Monday 30th May. It’s now one whole week since I completed the course of ARV’s (PEP) I feel so much better. I didn’t quite realize how much these drugs had affected me until I finished them. I feel so much stronger and far less tired. More importantly I feel so much more positive and emotionally stable. At the end of this week I will take an HIV test which will then be repeated again in two months time. It will only be then that I can be sure that the virus has not been transmitted. However, I am feeling very positive and believe that I will be tested negative.
Bwaila continues to be both challenging and rewarding. The in-service training that I set up within the first months of arriving over three years ago but that became irregular during last year due to the withdrawal of funding has now been started up again. I am pleased and encouraged to see how well this has been received by the midwives who are enthusiastic participants. My role in this has changed somewhat as I hand over the facilitation to my Malawian colleagues and take up my new role as mentor or teacher of the teachers. Since January I have taken on the leadership of the daily ‘ward round’ on Labour Ward each morning. This is an excellent teaching opportunity attended by all cadres including students and trained staff. We discuss each case at length particularly those that are more complicated or ‘high risk.’ The participants are encouraged to assess each case and make plans for actions necessary and care needed. I particularly enjoy this type of teaching sharing all my knowledge and experience with the aim of improving the outcomes for the mothers and babies attended at Bwaila.
We are specifically looking at improving our Neonatal death rates. Birth asphyxia, which is most often caused by lack of diligent care during labour, is the main cause of neonatal deaths on our unit. We need to prevent our babies being born in poor condition thus needing resuscitation and nursery care. Many of our babies born with birth asphyxia will be the result of obstructed or prolonged labour. I have been working tirelessly both in the clinical situation and in the classroom to address this challenge. I hope that this effort will be reflected in our statistics during the next few months but more importantly that our aim to discharge healthy mothers and babies will be achieved
Wednesday, 22 June 2011
MEDIUM RISK
Twenty eight days of taking ARV’s and only two more to go!
It’s been a long hard month which has been an extremely testing time for me. I was warned very seriously from those that had taken these medications(PEP) that the side effects were many and unpleasant but in true Rachel style I was determined that this would not be the case for me That somehow I would be stronger, more resilient and not let them effect me. So I started out on a positive note as usual which I was able to maintain for the first two weeks. I was truly amazed to find that apart from slight nausea, lack of appetite and a general tiredness which I could overcome keeping myself busy I kept myself remarkably well physically. Emotionally it was a different matter and I found myself rejecting the medication each and every time I had to swallow those three huge pills. It felt as if I really poisoning my otherwise healthy body. After two weeks I came down with some sort of infection. Whether it was ‘flu or some weird virus I started to feel a sickness come over my whole body. It started by finding hugely painfully enlarged glands in my neck. At one point I tested for Malaria even though the symptoms were not typical and I felt sure this was not the problem. I began to worry that I was developing full blown AIDS. I was sufficiently worried to visit one of our specialist doctors who reassured me that it was extremely unlikely. The underlying doubts still remain. I spent three days at home determined to care for my health and fully recover. It took nearly a week to clear with just a few painkillers and anti inflammatory drugs. The week ended with a relaxing three days at the lake which always serves to renew and refresh me in body and spirit. I am not feeling good. However positive I try to be, the fact is, I still feel as if these drugs are poisoning me and therefore am experiencing the side effects more acutely. I am tired, just so tired. The one thing that keeps me going is to be on Labour Ward. Once I am there and involved in my work I don’t even notice the tiredness. When I stop, when I come home it is there again. Just two more days then I will be eliminating the drugs from my body and start to be Rachel, return to the enthusiastic, energetic Rachel that I know I am. Until then I will care for me, I will rest and I will find the strong positive Rachel which has pulled me through so many difficult situations so many times.
Am I still worried that I may still test positive in a few weeks time? Yes…. I guess I still have that niggling doubt, however small. The chances are very small the statistics assure me that it is very unlikely, but…..
It’s been a long hard month which has been an extremely testing time for me. I was warned very seriously from those that had taken these medications(PEP) that the side effects were many and unpleasant but in true Rachel style I was determined that this would not be the case for me That somehow I would be stronger, more resilient and not let them effect me. So I started out on a positive note as usual which I was able to maintain for the first two weeks. I was truly amazed to find that apart from slight nausea, lack of appetite and a general tiredness which I could overcome keeping myself busy I kept myself remarkably well physically. Emotionally it was a different matter and I found myself rejecting the medication each and every time I had to swallow those three huge pills. It felt as if I really poisoning my otherwise healthy body. After two weeks I came down with some sort of infection. Whether it was ‘flu or some weird virus I started to feel a sickness come over my whole body. It started by finding hugely painfully enlarged glands in my neck. At one point I tested for Malaria even though the symptoms were not typical and I felt sure this was not the problem. I began to worry that I was developing full blown AIDS. I was sufficiently worried to visit one of our specialist doctors who reassured me that it was extremely unlikely. The underlying doubts still remain. I spent three days at home determined to care for my health and fully recover. It took nearly a week to clear with just a few painkillers and anti inflammatory drugs. The week ended with a relaxing three days at the lake which always serves to renew and refresh me in body and spirit. I am not feeling good. However positive I try to be, the fact is, I still feel as if these drugs are poisoning me and therefore am experiencing the side effects more acutely. I am tired, just so tired. The one thing that keeps me going is to be on Labour Ward. Once I am there and involved in my work I don’t even notice the tiredness. When I stop, when I come home it is there again. Just two more days then I will be eliminating the drugs from my body and start to be Rachel, return to the enthusiastic, energetic Rachel that I know I am. Until then I will care for me, I will rest and I will find the strong positive Rachel which has pulled me through so many difficult situations so many times.
Am I still worried that I may still test positive in a few weeks time? Yes…. I guess I still have that niggling doubt, however small. The chances are very small the statistics assure me that it is very unlikely, but…..
HIGH RISK
I’m confused but I’m not afraid, I’m strong but I need to feel comforted and supported.
It was one of those usual busy days on labour ward at Bwaila. Most of my time is now spent teaching students of all categories sharing my skills and knowledge so that others may learn. Clinical/ bedside teaching is what I love, what I do best. My role is well accepted and well established now and I am sought out by the students to supervise their work.
So it was that two weeks ago whilst supervising one of our students I received a needle stick injury. Having administered the injection of Oxytocin for the removal of the placenta I had carelessly left the uncovered syringe and needle on the bed. Later whilst wrapping up the cloths on which she had birthed the needle entered deeply onto my left hand. I removed my gloves (we wear two pairs for extra protection) and went to the sink to wash. The best thing in these situations is to squeeze the wound to make it bleed. Unfortunately as the entry had been deep there was little blood however hard I squeezed I knew this mother was HIV positive and that I should therefore seek assistance promptly. Alongside the maternity unit there is a busy and successful HIV clinic that supports our work. I hurriedly left the labour ward to visit their clinicians. I am working on the busiest labour ward in Malawi and possibly in the whole of Southern Africa, I am working at Bwaila. It is an extremely high risk situation in which we try to protect ourselves but inevitably accidents do happen. Since arriving here over 3 years ago I have been regularly tested for HIV as a matter of course. Small needle prick injuries whilst suturing have not alarmed me but this was different. After testing negative at the present time I was prescribed the usual medications to assist my body in rejecting the virus. Post Exposure Profilaxis (PEP) is a combination of Anti Retrovirals ( ARV) I will have to take these drugs for one month then be retested after three months to ensure that I havn’t been infected.
So how do I feel?
My first reaction two weeks ago was that of anger. How could I be so careless?
Every morning and evening I have to take the medication. This is the hardest for me. Consciously putting these powerful drugs into my otherwise healthy body to do all manner of harm to my cells and tissues whilst supposedly preventing transmission, which I may not even need, I find hugely distressing.
I was warned of all the possible side effects, nausea, diarrhea, weakness, tiredness etc. ‘you will feel sick for month’ I was told. I was having none of this I decided! I would be fine, I would feel fine, and life will go on as usual!
And to some extent it has. Sometimes I get a bit weepy, I am often very tired and weak but apart from the occasional wave of nausea, I am just fine.
I am not afraid; I truly do not think I will contract HIV
I won’t publish this now but wait for 3 months to share this with you all.
It was one of those usual busy days on labour ward at Bwaila. Most of my time is now spent teaching students of all categories sharing my skills and knowledge so that others may learn. Clinical/ bedside teaching is what I love, what I do best. My role is well accepted and well established now and I am sought out by the students to supervise their work.
So it was that two weeks ago whilst supervising one of our students I received a needle stick injury. Having administered the injection of Oxytocin for the removal of the placenta I had carelessly left the uncovered syringe and needle on the bed. Later whilst wrapping up the cloths on which she had birthed the needle entered deeply onto my left hand. I removed my gloves (we wear two pairs for extra protection) and went to the sink to wash. The best thing in these situations is to squeeze the wound to make it bleed. Unfortunately as the entry had been deep there was little blood however hard I squeezed I knew this mother was HIV positive and that I should therefore seek assistance promptly. Alongside the maternity unit there is a busy and successful HIV clinic that supports our work. I hurriedly left the labour ward to visit their clinicians. I am working on the busiest labour ward in Malawi and possibly in the whole of Southern Africa, I am working at Bwaila. It is an extremely high risk situation in which we try to protect ourselves but inevitably accidents do happen. Since arriving here over 3 years ago I have been regularly tested for HIV as a matter of course. Small needle prick injuries whilst suturing have not alarmed me but this was different. After testing negative at the present time I was prescribed the usual medications to assist my body in rejecting the virus. Post Exposure Profilaxis (PEP) is a combination of Anti Retrovirals ( ARV) I will have to take these drugs for one month then be retested after three months to ensure that I havn’t been infected.
So how do I feel?
My first reaction two weeks ago was that of anger. How could I be so careless?
Every morning and evening I have to take the medication. This is the hardest for me. Consciously putting these powerful drugs into my otherwise healthy body to do all manner of harm to my cells and tissues whilst supposedly preventing transmission, which I may not even need, I find hugely distressing.
I was warned of all the possible side effects, nausea, diarrhea, weakness, tiredness etc. ‘you will feel sick for month’ I was told. I was having none of this I decided! I would be fine, I would feel fine, and life will go on as usual!
And to some extent it has. Sometimes I get a bit weepy, I am often very tired and weak but apart from the occasional wave of nausea, I am just fine.
I am not afraid; I truly do not think I will contract HIV
I won’t publish this now but wait for 3 months to share this with you all.
Friday, 6 May 2011
MORE MALAWI MIRACLES
Yesterday was one of those busy days at Bwaila. Most of my time now is spent supervising the student midwives on Labour Ward, ensuring that they understand what they are doing that they become skilled at recognizing when things are going wrong not just ‘catching’ babies as they ‘pop out’ nor focusing only achieving numbers to fill up their books. Although we are now a District Unit and our most serious high risk women will be transferred to the new unit at the Central Hospital we continue to receive and care for many high risk situations. This is inevitable due to the huge number of women and babies we are attending and the fact that they are the most poor and disadvantaged Malawian women with all their underlying health problems. The day started badly when I realized that the women whose HIV status was unknown could not be tested due to the fact that no kits were available. This is a totally unacceptable situation in the light of the funds that are pouring into the country specifically aimed at preventing Mother to Child transmission. I took time out to visit the DHO in his offices next door. I found him in a meeting discussing the pharmacy issues. This was just what I needed. I interrupted the meeting to request that they please discuss this especially as we are approaching Easter. If this was not sorted out immediately we would be passing the whole Easter weekend in the same situation. What would become of those women? What would become of those babies? I was informed that this was a country wide problem but, as usual, mostly affecting the public hospitals…once more the private hospitals had their own supplies, once more the rich would win!
Since early morning I had been especially caring for a very young 18year old mother whose labour was progressing extremely slowly. When I took her over from the night staff I was told that she was ’hysterical and uncooperative’. She had been rolling on the floor in pain, had removed her IV line and was ‘totally uncontrollable.’ She was young and alone and very frightened. After assessing her situation I decided to administer Pethidine ( a strong pain killer) and instructed one of the students to take over her care to gain her trust and therefore her cooperation. As the drug began to work she became calm and sleepy, ceasing to cry out in pain with every contraction and rested on the bed. This new situation allowed me to then administer hormones to increase her contractions and therefore speed up her already prolonged labour. This she tolerated well .I would not leave until her baby was born. Slowly but surely her baby descended and her cervix opened to allow him to pass through. Once the baby was well down in the pelvis I took a vacuum extraction cup and with the help of the young student midwife who had gained her trust I slowly guided her baby into this world. It was wonderful teaching situation not only in the skills of assisting in the more difficult situations but how to really ‘care’ for women.
.
We only have one ambulance at Bwaila. At present it is in the workshop being repaired after an accident so we are managing as best we can with totally unsuitable vehicles.
It was nearly 4pm when Kristine arrived on labour ward. She had been found in her hut in the village by some neighboring women. She had delivered her first baby totally alone .Kristine was 18 years old. The first thing that I noticed was that she was extremely ‘pale’ with a very high fever. That might seem strange to you. How can a black skinned person be pale? Well she can, and she was,’ pale.’ It feels good to be able to recognize this now! Reading her health passport from the two antenatal visits I found that she had been diagnosed with severe anemia over one month ago and had not been treated or transfused. She was weak but conscious and coherent. She was not actively bleeding but I had no way of knowing how much blood she had lost before arrival. With the help of one of my students we quickly erected IV lines took blood samples and sent them to the laboratory. It was her lucky day..…One pack of blood was available. We started to transfuse. She badly needed IV antibiotics, but we had none. After inspection it became clear that some parts of placenta were still in her uterus. This would continue to be a high risk situation for her until they were removed. We had no doctor that day and it was now 4.30pm. We decided that, once stabilized, she should be referred to the Central Hospital. Any blood loss now could prove fatal for her. I called for the ambulance only to find that it would not be available for at least 2 hours. Could Kristine wait for two hours? I decided to take her myself. I put down the back seats, covered the carpets with plastic and assisted Kristine, two IV lines, blood transfusion, two guardians, her baby (1.6kgs.) a bundle of firewood, plastic basins and cooking pots into my Honda CRV. We arrived safely. The next day I heard they had found one more bag of blood for her and she was doing well.
Agness gave birth to the first of her twins in an outlying health center at 12.30miday.the baby was born without incident but number two didn’t seem to want to come down. The inexperienced attendant diagnosed that the second was presenting with a hand which could not be delivered normally. She was taken by ambulance to one of our community hospitals. Unfortunately there was no clinician at this center and I presume the attending nurse midwife was neither confident nor experienced enough to assess the situation, so she was sent to us. She arrived at 4.25pm. Four hours later! Quickly reading the referral letter I knew we were dealing with a very delayed/retained second twin with a hand presentation. I had no idea if the baby was still alive so called for the ultra sound scanner. Meanwhile I examined her only to find a small foot in her vagina. I wasted no time and took hold of the foot bringing the second foot down and delivered the breech. I still didn’t know if the baby was alive and my first impression was that she had arrived too late for the little one. Feeling the chest wall I found a very slow heart beat! I ran with the baby to the resuscitaire and with the help of a colleague we brought the baby back to life. It took a long time but we were efficiently maintaining heart activity with cardiac massage and ventilation. After 20 minutes we decided to leave the baby to ‘go it alone’ I went back to the delivery room to check up on the mother. Ten minutes later one of the midwives called to me
’Your baby’s crying!‘ she said.
Another miracle at Bwaila!
Since early morning I had been especially caring for a very young 18year old mother whose labour was progressing extremely slowly. When I took her over from the night staff I was told that she was ’hysterical and uncooperative’. She had been rolling on the floor in pain, had removed her IV line and was ‘totally uncontrollable.’ She was young and alone and very frightened. After assessing her situation I decided to administer Pethidine ( a strong pain killer) and instructed one of the students to take over her care to gain her trust and therefore her cooperation. As the drug began to work she became calm and sleepy, ceasing to cry out in pain with every contraction and rested on the bed. This new situation allowed me to then administer hormones to increase her contractions and therefore speed up her already prolonged labour. This she tolerated well .I would not leave until her baby was born. Slowly but surely her baby descended and her cervix opened to allow him to pass through. Once the baby was well down in the pelvis I took a vacuum extraction cup and with the help of the young student midwife who had gained her trust I slowly guided her baby into this world. It was wonderful teaching situation not only in the skills of assisting in the more difficult situations but how to really ‘care’ for women.
.
We only have one ambulance at Bwaila. At present it is in the workshop being repaired after an accident so we are managing as best we can with totally unsuitable vehicles.
It was nearly 4pm when Kristine arrived on labour ward. She had been found in her hut in the village by some neighboring women. She had delivered her first baby totally alone .Kristine was 18 years old. The first thing that I noticed was that she was extremely ‘pale’ with a very high fever. That might seem strange to you. How can a black skinned person be pale? Well she can, and she was,’ pale.’ It feels good to be able to recognize this now! Reading her health passport from the two antenatal visits I found that she had been diagnosed with severe anemia over one month ago and had not been treated or transfused. She was weak but conscious and coherent. She was not actively bleeding but I had no way of knowing how much blood she had lost before arrival. With the help of one of my students we quickly erected IV lines took blood samples and sent them to the laboratory. It was her lucky day..…One pack of blood was available. We started to transfuse. She badly needed IV antibiotics, but we had none. After inspection it became clear that some parts of placenta were still in her uterus. This would continue to be a high risk situation for her until they were removed. We had no doctor that day and it was now 4.30pm. We decided that, once stabilized, she should be referred to the Central Hospital. Any blood loss now could prove fatal for her. I called for the ambulance only to find that it would not be available for at least 2 hours. Could Kristine wait for two hours? I decided to take her myself. I put down the back seats, covered the carpets with plastic and assisted Kristine, two IV lines, blood transfusion, two guardians, her baby (1.6kgs.) a bundle of firewood, plastic basins and cooking pots into my Honda CRV. We arrived safely. The next day I heard they had found one more bag of blood for her and she was doing well.
Agness gave birth to the first of her twins in an outlying health center at 12.30miday.the baby was born without incident but number two didn’t seem to want to come down. The inexperienced attendant diagnosed that the second was presenting with a hand which could not be delivered normally. She was taken by ambulance to one of our community hospitals. Unfortunately there was no clinician at this center and I presume the attending nurse midwife was neither confident nor experienced enough to assess the situation, so she was sent to us. She arrived at 4.25pm. Four hours later! Quickly reading the referral letter I knew we were dealing with a very delayed/retained second twin with a hand presentation. I had no idea if the baby was still alive so called for the ultra sound scanner. Meanwhile I examined her only to find a small foot in her vagina. I wasted no time and took hold of the foot bringing the second foot down and delivered the breech. I still didn’t know if the baby was alive and my first impression was that she had arrived too late for the little one. Feeling the chest wall I found a very slow heart beat! I ran with the baby to the resuscitaire and with the help of a colleague we brought the baby back to life. It took a long time but we were efficiently maintaining heart activity with cardiac massage and ventilation. After 20 minutes we decided to leave the baby to ‘go it alone’ I went back to the delivery room to check up on the mother. Ten minutes later one of the midwives called to me
’Your baby’s crying!‘ she said.
Another miracle at Bwaila!
Wednesday, 13 April 2011
MALARIA AND MORE
It’s nearly two whole months since I last wrote to you all. Fiona has been and gone. It was a truly wonderful time with her. Fiona is so easy to please and just slotted straight into our lives here in Malawi. I don’t think that it was always easy for her. Living and working in such a poor country inevitably needs a great deal of adaptation. She enjoyed her work experience at Lucas’ school as well as very bravely making regular visits to one of the local orphanages. The children all adored her and she made special little friends. She found it heartbreaking each and every time when she had to pack up the toys and leave. The little ones clung to her with tears in their eyes as she gave them a final cuddle. Lucas just loved having his big sister around. He too clung to her at the airport last week not wanting to say goodbye. The house is quiet now.
Bwaila continues to arouse in me all manner of conflicting emotions each and every day. It has been an exceptionally busy couple of months with totally inadequate staffing. We have had to rely on our students to ease the workload which is far from ideal as they have little experience or practical knowledge. My priority has been to work with all these students. Teaching supervising and mentoring on labour ward is essential as well as sorting out the more complicated situations as they arrive. It is very tiring work but hugely rewarding to see the students learning and improving.
I have been actively involved with our Quality Improvement Team for the past 3 years. Last month we put together a presentation of the data/statistics of the past 2 years. It was encouraging to see that although the number of deliveries has increased substantially (more than 2.400 births during 2010 compared to 2009) our Maternal Mortality Rate has reduced. Death due to hemorrhage was previously the main cause of death but this has now been successfully addressed and I am happy with the way that our permanent staff respond to this emergency as well as taking measures to prevent it.
We are still losing too many babies during the first few days of life due to Birth Asphyxia. This has mostly been caused by inadequate monitoring and prompt decision making during labour. We are now working towards reducing these numbers. These initiatives demand an important amount of more formal instruction as well as bedside supervision and teaching.
Since January both Dr Ibe Iwuh (our Nigerian registrar) and I have worked to ensure regular teaching on the morning round. This is mostly attended by intern doctors and clinical officer students but I continue to encourage the student midwives to participate. As the most experienced midwife on labour ward I take on this teaching role each and every morning. My work in this area is greatly appreciated by the students themselves.
But ‘incidents’ still happen only too often.
Yesterday we lost 2 mothers. It was a bad day.
Today we lost 2 babies. It was another bad day.
Catharine had been referred to us from one of our outlying community hospitals. They had already decided several hours earlier that she needed her second c/section due to a large baby and inadequate pelvis. They had not been able to perform the operation as they “had no anesthetist.” By the time she arrived with us several hours later the baby was severely distressed and her uterus on the point of rupturing. We quickly prepared her for theatre and advised the operating staff. Unfortunately they had just started another intervention. I ran to theatre to find out how long she had to wait. And found the place in darkness! The main theatre electric switch had ‘tripped.’ I found the switch but it would not move. Looking into theatre I saw that the c/section baby was being extracted by the light of 3 mobile phones! I am proud and continuously amazed by the resourcefulness of our staff. I ran to switchboard to ring the electricians. ‘msanga msanga’ (quick quick) I implored them. I managed to find a torch that was functioning on the Post natal ward and took it into theatre. By the time I had sorted all that out I went back to labour ward to see how Catharine was doing. The fetal heart beat was consistently low. Maybe it would be possible to open up the 2nd theatre as I knew we had a 2nd anesthetist that morning. So that is what we did. Unfortunately we had delayed too long and though I was present in theatre to receive the baby and ready to resuscitate, the little one was born dead. The uterus was on the point of rupture but with some good surgery was repaired. We saved the mother but not her baby.
Last week I visited this same community Hospital. The ‘road’ was almost impassable at times. Luckily we had taken a good 4* 4 vehicle and only got stuck once in deep mud. It’s the rainy season and many health centers and villages are almost unreachable. This particular Hospital has a 110 bed capacity. Of course there are many who will be on the floor. They have one clinical officer and 16 nurses in total to cover all the shifts. This is Malawi reality.
February saw the visit to Malawi of Annie Lennox as an ambassador of the Scottish parliament. She visited Bwaila and publically recognized the work that we are doing there. It was a huge morale booster for our staff. I was present at a reception given in her honour where my own work at Bwaila was also personally recognized. As a result of this I was invited to meet with the Malawian First Lady, wife of the president Bingu Mutharika. I felt rather nervous as I drove through the gates of State House and wondered how was it possible that I got here to this place It was a great privilege for me to be able to talk with her personally as a representative of the hospital. My first aim was to get her to promise to visit the unit. This I achieved and true to her word she visited us last Thursday. It was an informal visit at short notice, as she had requested, with little pomp and ceremony, but it was hugely important for our midwives who felt encouraged and boosted by her words of thanks and appreciation. How amazing it must be to be able to make so many people so happy just by one short visit.
Today was a quiet day for Bwaila but not without incident. Patricia arrived around 10am. She came from home. It was her 3rd pregnancy, the previous 2 had ended in normal healthy deliveries .She was being admitted by two of our junior students when I entered the room in my teaching/supervisory capacity. The young student was examining her so I asked her to tell me her findings. ‘Is the baby ok?’ I asked. She assured me it was .On checking her examination I failed to hear the fetal heart beat. Checking with the ultra sound scan I could see no fetal heart activity. During all this time she had no contractions but was fully dilated and therefore should be ready for the expulsive stage. Uterine rupture is extremely rare in the richer countries but here in Malawi we see it only too often. I immediately suspected that this had occurred and called for help from my colleagues. There was no doctor on the unit and our most experienced Clinical Officer was in theatre. We attended to her quickly and called the ambulance to transfer her to the central hospital as she would need an emergency hysterectomy ( removal of the uterus) and was at risk of huge hemorrhage. Whilst we waited for transport we were able to get 2 bags of blood for her and immediately started the transfusion. Our transport vehicles are far from adequate so we had to literally bundle her into the back of the 4*4 half on and half off the back seats. She arrived safely, was operated and is now in the intensive care unit in a stable condition.
Shortly after arriving home I received a phone call from a Malawian woman who said she had given birth with me. I have no idea who she is. She explained that her daughter, now pregnant had been admitted to our ante natal ward last Sunday with Malaria. Her voice was of fear and concern as she explained that the nurse had told her that her daughter could not be treated for the illness as the hospital didn’t have any Malaria medication. This morning in the hand over meeting it was reported by the nurses that they had run out of Malaria drugs and had been informed that they were not available. They had been told that Malaria drugs were not to be found anywhere in Malawi. I had listened but I had not taken in the true reality of the situation. Labour Ward has its own issues and Malaria drugs is not one of them .I immediately phoned the nurse on duty to ask about the situation. It is true, we have no Malaria drugs! Now what was I going to say to this mother who would have to spend another night not knowing if her daughter’s condition would deteriorate with no possibility of treatment. Her only possibility was to try the local pharmacies to see if she could buy the drug privately. Even if she was able to locate the drug this would probably economically impossible. I promised I would see her tomorrow. I cannot stop thinking about her…but what do I do? She is not the only woman on the ward who is being deprived of treatment, I can’t possibly solve this problem for them all….Tomorrow I will see her, I hope I am not too late? I must have been her last hope and I have failed her…. If this is really true, if Malaria drugs are out of stock country wide many women and children will die. We are still in the rainy season, which is the time of most incidents of Malaria, this is a terrible thing. Many will die, but mostly the poor, as the rich will always find a way.
Bwaila continues to arouse in me all manner of conflicting emotions each and every day. It has been an exceptionally busy couple of months with totally inadequate staffing. We have had to rely on our students to ease the workload which is far from ideal as they have little experience or practical knowledge. My priority has been to work with all these students. Teaching supervising and mentoring on labour ward is essential as well as sorting out the more complicated situations as they arrive. It is very tiring work but hugely rewarding to see the students learning and improving.
I have been actively involved with our Quality Improvement Team for the past 3 years. Last month we put together a presentation of the data/statistics of the past 2 years. It was encouraging to see that although the number of deliveries has increased substantially (more than 2.400 births during 2010 compared to 2009) our Maternal Mortality Rate has reduced. Death due to hemorrhage was previously the main cause of death but this has now been successfully addressed and I am happy with the way that our permanent staff respond to this emergency as well as taking measures to prevent it.
We are still losing too many babies during the first few days of life due to Birth Asphyxia. This has mostly been caused by inadequate monitoring and prompt decision making during labour. We are now working towards reducing these numbers. These initiatives demand an important amount of more formal instruction as well as bedside supervision and teaching.
Since January both Dr Ibe Iwuh (our Nigerian registrar) and I have worked to ensure regular teaching on the morning round. This is mostly attended by intern doctors and clinical officer students but I continue to encourage the student midwives to participate. As the most experienced midwife on labour ward I take on this teaching role each and every morning. My work in this area is greatly appreciated by the students themselves.
But ‘incidents’ still happen only too often.
Yesterday we lost 2 mothers. It was a bad day.
Today we lost 2 babies. It was another bad day.
Catharine had been referred to us from one of our outlying community hospitals. They had already decided several hours earlier that she needed her second c/section due to a large baby and inadequate pelvis. They had not been able to perform the operation as they “had no anesthetist.” By the time she arrived with us several hours later the baby was severely distressed and her uterus on the point of rupturing. We quickly prepared her for theatre and advised the operating staff. Unfortunately they had just started another intervention. I ran to theatre to find out how long she had to wait. And found the place in darkness! The main theatre electric switch had ‘tripped.’ I found the switch but it would not move. Looking into theatre I saw that the c/section baby was being extracted by the light of 3 mobile phones! I am proud and continuously amazed by the resourcefulness of our staff. I ran to switchboard to ring the electricians. ‘msanga msanga’ (quick quick) I implored them. I managed to find a torch that was functioning on the Post natal ward and took it into theatre. By the time I had sorted all that out I went back to labour ward to see how Catharine was doing. The fetal heart beat was consistently low. Maybe it would be possible to open up the 2nd theatre as I knew we had a 2nd anesthetist that morning. So that is what we did. Unfortunately we had delayed too long and though I was present in theatre to receive the baby and ready to resuscitate, the little one was born dead. The uterus was on the point of rupture but with some good surgery was repaired. We saved the mother but not her baby.
Last week I visited this same community Hospital. The ‘road’ was almost impassable at times. Luckily we had taken a good 4* 4 vehicle and only got stuck once in deep mud. It’s the rainy season and many health centers and villages are almost unreachable. This particular Hospital has a 110 bed capacity. Of course there are many who will be on the floor. They have one clinical officer and 16 nurses in total to cover all the shifts. This is Malawi reality.
February saw the visit to Malawi of Annie Lennox as an ambassador of the Scottish parliament. She visited Bwaila and publically recognized the work that we are doing there. It was a huge morale booster for our staff. I was present at a reception given in her honour where my own work at Bwaila was also personally recognized. As a result of this I was invited to meet with the Malawian First Lady, wife of the president Bingu Mutharika. I felt rather nervous as I drove through the gates of State House and wondered how was it possible that I got here to this place It was a great privilege for me to be able to talk with her personally as a representative of the hospital. My first aim was to get her to promise to visit the unit. This I achieved and true to her word she visited us last Thursday. It was an informal visit at short notice, as she had requested, with little pomp and ceremony, but it was hugely important for our midwives who felt encouraged and boosted by her words of thanks and appreciation. How amazing it must be to be able to make so many people so happy just by one short visit.
Today was a quiet day for Bwaila but not without incident. Patricia arrived around 10am. She came from home. It was her 3rd pregnancy, the previous 2 had ended in normal healthy deliveries .She was being admitted by two of our junior students when I entered the room in my teaching/supervisory capacity. The young student was examining her so I asked her to tell me her findings. ‘Is the baby ok?’ I asked. She assured me it was .On checking her examination I failed to hear the fetal heart beat. Checking with the ultra sound scan I could see no fetal heart activity. During all this time she had no contractions but was fully dilated and therefore should be ready for the expulsive stage. Uterine rupture is extremely rare in the richer countries but here in Malawi we see it only too often. I immediately suspected that this had occurred and called for help from my colleagues. There was no doctor on the unit and our most experienced Clinical Officer was in theatre. We attended to her quickly and called the ambulance to transfer her to the central hospital as she would need an emergency hysterectomy ( removal of the uterus) and was at risk of huge hemorrhage. Whilst we waited for transport we were able to get 2 bags of blood for her and immediately started the transfusion. Our transport vehicles are far from adequate so we had to literally bundle her into the back of the 4*4 half on and half off the back seats. She arrived safely, was operated and is now in the intensive care unit in a stable condition.
Shortly after arriving home I received a phone call from a Malawian woman who said she had given birth with me. I have no idea who she is. She explained that her daughter, now pregnant had been admitted to our ante natal ward last Sunday with Malaria. Her voice was of fear and concern as she explained that the nurse had told her that her daughter could not be treated for the illness as the hospital didn’t have any Malaria medication. This morning in the hand over meeting it was reported by the nurses that they had run out of Malaria drugs and had been informed that they were not available. They had been told that Malaria drugs were not to be found anywhere in Malawi. I had listened but I had not taken in the true reality of the situation. Labour Ward has its own issues and Malaria drugs is not one of them .I immediately phoned the nurse on duty to ask about the situation. It is true, we have no Malaria drugs! Now what was I going to say to this mother who would have to spend another night not knowing if her daughter’s condition would deteriorate with no possibility of treatment. Her only possibility was to try the local pharmacies to see if she could buy the drug privately. Even if she was able to locate the drug this would probably economically impossible. I promised I would see her tomorrow. I cannot stop thinking about her…but what do I do? She is not the only woman on the ward who is being deprived of treatment, I can’t possibly solve this problem for them all….Tomorrow I will see her, I hope I am not too late? I must have been her last hope and I have failed her…. If this is really true, if Malaria drugs are out of stock country wide many women and children will die. We are still in the rainy season, which is the time of most incidents of Malaria, this is a terrible thing. Many will die, but mostly the poor, as the rich will always find a way.
Monday, 14 February 2011
BACK TO BWAILA
Its 6.30am. Saturday 12th February. I am sitting in my lounge in the lovely house we have made home here in Lilongwe with the warm African sun blazing in through the window. The only noises I hear are the chirping of the birds in the garden, which due to the heavy rains at this time of year, is lush and green. Fiona is still asleep in Lucas’ room and I feel content. Fiona will stay with us in Malawi for 2 months whilst she carries out her experiential learning with the year 1 children at Lucas’ school. Lucas is thrilled to have her here. And me? Well I just feel so grateful for the opportunity she has given me to be her Mum ‘close up’ for a while.
Europe, Christmas and Katy and Nicks wedding seems lost in a different world, in the distant past, but of course it was only just over one month ago. Time spent away from Malawi and away from Bwaila was therapeutic and healing, just as imagined it would be. Flying back into my other world into my other reality caused me the same conflicts and confusion as it has always done. It always takes me time to adapt back to that huge sense of wealth and excess that oozes from the pores of European living. But I did and I enjoyed every minute. I was able to spend nearly 3 weeks in England in the loving and safe arms of my friends and family. It was good to see how my Mum was recovering from her recent stroke and on her way to resuming her independent life once more. Time spent in Yorkshire with Katy and Nick in the final weeks before their wedding was full of excitement and joy. I felt privileged to be able to share this time with them. Christmas was spent in Spain surrounded by the usual hectic rush and tumble of pre Christmas plans then the beautiful giving and receiving of presents. All my four children have acquired the ability to find the perfect gift chosen with such thought and given with great excitement and love.
Katy and Nick’s wedding on 30th December was a fairy tale. Everything was just wonderful and beautiful especially my daughter, the bride. My role as mother of the bride was just so special, I enjoyed each and every single moment. What a wonderful feeling, as a mother, to witness my own child moving forward into a loving relationship with the man of her choice with an unknown but exciting future ahead. As I read in the wedding ceremony from the words of Kahlil Gibram …..
Your children are not your children They are the sons and daughters of life’s longing for itself. They come through you but not from you. And though they are with you they belong not to you……. child You are the bows from which your children as living arrows are sent forth…
Ending my time in Europe I was able to enjoy 6 days in Norway with my eldest son Alasdair before he took up his first job in England since recently qualifying as a vet. I was grateful for this time with him as his possibilities for long holidays and ‘time with Mum’ are so much less now that he has left student life behind and embarks on his chosen career. I never cease to give thanks for my children each one so special in their own way.
And so I returned to Malawi. I must admit having felt rather apprehensive during the last few days in UK. I was ready to return, I felt strong and enthusiastic but leaving the comfort and security of family to return to the huge challenges of living and working in one of the poorest countries in the world left me feeling somewhat fearful.
Needless to say the sight of our dear friends and neighbors who were at the airport to meet us, soon chased away any feeling of doubt I had regarding continuing with my work and our life here in Lilongwe.
So I returned to Bwaila. Having played such a huge role in the setting up of the new Bwaila Maternity Unit it felt like going home as I walked through the doors of labour ward, that first day after nearly 6 weeks away, to be greeted with screams of welcome by my midwife colleagues.
It had been a difficult December as the unit had been without regular medical cover leaving the midwives and clinical officers to take full responsibility for the everyday running of what is probably the busiest maternity in the whole of Southern Africa. Despite predictions that the work load at Bwaila would decrease substantially after the opening of the new tertiary care wing at the Lilongwe central hospital ( Ethel Mutharika Maternity Wing) this has not proved to be the case and we continue to attend more than 1,000 births a month. The high risk mothers are now being transferred and the health centers are sending their difficult cases directly to EMMW. We still have many extremely sick women and emergencies to attend. I can honestly say that the past 6 weeks have been some of the busiest I have experienced since I arrived 3 years ago.
January sees the start of the clinical placements for our midwifery students. This year with an increase in students being trained it also means an increase in the number of students needing close supervision and clinical teaching in the ward situation. We have also had a new set of interns and clinical officer students on the unit all of whom need constant teaching. I quickly decided on my return that I should make my priority during this time the teaching and supervision of students of all cadres. It has been a pleasure to work with the interns, most of whom are highly motivated and enthusiastic learners. They are quick to learn and quickly become essential to the safe medical coverage of the unit. The student midwives are of varying levels of enthusiasm and competence. They have little input from the college staff due to shortage of tutors which means that their practical skills need to be taught by our own permanent midwifery staff. There is still some reluctance on the part of some of these to undertake this role. Others truly do not have the necessary skills to pass on their knowledge to students. I have spent most of my time this past month dedicated to this. I actually enjoy this part of my work tremendously and find that my own enthusiasm plays a key part in effectively creating greater interest and understanding thus leading to better and more adequate care.
As well as teaching I often find that I am the most experienced obstetric professional on the unit. This means that my expertise is being constantly sought to aid in difficult and emergency situations. I was very pleased to welcome a new Nigerian registrar onto the unit. We have already worked together in the past and are personal friends. We refer to each other constantly which gives vital strength to the medical and midwifery cover. I truly feel that together the possibilities to effectuate change are more than ever present.
This doesn’t mean that labour ward is without its distressing incidents.
I had decide to finish a little earlier last Friday afternoon to allow myself time to catch up on some of the more formal teaching preparation and administrative work that forms an important part of my work. It was 3.30pm and the ward was quieter and under control. There were 3 women still waiting for their emergency c/sections, one of whom had been waiting for more than 3 hours. The interns were operating which inevitably leads to delays as their inexperience means that the procedure takes much longer. I had already requested that a more experienced person took over for the 2nd patient as I feared that the outcomes of the waiting women and their babies would be adversely affected if they delayed further. The 2nd c/section was performed by one of our clinical officers but 2 were still waiting. A young 16 year old was just not progressing to delivery. She had been referred by a district health centre and despite all our efforts it became clear that the baby needed to be delivered abdominally. The other was a very small, very short young mother who had not been able to deliver her first child vaginally due to a disproportion between the pelvis and the fetus. There are many women in Malawi whose growth has been arrested during childhood and adolescence due to malnutrition or illness resulting in inadequate development of the bony pelvis which does not allow for normal delivery. Although a c/section is a life saving procedure for both mother and baby we are very reluctant to put a woman through surgery unless it is absolutely necessary. Once she has a scarred uterus she carries the added risk of rupture in any subsequent pregnancy. This is a real danger to our Malawian women living in the more rural areas with no adequate transport to a health facility and with the frequent use of local roots and herbs to induce or speed up labour in a very aggressive manner. I had collected my belongings and was walking out of the ward when greeted by a new referred patient with ‘a retained 2nd twin with fetal distress’, of course I could not leave. Calling for one of our clinical officers who just happened to be around I quickly took her into a delivery room to assess the situation. We performed a quick ultra sound scan on the baby and found a very slow irregular heart beat. This baby needed to be born fast! A c/section was not an option for at least 2 hours so I decided to attempt a vaginal delivery to save the baby. I called another midwife to help set up an IV line, empty the bladder and bring a vacuum extractor. It was not an easy procedure. The fetal head was high and the vaginal tissue, cervix and first umbilical cord were all in the way as I tried to place the vacuum cup on the baby’s head. It took almost 15 minutes to successfully extract the baby and I feared for its life. I have done this procedure before and it requires a great deal of cooperation from the mother and the medical team. At last the cup was placed and the baby extracted with ease. I was amazed and exhilarated when it came out alive! With a little resuscitation the baby was soon crying though still with breathing difficulties so I sent him to nursery for further management. Today he is doing well.
It was now past 4.30pm Before I left I went to theatre to make sure that the clinician on the night shift was aware of the 2 women still waiting for their operations. I could do no more and there was no time to consider administrative tasks. I arrived home after 5pm exhausted. It was Friday afternoon and the thought of the weekend, the rest and free time with Fiona and Lucas filled me with joy and hope.
Despite everything…..I love Bwaila!
When love beckons to you, follow him, Though his ways be hard and steep. . And when his wings enfold you yield to him, Though the sword hidden among his pinions may wound you…… For even as love crowns you so shall he crucify you. Even as he is for your growth so is he for your pruning…… All these things shall love do unto you that you may know the secrets of your heart… And think not that you can direct the course of love, for love, if it finds you worthy, directs your course.
Europe, Christmas and Katy and Nicks wedding seems lost in a different world, in the distant past, but of course it was only just over one month ago. Time spent away from Malawi and away from Bwaila was therapeutic and healing, just as imagined it would be. Flying back into my other world into my other reality caused me the same conflicts and confusion as it has always done. It always takes me time to adapt back to that huge sense of wealth and excess that oozes from the pores of European living. But I did and I enjoyed every minute. I was able to spend nearly 3 weeks in England in the loving and safe arms of my friends and family. It was good to see how my Mum was recovering from her recent stroke and on her way to resuming her independent life once more. Time spent in Yorkshire with Katy and Nick in the final weeks before their wedding was full of excitement and joy. I felt privileged to be able to share this time with them. Christmas was spent in Spain surrounded by the usual hectic rush and tumble of pre Christmas plans then the beautiful giving and receiving of presents. All my four children have acquired the ability to find the perfect gift chosen with such thought and given with great excitement and love.
Katy and Nick’s wedding on 30th December was a fairy tale. Everything was just wonderful and beautiful especially my daughter, the bride. My role as mother of the bride was just so special, I enjoyed each and every single moment. What a wonderful feeling, as a mother, to witness my own child moving forward into a loving relationship with the man of her choice with an unknown but exciting future ahead. As I read in the wedding ceremony from the words of Kahlil Gibram …..
Your children are not your children They are the sons and daughters of life’s longing for itself. They come through you but not from you. And though they are with you they belong not to you……. child You are the bows from which your children as living arrows are sent forth…
Ending my time in Europe I was able to enjoy 6 days in Norway with my eldest son Alasdair before he took up his first job in England since recently qualifying as a vet. I was grateful for this time with him as his possibilities for long holidays and ‘time with Mum’ are so much less now that he has left student life behind and embarks on his chosen career. I never cease to give thanks for my children each one so special in their own way.
And so I returned to Malawi. I must admit having felt rather apprehensive during the last few days in UK. I was ready to return, I felt strong and enthusiastic but leaving the comfort and security of family to return to the huge challenges of living and working in one of the poorest countries in the world left me feeling somewhat fearful.
Needless to say the sight of our dear friends and neighbors who were at the airport to meet us, soon chased away any feeling of doubt I had regarding continuing with my work and our life here in Lilongwe.
So I returned to Bwaila. Having played such a huge role in the setting up of the new Bwaila Maternity Unit it felt like going home as I walked through the doors of labour ward, that first day after nearly 6 weeks away, to be greeted with screams of welcome by my midwife colleagues.
It had been a difficult December as the unit had been without regular medical cover leaving the midwives and clinical officers to take full responsibility for the everyday running of what is probably the busiest maternity in the whole of Southern Africa. Despite predictions that the work load at Bwaila would decrease substantially after the opening of the new tertiary care wing at the Lilongwe central hospital ( Ethel Mutharika Maternity Wing) this has not proved to be the case and we continue to attend more than 1,000 births a month. The high risk mothers are now being transferred and the health centers are sending their difficult cases directly to EMMW. We still have many extremely sick women and emergencies to attend. I can honestly say that the past 6 weeks have been some of the busiest I have experienced since I arrived 3 years ago.
January sees the start of the clinical placements for our midwifery students. This year with an increase in students being trained it also means an increase in the number of students needing close supervision and clinical teaching in the ward situation. We have also had a new set of interns and clinical officer students on the unit all of whom need constant teaching. I quickly decided on my return that I should make my priority during this time the teaching and supervision of students of all cadres. It has been a pleasure to work with the interns, most of whom are highly motivated and enthusiastic learners. They are quick to learn and quickly become essential to the safe medical coverage of the unit. The student midwives are of varying levels of enthusiasm and competence. They have little input from the college staff due to shortage of tutors which means that their practical skills need to be taught by our own permanent midwifery staff. There is still some reluctance on the part of some of these to undertake this role. Others truly do not have the necessary skills to pass on their knowledge to students. I have spent most of my time this past month dedicated to this. I actually enjoy this part of my work tremendously and find that my own enthusiasm plays a key part in effectively creating greater interest and understanding thus leading to better and more adequate care.
As well as teaching I often find that I am the most experienced obstetric professional on the unit. This means that my expertise is being constantly sought to aid in difficult and emergency situations. I was very pleased to welcome a new Nigerian registrar onto the unit. We have already worked together in the past and are personal friends. We refer to each other constantly which gives vital strength to the medical and midwifery cover. I truly feel that together the possibilities to effectuate change are more than ever present.
This doesn’t mean that labour ward is without its distressing incidents.
I had decide to finish a little earlier last Friday afternoon to allow myself time to catch up on some of the more formal teaching preparation and administrative work that forms an important part of my work. It was 3.30pm and the ward was quieter and under control. There were 3 women still waiting for their emergency c/sections, one of whom had been waiting for more than 3 hours. The interns were operating which inevitably leads to delays as their inexperience means that the procedure takes much longer. I had already requested that a more experienced person took over for the 2nd patient as I feared that the outcomes of the waiting women and their babies would be adversely affected if they delayed further. The 2nd c/section was performed by one of our clinical officers but 2 were still waiting. A young 16 year old was just not progressing to delivery. She had been referred by a district health centre and despite all our efforts it became clear that the baby needed to be delivered abdominally. The other was a very small, very short young mother who had not been able to deliver her first child vaginally due to a disproportion between the pelvis and the fetus. There are many women in Malawi whose growth has been arrested during childhood and adolescence due to malnutrition or illness resulting in inadequate development of the bony pelvis which does not allow for normal delivery. Although a c/section is a life saving procedure for both mother and baby we are very reluctant to put a woman through surgery unless it is absolutely necessary. Once she has a scarred uterus she carries the added risk of rupture in any subsequent pregnancy. This is a real danger to our Malawian women living in the more rural areas with no adequate transport to a health facility and with the frequent use of local roots and herbs to induce or speed up labour in a very aggressive manner. I had collected my belongings and was walking out of the ward when greeted by a new referred patient with ‘a retained 2nd twin with fetal distress’, of course I could not leave. Calling for one of our clinical officers who just happened to be around I quickly took her into a delivery room to assess the situation. We performed a quick ultra sound scan on the baby and found a very slow irregular heart beat. This baby needed to be born fast! A c/section was not an option for at least 2 hours so I decided to attempt a vaginal delivery to save the baby. I called another midwife to help set up an IV line, empty the bladder and bring a vacuum extractor. It was not an easy procedure. The fetal head was high and the vaginal tissue, cervix and first umbilical cord were all in the way as I tried to place the vacuum cup on the baby’s head. It took almost 15 minutes to successfully extract the baby and I feared for its life. I have done this procedure before and it requires a great deal of cooperation from the mother and the medical team. At last the cup was placed and the baby extracted with ease. I was amazed and exhilarated when it came out alive! With a little resuscitation the baby was soon crying though still with breathing difficulties so I sent him to nursery for further management. Today he is doing well.
It was now past 4.30pm Before I left I went to theatre to make sure that the clinician on the night shift was aware of the 2 women still waiting for their operations. I could do no more and there was no time to consider administrative tasks. I arrived home after 5pm exhausted. It was Friday afternoon and the thought of the weekend, the rest and free time with Fiona and Lucas filled me with joy and hope.
Despite everything…..I love Bwaila!
When love beckons to you, follow him, Though his ways be hard and steep. . And when his wings enfold you yield to him, Though the sword hidden among his pinions may wound you…… For even as love crowns you so shall he crucify you. Even as he is for your growth so is he for your pruning…… All these things shall love do unto you that you may know the secrets of your heart… And think not that you can direct the course of love, for love, if it finds you worthy, directs your course.
Sunday, 28 November 2010
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.
‘
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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