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.
Friday, 9 May 2008
Friday, 25 April 2008
MALARIA AND MIRACLES
Lucas has had Malaria!!
I knew this could happen. Actually what worried me most was not recognizing the symptoms sufficiently quickly for early treatment. I had been told by all that rapid diagnosis and treatment was the key to success. As it happened I need not have worried. Lucas had a text book case, it was unmistakeable even for my untrained eye. Saturday morning we went off to football as usual. Lucas played well though I felt he was more distracted and came to the side line more often for a 'water break' After, we passed by a small shopping centre to pick up some groceries and met Tarek. It was his birthday so we stayed to have a milkshake with him. Without finishing his drink Lucas proceeded to fall asleep at the table. We made some comment about men and there sleeping habits but I knew something was wrong. Lucas NEVER slept during the day. By the time we reached home he had a slight fever 37.5C I wondered what he was sickening for? Over the next 2 hours his temperature rose to 40 C . He was sleepy and complained of headache. He was too tired to eat or drink and was too weak to even walk to the bathroom. I didn't hesitate. I carried him to the car and drove less than 10 minutes to a small clinic that had been recommended by a friend. We were seen immediately. Excluding any other signs or symptoms of infection a small finger prick sample of blood was taken which they examined straightaway under the microscope. It was confirmed in minutes. Affected red cells were seen but we had caught it in its early stages. Treatment in the form of tablets was prescribed and we went home. I was advised to use paracetamol to lower his fever and cold flannels or baths if necessary. Well everything prooved necessary! His temperature osscilated between 38.4 C and 40C for 36 hours. All weekend activities, including a birthday party and " sleep-over were cancelled. I stayed at his side constantly during that time either in bed or on the sofa. I was amazingly support by friends both by phone, messages and visits. Most had experience of the same with their young children, I found this most comforting. I think the worst moment was the first night at midnight when he was supposed to take his second dose of treatment. He immediatly vomited the lot! I phoned the clinic who helpfully told me to give an anti sickness tablet, wait 30 minutes and repeat the dose. This I did and much to my relief it stayed down. Then it was a waiting game. Sunday didn't see much change and I had my doubting moments but he was also not getting worse, which served to console me. Monday saw some improvement and he started to eat and drink a little. Its amazing how we feel so much better when children eat! Right from baby and infant time if they would only eat, breast feed, take the bottle, then they must be alright! By the evening I could see the difference and on Tuesday he wanted to go back to school! He stayed at home with his nanny and I felt confident enough to leave him. Wednesday he went back to school and is now active and happy once more and very proud to be the only one in his family who has had Malaria!
In conclusion I would say it has been a great learning experience for us both. That Africa is definitely the best place to be sick with Malaria! They really know what they are doing. The attention and treatment was fast and effective. The medical staff were knowledgeable, understanding and efficient...in short ,with all their short comings in other ares I could not fault them.
So now I'm not so scared of Malaria! It might still sound desperate and frightening to you all but this is Africa and we are learning to live with and in it.
Malaria is a killer disease here in Malawi. The people live too far away from health facilities. They have no money for transport. Although medicines should be available free many times charges are made and the 500 MKW is more than most can afford. ( I paid 3.500 MKW in total for Lukis treatment as we attended a private clinic, this is totally out of the reach of most Malawians who maybe only earn that much in a whole month)
There is so much malnutrition, HIV, Hepatitis, chronic anaemia and other ailments that Malaria kills. We are the lucky ones. Lucas is a fit healthy active child. He was diagnosed and treated fast and his body responded. Yes, the medication is available....but only for some. Yes, the medication works.... but only for some.
And what about the miracles then?
I arrived on Labour ward, as usual, at 7.30ish on Tuesday morning. What would I find today? A second twin waiting to be born! Quickly I looked in the notes to see the time of birth of the first....5.30am! more than 2 hours ago! I tried to find the fetal heart but without success..or maybe yes, maybe I could hear a faint heartbeat or not? I decided to actively get that baby born. It was her 4th child she should be able to push it out quickly, it would be quicker than a c/section if it was alive and I could not send her for a c/section if it was dead. So where was that baby and why hadn't it been born yet? I examined her, she was fully dilated, was it a head I felt? I broke her waters and found a hand and an arm! Oh no this was not a good sign. But wait, I was right, I could also feel a little head. I called for assistance and encouraged her to push. Chimani...Chimani...push..push, kwambiri....kwambiri...more..more. That mother was amazing. I dont know if she realized she was pushing to save the life of her baby or if she could hear the urgency in my voice, could sense the need to respond, but she just pushed with all her strength and out came that 2nd little girl with one hand up alongside her head. I thought she was dead. Quickly cutting the cord I felt for a heart beat. I couldn't believe it! It was slow, but it was there. At my side was Anne the Norwegian midwife, she took the baby from me straight to the resussitaire and started work...suctioning out the mucus that obstructed her airway and forcing oxygen into her little lungs. I heard a small infant cry! "She 's coming round" shouted Anne. And she was! An hour later her mother got up, showered and proudly took her 2 little babies to postnatal ward after breast feeding them both. It took a while for the adrenelin to subside but I'd never felt so alive!
Today I had a meeting with Lucas' teachers at 11.45 so I decided to go to labour ward for a few hours untill 11.30. Lucky I did, as we were just 3 midwives, 5 students and a full ward. Anne and I started to sort out who needed what and when and before 11am most of the babies had been born. I was walking past a bed where a doctor was examining a newly admitted referred patient. I could see the umbilical cord pretruding from her vagina. Oh no! cord prolapse! Is the baby dead? Is the cord pulsating? " Yes" When, at what time, how long had the referral and journey taken? There was no time for those questions they were not important now.. First baby or multigravida? "3rd" is she fully dilated? " yes" what is the presenting part? " a foot " Then we can get the feet down and pull, we can deliver this baby, it will be its best bet, its only hope.
The Norwegian obstetrician was at my side, Anne came quickly to help, we worked as a team and the little one was born. Just a faint heart beat was felt. We worked together to help that baby to survive. It took a while but slowly he started gasping, taking little breaths, getting pink ( yes African babies get PINK too!) I took him to nursery. Will he make it? I don't know yet but at least we have given him a chance.
I could tell of the ones that didn't make it but I think that this week I'd rather end on a positive note. The two Norwegians that I have talked of will be leaving next week. Two more have come in their place. Their government has promised to supply these medical staff for a period of 5 years. They each do a 6 month stint. I shall be sad to see them go. They have become well trained and experienced collegues during their time here, they will be greatly missed on labour ward. It takes time to learn and accustom oneself to Bwaila and now they are leaving. I wish them well. Who knows, maybe one day they will come back? Africa needs such as them, Bwaila needs such as them, the mums and babies need such as them, I need such as them.
I knew this could happen. Actually what worried me most was not recognizing the symptoms sufficiently quickly for early treatment. I had been told by all that rapid diagnosis and treatment was the key to success. As it happened I need not have worried. Lucas had a text book case, it was unmistakeable even for my untrained eye. Saturday morning we went off to football as usual. Lucas played well though I felt he was more distracted and came to the side line more often for a 'water break' After, we passed by a small shopping centre to pick up some groceries and met Tarek. It was his birthday so we stayed to have a milkshake with him. Without finishing his drink Lucas proceeded to fall asleep at the table. We made some comment about men and there sleeping habits but I knew something was wrong. Lucas NEVER slept during the day. By the time we reached home he had a slight fever 37.5C I wondered what he was sickening for? Over the next 2 hours his temperature rose to 40 C . He was sleepy and complained of headache. He was too tired to eat or drink and was too weak to even walk to the bathroom. I didn't hesitate. I carried him to the car and drove less than 10 minutes to a small clinic that had been recommended by a friend. We were seen immediately. Excluding any other signs or symptoms of infection a small finger prick sample of blood was taken which they examined straightaway under the microscope. It was confirmed in minutes. Affected red cells were seen but we had caught it in its early stages. Treatment in the form of tablets was prescribed and we went home. I was advised to use paracetamol to lower his fever and cold flannels or baths if necessary. Well everything prooved necessary! His temperature osscilated between 38.4 C and 40C for 36 hours. All weekend activities, including a birthday party and " sleep-over were cancelled. I stayed at his side constantly during that time either in bed or on the sofa. I was amazingly support by friends both by phone, messages and visits. Most had experience of the same with their young children, I found this most comforting. I think the worst moment was the first night at midnight when he was supposed to take his second dose of treatment. He immediatly vomited the lot! I phoned the clinic who helpfully told me to give an anti sickness tablet, wait 30 minutes and repeat the dose. This I did and much to my relief it stayed down. Then it was a waiting game. Sunday didn't see much change and I had my doubting moments but he was also not getting worse, which served to console me. Monday saw some improvement and he started to eat and drink a little. Its amazing how we feel so much better when children eat! Right from baby and infant time if they would only eat, breast feed, take the bottle, then they must be alright! By the evening I could see the difference and on Tuesday he wanted to go back to school! He stayed at home with his nanny and I felt confident enough to leave him. Wednesday he went back to school and is now active and happy once more and very proud to be the only one in his family who has had Malaria!
In conclusion I would say it has been a great learning experience for us both. That Africa is definitely the best place to be sick with Malaria! They really know what they are doing. The attention and treatment was fast and effective. The medical staff were knowledgeable, understanding and efficient...in short ,with all their short comings in other ares I could not fault them.
So now I'm not so scared of Malaria! It might still sound desperate and frightening to you all but this is Africa and we are learning to live with and in it.
Malaria is a killer disease here in Malawi. The people live too far away from health facilities. They have no money for transport. Although medicines should be available free many times charges are made and the 500 MKW is more than most can afford. ( I paid 3.500 MKW in total for Lukis treatment as we attended a private clinic, this is totally out of the reach of most Malawians who maybe only earn that much in a whole month)
There is so much malnutrition, HIV, Hepatitis, chronic anaemia and other ailments that Malaria kills. We are the lucky ones. Lucas is a fit healthy active child. He was diagnosed and treated fast and his body responded. Yes, the medication is available....but only for some. Yes, the medication works.... but only for some.
And what about the miracles then?
I arrived on Labour ward, as usual, at 7.30ish on Tuesday morning. What would I find today? A second twin waiting to be born! Quickly I looked in the notes to see the time of birth of the first....5.30am! more than 2 hours ago! I tried to find the fetal heart but without success..or maybe yes, maybe I could hear a faint heartbeat or not? I decided to actively get that baby born. It was her 4th child she should be able to push it out quickly, it would be quicker than a c/section if it was alive and I could not send her for a c/section if it was dead. So where was that baby and why hadn't it been born yet? I examined her, she was fully dilated, was it a head I felt? I broke her waters and found a hand and an arm! Oh no this was not a good sign. But wait, I was right, I could also feel a little head. I called for assistance and encouraged her to push. Chimani...Chimani...push..push, kwambiri....kwambiri...more..more. That mother was amazing. I dont know if she realized she was pushing to save the life of her baby or if she could hear the urgency in my voice, could sense the need to respond, but she just pushed with all her strength and out came that 2nd little girl with one hand up alongside her head. I thought she was dead. Quickly cutting the cord I felt for a heart beat. I couldn't believe it! It was slow, but it was there. At my side was Anne the Norwegian midwife, she took the baby from me straight to the resussitaire and started work...suctioning out the mucus that obstructed her airway and forcing oxygen into her little lungs. I heard a small infant cry! "She 's coming round" shouted Anne. And she was! An hour later her mother got up, showered and proudly took her 2 little babies to postnatal ward after breast feeding them both. It took a while for the adrenelin to subside but I'd never felt so alive!
Today I had a meeting with Lucas' teachers at 11.45 so I decided to go to labour ward for a few hours untill 11.30. Lucky I did, as we were just 3 midwives, 5 students and a full ward. Anne and I started to sort out who needed what and when and before 11am most of the babies had been born. I was walking past a bed where a doctor was examining a newly admitted referred patient. I could see the umbilical cord pretruding from her vagina. Oh no! cord prolapse! Is the baby dead? Is the cord pulsating? " Yes" When, at what time, how long had the referral and journey taken? There was no time for those questions they were not important now.. First baby or multigravida? "3rd" is she fully dilated? " yes" what is the presenting part? " a foot " Then we can get the feet down and pull, we can deliver this baby, it will be its best bet, its only hope.
The Norwegian obstetrician was at my side, Anne came quickly to help, we worked as a team and the little one was born. Just a faint heart beat was felt. We worked together to help that baby to survive. It took a while but slowly he started gasping, taking little breaths, getting pink ( yes African babies get PINK too!) I took him to nursery. Will he make it? I don't know yet but at least we have given him a chance.
I could tell of the ones that didn't make it but I think that this week I'd rather end on a positive note. The two Norwegians that I have talked of will be leaving next week. Two more have come in their place. Their government has promised to supply these medical staff for a period of 5 years. They each do a 6 month stint. I shall be sad to see them go. They have become well trained and experienced collegues during their time here, they will be greatly missed on labour ward. It takes time to learn and accustom oneself to Bwaila and now they are leaving. I wish them well. Who knows, maybe one day they will come back? Africa needs such as them, Bwaila needs such as them, the mums and babies need such as them, I need such as them.
Friday, 18 April 2008
TEACHING OR FACILITATING
As time flies by and each week passes I find it increasingly difficult to find the right moment to sit down and write to you all. Everyday there are stories to tell as I become more and more involved in the different aspects of African life and health care.
It has been a week full of teaching. I find myself particularly involved with the clinical teaching on labour ward passing from bed to bed observing and questioning, trying to make the students think about their practise in a new way. To see the woman as an individual with a story to tell quite unique and special and therefore to be treated as such. Sometimes its difficult to stand back and let them attend, even whilst I am supervising. Inexpert and clumsy, results in torn perineums or less sensitive handling of mother and baby as they perform their tasks but I guess thats just part of teaching. and learning. Its a priveledge to be with them to be part of their training, to maybe have some influence. I hope that my words will be remembered and my example sufficient to aid them to be better more caring and knowledgeable midwives in the future.
But not all the students are receptive and many have a dangerous overconfidence after just a short time on labour ward. Then there are the students that are more concerned about filling in their papers for x number of vacuum extractions, twins or breech deliveries and can be found attending these births totally or inadequately supervised. I returned from workshop on Tuesday to the cries of a woman in bed 2. Behind the curtains I found a very newly trained CO supervising a student midwife with a vacuum extraction. I had been aware earlier that she was "on the look out" for vacuum extractions. Things didnt seem to be going well. The whole scene was chaos and the woman out of control. On enquiring as to the whereabouts of the fetal stethescope to check the baby's condition I found that they didnt have one. They hadn't seen it as and important part of thier equipment! I could not let this continue and pushed past to examine the lady. I found that the conditions were not favourable for this sort of intervention and told them to stop untill I called a senior clinician. I ran to operating theatre where I found him having lunch. Fortunately he was finishing and came straight away. ( Luch hour in Malawi is sacred and even an emergency will not be attended to untill after lunch!) He attempted to extract the baby but soon decided it was not possible. I hurried her to theatre where the baby was born by a difficult c/section. I stayed to recussitate a very floppy baby then transferred him to nursery. Today the baby has been discharged from nursery and is with his mother. He is one of the lucky ones. I dont understand this behaviour. I cannot condone this behaviour. But it exists and it continues. The workshops are going well. I am called the ' facilitator' Its the new word instead of teacher. I rather like it! I have now finished the first session which consisted of 4 groups. 35 midwives attended in total. Feedback has been good so far and I am encouraged. Next week I will introduce a new topic as we start to analize our individual practices and attitudes.
Pilirani and the twins Edward and Alex are still doing well. They now weigh in at 3.700 and 3.050 kgs. respectively. The harvest has begun. The maize is picked and being ground into flour. This week she did not complain of hunger. The boys are hungry babies and growing fast. They are still taking 2 formula feeds a day and I continue to supply them with milk powder. I have however advised her to try stop these supplements now that both mother and babies are stronger.
Grace spent 5 days in hospital with little Angela whilst they treated a chest infection with antibiotics. I was disappointed to find that when I visited on Monday she had already been discharged without doing the cardiac scan. This happens often. If she has a cardiac complaint it will not be investigated untill next time she is admitted with the next infection or failure to thrive.
It is frustrating but it is Malawi. I hope that she will start to grow and gain weight and that it wont be necessary.
It is not uncommon for me to attend 5 to 7 births in one 9 hour shift. Some are quick and straight forward but many long and complicated requiring the maximum of my skills.
Just 2 examples this week...1. A referred case with prolonged dilatation phase. Aparently she would be unable to deliver due to an abnormal cervix. I was told to try a vaginal birth but it was unlikely. After much care she pushed out a healthy boy and avoided a c/section.
.... 2. It was her 5th pregnancy and she still didnt have a living child. She had been admitted during the night and was well in labour. I started caring for her at 7.30am. At 8.30am. the doctors do there "round" The orders were clear.. " This lady will be c/sectioned immediately " It was not for me to question this decision which was made in the interest of mother and child but I do question as to whether a c/section is really the safest option, not only here in Bwaila but in any part of the world? I started to prepare her for theatre. IV infusion, urinary catheter, consent form etc. She started pushing, what could I do? Ten minutes later she birthed a healthy bouncing baby boy! She was so happy and so was I! I'm not sure if the boss knows yet but I'm sure not going to tell her!!
It has been a week full of teaching. I find myself particularly involved with the clinical teaching on labour ward passing from bed to bed observing and questioning, trying to make the students think about their practise in a new way. To see the woman as an individual with a story to tell quite unique and special and therefore to be treated as such. Sometimes its difficult to stand back and let them attend, even whilst I am supervising. Inexpert and clumsy, results in torn perineums or less sensitive handling of mother and baby as they perform their tasks but I guess thats just part of teaching. and learning. Its a priveledge to be with them to be part of their training, to maybe have some influence. I hope that my words will be remembered and my example sufficient to aid them to be better more caring and knowledgeable midwives in the future.
But not all the students are receptive and many have a dangerous overconfidence after just a short time on labour ward. Then there are the students that are more concerned about filling in their papers for x number of vacuum extractions, twins or breech deliveries and can be found attending these births totally or inadequately supervised. I returned from workshop on Tuesday to the cries of a woman in bed 2. Behind the curtains I found a very newly trained CO supervising a student midwife with a vacuum extraction. I had been aware earlier that she was "on the look out" for vacuum extractions. Things didnt seem to be going well. The whole scene was chaos and the woman out of control. On enquiring as to the whereabouts of the fetal stethescope to check the baby's condition I found that they didnt have one. They hadn't seen it as and important part of thier equipment! I could not let this continue and pushed past to examine the lady. I found that the conditions were not favourable for this sort of intervention and told them to stop untill I called a senior clinician. I ran to operating theatre where I found him having lunch. Fortunately he was finishing and came straight away. ( Luch hour in Malawi is sacred and even an emergency will not be attended to untill after lunch!) He attempted to extract the baby but soon decided it was not possible. I hurried her to theatre where the baby was born by a difficult c/section. I stayed to recussitate a very floppy baby then transferred him to nursery. Today the baby has been discharged from nursery and is with his mother. He is one of the lucky ones. I dont understand this behaviour. I cannot condone this behaviour. But it exists and it continues. The workshops are going well. I am called the ' facilitator' Its the new word instead of teacher. I rather like it! I have now finished the first session which consisted of 4 groups. 35 midwives attended in total. Feedback has been good so far and I am encouraged. Next week I will introduce a new topic as we start to analize our individual practices and attitudes.
Pilirani and the twins Edward and Alex are still doing well. They now weigh in at 3.700 and 3.050 kgs. respectively. The harvest has begun. The maize is picked and being ground into flour. This week she did not complain of hunger. The boys are hungry babies and growing fast. They are still taking 2 formula feeds a day and I continue to supply them with milk powder. I have however advised her to try stop these supplements now that both mother and babies are stronger.
Grace spent 5 days in hospital with little Angela whilst they treated a chest infection with antibiotics. I was disappointed to find that when I visited on Monday she had already been discharged without doing the cardiac scan. This happens often. If she has a cardiac complaint it will not be investigated untill next time she is admitted with the next infection or failure to thrive.
It is frustrating but it is Malawi. I hope that she will start to grow and gain weight and that it wont be necessary.
It is not uncommon for me to attend 5 to 7 births in one 9 hour shift. Some are quick and straight forward but many long and complicated requiring the maximum of my skills.
Just 2 examples this week...1. A referred case with prolonged dilatation phase. Aparently she would be unable to deliver due to an abnormal cervix. I was told to try a vaginal birth but it was unlikely. After much care she pushed out a healthy boy and avoided a c/section.
.... 2. It was her 5th pregnancy and she still didnt have a living child. She had been admitted during the night and was well in labour. I started caring for her at 7.30am. At 8.30am. the doctors do there "round" The orders were clear.. " This lady will be c/sectioned immediately " It was not for me to question this decision which was made in the interest of mother and child but I do question as to whether a c/section is really the safest option, not only here in Bwaila but in any part of the world? I started to prepare her for theatre. IV infusion, urinary catheter, consent form etc. She started pushing, what could I do? Ten minutes later she birthed a healthy bouncing baby boy! She was so happy and so was I! I'm not sure if the boss knows yet but I'm sure not going to tell her!!
Wednesday, 9 April 2008
TOO MUCH TO TELL
Some days I sit down here in front of the screen and dont know where to start. Today is one of those days.
I am back on labour ward. This week we had an influx of students. Clinical Officer students and nurse/midwife students. Its their first time on labour ward, they need so much clinical teaching and training which is not readily available. They stand around confused or try to do the little that they know how, often making mistakes, not realizing the importance of listening correctly to a fetal heart or checking the uterine contraction after birth. The CO's have so little knowledge I am amazed, the midwives somewhat more. They need constant supervision but find trained staff with little enthusiasm for the task. I regularly find myself with 5 or 6 students round the bed, not ideal for the labouring mother, but I am aware that their need for training is so great there is no option. I enjoy this part of my work and find the students generally open and enthusiastic to learn. We are using the birthing chair more often and now I am not seen as crazy when attending a mother who chooses crouching position or ' all fours' to give birth. Yesterday one of the very newly trained midwives came to me to ask for the stool. She thought that 2nd stage (pushing) would be more effective in that position. She and another young midwife assisted the mother to birth on the stool and I was around to help. It was most encouraging.
My first official group session with the midwives took off yesterday. There were 8 midwives from both Bwaila hospital and Kamuzu Central. It turned out to be a relaxed fun time, which was my intention, but I was able to challenge them with some pertinent questions. If you,or your daughter were pregnant now and looking for the best possible care for you and your baby would you come to Bwaila hospital ante natal clinic ? Bwaila labour ward or postnatal ward? Would you have your baby looked after in Bwaila nursery? We looked at our own expectations of care and the care that we are giving. We looked at the uniqueness and individuality of birth and talked of choice. I showed some images of birth in Europe, natural birth in various positions with caring midwives and partners. They were able to see the joy and happiness that can and should be part of giving birth and which is far from present in our hospital. It was good to see their faces as I presented a totally different concept from that which they are used to. They all noted and commented favourably on the presence of the fathers in the birth. I realized that deep down, despite their culture and customs these Malawian women felt just like us, the need to be loved, cared for, and supported, especially at this time. To share the birth, this life changing event, with the person they love most, the father of their child.
Somebody said to me today that the Malawians are cold, emotionally dead, that they dont care. That they dont know how to love their children that none of that really matters. I dont believe it. Maybe their circumstances and experiences have made them keep their distance, not love too
much for fear of being hurt, for fear of too much pain, for fear of loosing. Maybe they have just shut down, maybe its the only way to survive.
I arrived on labour ward at 7.15am. The clinical officer had been called to attend a possible ruptured uterus. The baby was dead. Had died in the time the mother was on labour ward. There was not time to ask questions to find out why. I was asked to assist a vacuum extraction. The baby came easily. I think he forgot that it was dead and started to place it on the mothers abdomen. I took the baby, dried it and carefully wrapped it in the special 'chitenge' cloth she had brought. I looked into the mothers staring emotionless eyes and said I was so sorry and asked if she wanted to hold her baby. Her face told me nothing not grief, not suprise, nothing, it was blank. I was troubled. I asked the CO if anyone had told the women that her baby had died. He asked her.. in Chichewa. NO ! No one had thought to tell this mother. She was expecting a live child! I could not believe it, this is not acceptable, this is not professional, this is inhumane.
It made me question once again, had they been right ? did they really not care!
Update on Pilirani and the twins... Last week both babies looked good. Both looked lively and active. They were needing to supplement breast feeding twice a day with milk formula but they were growing and gaining weight. I could see that Pilirani had lost weight. I was not suprised as I know they will be hungry untill they start harvesting next month. This time I found maize flour to take plus sugar and other fresh fruit and veg. Not enough, but it will never be enough. I gave her a tin of milk powder for the babies. It is relatively expensive and out of reach economically for most families. It can be supplied freely at some centres but most do not have the means or money for transport to collect it. Also breast feeding is 100% encouraged for all its other benefits. Before I left the older children were sent out to the field to cut some maize cobs for us to take home. I look forward to my visits to this village these people are just amazing!
Our visit to Grace was somewhat frustrating. We arrived at the famous wobbly plank bridge to find that a minibus had broken down right in front of it, blocking our passage. It took us more than an hour to find our way over and around the small stream that separated us from her house. We could see her house in the distance but it was not safe to leave the car and walk. When we eventually arrived I was pleased to find that baby Angela had gained 400g in 2 weeks. She looked peaceful and content. Grace looked well. I could see her Aunt had been feeding her well and that she had gained weight. Grace wanted to know when she could come to my house? Maybe next time I assured her. Or am I creating a dependancy that could become difficult? How difficult? Why difficult? What am I afraid of?
Grace phoned me yesterday to tell me that her baby was sick that she was not feeding and crying a lot. I told her to take her to the hospital but I doubted that she would. This morning when I spoke to her she had no transport nor money. I picked them up at 11am. and we went to Central hospital ' under five clinic' Baby Angela has been admitted to the nursery with an infection. I mentioned that she may have an underlying heart problem so they have ordered a scan. Her condition did not look too bad though once again she had not gained weight in a week. I am pleased that this will be an opportunity to investigate a possible heart problem and that we took her in plenty of time to be treated sucessfully. One of the problems in health care, in general, is that by the time the children(or adults) are taken to be seen at the hospital they have already passed through the local health clinic, the traditional medicine (witch doctor) and often arrive much too late for our medicine to be effective. Tomorrow I will return to see how Angela is doing and take some food for Grace.
My last assignment to finish my "orientation" was a few days on the postnatal ward. There are 2 midwives on each shift. They are caring for High risk postnatal, postnatal and ante natal mothers. Around 70 to 80 women. This is what I wrote as I came off duty last Friday...
Today I felt that however much I do there will always be more to do. However much I give it will never be enough. However much I care still more will be needed. The queues are endless the corridors are full and overflowing. As we emptied out the beds so they filled. High risk went to low risk. Low risk went home and high risk was filled again from theatre. No bed available ? just put her on a matress, from that pile, on the floor. I laughed to find myself kneeling down on the floor putting up an IV infusion, taking blood samples and cleaning dressings. There was very little chance to get to know the women just get the basics done. The drugs, the dressings, IV lines urinary catheters, but its fun to do it with a smile and a word of encouragement even if more than half didn't understand a word I was saying! Being on postnatal ward also means attending the outpatients who come back for removal of sutures or any other postnatal complaint. If labour ward was busy, if Antenatal clinic was busy, if in nursery I never stopped, well postnatal was no different! Is it any wonder things get missed or mistakes are made ? Is it any wonder?
Two of the midwives were talking together I didnt understand but I knew it was serious. I asked what was it that was bothering them? They told me it was the extra shifts. They were expected, though not obliged, to work 2 or more extra shifts a week. For each shift they are paid 600MK. (3 euros) or 800MK for nights (4 euros) By the time they pay their transport and a meal there is almost nothing left. I asked them " so why do you do it?"
" because if we dont there is no one to care for the women they will be left unattended"
I felt humbled..
" so now if you see us sitting down, you know why"
I felt ashamed..
Life in Malawi is full of conflicts, life at Bwaila hospital is continually confusing..
But I love it!
I am back on labour ward. This week we had an influx of students. Clinical Officer students and nurse/midwife students. Its their first time on labour ward, they need so much clinical teaching and training which is not readily available. They stand around confused or try to do the little that they know how, often making mistakes, not realizing the importance of listening correctly to a fetal heart or checking the uterine contraction after birth. The CO's have so little knowledge I am amazed, the midwives somewhat more. They need constant supervision but find trained staff with little enthusiasm for the task. I regularly find myself with 5 or 6 students round the bed, not ideal for the labouring mother, but I am aware that their need for training is so great there is no option. I enjoy this part of my work and find the students generally open and enthusiastic to learn. We are using the birthing chair more often and now I am not seen as crazy when attending a mother who chooses crouching position or ' all fours' to give birth. Yesterday one of the very newly trained midwives came to me to ask for the stool. She thought that 2nd stage (pushing) would be more effective in that position. She and another young midwife assisted the mother to birth on the stool and I was around to help. It was most encouraging.
My first official group session with the midwives took off yesterday. There were 8 midwives from both Bwaila hospital and Kamuzu Central. It turned out to be a relaxed fun time, which was my intention, but I was able to challenge them with some pertinent questions. If you,or your daughter were pregnant now and looking for the best possible care for you and your baby would you come to Bwaila hospital ante natal clinic ? Bwaila labour ward or postnatal ward? Would you have your baby looked after in Bwaila nursery? We looked at our own expectations of care and the care that we are giving. We looked at the uniqueness and individuality of birth and talked of choice. I showed some images of birth in Europe, natural birth in various positions with caring midwives and partners. They were able to see the joy and happiness that can and should be part of giving birth and which is far from present in our hospital. It was good to see their faces as I presented a totally different concept from that which they are used to. They all noted and commented favourably on the presence of the fathers in the birth. I realized that deep down, despite their culture and customs these Malawian women felt just like us, the need to be loved, cared for, and supported, especially at this time. To share the birth, this life changing event, with the person they love most, the father of their child.
Somebody said to me today that the Malawians are cold, emotionally dead, that they dont care. That they dont know how to love their children that none of that really matters. I dont believe it. Maybe their circumstances and experiences have made them keep their distance, not love too
much for fear of being hurt, for fear of too much pain, for fear of loosing. Maybe they have just shut down, maybe its the only way to survive.
I arrived on labour ward at 7.15am. The clinical officer had been called to attend a possible ruptured uterus. The baby was dead. Had died in the time the mother was on labour ward. There was not time to ask questions to find out why. I was asked to assist a vacuum extraction. The baby came easily. I think he forgot that it was dead and started to place it on the mothers abdomen. I took the baby, dried it and carefully wrapped it in the special 'chitenge' cloth she had brought. I looked into the mothers staring emotionless eyes and said I was so sorry and asked if she wanted to hold her baby. Her face told me nothing not grief, not suprise, nothing, it was blank. I was troubled. I asked the CO if anyone had told the women that her baby had died. He asked her.. in Chichewa. NO ! No one had thought to tell this mother. She was expecting a live child! I could not believe it, this is not acceptable, this is not professional, this is inhumane.
It made me question once again, had they been right ? did they really not care!
Update on Pilirani and the twins... Last week both babies looked good. Both looked lively and active. They were needing to supplement breast feeding twice a day with milk formula but they were growing and gaining weight. I could see that Pilirani had lost weight. I was not suprised as I know they will be hungry untill they start harvesting next month. This time I found maize flour to take plus sugar and other fresh fruit and veg. Not enough, but it will never be enough. I gave her a tin of milk powder for the babies. It is relatively expensive and out of reach economically for most families. It can be supplied freely at some centres but most do not have the means or money for transport to collect it. Also breast feeding is 100% encouraged for all its other benefits. Before I left the older children were sent out to the field to cut some maize cobs for us to take home. I look forward to my visits to this village these people are just amazing!
Our visit to Grace was somewhat frustrating. We arrived at the famous wobbly plank bridge to find that a minibus had broken down right in front of it, blocking our passage. It took us more than an hour to find our way over and around the small stream that separated us from her house. We could see her house in the distance but it was not safe to leave the car and walk. When we eventually arrived I was pleased to find that baby Angela had gained 400g in 2 weeks. She looked peaceful and content. Grace looked well. I could see her Aunt had been feeding her well and that she had gained weight. Grace wanted to know when she could come to my house? Maybe next time I assured her. Or am I creating a dependancy that could become difficult? How difficult? Why difficult? What am I afraid of?
Grace phoned me yesterday to tell me that her baby was sick that she was not feeding and crying a lot. I told her to take her to the hospital but I doubted that she would. This morning when I spoke to her she had no transport nor money. I picked them up at 11am. and we went to Central hospital ' under five clinic' Baby Angela has been admitted to the nursery with an infection. I mentioned that she may have an underlying heart problem so they have ordered a scan. Her condition did not look too bad though once again she had not gained weight in a week. I am pleased that this will be an opportunity to investigate a possible heart problem and that we took her in plenty of time to be treated sucessfully. One of the problems in health care, in general, is that by the time the children(or adults) are taken to be seen at the hospital they have already passed through the local health clinic, the traditional medicine (witch doctor) and often arrive much too late for our medicine to be effective. Tomorrow I will return to see how Angela is doing and take some food for Grace.
My last assignment to finish my "orientation" was a few days on the postnatal ward. There are 2 midwives on each shift. They are caring for High risk postnatal, postnatal and ante natal mothers. Around 70 to 80 women. This is what I wrote as I came off duty last Friday...
Today I felt that however much I do there will always be more to do. However much I give it will never be enough. However much I care still more will be needed. The queues are endless the corridors are full and overflowing. As we emptied out the beds so they filled. High risk went to low risk. Low risk went home and high risk was filled again from theatre. No bed available ? just put her on a matress, from that pile, on the floor. I laughed to find myself kneeling down on the floor putting up an IV infusion, taking blood samples and cleaning dressings. There was very little chance to get to know the women just get the basics done. The drugs, the dressings, IV lines urinary catheters, but its fun to do it with a smile and a word of encouragement even if more than half didn't understand a word I was saying! Being on postnatal ward also means attending the outpatients who come back for removal of sutures or any other postnatal complaint. If labour ward was busy, if Antenatal clinic was busy, if in nursery I never stopped, well postnatal was no different! Is it any wonder things get missed or mistakes are made ? Is it any wonder?
Two of the midwives were talking together I didnt understand but I knew it was serious. I asked what was it that was bothering them? They told me it was the extra shifts. They were expected, though not obliged, to work 2 or more extra shifts a week. For each shift they are paid 600MK. (3 euros) or 800MK for nights (4 euros) By the time they pay their transport and a meal there is almost nothing left. I asked them " so why do you do it?"
" because if we dont there is no one to care for the women they will be left unattended"
I felt humbled..
" so now if you see us sitting down, you know why"
I felt ashamed..
Life in Malawi is full of conflicts, life at Bwaila hospital is continually confusing..
But I love it!
Wednesday, 26 March 2008
BEAUTY AND FRUSTRATIONS
This morning I decided I should finish my obligatory "orientation program" for my official registration with the Malawi nurses council. This means spending 3 days in the Ante natal clinic. Up to 100 mothers are seen between 8am. and 12am. As you can imagine they are passed through at great speed. It seems that the basic checks are done but there isn't much time for midwife/mum chit-chat! In the same building is the underfive vaccination clinic, family planning and a special HIV follow up clinic.This means lots of mums and babies milling around. I am amazed to see how well everyone knows where to go and in which line to queue. On asking for an explanation for this very organized chaos I was told that there is excellent communication and support between the mothers. It was evident, the next mother in the line would look after the young baby or child while she was being seen. I think we could all take example from these women in this way and also find some of their endless patience as they wait their turn happily chatting away to each other without that feeling of anxiety, impatience and stress that is so palpable in European waiting rooms.
Before I tell you all about our weekend on the Lake, I should first let you know how Pilirani and her twins are getting on.
OnWednesday morning we (Doreen and I) set out early to do our visits. Lucas was at school and would be picked up at lunch time by a friend.
First I called in to the nursery to fetch the portable scales for weighing the babies. We then passed by the market and bought fruit, vegetables and bread. I had already prepared a tray of hard boiled eggs as I worry about the lack of protein in the average diet which mainly consists of a maize flour porridge. This serves to fill their stomachs but instead of being used as part of a balanced diet it is often the only thing they eat.
I had been in contact almost daily with Grace and her tiny, prem baby. She had left nursery weighing only 1.500kg. and with a possible heart problem. We would first go to see her.
I wrote the above last Wednesday and have tried unsucessfully to complete and post 5 times since then! It has been so frustrating! I am daily learning the lesson of how little control I really have over so many things. I am told that all the internet conections in Malawi were either down or slow and could only access some sites.. obviously my blog wasn't one of them! So, for those of you who began to worry that you hadn't heard, I thank you for your concern and for those who are eagerly awaiting my next installment...here goes!!
Grace met us on the "main" road, a muddy potholed track leading to who knows where! She was thrilled to see me and gave me a big hug. She climbed in the car and off we went onto the minor tracks. I still havn't managed to acquire a more suitable vehicle so was particularly challenged by a narrow wooden plank bridge and a steep muddy grooved incline. I even stopped to take pictures as I thought no one would believe it possible to pass! I have now realized why both Doreen and Grace are so confident that we will get through...Neither of them has ever driven a car!! Still their encouragement definitely helped! Grace is living temporarily with an aunt and uncle whilst the baby is so tiny. It was obvious that they have a little more money as the house is built of bricks and there is a small amount of furniture. I was shown into the main room and we sat on the sofa and talked for a while. Grace speaks some english but it was good to have Doreen there to make sure that we fully understood each other . The baby had not gained weight in the 2 weeks since discharge from the nursery. This is typical of babys with heart problems. I also felt that she was not giving enough feeds so advised her on 2-3 hourly feeds day and night. The little one, weighing just 1.5kg looked strong and active so I hope that when I next visit I will see some weight gain. I left her with the milk, sugar and fruit I had brought promising to return in 2 weeks time. Before leaving I was desperate for a bathroom so I was shown to the toilet facilities. I have still to improve my aim when peeing down a small hole in the ground but am working on it! I was touched when they brought me a bowl of HOT water to wash my hands. Its these little things that bring me such pleasure.
Precariously we took the road back, I was glad to reach the main road and drove the 30 minutes to reach Piliranis village. The welcome was tremendous we were greeted this time by the great grand parents. On enquiring their age nobody could remember ! The twins looked great and had regained the weight they had lost. I do hope this continues. I am concerned about Piliranis diet untill the new harvest begins. It is a great strain on an already hungry body to be feeding 2 hungry babies. I shall take what I can but I can't feed the whole village, I never feel I have taken enough.
Easter weekend was spent on the southern shore of Lake Malawi. It was an oasis of calm and peace. The incredible richness and beauty of this country made it hard to believe the reality of its poverty.
We were generously entertained by some friends we had met at the airport on arrival.
Time was spent relaxing, eating, swimming, canoeing, snorkeling and daily trips in the speed boat to visit small islands and coves. Luki was able to show off his already acquired fishing skills (endless hours fishing with his father in Spain) catching 3 or4 fish each day. These were later prepared and served for our supper. One of the highlites had to be "feeding the fish eagles" Fish were caught in the evening, then on an early morning trip to a nearby island they were thrown to the eagles who swooped down to retrieve them as they touched the water.It was truely amazing! After 5 days of sheer bliss we returned to Lilongwe.As you can imagine Luki wanted to stay for ever. I wouldn't have minded either!
Back at the hospital and after 3 days in Antenatal clinic I returned to labour ward. They were obviously pleased to see me. It is good now to feel part of the team. I am accepted and welcomed in all departments. Yesterday I was attending a young unmarried girl, first baby.( Its difficult in Malawi to have a baby outside marriage, culturally not acceptable) It was a long tiring labour and equally long 'pushing' stage. We went over the official time limit both for first and second stage. The senior midwives began to ask questions. Although I explain clearly that both mother and baby are fine, that women are all different, that we must be capable of adapting to the individual needs of each woman and each birth, they find this concept almost impossible. I was not following the rules and that made them feel insecure. At last a healthy baby boy was born with minimum intervention and a lot of hard work on my part. Not to mention that young mother. The senior midwife commented that I must be very tired. They do watch! they are noticing! at the moment that is enough for me. I managed to catch 2 other babies during the same shift and although labour ward was not busy, women laboured alone and even one popped out unattended.
Where were the other midwives? Why weren't they alongside caring and encouraging? I still can't answer this.
Next week I start teaching... officially! I prefer to think of it as group leadership of midwives who will regularly get together to talk, share, discuss and learn. It will be a time to explore our own feelings and motivation. We will be realistic within the environment in which we work but we will be willing to change, to improve. From these groups we will go out with a new/renewed vision to experiment new techniques with the sole aim to improve our care to women and babies.
Well at least I hope so!!!
Before I tell you all about our weekend on the Lake, I should first let you know how Pilirani and her twins are getting on.
OnWednesday morning we (Doreen and I) set out early to do our visits. Lucas was at school and would be picked up at lunch time by a friend.
First I called in to the nursery to fetch the portable scales for weighing the babies. We then passed by the market and bought fruit, vegetables and bread. I had already prepared a tray of hard boiled eggs as I worry about the lack of protein in the average diet which mainly consists of a maize flour porridge. This serves to fill their stomachs but instead of being used as part of a balanced diet it is often the only thing they eat.
I had been in contact almost daily with Grace and her tiny, prem baby. She had left nursery weighing only 1.500kg. and with a possible heart problem. We would first go to see her.
I wrote the above last Wednesday and have tried unsucessfully to complete and post 5 times since then! It has been so frustrating! I am daily learning the lesson of how little control I really have over so many things. I am told that all the internet conections in Malawi were either down or slow and could only access some sites.. obviously my blog wasn't one of them! So, for those of you who began to worry that you hadn't heard, I thank you for your concern and for those who are eagerly awaiting my next installment...here goes!!
Grace met us on the "main" road, a muddy potholed track leading to who knows where! She was thrilled to see me and gave me a big hug. She climbed in the car and off we went onto the minor tracks. I still havn't managed to acquire a more suitable vehicle so was particularly challenged by a narrow wooden plank bridge and a steep muddy grooved incline. I even stopped to take pictures as I thought no one would believe it possible to pass! I have now realized why both Doreen and Grace are so confident that we will get through...Neither of them has ever driven a car!! Still their encouragement definitely helped! Grace is living temporarily with an aunt and uncle whilst the baby is so tiny. It was obvious that they have a little more money as the house is built of bricks and there is a small amount of furniture. I was shown into the main room and we sat on the sofa and talked for a while. Grace speaks some english but it was good to have Doreen there to make sure that we fully understood each other . The baby had not gained weight in the 2 weeks since discharge from the nursery. This is typical of babys with heart problems. I also felt that she was not giving enough feeds so advised her on 2-3 hourly feeds day and night. The little one, weighing just 1.5kg looked strong and active so I hope that when I next visit I will see some weight gain. I left her with the milk, sugar and fruit I had brought promising to return in 2 weeks time. Before leaving I was desperate for a bathroom so I was shown to the toilet facilities. I have still to improve my aim when peeing down a small hole in the ground but am working on it! I was touched when they brought me a bowl of HOT water to wash my hands. Its these little things that bring me such pleasure.
Precariously we took the road back, I was glad to reach the main road and drove the 30 minutes to reach Piliranis village. The welcome was tremendous we were greeted this time by the great grand parents. On enquiring their age nobody could remember ! The twins looked great and had regained the weight they had lost. I do hope this continues. I am concerned about Piliranis diet untill the new harvest begins. It is a great strain on an already hungry body to be feeding 2 hungry babies. I shall take what I can but I can't feed the whole village, I never feel I have taken enough.
Easter weekend was spent on the southern shore of Lake Malawi. It was an oasis of calm and peace. The incredible richness and beauty of this country made it hard to believe the reality of its poverty.
We were generously entertained by some friends we had met at the airport on arrival.
Time was spent relaxing, eating, swimming, canoeing, snorkeling and daily trips in the speed boat to visit small islands and coves. Luki was able to show off his already acquired fishing skills (endless hours fishing with his father in Spain) catching 3 or4 fish each day. These were later prepared and served for our supper. One of the highlites had to be "feeding the fish eagles" Fish were caught in the evening, then on an early morning trip to a nearby island they were thrown to the eagles who swooped down to retrieve them as they touched the water.It was truely amazing! After 5 days of sheer bliss we returned to Lilongwe.As you can imagine Luki wanted to stay for ever. I wouldn't have minded either!
Back at the hospital and after 3 days in Antenatal clinic I returned to labour ward. They were obviously pleased to see me. It is good now to feel part of the team. I am accepted and welcomed in all departments. Yesterday I was attending a young unmarried girl, first baby.( Its difficult in Malawi to have a baby outside marriage, culturally not acceptable) It was a long tiring labour and equally long 'pushing' stage. We went over the official time limit both for first and second stage. The senior midwives began to ask questions. Although I explain clearly that both mother and baby are fine, that women are all different, that we must be capable of adapting to the individual needs of each woman and each birth, they find this concept almost impossible. I was not following the rules and that made them feel insecure. At last a healthy baby boy was born with minimum intervention and a lot of hard work on my part. Not to mention that young mother. The senior midwife commented that I must be very tired. They do watch! they are noticing! at the moment that is enough for me. I managed to catch 2 other babies during the same shift and although labour ward was not busy, women laboured alone and even one popped out unattended.
Where were the other midwives? Why weren't they alongside caring and encouraging? I still can't answer this.
Next week I start teaching... officially! I prefer to think of it as group leadership of midwives who will regularly get together to talk, share, discuss and learn. It will be a time to explore our own feelings and motivation. We will be realistic within the environment in which we work but we will be willing to change, to improve. From these groups we will go out with a new/renewed vision to experiment new techniques with the sole aim to improve our care to women and babies.
Well at least I hope so!!!
Monday, 17 March 2008
SOMETIMES ITS ALL TOO MUCH
I didn't write last week, I couldn't write last week.
What could I tell you?
Of the mother that should have been taken to operating theatre at four in the morning, who failed to be assessed and examined by the clinical officer on duty. The c/section was done at 8am. the baby was dead, the mother hemorraged so severely she needed a hysterectomy and later died in the ambulance on the way to intensive care in the central hospital. No blood was available at either hospital .
OK.. so she was HIV positive which was probably the cause of her poor general state, would further complicate her chances of responding to the hemmorage and lead to her death ...BUT ... here in Malawi there are more NGO', charity organizations and do-gooders spending huge sums of money on AIDS projects then any other cause, so I am afraid I can only ask why? why?
Or should I tell you of the morning that on arriving at labour ward I was asked to attend bed two where the 2nd twin was waiting to be born. I listened for the fetal heart and found nothing. I examined her and felt the umbilical cord presenting and not pulsating.The baby was in an impossible position for a vaginal delivery. So when had the 1st twin been born? At 4.20 am. more than 3 hours ago! The clinical officer had visited at 5.10 am. the fetal heart was heard, he told the midwife to wait! She waited. Too long for that baby. ( one midwife's comment was " well she does have one" )
But she had two babies! two healthy babies! untill she came into the hospital!
Or maybe I should tell you of the 2 prem babies. Just 28 weeks gestation, weighing around 1kg. Both breech presentations both difficult to deliver the head. The first was determined to live but lasted just 5 days the second was just too prem. too small.
Or I could tell you of the mother that transferred in after delivering the first twin in a local health centre. It took 3 hours for the ambulance to arrive. The second twin was dead and the mother needed a c/ section for bad presentation.This was confirmed by an ultrasound scan done by one of our clinical officers. Whilst waiting to be taken to theatre she pushed out a live healthy 2nd twin head first!!!
I can talk about it now but I couldn't write it all down last week.
I went to see Tarek, I just needed to talk, to get it all out of me. As usual, he listened and he talked and I felt better. He also gave me something to read, things he had written about human rights.. what are they..what do they really mean to us, to you, to the developed world, the politicians and how relevant are they to the mothers and babies in our care. It started with a quote which I would like to share (actually I'd like to share it all, but its not mine to share.
"It is possible to adapt to a given situation precisely because you have got to live it and you have got to live it everyday. But adapting does not mean that you forget.You go to the mill everyday-it is always unaceptable to you, it has always been unaceptable to you and it remains so for life-but you adapt in the sense that you cannot continue to live in a state 0f conflict with yourself"
My second visit to Pilirani was less eventful as we managed to take all the right turns.
She looks well and the c/section scar is totally healed. When I asked if she felt strong her mother replied that she can now carry a full bucket of water on her head. I guess that means she is very strong! I certainly couldn't!
Unfortunately the twins Edward and Alex weren't doing as well as I expected.They both looked lively and active but underfed and not gaining weight. In fact Edward who had been doing so well had lost weight. We talked about breast feeding, she said "they are very hungry babies" I could see that! She seemed to have plenty of milk but I did suggest that maybe she should supplement. I asked about her diet. She was eating just beans and potatoes.
Last year Malawi produced a bumper crop of maize..the staple diet. More than enough to see them through till the next harvest. Unfortunately someone sold off a large amount to neighbouring Zimbabwe and S.Africa leaving insufficient for the people of Malawi! No one seems to know how or why it happened but poor Malawians are now dying of hunger and severly under nourished due to some high-up political "mistake"
I took bread and bananas, it was not enough. This week I shall take eggs (hard boiled) and rice.
As I got up to leave, Pilirani went to her mud hut and came out with a plate of dried beans for me. She had so little but still gave me of the little she had. It was so difficult to take but I knew I should. I got in the car and cried. This is just one family that I have the priviledge to be part of, but how many more are there like that? It was all too much for me last week.
I must just tell you a last detail..... As we walked through the fields of maize that leads to her house we met a very small child walking towards us. I recognized her as one of Piliranis elder children.She is just 4 years old. On her back she carried what I thought was a doll (silly of me.. little girls in Malawi don't have dolls) I could not believe it when I realized she was carrying Alex the smallest of the twins, now weighing 1.550kg.!
Friday was my day off. I dyed my hair and painted my toenails with my friend Filly. The choice was dark or light brown. I now have a very youthful dark head of hair and bright pink nails. It felt good to do that!
On Saturday evening I had my first real "night out" since arriving. It was a charity dinner dance in one of Lilongwe's nicest hotels. It was a great night. The food only reasonable but the music and company fabulous. It was totally therapeutic. I danced nearly all night to the golden oldies.. of my era, lots of Rolling Stones, Meat loaf, Rod Stewart and Michael Jackson. I was exhausted but happy and felt this was a good way to recharge and prepare myself for what I might find this week.
Easter is close and school holidays.We will be going to spend a few days by the Lake with some kind friends. We are very much looking forward to the break. I am looking forward to the rest and Luki to the snakes!
On Tuesday I shall go to visit Pilirani again and also Grace, who has been phoning me everyday just to make sure that I havn't forgotten her. Well actually she gives me a missed call and I phone her back, but its always to say the same " dont worry I will come to visit and I havn't forgotten you"
.
What could I tell you?
Of the mother that should have been taken to operating theatre at four in the morning, who failed to be assessed and examined by the clinical officer on duty. The c/section was done at 8am. the baby was dead, the mother hemorraged so severely she needed a hysterectomy and later died in the ambulance on the way to intensive care in the central hospital. No blood was available at either hospital .
OK.. so she was HIV positive which was probably the cause of her poor general state, would further complicate her chances of responding to the hemmorage and lead to her death ...BUT ... here in Malawi there are more NGO', charity organizations and do-gooders spending huge sums of money on AIDS projects then any other cause, so I am afraid I can only ask why? why?
Or should I tell you of the morning that on arriving at labour ward I was asked to attend bed two where the 2nd twin was waiting to be born. I listened for the fetal heart and found nothing. I examined her and felt the umbilical cord presenting and not pulsating.The baby was in an impossible position for a vaginal delivery. So when had the 1st twin been born? At 4.20 am. more than 3 hours ago! The clinical officer had visited at 5.10 am. the fetal heart was heard, he told the midwife to wait! She waited. Too long for that baby. ( one midwife's comment was " well she does have one" )
But she had two babies! two healthy babies! untill she came into the hospital!
Or maybe I should tell you of the 2 prem babies. Just 28 weeks gestation, weighing around 1kg. Both breech presentations both difficult to deliver the head. The first was determined to live but lasted just 5 days the second was just too prem. too small.
Or I could tell you of the mother that transferred in after delivering the first twin in a local health centre. It took 3 hours for the ambulance to arrive. The second twin was dead and the mother needed a c/ section for bad presentation.This was confirmed by an ultrasound scan done by one of our clinical officers. Whilst waiting to be taken to theatre she pushed out a live healthy 2nd twin head first!!!
I can talk about it now but I couldn't write it all down last week.
I went to see Tarek, I just needed to talk, to get it all out of me. As usual, he listened and he talked and I felt better. He also gave me something to read, things he had written about human rights.. what are they..what do they really mean to us, to you, to the developed world, the politicians and how relevant are they to the mothers and babies in our care. It started with a quote which I would like to share (actually I'd like to share it all, but its not mine to share.
"It is possible to adapt to a given situation precisely because you have got to live it and you have got to live it everyday. But adapting does not mean that you forget.You go to the mill everyday-it is always unaceptable to you, it has always been unaceptable to you and it remains so for life-but you adapt in the sense that you cannot continue to live in a state 0f conflict with yourself"
My second visit to Pilirani was less eventful as we managed to take all the right turns.
She looks well and the c/section scar is totally healed. When I asked if she felt strong her mother replied that she can now carry a full bucket of water on her head. I guess that means she is very strong! I certainly couldn't!
Unfortunately the twins Edward and Alex weren't doing as well as I expected.They both looked lively and active but underfed and not gaining weight. In fact Edward who had been doing so well had lost weight. We talked about breast feeding, she said "they are very hungry babies" I could see that! She seemed to have plenty of milk but I did suggest that maybe she should supplement. I asked about her diet. She was eating just beans and potatoes.
Last year Malawi produced a bumper crop of maize..the staple diet. More than enough to see them through till the next harvest. Unfortunately someone sold off a large amount to neighbouring Zimbabwe and S.Africa leaving insufficient for the people of Malawi! No one seems to know how or why it happened but poor Malawians are now dying of hunger and severly under nourished due to some high-up political "mistake"
I took bread and bananas, it was not enough. This week I shall take eggs (hard boiled) and rice.
As I got up to leave, Pilirani went to her mud hut and came out with a plate of dried beans for me. She had so little but still gave me of the little she had. It was so difficult to take but I knew I should. I got in the car and cried. This is just one family that I have the priviledge to be part of, but how many more are there like that? It was all too much for me last week.
I must just tell you a last detail..... As we walked through the fields of maize that leads to her house we met a very small child walking towards us. I recognized her as one of Piliranis elder children.She is just 4 years old. On her back she carried what I thought was a doll (silly of me.. little girls in Malawi don't have dolls) I could not believe it when I realized she was carrying Alex the smallest of the twins, now weighing 1.550kg.!
Friday was my day off. I dyed my hair and painted my toenails with my friend Filly. The choice was dark or light brown. I now have a very youthful dark head of hair and bright pink nails. It felt good to do that!
On Saturday evening I had my first real "night out" since arriving. It was a charity dinner dance in one of Lilongwe's nicest hotels. It was a great night. The food only reasonable but the music and company fabulous. It was totally therapeutic. I danced nearly all night to the golden oldies.. of my era, lots of Rolling Stones, Meat loaf, Rod Stewart and Michael Jackson. I was exhausted but happy and felt this was a good way to recharge and prepare myself for what I might find this week.
Easter is close and school holidays.We will be going to spend a few days by the Lake with some kind friends. We are very much looking forward to the break. I am looking forward to the rest and Luki to the snakes!
On Tuesday I shall go to visit Pilirani again and also Grace, who has been phoning me everyday just to make sure that I havn't forgotten her. Well actually she gives me a missed call and I phone her back, but its always to say the same " dont worry I will come to visit and I havn't forgotten you"
.
Friday, 7 March 2008
BANK HOLIDAY ADVENTURE
Monday was bank holiday, Lucas had a day off school so we decided it would be a good day to go looking for Pirilana and her twins. At 7am I was in the hospital nursery starting the days work. I knew they would be short staffed that day so I was able to help out with the daily cleaning of cots and weighing of babies. The mothers wait anxiously to see if their baby has gained weight, if today will be the day she can return home? Some of these mothers live a distance from the hospital which means that they may have arrived well before giving birth and been camping out away from home for some time. Their stay is then extended whilst the baby is in nursery making them impatient to get home. Most of them will be accompanied by a "guardian" and often other siblings. The guardian will look after them during this time preparing their food in the basic hospital kitchen and washing their clothes. They will have very little money to buy food so if they then have to stay a week or more after birth it becomes very difficult for them. Basic meals are provided by the hospital courtsey of an NGO. but are not always sufficient. Breast feeding one or two infants whilst recovering from giving birth often with underlying chronic conditions like anaemia, TB. HIV. Hepatitis , malnutrition etc. demands a good diet and care, this is not present. I was able to give my sandwich and fruit juice to one of my mums the other day who had not eaten for 24 hours. It felt good to sit at her side and share in this way reminding me once again how much I have and how little they expect.
But back to my story of Pilrani and her twins!
I collected a portable weighing basket, met up with Evelyn (a Dutch medical student who is here for 2 months) who had asked to acompany me and went home to pick up Lucas. I had decided to take our " nanny " Doreen, with us to translate. Pilirani does not speak English and I doubted if I would find English speakers in her village. I met Doreen last time I was in Malawi so was pleased to employ her to look after Lucas whilist I am working. Though outdated, the word "nanny" is widely used to describe these ladies, as are many of the words used here dating back to the British colonial days. So we set off with our instuctions of how to arrive. Doreen insisted she knew where we were going and I believed her...first mistake! She was eager to please but her experience of travelling everwhere in an overpacked minibus had not made it easy for her to understand exact directions. So we missed the turnoff! By the time we had nearly arrived at the airport I guessed we had gone wrong so we stopped and asked! I was glad to have Doreen with us. We set off again with new directions and decided to take the "short cut" Turning onto a mud road I began to doubt we would arrive. Doreen assured me it was a good road! We are still in rainy season so although a dry sunny day the ridges, bumps and holes caused by the rain were evident! I am still driving a hire car..just a normal saloon..definitely not the best car for this sort of adventure. My farming background and four wheel drive experience came in handy and slowly, very slowly we manouvered our way through and around the difficult bits and arrived at the house with a white flag. I must admit I was expecting a large white banner, we found a small piece of rag, the size of a handkerchief, tied to a stick! Once again.. lucky Doreen was there !
There were a few mud huts alongside the track so we enquired as to the whereabouts of Pilirani.
From out of nowhere men and children appeared and offered to take us to her hut. Leaving the car to be watched over by one young man, we set off behind a " gaggle" of children all laughing and talking and running at our side. Through the plantations of maize ( this is used for everything and upon which their whole diet is based) winding round the outskirts of the village past the small mud huts with thatched roofs...yes just like the postcards or images on the tele..we turned the corner and there she was sitting on the step of her hut, home, breast feeding one of the twins. What a suprise! she didn't think I would come! She cried out and covered her face but we could sense how pleased she was to see us. It was a very special moment. The other ladies ( we later found out were her sister, sister-in-law and other family members) jumped up and fetched a cane mat.This they spread out on the ground for us to sit on. We took off our shoes and sat down. Again it was good to have Doreen who translated for me. She showed me the twin boys..Edward and Alex.. I could see that Edward, the largest, first born was doing well but Alex looked thin and ill. I guess I was glad to see them alive but became worried by Alex' condition. We weighed the babies and sure enough Edward had gained 400g in the 2 weeks since discharge but Alex remained the same. Doreen helped me to ask the questions and understand as Pilirani explain how they were feeding and her own worries about Alex. I took his temperature and was relieved to find that it was normal. His breathing was good. I listened to his lungs and they seemed clear. He showed no signs of infection but was clearly severely underfed. Edward was obviously taking the best, leaving little for his brother. I advised her to express breast milk and give it in a cup, thus supplementing the poor feeds as he was becoming slowly weaker and less able to take directly from the breast. I also left her some packets of milk formula with strict instructions, once again, on how to make and use them should she find that she does not have sufficient milk. I hope I did the right thing?
I had bought gifts of knitted blankets and hats for the boys and left them with one of my home baked chocolate and banana cakes. There would not be sufficient to feed the growing crowd that had by now gathered around to inspect the " msungu" ..white lady, but maybe enough for Pilirani and her family. We met her 2 older children and her husband, were introduced to the great grandmother and head lady of the village who came to meet us and shook hands with everyone. Lucas was rather overwhelmed by so many staring faces. His blonde hair is particularly interesting to the local children who laugh and giggle in a way that can be disconcerting to a 7 year old boy. After promising to return next week we followed the children back to the car where the young man was still on guard. The 100kw note (50 cent.) for his services was received as if it were gold and the car was intact. We waved goodbye. Finding the correct way home was far simpler but not nearly as exciting. I am negotiating the purchase of a small jeep which until bought I think I will return the easy way!
I think of Pilirani and her boys everyday. I hope I will find them alive and healthy when we return though I cannot be sure . They still have along way to go before I can feel they are out of danger. Edward weighs 2.250kg and Alex 1.450kg. In most countries they would still be incubators!
It was hard to leave nursery but I felt I should go back to labour ward. I have made friends there so will return often and have told them to call me if they are particularly short staffed or overworked. I hope they will. I will keep up contact with the mums who are caring for their babies in the "kangaroo" nursery I have some very special mums there. Look out for news of Grace and her little one. She has a heart murmur which seems to be the cause of her slow weight gain and "failure to thrive" Grace is a dedicated mum and we have a special relationship. I shall not loose contact with her.
My return to Labour ward was dramatic with breech twins. Helping to save this mother from an almost inevitable c/section was good. There were a few " adrenalin" moments but all turned out well. 2 boys ...1.900kg first then 2.200kg came quickly behind. Wow! am I learning a lot ! Mother nature is wonderful and so knowing and babies and mothers are stong even under the worst conditions. Thankyou!
But back to my story of Pilrani and her twins!
I collected a portable weighing basket, met up with Evelyn (a Dutch medical student who is here for 2 months) who had asked to acompany me and went home to pick up Lucas. I had decided to take our " nanny " Doreen, with us to translate. Pilirani does not speak English and I doubted if I would find English speakers in her village. I met Doreen last time I was in Malawi so was pleased to employ her to look after Lucas whilist I am working. Though outdated, the word "nanny" is widely used to describe these ladies, as are many of the words used here dating back to the British colonial days. So we set off with our instuctions of how to arrive. Doreen insisted she knew where we were going and I believed her...first mistake! She was eager to please but her experience of travelling everwhere in an overpacked minibus had not made it easy for her to understand exact directions. So we missed the turnoff! By the time we had nearly arrived at the airport I guessed we had gone wrong so we stopped and asked! I was glad to have Doreen with us. We set off again with new directions and decided to take the "short cut" Turning onto a mud road I began to doubt we would arrive. Doreen assured me it was a good road! We are still in rainy season so although a dry sunny day the ridges, bumps and holes caused by the rain were evident! I am still driving a hire car..just a normal saloon..definitely not the best car for this sort of adventure. My farming background and four wheel drive experience came in handy and slowly, very slowly we manouvered our way through and around the difficult bits and arrived at the house with a white flag. I must admit I was expecting a large white banner, we found a small piece of rag, the size of a handkerchief, tied to a stick! Once again.. lucky Doreen was there !
There were a few mud huts alongside the track so we enquired as to the whereabouts of Pilirani.
From out of nowhere men and children appeared and offered to take us to her hut. Leaving the car to be watched over by one young man, we set off behind a " gaggle" of children all laughing and talking and running at our side. Through the plantations of maize ( this is used for everything and upon which their whole diet is based) winding round the outskirts of the village past the small mud huts with thatched roofs...yes just like the postcards or images on the tele..we turned the corner and there she was sitting on the step of her hut, home, breast feeding one of the twins. What a suprise! she didn't think I would come! She cried out and covered her face but we could sense how pleased she was to see us. It was a very special moment. The other ladies ( we later found out were her sister, sister-in-law and other family members) jumped up and fetched a cane mat.This they spread out on the ground for us to sit on. We took off our shoes and sat down. Again it was good to have Doreen who translated for me. She showed me the twin boys..Edward and Alex.. I could see that Edward, the largest, first born was doing well but Alex looked thin and ill. I guess I was glad to see them alive but became worried by Alex' condition. We weighed the babies and sure enough Edward had gained 400g in the 2 weeks since discharge but Alex remained the same. Doreen helped me to ask the questions and understand as Pilirani explain how they were feeding and her own worries about Alex. I took his temperature and was relieved to find that it was normal. His breathing was good. I listened to his lungs and they seemed clear. He showed no signs of infection but was clearly severely underfed. Edward was obviously taking the best, leaving little for his brother. I advised her to express breast milk and give it in a cup, thus supplementing the poor feeds as he was becoming slowly weaker and less able to take directly from the breast. I also left her some packets of milk formula with strict instructions, once again, on how to make and use them should she find that she does not have sufficient milk. I hope I did the right thing?
I had bought gifts of knitted blankets and hats for the boys and left them with one of my home baked chocolate and banana cakes. There would not be sufficient to feed the growing crowd that had by now gathered around to inspect the " msungu" ..white lady, but maybe enough for Pilirani and her family. We met her 2 older children and her husband, were introduced to the great grandmother and head lady of the village who came to meet us and shook hands with everyone. Lucas was rather overwhelmed by so many staring faces. His blonde hair is particularly interesting to the local children who laugh and giggle in a way that can be disconcerting to a 7 year old boy. After promising to return next week we followed the children back to the car where the young man was still on guard. The 100kw note (50 cent.) for his services was received as if it were gold and the car was intact. We waved goodbye. Finding the correct way home was far simpler but not nearly as exciting. I am negotiating the purchase of a small jeep which until bought I think I will return the easy way!
I think of Pilirani and her boys everyday. I hope I will find them alive and healthy when we return though I cannot be sure . They still have along way to go before I can feel they are out of danger. Edward weighs 2.250kg and Alex 1.450kg. In most countries they would still be incubators!
It was hard to leave nursery but I felt I should go back to labour ward. I have made friends there so will return often and have told them to call me if they are particularly short staffed or overworked. I hope they will. I will keep up contact with the mums who are caring for their babies in the "kangaroo" nursery I have some very special mums there. Look out for news of Grace and her little one. She has a heart murmur which seems to be the cause of her slow weight gain and "failure to thrive" Grace is a dedicated mum and we have a special relationship. I shall not loose contact with her.
My return to Labour ward was dramatic with breech twins. Helping to save this mother from an almost inevitable c/section was good. There were a few " adrenalin" moments but all turned out well. 2 boys ...1.900kg first then 2.200kg came quickly behind. Wow! am I learning a lot ! Mother nature is wonderful and so knowing and babies and mothers are stong even under the worst conditions. Thankyou!
Subscribe to:
Posts (Atom)
