approached by the clinician who had been on call that night. ‘How’s the night been?’ I enquired. ‘Bad, really bad!‘ he replied and proceeded to explain the situation. He asked me to come and see the woman in room 1. It was her 3rd pregnancy. She was fully dilated and had been pushing since 1am. That was over six and half hours ago! The clinician had tried to extract the baby with the aid of a vacuum extraction somewhere around 2am. but without success. He tried in vain to send her to the referral unit but was told that they were too busy. Unable to make any other arrangements and without the anesthetic necessary to perform the emergency c/section, she was still in her room contracting and pushing when I examined her at 7.30am. The fetal heart beat was still present but inevitably showed signs of severe distress. It was immediately apparent that there was no way this baby could be born vaginally. Time was running out for the baby and possibly for the mother, who after so many hours of obstructed labour was in danger of rupturing her uterus which would result in the need to remove the uterus and could lead to severe haemorrage and possible death. I quickly made sure that she was prepared for theatre and asked the clinician to find out if theatre staff could take her in immediately. Fortunately the anesthetist on duty Monday morning had just arrived. Our voluntary obstetrician from the UK was also present and surgery was commenced. It was a risky and complicated procedure due to the time that she had been obstructed needing the help of our German consultant obstetrician. Having extracted a dead baby they then went on to remove her uterus which had been on the point of rupturing with uncontrollable bleeding.
Today she is recovering in our high risk postnatal ward, she is not in danger of losing her life and that is a good.
Of course this is not acceptable. Of course this brings feeling of anger and frustration but we are in one of the poorest countries in the world. The whole health system is inadequate for its people. We are understaffed, under skilled and poor equipped in every way. As clinicians and midwives at Bwaila we are improving, the care and attention to the patient is rarely consistent and the infrastructure does not always support us but we must keep positive and enthusiastic as we aim for excellence.
The new Ethel Mutharika Maternity Wing has now opened at the central hospital. Bwaila will slowly change its function to becoming the District Maternity Unit. All the high risk patients will be sent to the new wing where they can be cared for by a larger medical team and backed-up with an intensive care unit and improved neonatal services.
We will continue to be extremely busy as we the care for the women and babies of the ever increasing and expanding population of the district of Lilongwe. We will still receive referrals from the health centres and villages as well as caring for the pregnancies, babies and young children of the area. Dealing with emergencies, stabilizing patients for transfer and maintaining our own operating theatres will continue to be a huge task. We will lose our doctors to the central hospital leaving the unit to be staffed by Clinical Officers and midwives. The need for more highly skilled midwives will be greater than ever. Midwives able and ready to use their knowledge, make accurate assessments, good decisions and follow through as skilled practitioners is my aim.
I continue to do classroom teaching twice a week and bedside teaching on a daily basis. It’s tiring and often frustrating but it’s slowly making a difference and I am proud of the way some of our midwives are responding.
At the beginning of the year I was able to find funding to present a ‘midwife of the month award’ as a means of encouraging good practice. At that time it was very clear who would win the award as those few clearly out-shone all others. I am pleased to say that we are now finding it very difficult to select just one person each month. This is a sure sign that there are now many outstanding midwives. I find this extremely encouraging…..and you should too!
Last week was a quiet week. Just 25 to 30 births each day. We continued to keep busy but without the sensation that many of the women were receiving less than adequate care.
Today is Monday. I arrived on labour ward soon after 7am. 18 babies were born before 12midday. Just 5 midwives reported for duty this morning. We then lost 2 of them to meetings which left 3 of us to cover the ward, admission room and theatre. There are always problems to solve from the night and also things left over from the weekend. Inductions, prolonged labours, fetal distress, referrals, all needing our time and skills. This generally means that the easy ones end up birthing alone, calling out for the midwife as they push their babies out onto the bed. We enter the room just to clamp the cord delivery the placenta and move on. The babies get weighed, later…. if we find time, the documentation is scanty and the after-care often non- existent. I must have delivered more than 10 babies myself but did not have time to take even one blood pressure. In an attempt to avoid un-necessary c/sections I assisted two women with vacuum extractions and successfully delivered a breech on a very young primigravida. The baby needed resuscitating and the mother suturing. The outcome was good for both, but extremely time consuming, meaning that other mothers just had to wait. The midwives seem tired and demotivated today which I always find distressing. We very quickly ran out of delivery packs meaning that for each and every birth I had to search the ward for some way to improvise. The cupboards were almost empty as they had not yet been restocked after the weekend. I could not find any suture material or cord clamps. It was a hard day for me both physically and emotionally.
Last Thursday we had a visit from a team representing the Nursing Council. They came to inspect the ward and the care and attention we are giving to the mothers and babies. The meeting this morning, which I would like to have attended but could not due to shortage of labour ward staff and heavy workload, was to receive the feedback from their visit. Later this afternoon I found time to hear from one of my colleagues the contents of the report. It was highly critical. The infection prevention standards are not being met. The documentation was poor. The care was not up to standard. The midwives had a very defensive attitude. I was angry and disappointed but not surprised. No account was taken of either the huge lack of staff or materials. This report in my opinion served only to decrease an already low morale. So much of my time at Bwaila is spent in raising morale, keeping the atmosphere happy and positive, giving praise for simple tasks done correctly and celebrating good outcomes. I truly believe that although some official appraisal and control of standards is vital it must be done in a realistic and positive way. I wonder how long it will take to get back the enthusiasm at Bwaila?
Just to end on a happier note…..
Fiona has just celebrated her 21st Birthday in Leeds. I was sad not to be able to be with her but will have a special something with her in December when I am in UK.
Katy and Nick’s wedding is getting nearer (Dec.30th) Invitations are being sent and the dress fittings will start soon. It’s all so exciting I can’t wait!
Alasdair is on the lookout for a good job now that he is a fully qualified vet. He was recently interviewed but hasn’t heard yet if he has been successful …….
Lucas is fit and well again after having being diagnosed and treated for Bilharzia. (A nasty little bug picked up in the lake.) He took part in his 1st fishing competition last weekend. He was delighted to win 4th prize.
Sometimes we have to struggle…..sometimes not. The issue is not the struggle: the issue is who we are as we engage in it.