As I sit here in the comfort and warmth of my brothers home in England I am thinking of Malawi . I want to write to update you with news of my women and babies, left behind, so far away in a different reality to that in which I now find myself. We arrived this morning after a long and tiring flight through Lusaka and Nairobi. With just 30 minutes left before landing we were told that due to intense fog conditions at Heathrow airport we would likely have to divert to Amsterdam. At that moment it just seemed too much to bear! I confess I sent up a word to the Almighty for a safe landing...preferably at Heathrow!
After circling for 20 minutes we were told we could land a Gatwick....that was better, at least we would be in England! With 5 minutes till landing another announcement told us we would be turning round to land at Heathrow as planned.. the fog had lifted! Joy of joys we arrived only 40minutes later than scheduled. What a priviledge to have that feeling of somehow being "looked after"
I went to visit Flora twice before I left. I took her some more food and some of my daughter Fionas old clothes. She was so happy to receive them especially a pair of pink shoes that I had no need of. On the first visit her investigations had still not been done nor had she been transfused the prescribed blood. I insisted that this be done and they assured me they would attend to it. I was not confident but could do no more. The second time I visited she had already been discharged home. I went to see the attending clinician and together we examined her file, She had been given 2 bags of blood, her Hb had risen to 6.2. The investigations revealed her to be suffering from a common parasite found in the waters of Lake Malawi( Bilharzia) This had been adequately treated. As chronic condition this had been the cause of her severe anaemia . There was no reason to think that she should not now recover fully. I left the hospital feeling happy and content. Although I did wonder what would have happened, if the outcome would have been different had I not taken a special interest in her? I hope that one day when I visit the lake I will be able to find her and see how she is progressing.
The day before leaving I took a trip out to the villages to follow up my twins, Edward and Alex. Pilirani had called me two weeks ago saying that they were starting to go hungry. Last years maize was finished and they were now planting for a harvest in March of 2009. I took with me a 50kg. sack of maize which should feed her family for a month. As usual all the children came running out to greet me. They all want to watch over my car or carry my bags as they know this will result in a 20mk or 50 mk payment. I sat down to talk to the ladies of the village. Looking round at them all especially the children I was overwhelmed by such a strong feeling that whatever I brought, however much, it would never be enough. This is how I have been feeling these last days . Never, oh never enough!
After a short trip this afternoon to a local shopping centre I find myself with all sorts of confusing feelings and emotions and cant stop thinking about my life in Lilongwe so different, so far removed from what I will be seeing and experiencing during the next few weeks. I look at the busy people rushing around doing their Christmas shopping seemingly totally unaware of what it is like for my poor women and babies in Malawi. I want to scream and shout and tell them to stop buying un necessary things, to stop spending their money on trivialities, what importance have they? dont they realize that just a plane journey away the people are suffering, are hungry, have nothing, no presents, no chocolates, no pillow to lay their head, no shoes on their feet. Different countries, different realities.
As I passed through labour ward on Friday to bid farewell to my colleagues a young woman called to me, her arms outstretched, " Nursey, nursey come and help me, please come and help me! " I could see that the babys head was close to being born. I could not attend her. I had other things to do. I had no uniform or gloves. What excuses I gave! I called to another Malawian midwife to attend ..the birth was imminent. " No, no, no the young woman pleaded with me " You nursey..., asungu, asungu, asungu......" ( She wanted this white woman to care for her, not anyone, just this white woman) I had to leave, the other midwife went to her. I can still see her arms stretched out to me and hear her voice " asungu, asungu!" and I left...
And here I am in England, doing my Christmas shopping along with all the rest.........
Sunday 14 December 2008
Wednesday 26 November 2008
MAKING A DIFFERENCE
Today I want to share two of my many stories with you.
The first time I met Flora she was lying on a bed in labour ward her mum was standing alongside her. I was suprised at how young she looked and immediately noticed the worry and concern reflected on her mum's face. Maybe that was how I identified with her in that moment, somehow not as a patient and guardian, of which I see many, but as a Mum with her precious daughter. It is unusual to find mothers on labour ward except with very sick patients so I immediately presumed that her condition must be critical. I inspected her file to familiarize myself with her case and found that indeed she was a very ill girl/woman. Flora had been referred from the health centre in Salima, more than an hours drive from Lilongwe and situated on the side of Lake Malawi. She was around 30 weeks into her first pregnancy but was carrying a dead baby. She had last felt her baby's movements over one week ago. But that was not her only problem. She was suffering from severe and chronic anaemia. Her Hb. (normally 12 to 14) was 3.1 .The clinician who had admitted her described her appearance as "paper white" This may seem a strange way to describe a person with black skin but certainly makes you realize the seriousness of her condition. Flora is 20 years old, but looks 15! Apart from the pregnancy she had also been vomiting blood for several days. The reason for this was not known at that time but was an important contributing factor to her anaemic state. The hospital at Salima had transfused 3 bags of blood but could do no more. It was now extremely important to deliver the dead child but her critical condition made this very dangerous so she was referred to us at Bwaila.
By the time I arrived she had been transfused one more bag of blood and induction of labour had been iniciated. I decided to take over her care. I quickly made friends with her Mum, even though she spoke very little English and was grateful for her presence throughout the day. I soon realized that they had arrived in an ambulance from Salima with no posessions, money or food. I gave her Mum 500mk(less than 3 euros) with which to buy some basic food and essentials. It quickly became obvious that Flora had been sexually abused and therefore it was very difficult to perform the necessary examinations and procedures. However, I refused to do this by force ( she had been forced too many times) and though it took a great deal of time and effort, talking and explaining, and being as gentle as possible, I slowly began to gain her trust and confidence. She laboured quickly during the day and by early afternoon she was ready to deliver. I had been able to transfuse 2 bags of blood and also blood extracts during the morning and hoped that would be enough. It was all that was available. We had been promised more later. I was concerned as to how she would cope during and after the birth and did all I could to ensure minimum blood loss at that time. The fetus and placenta was expelled easily without haemorrage but she continued to ooze afterwards. When I left her on Friday afternoon she was on the way to operating theatre for an exploratory procedure to establish the cause of bleeding. It was just too difficult to examine her properlywithout sedation or anesthetic. My last words to the clinical officer was " Please look after Flora I want to see her on Monday"
" I'll do my best " he replied. I could ask no more.
I spent most of the weekend thinking of her.
My first call on Monday morning was to post natal ward. I was delighted to find Flora alive. Not healthy, not strong, but alive.
The same day she was transferred to the gynae.ward at the central hospital for further investigations. She was still vomiting blood.
Today I went to see her and took her some boxes of milk, nutricious cereals, a bar of soap and some washing powder. I found her sitting up in bed, still ' paper white' but still alive.
When I enquired of the clinicians as to her condition I found that the investigations were still not done and they were not aware of her most recent blood results. Her Hb. post delivery is now 2.9.
I do assure you that in the developed countries 2.9 is considered nearly dead!
I requested that they ensure she receives more blood and that the investigations be carried out as soon as possible. I will return in 2 days to make sure.
Now I must quickly tell you about Larson.
My friend and fellow midwife Joanne, now living in Ghana, but who spent 3 years working at Bwaila, is here on holiday. It has been great to spend time with her, she's a remarkable lady.
On Saturday she sent me a message telling me of a Malawian family that she knows. Larson was desperate to find work. Did I know of any opportunities? At the time I didn't. Later that day I was talking to my neighbour who informed me she would be moving to a new house. It would be a good thing as there would be a big garden for her boys to play in but unfortunately being the other side of town she would need a driver to shuttle her sons back and forth to school and their various activities. I immediately thought of Joanne and her friend.
The interview was arranged for Sunday morning. Joanne arrived with Larson and I introduced them to Rose. We sat on the verandah and Larson began to talk. A married man with 3 children his wife was expecting the 4th. He had been out of work for 2 years and during that time had trained and gained a licience to drive taxis. He started his own business as a taxi driver but a year ago he was attacked at gun point and his taxi was stolen.He is lucky to be alive. Understandably, he will not drive a taxi again.
We asked how he and the family had survived during the past year? He explained that by doing small jobs he could earn some money so the family could eat and if not they just had water. It was shocking to hear this type of story first hand. We all know how many families here in Malawi live this way but it was disturbing for us to listen to his words and hear the emotion in his voice. The voice of a good man who so often could not provide for his family.
" I promise I will work hard, madam. " he said. " You can trust me. I will look after your boys as if they were my own. "
Rose decided to offer him the job. She was concerned that it would not start untill January.
" That's OK, madam, I have been waiting so many months I can wait one more"
The tears in his eyes and the smile on his face as he left to walk the 6km home to tell his wife the good news were a joy to behold!
What an incredibly humbling experience it had been for us all.
" You have just employed a driver " I said to Rose " But you have turned his whole life round"
Larston would go home to tell his pregnant wife that the future was brighter. 2009 would bring food on the table, clothes for his children and who knows maybe schools and medicines too.
" There was always much love in that family." said Joanne.
" Now there is hope"
How little we really had to do to make a difference. How little YOU really have to do to make a difference.
The first time I met Flora she was lying on a bed in labour ward her mum was standing alongside her. I was suprised at how young she looked and immediately noticed the worry and concern reflected on her mum's face. Maybe that was how I identified with her in that moment, somehow not as a patient and guardian, of which I see many, but as a Mum with her precious daughter. It is unusual to find mothers on labour ward except with very sick patients so I immediately presumed that her condition must be critical. I inspected her file to familiarize myself with her case and found that indeed she was a very ill girl/woman. Flora had been referred from the health centre in Salima, more than an hours drive from Lilongwe and situated on the side of Lake Malawi. She was around 30 weeks into her first pregnancy but was carrying a dead baby. She had last felt her baby's movements over one week ago. But that was not her only problem. She was suffering from severe and chronic anaemia. Her Hb. (normally 12 to 14) was 3.1 .The clinician who had admitted her described her appearance as "paper white" This may seem a strange way to describe a person with black skin but certainly makes you realize the seriousness of her condition. Flora is 20 years old, but looks 15! Apart from the pregnancy she had also been vomiting blood for several days. The reason for this was not known at that time but was an important contributing factor to her anaemic state. The hospital at Salima had transfused 3 bags of blood but could do no more. It was now extremely important to deliver the dead child but her critical condition made this very dangerous so she was referred to us at Bwaila.
By the time I arrived she had been transfused one more bag of blood and induction of labour had been iniciated. I decided to take over her care. I quickly made friends with her Mum, even though she spoke very little English and was grateful for her presence throughout the day. I soon realized that they had arrived in an ambulance from Salima with no posessions, money or food. I gave her Mum 500mk(less than 3 euros) with which to buy some basic food and essentials. It quickly became obvious that Flora had been sexually abused and therefore it was very difficult to perform the necessary examinations and procedures. However, I refused to do this by force ( she had been forced too many times) and though it took a great deal of time and effort, talking and explaining, and being as gentle as possible, I slowly began to gain her trust and confidence. She laboured quickly during the day and by early afternoon she was ready to deliver. I had been able to transfuse 2 bags of blood and also blood extracts during the morning and hoped that would be enough. It was all that was available. We had been promised more later. I was concerned as to how she would cope during and after the birth and did all I could to ensure minimum blood loss at that time. The fetus and placenta was expelled easily without haemorrage but she continued to ooze afterwards. When I left her on Friday afternoon she was on the way to operating theatre for an exploratory procedure to establish the cause of bleeding. It was just too difficult to examine her properlywithout sedation or anesthetic. My last words to the clinical officer was " Please look after Flora I want to see her on Monday"
" I'll do my best " he replied. I could ask no more.
I spent most of the weekend thinking of her.
My first call on Monday morning was to post natal ward. I was delighted to find Flora alive. Not healthy, not strong, but alive.
The same day she was transferred to the gynae.ward at the central hospital for further investigations. She was still vomiting blood.
Today I went to see her and took her some boxes of milk, nutricious cereals, a bar of soap and some washing powder. I found her sitting up in bed, still ' paper white' but still alive.
When I enquired of the clinicians as to her condition I found that the investigations were still not done and they were not aware of her most recent blood results. Her Hb. post delivery is now 2.9.
I do assure you that in the developed countries 2.9 is considered nearly dead!
I requested that they ensure she receives more blood and that the investigations be carried out as soon as possible. I will return in 2 days to make sure.
Now I must quickly tell you about Larson.
My friend and fellow midwife Joanne, now living in Ghana, but who spent 3 years working at Bwaila, is here on holiday. It has been great to spend time with her, she's a remarkable lady.
On Saturday she sent me a message telling me of a Malawian family that she knows. Larson was desperate to find work. Did I know of any opportunities? At the time I didn't. Later that day I was talking to my neighbour who informed me she would be moving to a new house. It would be a good thing as there would be a big garden for her boys to play in but unfortunately being the other side of town she would need a driver to shuttle her sons back and forth to school and their various activities. I immediately thought of Joanne and her friend.
The interview was arranged for Sunday morning. Joanne arrived with Larson and I introduced them to Rose. We sat on the verandah and Larson began to talk. A married man with 3 children his wife was expecting the 4th. He had been out of work for 2 years and during that time had trained and gained a licience to drive taxis. He started his own business as a taxi driver but a year ago he was attacked at gun point and his taxi was stolen.He is lucky to be alive. Understandably, he will not drive a taxi again.
We asked how he and the family had survived during the past year? He explained that by doing small jobs he could earn some money so the family could eat and if not they just had water. It was shocking to hear this type of story first hand. We all know how many families here in Malawi live this way but it was disturbing for us to listen to his words and hear the emotion in his voice. The voice of a good man who so often could not provide for his family.
" I promise I will work hard, madam. " he said. " You can trust me. I will look after your boys as if they were my own. "
Rose decided to offer him the job. She was concerned that it would not start untill January.
" That's OK, madam, I have been waiting so many months I can wait one more"
The tears in his eyes and the smile on his face as he left to walk the 6km home to tell his wife the good news were a joy to behold!
What an incredibly humbling experience it had been for us all.
" You have just employed a driver " I said to Rose " But you have turned his whole life round"
Larston would go home to tell his pregnant wife that the future was brighter. 2009 would bring food on the table, clothes for his children and who knows maybe schools and medicines too.
" There was always much love in that family." said Joanne.
" Now there is hope"
How little we really had to do to make a difference. How little YOU really have to do to make a difference.
Tuesday 11 November 2008
BLOODY MATTERS
A new blood bank is being built in Lilongwe. Until this is finished the blood comes from a central supply in Blantyre., more than 3 hours drive from here. It is ordered and received daily but invariably there is never enough. Most of the donors are young students which means in holiday times there is a marked shortage. Iam sure that the particular lack of supply two weeks ago was the cause of many tragic incidents all over the country but I can only tell you of those in which I was involved. The lady that I talked of last time was eventualy delivered of a still born infant later in the day. A normal delivery saved her from a c/section. Her life was not put at risk by operating with out the necessary blood supplies but for her baby it was too late. The following day I was attending a very young girl, just 17 years old, having her first baby. She had been suffering from severe malnutrition and chronic anaemia for some time. (Hb 4.2) As her labour progressed I prepared myself and her for possible complications. An IV line was inserted and the appropiate medications were prepared and ready for use as soon as the baby was born. Her blood loss should be minimal if she was to maintain her condition. I aided the last part of her labour by assisting with a vacuum extraction. Such severe anaemia brings with it an overload on the heart and inability to cope with extreme effort such as pushing out a baby. The placenta was delivered quickly with minimum blood loss. It was then she started to haemorrage. I knew that I would be lucky to find blood for her but had send off a petition earlier. It was still not available. After following all the procedures in event of severe haemorrage she still continued to bleed. We were begining to get worried. As with any wound or area of blood loss, compression of the site willreduce bleeding. It was the only thing left to do and for the time necessary to stem the haemorrage or untill the arrival of the blood so that she could be taken to theatre for a hysterectomy.The poorly contracted uterus was the cause of the haemorrage with the underlying chronic anaemia. This meant that removing the uterus would be the only option. So it was that I found myself performing bi-manual uterine compression for more than 30 minutes. This means that I had to compress the uterus between my two hands, one externally and the other internally, in the vagina. It is a procedure that we are taught in our training and that I continue to teach for emergency situations but is rarely needed as by this stage the woman should be in the operating theatre. The senior obstetrician was called to review the situation. She decided to go ahead and operate. The anaesthetist was not happy. "She can die here from her bleeding and we do nothing or we can try and operate and she dies in theatre.... we must give her a chance. Some things we just have to leave to God" the obstetrician remarked encouragingly. I found myself in operating theatre with this young girl. At worst she would not survive and at best she would be 17 years old with no uterus! I waited by her side for the surgeons to get ready and the theatre to be prepared. I was continuously checking for the contraction of the uterus and signs that the bleeding had ceased. All was ready. "Please can you check the vaginal packs once more " I asked, " I think she has stopped bleeding ,her uterus is contracted " And it was! There was no need to operate, I couldn't believe it! She was taken to post natal ward where later that night she received 5 packs of blood. When I went to see her the next day she was sitting up feeding her baby!
Maybe I should end with that story so that you can all feel better and happy? But no .... I cannot, you need to know the whole truth, all the stories. The following day the situation was still the same. Little or no blood to be found. The lady who was brought to us from the health centre was already in a poor state as she had started to haemorrage in her home, in the village. The placenta was lying low down, in front of the baby's head (placenta previa)as the cervix began to stretch it was pulled away from the uterine wall and began to bleed. She had already lost a huge amount of blood when she arrived in the early hours of the morning. The treatment for this condition is emergency c/section. She was unstable and there was no blood available. The anaesthetist decided her condition was too precarious to operate.The young clinician could not contact his superior and the woman bled to death one hour and a half after arriving at the hospital. Her baby was still inside her. Should she have been taken to theatre in any case? without any posibility of transfusion! Maybe yes? Maybe no? Would any doctor like to be faced with that decision? would you like to be faced with that decision?
Don't worry you won't have to ! You'll always have blood available for transfusion. Your blood banks work, your donor schemes work. You are rich, you can protest and complain! The women...especially the women...the poor women of Malawi have no voice, will not be heard, so they die because there is no blood to give them.
The new Bwaila hospital is well underway and nearing completion.It should be ready March of April next year and I'm getting involved!
The Rose Project from Ireland (www.roseproject.org). are funding the building and equipping. It will then be turned over to the Malawian district health authority to staff and run. So thats where I fit in. I will be co ordinating and advising to help to achieve the vision and aims of the donors and sponsors. To create a maternity hospital of excellence here in Lilongwe.
More about that next time.Suffice to say its all very exciting for me and a whole new challenge. Keep supporting me, please, I'll need it!
Maybe I should end with that story so that you can all feel better and happy? But no .... I cannot, you need to know the whole truth, all the stories. The following day the situation was still the same. Little or no blood to be found. The lady who was brought to us from the health centre was already in a poor state as she had started to haemorrage in her home, in the village. The placenta was lying low down, in front of the baby's head (placenta previa)as the cervix began to stretch it was pulled away from the uterine wall and began to bleed. She had already lost a huge amount of blood when she arrived in the early hours of the morning. The treatment for this condition is emergency c/section. She was unstable and there was no blood available. The anaesthetist decided her condition was too precarious to operate.The young clinician could not contact his superior and the woman bled to death one hour and a half after arriving at the hospital. Her baby was still inside her. Should she have been taken to theatre in any case? without any posibility of transfusion! Maybe yes? Maybe no? Would any doctor like to be faced with that decision? would you like to be faced with that decision?
Don't worry you won't have to ! You'll always have blood available for transfusion. Your blood banks work, your donor schemes work. You are rich, you can protest and complain! The women...especially the women...the poor women of Malawi have no voice, will not be heard, so they die because there is no blood to give them.
The new Bwaila hospital is well underway and nearing completion.It should be ready March of April next year and I'm getting involved!
The Rose Project from Ireland (www.roseproject.org). are funding the building and equipping. It will then be turned over to the Malawian district health authority to staff and run. So thats where I fit in. I will be co ordinating and advising to help to achieve the vision and aims of the donors and sponsors. To create a maternity hospital of excellence here in Lilongwe.
More about that next time.Suffice to say its all very exciting for me and a whole new challenge. Keep supporting me, please, I'll need it!
Tuesday 28 October 2008
HOW LUCKY WE ARE
The workshops that I started up several months ago for the midwives at Bwaila and Kamuzu Central Hospital continue to be enthusiastically attended. Sometimes I wonder how much of what we share and learn is ever taken back into the clinical situation but that is on my more negative days. As requested by the midwives, in the evaluations, we have been covering topics that are directly linked to their everyday practise. Skills and knowledge that I inicially took for granted would not be necessary have been well received. Many of these topics have covered actuation in emergency obstetric situations. I was priviledged to have attended an excellent course last year before coming to Malawi on these same subjects which has helped me to prepare a more structured presentation. Todal we were looking at post partum haemorrage. This is profuse bleeding after delivery.This is one of the main causes of maternal death in our hospital. Prompt and acurate dignosis and attention really does save lives. After learning the basic theory I set up a clinical situation in which they could practice. As I lay on the conference table pushing out my baby and then fainting from blood loss the midwives practised how to call for help, organize the team and methodically go through the process of attending to this simulated emergency situation. As you can imagine much fun was had by all and amoungst shouting a laughter I hope we all learnt something. I did, however, draw the line at having medication inserted in my rectum!! I have also been using case histories as a means of looking crictically at our work. We were not suprised but were concerned by what we discovered.
After I had finished teaching I returned to the labour ward positive and encouraged. Unfortunately I was met by an alarming situation. The woman was 34 weeks pregnant with here 4th child. She had been suffering from severe anaemia during most of her pregnancy this is not uncommom due to extremely poor diet and hunger. She had been regularly attended in the antenatal clinic as well as being an in-patient for some time. Her membranes had ruptured spontaneously several days ago with no other signs of labour. It was decided to incuce labour. The procedure is to insert medication in the vagina to ripen the cervix. This was done earlier this morning. At 1pm when she was being assessed it was noticed that the baby had an irregular, slow heartbeat. A monitorization showed severe fetal distress. She would need and immediate c/section to try and save the baby's life. We prepared her for theatre and called the clinician. It was noted that her anaemia was still severe ( her Hb was now 5 having been increased from 3.9 with blood transfusion, a normal healthy Hb is around 12 to 14) Blood samples had been taken during the morning to prepare blood for her to be given as soon as possible. We contacted the laboratory who told us that there was no blood available. They would be processing blood at 2pm but it would not be ready untill later in the afternoon. It was not that there was no blood for her, she has a very common blood group, the situation was that in the biggest hospital in Lilongwe, the capital of Malawi, there was NO BLOOD AVAILABLE. I went to theatre to talk to the anaesthetist who confirmed that it would be too risky to operate without blood, that she would have to wait. I walked slowly back to labour ward to give the news my heart was so heavy. The young Irish midwife, who had been looking after her, cried out" This cannot be happening! " But it was true. I told her to remove the fetal monitor, there was nothing more we could do and listening to the baby's slow heart beat was not going to help. She cried. I tried to console her and felt resigned. I did notweep as I would have done a few months ago. Am I starting to harden to these situations? am I accepting them? I hope not.
The lights have just gone off, there is a powercut in this place that I come to talk to you all. How strange that the computer still works! Here I share my highs and my lows, my laughter and my tears. I let you into my life and my work, into the lives of the poor women of Malawi. Why? Just so you know how lucky you are! Just so you realize how much you take for granted! Just so you think again when you complain of the health care you receive! Just so you appreciate every day and moment of your comfortable lives! Just so you love and care!
My midwife friend Joanne sent me this ( she was working at Bwaila before me) I thank her for her insight and her continued concern for Bwaila.
"If we are lucky, we will suffer a taste of powerlessness in our own private lives. Because then things change. Then we begin to see with a gentler, broader vision and talk with a kinder tongue and feel with deeper feelings for those for whom powerlessness is a way of life." Joan Chittister
After I had finished teaching I returned to the labour ward positive and encouraged. Unfortunately I was met by an alarming situation. The woman was 34 weeks pregnant with here 4th child. She had been suffering from severe anaemia during most of her pregnancy this is not uncommom due to extremely poor diet and hunger. She had been regularly attended in the antenatal clinic as well as being an in-patient for some time. Her membranes had ruptured spontaneously several days ago with no other signs of labour. It was decided to incuce labour. The procedure is to insert medication in the vagina to ripen the cervix. This was done earlier this morning. At 1pm when she was being assessed it was noticed that the baby had an irregular, slow heartbeat. A monitorization showed severe fetal distress. She would need and immediate c/section to try and save the baby's life. We prepared her for theatre and called the clinician. It was noted that her anaemia was still severe ( her Hb was now 5 having been increased from 3.9 with blood transfusion, a normal healthy Hb is around 12 to 14) Blood samples had been taken during the morning to prepare blood for her to be given as soon as possible. We contacted the laboratory who told us that there was no blood available. They would be processing blood at 2pm but it would not be ready untill later in the afternoon. It was not that there was no blood for her, she has a very common blood group, the situation was that in the biggest hospital in Lilongwe, the capital of Malawi, there was NO BLOOD AVAILABLE. I went to theatre to talk to the anaesthetist who confirmed that it would be too risky to operate without blood, that she would have to wait. I walked slowly back to labour ward to give the news my heart was so heavy. The young Irish midwife, who had been looking after her, cried out" This cannot be happening! " But it was true. I told her to remove the fetal monitor, there was nothing more we could do and listening to the baby's slow heart beat was not going to help. She cried. I tried to console her and felt resigned. I did notweep as I would have done a few months ago. Am I starting to harden to these situations? am I accepting them? I hope not.
The lights have just gone off, there is a powercut in this place that I come to talk to you all. How strange that the computer still works! Here I share my highs and my lows, my laughter and my tears. I let you into my life and my work, into the lives of the poor women of Malawi. Why? Just so you know how lucky you are! Just so you realize how much you take for granted! Just so you think again when you complain of the health care you receive! Just so you appreciate every day and moment of your comfortable lives! Just so you love and care!
My midwife friend Joanne sent me this ( she was working at Bwaila before me) I thank her for her insight and her continued concern for Bwaila.
"If we are lucky, we will suffer a taste of powerlessness in our own private lives. Because then things change. Then we begin to see with a gentler, broader vision and talk with a kinder tongue and feel with deeper feelings for those for whom powerlessness is a way of life." Joan Chittister
Friday 17 October 2008
TIME PASSES BUT WHAT CHANGES?
I really can't believe that nearly three weeks have passed since I last wrote to you all of my life here in Lilongwe Malawi. Time passes so quickly and I am already starting to make plans for our return to Europe in time for Lucas' birthday and for Christmas. These are special times for us as a family and it will be good to be together again. My mum has be operated on recently and although she seems to be recovering it has not been without its difficulties. I am grateful to have my brothers and especially my sister available for her as I am really not much use to her being so far away. I sometimes question my dedication and availability to the poor, the women and babies of Malawi when I am not even able to care for my own mother. Still ....I guess life is full of confusing and conflictive thoughts ....nowhere more so than here in Malawi, one of the poorest countries in the world. It is evident that huge amounts of donor money is being poured into this country. Many projects covering a huge multitude of different areas of health, education, agriculture, etc.etc. Conferences and congresses. Training programs and education to improve knowledge and skills. But yesterday we found ourselves with no gloves. Just for 15 minutes whilst someone went off to find the matron and replenish supplies, but during these 15 minutes nothing could be done! Well not quite true... I managed to deliver a baby and resuscitate another without gloves... much to the horror and disgust of all my colleagues. On our busy labour ward many things can happen in 15 minutes it is not acceptable to be without gloves. Proper suture material has been absent during most of this week. Yes, women are being sutured but not as well as they could. But this is normal at Bwaila hospital this has become acceptable ...at least to some. So all this money pouring into the country and we have no gloves and no suture material. Not to mention scissors, forceps, curtains, vacuum extractor, beds, sheets, lights, soap, syringes, needles, washing facilities, showers, hot water...........do you want me to continue? But I'm not saying that the answer is to keep donating these necessities. I just want to emphasize that these are necessities for dignant care.
I have heard that large sums of money are being spent on courses and training on how to deal with a major crisis or disaster. Earthquake, floods, tsunami or the likes. I'm sure it is very relevant and important but hunger, poverty, lack of decent health care and education are here with us now. Crisis and disaster are here with us now and we are not managing to deal with it effectively.
The twins that I wrote of in my last blog were able to go home after just 5 days in the nursery. They returned one week later for a check-up and were looking fine and healthy both having gained weight. Before discharge their mother had asked me to give names to the two little girls. This is a great honour and one becomes as if a god-mother. I shall have to be careful not to take on too many of these adopted children! I decided to call them Ruth and Rachel ( My elder sister and I) When she came to show me the girls they were dressed in the clothes I had given them and wrapped in the little blue Ikea blankets that Katy had brought out. She proudly told me in broken English that Ruth and Rachel were doing well and would like me to visit them. I shall put aside a day next week to do just that.
Some days are more chaotic than others. Very often labour ward is full of staff. Students of all types mill around with what seems like as a total lack of direction. Many times that is so. I continue to try and teach as much as possible. I move from bed to bed trying to keep aware of what is happening ask questions and discuss care plans. I am always particularly vigilant to make sure that the referred cases are assesed promptly. This is still a problem. This past 2 weeks my in-service training sessions have been looking at case studies to try and pick up any mistakes made and learn from them. I was suprised to find that most of the midwives were quick to spot the delays in giving the appropiate care and could easily present the case and make the corrections. They also could appreciate the evident lack of record keeping. They found the sessions stimulating and helpful...or so they said... I was dissappointed to find that the following days showed that this knowledge was not being put into practice. They were not able to perform the care that they knew was correct. Or they were too busy or tired or complacent. This ended in two particularly sad cases where the result was two dead babies. If they had acted quicker or made a more responsable decision instead of waiting these babies would not have died. Much of the delay is in getting to the hospital but we need to confront the obvious delays that are occuring in our own labour ward.
I will try not to leave it so long before writing again.
Many times I just don't feel like writing it all down as its too upsetting or just too repetative.
My moods change and swing each day and sometimes many times in a day. Today I am not so positive and just a little tired and angry. I am sure it reflects in my writing.
Lucas has been on half term holiday this week. We were so lucky to be invited to spend a long weekend at a cottage on the lake shore. It was a fun and peaceful few days. We feel very fortunate to have such good generous friends.
I remain with the image of the sun rising over the lake. A huge fiery red, orange and pink circle changing the colours of the sky as each minute passed and a new day began. I crept out of bed quietly and wandered down to the lake for a morning swim in its calm sweet waters. I have so much to be grateful for. Sometimes the contrast from that to my work with the women is too much to bear.
I have heard that large sums of money are being spent on courses and training on how to deal with a major crisis or disaster. Earthquake, floods, tsunami or the likes. I'm sure it is very relevant and important but hunger, poverty, lack of decent health care and education are here with us now. Crisis and disaster are here with us now and we are not managing to deal with it effectively.
The twins that I wrote of in my last blog were able to go home after just 5 days in the nursery. They returned one week later for a check-up and were looking fine and healthy both having gained weight. Before discharge their mother had asked me to give names to the two little girls. This is a great honour and one becomes as if a god-mother. I shall have to be careful not to take on too many of these adopted children! I decided to call them Ruth and Rachel ( My elder sister and I) When she came to show me the girls they were dressed in the clothes I had given them and wrapped in the little blue Ikea blankets that Katy had brought out. She proudly told me in broken English that Ruth and Rachel were doing well and would like me to visit them. I shall put aside a day next week to do just that.
Some days are more chaotic than others. Very often labour ward is full of staff. Students of all types mill around with what seems like as a total lack of direction. Many times that is so. I continue to try and teach as much as possible. I move from bed to bed trying to keep aware of what is happening ask questions and discuss care plans. I am always particularly vigilant to make sure that the referred cases are assesed promptly. This is still a problem. This past 2 weeks my in-service training sessions have been looking at case studies to try and pick up any mistakes made and learn from them. I was suprised to find that most of the midwives were quick to spot the delays in giving the appropiate care and could easily present the case and make the corrections. They also could appreciate the evident lack of record keeping. They found the sessions stimulating and helpful...or so they said... I was dissappointed to find that the following days showed that this knowledge was not being put into practice. They were not able to perform the care that they knew was correct. Or they were too busy or tired or complacent. This ended in two particularly sad cases where the result was two dead babies. If they had acted quicker or made a more responsable decision instead of waiting these babies would not have died. Much of the delay is in getting to the hospital but we need to confront the obvious delays that are occuring in our own labour ward.
I will try not to leave it so long before writing again.
Many times I just don't feel like writing it all down as its too upsetting or just too repetative.
My moods change and swing each day and sometimes many times in a day. Today I am not so positive and just a little tired and angry. I am sure it reflects in my writing.
Lucas has been on half term holiday this week. We were so lucky to be invited to spend a long weekend at a cottage on the lake shore. It was a fun and peaceful few days. We feel very fortunate to have such good generous friends.
I remain with the image of the sun rising over the lake. A huge fiery red, orange and pink circle changing the colours of the sky as each minute passed and a new day began. I crept out of bed quietly and wandered down to the lake for a morning swim in its calm sweet waters. I have so much to be grateful for. Sometimes the contrast from that to my work with the women is too much to bear.
Thursday 25 September 2008
MANY BABIES AND NO BEDS
We have 14 beds on labour ward at Bwaila hospital. It is the traditional ' nightingale ward ' which allows little or no privacy for the labouring women as more often than not the curtains hanging round each bed ar either torn broken or not present. The beds are about 1.5m apart which does not allow much freedom of movement for the woman or the midwife. However this ' layout ' does have its advantages as it allows the understaffed midwives to, at least, be aware of what is going on in most of the ward. If you can't see them you can hear them. " Nursey! nursey! nursey! " they cry to attract our attention., very often when the babies head is emerging, so all we can do is run to catch the little one coming out. However it doesn't always work. I should tell you of the birth on night duty, I wasn't present. The woman cried out alerting the staff that the baby had been born. The midwife approached the bed with her equipment but there was no sign of the baby. On closer inspection the newborn was found dangling by the umbilical cord over the side of the bed! Both mother and baby are fine.....now!
We are attending around 40 to 50 births a day so, as you can imagine, it is not unusual to find that we have no spare beds. Labouring women will stand beside the bed of a recently delivered mother just waiting for her to get up and go to the shower so she can claim her bed! ( It reminds me of people waiting in restaurant queues for the next available table. Trying to judge if the diners on table one, who are taking coffee, will then ask for a liquor after or just go straight for the bill and what a relief when you see them putting on their coats and getting up to go!) No spare beds means that women will birth on the floor. This can be an advantage as she will rarely lie down but be in whatever position she finds most comfortable but the disadvantages are that the cement floors are extremely dirty, hardly ideal for receiving a newborn and most midwives would not get down on the floor to assist. And so it was on Monday morning when I arrived. " A full house! " I was told. I enquired as to where I should start? Who was pushing? Any problems? I was asked to attend bed 8. " She was fully dilated at 6am. but we've been so busy we told her she would have to wait " And she had! As I went to her bed I passed a woman crouching on ' all fours' on the floor. She was moaning loudly, obviously in advanced labour, but as there was no bed and I had another to attend I left her on the floor. It was her first baby and the head was low. I got her out of bed and onto the birthing stool. " Can I push now" she enquired and was happy and relieved that she didn't have to wait any longer, that she had someone to care for her and so she started pushing. Ten minutes later, with much encouragement I started to see the head, the fetal heart was fine and she was doing well. I had been looking over regularly at the woman on the floor to see how she was doing and shouting words of encouragement. " We'll have a bed soon, don't worry " I dont expect she understood me but then again my words were not only for her, but for the other midwives standing around. Its a dangerous time to give birth as the night nurses have finished and the day staff have not yet started. " Can someone attend that woman please I begged" Too late! The cleaner shouted out " Baby born!" Still no one seemed to move, so I left my young first timer and rushed to her side. The baby had been born by the breech ( bum first) and was hanging by its head while she stayed on all fours position. This is a great position for normal births but absolutely NOT for breeches. I got on the floor and quickly managed to help the head to be born, it was not easy, even with my experience in attending in all sorts of positions. The baby needed immediate resuscitation which I did. Still no movement from my colleagues! " Please will someone get her onto a bed " I cried. " Can you check if there is a twin as the baby is quite small. " I asked. It took about 10 minutes to get another woman off to the shower and wash the bed. In that time I continued to work on the baby all the time asking for them to hurry up and please check if there was a twin. By the time she was on the bed and being attended by 2 students the baby was breathing spontaneously so I left her with oxygen and approached the bed. They had confirmed a 2nd twin but still had not listened for the fetal heart or determined the presentation. I continue to be amazed by the total lack of a sense of urgency amoung my fellow midwives. I could not bear it, so I just took over. "She has one nearly dead baby by god we're going to save this one " I exclaimed. They had not heard a heart beat! I examined her, determined a head presentation, ruptured the membranes, applied a vacuum extraction and as she pushed I pulled that baby out. It was not difficult but it was urgent. The baby's condition was poor so I left the students to attend to the woman and resuscitated the 2nd little girl. Both babies responded well and are now in nursery. The students working in Nursery have taken a special interest in them and I have visited them everyday since. I am happy to say that they are doing well. Both are breast feeding, they have lost weight and are being treated with antibiotics but after the first 24hours on oxygen are now maintaining well. I was able to take them some of the clothes and blankets that Katy brought over given by very generous donations. I hope to continue to follow their progress when they are discharged.
Just to finish I should tell you of our visitors to labour ward this week. We have received a large group of senior midwives, tutors, matrons, clinical instructors etc.from all the different university training centres in Malawi. They are on a 3 week goverment course funded by an NGO specifically to revise and refresh their practical knowledge so has to improve their teaching both in the classroom and in the clinical situation. Part of their updating is to look at different birthing positions, freedom of movement in labour, spontaneous pushing and instinctive birthing behaviour. They had been told that in Bwaila maternity unit we are already practising this type of care. Hallelujuh ! Its just what I have been teaching and trying to implement, but how much better that it now comes from official ministry sources and encouraged by their own people. I have had the opportunity to work with these midwives this week and we have had more vertical births than ever. Women were seen crouching, standing, moving around and generally off the bed. Yesterday I was able to demonstrate how to attend the delivery of twins with the woman sitting on the birthing stool.
I am happy and extremely encouraged.
We are attending around 40 to 50 births a day so, as you can imagine, it is not unusual to find that we have no spare beds. Labouring women will stand beside the bed of a recently delivered mother just waiting for her to get up and go to the shower so she can claim her bed! ( It reminds me of people waiting in restaurant queues for the next available table. Trying to judge if the diners on table one, who are taking coffee, will then ask for a liquor after or just go straight for the bill and what a relief when you see them putting on their coats and getting up to go!) No spare beds means that women will birth on the floor. This can be an advantage as she will rarely lie down but be in whatever position she finds most comfortable but the disadvantages are that the cement floors are extremely dirty, hardly ideal for receiving a newborn and most midwives would not get down on the floor to assist. And so it was on Monday morning when I arrived. " A full house! " I was told. I enquired as to where I should start? Who was pushing? Any problems? I was asked to attend bed 8. " She was fully dilated at 6am. but we've been so busy we told her she would have to wait " And she had! As I went to her bed I passed a woman crouching on ' all fours' on the floor. She was moaning loudly, obviously in advanced labour, but as there was no bed and I had another to attend I left her on the floor. It was her first baby and the head was low. I got her out of bed and onto the birthing stool. " Can I push now" she enquired and was happy and relieved that she didn't have to wait any longer, that she had someone to care for her and so she started pushing. Ten minutes later, with much encouragement I started to see the head, the fetal heart was fine and she was doing well. I had been looking over regularly at the woman on the floor to see how she was doing and shouting words of encouragement. " We'll have a bed soon, don't worry " I dont expect she understood me but then again my words were not only for her, but for the other midwives standing around. Its a dangerous time to give birth as the night nurses have finished and the day staff have not yet started. " Can someone attend that woman please I begged" Too late! The cleaner shouted out " Baby born!" Still no one seemed to move, so I left my young first timer and rushed to her side. The baby had been born by the breech ( bum first) and was hanging by its head while she stayed on all fours position. This is a great position for normal births but absolutely NOT for breeches. I got on the floor and quickly managed to help the head to be born, it was not easy, even with my experience in attending in all sorts of positions. The baby needed immediate resuscitation which I did. Still no movement from my colleagues! " Please will someone get her onto a bed " I cried. " Can you check if there is a twin as the baby is quite small. " I asked. It took about 10 minutes to get another woman off to the shower and wash the bed. In that time I continued to work on the baby all the time asking for them to hurry up and please check if there was a twin. By the time she was on the bed and being attended by 2 students the baby was breathing spontaneously so I left her with oxygen and approached the bed. They had confirmed a 2nd twin but still had not listened for the fetal heart or determined the presentation. I continue to be amazed by the total lack of a sense of urgency amoung my fellow midwives. I could not bear it, so I just took over. "She has one nearly dead baby by god we're going to save this one " I exclaimed. They had not heard a heart beat! I examined her, determined a head presentation, ruptured the membranes, applied a vacuum extraction and as she pushed I pulled that baby out. It was not difficult but it was urgent. The baby's condition was poor so I left the students to attend to the woman and resuscitated the 2nd little girl. Both babies responded well and are now in nursery. The students working in Nursery have taken a special interest in them and I have visited them everyday since. I am happy to say that they are doing well. Both are breast feeding, they have lost weight and are being treated with antibiotics but after the first 24hours on oxygen are now maintaining well. I was able to take them some of the clothes and blankets that Katy brought over given by very generous donations. I hope to continue to follow their progress when they are discharged.
Just to finish I should tell you of our visitors to labour ward this week. We have received a large group of senior midwives, tutors, matrons, clinical instructors etc.from all the different university training centres in Malawi. They are on a 3 week goverment course funded by an NGO specifically to revise and refresh their practical knowledge so has to improve their teaching both in the classroom and in the clinical situation. Part of their updating is to look at different birthing positions, freedom of movement in labour, spontaneous pushing and instinctive birthing behaviour. They had been told that in Bwaila maternity unit we are already practising this type of care. Hallelujuh ! Its just what I have been teaching and trying to implement, but how much better that it now comes from official ministry sources and encouraged by their own people. I have had the opportunity to work with these midwives this week and we have had more vertical births than ever. Women were seen crouching, standing, moving around and generally off the bed. Yesterday I was able to demonstrate how to attend the delivery of twins with the woman sitting on the birthing stool.
I am happy and extremely encouraged.
Thursday 18 September 2008
HORRIBLE AND HAPPY
I was glad to be back on labour ward on Monday. I spent the weekend missing my girls and feeling a bit sorry for myself.
It was as busy as ever and we had a new set of student midwives who had started whilst I was away. Their time is to be spent attending high risk women so this is a very important part of their clinical training.
These midwives will soon be out on their own in the district health centres and hospitals so I am quick to point out to them the district referrals that we receive so as they can become aware of the dangers of waiting to long before sending these women to us. We had an especially busy morning on Tuesday when we received up to 10 referred cases. I was appalled to find one woman, labouring her 5th child, who had been pushing "since yesterday"
Her whole lower regions were swollen beyond recognition. I quickly and easily diagnosed a posterior prestentation ( the baby looks up instead of down) a huge full bladder that obstructed the descent of the babys head and severe fetal distress. Examing her I felt sure that we could assist a vaginal delivery, though difficult. I made a quick decision that the childs life was already compromised that a c/section would take at least 30 minutes to get the baby out and that her other 4 children needed a fit healthy mother. She has more chance of this with a vaginal delivery. Any operative procedure carries a very high risk for the mothers here in Malawi. From haemorrage, underlying conditions such as Hepatitis or HIV,severe and chronic anaemia and sepsis due to little personal hygiene, no clean or running water, not to mention the deplorable state of the operating theatres and the sometimes very inexperienced clinicians. I referred to the clinician on duty and the senior midwife. Neither were too sure but I have now built up a good relationship with them all. They trust me and will refer to me in many difficult situations where decisions have to be made. So we worked together and the baby was born with the assistance of a vacuum extraction. Leaving the clinician to care for the mother I rushed the little one to the resuscitaire and commenced profound resuscitation. I did not feel confident that my efforts would be successful but at least I could try. The baby responded slowly so I continued to work on him. When I had achieved spontaneous breathing , though still with difficulty I transferred him to the nursery. I handed him over to the nursery nurses telling them that I was not hopeful that he would survive. It was a long hard morning. I had intended to leave at 3pm having worked non stop since 7.15 am but just had to help sort out 2 other situations before I left. Sometime around midday a young woman having her 1st baby arrived. A very late referral for prolonged labour. We could only find a slow heart beat. My Norweigian midwife colleague called me to assist a vacuum extraction, she felt sure the baby would come with a little help. She was not successful with her first pull so asked me to take over. The baby would not come even though it was very close. I felt that there was some other reason for this difficulty.. it didn't make sense.. I tried to find the babys heart beat before continuing but it was not to be found. When a baby has died in the uterus it is much more difficult to birth. Babies also play a part in facilitating their own birth. My colleague agreed that she had probably been hearing the mothers pulse. This we confirmed on ultra sound scan. Sadly we explained to her that her baby had died, she had been pushing too long.We decided to leave her a while to see if she could birth with less violence as now there was no hurry to get the baby out. I gave her some sedation so she could rest and would feel less pain.At 3pm she was still no closer to birthing her dead child. I enquired of the clinician on duty as to when she would come to assist the woman. She was the only clinician left on duty. Where the others had gone I dont know . She had to do an urgent c/section and possibly another after. I could not go home and leave this woman. It was likely that she could not be attended for several hours. Her uterus was still contracting.she was still being forced by her own body to push her child out. I called to another midwife and a student to assist me. A c/section in these circumstances would be unforgivable. The only other option is to destoy the baby. I had to try. I pulled and she pushed
my fellow midwives encouraged her to use all her strength. I sweated and manipulated untill at last the little one came. What a relief ! Not nice, not at all pleasant, never to be done in your rich and well developed world where clean and safe operating theatres are the norm. Where anesthetics and anaesthetists are readily available but the best option here. Today she was discharged home, without a baby but alive and well and with the possibility of other pregnancys, of other babies...I hope.
I eventually left at 4pm!
Arriving on Wednesday morning I was greeted by a call from a fellow midwife who was having problems. I don't know how long the woman had been pushing but the baby was not coming. I could see a large part of the fetal skull so suggested an episiotomy (cut in the perineum) might be helpful. This she did . The head was born and the shoulders got stuck. Following the correct manouvers of which I have now had plenty of practice the baby was born. I immediatley realized that this baby was severely distressed so quickly carried his floppy body over to the resuscitaire. I found a slow heart beat but nothing else. It was 7.15am. I had just arrived. Hardly time to put on my apron and I found myself resuscitating a nearly dead baby. As I stood there doing all I could. Giving my best . Inflating his little lungs suctioning the mucous from his throat, I began to wonder when this would all stop? How much longer would the rich world let this carry on? Its not as if they don't try .....millions of dollars are being poured into Malawi so why is it not working? Why am I still finding these hopeless situations daily? The baby was pink, the chest was rising I was inflating his little lungs the heart was beating strongly but he just would not breath. I could see that his pupils were already dilated, he was already brain damaged the respiratory centres in his brain were not functioning but I carried on. At 7.40am the students started to arrive. I had been breathing for him for 25 minutes but he still showed no signs of improvement. How long do I carry on? Can I really stop? When? I asked a student to take over, we would continue a while longer. I went to look at the mothers file and give her the news that her baby would not survive. The labour graph told me that niether she nor the baby had not been attended since 12midnight, when she was found to be 8cms dilated. That means she would have expected to give birth between 2 and 4 am. the baby was born at 7.15 am! I went back and told the student to cease resuscitation. It was nearly an hour since the birth. The baby was making a few gasping sounds so I left him under the warm heater with an oxygen supply. The doctors and clinicians came to make their grand "round" It was commented by a white visiting doctor as to "why had that baby been left there and abandoned? " I just cried. My Malawian midwife colleague held in her arms andgave me a big hug and reminded me we can only do so much, we can only do our best, we cant do more. The baby died in nursery during the afternoon. Later I went back to check the labour graph and found that the times had been changed that the graph had been manipulated. It is not the first time that I have witnessed this but this is still too big for me to confront.
Most afternoons I call by nursery to see 'my' babies. I found the woman I had attended the day before sitting on the floor with her baby in her arms. I asked the staff how he was as I had expected him to die. " Improving" they assured me. I knelt on the floor and the mother started talking to me. "What is she saying?" I asked.
" She says she has no milk for him" I gently squeezed her breast and out came those precious drops of calostrum which I put onto his lips. He began to respond so I squeezed out more. Bringing the baby close to the breast I carefully put her nipple into his mouth. He sucked! There was no hesitation, he latched on beautifully and wouldn't let go! His mum gave me a huge smile and the students working in nursery looked on in amazement. I still wonder if he will be brain damaged and if so, how severely but at the present he is happily sucking away at his happy mum's breast.
Yes that will keep me going for a while!
It was as busy as ever and we had a new set of student midwives who had started whilst I was away. Their time is to be spent attending high risk women so this is a very important part of their clinical training.
These midwives will soon be out on their own in the district health centres and hospitals so I am quick to point out to them the district referrals that we receive so as they can become aware of the dangers of waiting to long before sending these women to us. We had an especially busy morning on Tuesday when we received up to 10 referred cases. I was appalled to find one woman, labouring her 5th child, who had been pushing "since yesterday"
Her whole lower regions were swollen beyond recognition. I quickly and easily diagnosed a posterior prestentation ( the baby looks up instead of down) a huge full bladder that obstructed the descent of the babys head and severe fetal distress. Examing her I felt sure that we could assist a vaginal delivery, though difficult. I made a quick decision that the childs life was already compromised that a c/section would take at least 30 minutes to get the baby out and that her other 4 children needed a fit healthy mother. She has more chance of this with a vaginal delivery. Any operative procedure carries a very high risk for the mothers here in Malawi. From haemorrage, underlying conditions such as Hepatitis or HIV,severe and chronic anaemia and sepsis due to little personal hygiene, no clean or running water, not to mention the deplorable state of the operating theatres and the sometimes very inexperienced clinicians. I referred to the clinician on duty and the senior midwife. Neither were too sure but I have now built up a good relationship with them all. They trust me and will refer to me in many difficult situations where decisions have to be made. So we worked together and the baby was born with the assistance of a vacuum extraction. Leaving the clinician to care for the mother I rushed the little one to the resuscitaire and commenced profound resuscitation. I did not feel confident that my efforts would be successful but at least I could try. The baby responded slowly so I continued to work on him. When I had achieved spontaneous breathing , though still with difficulty I transferred him to the nursery. I handed him over to the nursery nurses telling them that I was not hopeful that he would survive. It was a long hard morning. I had intended to leave at 3pm having worked non stop since 7.15 am but just had to help sort out 2 other situations before I left. Sometime around midday a young woman having her 1st baby arrived. A very late referral for prolonged labour. We could only find a slow heart beat. My Norweigian midwife colleague called me to assist a vacuum extraction, she felt sure the baby would come with a little help. She was not successful with her first pull so asked me to take over. The baby would not come even though it was very close. I felt that there was some other reason for this difficulty.. it didn't make sense.. I tried to find the babys heart beat before continuing but it was not to be found. When a baby has died in the uterus it is much more difficult to birth. Babies also play a part in facilitating their own birth. My colleague agreed that she had probably been hearing the mothers pulse. This we confirmed on ultra sound scan. Sadly we explained to her that her baby had died, she had been pushing too long.We decided to leave her a while to see if she could birth with less violence as now there was no hurry to get the baby out. I gave her some sedation so she could rest and would feel less pain.At 3pm she was still no closer to birthing her dead child. I enquired of the clinician on duty as to when she would come to assist the woman. She was the only clinician left on duty. Where the others had gone I dont know . She had to do an urgent c/section and possibly another after. I could not go home and leave this woman. It was likely that she could not be attended for several hours. Her uterus was still contracting.she was still being forced by her own body to push her child out. I called to another midwife and a student to assist me. A c/section in these circumstances would be unforgivable. The only other option is to destoy the baby. I had to try. I pulled and she pushed
my fellow midwives encouraged her to use all her strength. I sweated and manipulated untill at last the little one came. What a relief ! Not nice, not at all pleasant, never to be done in your rich and well developed world where clean and safe operating theatres are the norm. Where anesthetics and anaesthetists are readily available but the best option here. Today she was discharged home, without a baby but alive and well and with the possibility of other pregnancys, of other babies...I hope.
I eventually left at 4pm!
Arriving on Wednesday morning I was greeted by a call from a fellow midwife who was having problems. I don't know how long the woman had been pushing but the baby was not coming. I could see a large part of the fetal skull so suggested an episiotomy (cut in the perineum) might be helpful. This she did . The head was born and the shoulders got stuck. Following the correct manouvers of which I have now had plenty of practice the baby was born. I immediatley realized that this baby was severely distressed so quickly carried his floppy body over to the resuscitaire. I found a slow heart beat but nothing else. It was 7.15am. I had just arrived. Hardly time to put on my apron and I found myself resuscitating a nearly dead baby. As I stood there doing all I could. Giving my best . Inflating his little lungs suctioning the mucous from his throat, I began to wonder when this would all stop? How much longer would the rich world let this carry on? Its not as if they don't try .....millions of dollars are being poured into Malawi so why is it not working? Why am I still finding these hopeless situations daily? The baby was pink, the chest was rising I was inflating his little lungs the heart was beating strongly but he just would not breath. I could see that his pupils were already dilated, he was already brain damaged the respiratory centres in his brain were not functioning but I carried on. At 7.40am the students started to arrive. I had been breathing for him for 25 minutes but he still showed no signs of improvement. How long do I carry on? Can I really stop? When? I asked a student to take over, we would continue a while longer. I went to look at the mothers file and give her the news that her baby would not survive. The labour graph told me that niether she nor the baby had not been attended since 12midnight, when she was found to be 8cms dilated. That means she would have expected to give birth between 2 and 4 am. the baby was born at 7.15 am! I went back and told the student to cease resuscitation. It was nearly an hour since the birth. The baby was making a few gasping sounds so I left him under the warm heater with an oxygen supply. The doctors and clinicians came to make their grand "round" It was commented by a white visiting doctor as to "why had that baby been left there and abandoned? " I just cried. My Malawian midwife colleague held in her arms andgave me a big hug and reminded me we can only do so much, we can only do our best, we cant do more. The baby died in nursery during the afternoon. Later I went back to check the labour graph and found that the times had been changed that the graph had been manipulated. It is not the first time that I have witnessed this but this is still too big for me to confront.
Most afternoons I call by nursery to see 'my' babies. I found the woman I had attended the day before sitting on the floor with her baby in her arms. I asked the staff how he was as I had expected him to die. " Improving" they assured me. I knelt on the floor and the mother started talking to me. "What is she saying?" I asked.
" She says she has no milk for him" I gently squeezed her breast and out came those precious drops of calostrum which I put onto his lips. He began to respond so I squeezed out more. Bringing the baby close to the breast I carefully put her nipple into his mouth. He sucked! There was no hesitation, he latched on beautifully and wouldn't let go! His mum gave me a huge smile and the students working in nursery looked on in amazement. I still wonder if he will be brain damaged and if so, how severely but at the present he is happily sucking away at his happy mum's breast.
Yes that will keep me going for a while!
Friday 12 September 2008
MY GIRLS IN MALAWI
I have just returned form leaving my two girls, Katy and Fiona at the airport. I am sad.
They have been with me for 9 days and we were able to take a short trip to the lake and the game park and thus introduce them to a little of Malawi, of Africa.
It has been a wonderful time for me. I have enjoy their company, their love and their interest in everything.
During the first few days I was able to take them to Bwaila hospital to show them where I am working and the conditions under which the poor women of Lilongwe are being attended. They were both amazed and saddened to experience, first hand, some of the things they have been following in my blog and our regular phone calls. They were particularly interested in our nursery and the tiny babies that are being cared for. Just 900 grams and very premature it was difficult for the girls to hear that these babies have very little chance of surviving as both the facilities, the equipment and the medical expertise are not available.
Katy had been busy collecting money, clothing and toys, crayons, books and note pads for the past months. The response to her call was wonderful making it possible for her to bring not only a large number of these things but also more expensive items such as a doppler for listening to fetal heart rate, and weighing scales much needed by the Traditional Birth Attendents in the villages. We were able to visit an orphanage, a small mission clinic by the lake, two TBA's as well as distributing to the many women and babies "camped out" in the grounds of Bwaila hospital.
We visited my twins in the village and also one of my "miracle babies" These were both wonderfully enriching experiences for the girls who were able to appreciate true Malawian village life. We we received by the head man of the village which was a great honour.
We were entertained to homemade doughnuts sitting inside a cool mud hut and much time was spent blowing up and playing with balloons with the numerous children many of whom had never seen nor touched a balloon. We warned them that it may pop making a loud noise but it still suprised them!
The twins were looking big ! They are now nearly 8 months old. Unfortunatly they were suffering from vomiting and diarrhoea so we took them all, in my small jeep, to the clinic and left Pilirani with money for medicine and transport home. It was quite a squash... 6 adults and 2 babies ...but nobody seemed to mind!
The girls soon became aware that wherever we went there was poverty and need. They were able to give small gifts to the children as we travelled and were rewarded with dancing, with obvious joy and huge smiles. But they too soon found that there was never enough to give. Where they thought there were just 2 or 3 children, suddenly, out of nowhere, dozens of little ones appeared. At times it was very frustrating. They too felt the conflict and confusion of bargaining for every small wooden carving or craft that they wanted to buy. How much to pay ? Was it enough ? Maybe they could pay more? Should they pay more?
I am looking forward to going back to labour ward tomorrow after a week off. I know it continues to be very busy and there are many new students. I feel strong and positive. There is much to do...
They have been with me for 9 days and we were able to take a short trip to the lake and the game park and thus introduce them to a little of Malawi, of Africa.
It has been a wonderful time for me. I have enjoy their company, their love and their interest in everything.
During the first few days I was able to take them to Bwaila hospital to show them where I am working and the conditions under which the poor women of Lilongwe are being attended. They were both amazed and saddened to experience, first hand, some of the things they have been following in my blog and our regular phone calls. They were particularly interested in our nursery and the tiny babies that are being cared for. Just 900 grams and very premature it was difficult for the girls to hear that these babies have very little chance of surviving as both the facilities, the equipment and the medical expertise are not available.
Katy had been busy collecting money, clothing and toys, crayons, books and note pads for the past months. The response to her call was wonderful making it possible for her to bring not only a large number of these things but also more expensive items such as a doppler for listening to fetal heart rate, and weighing scales much needed by the Traditional Birth Attendents in the villages. We were able to visit an orphanage, a small mission clinic by the lake, two TBA's as well as distributing to the many women and babies "camped out" in the grounds of Bwaila hospital.
We visited my twins in the village and also one of my "miracle babies" These were both wonderfully enriching experiences for the girls who were able to appreciate true Malawian village life. We we received by the head man of the village which was a great honour.
We were entertained to homemade doughnuts sitting inside a cool mud hut and much time was spent blowing up and playing with balloons with the numerous children many of whom had never seen nor touched a balloon. We warned them that it may pop making a loud noise but it still suprised them!
The twins were looking big ! They are now nearly 8 months old. Unfortunatly they were suffering from vomiting and diarrhoea so we took them all, in my small jeep, to the clinic and left Pilirani with money for medicine and transport home. It was quite a squash... 6 adults and 2 babies ...but nobody seemed to mind!
The girls soon became aware that wherever we went there was poverty and need. They were able to give small gifts to the children as we travelled and were rewarded with dancing, with obvious joy and huge smiles. But they too soon found that there was never enough to give. Where they thought there were just 2 or 3 children, suddenly, out of nowhere, dozens of little ones appeared. At times it was very frustrating. They too felt the conflict and confusion of bargaining for every small wooden carving or craft that they wanted to buy. How much to pay ? Was it enough ? Maybe they could pay more? Should they pay more?
I am looking forward to going back to labour ward tomorrow after a week off. I know it continues to be very busy and there are many new students. I feel strong and positive. There is much to do...
Thursday 28 August 2008
MAKING A DIFFERENCE
I am physically and emotionally exhausted !
These past few days have been exceptionally busy, not just the number of births attended but the nature of them. As I have explained before, Bwaila maternity hospital serves as the referral unit for the whole of Lilongwe and surrounding areas. This means that anything that can't be sorted out at health centre or district level comes to us.
Today has been one of those days when we have been continually receiving referred patients. Yes these are true patients. There situation/condition means that the birth is now not normal, has passed to the realms of pathalogical, of difficult, of dangerous or very dangerous.
I arrived as usual soon after 7am. at the same time as an ambulance bringing us 3 women from the same health centre. It sometimes makes me wonder what they have been doing with these ladies all night ? A retained twin, now dead with one arm visibly hanging from the vagina.Two prolonged 2nd stage..this means that they have been pushing in vain for hours without result.
I started to prioritize. We have only one operating theatre, so who needs to go first?
The baby is already dead, in case one, so she can wait. Severe fetal distress in the second means an emergency c/section to save the baby. But the third although there was no fetal heartbeat to be heard the mother had a ruptured uterus thus endangering her life. Maternal life before fetal wellbeing meant the second had to wait. Her operation was carried out later and the baby is alive....just!
And that was how the morning went. When I had time to look at the clock I found it to be already 1pm. No wonder I was hungry and thirsty!
It was a morning of assesment, evaluation and decision making. It was an immensely challenging morning. I was encouraged at times to find a true feeling of team work with my Malawian colleagues, clinical officers, medical staff and midwives. As we hurriedly passed each other in the ward, one of the C.O's gave me a "thumbs up" sign as if to say " another one safely delivered" It was great to see his obvious pleasure at a job well done. This is not something I see very often as mostly I think that the Malawian staff don't believe that what they do, how they act, will really make any difference. It made me realize how driven I am, personally, by this feeling of 'making a difference.' To just one mother or baby just one at a time. Its what keeps me going. Its what makes my days worthwhile. Its what makes me cope with the tiredness, the exhaustion ,the frustrations, that feeling that I am really making a difference. The day I dont feel this I might as well give up. If money isn't an incentive, which here in Malawi it obviously isn't, then there has to be some reason to keep going. If they rarely feel they make a difference then this may account for the uncaring, negligent behaviour I often encounter.
I was further challenged to assist a twin breech delivery. Both came feet first and weighed over 2.5kgs. this is large by Malawian standards. Both presented difficulty with the birth of the aftercoming head but with my now greater knowledge and experience I was able to help these little ones out safely.
I cannot tell you all the situations that I find myself confronting in labour ward, but sufficient to say that daily I find myself putting my skills to the test, learning, becoming more practised and confident and able to help these lovely Malawian women and babies.
My girls will be here this time next week. I can't wait!
Untill then I go to rest, to have fun time with Lucas and my friends, to live each day to its full.
There is so much to do and so little time....ENJOY!
These past few days have been exceptionally busy, not just the number of births attended but the nature of them. As I have explained before, Bwaila maternity hospital serves as the referral unit for the whole of Lilongwe and surrounding areas. This means that anything that can't be sorted out at health centre or district level comes to us.
Today has been one of those days when we have been continually receiving referred patients. Yes these are true patients. There situation/condition means that the birth is now not normal, has passed to the realms of pathalogical, of difficult, of dangerous or very dangerous.
I arrived as usual soon after 7am. at the same time as an ambulance bringing us 3 women from the same health centre. It sometimes makes me wonder what they have been doing with these ladies all night ? A retained twin, now dead with one arm visibly hanging from the vagina.Two prolonged 2nd stage..this means that they have been pushing in vain for hours without result.
I started to prioritize. We have only one operating theatre, so who needs to go first?
The baby is already dead, in case one, so she can wait. Severe fetal distress in the second means an emergency c/section to save the baby. But the third although there was no fetal heartbeat to be heard the mother had a ruptured uterus thus endangering her life. Maternal life before fetal wellbeing meant the second had to wait. Her operation was carried out later and the baby is alive....just!
And that was how the morning went. When I had time to look at the clock I found it to be already 1pm. No wonder I was hungry and thirsty!
It was a morning of assesment, evaluation and decision making. It was an immensely challenging morning. I was encouraged at times to find a true feeling of team work with my Malawian colleagues, clinical officers, medical staff and midwives. As we hurriedly passed each other in the ward, one of the C.O's gave me a "thumbs up" sign as if to say " another one safely delivered" It was great to see his obvious pleasure at a job well done. This is not something I see very often as mostly I think that the Malawian staff don't believe that what they do, how they act, will really make any difference. It made me realize how driven I am, personally, by this feeling of 'making a difference.' To just one mother or baby just one at a time. Its what keeps me going. Its what makes my days worthwhile. Its what makes me cope with the tiredness, the exhaustion ,the frustrations, that feeling that I am really making a difference. The day I dont feel this I might as well give up. If money isn't an incentive, which here in Malawi it obviously isn't, then there has to be some reason to keep going. If they rarely feel they make a difference then this may account for the uncaring, negligent behaviour I often encounter.
I was further challenged to assist a twin breech delivery. Both came feet first and weighed over 2.5kgs. this is large by Malawian standards. Both presented difficulty with the birth of the aftercoming head but with my now greater knowledge and experience I was able to help these little ones out safely.
I cannot tell you all the situations that I find myself confronting in labour ward, but sufficient to say that daily I find myself putting my skills to the test, learning, becoming more practised and confident and able to help these lovely Malawian women and babies.
My girls will be here this time next week. I can't wait!
Untill then I go to rest, to have fun time with Lucas and my friends, to live each day to its full.
There is so much to do and so little time....ENJOY!
Wednesday 20 August 2008
ANGER TURNED TO HOPE.
Friday of last week I was going to write to you but I was too angry. I went to a braii (barbeque) instead! Tarek had arrived back from his time away in Europe and along with him a new obstetrician and nurse from Holland. It was good to meet new colleagues although, unfortunately, they will only be here for 5 weeks. I was also able to vent my anger and frustrations to a listening understanding ear. As I have mentioned before Tarek normally comes up with some helpful insight into the situation and he didnt let me down this time. Opinions that evening were that I should still write. I should write with my anger along with all the other confusing emotions that confront me daily. But now it is Wednesday and the anger has calmed. Today I still feel some of those angry feeings but I am also encouraged by the students with whom I have been working hard during the past 3 weeks and their changing attitudes.
Sometimes we are so busy on labour ward that we really cannot attend all the women and babies however hard we try. Women are neglected to birth alone and difficult births end in tragedy.
But on Thursday morning there were only 3 women to attend. I arrived later than usual (8am)
The midwives change shift at 7.30am. I was met by 8 senior student midwives and 3 midwives chatting, cleaning, generally milling around. Having greeted everyone I donned my plastic apron and approached the first bed. There was no record of maternal or fetal observations in the past 2 hours. I listened to the fetal heart beat...I heard severe fetal distress. On examining her I realized I could assist the birth with a vacuum extraction. I called one of the students to help and the baby was born quickly. I resuscitated the child whilst the student attended the mother and all was well. It was now 8.30am. I passed on to the second bed...to my horror I saw that this baby was last observed at 6.45am. now nearly 2 hours ago. The baby was ok, so after encouraging the mother to get off the bed and try some more comfortable positions I then went to the 3rd bed. This mother and baby had not been attended since 7.20am. It was now 8.40am.
Only 3 women .... 3 neglected women and babies.
I was furious! I marched over to the milling crowd of midwives and students...
" We have only 3 women to attend" I shouted. " I have already assisted a baby with fetal distress and the other 2 have not been attended for 1 or 2 hours this is not acceptable, I cannot cope with this!"
I attended one woman, whilst 2 students went to the other bed. They called me immediately. The heart beat was low the woman could not push out her baby she needed an emergency c/section. At 9.40 the baby was extracted in operating theatre. It was necessary for us to perform extensive resuscitation but the baby lived...just... and is now doing well.
Later I apologized for shouting. " No, no " they replied, "you were right" Overall they are a really good set of students and I am encouraged daily by their progress and how they are quickly learning to become competant in their tasks. It was also good to hear them readily accept that in this instance they had failed. I hope they will remember my anger and it will teach them just a little about their responsibilty to the women and babies in their care.
I am continuing with the weekly ' workshops' for our midwives at Bwaila. I was thrilled to find that whilst I had been sick and then away with Alasdair the courses had continued under the leadership of the matrons. They had been well attended and the midwives were very positive about them. In meeting with thematrons to plan ahead for the period from now untill the end of the year we were able to agree on subjects to be covered and divide the teaching between us.
I am so pleased ! This may just be sustainable... and thats what its all about. How much better that they are also being lead and encouraged by their own matrons.
Lucas is back at school. He seems happy with his new teacher, "...who doesnt shout, not like you mummy!" But seems to have some pretty tight rules!
Social life has started up again as everyone returns from their summer(Europe) winter(Malawi)
holidays. We have a new Zimbabwean family living on the compound which means Lucas has constant playmates. Not always a good thing!
We are counting the days untill Katy and Fiona arrive at the beginning of September...wow do I miss my kids!
I want to leave you with one of Luki's many astounding comments /observations.
" I dont know why children are not allowed to watch Lord of the Rings because it is too violent? It is the adults that shouldn't watch fighting and killing because they can do it, but the children can't, they just stay with their mummies."
Worth thinking about don't you think?
Sometimes we are so busy on labour ward that we really cannot attend all the women and babies however hard we try. Women are neglected to birth alone and difficult births end in tragedy.
But on Thursday morning there were only 3 women to attend. I arrived later than usual (8am)
The midwives change shift at 7.30am. I was met by 8 senior student midwives and 3 midwives chatting, cleaning, generally milling around. Having greeted everyone I donned my plastic apron and approached the first bed. There was no record of maternal or fetal observations in the past 2 hours. I listened to the fetal heart beat...I heard severe fetal distress. On examining her I realized I could assist the birth with a vacuum extraction. I called one of the students to help and the baby was born quickly. I resuscitated the child whilst the student attended the mother and all was well. It was now 8.30am. I passed on to the second bed...to my horror I saw that this baby was last observed at 6.45am. now nearly 2 hours ago. The baby was ok, so after encouraging the mother to get off the bed and try some more comfortable positions I then went to the 3rd bed. This mother and baby had not been attended since 7.20am. It was now 8.40am.
Only 3 women .... 3 neglected women and babies.
I was furious! I marched over to the milling crowd of midwives and students...
" We have only 3 women to attend" I shouted. " I have already assisted a baby with fetal distress and the other 2 have not been attended for 1 or 2 hours this is not acceptable, I cannot cope with this!"
I attended one woman, whilst 2 students went to the other bed. They called me immediately. The heart beat was low the woman could not push out her baby she needed an emergency c/section. At 9.40 the baby was extracted in operating theatre. It was necessary for us to perform extensive resuscitation but the baby lived...just... and is now doing well.
Later I apologized for shouting. " No, no " they replied, "you were right" Overall they are a really good set of students and I am encouraged daily by their progress and how they are quickly learning to become competant in their tasks. It was also good to hear them readily accept that in this instance they had failed. I hope they will remember my anger and it will teach them just a little about their responsibilty to the women and babies in their care.
I am continuing with the weekly ' workshops' for our midwives at Bwaila. I was thrilled to find that whilst I had been sick and then away with Alasdair the courses had continued under the leadership of the matrons. They had been well attended and the midwives were very positive about them. In meeting with thematrons to plan ahead for the period from now untill the end of the year we were able to agree on subjects to be covered and divide the teaching between us.
I am so pleased ! This may just be sustainable... and thats what its all about. How much better that they are also being lead and encouraged by their own matrons.
Lucas is back at school. He seems happy with his new teacher, "...who doesnt shout, not like you mummy!" But seems to have some pretty tight rules!
Social life has started up again as everyone returns from their summer(Europe) winter(Malawi)
holidays. We have a new Zimbabwean family living on the compound which means Lucas has constant playmates. Not always a good thing!
We are counting the days untill Katy and Fiona arrive at the beginning of September...wow do I miss my kids!
I want to leave you with one of Luki's many astounding comments /observations.
" I dont know why children are not allowed to watch Lord of the Rings because it is too violent? It is the adults that shouldn't watch fighting and killing because they can do it, but the children can't, they just stay with their mummies."
Worth thinking about don't you think?
Wednesday 6 August 2008
TOTALLY CRAZY
My health has forced me to take time off from my work at the hospital. This beautifully coincided with the return of Lucas to Malwai after his trip to Europe. He was able to have time with my family in UK and catch up with his dad in Spain. He was accompanied...I'm not sure who accompanied who?... by my eldest son, Alasdair, who stayed with us for nearly three weeks. The timing was perfect. I was in great need of family love and care which is exactly what he's good at and which he did to perfection...thanks Alasdair. We had already organized to explore some of the Southern part of Malawi together and were away for 9 days. Alasdair got thrown into Malawi life straight away as he took over all the driving. Our trip included time at the lake..warm sunny and swimming. 2 days in the mountains... chilly, log fires and pine forests, followed by a 2 day safari. This was an amazing experience for us all. Unrepeatable episodes with elephants were the highlights of our trip as we managed to get the car into the middle of the herd.. this is not recommended and was a cause of a huge adrenalin rush and much fear for a while! We also had a huge bull elephant grazing outside our cottage just 1 metre from the window! I should also mention the tyre that punctured on the road to the lake. We thought we were in a pretty remote spot untill we found ourselves rapidly surrounded by a dozen locals all offering there services. I must admit the pit stop was unbelievably quick. Alasdair was quite willing and able to change the tyre but didnt get a look in, he just handed out wet wipes for hand washing afterwards much to the amazement and amusement of all!
We have many lovely stories and incidents from our trip too many to write down now but sufficient to say it really was just what I needed. I feel strong, I feel positive and refreshed I am ready to continue with all that I believe I still have to do here. I am looking forward to being back with the women and the babies at Bwaila.
Last Thursday we said a sad farewell to Alasdair and on Friday morning, bright a early, I was back on labour ward.
I was very warmly welcomed back. My fellow midwives kept telling me how much they had missed me. ( I expect they have to work harder when I'm not there!) I too had missed them, the work, the mums and the babies.
I have worked every day since then. I shall tell you that when I left this afternoon we had recorded 340 births during the month of August. Today is the 6th ( tomorrow is my birthday!) that means more than 50 births a day!
This is unbelievable, this unimaginable, this is totally crazy! If you could just see the size and condition of labour ward. The women who dont have a bed and birth on the floor. The lack of clean ..not to mention sterilized instruments, of gauze swabs or cottonwool, of gloves, but more importantly of midwives. Today I apologized to the woman in the bed opposite..."pepani, pepani... sorry, sorry". No one should birth alone. I was attending a post partum hemorrage an emergency situation. She screamed and she pushed "nursey, nursey" but I could not go to her so her little one slithered out alone. They were alone. I called to her to encourage her I could do nothing more. My priority was to attend the other woman. So there were no caring hands to catch him, no one to scoop him up and clean him off, no one to stimulate his first breath he /they were alone. It was lunch time. The student midwives and clinicians had gone for lunch, one midwife was in the admission room and the other was in theatre with a c/section. I looked up, I looked around, I was alone. I attended 5 births in the next 2 hours. At last I saw a clinician attending at the other end of the ward. I called for help. When he arrived it was to ask me to help him perform a vacuum extraction for fetal distress. I quickly left the woman that I was suturing..that could wait till later..the intervention was quick and simple the baby was fine, I left him and returned to another woman pushing. She had been on labour ward for more than 1 hour but nobody had examined her or listened to the baby's heartbeat. I could see the baby's head. I tried to explain to the lady I was suturing that I would be back, that I had not forgotten her as I rushed to find some instruments, some basic materiales to attend this birth. Three pushes and the child was born but its condition was not good. I hurriedly took him to the resuscitation area. As I worked on the baby, who responded well, I was thinking of the woman lying there on her own. Was she bleeding? Was the placenta out? did she need me? Where should I be? with the mother or the baby? There was no one to help me, I was on my own too.
All these mothers and babies are now fine and well. When I had finished and left them all clean and dry with their babies suckling at the breast I had to fill in the labour files and charts and found I could not remember most of the details of each one, no times of birth, boys or girls? it wasn't important so I didnt know! 2 hours had passed as if it had been 5 minutes!
Dont think this is a strange situation, that this happens every now and then. No.. this is happening nearly every day and most nights. Where are the other staff? how is it possible for them all to disappear at once? These are the very questions I continually ask. And I do ask, but I get no answers. Now can you understand why the busiest maternity unit in Malawi and one of the busiest in the whole of the South African continent has such a high maternal and neonatal mortality rate? Why oh why is it like this? why do these women not deserve better? They do deserve better. I am trying oh how I am trying, but it sometimes feels impossible. However hard I work, however quick I run I just can't reach them all. I suppose this is normality for the Malawian staff, but I have seen better, I know better, I know what should be, but how?
I was so angry yesterday. I was told that on " bed one" the baby had died in the first hour of life. On examining her file I found that she had been pushing for 5 hours. The clinician had been called but arrived 3 hours later, meanwhile no one had checked nor the maternal nor the fetal condition, nor had they used any interventions to aid the birth. This happens with referral cases that have to journey fron outlying districts, or have been attended by poorly qualified attendants. But this woman was on our labour ward in our hospital! I informed as many people as possible. I was not prepared to keep letting these incidents happen without any accountability without any responsibility. On talking to one midwife she informed me that some midwives believe that if the woman pushes and the baby doesn't come it is her fault for not doing it properly for not putting in enough effort. The mother is responsible! This is the attitude I knew existed in the villages but we are a hospital with trained midwives! Could it possibly be that some of our midwives share these beliefs? I despair.....but I am strong and I can carry on.
There is so much I could write today. I am feeling good and positive and confident despite all that I face daily. If I can save just one baby or one mother If just one baby or one mother is better cared for because of me it is enough. At least for today...I wonder how I will feel tomorrow?
We have many lovely stories and incidents from our trip too many to write down now but sufficient to say it really was just what I needed. I feel strong, I feel positive and refreshed I am ready to continue with all that I believe I still have to do here. I am looking forward to being back with the women and the babies at Bwaila.
Last Thursday we said a sad farewell to Alasdair and on Friday morning, bright a early, I was back on labour ward.
I was very warmly welcomed back. My fellow midwives kept telling me how much they had missed me. ( I expect they have to work harder when I'm not there!) I too had missed them, the work, the mums and the babies.
I have worked every day since then. I shall tell you that when I left this afternoon we had recorded 340 births during the month of August. Today is the 6th ( tomorrow is my birthday!) that means more than 50 births a day!
This is unbelievable, this unimaginable, this is totally crazy! If you could just see the size and condition of labour ward. The women who dont have a bed and birth on the floor. The lack of clean ..not to mention sterilized instruments, of gauze swabs or cottonwool, of gloves, but more importantly of midwives. Today I apologized to the woman in the bed opposite..."pepani, pepani... sorry, sorry". No one should birth alone. I was attending a post partum hemorrage an emergency situation. She screamed and she pushed "nursey, nursey" but I could not go to her so her little one slithered out alone. They were alone. I called to her to encourage her I could do nothing more. My priority was to attend the other woman. So there were no caring hands to catch him, no one to scoop him up and clean him off, no one to stimulate his first breath he /they were alone. It was lunch time. The student midwives and clinicians had gone for lunch, one midwife was in the admission room and the other was in theatre with a c/section. I looked up, I looked around, I was alone. I attended 5 births in the next 2 hours. At last I saw a clinician attending at the other end of the ward. I called for help. When he arrived it was to ask me to help him perform a vacuum extraction for fetal distress. I quickly left the woman that I was suturing..that could wait till later..the intervention was quick and simple the baby was fine, I left him and returned to another woman pushing. She had been on labour ward for more than 1 hour but nobody had examined her or listened to the baby's heartbeat. I could see the baby's head. I tried to explain to the lady I was suturing that I would be back, that I had not forgotten her as I rushed to find some instruments, some basic materiales to attend this birth. Three pushes and the child was born but its condition was not good. I hurriedly took him to the resuscitation area. As I worked on the baby, who responded well, I was thinking of the woman lying there on her own. Was she bleeding? Was the placenta out? did she need me? Where should I be? with the mother or the baby? There was no one to help me, I was on my own too.
All these mothers and babies are now fine and well. When I had finished and left them all clean and dry with their babies suckling at the breast I had to fill in the labour files and charts and found I could not remember most of the details of each one, no times of birth, boys or girls? it wasn't important so I didnt know! 2 hours had passed as if it had been 5 minutes!
Dont think this is a strange situation, that this happens every now and then. No.. this is happening nearly every day and most nights. Where are the other staff? how is it possible for them all to disappear at once? These are the very questions I continually ask. And I do ask, but I get no answers. Now can you understand why the busiest maternity unit in Malawi and one of the busiest in the whole of the South African continent has such a high maternal and neonatal mortality rate? Why oh why is it like this? why do these women not deserve better? They do deserve better. I am trying oh how I am trying, but it sometimes feels impossible. However hard I work, however quick I run I just can't reach them all. I suppose this is normality for the Malawian staff, but I have seen better, I know better, I know what should be, but how?
I was so angry yesterday. I was told that on " bed one" the baby had died in the first hour of life. On examining her file I found that she had been pushing for 5 hours. The clinician had been called but arrived 3 hours later, meanwhile no one had checked nor the maternal nor the fetal condition, nor had they used any interventions to aid the birth. This happens with referral cases that have to journey fron outlying districts, or have been attended by poorly qualified attendants. But this woman was on our labour ward in our hospital! I informed as many people as possible. I was not prepared to keep letting these incidents happen without any accountability without any responsibility. On talking to one midwife she informed me that some midwives believe that if the woman pushes and the baby doesn't come it is her fault for not doing it properly for not putting in enough effort. The mother is responsible! This is the attitude I knew existed in the villages but we are a hospital with trained midwives! Could it possibly be that some of our midwives share these beliefs? I despair.....but I am strong and I can carry on.
There is so much I could write today. I am feeling good and positive and confident despite all that I face daily. If I can save just one baby or one mother If just one baby or one mother is better cared for because of me it is enough. At least for today...I wonder how I will feel tomorrow?
Saturday 12 July 2008
WITHOUT MY HEALTH I AM..........?
Its been two weeks since I was last able to have access to my mails and to my blog. Its been one week since I was able to work on labour ward. I have felt frustrated, out of touch and very low.
As can be seen by all my writing over the past months Malawi is not the place to be in need of health care. I am strong I am healthy. I have a natural capacity to look for and find the positive side of even the most difficult situation but during the past week I have been severely tried and tested. I have entered a Malawi operating theatre, as a patient, only minor surgery but how much better it feels to be wearing the nurses uniform and not the patients gown. As a nurse and midwife for so many years the familarity of the hospital feels like home, the ward my bedroom, the operating theatre my kitchen. Its not strange, not worrying, its known, its familiar at least untill I became a patient. What a lesson it has been to me to have this insight into how these uneducated village women must feel as they confront the unknown sights and sounds of the labour ward and especially, of the operating theatre. I think I am mending though the process will be slow and I will need a great deal of patience... this will be another lesson for me. With the help, support and love of my family and of my good friends I will achieve this..
Alasdair arrives with Lucas on Tuesday.... at last! Just what I need at this time. I had already decided to take some time off work and had planned a small trip so it will be a wonderful convalescent period for me. I need to be fit and well, I need my health restored my strength so that I may continue to give of myself, to love and to care for the women and babies at Bwaila.
I have recently informed my employers in Acuario (Spain) that I will be staying here untill the end of the year. My work here is still not done, I feel I have more to do/to share, it is too soon to return, I search and pray for guidance. In the same way that it became so totally clear when I made my decision to come to Malawi I am confident I will know when it is time to leave.
Today I will share with you the experience of my Norwegian midwife colleague.
We are continually receiving referred cases from the outlying health centres, it is the first place the woman will be taken when things go wrong with the attention of the TBA ( traditional birth attendant) in the villages. Nina decided to spend a day in one of these places. We know they are extremely understaffed very often without a doctor or medical cover. There have few materiales and only the minimum of emergency supplies.
The mother was carried into the centre by her husband accompanied by the TBA who was attending the birth of her twins. Twin pregnancy is considered high risk and therefore one of the reasons that they are advised to have a hospital birth. She was stiff and unconscious. She was having and eclamptic fit. The two nurse/midwives on duty began life saving tasks with the limited equipment and drugs available. They phoned for an ambulance for immediate transfer to Bwaila. This would take a minimum of one hour. On examining the woman they realized that the child had already been born, though the placenta was still in place. When? Yesterday.....and... the 2nd twin was still inside the uterus! More than 24 hours had passed! Why hadnt she bought her before? Because she will not be paid if she doesnt deliver the child!
Eclampsia demands the immediate delivery of the baby as it is the only way to save the mother. In these cases mothers life is always considered before the child. But it was not possible to deliver the 2nd twin . At last the ambulance arrived, the mothers condition had not improved, No one even thought to listen for a fetal heart beat ..what was the point? Did she live or die?
We dont know, as she was taken to a mission hospital that was closer. We shall try to find out. But no one else will. The mission hospitals are paying hospitals so many women cannot afford to go.They do attend emergency cases without payment. Nina came to see me that evening at home. She was noteably distressed. She said she will not go back again to the health centres as although she knew Bwaila hospital was not always adequate she could not cope with feeling so utterly alone and unsupported with not even the basic necessities for life saving tasks. We talked, we hugged, I was able to support her and give her the assurance she needed that she had done all that she could. Yes we are doing all that we can...not enough..never enough ... but all that we can.
As can be seen by all my writing over the past months Malawi is not the place to be in need of health care. I am strong I am healthy. I have a natural capacity to look for and find the positive side of even the most difficult situation but during the past week I have been severely tried and tested. I have entered a Malawi operating theatre, as a patient, only minor surgery but how much better it feels to be wearing the nurses uniform and not the patients gown. As a nurse and midwife for so many years the familarity of the hospital feels like home, the ward my bedroom, the operating theatre my kitchen. Its not strange, not worrying, its known, its familiar at least untill I became a patient. What a lesson it has been to me to have this insight into how these uneducated village women must feel as they confront the unknown sights and sounds of the labour ward and especially, of the operating theatre. I think I am mending though the process will be slow and I will need a great deal of patience... this will be another lesson for me. With the help, support and love of my family and of my good friends I will achieve this..
Alasdair arrives with Lucas on Tuesday.... at last! Just what I need at this time. I had already decided to take some time off work and had planned a small trip so it will be a wonderful convalescent period for me. I need to be fit and well, I need my health restored my strength so that I may continue to give of myself, to love and to care for the women and babies at Bwaila.
I have recently informed my employers in Acuario (Spain) that I will be staying here untill the end of the year. My work here is still not done, I feel I have more to do/to share, it is too soon to return, I search and pray for guidance. In the same way that it became so totally clear when I made my decision to come to Malawi I am confident I will know when it is time to leave.
Today I will share with you the experience of my Norwegian midwife colleague.
We are continually receiving referred cases from the outlying health centres, it is the first place the woman will be taken when things go wrong with the attention of the TBA ( traditional birth attendant) in the villages. Nina decided to spend a day in one of these places. We know they are extremely understaffed very often without a doctor or medical cover. There have few materiales and only the minimum of emergency supplies.
The mother was carried into the centre by her husband accompanied by the TBA who was attending the birth of her twins. Twin pregnancy is considered high risk and therefore one of the reasons that they are advised to have a hospital birth. She was stiff and unconscious. She was having and eclamptic fit. The two nurse/midwives on duty began life saving tasks with the limited equipment and drugs available. They phoned for an ambulance for immediate transfer to Bwaila. This would take a minimum of one hour. On examining the woman they realized that the child had already been born, though the placenta was still in place. When? Yesterday.....and... the 2nd twin was still inside the uterus! More than 24 hours had passed! Why hadnt she bought her before? Because she will not be paid if she doesnt deliver the child!
Eclampsia demands the immediate delivery of the baby as it is the only way to save the mother. In these cases mothers life is always considered before the child. But it was not possible to deliver the 2nd twin . At last the ambulance arrived, the mothers condition had not improved, No one even thought to listen for a fetal heart beat ..what was the point? Did she live or die?
We dont know, as she was taken to a mission hospital that was closer. We shall try to find out. But no one else will. The mission hospitals are paying hospitals so many women cannot afford to go.They do attend emergency cases without payment. Nina came to see me that evening at home. She was noteably distressed. She said she will not go back again to the health centres as although she knew Bwaila hospital was not always adequate she could not cope with feeling so utterly alone and unsupported with not even the basic necessities for life saving tasks. We talked, we hugged, I was able to support her and give her the assurance she needed that she had done all that she could. Yes we are doing all that we can...not enough..never enough ... but all that we can.
Sunday 29 June 2008
ZIMBABWE AND MORE
Zimbabwe is a sad place to be at this time. That was my feeling after spending 4 days there. I did not feel threatened or afraid but there was a noticeable tension and fear in the eyes and the behaviour of its people. There was little chatting in the bare, half empty shops as we queued to pay for our kilo of carrots costing billions of Zim.dollars. Yes, I became a billionaire overnight, though when I paid 5 billion dollars for a postcard and stamp I realized it wasn't worth much!
Life in Harare continues as best it can, the city people going about their business and everyone wondering what will happen next. There was a definite state of insecurity and those that would talk with their conjectures of what may happen but not really knowing what tomorrow would bring.We heard many distressing stories of torture and violence and many rumours which all led to a sense of the fear and the unknown.The people feel intimidated and controlled but by what and by whom? Who might be listening who could be trusted? The people are tired of living this way. They just want a normal life but they dont know how it can be nor who will find the way to create this change. They are looking for help .From where? from whom? They are praying to God, they are asking for help, to the rest of Africa, to the rest of the world, they dont know when this will end but they still have hope. I too hope and pray that the world and its powers will not desert them, that a way will be found to ease their pain and their fear and change this totally unacceptable situation that is life in Zimbabwe.
The long road to Harare was a wonderful experience for me. As I was not driving I was able to really take in the beautiful changing scenery as we passed over the Malawian border through Mozambique and down to Zimbabwe. We were able to break our journey with an overnight stay in Tete boths ways. We were wonderfully entertained by friends and I was able to enjoy a truly Mozambique experience as we climbed up high in the evening to watch sunset over the Zambezi river. It was interesting to see and feel the differences between the 3 countries their dress, their villages and their cultures. I was suprised to find the city of Harare so much more of a developed city than Lilongwe with its tall buildings, good roads, lighting etc. The infrastucture is still there, very obviously still present and that is what the people rely on to bring it back to prosperity, as and when this dire situation resolves.
My visit to Zim.was made possible by my good friend Sandy who invited me to accompany her on this trip. She was able to take food and provisions to her family and staff whom without this trip would have been sadly lacking in basic food stuffs and as in the case of the staff become very hungry. They were the lucky ones. As we crossed the border on our return journey we realized that we were the lucky ones. There are many Zimbabweans in the surrounding countries who have not given up hope of things coming right and are just waiting to go home. I hope that will be soon for them.
My best story from my visit is as follows...
When asked "How are you?" doesn't everyone answer "Fine thankyou"
Well it was the same in Zim.
Untill one day I asked the Zimbabwean housemaid at a families' residence.
"I'm not good " she replied.
Full of concern I asked as to what was her ailment.
" My body is fine thankyou" she said, " but my country is not fine, my country is sick and I pray for it to become well"
On Friday I was back on labour ward. My first task was to assist at the birth of triplets. It was a great experience for me and more so as I was able to team up with a young Norweigian obstetrician and work together to achieve a positive outcome for both mother and babies. Just 32 weeks pregnant so the babies would be small and premature. After a quick scan we confirmed they were all presenting breech. (or more acurately feet first) This shouldn't be a problem as it was her 3rd pegnancy and they would be small. As I got to work to deliver the three babies the doctor was scanning and checking heartbeats and positions. We soon had a audience of young Malawian clinical officers and interns looking on. It was great to show, by our example, how to actively manage safely this type of siuation. First a girl weighing 1.400kgs. Then 2 boys both weighing 1.500kgs. I checked up on them yesterday in nursery and they seemed to be doing ok. Its early days yet so I am not being too optimistic but at least they have a chance of surviving. I will continue to follow their progress and offer to help out with clothing, blankets and formula milk, if it becomes necessary.
Due to lack of medical staff and experienced clinical officers I have now learnt and am becoming capable of performing assisted birth with vacuum extraction. I have spent many years assessing the conditions and safety of performing this intervention so have now moved on to take this extra responsibility.
I was particularly pleased with yesterday's events. When taking the decision for an urgent vacuum extraction for fetal distress and finding that the only clinical officer available was involved with an eclamptic mother, I was able to
to perform quickly and safely this procedure and save the baby's life. Alongside me was a young Noweign midwife who had been caring for the mother and recognized the problem. We both felt good after that!
When things are difficult and black we can pull on these moments to keep our spirits up and know that what we are doing is worthwhile.
I have been feeling rather sad and lonely these days.( though my friends are great) I am missing all my children and my family. Its been 6 months now since I last saw them. I know it feels more exaggerated by not having Lucas around but I can't help wondering if I'm doing the right thing being so far away?
How difficult it is at times to see clearly where we should be and what we should be doing. How torn between our responsibilities and our needs. Responsable to who? Needing who and what? I feel I have so much to give so much love to share. Whose needs are more important? I have gifts, we all have gifts, I am enjoying using those gifts but its confusing ......I look for clarity, I pray for guidance. I am thankful for what I have and for where I am, so many people needing help, needing care, needing love..........
Life in Harare continues as best it can, the city people going about their business and everyone wondering what will happen next. There was a definite state of insecurity and those that would talk with their conjectures of what may happen but not really knowing what tomorrow would bring.We heard many distressing stories of torture and violence and many rumours which all led to a sense of the fear and the unknown.The people feel intimidated and controlled but by what and by whom? Who might be listening who could be trusted? The people are tired of living this way. They just want a normal life but they dont know how it can be nor who will find the way to create this change. They are looking for help .From where? from whom? They are praying to God, they are asking for help, to the rest of Africa, to the rest of the world, they dont know when this will end but they still have hope. I too hope and pray that the world and its powers will not desert them, that a way will be found to ease their pain and their fear and change this totally unacceptable situation that is life in Zimbabwe.
The long road to Harare was a wonderful experience for me. As I was not driving I was able to really take in the beautiful changing scenery as we passed over the Malawian border through Mozambique and down to Zimbabwe. We were able to break our journey with an overnight stay in Tete boths ways. We were wonderfully entertained by friends and I was able to enjoy a truly Mozambique experience as we climbed up high in the evening to watch sunset over the Zambezi river. It was interesting to see and feel the differences between the 3 countries their dress, their villages and their cultures. I was suprised to find the city of Harare so much more of a developed city than Lilongwe with its tall buildings, good roads, lighting etc. The infrastucture is still there, very obviously still present and that is what the people rely on to bring it back to prosperity, as and when this dire situation resolves.
My visit to Zim.was made possible by my good friend Sandy who invited me to accompany her on this trip. She was able to take food and provisions to her family and staff whom without this trip would have been sadly lacking in basic food stuffs and as in the case of the staff become very hungry. They were the lucky ones. As we crossed the border on our return journey we realized that we were the lucky ones. There are many Zimbabweans in the surrounding countries who have not given up hope of things coming right and are just waiting to go home. I hope that will be soon for them.
My best story from my visit is as follows...
When asked "How are you?" doesn't everyone answer "Fine thankyou"
Well it was the same in Zim.
Untill one day I asked the Zimbabwean housemaid at a families' residence.
"I'm not good " she replied.
Full of concern I asked as to what was her ailment.
" My body is fine thankyou" she said, " but my country is not fine, my country is sick and I pray for it to become well"
On Friday I was back on labour ward. My first task was to assist at the birth of triplets. It was a great experience for me and more so as I was able to team up with a young Norweigian obstetrician and work together to achieve a positive outcome for both mother and babies. Just 32 weeks pregnant so the babies would be small and premature. After a quick scan we confirmed they were all presenting breech. (or more acurately feet first) This shouldn't be a problem as it was her 3rd pegnancy and they would be small. As I got to work to deliver the three babies the doctor was scanning and checking heartbeats and positions. We soon had a audience of young Malawian clinical officers and interns looking on. It was great to show, by our example, how to actively manage safely this type of siuation. First a girl weighing 1.400kgs. Then 2 boys both weighing 1.500kgs. I checked up on them yesterday in nursery and they seemed to be doing ok. Its early days yet so I am not being too optimistic but at least they have a chance of surviving. I will continue to follow their progress and offer to help out with clothing, blankets and formula milk, if it becomes necessary.
Due to lack of medical staff and experienced clinical officers I have now learnt and am becoming capable of performing assisted birth with vacuum extraction. I have spent many years assessing the conditions and safety of performing this intervention so have now moved on to take this extra responsibility.
I was particularly pleased with yesterday's events. When taking the decision for an urgent vacuum extraction for fetal distress and finding that the only clinical officer available was involved with an eclamptic mother, I was able to
to perform quickly and safely this procedure and save the baby's life. Alongside me was a young Noweign midwife who had been caring for the mother and recognized the problem. We both felt good after that!
When things are difficult and black we can pull on these moments to keep our spirits up and know that what we are doing is worthwhile.
I have been feeling rather sad and lonely these days.( though my friends are great) I am missing all my children and my family. Its been 6 months now since I last saw them. I know it feels more exaggerated by not having Lucas around but I can't help wondering if I'm doing the right thing being so far away?
How difficult it is at times to see clearly where we should be and what we should be doing. How torn between our responsibilities and our needs. Responsable to who? Needing who and what? I feel I have so much to give so much love to share. Whose needs are more important? I have gifts, we all have gifts, I am enjoying using those gifts but its confusing ......I look for clarity, I pray for guidance. I am thankful for what I have and for where I am, so many people needing help, needing care, needing love..........
Tuesday 17 June 2008
LUCAS LEAVES
I didn't write about Grace's baby last time. There are always so many things to tell. During her stay in the pediatric ward at the central hospital here in Lilongwe her condition seemed to deteriorate daily. It was impossible to make a diagnosis as neither the technology nor the experienced operators can be found here in Malawi. As her breathing became more and more difficult and laboured they could only treat with antibiotics, just in case she had a chest infection diuretics for her pulmonary and cardiac congestion and oxygen to help her breath, to try and keep her more comfortable. It didn't work and although I visited daily and she received more medical care and attention than any other baby on the ward Grace's baby Angela died last week. She was just 4 months old. Maybe her little lungs were too immature? or maybe she did have that congenital heart defect? Whatever.... the necessary neonatal care and attention were not available and another Malawian baby dies. Born too soon and in the wrong place.
I was invited to attend the funeral and visit her house the following day. It was a sad day, I could only give Grace a hug and tell her how well she had loved and cared well for her beautiful baby. That she had been a good mummy. Baby Angela would remain forever in her heart...and in mine.
I am challenged daily and that is exciting and stimulating. Labour ward continues to be busy and many bad things happen that are avoidable but I think that now after nearly 6 months I am finding my way to work, to care and to live with the reality of the situation that faces me daily.
I dont like it, I will never like it. Its not acceptable, it will never be acceptable but I am happy in my work and enjoy great pleasure when it goes right. I do everything I can to make it go right and with the support of my friends and a few colleagues, I cope when it goes wrong.
There are always many students to teach and many inexperienced young clinical officers. They now come looking for me as they know I will always be kean and eager to share as much of my knowledge as I can. Today I arrived just in time to find one midwife attending a breech birth very obviously without even the most basic knowledge of how to assist. I was able to instruct her as to the different manouvers necessary and them take over when it became difficult. It was satisfying to achieve a healthy baby and a better informed midwife.
Last Sunday I said goodbye to my little Lucas for a month. He left on his own to go to spend some time in England with my family and then on to Spain to be with his Dad, with Alasdair and with Fiona. Just 7 years old but with so much confidence as he bade me goodbye and went off to board the plane for the long flight to London. I had given him a small wooden crocodile necklace. Everytime he touched it he was to think of me. We spoke on the phone whilst he was waiting in Nairobi for his connection. " I've touched the necklace twice he told me!" He will have a wonderful time but I will miss him.
On the way back from the airport I went to visit Pilirani and her twins, Edward and Alex. I am always a little nervous as I never know if I will find them healthy and well. They were doing incredibly well but are still very vunerable. As usual the children from the village came running to greet me and carry my bags. 20mk ( 200mk/1 euro) for looking after my car...thats normally at least 4 of them and 20mk for carring the bag! The boys were fit and well. Both weighing well over 4kgs. now with chubby cheeks and more chins than me! Pilirani is still supplementing her breast feeding with 2 formula feeds a day so she needs me to continue taking the milk. At nearly 1.000mk a tin she could definitely not afford it. As I got up to say goodbye the Aunt came out of the house carring the twins elder sister,age 4 years. She was obviously sick. I examined her as best I could and asked many questions. It seems she had been sick for 3 weeks. She was covered in a rash that she had been scratching and was bleeding. Her skin was dry, she refused food and took little water. I'm a midwife and a nurse but not a doctor. I could not diagnose her condition but I knew she needed help. I gave them money for transport and made them promise to take her to the hospital the following day. I am anxious to know how she is. Talking to medical friends it may well be a vitamin deficiency ...this would not suprise me. The diet for the majority of the village people is maize flour made into dumplings and little else. Not dying of hunger but of malnutrition.
I have been invited to accompany a good friend and her family to Zimbabwe for 5 days this weekend. My family are very concerned for my safety due to the political situation at this time in that country. My Zimbabwian friends are in constant contact with their families living in Harare and feel it will be OK for the trip to go ahead. I will tell you all about it when I return. We will drive through Mozambique and onto Zimbabwe. I am looking forward to seeing more of Africa. It is a beautiful and fascinating continent its places and its people. I feel very lucky to be here.
I was invited to attend the funeral and visit her house the following day. It was a sad day, I could only give Grace a hug and tell her how well she had loved and cared well for her beautiful baby. That she had been a good mummy. Baby Angela would remain forever in her heart...and in mine.
I am challenged daily and that is exciting and stimulating. Labour ward continues to be busy and many bad things happen that are avoidable but I think that now after nearly 6 months I am finding my way to work, to care and to live with the reality of the situation that faces me daily.
I dont like it, I will never like it. Its not acceptable, it will never be acceptable but I am happy in my work and enjoy great pleasure when it goes right. I do everything I can to make it go right and with the support of my friends and a few colleagues, I cope when it goes wrong.
There are always many students to teach and many inexperienced young clinical officers. They now come looking for me as they know I will always be kean and eager to share as much of my knowledge as I can. Today I arrived just in time to find one midwife attending a breech birth very obviously without even the most basic knowledge of how to assist. I was able to instruct her as to the different manouvers necessary and them take over when it became difficult. It was satisfying to achieve a healthy baby and a better informed midwife.
Last Sunday I said goodbye to my little Lucas for a month. He left on his own to go to spend some time in England with my family and then on to Spain to be with his Dad, with Alasdair and with Fiona. Just 7 years old but with so much confidence as he bade me goodbye and went off to board the plane for the long flight to London. I had given him a small wooden crocodile necklace. Everytime he touched it he was to think of me. We spoke on the phone whilst he was waiting in Nairobi for his connection. " I've touched the necklace twice he told me!" He will have a wonderful time but I will miss him.
On the way back from the airport I went to visit Pilirani and her twins, Edward and Alex. I am always a little nervous as I never know if I will find them healthy and well. They were doing incredibly well but are still very vunerable. As usual the children from the village came running to greet me and carry my bags. 20mk ( 200mk/1 euro) for looking after my car...thats normally at least 4 of them and 20mk for carring the bag! The boys were fit and well. Both weighing well over 4kgs. now with chubby cheeks and more chins than me! Pilirani is still supplementing her breast feeding with 2 formula feeds a day so she needs me to continue taking the milk. At nearly 1.000mk a tin she could definitely not afford it. As I got up to say goodbye the Aunt came out of the house carring the twins elder sister,age 4 years. She was obviously sick. I examined her as best I could and asked many questions. It seems she had been sick for 3 weeks. She was covered in a rash that she had been scratching and was bleeding. Her skin was dry, she refused food and took little water. I'm a midwife and a nurse but not a doctor. I could not diagnose her condition but I knew she needed help. I gave them money for transport and made them promise to take her to the hospital the following day. I am anxious to know how she is. Talking to medical friends it may well be a vitamin deficiency ...this would not suprise me. The diet for the majority of the village people is maize flour made into dumplings and little else. Not dying of hunger but of malnutrition.
I have been invited to accompany a good friend and her family to Zimbabwe for 5 days this weekend. My family are very concerned for my safety due to the political situation at this time in that country. My Zimbabwian friends are in constant contact with their families living in Harare and feel it will be OK for the trip to go ahead. I will tell you all about it when I return. We will drive through Mozambique and onto Zimbabwe. I am looking forward to seeing more of Africa. It is a beautiful and fascinating continent its places and its people. I feel very lucky to be here.
Monday 2 June 2008
BEING ACCOUNTABLE
I'm begining to think Thursday is my unlucky day, or more correctly unlucky for those little babies and mums on labour ward.
That's why I didn't write last week. You see I felt just too responsable and responsabilty weighs heavy at times.
It was a busy morning, starting at 7.15am. yet another 2nd twin born over 2 hours after the first. I found him on the resussitaire barely alive just a small heart beat and nothing else. Oh no not again! Each and every time it happens I try to find the person responsable but no one feels responsable. I try to explain how we should have cared for that mother and her babies, what was the correct procedure for a better outcome but I am obviously not being heard or I'm not speaking loud enough.
I did report the case loudly and clearly on the ward round. The clinical officer who attended told me he didn't want to do a c/section because the baby was well presented. Well presented and almost dead! He died at 4pm. that afternoon...thankfully....as the level of brain damage would have been huge.
Two rather complicated referred cases both with prolonged labour needed my attention. They had been fully dilated and pushing for how long? Together with the students I started sorting out how to deal with these women. Their was no immediate urgency as both babies were fine, but neither could they be left without constant care and observation. Unfortunately I have to leave the ward on Tuesday and Thursday to lead our workshops. At 10.30am. I handed over to a senior midwife and to the clinician on duty. I explained everything to the young student who had been working with me and reluctantly left their side. My instructions were clear. One woman could be encouraged with the help of a drip for just 30 minutes more, before assisting with a vacuum extraction, and the other should birth within the hour or be seriously considered for a c/section.
It was not untill I returned two and a half hours later that I realized my mistake.
Both babies had been born vaginally. Both had been born 1-2 hours after I left. Both in poor condition needing intensive resusitation. Both had been admitted to nursery. Both these outcomes could have been avoided.
So what had been my big mistake?
I suddenly realized that 3 midwives from labour ward had been present in the workshop, plus myself. This had left just one midwife on the ward with all the students and a very inexperienced clinical officer.
What was the point of teaching them in the workshop when there were distressed babies and birthing women unattended just 20 metres away?
It still lays heavily on my shoulders, I still don't understand how this can have happened. Of course its not really my responsability, I was not in charge of labour ward. There was a clinician on duty. But that's what I am hearing just too often. Of course I take responsability, we must all be responsable, we must be accountable. Accountable to such a degree that we realize that what we do, that how we act, does and will always make a difference.
This morning I arrived in labour ward and was greeted with the usual " bed 6 is pushing'
I hurriedly ( I think I'm the only person in Malawi who hurrys) collected what I needed and came to her bedside. How long had she been pushing? A referred case with prolonged 2nd stage. She had arrived on labour ward at least 20 minutes ago. Why hadn't anyone done anything? Listening to the fetal heart I knew that this baby needed to be born quickly. I encouraged her to push, performed a good size episiotomy ( incision to facilitate a greater vaginal opening and therefore a quicker birth) and with 3 pushes the baby was out. Floopy baby..not breathing, slow heart rate....not again! I quickly resuscitated the little one and slowly but surely he came round. When I took him to nursery later for a 24 hour observation period he had already had a good breast feed with his happy mum.
Ok so where do I go next? " There's a twin in bed 10...fully dilated...we know you like twins" the night staff called out to me, glad to be able to hand over after a long and busy night.
Twin one came out head first with no problem. Twin two was a breech and needed more care and attention but with active help on my part was born just 10 minutes later.
Before the night staff left they had all become aware that twins can and should be managed actively and safely. I said nothing, but hope that this would be an example to them.
" Good work, thankyou " commented the midwife in charge at night.
I felt positive and pleased. It was enough to keep me going for what turned out to be a long and difficult morning.
Lucas ' ran for his life ' on Saturday! Well actually he ' Ran for Wildlife' but he got the name wrong !! It was a sponsored run in aid of preserving the Malawian wildlife and endangered species. He had to run round the athletics track for one hour and would be sponsored according to the number of laps completed. I was very proud to see how he never stopped however tired and managed to complete 10 laps. This was an excellent run and more than most who were much older than him. He too was proud of himself, especially when he went round collecting money. I might find it more worthwhile to collect for health related projects but Lucas definitely finds it a worthy cause and as we are hoping to enjoy a safari with Alasdair and then Katy and Fiona when they come to see us I guess we should pay attention to other issues too.
That's why I didn't write last week. You see I felt just too responsable and responsabilty weighs heavy at times.
It was a busy morning, starting at 7.15am. yet another 2nd twin born over 2 hours after the first. I found him on the resussitaire barely alive just a small heart beat and nothing else. Oh no not again! Each and every time it happens I try to find the person responsable but no one feels responsable. I try to explain how we should have cared for that mother and her babies, what was the correct procedure for a better outcome but I am obviously not being heard or I'm not speaking loud enough.
I did report the case loudly and clearly on the ward round. The clinical officer who attended told me he didn't want to do a c/section because the baby was well presented. Well presented and almost dead! He died at 4pm. that afternoon...thankfully....as the level of brain damage would have been huge.
Two rather complicated referred cases both with prolonged labour needed my attention. They had been fully dilated and pushing for how long? Together with the students I started sorting out how to deal with these women. Their was no immediate urgency as both babies were fine, but neither could they be left without constant care and observation. Unfortunately I have to leave the ward on Tuesday and Thursday to lead our workshops. At 10.30am. I handed over to a senior midwife and to the clinician on duty. I explained everything to the young student who had been working with me and reluctantly left their side. My instructions were clear. One woman could be encouraged with the help of a drip for just 30 minutes more, before assisting with a vacuum extraction, and the other should birth within the hour or be seriously considered for a c/section.
It was not untill I returned two and a half hours later that I realized my mistake.
Both babies had been born vaginally. Both had been born 1-2 hours after I left. Both in poor condition needing intensive resusitation. Both had been admitted to nursery. Both these outcomes could have been avoided.
So what had been my big mistake?
I suddenly realized that 3 midwives from labour ward had been present in the workshop, plus myself. This had left just one midwife on the ward with all the students and a very inexperienced clinical officer.
What was the point of teaching them in the workshop when there were distressed babies and birthing women unattended just 20 metres away?
It still lays heavily on my shoulders, I still don't understand how this can have happened. Of course its not really my responsability, I was not in charge of labour ward. There was a clinician on duty. But that's what I am hearing just too often. Of course I take responsability, we must all be responsable, we must be accountable. Accountable to such a degree that we realize that what we do, that how we act, does and will always make a difference.
This morning I arrived in labour ward and was greeted with the usual " bed 6 is pushing'
I hurriedly ( I think I'm the only person in Malawi who hurrys) collected what I needed and came to her bedside. How long had she been pushing? A referred case with prolonged 2nd stage. She had arrived on labour ward at least 20 minutes ago. Why hadn't anyone done anything? Listening to the fetal heart I knew that this baby needed to be born quickly. I encouraged her to push, performed a good size episiotomy ( incision to facilitate a greater vaginal opening and therefore a quicker birth) and with 3 pushes the baby was out. Floopy baby..not breathing, slow heart rate....not again! I quickly resuscitated the little one and slowly but surely he came round. When I took him to nursery later for a 24 hour observation period he had already had a good breast feed with his happy mum.
Ok so where do I go next? " There's a twin in bed 10...fully dilated...we know you like twins" the night staff called out to me, glad to be able to hand over after a long and busy night.
Twin one came out head first with no problem. Twin two was a breech and needed more care and attention but with active help on my part was born just 10 minutes later.
Before the night staff left they had all become aware that twins can and should be managed actively and safely. I said nothing, but hope that this would be an example to them.
" Good work, thankyou " commented the midwife in charge at night.
I felt positive and pleased. It was enough to keep me going for what turned out to be a long and difficult morning.
Lucas ' ran for his life ' on Saturday! Well actually he ' Ran for Wildlife' but he got the name wrong !! It was a sponsored run in aid of preserving the Malawian wildlife and endangered species. He had to run round the athletics track for one hour and would be sponsored according to the number of laps completed. I was very proud to see how he never stopped however tired and managed to complete 10 laps. This was an excellent run and more than most who were much older than him. He too was proud of himself, especially when he went round collecting money. I might find it more worthwhile to collect for health related projects but Lucas definitely finds it a worthy cause and as we are hoping to enjoy a safari with Alasdair and then Katy and Fiona when they come to see us I guess we should pay attention to other issues too.
Friday 23 May 2008
TIME OUT
Today I'm taking "time out" I can do this. I need to do this
Teaching is going well . My twins and my miracle babies are just fine. But yesterday was just
awful!
Labour ward was as busy as it gets. We were 5 midwives and many students. With 1 midwife in admissions and another nearly all day in theatre we remained just 3 on the ward. The students, with little experience, were attending births with little supervision. I moved from bed to bed trying to keep abreast of each situation, helping out when things were going wrong whilst also trying to care for the more complicated "referred " cases. I had to drag myself away for 2 hours to teach in my workshops, and found on arriving back the situation was no better, it was worse. We only have one operating theatre at Bwaila hospital so please tell me what to do when we have 4 very serious cases waiting for a c/section? Just please tell me which one has priority?
The woman with the cord prolapse who was referred from a health centre. The cord was still pulsating, the baby was still alive ..but for how long? Or maybe the young primigravida who was sent by the TBA (tradition birth attendant) from her village. She had been "pushing "for more than 24 hours, her baby was still alive but severely distressed and she could rupture her uterus at any minute? Or the woman on her 10th pregnancy with 4 live children and severe fetal ditress? or maybe the woman who arrived with ruptured uterus with a dead baby but in risk of loosing her own life?
Someone just tell me, just please tell me who has preference? Who should make this decision? What are the priorities ? Who should live and who should die? Whose life is more important ? What should be our criteria?
Nobody told me how to make such decisions, it wasn't part of my training, yet I found myself there alongside the doctor doing just that.
That woman has already 4 children and her life is not in danger...Yet...That one is her first child and she may rupture. Was that a good enough reason for taking her first?
By 5.30pm. they had all been attended. I had been at work since 7.15am. without taking a break. And even as I tried to leave a student called me to help her with some difficult shoulders and another to suture a perineum. So it was gloves on and "just these 2 more and I must go" We left the ward full of women in labour for the night shift. As I walked away I heard comment. "At least with all that we only lost 1 baby" It was true, but that was someones baby, some mothers child she had loved and carried for 9 months, she had laboured and pushed for two days. Some fathers son, some grandmothers grandchild. It was one loss too many. It was avoidable if the conditions had been right and adequate, if these women really did have the right to decent proper health care if these women and babies really did have just some basic human rights.
TBA's form an important part of Malwian health care. There is such a huge shortage of midwives a least someone is attending the women in the rural areas. These women have no official training but will have learnt their skills from other women in the village. Passed on by the older women as tradition allows. Some will be good wise women who work skilfully and have achieved great knowledge and art. Unfortunately, others will have little or no skills and can be downright dangerous. The ministry of health has a problem. On the one hand they need them as they cannot supply enough trained nurses or midwives so they wish them to have some formal training. On the other hand they would like all women to be attended in health centres or hospitals so don't want to encourage them by giving training. Malawi is not supplying sufficient health care to do without them and does have not the means to do that. It is a problem. I have already made contact with a NGO who are looking at a project to provide these women with basic skills. I find this an exciting and interesting challenge. I will keep you posted.
Grace's baby is back in hospital with another chest infection. She is just 3 months old, weighs 2.800kg. and has been in hospital twice. I still wonder if she does have that underlying congenital heart condition but it seems impossible to get anyone to do any further investigations. Could it be that its just not worth it? There is no pediatric cardiac surgery available in Malawi so why bother making a diagnosis?
Today I had breakfast with some good girl friends and tonight we will go out to supper with other friends. I feel loved and supported. Today I had a good moan to Tarek too. Of course he understands perfectly. Has seen and heard it all before. But he's a good listener and I thank him for that.
Luki is having fun. He's looking forward to being in Spain with his dad and brother and sister next month, though I shall miss him terribly. I manage to talk to my other children regularly and that makes me feel so good. I have started to make plans and bookings for Alasdairs visit in July it will be such fun to visit new parts of this beautiful country. Sometimes its hard to believe the things that are happening behind the walls of Bwaila hospital. We must not close our eyes and pretend they are not there, that they do not exist. That is why I write, so that you too can know the reality of the very poor, the powerless, the defenceless, the women and babies of Malawi. Only then can something be done, can we begin to encourage, to force, someone to take notice, can we begin to make a difference.
Teaching is going well . My twins and my miracle babies are just fine. But yesterday was just
awful!
Labour ward was as busy as it gets. We were 5 midwives and many students. With 1 midwife in admissions and another nearly all day in theatre we remained just 3 on the ward. The students, with little experience, were attending births with little supervision. I moved from bed to bed trying to keep abreast of each situation, helping out when things were going wrong whilst also trying to care for the more complicated "referred " cases. I had to drag myself away for 2 hours to teach in my workshops, and found on arriving back the situation was no better, it was worse. We only have one operating theatre at Bwaila hospital so please tell me what to do when we have 4 very serious cases waiting for a c/section? Just please tell me which one has priority?
The woman with the cord prolapse who was referred from a health centre. The cord was still pulsating, the baby was still alive ..but for how long? Or maybe the young primigravida who was sent by the TBA (tradition birth attendant) from her village. She had been "pushing "for more than 24 hours, her baby was still alive but severely distressed and she could rupture her uterus at any minute? Or the woman on her 10th pregnancy with 4 live children and severe fetal ditress? or maybe the woman who arrived with ruptured uterus with a dead baby but in risk of loosing her own life?
Someone just tell me, just please tell me who has preference? Who should make this decision? What are the priorities ? Who should live and who should die? Whose life is more important ? What should be our criteria?
Nobody told me how to make such decisions, it wasn't part of my training, yet I found myself there alongside the doctor doing just that.
That woman has already 4 children and her life is not in danger...Yet...That one is her first child and she may rupture. Was that a good enough reason for taking her first?
By 5.30pm. they had all been attended. I had been at work since 7.15am. without taking a break. And even as I tried to leave a student called me to help her with some difficult shoulders and another to suture a perineum. So it was gloves on and "just these 2 more and I must go" We left the ward full of women in labour for the night shift. As I walked away I heard comment. "At least with all that we only lost 1 baby" It was true, but that was someones baby, some mothers child she had loved and carried for 9 months, she had laboured and pushed for two days. Some fathers son, some grandmothers grandchild. It was one loss too many. It was avoidable if the conditions had been right and adequate, if these women really did have the right to decent proper health care if these women and babies really did have just some basic human rights.
TBA's form an important part of Malwian health care. There is such a huge shortage of midwives a least someone is attending the women in the rural areas. These women have no official training but will have learnt their skills from other women in the village. Passed on by the older women as tradition allows. Some will be good wise women who work skilfully and have achieved great knowledge and art. Unfortunately, others will have little or no skills and can be downright dangerous. The ministry of health has a problem. On the one hand they need them as they cannot supply enough trained nurses or midwives so they wish them to have some formal training. On the other hand they would like all women to be attended in health centres or hospitals so don't want to encourage them by giving training. Malawi is not supplying sufficient health care to do without them and does have not the means to do that. It is a problem. I have already made contact with a NGO who are looking at a project to provide these women with basic skills. I find this an exciting and interesting challenge. I will keep you posted.
Grace's baby is back in hospital with another chest infection. She is just 3 months old, weighs 2.800kg. and has been in hospital twice. I still wonder if she does have that underlying congenital heart condition but it seems impossible to get anyone to do any further investigations. Could it be that its just not worth it? There is no pediatric cardiac surgery available in Malawi so why bother making a diagnosis?
Today I had breakfast with some good girl friends and tonight we will go out to supper with other friends. I feel loved and supported. Today I had a good moan to Tarek too. Of course he understands perfectly. Has seen and heard it all before. But he's a good listener and I thank him for that.
Luki is having fun. He's looking forward to being in Spain with his dad and brother and sister next month, though I shall miss him terribly. I manage to talk to my other children regularly and that makes me feel so good. I have started to make plans and bookings for Alasdairs visit in July it will be such fun to visit new parts of this beautiful country. Sometimes its hard to believe the things that are happening behind the walls of Bwaila hospital. We must not close our eyes and pretend they are not there, that they do not exist. That is why I write, so that you too can know the reality of the very poor, the powerless, the defenceless, the women and babies of Malawi. Only then can something be done, can we begin to encourage, to force, someone to take notice, can we begin to make a difference.
Friday 16 May 2008
MAKING A DIFFERENCE
I arrived at labour ward yesterday ay 7.15am. By 7.45am. I had attended 2 births, performing vacuum extraction for fetal distress on one and resuscitating both babies. Thats how it is in the morning. The night staff are tired after their long 15 hour shift. Those that are unlucky enough to need attention between 5.30 and 7.30am. will be at risk. I never quite know what may have happened during the night which makes it difficult take over in the morning. How long has she been pushing? Are these signs of fetal distress recent or is this baby in its final stages of coping?
Was this woman with a previous c/section really in labour all night with a baby that is just too big to come down or should I wait a little longer and risk a uterine rupture? It is very often difficult to make the right decision so I try to watch her closely and hope that Tarek or one of the "real" doctors will be along soon to discuss the case. Protocol is to call for the clinical officer.It sometimes works, most are now quite willing to listen to me, but so many of them have so little experience I find it difficult to refer to them. The charge midwife called to say she would be late as her transport had not arrived. As the most senior midwife I took charge. Assessing the women, organizing the students, trying to ensure that they are suitably supervised ( difficult with just 2 other trained staff!) Then there is the ward round. At 8.30am. the obstetricians plus a whole host of CO's, students and others, patrol from bed to bed discussing each woman, taking the opportunity to teach the students or make decisions on difficult cases. I insist on maintaining as much intimacy and privacy as possible for the labouring women.This is a huge task. The curtains that should hang between the beds to give just a pretence of privacy are either broken or torn, many are just not there. Up to 20 persons trying to fit round the bed..most of them male.. make it almost impossible, but we try. Covering the women with their colourful cloths (chitenges) putting ourselves physically between her and the crowd, we achieve something. Yesterday was full of problems. Everyday we receive many women referred from other centres. By the time they reach us at Bwaila they have already passed through the health centre and maybe a local hospital. After waiting for transport between each centre these "emergencies"arrive on labour ward. We were just finishing the "round"
" Ruptured uterus" I heard them cry, as they wheeled in this poor, shocked, traumatised woman. Without waiting I went to the bedside. Luck was on her side as all the medical staff were still on the ward. The decision was made for immediate c/section and hysterectomy. I knew we should move fast. But "fast" is not, evidently, part of the Malawian vocabulary! IV line, urinary catheter..she was bleeding from the urethra..not a good sign, Consent signed, take blood for laboratory, she would most certainly need a transfusion. I got hold of the trolley and started pushing her down the corridor towards theatre, administring her IV antibiotic on the way. Later I heard that one of the CO's had gone to theatre to inform them and shouted loudly that they had better get on and stop laughing and talking there was a ruptured uterus on its way! It is so unusual and so pleasing to hear that someone understood the emergency.
The operation was quickly underway and whilst I stood waiting to receive the baby I realized that we had not listened for fetal heart sounds. I remember reading in her referral notes that they were not sure if it could be heard. What the heck! What difference would it make? We couldn't move any faster and we were saving the mothers life. I commented to the surgeon. "I dont know if the baby is still alive but I doubt it" It was not an easy c/section, intense hemorrage made things difficult. The baby was well down in the pelvis, stuck in the bony outlet for how long? Completely stuck for enough time to cause her uterus to rupture in its intent to push it out. I pushed upwards on the head whilst the surgeon tried to pull through the abdominal opening. It took a while, I thought it would never come, but then I felt it come loose and the baby was delivered.
" Its alive! " the surgeon exclaimed as the baby made a small noise. I knew it was now up to me. This baby deserved chance! I must do a good job on resuscitating. As I inflated its little lungs with oxygen and sucked the liquor and mucous from its nose and mouth I really prayed for this little one to make it, to find the strength to live. And it did! Small gasps at first then stronger and it started crying. Turning a lovely shade of pinky brown I knew it was on its way. Boy or girl ? they asked me. Its a girl. Of course it would be! Everyone knows that girls are stronger, real fighters! You may laugh, we all laughed in theatre but its true, the girl babies do fight harder ( comments welcome!) The outcome of that story will keep me going for a week. You see it made me realize that it can be done in Malawi, it can be done in Bwaila. It justs needs the whole team to work together, to move fast, to really believe that the way they work that what they do WILL and DOES make a difference. That it is in their power to save lives not once or twice but many times. Before I left theatre with that baby and put it into the outstretched hands of the guardian I thanked them all, the doctors and nurses and theatre staff and told them what a wonderful job they had done. Later I used this example in my workshop to illustrate once more that what we do and how we act can make a difference. They need to be told. I think that they often think that what ever they do nothing will change.I dont believe it ...not yet...please.. not ever.
Befoer I left today I went to post natal ward. There I found her. A strong looking woman lying on her side with her little girl suckling at her breast. I wonder if she realizes how lucky she is to be alive and to have a live baby?
I've bought my car! Its blue, its little and its nippy! Its a four wheel drive and much higher off the ground, just right for my vivits to the villages. Next week I shall try it out as I go to visit my twins and my miracle baby. Now I have another miracle baby.... I hope I will have many more.
Some of you have asked how you can help my mums and babies how you can get involved. I refer you to my friend Carol who is supervising my sponsorship and continues to raise money for Bwaila hospital. SOS Malawi carolarad2000@yahoo.com I'm sure she will be pleased to hear from you.
Was this woman with a previous c/section really in labour all night with a baby that is just too big to come down or should I wait a little longer and risk a uterine rupture? It is very often difficult to make the right decision so I try to watch her closely and hope that Tarek or one of the "real" doctors will be along soon to discuss the case. Protocol is to call for the clinical officer.It sometimes works, most are now quite willing to listen to me, but so many of them have so little experience I find it difficult to refer to them. The charge midwife called to say she would be late as her transport had not arrived. As the most senior midwife I took charge. Assessing the women, organizing the students, trying to ensure that they are suitably supervised ( difficult with just 2 other trained staff!) Then there is the ward round. At 8.30am. the obstetricians plus a whole host of CO's, students and others, patrol from bed to bed discussing each woman, taking the opportunity to teach the students or make decisions on difficult cases. I insist on maintaining as much intimacy and privacy as possible for the labouring women.This is a huge task. The curtains that should hang between the beds to give just a pretence of privacy are either broken or torn, many are just not there. Up to 20 persons trying to fit round the bed..most of them male.. make it almost impossible, but we try. Covering the women with their colourful cloths (chitenges) putting ourselves physically between her and the crowd, we achieve something. Yesterday was full of problems. Everyday we receive many women referred from other centres. By the time they reach us at Bwaila they have already passed through the health centre and maybe a local hospital. After waiting for transport between each centre these "emergencies"arrive on labour ward. We were just finishing the "round"
" Ruptured uterus" I heard them cry, as they wheeled in this poor, shocked, traumatised woman. Without waiting I went to the bedside. Luck was on her side as all the medical staff were still on the ward. The decision was made for immediate c/section and hysterectomy. I knew we should move fast. But "fast" is not, evidently, part of the Malawian vocabulary! IV line, urinary catheter..she was bleeding from the urethra..not a good sign, Consent signed, take blood for laboratory, she would most certainly need a transfusion. I got hold of the trolley and started pushing her down the corridor towards theatre, administring her IV antibiotic on the way. Later I heard that one of the CO's had gone to theatre to inform them and shouted loudly that they had better get on and stop laughing and talking there was a ruptured uterus on its way! It is so unusual and so pleasing to hear that someone understood the emergency.
The operation was quickly underway and whilst I stood waiting to receive the baby I realized that we had not listened for fetal heart sounds. I remember reading in her referral notes that they were not sure if it could be heard. What the heck! What difference would it make? We couldn't move any faster and we were saving the mothers life. I commented to the surgeon. "I dont know if the baby is still alive but I doubt it" It was not an easy c/section, intense hemorrage made things difficult. The baby was well down in the pelvis, stuck in the bony outlet for how long? Completely stuck for enough time to cause her uterus to rupture in its intent to push it out. I pushed upwards on the head whilst the surgeon tried to pull through the abdominal opening. It took a while, I thought it would never come, but then I felt it come loose and the baby was delivered.
" Its alive! " the surgeon exclaimed as the baby made a small noise. I knew it was now up to me. This baby deserved chance! I must do a good job on resuscitating. As I inflated its little lungs with oxygen and sucked the liquor and mucous from its nose and mouth I really prayed for this little one to make it, to find the strength to live. And it did! Small gasps at first then stronger and it started crying. Turning a lovely shade of pinky brown I knew it was on its way. Boy or girl ? they asked me. Its a girl. Of course it would be! Everyone knows that girls are stronger, real fighters! You may laugh, we all laughed in theatre but its true, the girl babies do fight harder ( comments welcome!) The outcome of that story will keep me going for a week. You see it made me realize that it can be done in Malawi, it can be done in Bwaila. It justs needs the whole team to work together, to move fast, to really believe that the way they work that what they do WILL and DOES make a difference. That it is in their power to save lives not once or twice but many times. Before I left theatre with that baby and put it into the outstretched hands of the guardian I thanked them all, the doctors and nurses and theatre staff and told them what a wonderful job they had done. Later I used this example in my workshop to illustrate once more that what we do and how we act can make a difference. They need to be told. I think that they often think that what ever they do nothing will change.I dont believe it ...not yet...please.. not ever.
Befoer I left today I went to post natal ward. There I found her. A strong looking woman lying on her side with her little girl suckling at her breast. I wonder if she realizes how lucky she is to be alive and to have a live baby?
I've bought my car! Its blue, its little and its nippy! Its a four wheel drive and much higher off the ground, just right for my vivits to the villages. Next week I shall try it out as I go to visit my twins and my miracle baby. Now I have another miracle baby.... I hope I will have many more.
Some of you have asked how you can help my mums and babies how you can get involved. I refer you to my friend Carol who is supervising my sponsorship and continues to raise money for Bwaila hospital. SOS Malawi carolarad2000@yahoo.com I'm sure she will be pleased to hear from you.
Friday 9 May 2008
HOT GUYS AND GIFTS
Firstly I would like to say to all those who send comments to my blog "Thankyou" Yes I do receive them. Yes I do read them. It feels good to know that you are out there sharing with me these amazing experiences and supporting me with your love and thoughts and words.
"Keep them coming"
Its two weeks since I last wrote and many things have happened since then. Last week Linda ( from Scotland) came to visit. Linda is responsible for a small charity called MUMS ( Malawis underpriviledged mums) She/they have done amazing things in raising huge sums of money to directly support Bwaila hospital and in particular the new hospital buildings. They are also involved in other projects here in Lilongwe. MUMS is one of my sponsors who along with one other private businessman have and are making it possible for me to be here. It was good to spend time with her. Apart from having a fun time together we were also able to make some useful and rewarding contacts with others involved in our area of work. I was particulaly impressed by the director of the Nurses and Midwives Association ( who act as a trade union supporting and caring for the carers) A strong passionate woman not afraid to speak out in favour of the health workers, doing a wonderful job at local and government level to try and improve things for nurses and midwives. Looking for ways and incentives to keep these valued professionals here in Malawi. I hope to keep contact with her. It is unusual to find a Malawian of her kind , especially a woman.
I cannot let Lindas visit pass with out telling you of the ' dance ' we attended . We were invited to attend a dance with local music and including a famous Malawian singer. It was to be in aid of the 'national nurses day' to be celebrated this week. We both imagined a large hall filled with midwives and a traditional band, so we deciced it should be fun. To our amazement, when we arrived, the venue was full of young men! I mean 100 men and no more than 10 women! Why should we back out now? We took a deep breath and entered. Well it was like bees to a honey pot! Most of the guys were young enough to be our sons but what the heck ! In the absence of greater and more beautiful talent we spent the entire evening dancing with and being surrounded by young, good looking, girating, black men! It did wonders for our ego but when several hours later the drum beat started hotting up and the beer taking effect ( its amazing how even an older white woman can suddenly become very attractive to these young guys in search of free beer!) we decided it was time to leave. I became slightly worried when one guy told me that the one I had been dancing with was only a 3rd year student whilst he already had a proper job earning 100.000MK ( 500 euros) a month . Definitely time to go !
I must tell you about my little miracle baby. The one whose mother arrived with the umbilical cord prolapse and I thought would never survive. I try to follow up the mums and babies that I attend who have special needs. It is impossible to remember all of them. So on Monday morning I went straight to nursery to see how this little one was getting on. It is with some trepidation that I enter. I always fear the worst as so many of those little ones just dont make it. I couldnt find him! On asking of his whereabouts I was told that the mother and grandmother had signed his discharge against medical advice and that he had gone home on Sunday. I was determined to find out how he was, so took note of the name of his mother and the village where they lived. My opportunity came the following day. After finishing my workshop I found labour ward was quiet and one of the midwives who had attended the training was eager to accompany me. So we set out for the village. I had asked directions but after following this route down a dusty mud road for more than 6 km. and still not finding the village, we decided to go back. I was not to be beaten. Its always good to have a native Chichewa speaker to ask directions and soon we were on the right track. This took us right through the middle of a typical mud hut village where as usual I caused a stir as the children ran out to the car shouting "msungu..msungu" ( white woman)
At last we found the village and asked for the family ' Luko' We were taken to the hut and welcomed with huge smiles by the whole family who were amazed to see me. My midwife companion was able to translate as she told us the story of her journey to the hospital via the health centre . The grandmother said when she saw the cord protruding she knew that it was dangerous for the baby. The mother had talked of the white midwife who had helped and been kind to her. They knew that we had saved the life of her baby. I asked to see the baby. We were invited to enter her hut and a cane mat was spread on the floor. We took off our shoes and sat down. I had taken some gifts of fruit and vegetables but hadnt dared to take baby clothes. I half expected the little one to have died. There he was lying on the ground, round and fit and healthy. Tears came to my eyes, I really did feel that he was a miracle baby! I was asked to give the baby a name, this is quite a honour, a bit like being a god parent. One is expected to maintain an interest in that child as he grows bringing gifts and food. ( so maybe there was a ulteria motive?) Never mind, I felt proud and priveledged ! At first I thought of Lucas but Lucas Luko was not a good idea! I said I would think of a name for next time. Maybe he will be called Joseph ( son of Rachel in the bible) certainly he was a lucky guy!
On Wednesday I was invited to attend a meeting at the District Health Office. These are monthly sessions to discuss maternal mortality rates. (The rate in developed countries will be around 5-10deaths in 100.000 whereas in Malawi it can be as high as 1.800 in 100.000) Cases are presented, discussed and questioned. Positive critiscism is encouraged to try to evaluate where, why and at what level there may have been a lack of care, materiales, information etc. This evalution will be returned to the health facilities involved in an effort to reduce maternal deaths and improve care. There must have been 50 or 60 health care workers present. I think that not more than 6 made any contribution to the discussion and one of those was me! The case studies lacked vital information. The recording of care is a real problem, one never knows if it wasnt done or wasnt recorded. One of the cases was a young 14 year old girl, married and in her first pregnancy. She died of Streptococcal meningitis, an illness perfectly treatable in the developed countries. We found a delay in taking her to the health centre on the part of her family..reasons unknown. A lack of care at the health centre who did not examine her fully and did not begin treatment of any kind. They immediatly referried her to the hospital. It was not recorded as to how long it took for transport to arrive. An overnight delay in her being seen by a clinician once admited in the hospital was evident so that when correct treatment was started it was too late.
This story is not uncommon, stories like this are heard everyday somehow along the way they have become acceptable. We are not suprised but for some of us we are sad, we are frustrated, we are angry. What were her rights to health care ? To good health care ? What were her human rights? What are Human rights? Where are they in Malawi ? What do they really mean in Malawi for these poor women?
Witchcraft is very much part of Malawi. It is very much part of day to day life. Superstitions and 'traditional medicine' is often where the people go to, turning only to the health care and hospitals when that has failed. There is, nominally, a move to educate the people away from this but it is slow and not terribly effective. On discussing the second case I was surprised when no formal diagnosis or cause of death was recorded or seemed to be necessay. I suggested that if the medical profession bothered to give families a real cause of death this would make it hard to blame it on some witchcraft or bad omen or as a result of evil behaviour. This was taken down and recorded. It seems that nobody had ever thought of this before!
This weekend we are going to Dwangwa sugar plantations. It is good to get away from Lilongwe every now and again. I need this time to forget for a while, to refresh and recharge. I am grateful to the good friends I have made who make this possible.
Last big news...I have found a small, jeep type, car to buy. I hope to take possesion of it on Tuesday. It will be better for my village visits and hopefully more economical than renting.
"Keep them coming"
Its two weeks since I last wrote and many things have happened since then. Last week Linda ( from Scotland) came to visit. Linda is responsible for a small charity called MUMS ( Malawis underpriviledged mums) She/they have done amazing things in raising huge sums of money to directly support Bwaila hospital and in particular the new hospital buildings. They are also involved in other projects here in Lilongwe. MUMS is one of my sponsors who along with one other private businessman have and are making it possible for me to be here. It was good to spend time with her. Apart from having a fun time together we were also able to make some useful and rewarding contacts with others involved in our area of work. I was particulaly impressed by the director of the Nurses and Midwives Association ( who act as a trade union supporting and caring for the carers) A strong passionate woman not afraid to speak out in favour of the health workers, doing a wonderful job at local and government level to try and improve things for nurses and midwives. Looking for ways and incentives to keep these valued professionals here in Malawi. I hope to keep contact with her. It is unusual to find a Malawian of her kind , especially a woman.
I cannot let Lindas visit pass with out telling you of the ' dance ' we attended . We were invited to attend a dance with local music and including a famous Malawian singer. It was to be in aid of the 'national nurses day' to be celebrated this week. We both imagined a large hall filled with midwives and a traditional band, so we deciced it should be fun. To our amazement, when we arrived, the venue was full of young men! I mean 100 men and no more than 10 women! Why should we back out now? We took a deep breath and entered. Well it was like bees to a honey pot! Most of the guys were young enough to be our sons but what the heck ! In the absence of greater and more beautiful talent we spent the entire evening dancing with and being surrounded by young, good looking, girating, black men! It did wonders for our ego but when several hours later the drum beat started hotting up and the beer taking effect ( its amazing how even an older white woman can suddenly become very attractive to these young guys in search of free beer!) we decided it was time to leave. I became slightly worried when one guy told me that the one I had been dancing with was only a 3rd year student whilst he already had a proper job earning 100.000MK ( 500 euros) a month . Definitely time to go !
I must tell you about my little miracle baby. The one whose mother arrived with the umbilical cord prolapse and I thought would never survive. I try to follow up the mums and babies that I attend who have special needs. It is impossible to remember all of them. So on Monday morning I went straight to nursery to see how this little one was getting on. It is with some trepidation that I enter. I always fear the worst as so many of those little ones just dont make it. I couldnt find him! On asking of his whereabouts I was told that the mother and grandmother had signed his discharge against medical advice and that he had gone home on Sunday. I was determined to find out how he was, so took note of the name of his mother and the village where they lived. My opportunity came the following day. After finishing my workshop I found labour ward was quiet and one of the midwives who had attended the training was eager to accompany me. So we set out for the village. I had asked directions but after following this route down a dusty mud road for more than 6 km. and still not finding the village, we decided to go back. I was not to be beaten. Its always good to have a native Chichewa speaker to ask directions and soon we were on the right track. This took us right through the middle of a typical mud hut village where as usual I caused a stir as the children ran out to the car shouting "msungu..msungu" ( white woman)
At last we found the village and asked for the family ' Luko' We were taken to the hut and welcomed with huge smiles by the whole family who were amazed to see me. My midwife companion was able to translate as she told us the story of her journey to the hospital via the health centre . The grandmother said when she saw the cord protruding she knew that it was dangerous for the baby. The mother had talked of the white midwife who had helped and been kind to her. They knew that we had saved the life of her baby. I asked to see the baby. We were invited to enter her hut and a cane mat was spread on the floor. We took off our shoes and sat down. I had taken some gifts of fruit and vegetables but hadnt dared to take baby clothes. I half expected the little one to have died. There he was lying on the ground, round and fit and healthy. Tears came to my eyes, I really did feel that he was a miracle baby! I was asked to give the baby a name, this is quite a honour, a bit like being a god parent. One is expected to maintain an interest in that child as he grows bringing gifts and food. ( so maybe there was a ulteria motive?) Never mind, I felt proud and priveledged ! At first I thought of Lucas but Lucas Luko was not a good idea! I said I would think of a name for next time. Maybe he will be called Joseph ( son of Rachel in the bible) certainly he was a lucky guy!
On Wednesday I was invited to attend a meeting at the District Health Office. These are monthly sessions to discuss maternal mortality rates. (The rate in developed countries will be around 5-10deaths in 100.000 whereas in Malawi it can be as high as 1.800 in 100.000) Cases are presented, discussed and questioned. Positive critiscism is encouraged to try to evaluate where, why and at what level there may have been a lack of care, materiales, information etc. This evalution will be returned to the health facilities involved in an effort to reduce maternal deaths and improve care. There must have been 50 or 60 health care workers present. I think that not more than 6 made any contribution to the discussion and one of those was me! The case studies lacked vital information. The recording of care is a real problem, one never knows if it wasnt done or wasnt recorded. One of the cases was a young 14 year old girl, married and in her first pregnancy. She died of Streptococcal meningitis, an illness perfectly treatable in the developed countries. We found a delay in taking her to the health centre on the part of her family..reasons unknown. A lack of care at the health centre who did not examine her fully and did not begin treatment of any kind. They immediatly referried her to the hospital. It was not recorded as to how long it took for transport to arrive. An overnight delay in her being seen by a clinician once admited in the hospital was evident so that when correct treatment was started it was too late.
This story is not uncommon, stories like this are heard everyday somehow along the way they have become acceptable. We are not suprised but for some of us we are sad, we are frustrated, we are angry. What were her rights to health care ? To good health care ? What were her human rights? What are Human rights? Where are they in Malawi ? What do they really mean in Malawi for these poor women?
Witchcraft is very much part of Malawi. It is very much part of day to day life. Superstitions and 'traditional medicine' is often where the people go to, turning only to the health care and hospitals when that has failed. There is, nominally, a move to educate the people away from this but it is slow and not terribly effective. On discussing the second case I was surprised when no formal diagnosis or cause of death was recorded or seemed to be necessay. I suggested that if the medical profession bothered to give families a real cause of death this would make it hard to blame it on some witchcraft or bad omen or as a result of evil behaviour. This was taken down and recorded. It seems that nobody had ever thought of this before!
This weekend we are going to Dwangwa sugar plantations. It is good to get away from Lilongwe every now and again. I need this time to forget for a while, to refresh and recharge. I am grateful to the good friends I have made who make this possible.
Last big news...I have found a small, jeep type, car to buy. I hope to take possesion of it on Tuesday. It will be better for my village visits and hopefully more economical than renting.
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