I really can't believe that nearly three weeks have passed since I last wrote to you all of my life here in Lilongwe Malawi. Time passes so quickly and I am already starting to make plans for our return to Europe in time for Lucas' birthday and for Christmas. These are special times for us as a family and it will be good to be together again. My mum has be operated on recently and although she seems to be recovering it has not been without its difficulties. I am grateful to have my brothers and especially my sister available for her as I am really not much use to her being so far away. I sometimes question my dedication and availability to the poor, the women and babies of Malawi when I am not even able to care for my own mother. Still ....I guess life is full of confusing and conflictive thoughts ....nowhere more so than here in Malawi, one of the poorest countries in the world. It is evident that huge amounts of donor money is being poured into this country. Many projects covering a huge multitude of different areas of health, education, agriculture, etc.etc. Conferences and congresses. Training programs and education to improve knowledge and skills. But yesterday we found ourselves with no gloves. Just for 15 minutes whilst someone went off to find the matron and replenish supplies, but during these 15 minutes nothing could be done! Well not quite true... I managed to deliver a baby and resuscitate another without gloves... much to the horror and disgust of all my colleagues. On our busy labour ward many things can happen in 15 minutes it is not acceptable to be without gloves. Proper suture material has been absent during most of this week. Yes, women are being sutured but not as well as they could. But this is normal at Bwaila hospital this has become acceptable ...at least to some. So all this money pouring into the country and we have no gloves and no suture material. Not to mention scissors, forceps, curtains, vacuum extractor, beds, sheets, lights, soap, syringes, needles, washing facilities, showers, hot water...........do you want me to continue? But I'm not saying that the answer is to keep donating these necessities. I just want to emphasize that these are necessities for dignant care.
I have heard that large sums of money are being spent on courses and training on how to deal with a major crisis or disaster. Earthquake, floods, tsunami or the likes. I'm sure it is very relevant and important but hunger, poverty, lack of decent health care and education are here with us now. Crisis and disaster are here with us now and we are not managing to deal with it effectively.
The twins that I wrote of in my last blog were able to go home after just 5 days in the nursery. They returned one week later for a check-up and were looking fine and healthy both having gained weight. Before discharge their mother had asked me to give names to the two little girls. This is a great honour and one becomes as if a god-mother. I shall have to be careful not to take on too many of these adopted children! I decided to call them Ruth and Rachel ( My elder sister and I) When she came to show me the girls they were dressed in the clothes I had given them and wrapped in the little blue Ikea blankets that Katy had brought out. She proudly told me in broken English that Ruth and Rachel were doing well and would like me to visit them. I shall put aside a day next week to do just that.
Some days are more chaotic than others. Very often labour ward is full of staff. Students of all types mill around with what seems like as a total lack of direction. Many times that is so. I continue to try and teach as much as possible. I move from bed to bed trying to keep aware of what is happening ask questions and discuss care plans. I am always particularly vigilant to make sure that the referred cases are assesed promptly. This is still a problem. This past 2 weeks my in-service training sessions have been looking at case studies to try and pick up any mistakes made and learn from them. I was suprised to find that most of the midwives were quick to spot the delays in giving the appropiate care and could easily present the case and make the corrections. They also could appreciate the evident lack of record keeping. They found the sessions stimulating and helpful...or so they said... I was dissappointed to find that the following days showed that this knowledge was not being put into practice. They were not able to perform the care that they knew was correct. Or they were too busy or tired or complacent. This ended in two particularly sad cases where the result was two dead babies. If they had acted quicker or made a more responsable decision instead of waiting these babies would not have died. Much of the delay is in getting to the hospital but we need to confront the obvious delays that are occuring in our own labour ward.
I will try not to leave it so long before writing again.
Many times I just don't feel like writing it all down as its too upsetting or just too repetative.
My moods change and swing each day and sometimes many times in a day. Today I am not so positive and just a little tired and angry. I am sure it reflects in my writing.
Lucas has been on half term holiday this week. We were so lucky to be invited to spend a long weekend at a cottage on the lake shore. It was a fun and peaceful few days. We feel very fortunate to have such good generous friends.
I remain with the image of the sun rising over the lake. A huge fiery red, orange and pink circle changing the colours of the sky as each minute passed and a new day began. I crept out of bed quietly and wandered down to the lake for a morning swim in its calm sweet waters. I have so much to be grateful for. Sometimes the contrast from that to my work with the women is too much to bear.
Friday, 17 October 2008
Thursday, 25 September 2008
MANY BABIES AND NO BEDS
We have 14 beds on labour ward at Bwaila hospital. It is the traditional ' nightingale ward ' which allows little or no privacy for the labouring women as more often than not the curtains hanging round each bed ar either torn broken or not present. The beds are about 1.5m apart which does not allow much freedom of movement for the woman or the midwife. However this ' layout ' does have its advantages as it allows the understaffed midwives to, at least, be aware of what is going on in most of the ward. If you can't see them you can hear them. " Nursey! nursey! nursey! " they cry to attract our attention., very often when the babies head is emerging, so all we can do is run to catch the little one coming out. However it doesn't always work. I should tell you of the birth on night duty, I wasn't present. The woman cried out alerting the staff that the baby had been born. The midwife approached the bed with her equipment but there was no sign of the baby. On closer inspection the newborn was found dangling by the umbilical cord over the side of the bed! Both mother and baby are fine.....now!
We are attending around 40 to 50 births a day so, as you can imagine, it is not unusual to find that we have no spare beds. Labouring women will stand beside the bed of a recently delivered mother just waiting for her to get up and go to the shower so she can claim her bed! ( It reminds me of people waiting in restaurant queues for the next available table. Trying to judge if the diners on table one, who are taking coffee, will then ask for a liquor after or just go straight for the bill and what a relief when you see them putting on their coats and getting up to go!) No spare beds means that women will birth on the floor. This can be an advantage as she will rarely lie down but be in whatever position she finds most comfortable but the disadvantages are that the cement floors are extremely dirty, hardly ideal for receiving a newborn and most midwives would not get down on the floor to assist. And so it was on Monday morning when I arrived. " A full house! " I was told. I enquired as to where I should start? Who was pushing? Any problems? I was asked to attend bed 8. " She was fully dilated at 6am. but we've been so busy we told her she would have to wait " And she had! As I went to her bed I passed a woman crouching on ' all fours' on the floor. She was moaning loudly, obviously in advanced labour, but as there was no bed and I had another to attend I left her on the floor. It was her first baby and the head was low. I got her out of bed and onto the birthing stool. " Can I push now" she enquired and was happy and relieved that she didn't have to wait any longer, that she had someone to care for her and so she started pushing. Ten minutes later, with much encouragement I started to see the head, the fetal heart was fine and she was doing well. I had been looking over regularly at the woman on the floor to see how she was doing and shouting words of encouragement. " We'll have a bed soon, don't worry " I dont expect she understood me but then again my words were not only for her, but for the other midwives standing around. Its a dangerous time to give birth as the night nurses have finished and the day staff have not yet started. " Can someone attend that woman please I begged" Too late! The cleaner shouted out " Baby born!" Still no one seemed to move, so I left my young first timer and rushed to her side. The baby had been born by the breech ( bum first) and was hanging by its head while she stayed on all fours position. This is a great position for normal births but absolutely NOT for breeches. I got on the floor and quickly managed to help the head to be born, it was not easy, even with my experience in attending in all sorts of positions. The baby needed immediate resuscitation which I did. Still no movement from my colleagues! " Please will someone get her onto a bed " I cried. " Can you check if there is a twin as the baby is quite small. " I asked. It took about 10 minutes to get another woman off to the shower and wash the bed. In that time I continued to work on the baby all the time asking for them to hurry up and please check if there was a twin. By the time she was on the bed and being attended by 2 students the baby was breathing spontaneously so I left her with oxygen and approached the bed. They had confirmed a 2nd twin but still had not listened for the fetal heart or determined the presentation. I continue to be amazed by the total lack of a sense of urgency amoung my fellow midwives. I could not bear it, so I just took over. "She has one nearly dead baby by god we're going to save this one " I exclaimed. They had not heard a heart beat! I examined her, determined a head presentation, ruptured the membranes, applied a vacuum extraction and as she pushed I pulled that baby out. It was not difficult but it was urgent. The baby's condition was poor so I left the students to attend to the woman and resuscitated the 2nd little girl. Both babies responded well and are now in nursery. The students working in Nursery have taken a special interest in them and I have visited them everyday since. I am happy to say that they are doing well. Both are breast feeding, they have lost weight and are being treated with antibiotics but after the first 24hours on oxygen are now maintaining well. I was able to take them some of the clothes and blankets that Katy brought over given by very generous donations. I hope to continue to follow their progress when they are discharged.
Just to finish I should tell you of our visitors to labour ward this week. We have received a large group of senior midwives, tutors, matrons, clinical instructors etc.from all the different university training centres in Malawi. They are on a 3 week goverment course funded by an NGO specifically to revise and refresh their practical knowledge so has to improve their teaching both in the classroom and in the clinical situation. Part of their updating is to look at different birthing positions, freedom of movement in labour, spontaneous pushing and instinctive birthing behaviour. They had been told that in Bwaila maternity unit we are already practising this type of care. Hallelujuh ! Its just what I have been teaching and trying to implement, but how much better that it now comes from official ministry sources and encouraged by their own people. I have had the opportunity to work with these midwives this week and we have had more vertical births than ever. Women were seen crouching, standing, moving around and generally off the bed. Yesterday I was able to demonstrate how to attend the delivery of twins with the woman sitting on the birthing stool.
I am happy and extremely encouraged.
We are attending around 40 to 50 births a day so, as you can imagine, it is not unusual to find that we have no spare beds. Labouring women will stand beside the bed of a recently delivered mother just waiting for her to get up and go to the shower so she can claim her bed! ( It reminds me of people waiting in restaurant queues for the next available table. Trying to judge if the diners on table one, who are taking coffee, will then ask for a liquor after or just go straight for the bill and what a relief when you see them putting on their coats and getting up to go!) No spare beds means that women will birth on the floor. This can be an advantage as she will rarely lie down but be in whatever position she finds most comfortable but the disadvantages are that the cement floors are extremely dirty, hardly ideal for receiving a newborn and most midwives would not get down on the floor to assist. And so it was on Monday morning when I arrived. " A full house! " I was told. I enquired as to where I should start? Who was pushing? Any problems? I was asked to attend bed 8. " She was fully dilated at 6am. but we've been so busy we told her she would have to wait " And she had! As I went to her bed I passed a woman crouching on ' all fours' on the floor. She was moaning loudly, obviously in advanced labour, but as there was no bed and I had another to attend I left her on the floor. It was her first baby and the head was low. I got her out of bed and onto the birthing stool. " Can I push now" she enquired and was happy and relieved that she didn't have to wait any longer, that she had someone to care for her and so she started pushing. Ten minutes later, with much encouragement I started to see the head, the fetal heart was fine and she was doing well. I had been looking over regularly at the woman on the floor to see how she was doing and shouting words of encouragement. " We'll have a bed soon, don't worry " I dont expect she understood me but then again my words were not only for her, but for the other midwives standing around. Its a dangerous time to give birth as the night nurses have finished and the day staff have not yet started. " Can someone attend that woman please I begged" Too late! The cleaner shouted out " Baby born!" Still no one seemed to move, so I left my young first timer and rushed to her side. The baby had been born by the breech ( bum first) and was hanging by its head while she stayed on all fours position. This is a great position for normal births but absolutely NOT for breeches. I got on the floor and quickly managed to help the head to be born, it was not easy, even with my experience in attending in all sorts of positions. The baby needed immediate resuscitation which I did. Still no movement from my colleagues! " Please will someone get her onto a bed " I cried. " Can you check if there is a twin as the baby is quite small. " I asked. It took about 10 minutes to get another woman off to the shower and wash the bed. In that time I continued to work on the baby all the time asking for them to hurry up and please check if there was a twin. By the time she was on the bed and being attended by 2 students the baby was breathing spontaneously so I left her with oxygen and approached the bed. They had confirmed a 2nd twin but still had not listened for the fetal heart or determined the presentation. I continue to be amazed by the total lack of a sense of urgency amoung my fellow midwives. I could not bear it, so I just took over. "She has one nearly dead baby by god we're going to save this one " I exclaimed. They had not heard a heart beat! I examined her, determined a head presentation, ruptured the membranes, applied a vacuum extraction and as she pushed I pulled that baby out. It was not difficult but it was urgent. The baby's condition was poor so I left the students to attend to the woman and resuscitated the 2nd little girl. Both babies responded well and are now in nursery. The students working in Nursery have taken a special interest in them and I have visited them everyday since. I am happy to say that they are doing well. Both are breast feeding, they have lost weight and are being treated with antibiotics but after the first 24hours on oxygen are now maintaining well. I was able to take them some of the clothes and blankets that Katy brought over given by very generous donations. I hope to continue to follow their progress when they are discharged.
Just to finish I should tell you of our visitors to labour ward this week. We have received a large group of senior midwives, tutors, matrons, clinical instructors etc.from all the different university training centres in Malawi. They are on a 3 week goverment course funded by an NGO specifically to revise and refresh their practical knowledge so has to improve their teaching both in the classroom and in the clinical situation. Part of their updating is to look at different birthing positions, freedom of movement in labour, spontaneous pushing and instinctive birthing behaviour. They had been told that in Bwaila maternity unit we are already practising this type of care. Hallelujuh ! Its just what I have been teaching and trying to implement, but how much better that it now comes from official ministry sources and encouraged by their own people. I have had the opportunity to work with these midwives this week and we have had more vertical births than ever. Women were seen crouching, standing, moving around and generally off the bed. Yesterday I was able to demonstrate how to attend the delivery of twins with the woman sitting on the birthing stool.
I am happy and extremely encouraged.
Thursday, 18 September 2008
HORRIBLE AND HAPPY
I was glad to be back on labour ward on Monday. I spent the weekend missing my girls and feeling a bit sorry for myself.
It was as busy as ever and we had a new set of student midwives who had started whilst I was away. Their time is to be spent attending high risk women so this is a very important part of their clinical training.
These midwives will soon be out on their own in the district health centres and hospitals so I am quick to point out to them the district referrals that we receive so as they can become aware of the dangers of waiting to long before sending these women to us. We had an especially busy morning on Tuesday when we received up to 10 referred cases. I was appalled to find one woman, labouring her 5th child, who had been pushing "since yesterday"
Her whole lower regions were swollen beyond recognition. I quickly and easily diagnosed a posterior prestentation ( the baby looks up instead of down) a huge full bladder that obstructed the descent of the babys head and severe fetal distress. Examing her I felt sure that we could assist a vaginal delivery, though difficult. I made a quick decision that the childs life was already compromised that a c/section would take at least 30 minutes to get the baby out and that her other 4 children needed a fit healthy mother. She has more chance of this with a vaginal delivery. Any operative procedure carries a very high risk for the mothers here in Malawi. From haemorrage, underlying conditions such as Hepatitis or HIV,severe and chronic anaemia and sepsis due to little personal hygiene, no clean or running water, not to mention the deplorable state of the operating theatres and the sometimes very inexperienced clinicians. I referred to the clinician on duty and the senior midwife. Neither were too sure but I have now built up a good relationship with them all. They trust me and will refer to me in many difficult situations where decisions have to be made. So we worked together and the baby was born with the assistance of a vacuum extraction. Leaving the clinician to care for the mother I rushed the little one to the resuscitaire and commenced profound resuscitation. I did not feel confident that my efforts would be successful but at least I could try. The baby responded slowly so I continued to work on him. When I had achieved spontaneous breathing , though still with difficulty I transferred him to the nursery. I handed him over to the nursery nurses telling them that I was not hopeful that he would survive. It was a long hard morning. I had intended to leave at 3pm having worked non stop since 7.15 am but just had to help sort out 2 other situations before I left. Sometime around midday a young woman having her 1st baby arrived. A very late referral for prolonged labour. We could only find a slow heart beat. My Norweigian midwife colleague called me to assist a vacuum extraction, she felt sure the baby would come with a little help. She was not successful with her first pull so asked me to take over. The baby would not come even though it was very close. I felt that there was some other reason for this difficulty.. it didn't make sense.. I tried to find the babys heart beat before continuing but it was not to be found. When a baby has died in the uterus it is much more difficult to birth. Babies also play a part in facilitating their own birth. My colleague agreed that she had probably been hearing the mothers pulse. This we confirmed on ultra sound scan. Sadly we explained to her that her baby had died, she had been pushing too long.We decided to leave her a while to see if she could birth with less violence as now there was no hurry to get the baby out. I gave her some sedation so she could rest and would feel less pain.At 3pm she was still no closer to birthing her dead child. I enquired of the clinician on duty as to when she would come to assist the woman. She was the only clinician left on duty. Where the others had gone I dont know . She had to do an urgent c/section and possibly another after. I could not go home and leave this woman. It was likely that she could not be attended for several hours. Her uterus was still contracting.she was still being forced by her own body to push her child out. I called to another midwife and a student to assist me. A c/section in these circumstances would be unforgivable. The only other option is to destoy the baby. I had to try. I pulled and she pushed
my fellow midwives encouraged her to use all her strength. I sweated and manipulated untill at last the little one came. What a relief ! Not nice, not at all pleasant, never to be done in your rich and well developed world where clean and safe operating theatres are the norm. Where anesthetics and anaesthetists are readily available but the best option here. Today she was discharged home, without a baby but alive and well and with the possibility of other pregnancys, of other babies...I hope.
I eventually left at 4pm!
Arriving on Wednesday morning I was greeted by a call from a fellow midwife who was having problems. I don't know how long the woman had been pushing but the baby was not coming. I could see a large part of the fetal skull so suggested an episiotomy (cut in the perineum) might be helpful. This she did . The head was born and the shoulders got stuck. Following the correct manouvers of which I have now had plenty of practice the baby was born. I immediatley realized that this baby was severely distressed so quickly carried his floppy body over to the resuscitaire. I found a slow heart beat but nothing else. It was 7.15am. I had just arrived. Hardly time to put on my apron and I found myself resuscitating a nearly dead baby. As I stood there doing all I could. Giving my best . Inflating his little lungs suctioning the mucous from his throat, I began to wonder when this would all stop? How much longer would the rich world let this carry on? Its not as if they don't try .....millions of dollars are being poured into Malawi so why is it not working? Why am I still finding these hopeless situations daily? The baby was pink, the chest was rising I was inflating his little lungs the heart was beating strongly but he just would not breath. I could see that his pupils were already dilated, he was already brain damaged the respiratory centres in his brain were not functioning but I carried on. At 7.40am the students started to arrive. I had been breathing for him for 25 minutes but he still showed no signs of improvement. How long do I carry on? Can I really stop? When? I asked a student to take over, we would continue a while longer. I went to look at the mothers file and give her the news that her baby would not survive. The labour graph told me that niether she nor the baby had not been attended since 12midnight, when she was found to be 8cms dilated. That means she would have expected to give birth between 2 and 4 am. the baby was born at 7.15 am! I went back and told the student to cease resuscitation. It was nearly an hour since the birth. The baby was making a few gasping sounds so I left him under the warm heater with an oxygen supply. The doctors and clinicians came to make their grand "round" It was commented by a white visiting doctor as to "why had that baby been left there and abandoned? " I just cried. My Malawian midwife colleague held in her arms andgave me a big hug and reminded me we can only do so much, we can only do our best, we cant do more. The baby died in nursery during the afternoon. Later I went back to check the labour graph and found that the times had been changed that the graph had been manipulated. It is not the first time that I have witnessed this but this is still too big for me to confront.
Most afternoons I call by nursery to see 'my' babies. I found the woman I had attended the day before sitting on the floor with her baby in her arms. I asked the staff how he was as I had expected him to die. " Improving" they assured me. I knelt on the floor and the mother started talking to me. "What is she saying?" I asked.
" She says she has no milk for him" I gently squeezed her breast and out came those precious drops of calostrum which I put onto his lips. He began to respond so I squeezed out more. Bringing the baby close to the breast I carefully put her nipple into his mouth. He sucked! There was no hesitation, he latched on beautifully and wouldn't let go! His mum gave me a huge smile and the students working in nursery looked on in amazement. I still wonder if he will be brain damaged and if so, how severely but at the present he is happily sucking away at his happy mum's breast.
Yes that will keep me going for a while!
It was as busy as ever and we had a new set of student midwives who had started whilst I was away. Their time is to be spent attending high risk women so this is a very important part of their clinical training.
These midwives will soon be out on their own in the district health centres and hospitals so I am quick to point out to them the district referrals that we receive so as they can become aware of the dangers of waiting to long before sending these women to us. We had an especially busy morning on Tuesday when we received up to 10 referred cases. I was appalled to find one woman, labouring her 5th child, who had been pushing "since yesterday"
Her whole lower regions were swollen beyond recognition. I quickly and easily diagnosed a posterior prestentation ( the baby looks up instead of down) a huge full bladder that obstructed the descent of the babys head and severe fetal distress. Examing her I felt sure that we could assist a vaginal delivery, though difficult. I made a quick decision that the childs life was already compromised that a c/section would take at least 30 minutes to get the baby out and that her other 4 children needed a fit healthy mother. She has more chance of this with a vaginal delivery. Any operative procedure carries a very high risk for the mothers here in Malawi. From haemorrage, underlying conditions such as Hepatitis or HIV,severe and chronic anaemia and sepsis due to little personal hygiene, no clean or running water, not to mention the deplorable state of the operating theatres and the sometimes very inexperienced clinicians. I referred to the clinician on duty and the senior midwife. Neither were too sure but I have now built up a good relationship with them all. They trust me and will refer to me in many difficult situations where decisions have to be made. So we worked together and the baby was born with the assistance of a vacuum extraction. Leaving the clinician to care for the mother I rushed the little one to the resuscitaire and commenced profound resuscitation. I did not feel confident that my efforts would be successful but at least I could try. The baby responded slowly so I continued to work on him. When I had achieved spontaneous breathing , though still with difficulty I transferred him to the nursery. I handed him over to the nursery nurses telling them that I was not hopeful that he would survive. It was a long hard morning. I had intended to leave at 3pm having worked non stop since 7.15 am but just had to help sort out 2 other situations before I left. Sometime around midday a young woman having her 1st baby arrived. A very late referral for prolonged labour. We could only find a slow heart beat. My Norweigian midwife colleague called me to assist a vacuum extraction, she felt sure the baby would come with a little help. She was not successful with her first pull so asked me to take over. The baby would not come even though it was very close. I felt that there was some other reason for this difficulty.. it didn't make sense.. I tried to find the babys heart beat before continuing but it was not to be found. When a baby has died in the uterus it is much more difficult to birth. Babies also play a part in facilitating their own birth. My colleague agreed that she had probably been hearing the mothers pulse. This we confirmed on ultra sound scan. Sadly we explained to her that her baby had died, she had been pushing too long.We decided to leave her a while to see if she could birth with less violence as now there was no hurry to get the baby out. I gave her some sedation so she could rest and would feel less pain.At 3pm she was still no closer to birthing her dead child. I enquired of the clinician on duty as to when she would come to assist the woman. She was the only clinician left on duty. Where the others had gone I dont know . She had to do an urgent c/section and possibly another after. I could not go home and leave this woman. It was likely that she could not be attended for several hours. Her uterus was still contracting.she was still being forced by her own body to push her child out. I called to another midwife and a student to assist me. A c/section in these circumstances would be unforgivable. The only other option is to destoy the baby. I had to try. I pulled and she pushed
my fellow midwives encouraged her to use all her strength. I sweated and manipulated untill at last the little one came. What a relief ! Not nice, not at all pleasant, never to be done in your rich and well developed world where clean and safe operating theatres are the norm. Where anesthetics and anaesthetists are readily available but the best option here. Today she was discharged home, without a baby but alive and well and with the possibility of other pregnancys, of other babies...I hope.
I eventually left at 4pm!
Arriving on Wednesday morning I was greeted by a call from a fellow midwife who was having problems. I don't know how long the woman had been pushing but the baby was not coming. I could see a large part of the fetal skull so suggested an episiotomy (cut in the perineum) might be helpful. This she did . The head was born and the shoulders got stuck. Following the correct manouvers of which I have now had plenty of practice the baby was born. I immediatley realized that this baby was severely distressed so quickly carried his floppy body over to the resuscitaire. I found a slow heart beat but nothing else. It was 7.15am. I had just arrived. Hardly time to put on my apron and I found myself resuscitating a nearly dead baby. As I stood there doing all I could. Giving my best . Inflating his little lungs suctioning the mucous from his throat, I began to wonder when this would all stop? How much longer would the rich world let this carry on? Its not as if they don't try .....millions of dollars are being poured into Malawi so why is it not working? Why am I still finding these hopeless situations daily? The baby was pink, the chest was rising I was inflating his little lungs the heart was beating strongly but he just would not breath. I could see that his pupils were already dilated, he was already brain damaged the respiratory centres in his brain were not functioning but I carried on. At 7.40am the students started to arrive. I had been breathing for him for 25 minutes but he still showed no signs of improvement. How long do I carry on? Can I really stop? When? I asked a student to take over, we would continue a while longer. I went to look at the mothers file and give her the news that her baby would not survive. The labour graph told me that niether she nor the baby had not been attended since 12midnight, when she was found to be 8cms dilated. That means she would have expected to give birth between 2 and 4 am. the baby was born at 7.15 am! I went back and told the student to cease resuscitation. It was nearly an hour since the birth. The baby was making a few gasping sounds so I left him under the warm heater with an oxygen supply. The doctors and clinicians came to make their grand "round" It was commented by a white visiting doctor as to "why had that baby been left there and abandoned? " I just cried. My Malawian midwife colleague held in her arms andgave me a big hug and reminded me we can only do so much, we can only do our best, we cant do more. The baby died in nursery during the afternoon. Later I went back to check the labour graph and found that the times had been changed that the graph had been manipulated. It is not the first time that I have witnessed this but this is still too big for me to confront.
Most afternoons I call by nursery to see 'my' babies. I found the woman I had attended the day before sitting on the floor with her baby in her arms. I asked the staff how he was as I had expected him to die. " Improving" they assured me. I knelt on the floor and the mother started talking to me. "What is she saying?" I asked.
" She says she has no milk for him" I gently squeezed her breast and out came those precious drops of calostrum which I put onto his lips. He began to respond so I squeezed out more. Bringing the baby close to the breast I carefully put her nipple into his mouth. He sucked! There was no hesitation, he latched on beautifully and wouldn't let go! His mum gave me a huge smile and the students working in nursery looked on in amazement. I still wonder if he will be brain damaged and if so, how severely but at the present he is happily sucking away at his happy mum's breast.
Yes that will keep me going for a while!
Friday, 12 September 2008
MY GIRLS IN MALAWI
I have just returned form leaving my two girls, Katy and Fiona at the airport. I am sad.
They have been with me for 9 days and we were able to take a short trip to the lake and the game park and thus introduce them to a little of Malawi, of Africa.
It has been a wonderful time for me. I have enjoy their company, their love and their interest in everything.
During the first few days I was able to take them to Bwaila hospital to show them where I am working and the conditions under which the poor women of Lilongwe are being attended. They were both amazed and saddened to experience, first hand, some of the things they have been following in my blog and our regular phone calls. They were particularly interested in our nursery and the tiny babies that are being cared for. Just 900 grams and very premature it was difficult for the girls to hear that these babies have very little chance of surviving as both the facilities, the equipment and the medical expertise are not available.
Katy had been busy collecting money, clothing and toys, crayons, books and note pads for the past months. The response to her call was wonderful making it possible for her to bring not only a large number of these things but also more expensive items such as a doppler for listening to fetal heart rate, and weighing scales much needed by the Traditional Birth Attendents in the villages. We were able to visit an orphanage, a small mission clinic by the lake, two TBA's as well as distributing to the many women and babies "camped out" in the grounds of Bwaila hospital.
We visited my twins in the village and also one of my "miracle babies" These were both wonderfully enriching experiences for the girls who were able to appreciate true Malawian village life. We we received by the head man of the village which was a great honour.
We were entertained to homemade doughnuts sitting inside a cool mud hut and much time was spent blowing up and playing with balloons with the numerous children many of whom had never seen nor touched a balloon. We warned them that it may pop making a loud noise but it still suprised them!
The twins were looking big ! They are now nearly 8 months old. Unfortunatly they were suffering from vomiting and diarrhoea so we took them all, in my small jeep, to the clinic and left Pilirani with money for medicine and transport home. It was quite a squash... 6 adults and 2 babies ...but nobody seemed to mind!
The girls soon became aware that wherever we went there was poverty and need. They were able to give small gifts to the children as we travelled and were rewarded with dancing, with obvious joy and huge smiles. But they too soon found that there was never enough to give. Where they thought there were just 2 or 3 children, suddenly, out of nowhere, dozens of little ones appeared. At times it was very frustrating. They too felt the conflict and confusion of bargaining for every small wooden carving or craft that they wanted to buy. How much to pay ? Was it enough ? Maybe they could pay more? Should they pay more?
I am looking forward to going back to labour ward tomorrow after a week off. I know it continues to be very busy and there are many new students. I feel strong and positive. There is much to do...
They have been with me for 9 days and we were able to take a short trip to the lake and the game park and thus introduce them to a little of Malawi, of Africa.
It has been a wonderful time for me. I have enjoy their company, their love and their interest in everything.
During the first few days I was able to take them to Bwaila hospital to show them where I am working and the conditions under which the poor women of Lilongwe are being attended. They were both amazed and saddened to experience, first hand, some of the things they have been following in my blog and our regular phone calls. They were particularly interested in our nursery and the tiny babies that are being cared for. Just 900 grams and very premature it was difficult for the girls to hear that these babies have very little chance of surviving as both the facilities, the equipment and the medical expertise are not available.
Katy had been busy collecting money, clothing and toys, crayons, books and note pads for the past months. The response to her call was wonderful making it possible for her to bring not only a large number of these things but also more expensive items such as a doppler for listening to fetal heart rate, and weighing scales much needed by the Traditional Birth Attendents in the villages. We were able to visit an orphanage, a small mission clinic by the lake, two TBA's as well as distributing to the many women and babies "camped out" in the grounds of Bwaila hospital.
We visited my twins in the village and also one of my "miracle babies" These were both wonderfully enriching experiences for the girls who were able to appreciate true Malawian village life. We we received by the head man of the village which was a great honour.
We were entertained to homemade doughnuts sitting inside a cool mud hut and much time was spent blowing up and playing with balloons with the numerous children many of whom had never seen nor touched a balloon. We warned them that it may pop making a loud noise but it still suprised them!
The twins were looking big ! They are now nearly 8 months old. Unfortunatly they were suffering from vomiting and diarrhoea so we took them all, in my small jeep, to the clinic and left Pilirani with money for medicine and transport home. It was quite a squash... 6 adults and 2 babies ...but nobody seemed to mind!
The girls soon became aware that wherever we went there was poverty and need. They were able to give small gifts to the children as we travelled and were rewarded with dancing, with obvious joy and huge smiles. But they too soon found that there was never enough to give. Where they thought there were just 2 or 3 children, suddenly, out of nowhere, dozens of little ones appeared. At times it was very frustrating. They too felt the conflict and confusion of bargaining for every small wooden carving or craft that they wanted to buy. How much to pay ? Was it enough ? Maybe they could pay more? Should they pay more?
I am looking forward to going back to labour ward tomorrow after a week off. I know it continues to be very busy and there are many new students. I feel strong and positive. There is much to do...
Thursday, 28 August 2008
MAKING A DIFFERENCE
I am physically and emotionally exhausted !
These past few days have been exceptionally busy, not just the number of births attended but the nature of them. As I have explained before, Bwaila maternity hospital serves as the referral unit for the whole of Lilongwe and surrounding areas. This means that anything that can't be sorted out at health centre or district level comes to us.
Today has been one of those days when we have been continually receiving referred patients. Yes these are true patients. There situation/condition means that the birth is now not normal, has passed to the realms of pathalogical, of difficult, of dangerous or very dangerous.
I arrived as usual soon after 7am. at the same time as an ambulance bringing us 3 women from the same health centre. It sometimes makes me wonder what they have been doing with these ladies all night ? A retained twin, now dead with one arm visibly hanging from the vagina.Two prolonged 2nd stage..this means that they have been pushing in vain for hours without result.
I started to prioritize. We have only one operating theatre, so who needs to go first?
The baby is already dead, in case one, so she can wait. Severe fetal distress in the second means an emergency c/section to save the baby. But the third although there was no fetal heartbeat to be heard the mother had a ruptured uterus thus endangering her life. Maternal life before fetal wellbeing meant the second had to wait. Her operation was carried out later and the baby is alive....just!
And that was how the morning went. When I had time to look at the clock I found it to be already 1pm. No wonder I was hungry and thirsty!
It was a morning of assesment, evaluation and decision making. It was an immensely challenging morning. I was encouraged at times to find a true feeling of team work with my Malawian colleagues, clinical officers, medical staff and midwives. As we hurriedly passed each other in the ward, one of the C.O's gave me a "thumbs up" sign as if to say " another one safely delivered" It was great to see his obvious pleasure at a job well done. This is not something I see very often as mostly I think that the Malawian staff don't believe that what they do, how they act, will really make any difference. It made me realize how driven I am, personally, by this feeling of 'making a difference.' To just one mother or baby just one at a time. Its what keeps me going. Its what makes my days worthwhile. Its what makes me cope with the tiredness, the exhaustion ,the frustrations, that feeling that I am really making a difference. The day I dont feel this I might as well give up. If money isn't an incentive, which here in Malawi it obviously isn't, then there has to be some reason to keep going. If they rarely feel they make a difference then this may account for the uncaring, negligent behaviour I often encounter.
I was further challenged to assist a twin breech delivery. Both came feet first and weighed over 2.5kgs. this is large by Malawian standards. Both presented difficulty with the birth of the aftercoming head but with my now greater knowledge and experience I was able to help these little ones out safely.
I cannot tell you all the situations that I find myself confronting in labour ward, but sufficient to say that daily I find myself putting my skills to the test, learning, becoming more practised and confident and able to help these lovely Malawian women and babies.
My girls will be here this time next week. I can't wait!
Untill then I go to rest, to have fun time with Lucas and my friends, to live each day to its full.
There is so much to do and so little time....ENJOY!
These past few days have been exceptionally busy, not just the number of births attended but the nature of them. As I have explained before, Bwaila maternity hospital serves as the referral unit for the whole of Lilongwe and surrounding areas. This means that anything that can't be sorted out at health centre or district level comes to us.
Today has been one of those days when we have been continually receiving referred patients. Yes these are true patients. There situation/condition means that the birth is now not normal, has passed to the realms of pathalogical, of difficult, of dangerous or very dangerous.
I arrived as usual soon after 7am. at the same time as an ambulance bringing us 3 women from the same health centre. It sometimes makes me wonder what they have been doing with these ladies all night ? A retained twin, now dead with one arm visibly hanging from the vagina.Two prolonged 2nd stage..this means that they have been pushing in vain for hours without result.
I started to prioritize. We have only one operating theatre, so who needs to go first?
The baby is already dead, in case one, so she can wait. Severe fetal distress in the second means an emergency c/section to save the baby. But the third although there was no fetal heartbeat to be heard the mother had a ruptured uterus thus endangering her life. Maternal life before fetal wellbeing meant the second had to wait. Her operation was carried out later and the baby is alive....just!
And that was how the morning went. When I had time to look at the clock I found it to be already 1pm. No wonder I was hungry and thirsty!
It was a morning of assesment, evaluation and decision making. It was an immensely challenging morning. I was encouraged at times to find a true feeling of team work with my Malawian colleagues, clinical officers, medical staff and midwives. As we hurriedly passed each other in the ward, one of the C.O's gave me a "thumbs up" sign as if to say " another one safely delivered" It was great to see his obvious pleasure at a job well done. This is not something I see very often as mostly I think that the Malawian staff don't believe that what they do, how they act, will really make any difference. It made me realize how driven I am, personally, by this feeling of 'making a difference.' To just one mother or baby just one at a time. Its what keeps me going. Its what makes my days worthwhile. Its what makes me cope with the tiredness, the exhaustion ,the frustrations, that feeling that I am really making a difference. The day I dont feel this I might as well give up. If money isn't an incentive, which here in Malawi it obviously isn't, then there has to be some reason to keep going. If they rarely feel they make a difference then this may account for the uncaring, negligent behaviour I often encounter.
I was further challenged to assist a twin breech delivery. Both came feet first and weighed over 2.5kgs. this is large by Malawian standards. Both presented difficulty with the birth of the aftercoming head but with my now greater knowledge and experience I was able to help these little ones out safely.
I cannot tell you all the situations that I find myself confronting in labour ward, but sufficient to say that daily I find myself putting my skills to the test, learning, becoming more practised and confident and able to help these lovely Malawian women and babies.
My girls will be here this time next week. I can't wait!
Untill then I go to rest, to have fun time with Lucas and my friends, to live each day to its full.
There is so much to do and so little time....ENJOY!
Wednesday, 20 August 2008
ANGER TURNED TO HOPE.
Friday of last week I was going to write to you but I was too angry. I went to a braii (barbeque) instead! Tarek had arrived back from his time away in Europe and along with him a new obstetrician and nurse from Holland. It was good to meet new colleagues although, unfortunately, they will only be here for 5 weeks. I was also able to vent my anger and frustrations to a listening understanding ear. As I have mentioned before Tarek normally comes up with some helpful insight into the situation and he didnt let me down this time. Opinions that evening were that I should still write. I should write with my anger along with all the other confusing emotions that confront me daily. But now it is Wednesday and the anger has calmed. Today I still feel some of those angry feeings but I am also encouraged by the students with whom I have been working hard during the past 3 weeks and their changing attitudes.
Sometimes we are so busy on labour ward that we really cannot attend all the women and babies however hard we try. Women are neglected to birth alone and difficult births end in tragedy.
But on Thursday morning there were only 3 women to attend. I arrived later than usual (8am)
The midwives change shift at 7.30am. I was met by 8 senior student midwives and 3 midwives chatting, cleaning, generally milling around. Having greeted everyone I donned my plastic apron and approached the first bed. There was no record of maternal or fetal observations in the past 2 hours. I listened to the fetal heart beat...I heard severe fetal distress. On examining her I realized I could assist the birth with a vacuum extraction. I called one of the students to help and the baby was born quickly. I resuscitated the child whilst the student attended the mother and all was well. It was now 8.30am. I passed on to the second bed...to my horror I saw that this baby was last observed at 6.45am. now nearly 2 hours ago. The baby was ok, so after encouraging the mother to get off the bed and try some more comfortable positions I then went to the 3rd bed. This mother and baby had not been attended since 7.20am. It was now 8.40am.
Only 3 women .... 3 neglected women and babies.
I was furious! I marched over to the milling crowd of midwives and students...
" We have only 3 women to attend" I shouted. " I have already assisted a baby with fetal distress and the other 2 have not been attended for 1 or 2 hours this is not acceptable, I cannot cope with this!"
I attended one woman, whilst 2 students went to the other bed. They called me immediately. The heart beat was low the woman could not push out her baby she needed an emergency c/section. At 9.40 the baby was extracted in operating theatre. It was necessary for us to perform extensive resuscitation but the baby lived...just... and is now doing well.
Later I apologized for shouting. " No, no " they replied, "you were right" Overall they are a really good set of students and I am encouraged daily by their progress and how they are quickly learning to become competant in their tasks. It was also good to hear them readily accept that in this instance they had failed. I hope they will remember my anger and it will teach them just a little about their responsibilty to the women and babies in their care.
I am continuing with the weekly ' workshops' for our midwives at Bwaila. I was thrilled to find that whilst I had been sick and then away with Alasdair the courses had continued under the leadership of the matrons. They had been well attended and the midwives were very positive about them. In meeting with thematrons to plan ahead for the period from now untill the end of the year we were able to agree on subjects to be covered and divide the teaching between us.
I am so pleased ! This may just be sustainable... and thats what its all about. How much better that they are also being lead and encouraged by their own matrons.
Lucas is back at school. He seems happy with his new teacher, "...who doesnt shout, not like you mummy!" But seems to have some pretty tight rules!
Social life has started up again as everyone returns from their summer(Europe) winter(Malawi)
holidays. We have a new Zimbabwean family living on the compound which means Lucas has constant playmates. Not always a good thing!
We are counting the days untill Katy and Fiona arrive at the beginning of September...wow do I miss my kids!
I want to leave you with one of Luki's many astounding comments /observations.
" I dont know why children are not allowed to watch Lord of the Rings because it is too violent? It is the adults that shouldn't watch fighting and killing because they can do it, but the children can't, they just stay with their mummies."
Worth thinking about don't you think?
Sometimes we are so busy on labour ward that we really cannot attend all the women and babies however hard we try. Women are neglected to birth alone and difficult births end in tragedy.
But on Thursday morning there were only 3 women to attend. I arrived later than usual (8am)
The midwives change shift at 7.30am. I was met by 8 senior student midwives and 3 midwives chatting, cleaning, generally milling around. Having greeted everyone I donned my plastic apron and approached the first bed. There was no record of maternal or fetal observations in the past 2 hours. I listened to the fetal heart beat...I heard severe fetal distress. On examining her I realized I could assist the birth with a vacuum extraction. I called one of the students to help and the baby was born quickly. I resuscitated the child whilst the student attended the mother and all was well. It was now 8.30am. I passed on to the second bed...to my horror I saw that this baby was last observed at 6.45am. now nearly 2 hours ago. The baby was ok, so after encouraging the mother to get off the bed and try some more comfortable positions I then went to the 3rd bed. This mother and baby had not been attended since 7.20am. It was now 8.40am.
Only 3 women .... 3 neglected women and babies.
I was furious! I marched over to the milling crowd of midwives and students...
" We have only 3 women to attend" I shouted. " I have already assisted a baby with fetal distress and the other 2 have not been attended for 1 or 2 hours this is not acceptable, I cannot cope with this!"
I attended one woman, whilst 2 students went to the other bed. They called me immediately. The heart beat was low the woman could not push out her baby she needed an emergency c/section. At 9.40 the baby was extracted in operating theatre. It was necessary for us to perform extensive resuscitation but the baby lived...just... and is now doing well.
Later I apologized for shouting. " No, no " they replied, "you were right" Overall they are a really good set of students and I am encouraged daily by their progress and how they are quickly learning to become competant in their tasks. It was also good to hear them readily accept that in this instance they had failed. I hope they will remember my anger and it will teach them just a little about their responsibilty to the women and babies in their care.
I am continuing with the weekly ' workshops' for our midwives at Bwaila. I was thrilled to find that whilst I had been sick and then away with Alasdair the courses had continued under the leadership of the matrons. They had been well attended and the midwives were very positive about them. In meeting with thematrons to plan ahead for the period from now untill the end of the year we were able to agree on subjects to be covered and divide the teaching between us.
I am so pleased ! This may just be sustainable... and thats what its all about. How much better that they are also being lead and encouraged by their own matrons.
Lucas is back at school. He seems happy with his new teacher, "...who doesnt shout, not like you mummy!" But seems to have some pretty tight rules!
Social life has started up again as everyone returns from their summer(Europe) winter(Malawi)
holidays. We have a new Zimbabwean family living on the compound which means Lucas has constant playmates. Not always a good thing!
We are counting the days untill Katy and Fiona arrive at the beginning of September...wow do I miss my kids!
I want to leave you with one of Luki's many astounding comments /observations.
" I dont know why children are not allowed to watch Lord of the Rings because it is too violent? It is the adults that shouldn't watch fighting and killing because they can do it, but the children can't, they just stay with their mummies."
Worth thinking about don't you think?
Wednesday, 6 August 2008
TOTALLY CRAZY
My health has forced me to take time off from my work at the hospital. This beautifully coincided with the return of Lucas to Malwai after his trip to Europe. He was able to have time with my family in UK and catch up with his dad in Spain. He was accompanied...I'm not sure who accompanied who?... by my eldest son, Alasdair, who stayed with us for nearly three weeks. The timing was perfect. I was in great need of family love and care which is exactly what he's good at and which he did to perfection...thanks Alasdair. We had already organized to explore some of the Southern part of Malawi together and were away for 9 days. Alasdair got thrown into Malawi life straight away as he took over all the driving. Our trip included time at the lake..warm sunny and swimming. 2 days in the mountains... chilly, log fires and pine forests, followed by a 2 day safari. This was an amazing experience for us all. Unrepeatable episodes with elephants were the highlights of our trip as we managed to get the car into the middle of the herd.. this is not recommended and was a cause of a huge adrenalin rush and much fear for a while! We also had a huge bull elephant grazing outside our cottage just 1 metre from the window! I should also mention the tyre that punctured on the road to the lake. We thought we were in a pretty remote spot untill we found ourselves rapidly surrounded by a dozen locals all offering there services. I must admit the pit stop was unbelievably quick. Alasdair was quite willing and able to change the tyre but didnt get a look in, he just handed out wet wipes for hand washing afterwards much to the amazement and amusement of all!
We have many lovely stories and incidents from our trip too many to write down now but sufficient to say it really was just what I needed. I feel strong, I feel positive and refreshed I am ready to continue with all that I believe I still have to do here. I am looking forward to being back with the women and the babies at Bwaila.
Last Thursday we said a sad farewell to Alasdair and on Friday morning, bright a early, I was back on labour ward.
I was very warmly welcomed back. My fellow midwives kept telling me how much they had missed me. ( I expect they have to work harder when I'm not there!) I too had missed them, the work, the mums and the babies.
I have worked every day since then. I shall tell you that when I left this afternoon we had recorded 340 births during the month of August. Today is the 6th ( tomorrow is my birthday!) that means more than 50 births a day!
This is unbelievable, this unimaginable, this is totally crazy! If you could just see the size and condition of labour ward. The women who dont have a bed and birth on the floor. The lack of clean ..not to mention sterilized instruments, of gauze swabs or cottonwool, of gloves, but more importantly of midwives. Today I apologized to the woman in the bed opposite..."pepani, pepani... sorry, sorry". No one should birth alone. I was attending a post partum hemorrage an emergency situation. She screamed and she pushed "nursey, nursey" but I could not go to her so her little one slithered out alone. They were alone. I called to her to encourage her I could do nothing more. My priority was to attend the other woman. So there were no caring hands to catch him, no one to scoop him up and clean him off, no one to stimulate his first breath he /they were alone. It was lunch time. The student midwives and clinicians had gone for lunch, one midwife was in the admission room and the other was in theatre with a c/section. I looked up, I looked around, I was alone. I attended 5 births in the next 2 hours. At last I saw a clinician attending at the other end of the ward. I called for help. When he arrived it was to ask me to help him perform a vacuum extraction for fetal distress. I quickly left the woman that I was suturing..that could wait till later..the intervention was quick and simple the baby was fine, I left him and returned to another woman pushing. She had been on labour ward for more than 1 hour but nobody had examined her or listened to the baby's heartbeat. I could see the baby's head. I tried to explain to the lady I was suturing that I would be back, that I had not forgotten her as I rushed to find some instruments, some basic materiales to attend this birth. Three pushes and the child was born but its condition was not good. I hurriedly took him to the resuscitation area. As I worked on the baby, who responded well, I was thinking of the woman lying there on her own. Was she bleeding? Was the placenta out? did she need me? Where should I be? with the mother or the baby? There was no one to help me, I was on my own too.
All these mothers and babies are now fine and well. When I had finished and left them all clean and dry with their babies suckling at the breast I had to fill in the labour files and charts and found I could not remember most of the details of each one, no times of birth, boys or girls? it wasn't important so I didnt know! 2 hours had passed as if it had been 5 minutes!
Dont think this is a strange situation, that this happens every now and then. No.. this is happening nearly every day and most nights. Where are the other staff? how is it possible for them all to disappear at once? These are the very questions I continually ask. And I do ask, but I get no answers. Now can you understand why the busiest maternity unit in Malawi and one of the busiest in the whole of the South African continent has such a high maternal and neonatal mortality rate? Why oh why is it like this? why do these women not deserve better? They do deserve better. I am trying oh how I am trying, but it sometimes feels impossible. However hard I work, however quick I run I just can't reach them all. I suppose this is normality for the Malawian staff, but I have seen better, I know better, I know what should be, but how?
I was so angry yesterday. I was told that on " bed one" the baby had died in the first hour of life. On examining her file I found that she had been pushing for 5 hours. The clinician had been called but arrived 3 hours later, meanwhile no one had checked nor the maternal nor the fetal condition, nor had they used any interventions to aid the birth. This happens with referral cases that have to journey fron outlying districts, or have been attended by poorly qualified attendants. But this woman was on our labour ward in our hospital! I informed as many people as possible. I was not prepared to keep letting these incidents happen without any accountability without any responsibility. On talking to one midwife she informed me that some midwives believe that if the woman pushes and the baby doesn't come it is her fault for not doing it properly for not putting in enough effort. The mother is responsible! This is the attitude I knew existed in the villages but we are a hospital with trained midwives! Could it possibly be that some of our midwives share these beliefs? I despair.....but I am strong and I can carry on.
There is so much I could write today. I am feeling good and positive and confident despite all that I face daily. If I can save just one baby or one mother If just one baby or one mother is better cared for because of me it is enough. At least for today...I wonder how I will feel tomorrow?
We have many lovely stories and incidents from our trip too many to write down now but sufficient to say it really was just what I needed. I feel strong, I feel positive and refreshed I am ready to continue with all that I believe I still have to do here. I am looking forward to being back with the women and the babies at Bwaila.
Last Thursday we said a sad farewell to Alasdair and on Friday morning, bright a early, I was back on labour ward.
I was very warmly welcomed back. My fellow midwives kept telling me how much they had missed me. ( I expect they have to work harder when I'm not there!) I too had missed them, the work, the mums and the babies.
I have worked every day since then. I shall tell you that when I left this afternoon we had recorded 340 births during the month of August. Today is the 6th ( tomorrow is my birthday!) that means more than 50 births a day!
This is unbelievable, this unimaginable, this is totally crazy! If you could just see the size and condition of labour ward. The women who dont have a bed and birth on the floor. The lack of clean ..not to mention sterilized instruments, of gauze swabs or cottonwool, of gloves, but more importantly of midwives. Today I apologized to the woman in the bed opposite..."pepani, pepani... sorry, sorry". No one should birth alone. I was attending a post partum hemorrage an emergency situation. She screamed and she pushed "nursey, nursey" but I could not go to her so her little one slithered out alone. They were alone. I called to her to encourage her I could do nothing more. My priority was to attend the other woman. So there were no caring hands to catch him, no one to scoop him up and clean him off, no one to stimulate his first breath he /they were alone. It was lunch time. The student midwives and clinicians had gone for lunch, one midwife was in the admission room and the other was in theatre with a c/section. I looked up, I looked around, I was alone. I attended 5 births in the next 2 hours. At last I saw a clinician attending at the other end of the ward. I called for help. When he arrived it was to ask me to help him perform a vacuum extraction for fetal distress. I quickly left the woman that I was suturing..that could wait till later..the intervention was quick and simple the baby was fine, I left him and returned to another woman pushing. She had been on labour ward for more than 1 hour but nobody had examined her or listened to the baby's heartbeat. I could see the baby's head. I tried to explain to the lady I was suturing that I would be back, that I had not forgotten her as I rushed to find some instruments, some basic materiales to attend this birth. Three pushes and the child was born but its condition was not good. I hurriedly took him to the resuscitation area. As I worked on the baby, who responded well, I was thinking of the woman lying there on her own. Was she bleeding? Was the placenta out? did she need me? Where should I be? with the mother or the baby? There was no one to help me, I was on my own too.
All these mothers and babies are now fine and well. When I had finished and left them all clean and dry with their babies suckling at the breast I had to fill in the labour files and charts and found I could not remember most of the details of each one, no times of birth, boys or girls? it wasn't important so I didnt know! 2 hours had passed as if it had been 5 minutes!
Dont think this is a strange situation, that this happens every now and then. No.. this is happening nearly every day and most nights. Where are the other staff? how is it possible for them all to disappear at once? These are the very questions I continually ask. And I do ask, but I get no answers. Now can you understand why the busiest maternity unit in Malawi and one of the busiest in the whole of the South African continent has such a high maternal and neonatal mortality rate? Why oh why is it like this? why do these women not deserve better? They do deserve better. I am trying oh how I am trying, but it sometimes feels impossible. However hard I work, however quick I run I just can't reach them all. I suppose this is normality for the Malawian staff, but I have seen better, I know better, I know what should be, but how?
I was so angry yesterday. I was told that on " bed one" the baby had died in the first hour of life. On examining her file I found that she had been pushing for 5 hours. The clinician had been called but arrived 3 hours later, meanwhile no one had checked nor the maternal nor the fetal condition, nor had they used any interventions to aid the birth. This happens with referral cases that have to journey fron outlying districts, or have been attended by poorly qualified attendants. But this woman was on our labour ward in our hospital! I informed as many people as possible. I was not prepared to keep letting these incidents happen without any accountability without any responsibility. On talking to one midwife she informed me that some midwives believe that if the woman pushes and the baby doesn't come it is her fault for not doing it properly for not putting in enough effort. The mother is responsible! This is the attitude I knew existed in the villages but we are a hospital with trained midwives! Could it possibly be that some of our midwives share these beliefs? I despair.....but I am strong and I can carry on.
There is so much I could write today. I am feeling good and positive and confident despite all that I face daily. If I can save just one baby or one mother If just one baby or one mother is better cared for because of me it is enough. At least for today...I wonder how I will feel tomorrow?
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