TIME OUT

Today I start my annual vacation. We will return to Europe for the month of December. I need rest; I need to recover, to find the renewed strength and enthusiasm vitally needed to face the ongoing challenges that will present at Bwaila next year. To put back, to replenish, to be in the company of my precious children, my family and old friends, to feel their love fill me and their support encourage me to continue to be able to give and to serve the very poor, very neglected, very under privileged women and babies of Malawi.
It’s been a very hard two weeks. Since the new referral unit opened at Kamuzu Central Hospital and we at Bwaila became a District Maternity Unit the number of births we are attending has hardly changed. We are daily attending more than 40 births many of which need very special care and attention.The new central unit took some of the more difficult cases but they also took ALL our medical staff. We are now led by the District Health Management Team who for many reasons, not least the huge area/population that falls into their responsibility, are noticeable by their absence. Staffed mainly by midwives, with their continued reluctance to take on more responsibility, a few clinical officers with very varying abilities plus interns and students it has become evident that the care we are giving is less than adequate and the women and babies are suffering.
Having diagnosed severe fetal distress in a young first time mother who was still not in active labour I found the clinician in charge to request an immediate c/section. It was 12.30pm. Theatre was informed, the admission nurse was ordered to prepare the mother for theatre and I had to leave the unit for one hour. On my return I asked after her and it was presumed that she was in theatre. I thought no more of her and continued with other work. A 2pm I overheard a conversation which sounded as if it concerned this woman. I was called to scan a woman as the midwife couldn't hear the fetal heart. Entering Room 8 I found my emergency c/section woman still waiting to be prepared for theatre. She had been put in a room and been forgotten. I quickly scanned her and to my relief found that the baby's heart beat was still present but extremely fast. This baby was in severe distress. We prepared her for theatre and the baby was extracted at 2.50pm nearly and two a half hours after I had first recognized the problem. The baby was born dead.
This is unacceptable.
Our protocol on the unit is to perform c/section on all first time mothers whose babies are presenting breech (bottom first)
Wednesday morning on arrival at labour ward I was told there was a breech delivery on a primigravida, fully dilated and pushing, in Room 4. On entering the room I could see that both the baby's feet and legs were visible, blue and puffy. This baby needed delivering fast. Realizing that it was too late for a c/section I quickly put up an IV and emptied her bladder. I delivered the baby with the appropriate maneuvers and some help from a young Norwegian midwife colleague. After resuscitating the baby it was able to stay with its mother without need for nursery care. This mother had been on our labour ward for most of the night but the breech presentation had not been diagnosed.
This is unacceptable
Thursday morning I arrived as usual at 7.15am. I enquired if there were any problems and was told there was a breech to be delivered in Room 2. On entering I found both feet and legs already delivered, blue and puffy. Glancing at her case file I realized she was a primigravida... NOT AGAIN! I commenced the IV line and emptied her bladder and couldn’t believe that I was facing the same again, two consecutive days. Slightly encouraged by the experience of the previous day though a little alarmed by the size of the baby's feet (I imagined a big baby) I started to deliver the breech. The shoulders came well, with the correct maneuvers, but the head got stuck. I attempted all the correct maneuvers, instructed a colleague to assist and at last the baby's head was born. I rushed the baby to the resuscitaire but my attempts were in vain. The baby died.3.3kg...Too big for a 17 year old woman. Looking back over her file I found that she had been admitted before midnight, the midwife had not been sure of the presenting part so requested USS confirmation. The young intern performed the scan and was also not sure but documented that the scan should be repeated in the morning by seniors. Both recorded a head presentation. She spent the night on the Ante Natal Ward calling for help around 7am as she felt her 'waters' break and 'something' in her vagina. She was attended 30 minutes later when she was found with the baby's feet protruding. They rushed her to labour ward which is where I found her. Three mistakes from inexperienced staff with no senior back up resulted in a young mother with no live baby.
This is unacceptable.
Friday morning I arrived at the same time. I looked into Room 2 and saw one of our new midwives attending a birth. I opened the door to greet her and ensure she was OK when I became aware that a breech was hanging out delivered to the level of the umbilicus. The shoulders and head had still not been born. I noted that the baby's colour was blue nearly white and the umbilical cord was not pulsating, this is not a good sign. I had no idea of what had happened prior to my entry nor how long the baby had been waiting to be born but I could see that it needed delivering quickly. I encouraged the midwife to actively assist with the birth of the shoulders when it became obvious that she was unsure as to how to manage the situation. I tried to explain but quickly had to 'take over.' The shoulders came easily. 'Is it her first?' I asked. 'No it's her second child' I was told. That made me feel better. I soon realized that no contractions were coming to facilitate the birth of the head. 'Put some Oxytocin in her IV line' I ordered. I looked up...There was no IV line! I had been quick but by now I was extremely concerned for the well being of the baby. Still there were hardly any contractions meaning that the mother’s pushes had little effect. I had already called for help from another midwife who I instructed to assist with the flexion of the after coming head. Should I take time to put up an IV line or continue to try and extract the head? Time was running out and I knew it....whatever I did would be wrong, whatever I did would probably not be in time....I couldn't believe it, I didn't have time to save this baby. Time had run out. Too much time had passed. The baby was already dead, maybe it had died before I entered the room? I don't know, but I felt useless, I felt impotent, I was angry, I was frustrated, I was devastated. I told the mother I could do no more. I calmly put up the IV line with Oxytocin, I emptied her bladder of over 1000mls. of urine and with no more than 3 good contractions and pushes I easily extracted her 2.9kg baby. The baby had died due to a full bladder that had prevented the head from descending, poor uterine contractions with no IV line to allow me to give the correct medication and a huge lack of skilled staff.
This is unacceptable.
Of course it is not only due to lack of staff, to lack of experienced staff, to lack of the drive to improve skills, to implement knowledge and skills that cause these tragedies. No, it is so much deeper and more complicated than that. The wages are unacceptably low, the work load is heavy, constantly heavy, the moral is low and the staff are little appreciated by the higher management. They are easily and quickly critiscised when things go wrong but rarely praised for their efforts.
This is unacceptable.
A few weeks ago our only ambulance was taken to be used on ‘stand by’ for the African Union Conference in Lilongwe. It was parked for a whole week outside the hotel just in case one of those eminent people should need emergency transport. An open ‘pick up’ truck was provided some days or else an old hard top truck. It was in these vehicles I made two emergency transfers to the central hospital. The mother had been transferred to us through a local health centre after a home birth. She had had a massive hemorrhage and was critically ill. We stabilized her condition at Bwaila and managed to find one bag of blood to transfuse but she needed more blood and to be cared for in the ICU. Just getting a patient in this condition into the back of a truck is a challenge but then we also had to transport her numerous relatives with bags and bowls and even a bundle of fire wood. I took up my seat in the front facing backwards to check her condition and carrying an ambu bag just in case she stopped breathing. I prayed that her condition would not deteriorate as I could not imagine performing effective resuscitation in this truck. I ordered the driver to get there quick, that this was an emergency. We started off out of the hospital and onto the busy shopping area surrounding Bwaila. “Put on the siren” I ordered. There was no siren. “OK , then sound the horn” The horn was not working. “Lights” No, not working either.
This is unacceptable
What an amazing driver! Totally oblivious to any danger, or so it seemed, he pulled out into the centre of all the traffic and just kept going. Not to be deterred by either on- coming trucks or pedestrians he just kept going. Luckily I was facing backwards for most of the journey, except when we came to junctions or traffic lights when I stuck my head out of the window, waved my ambu bag and shouted very impolitely for people to get out of the way. It worked .We arrived in record time and delivered our patient into the care of the ICU staff still alive. Our return journey was somewhat more sober. “ Madam,” exclaimed the driver. “ We were all very impressed with how you cared enough to make sure we got there quickly, this is not normal behavior, the relatives have asked me to thank you”
( No I guess this is not usual Malawi behavior but I had done it before. I was reminded of an incident when I was seen almost flying down the mountain road in Spain, waving my white flag out of the window, as I personally and successfully transported one of my ‘home birth’ mothers to the nearest hospital.)
Each and every one of these women stays with me today. My heart is sad and my spirits are low as I leave Malawi. It is such a difficult place to leave. So much to do, so much suffering, so much poverty, such a hard life for so many. I love these people, I want to always do my best for them and it is so hard to accept that even my best is often not enough.

Now I am back in England in the arms of my family and soon I will be reunited with my children.
One is loved because one is loved. One loves because one loves
No reason is needed for loving.
‘

COMPUTER TECHNOLOGY

There’s no denying that computer technology is the way forward. There is no denying that in the long term an electronic patient register along with accurate recording of hospital data will assist us in identifying our shortfalls and so technically lead to improved patient care.....but....
As you may well imagine it’s an attractive proposal for any would be donor. It looks good on paper and sounds convincing…but…
Over the past year I have been actively involved with an expert team as they worked on creating the appropriate software. Funding became available for the setting up of a simple registration system to suit the needs of the unit and provide the necessary hardware. For this we are grateful. Latterly more funds became available to expand the project, meaning that I have needed to dedicate more of my time to attend meetings and aid with preparatory work. I trust this time away from the clinical situation, away from labour ward has been well spent…but…
Inevitably there will be some resistance from the staff at first until they become familiar with this new method of record keeping but we hope that it will lead to far greater accuracy and therefore better care. Leaving paper behind and changing over to electronic recording should ease the constant challenge we face daily when paper is not available for photocopying. We are assured that it will prove to be easier and quicker but at present I doubt it!
I arrived on labour ward last Friday at the usual time (7.15am.) I found the ward full of laboring mothers with many women sitting on the floor outside the Admission Room waiting to be assessed. On enquiring as to how the night had been I was informed that for the second time in one week there had been just 3 midwives on duty…. Three midwives to attend 27 births.
My first job is to take a look round the ward and receive the ‘hand over’ from the night staff. I must make a quick assessment of the situation and start to prioritize. I am usually the first to arrive much to the relief of the tired and overworked night staff. The arrival of my daytime colleagues is generally delayed and sporadic, meaning I often find myself alone or with one other midwife for the following hour. It has always been a difficult time as I try to sort out the problems left over from the night performing vacuum extractions on prolonged labours and subsequently resuscitating babies that should have been born hours before.
The morning report in the conference room attended by the clinical staff, in-charge midwives and matrons begins at 8am. It is an important time when we get together as a team to discuss the events of the previous 24 hours and the plans for the day. Very often I am not able to attend as there is no one else to cover the labour ward.
At 9.30am I was called to a meeting with the matrons of the Family Health Unit ( antenatal clinic, immunizations, postnatal clinic, etc. …all out-patients) We were to meet with those involved in the development of the new ICT program. I left instructions with the student midwife as to the plan of care for the mother with prolonged labour in Room1 and asked a more qualified midwife to cover her. ‘ If she has not delivered in the next hour please assist with a vacuum extraction or send her to theatre’ I always feel uneasy leaving the more difficult cases but I was needed in the meeting. One and a half hours later I returned to labour ward. The baby had just been born and needed resuscitation and the mother was bleeding. I quickly performed the necessary resuscitation and as soon as I felt able to leave the baby went to assist the midwife who was attending the mother. After controlling the hemorrhage I left the student to suture and document.
So I was in a meeting with the aim of improving care, whilst a baby nearly died and a mother nearly bled to death!
How difficult it is at these times to appreciate the possible benefits of a computerized system when we are having such huge challenges just performing the basic care.
The day continued to be hugely busy with many complicated and demanding situations. I was due to attend a further ICT meeting at 1.30pm. but this was just impossible. I could not leave labour ward at this time, especially after my experience of the morning. Lunch breaks range from 12.30 until 2pm when we work with just a minimum staff. I have always chosen not to take a lunch break preferring to work during this critical time but aim to leave a little earlier. As you can imagine leaving a little earlier does not often happen! Two women with severe pre-eclampsia ( high blood pressure etc.) were admitted during this time. Finding myself without a clinician but now totally familiar with the protocol and treatment of this very serious condition I go ahead and administer the appropriate drugs and care. The challenge then became apparent…… I needed to inject (IM)large doses of Magnesium Sulphate to prevent convulsions a truly dangerous complication of pre eclampsia carrying a high risk both to the life of the mother and the baby. This medication needs to be mixed with local anesthetic otherwise it is an extremely painful procedure. I knew we had been running down our stocks for the past 4 days but were now completely without it. I was aware that the midwives had been suturing the women’s perineums without it, which is totally unacceptable, but assumed that either it was ‘on its way’ or I could ‘borrow’ from another ward. But NO there was no stock in the hospital nor in the pharmacy. I made calls to the Medical officer in-charge who was in a meeting and would call later. The question was now whether I should give the Mag. Sulph. without anesthetic and risk the possible consequences or cause the mother intense pain? I gave the IV dose and waited. Before I left to go home 10 bottles were supplied and I was able to give the medication. I wonder how long that lasted and whether there will be any tomorrow?
Physically and emotionally exhausted by 3pm on Friday afternoon I was further challenged by the admission of a woman in advanced labour carrying a twin pregnancy complicated by a previous c/section scar. Our protocol advises that in our circumstances these women should not labour as the risk of rupturing her uterus and causing death of the child and possibly of the mother is very high. I had just sent another mother for c/section so knew that the theatre would be occupied for some time. I decided that in view of the fact that she was almost ready to push her babies out I would attempt a vaginal delivery. The first twin I delivered quickly and easily assisting with a vacuum extraction to prevent unnecessary strain on the uterus. The second twin decided to put its hand alongside its head making the whole process much more difficult. The little one was born, also with the help of a vacuum extraction 30min. later needing intensive resuscitation which was successful .Even though I gave the necessary medication to prevent hemorrhage the mother still bled excessively , but these are strong women and the outcome for both mother and twins was good.
I went home exhausted…..I burst into tears ….I had a warm bath and a cup of tea… then danced and partied until 3 o’clock in the morning!
It was just another day at Bwaila……….
Today is Monday so I went to check up on my twins from Friday. The little boy(number 2) is still in nursery but doing really well. I am always amazed and humbled to recognize the great power and strength of our instimct to survive. I also visited mum and first twin(big sister) on postnatal ward. I was greeted by huge smiles and hugs. The mother was so happy to have avoided a second c/section making her so much more able to care for her twins.
The toilets are still blocked since Friday and we are running out of local anesthetic again but life goes on at Bwaila and I am happy to be here.