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.
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