Yesterday was one of those busy days at Bwaila. Most of my time now is spent supervising the student midwives on Labour Ward, ensuring that they understand what they are doing that they become skilled at recognizing when things are going wrong not just ‘catching’ babies as they ‘pop out’ nor focusing only achieving numbers to fill up their books. Although we are now a District Unit and our most serious high risk women will be transferred to the new unit at the Central Hospital we continue to receive and care for many high risk situations. This is inevitable due to the huge number of women and babies we are attending and the fact that they are the most poor and disadvantaged Malawian women with all their underlying health problems. The day started badly when I realized that the women whose HIV status was unknown could not be tested due to the fact that no kits were available. This is a totally unacceptable situation in the light of the funds that are pouring into the country specifically aimed at preventing Mother to Child transmission. I took time out to visit the DHO in his offices next door. I found him in a meeting discussing the pharmacy issues. This was just what I needed. I interrupted the meeting to request that they please discuss this especially as we are approaching Easter. If this was not sorted out immediately we would be passing the whole Easter weekend in the same situation. What would become of those women? What would become of those babies? I was informed that this was a country wide problem but, as usual, mostly affecting the public hospitals…once more the private hospitals had their own supplies, once more the rich would win!
Since early morning I had been especially caring for a very young 18year old mother whose labour was progressing extremely slowly. When I took her over from the night staff I was told that she was ’hysterical and uncooperative’. She had been rolling on the floor in pain, had removed her IV line and was ‘totally uncontrollable.’ She was young and alone and very frightened. After assessing her situation I decided to administer Pethidine ( a strong pain killer) and instructed one of the students to take over her care to gain her trust and therefore her cooperation. As the drug began to work she became calm and sleepy, ceasing to cry out in pain with every contraction and rested on the bed. This new situation allowed me to then administer hormones to increase her contractions and therefore speed up her already prolonged labour. This she tolerated well .I would not leave until her baby was born. Slowly but surely her baby descended and her cervix opened to allow him to pass through. Once the baby was well down in the pelvis I took a vacuum extraction cup and with the help of the young student midwife who had gained her trust I slowly guided her baby into this world. It was wonderful teaching situation not only in the skills of assisting in the more difficult situations but how to really ‘care’ for women.
.
We only have one ambulance at Bwaila. At present it is in the workshop being repaired after an accident so we are managing as best we can with totally unsuitable vehicles.
It was nearly 4pm when Kristine arrived on labour ward. She had been found in her hut in the village by some neighboring women. She had delivered her first baby totally alone .Kristine was 18 years old. The first thing that I noticed was that she was extremely ‘pale’ with a very high fever. That might seem strange to you. How can a black skinned person be pale? Well she can, and she was,’ pale.’ It feels good to be able to recognize this now! Reading her health passport from the two antenatal visits I found that she had been diagnosed with severe anemia over one month ago and had not been treated or transfused. She was weak but conscious and coherent. She was not actively bleeding but I had no way of knowing how much blood she had lost before arrival. With the help of one of my students we quickly erected IV lines took blood samples and sent them to the laboratory. It was her lucky day..…One pack of blood was available. We started to transfuse. She badly needed IV antibiotics, but we had none. After inspection it became clear that some parts of placenta were still in her uterus. This would continue to be a high risk situation for her until they were removed. We had no doctor that day and it was now 4.30pm. We decided that, once stabilized, she should be referred to the Central Hospital. Any blood loss now could prove fatal for her. I called for the ambulance only to find that it would not be available for at least 2 hours. Could Kristine wait for two hours? I decided to take her myself. I put down the back seats, covered the carpets with plastic and assisted Kristine, two IV lines, blood transfusion, two guardians, her baby (1.6kgs.) a bundle of firewood, plastic basins and cooking pots into my Honda CRV. We arrived safely. The next day I heard they had found one more bag of blood for her and she was doing well.
Agness gave birth to the first of her twins in an outlying health center at 12.30miday.the baby was born without incident but number two didn’t seem to want to come down. The inexperienced attendant diagnosed that the second was presenting with a hand which could not be delivered normally. She was taken by ambulance to one of our community hospitals. Unfortunately there was no clinician at this center and I presume the attending nurse midwife was neither confident nor experienced enough to assess the situation, so she was sent to us. She arrived at 4.25pm. Four hours later! Quickly reading the referral letter I knew we were dealing with a very delayed/retained second twin with a hand presentation. I had no idea if the baby was still alive so called for the ultra sound scanner. Meanwhile I examined her only to find a small foot in her vagina. I wasted no time and took hold of the foot bringing the second foot down and delivered the breech. I still didn’t know if the baby was alive and my first impression was that she had arrived too late for the little one. Feeling the chest wall I found a very slow heart beat! I ran with the baby to the resuscitaire and with the help of a colleague we brought the baby back to life. It took a long time but we were efficiently maintaining heart activity with cardiac massage and ventilation. After 20 minutes we decided to leave the baby to ‘go it alone’ I went back to the delivery room to check up on the mother. Ten minutes later one of the midwives called to me
’Your baby’s crying!‘ she said.
Another miracle at Bwaila!
Friday, 6 May 2011
Wednesday, 13 April 2011
MALARIA AND MORE
It’s nearly two whole months since I last wrote to you all. Fiona has been and gone. It was a truly wonderful time with her. Fiona is so easy to please and just slotted straight into our lives here in Malawi. I don’t think that it was always easy for her. Living and working in such a poor country inevitably needs a great deal of adaptation. She enjoyed her work experience at Lucas’ school as well as very bravely making regular visits to one of the local orphanages. The children all adored her and she made special little friends. She found it heartbreaking each and every time when she had to pack up the toys and leave. The little ones clung to her with tears in their eyes as she gave them a final cuddle. Lucas just loved having his big sister around. He too clung to her at the airport last week not wanting to say goodbye. The house is quiet now.
Bwaila continues to arouse in me all manner of conflicting emotions each and every day. It has been an exceptionally busy couple of months with totally inadequate staffing. We have had to rely on our students to ease the workload which is far from ideal as they have little experience or practical knowledge. My priority has been to work with all these students. Teaching supervising and mentoring on labour ward is essential as well as sorting out the more complicated situations as they arrive. It is very tiring work but hugely rewarding to see the students learning and improving.
I have been actively involved with our Quality Improvement Team for the past 3 years. Last month we put together a presentation of the data/statistics of the past 2 years. It was encouraging to see that although the number of deliveries has increased substantially (more than 2.400 births during 2010 compared to 2009) our Maternal Mortality Rate has reduced. Death due to hemorrhage was previously the main cause of death but this has now been successfully addressed and I am happy with the way that our permanent staff respond to this emergency as well as taking measures to prevent it.
We are still losing too many babies during the first few days of life due to Birth Asphyxia. This has mostly been caused by inadequate monitoring and prompt decision making during labour. We are now working towards reducing these numbers. These initiatives demand an important amount of more formal instruction as well as bedside supervision and teaching.
Since January both Dr Ibe Iwuh (our Nigerian registrar) and I have worked to ensure regular teaching on the morning round. This is mostly attended by intern doctors and clinical officer students but I continue to encourage the student midwives to participate. As the most experienced midwife on labour ward I take on this teaching role each and every morning. My work in this area is greatly appreciated by the students themselves.
But ‘incidents’ still happen only too often.
Yesterday we lost 2 mothers. It was a bad day.
Today we lost 2 babies. It was another bad day.
Catharine had been referred to us from one of our outlying community hospitals. They had already decided several hours earlier that she needed her second c/section due to a large baby and inadequate pelvis. They had not been able to perform the operation as they “had no anesthetist.” By the time she arrived with us several hours later the baby was severely distressed and her uterus on the point of rupturing. We quickly prepared her for theatre and advised the operating staff. Unfortunately they had just started another intervention. I ran to theatre to find out how long she had to wait. And found the place in darkness! The main theatre electric switch had ‘tripped.’ I found the switch but it would not move. Looking into theatre I saw that the c/section baby was being extracted by the light of 3 mobile phones! I am proud and continuously amazed by the resourcefulness of our staff. I ran to switchboard to ring the electricians. ‘msanga msanga’ (quick quick) I implored them. I managed to find a torch that was functioning on the Post natal ward and took it into theatre. By the time I had sorted all that out I went back to labour ward to see how Catharine was doing. The fetal heart beat was consistently low. Maybe it would be possible to open up the 2nd theatre as I knew we had a 2nd anesthetist that morning. So that is what we did. Unfortunately we had delayed too long and though I was present in theatre to receive the baby and ready to resuscitate, the little one was born dead. The uterus was on the point of rupture but with some good surgery was repaired. We saved the mother but not her baby.
Last week I visited this same community Hospital. The ‘road’ was almost impassable at times. Luckily we had taken a good 4* 4 vehicle and only got stuck once in deep mud. It’s the rainy season and many health centers and villages are almost unreachable. This particular Hospital has a 110 bed capacity. Of course there are many who will be on the floor. They have one clinical officer and 16 nurses in total to cover all the shifts. This is Malawi reality.
February saw the visit to Malawi of Annie Lennox as an ambassador of the Scottish parliament. She visited Bwaila and publically recognized the work that we are doing there. It was a huge morale booster for our staff. I was present at a reception given in her honour where my own work at Bwaila was also personally recognized. As a result of this I was invited to meet with the Malawian First Lady, wife of the president Bingu Mutharika. I felt rather nervous as I drove through the gates of State House and wondered how was it possible that I got here to this place It was a great privilege for me to be able to talk with her personally as a representative of the hospital. My first aim was to get her to promise to visit the unit. This I achieved and true to her word she visited us last Thursday. It was an informal visit at short notice, as she had requested, with little pomp and ceremony, but it was hugely important for our midwives who felt encouraged and boosted by her words of thanks and appreciation. How amazing it must be to be able to make so many people so happy just by one short visit.
Today was a quiet day for Bwaila but not without incident. Patricia arrived around 10am. She came from home. It was her 3rd pregnancy, the previous 2 had ended in normal healthy deliveries .She was being admitted by two of our junior students when I entered the room in my teaching/supervisory capacity. The young student was examining her so I asked her to tell me her findings. ‘Is the baby ok?’ I asked. She assured me it was .On checking her examination I failed to hear the fetal heart beat. Checking with the ultra sound scan I could see no fetal heart activity. During all this time she had no contractions but was fully dilated and therefore should be ready for the expulsive stage. Uterine rupture is extremely rare in the richer countries but here in Malawi we see it only too often. I immediately suspected that this had occurred and called for help from my colleagues. There was no doctor on the unit and our most experienced Clinical Officer was in theatre. We attended to her quickly and called the ambulance to transfer her to the central hospital as she would need an emergency hysterectomy ( removal of the uterus) and was at risk of huge hemorrhage. Whilst we waited for transport we were able to get 2 bags of blood for her and immediately started the transfusion. Our transport vehicles are far from adequate so we had to literally bundle her into the back of the 4*4 half on and half off the back seats. She arrived safely, was operated and is now in the intensive care unit in a stable condition.
Shortly after arriving home I received a phone call from a Malawian woman who said she had given birth with me. I have no idea who she is. She explained that her daughter, now pregnant had been admitted to our ante natal ward last Sunday with Malaria. Her voice was of fear and concern as she explained that the nurse had told her that her daughter could not be treated for the illness as the hospital didn’t have any Malaria medication. This morning in the hand over meeting it was reported by the nurses that they had run out of Malaria drugs and had been informed that they were not available. They had been told that Malaria drugs were not to be found anywhere in Malawi. I had listened but I had not taken in the true reality of the situation. Labour Ward has its own issues and Malaria drugs is not one of them .I immediately phoned the nurse on duty to ask about the situation. It is true, we have no Malaria drugs! Now what was I going to say to this mother who would have to spend another night not knowing if her daughter’s condition would deteriorate with no possibility of treatment. Her only possibility was to try the local pharmacies to see if she could buy the drug privately. Even if she was able to locate the drug this would probably economically impossible. I promised I would see her tomorrow. I cannot stop thinking about her…but what do I do? She is not the only woman on the ward who is being deprived of treatment, I can’t possibly solve this problem for them all….Tomorrow I will see her, I hope I am not too late? I must have been her last hope and I have failed her…. If this is really true, if Malaria drugs are out of stock country wide many women and children will die. We are still in the rainy season, which is the time of most incidents of Malaria, this is a terrible thing. Many will die, but mostly the poor, as the rich will always find a way.
Bwaila continues to arouse in me all manner of conflicting emotions each and every day. It has been an exceptionally busy couple of months with totally inadequate staffing. We have had to rely on our students to ease the workload which is far from ideal as they have little experience or practical knowledge. My priority has been to work with all these students. Teaching supervising and mentoring on labour ward is essential as well as sorting out the more complicated situations as they arrive. It is very tiring work but hugely rewarding to see the students learning and improving.
I have been actively involved with our Quality Improvement Team for the past 3 years. Last month we put together a presentation of the data/statistics of the past 2 years. It was encouraging to see that although the number of deliveries has increased substantially (more than 2.400 births during 2010 compared to 2009) our Maternal Mortality Rate has reduced. Death due to hemorrhage was previously the main cause of death but this has now been successfully addressed and I am happy with the way that our permanent staff respond to this emergency as well as taking measures to prevent it.
We are still losing too many babies during the first few days of life due to Birth Asphyxia. This has mostly been caused by inadequate monitoring and prompt decision making during labour. We are now working towards reducing these numbers. These initiatives demand an important amount of more formal instruction as well as bedside supervision and teaching.
Since January both Dr Ibe Iwuh (our Nigerian registrar) and I have worked to ensure regular teaching on the morning round. This is mostly attended by intern doctors and clinical officer students but I continue to encourage the student midwives to participate. As the most experienced midwife on labour ward I take on this teaching role each and every morning. My work in this area is greatly appreciated by the students themselves.
But ‘incidents’ still happen only too often.
Yesterday we lost 2 mothers. It was a bad day.
Today we lost 2 babies. It was another bad day.
Catharine had been referred to us from one of our outlying community hospitals. They had already decided several hours earlier that she needed her second c/section due to a large baby and inadequate pelvis. They had not been able to perform the operation as they “had no anesthetist.” By the time she arrived with us several hours later the baby was severely distressed and her uterus on the point of rupturing. We quickly prepared her for theatre and advised the operating staff. Unfortunately they had just started another intervention. I ran to theatre to find out how long she had to wait. And found the place in darkness! The main theatre electric switch had ‘tripped.’ I found the switch but it would not move. Looking into theatre I saw that the c/section baby was being extracted by the light of 3 mobile phones! I am proud and continuously amazed by the resourcefulness of our staff. I ran to switchboard to ring the electricians. ‘msanga msanga’ (quick quick) I implored them. I managed to find a torch that was functioning on the Post natal ward and took it into theatre. By the time I had sorted all that out I went back to labour ward to see how Catharine was doing. The fetal heart beat was consistently low. Maybe it would be possible to open up the 2nd theatre as I knew we had a 2nd anesthetist that morning. So that is what we did. Unfortunately we had delayed too long and though I was present in theatre to receive the baby and ready to resuscitate, the little one was born dead. The uterus was on the point of rupture but with some good surgery was repaired. We saved the mother but not her baby.
Last week I visited this same community Hospital. The ‘road’ was almost impassable at times. Luckily we had taken a good 4* 4 vehicle and only got stuck once in deep mud. It’s the rainy season and many health centers and villages are almost unreachable. This particular Hospital has a 110 bed capacity. Of course there are many who will be on the floor. They have one clinical officer and 16 nurses in total to cover all the shifts. This is Malawi reality.
February saw the visit to Malawi of Annie Lennox as an ambassador of the Scottish parliament. She visited Bwaila and publically recognized the work that we are doing there. It was a huge morale booster for our staff. I was present at a reception given in her honour where my own work at Bwaila was also personally recognized. As a result of this I was invited to meet with the Malawian First Lady, wife of the president Bingu Mutharika. I felt rather nervous as I drove through the gates of State House and wondered how was it possible that I got here to this place It was a great privilege for me to be able to talk with her personally as a representative of the hospital. My first aim was to get her to promise to visit the unit. This I achieved and true to her word she visited us last Thursday. It was an informal visit at short notice, as she had requested, with little pomp and ceremony, but it was hugely important for our midwives who felt encouraged and boosted by her words of thanks and appreciation. How amazing it must be to be able to make so many people so happy just by one short visit.
Today was a quiet day for Bwaila but not without incident. Patricia arrived around 10am. She came from home. It was her 3rd pregnancy, the previous 2 had ended in normal healthy deliveries .She was being admitted by two of our junior students when I entered the room in my teaching/supervisory capacity. The young student was examining her so I asked her to tell me her findings. ‘Is the baby ok?’ I asked. She assured me it was .On checking her examination I failed to hear the fetal heart beat. Checking with the ultra sound scan I could see no fetal heart activity. During all this time she had no contractions but was fully dilated and therefore should be ready for the expulsive stage. Uterine rupture is extremely rare in the richer countries but here in Malawi we see it only too often. I immediately suspected that this had occurred and called for help from my colleagues. There was no doctor on the unit and our most experienced Clinical Officer was in theatre. We attended to her quickly and called the ambulance to transfer her to the central hospital as she would need an emergency hysterectomy ( removal of the uterus) and was at risk of huge hemorrhage. Whilst we waited for transport we were able to get 2 bags of blood for her and immediately started the transfusion. Our transport vehicles are far from adequate so we had to literally bundle her into the back of the 4*4 half on and half off the back seats. She arrived safely, was operated and is now in the intensive care unit in a stable condition.
Shortly after arriving home I received a phone call from a Malawian woman who said she had given birth with me. I have no idea who she is. She explained that her daughter, now pregnant had been admitted to our ante natal ward last Sunday with Malaria. Her voice was of fear and concern as she explained that the nurse had told her that her daughter could not be treated for the illness as the hospital didn’t have any Malaria medication. This morning in the hand over meeting it was reported by the nurses that they had run out of Malaria drugs and had been informed that they were not available. They had been told that Malaria drugs were not to be found anywhere in Malawi. I had listened but I had not taken in the true reality of the situation. Labour Ward has its own issues and Malaria drugs is not one of them .I immediately phoned the nurse on duty to ask about the situation. It is true, we have no Malaria drugs! Now what was I going to say to this mother who would have to spend another night not knowing if her daughter’s condition would deteriorate with no possibility of treatment. Her only possibility was to try the local pharmacies to see if she could buy the drug privately. Even if she was able to locate the drug this would probably economically impossible. I promised I would see her tomorrow. I cannot stop thinking about her…but what do I do? She is not the only woman on the ward who is being deprived of treatment, I can’t possibly solve this problem for them all….Tomorrow I will see her, I hope I am not too late? I must have been her last hope and I have failed her…. If this is really true, if Malaria drugs are out of stock country wide many women and children will die. We are still in the rainy season, which is the time of most incidents of Malaria, this is a terrible thing. Many will die, but mostly the poor, as the rich will always find a way.
Monday, 14 February 2011
BACK TO BWAILA
Its 6.30am. Saturday 12th February. I am sitting in my lounge in the lovely house we have made home here in Lilongwe with the warm African sun blazing in through the window. The only noises I hear are the chirping of the birds in the garden, which due to the heavy rains at this time of year, is lush and green. Fiona is still asleep in Lucas’ room and I feel content. Fiona will stay with us in Malawi for 2 months whilst she carries out her experiential learning with the year 1 children at Lucas’ school. Lucas is thrilled to have her here. And me? Well I just feel so grateful for the opportunity she has given me to be her Mum ‘close up’ for a while.
Europe, Christmas and Katy and Nicks wedding seems lost in a different world, in the distant past, but of course it was only just over one month ago. Time spent away from Malawi and away from Bwaila was therapeutic and healing, just as imagined it would be. Flying back into my other world into my other reality caused me the same conflicts and confusion as it has always done. It always takes me time to adapt back to that huge sense of wealth and excess that oozes from the pores of European living. But I did and I enjoyed every minute. I was able to spend nearly 3 weeks in England in the loving and safe arms of my friends and family. It was good to see how my Mum was recovering from her recent stroke and on her way to resuming her independent life once more. Time spent in Yorkshire with Katy and Nick in the final weeks before their wedding was full of excitement and joy. I felt privileged to be able to share this time with them. Christmas was spent in Spain surrounded by the usual hectic rush and tumble of pre Christmas plans then the beautiful giving and receiving of presents. All my four children have acquired the ability to find the perfect gift chosen with such thought and given with great excitement and love.
Katy and Nick’s wedding on 30th December was a fairy tale. Everything was just wonderful and beautiful especially my daughter, the bride. My role as mother of the bride was just so special, I enjoyed each and every single moment. What a wonderful feeling, as a mother, to witness my own child moving forward into a loving relationship with the man of her choice with an unknown but exciting future ahead. As I read in the wedding ceremony from the words of Kahlil Gibram …..
Your children are not your children They are the sons and daughters of life’s longing for itself. They come through you but not from you. And though they are with you they belong not to you……. child You are the bows from which your children as living arrows are sent forth…
Ending my time in Europe I was able to enjoy 6 days in Norway with my eldest son Alasdair before he took up his first job in England since recently qualifying as a vet. I was grateful for this time with him as his possibilities for long holidays and ‘time with Mum’ are so much less now that he has left student life behind and embarks on his chosen career. I never cease to give thanks for my children each one so special in their own way.
And so I returned to Malawi. I must admit having felt rather apprehensive during the last few days in UK. I was ready to return, I felt strong and enthusiastic but leaving the comfort and security of family to return to the huge challenges of living and working in one of the poorest countries in the world left me feeling somewhat fearful.
Needless to say the sight of our dear friends and neighbors who were at the airport to meet us, soon chased away any feeling of doubt I had regarding continuing with my work and our life here in Lilongwe.
So I returned to Bwaila. Having played such a huge role in the setting up of the new Bwaila Maternity Unit it felt like going home as I walked through the doors of labour ward, that first day after nearly 6 weeks away, to be greeted with screams of welcome by my midwife colleagues.
It had been a difficult December as the unit had been without regular medical cover leaving the midwives and clinical officers to take full responsibility for the everyday running of what is probably the busiest maternity in the whole of Southern Africa. Despite predictions that the work load at Bwaila would decrease substantially after the opening of the new tertiary care wing at the Lilongwe central hospital ( Ethel Mutharika Maternity Wing) this has not proved to be the case and we continue to attend more than 1,000 births a month. The high risk mothers are now being transferred and the health centers are sending their difficult cases directly to EMMW. We still have many extremely sick women and emergencies to attend. I can honestly say that the past 6 weeks have been some of the busiest I have experienced since I arrived 3 years ago.
January sees the start of the clinical placements for our midwifery students. This year with an increase in students being trained it also means an increase in the number of students needing close supervision and clinical teaching in the ward situation. We have also had a new set of interns and clinical officer students on the unit all of whom need constant teaching. I quickly decided on my return that I should make my priority during this time the teaching and supervision of students of all cadres. It has been a pleasure to work with the interns, most of whom are highly motivated and enthusiastic learners. They are quick to learn and quickly become essential to the safe medical coverage of the unit. The student midwives are of varying levels of enthusiasm and competence. They have little input from the college staff due to shortage of tutors which means that their practical skills need to be taught by our own permanent midwifery staff. There is still some reluctance on the part of some of these to undertake this role. Others truly do not have the necessary skills to pass on their knowledge to students. I have spent most of my time this past month dedicated to this. I actually enjoy this part of my work tremendously and find that my own enthusiasm plays a key part in effectively creating greater interest and understanding thus leading to better and more adequate care.
As well as teaching I often find that I am the most experienced obstetric professional on the unit. This means that my expertise is being constantly sought to aid in difficult and emergency situations. I was very pleased to welcome a new Nigerian registrar onto the unit. We have already worked together in the past and are personal friends. We refer to each other constantly which gives vital strength to the medical and midwifery cover. I truly feel that together the possibilities to effectuate change are more than ever present.
This doesn’t mean that labour ward is without its distressing incidents.
I had decide to finish a little earlier last Friday afternoon to allow myself time to catch up on some of the more formal teaching preparation and administrative work that forms an important part of my work. It was 3.30pm and the ward was quieter and under control. There were 3 women still waiting for their emergency c/sections, one of whom had been waiting for more than 3 hours. The interns were operating which inevitably leads to delays as their inexperience means that the procedure takes much longer. I had already requested that a more experienced person took over for the 2nd patient as I feared that the outcomes of the waiting women and their babies would be adversely affected if they delayed further. The 2nd c/section was performed by one of our clinical officers but 2 were still waiting. A young 16 year old was just not progressing to delivery. She had been referred by a district health centre and despite all our efforts it became clear that the baby needed to be delivered abdominally. The other was a very small, very short young mother who had not been able to deliver her first child vaginally due to a disproportion between the pelvis and the fetus. There are many women in Malawi whose growth has been arrested during childhood and adolescence due to malnutrition or illness resulting in inadequate development of the bony pelvis which does not allow for normal delivery. Although a c/section is a life saving procedure for both mother and baby we are very reluctant to put a woman through surgery unless it is absolutely necessary. Once she has a scarred uterus she carries the added risk of rupture in any subsequent pregnancy. This is a real danger to our Malawian women living in the more rural areas with no adequate transport to a health facility and with the frequent use of local roots and herbs to induce or speed up labour in a very aggressive manner. I had collected my belongings and was walking out of the ward when greeted by a new referred patient with ‘a retained 2nd twin with fetal distress’, of course I could not leave. Calling for one of our clinical officers who just happened to be around I quickly took her into a delivery room to assess the situation. We performed a quick ultra sound scan on the baby and found a very slow irregular heart beat. This baby needed to be born fast! A c/section was not an option for at least 2 hours so I decided to attempt a vaginal delivery to save the baby. I called another midwife to help set up an IV line, empty the bladder and bring a vacuum extractor. It was not an easy procedure. The fetal head was high and the vaginal tissue, cervix and first umbilical cord were all in the way as I tried to place the vacuum cup on the baby’s head. It took almost 15 minutes to successfully extract the baby and I feared for its life. I have done this procedure before and it requires a great deal of cooperation from the mother and the medical team. At last the cup was placed and the baby extracted with ease. I was amazed and exhilarated when it came out alive! With a little resuscitation the baby was soon crying though still with breathing difficulties so I sent him to nursery for further management. Today he is doing well.
It was now past 4.30pm Before I left I went to theatre to make sure that the clinician on the night shift was aware of the 2 women still waiting for their operations. I could do no more and there was no time to consider administrative tasks. I arrived home after 5pm exhausted. It was Friday afternoon and the thought of the weekend, the rest and free time with Fiona and Lucas filled me with joy and hope.
Despite everything…..I love Bwaila!
When love beckons to you, follow him, Though his ways be hard and steep. . And when his wings enfold you yield to him, Though the sword hidden among his pinions may wound you…… For even as love crowns you so shall he crucify you. Even as he is for your growth so is he for your pruning…… All these things shall love do unto you that you may know the secrets of your heart… And think not that you can direct the course of love, for love, if it finds you worthy, directs your course.
Europe, Christmas and Katy and Nicks wedding seems lost in a different world, in the distant past, but of course it was only just over one month ago. Time spent away from Malawi and away from Bwaila was therapeutic and healing, just as imagined it would be. Flying back into my other world into my other reality caused me the same conflicts and confusion as it has always done. It always takes me time to adapt back to that huge sense of wealth and excess that oozes from the pores of European living. But I did and I enjoyed every minute. I was able to spend nearly 3 weeks in England in the loving and safe arms of my friends and family. It was good to see how my Mum was recovering from her recent stroke and on her way to resuming her independent life once more. Time spent in Yorkshire with Katy and Nick in the final weeks before their wedding was full of excitement and joy. I felt privileged to be able to share this time with them. Christmas was spent in Spain surrounded by the usual hectic rush and tumble of pre Christmas plans then the beautiful giving and receiving of presents. All my four children have acquired the ability to find the perfect gift chosen with such thought and given with great excitement and love.
Katy and Nick’s wedding on 30th December was a fairy tale. Everything was just wonderful and beautiful especially my daughter, the bride. My role as mother of the bride was just so special, I enjoyed each and every single moment. What a wonderful feeling, as a mother, to witness my own child moving forward into a loving relationship with the man of her choice with an unknown but exciting future ahead. As I read in the wedding ceremony from the words of Kahlil Gibram …..
Your children are not your children They are the sons and daughters of life’s longing for itself. They come through you but not from you. And though they are with you they belong not to you……. child You are the bows from which your children as living arrows are sent forth…
Ending my time in Europe I was able to enjoy 6 days in Norway with my eldest son Alasdair before he took up his first job in England since recently qualifying as a vet. I was grateful for this time with him as his possibilities for long holidays and ‘time with Mum’ are so much less now that he has left student life behind and embarks on his chosen career. I never cease to give thanks for my children each one so special in their own way.
And so I returned to Malawi. I must admit having felt rather apprehensive during the last few days in UK. I was ready to return, I felt strong and enthusiastic but leaving the comfort and security of family to return to the huge challenges of living and working in one of the poorest countries in the world left me feeling somewhat fearful.
Needless to say the sight of our dear friends and neighbors who were at the airport to meet us, soon chased away any feeling of doubt I had regarding continuing with my work and our life here in Lilongwe.
So I returned to Bwaila. Having played such a huge role in the setting up of the new Bwaila Maternity Unit it felt like going home as I walked through the doors of labour ward, that first day after nearly 6 weeks away, to be greeted with screams of welcome by my midwife colleagues.
It had been a difficult December as the unit had been without regular medical cover leaving the midwives and clinical officers to take full responsibility for the everyday running of what is probably the busiest maternity in the whole of Southern Africa. Despite predictions that the work load at Bwaila would decrease substantially after the opening of the new tertiary care wing at the Lilongwe central hospital ( Ethel Mutharika Maternity Wing) this has not proved to be the case and we continue to attend more than 1,000 births a month. The high risk mothers are now being transferred and the health centers are sending their difficult cases directly to EMMW. We still have many extremely sick women and emergencies to attend. I can honestly say that the past 6 weeks have been some of the busiest I have experienced since I arrived 3 years ago.
January sees the start of the clinical placements for our midwifery students. This year with an increase in students being trained it also means an increase in the number of students needing close supervision and clinical teaching in the ward situation. We have also had a new set of interns and clinical officer students on the unit all of whom need constant teaching. I quickly decided on my return that I should make my priority during this time the teaching and supervision of students of all cadres. It has been a pleasure to work with the interns, most of whom are highly motivated and enthusiastic learners. They are quick to learn and quickly become essential to the safe medical coverage of the unit. The student midwives are of varying levels of enthusiasm and competence. They have little input from the college staff due to shortage of tutors which means that their practical skills need to be taught by our own permanent midwifery staff. There is still some reluctance on the part of some of these to undertake this role. Others truly do not have the necessary skills to pass on their knowledge to students. I have spent most of my time this past month dedicated to this. I actually enjoy this part of my work tremendously and find that my own enthusiasm plays a key part in effectively creating greater interest and understanding thus leading to better and more adequate care.
As well as teaching I often find that I am the most experienced obstetric professional on the unit. This means that my expertise is being constantly sought to aid in difficult and emergency situations. I was very pleased to welcome a new Nigerian registrar onto the unit. We have already worked together in the past and are personal friends. We refer to each other constantly which gives vital strength to the medical and midwifery cover. I truly feel that together the possibilities to effectuate change are more than ever present.
This doesn’t mean that labour ward is without its distressing incidents.
I had decide to finish a little earlier last Friday afternoon to allow myself time to catch up on some of the more formal teaching preparation and administrative work that forms an important part of my work. It was 3.30pm and the ward was quieter and under control. There were 3 women still waiting for their emergency c/sections, one of whom had been waiting for more than 3 hours. The interns were operating which inevitably leads to delays as their inexperience means that the procedure takes much longer. I had already requested that a more experienced person took over for the 2nd patient as I feared that the outcomes of the waiting women and their babies would be adversely affected if they delayed further. The 2nd c/section was performed by one of our clinical officers but 2 were still waiting. A young 16 year old was just not progressing to delivery. She had been referred by a district health centre and despite all our efforts it became clear that the baby needed to be delivered abdominally. The other was a very small, very short young mother who had not been able to deliver her first child vaginally due to a disproportion between the pelvis and the fetus. There are many women in Malawi whose growth has been arrested during childhood and adolescence due to malnutrition or illness resulting in inadequate development of the bony pelvis which does not allow for normal delivery. Although a c/section is a life saving procedure for both mother and baby we are very reluctant to put a woman through surgery unless it is absolutely necessary. Once she has a scarred uterus she carries the added risk of rupture in any subsequent pregnancy. This is a real danger to our Malawian women living in the more rural areas with no adequate transport to a health facility and with the frequent use of local roots and herbs to induce or speed up labour in a very aggressive manner. I had collected my belongings and was walking out of the ward when greeted by a new referred patient with ‘a retained 2nd twin with fetal distress’, of course I could not leave. Calling for one of our clinical officers who just happened to be around I quickly took her into a delivery room to assess the situation. We performed a quick ultra sound scan on the baby and found a very slow irregular heart beat. This baby needed to be born fast! A c/section was not an option for at least 2 hours so I decided to attempt a vaginal delivery to save the baby. I called another midwife to help set up an IV line, empty the bladder and bring a vacuum extractor. It was not an easy procedure. The fetal head was high and the vaginal tissue, cervix and first umbilical cord were all in the way as I tried to place the vacuum cup on the baby’s head. It took almost 15 minutes to successfully extract the baby and I feared for its life. I have done this procedure before and it requires a great deal of cooperation from the mother and the medical team. At last the cup was placed and the baby extracted with ease. I was amazed and exhilarated when it came out alive! With a little resuscitation the baby was soon crying though still with breathing difficulties so I sent him to nursery for further management. Today he is doing well.
It was now past 4.30pm Before I left I went to theatre to make sure that the clinician on the night shift was aware of the 2 women still waiting for their operations. I could do no more and there was no time to consider administrative tasks. I arrived home after 5pm exhausted. It was Friday afternoon and the thought of the weekend, the rest and free time with Fiona and Lucas filled me with joy and hope.
Despite everything…..I love Bwaila!
When love beckons to you, follow him, Though his ways be hard and steep. . And when his wings enfold you yield to him, Though the sword hidden among his pinions may wound you…… For even as love crowns you so shall he crucify you. Even as he is for your growth so is he for your pruning…… All these things shall love do unto you that you may know the secrets of your heart… And think not that you can direct the course of love, for love, if it finds you worthy, directs your course.
Sunday, 28 November 2010
TIME OUT
Today I start my annual vacation. We will return to Europe for the month of December. I need rest; I need to recover, to find the renewed strength and enthusiasm vitally needed to face the ongoing challenges that will present at Bwaila next year. To put back, to replenish, to be in the company of my precious children, my family and old friends, to feel their love fill me and their support encourage me to continue to be able to give and to serve the very poor, very neglected, very under privileged women and babies of Malawi.
It’s been a very hard two weeks. Since the new referral unit opened at Kamuzu Central Hospital and we at Bwaila became a District Maternity Unit the number of births we are attending has hardly changed. We are daily attending more than 40 births many of which need very special care and attention.The new central unit took some of the more difficult cases but they also took ALL our medical staff. We are now led by the District Health Management Team who for many reasons, not least the huge area/population that falls into their responsibility, are noticeable by their absence. Staffed mainly by midwives, with their continued reluctance to take on more responsibility, a few clinical officers with very varying abilities plus interns and students it has become evident that the care we are giving is less than adequate and the women and babies are suffering.
Having diagnosed severe fetal distress in a young first time mother who was still not in active labour I found the clinician in charge to request an immediate c/section. It was 12.30pm. Theatre was informed, the admission nurse was ordered to prepare the mother for theatre and I had to leave the unit for one hour. On my return I asked after her and it was presumed that she was in theatre. I thought no more of her and continued with other work. A 2pm I overheard a conversation which sounded as if it concerned this woman. I was called to scan a woman as the midwife couldn't hear the fetal heart. Entering Room 8 I found my emergency c/section woman still waiting to be prepared for theatre. She had been put in a room and been forgotten. I quickly scanned her and to my relief found that the baby's heart beat was still present but extremely fast. This baby was in severe distress. We prepared her for theatre and the baby was extracted at 2.50pm nearly and two a half hours after I had first recognized the problem. The baby was born dead.
This is unacceptable.
Our protocol on the unit is to perform c/section on all first time mothers whose babies are presenting breech (bottom first)
Wednesday morning on arrival at labour ward I was told there was a breech delivery on a primigravida, fully dilated and pushing, in Room 4. On entering the room I could see that both the baby's feet and legs were visible, blue and puffy. This baby needed delivering fast. Realizing that it was too late for a c/section I quickly put up an IV and emptied her bladder. I delivered the baby with the appropriate maneuvers and some help from a young Norwegian midwife colleague. After resuscitating the baby it was able to stay with its mother without need for nursery care. This mother had been on our labour ward for most of the night but the breech presentation had not been diagnosed.
This is unacceptable
Thursday morning I arrived as usual at 7.15am. I enquired if there were any problems and was told there was a breech to be delivered in Room 2. On entering I found both feet and legs already delivered, blue and puffy. Glancing at her case file I realized she was a primigravida... NOT AGAIN! I commenced the IV line and emptied her bladder and couldn’t believe that I was facing the same again, two consecutive days. Slightly encouraged by the experience of the previous day though a little alarmed by the size of the baby's feet (I imagined a big baby) I started to deliver the breech. The shoulders came well, with the correct maneuvers, but the head got stuck. I attempted all the correct maneuvers, instructed a colleague to assist and at last the baby's head was born. I rushed the baby to the resuscitaire but my attempts were in vain. The baby died.3.3kg...Too big for a 17 year old woman. Looking back over her file I found that she had been admitted before midnight, the midwife had not been sure of the presenting part so requested USS confirmation. The young intern performed the scan and was also not sure but documented that the scan should be repeated in the morning by seniors. Both recorded a head presentation. She spent the night on the Ante Natal Ward calling for help around 7am as she felt her 'waters' break and 'something' in her vagina. She was attended 30 minutes later when she was found with the baby's feet protruding. They rushed her to labour ward which is where I found her. Three mistakes from inexperienced staff with no senior back up resulted in a young mother with no live baby.
This is unacceptable.
Friday morning I arrived at the same time. I looked into Room 2 and saw one of our new midwives attending a birth. I opened the door to greet her and ensure she was OK when I became aware that a breech was hanging out delivered to the level of the umbilicus. The shoulders and head had still not been born. I noted that the baby's colour was blue nearly white and the umbilical cord was not pulsating, this is not a good sign. I had no idea of what had happened prior to my entry nor how long the baby had been waiting to be born but I could see that it needed delivering quickly. I encouraged the midwife to actively assist with the birth of the shoulders when it became obvious that she was unsure as to how to manage the situation. I tried to explain but quickly had to 'take over.' The shoulders came easily. 'Is it her first?' I asked. 'No it's her second child' I was told. That made me feel better. I soon realized that no contractions were coming to facilitate the birth of the head. 'Put some Oxytocin in her IV line' I ordered. I looked up...There was no IV line! I had been quick but by now I was extremely concerned for the well being of the baby. Still there were hardly any contractions meaning that the mother’s pushes had little effect. I had already called for help from another midwife who I instructed to assist with the flexion of the after coming head. Should I take time to put up an IV line or continue to try and extract the head? Time was running out and I knew it....whatever I did would be wrong, whatever I did would probably not be in time....I couldn't believe it, I didn't have time to save this baby. Time had run out. Too much time had passed. The baby was already dead, maybe it had died before I entered the room? I don't know, but I felt useless, I felt impotent, I was angry, I was frustrated, I was devastated. I told the mother I could do no more. I calmly put up the IV line with Oxytocin, I emptied her bladder of over 1000mls. of urine and with no more than 3 good contractions and pushes I easily extracted her 2.9kg baby. The baby had died due to a full bladder that had prevented the head from descending, poor uterine contractions with no IV line to allow me to give the correct medication and a huge lack of skilled staff.
This is unacceptable.
Of course it is not only due to lack of staff, to lack of experienced staff, to lack of the drive to improve skills, to implement knowledge and skills that cause these tragedies. No, it is so much deeper and more complicated than that. The wages are unacceptably low, the work load is heavy, constantly heavy, the moral is low and the staff are little appreciated by the higher management. They are easily and quickly critiscised when things go wrong but rarely praised for their efforts.
This is unacceptable.
A few weeks ago our only ambulance was taken to be used on ‘stand by’ for the African Union Conference in Lilongwe. It was parked for a whole week outside the hotel just in case one of those eminent people should need emergency transport. An open ‘pick up’ truck was provided some days or else an old hard top truck. It was in these vehicles I made two emergency transfers to the central hospital. The mother had been transferred to us through a local health centre after a home birth. She had had a massive hemorrhage and was critically ill. We stabilized her condition at Bwaila and managed to find one bag of blood to transfuse but she needed more blood and to be cared for in the ICU. Just getting a patient in this condition into the back of a truck is a challenge but then we also had to transport her numerous relatives with bags and bowls and even a bundle of fire wood. I took up my seat in the front facing backwards to check her condition and carrying an ambu bag just in case she stopped breathing. I prayed that her condition would not deteriorate as I could not imagine performing effective resuscitation in this truck. I ordered the driver to get there quick, that this was an emergency. We started off out of the hospital and onto the busy shopping area surrounding Bwaila. “Put on the siren” I ordered. There was no siren. “OK , then sound the horn” The horn was not working. “Lights” No, not working either.
This is unacceptable
What an amazing driver! Totally oblivious to any danger, or so it seemed, he pulled out into the centre of all the traffic and just kept going. Not to be deterred by either on- coming trucks or pedestrians he just kept going. Luckily I was facing backwards for most of the journey, except when we came to junctions or traffic lights when I stuck my head out of the window, waved my ambu bag and shouted very impolitely for people to get out of the way. It worked .We arrived in record time and delivered our patient into the care of the ICU staff still alive. Our return journey was somewhat more sober. “ Madam,” exclaimed the driver. “ We were all very impressed with how you cared enough to make sure we got there quickly, this is not normal behavior, the relatives have asked me to thank you”
( No I guess this is not usual Malawi behavior but I had done it before. I was reminded of an incident when I was seen almost flying down the mountain road in Spain, waving my white flag out of the window, as I personally and successfully transported one of my ‘home birth’ mothers to the nearest hospital.)
Each and every one of these women stays with me today. My heart is sad and my spirits are low as I leave Malawi. It is such a difficult place to leave. So much to do, so much suffering, so much poverty, such a hard life for so many. I love these people, I want to always do my best for them and it is so hard to accept that even my best is often not enough.
Now I am back in England in the arms of my family and soon I will be reunited with my children.
One is loved because one is loved. One loves because one loves
No reason is needed for loving.
‘
It’s been a very hard two weeks. Since the new referral unit opened at Kamuzu Central Hospital and we at Bwaila became a District Maternity Unit the number of births we are attending has hardly changed. We are daily attending more than 40 births many of which need very special care and attention.The new central unit took some of the more difficult cases but they also took ALL our medical staff. We are now led by the District Health Management Team who for many reasons, not least the huge area/population that falls into their responsibility, are noticeable by their absence. Staffed mainly by midwives, with their continued reluctance to take on more responsibility, a few clinical officers with very varying abilities plus interns and students it has become evident that the care we are giving is less than adequate and the women and babies are suffering.
Having diagnosed severe fetal distress in a young first time mother who was still not in active labour I found the clinician in charge to request an immediate c/section. It was 12.30pm. Theatre was informed, the admission nurse was ordered to prepare the mother for theatre and I had to leave the unit for one hour. On my return I asked after her and it was presumed that she was in theatre. I thought no more of her and continued with other work. A 2pm I overheard a conversation which sounded as if it concerned this woman. I was called to scan a woman as the midwife couldn't hear the fetal heart. Entering Room 8 I found my emergency c/section woman still waiting to be prepared for theatre. She had been put in a room and been forgotten. I quickly scanned her and to my relief found that the baby's heart beat was still present but extremely fast. This baby was in severe distress. We prepared her for theatre and the baby was extracted at 2.50pm nearly and two a half hours after I had first recognized the problem. The baby was born dead.
This is unacceptable.
Our protocol on the unit is to perform c/section on all first time mothers whose babies are presenting breech (bottom first)
Wednesday morning on arrival at labour ward I was told there was a breech delivery on a primigravida, fully dilated and pushing, in Room 4. On entering the room I could see that both the baby's feet and legs were visible, blue and puffy. This baby needed delivering fast. Realizing that it was too late for a c/section I quickly put up an IV and emptied her bladder. I delivered the baby with the appropriate maneuvers and some help from a young Norwegian midwife colleague. After resuscitating the baby it was able to stay with its mother without need for nursery care. This mother had been on our labour ward for most of the night but the breech presentation had not been diagnosed.
This is unacceptable
Thursday morning I arrived as usual at 7.15am. I enquired if there were any problems and was told there was a breech to be delivered in Room 2. On entering I found both feet and legs already delivered, blue and puffy. Glancing at her case file I realized she was a primigravida... NOT AGAIN! I commenced the IV line and emptied her bladder and couldn’t believe that I was facing the same again, two consecutive days. Slightly encouraged by the experience of the previous day though a little alarmed by the size of the baby's feet (I imagined a big baby) I started to deliver the breech. The shoulders came well, with the correct maneuvers, but the head got stuck. I attempted all the correct maneuvers, instructed a colleague to assist and at last the baby's head was born. I rushed the baby to the resuscitaire but my attempts were in vain. The baby died.3.3kg...Too big for a 17 year old woman. Looking back over her file I found that she had been admitted before midnight, the midwife had not been sure of the presenting part so requested USS confirmation. The young intern performed the scan and was also not sure but documented that the scan should be repeated in the morning by seniors. Both recorded a head presentation. She spent the night on the Ante Natal Ward calling for help around 7am as she felt her 'waters' break and 'something' in her vagina. She was attended 30 minutes later when she was found with the baby's feet protruding. They rushed her to labour ward which is where I found her. Three mistakes from inexperienced staff with no senior back up resulted in a young mother with no live baby.
This is unacceptable.
Friday morning I arrived at the same time. I looked into Room 2 and saw one of our new midwives attending a birth. I opened the door to greet her and ensure she was OK when I became aware that a breech was hanging out delivered to the level of the umbilicus. The shoulders and head had still not been born. I noted that the baby's colour was blue nearly white and the umbilical cord was not pulsating, this is not a good sign. I had no idea of what had happened prior to my entry nor how long the baby had been waiting to be born but I could see that it needed delivering quickly. I encouraged the midwife to actively assist with the birth of the shoulders when it became obvious that she was unsure as to how to manage the situation. I tried to explain but quickly had to 'take over.' The shoulders came easily. 'Is it her first?' I asked. 'No it's her second child' I was told. That made me feel better. I soon realized that no contractions were coming to facilitate the birth of the head. 'Put some Oxytocin in her IV line' I ordered. I looked up...There was no IV line! I had been quick but by now I was extremely concerned for the well being of the baby. Still there were hardly any contractions meaning that the mother’s pushes had little effect. I had already called for help from another midwife who I instructed to assist with the flexion of the after coming head. Should I take time to put up an IV line or continue to try and extract the head? Time was running out and I knew it....whatever I did would be wrong, whatever I did would probably not be in time....I couldn't believe it, I didn't have time to save this baby. Time had run out. Too much time had passed. The baby was already dead, maybe it had died before I entered the room? I don't know, but I felt useless, I felt impotent, I was angry, I was frustrated, I was devastated. I told the mother I could do no more. I calmly put up the IV line with Oxytocin, I emptied her bladder of over 1000mls. of urine and with no more than 3 good contractions and pushes I easily extracted her 2.9kg baby. The baby had died due to a full bladder that had prevented the head from descending, poor uterine contractions with no IV line to allow me to give the correct medication and a huge lack of skilled staff.
This is unacceptable.
Of course it is not only due to lack of staff, to lack of experienced staff, to lack of the drive to improve skills, to implement knowledge and skills that cause these tragedies. No, it is so much deeper and more complicated than that. The wages are unacceptably low, the work load is heavy, constantly heavy, the moral is low and the staff are little appreciated by the higher management. They are easily and quickly critiscised when things go wrong but rarely praised for their efforts.
This is unacceptable.
A few weeks ago our only ambulance was taken to be used on ‘stand by’ for the African Union Conference in Lilongwe. It was parked for a whole week outside the hotel just in case one of those eminent people should need emergency transport. An open ‘pick up’ truck was provided some days or else an old hard top truck. It was in these vehicles I made two emergency transfers to the central hospital. The mother had been transferred to us through a local health centre after a home birth. She had had a massive hemorrhage and was critically ill. We stabilized her condition at Bwaila and managed to find one bag of blood to transfuse but she needed more blood and to be cared for in the ICU. Just getting a patient in this condition into the back of a truck is a challenge but then we also had to transport her numerous relatives with bags and bowls and even a bundle of fire wood. I took up my seat in the front facing backwards to check her condition and carrying an ambu bag just in case she stopped breathing. I prayed that her condition would not deteriorate as I could not imagine performing effective resuscitation in this truck. I ordered the driver to get there quick, that this was an emergency. We started off out of the hospital and onto the busy shopping area surrounding Bwaila. “Put on the siren” I ordered. There was no siren. “OK , then sound the horn” The horn was not working. “Lights” No, not working either.
This is unacceptable
What an amazing driver! Totally oblivious to any danger, or so it seemed, he pulled out into the centre of all the traffic and just kept going. Not to be deterred by either on- coming trucks or pedestrians he just kept going. Luckily I was facing backwards for most of the journey, except when we came to junctions or traffic lights when I stuck my head out of the window, waved my ambu bag and shouted very impolitely for people to get out of the way. It worked .We arrived in record time and delivered our patient into the care of the ICU staff still alive. Our return journey was somewhat more sober. “ Madam,” exclaimed the driver. “ We were all very impressed with how you cared enough to make sure we got there quickly, this is not normal behavior, the relatives have asked me to thank you”
( No I guess this is not usual Malawi behavior but I had done it before. I was reminded of an incident when I was seen almost flying down the mountain road in Spain, waving my white flag out of the window, as I personally and successfully transported one of my ‘home birth’ mothers to the nearest hospital.)
Each and every one of these women stays with me today. My heart is sad and my spirits are low as I leave Malawi. It is such a difficult place to leave. So much to do, so much suffering, so much poverty, such a hard life for so many. I love these people, I want to always do my best for them and it is so hard to accept that even my best is often not enough.
Now I am back in England in the arms of my family and soon I will be reunited with my children.
One is loved because one is loved. One loves because one loves
No reason is needed for loving.
‘
Monday, 15 November 2010
COMPUTER TECHNOLOGY
There’s no denying that computer technology is the way forward. There is no denying that in the long term an electronic patient register along with accurate recording of hospital data will assist us in identifying our shortfalls and so technically lead to improved patient care.....but....
As you may well imagine it’s an attractive proposal for any would be donor. It looks good on paper and sounds convincing…but…
Over the past year I have been actively involved with an expert team as they worked on creating the appropriate software. Funding became available for the setting up of a simple registration system to suit the needs of the unit and provide the necessary hardware. For this we are grateful. Latterly more funds became available to expand the project, meaning that I have needed to dedicate more of my time to attend meetings and aid with preparatory work. I trust this time away from the clinical situation, away from labour ward has been well spent…but…
Inevitably there will be some resistance from the staff at first until they become familiar with this new method of record keeping but we hope that it will lead to far greater accuracy and therefore better care. Leaving paper behind and changing over to electronic recording should ease the constant challenge we face daily when paper is not available for photocopying. We are assured that it will prove to be easier and quicker but at present I doubt it!
I arrived on labour ward last Friday at the usual time (7.15am.) I found the ward full of laboring mothers with many women sitting on the floor outside the Admission Room waiting to be assessed. On enquiring as to how the night had been I was informed that for the second time in one week there had been just 3 midwives on duty…. Three midwives to attend 27 births.
My first job is to take a look round the ward and receive the ‘hand over’ from the night staff. I must make a quick assessment of the situation and start to prioritize. I am usually the first to arrive much to the relief of the tired and overworked night staff. The arrival of my daytime colleagues is generally delayed and sporadic, meaning I often find myself alone or with one other midwife for the following hour. It has always been a difficult time as I try to sort out the problems left over from the night performing vacuum extractions on prolonged labours and subsequently resuscitating babies that should have been born hours before.
The morning report in the conference room attended by the clinical staff, in-charge midwives and matrons begins at 8am. It is an important time when we get together as a team to discuss the events of the previous 24 hours and the plans for the day. Very often I am not able to attend as there is no one else to cover the labour ward.
At 9.30am I was called to a meeting with the matrons of the Family Health Unit ( antenatal clinic, immunizations, postnatal clinic, etc. …all out-patients) We were to meet with those involved in the development of the new ICT program. I left instructions with the student midwife as to the plan of care for the mother with prolonged labour in Room1 and asked a more qualified midwife to cover her. ‘ If she has not delivered in the next hour please assist with a vacuum extraction or send her to theatre’ I always feel uneasy leaving the more difficult cases but I was needed in the meeting. One and a half hours later I returned to labour ward. The baby had just been born and needed resuscitation and the mother was bleeding. I quickly performed the necessary resuscitation and as soon as I felt able to leave the baby went to assist the midwife who was attending the mother. After controlling the hemorrhage I left the student to suture and document.
So I was in a meeting with the aim of improving care, whilst a baby nearly died and a mother nearly bled to death!
How difficult it is at these times to appreciate the possible benefits of a computerized system when we are having such huge challenges just performing the basic care.
The day continued to be hugely busy with many complicated and demanding situations. I was due to attend a further ICT meeting at 1.30pm. but this was just impossible. I could not leave labour ward at this time, especially after my experience of the morning. Lunch breaks range from 12.30 until 2pm when we work with just a minimum staff. I have always chosen not to take a lunch break preferring to work during this critical time but aim to leave a little earlier. As you can imagine leaving a little earlier does not often happen! Two women with severe pre-eclampsia ( high blood pressure etc.) were admitted during this time. Finding myself without a clinician but now totally familiar with the protocol and treatment of this very serious condition I go ahead and administer the appropriate drugs and care. The challenge then became apparent…… I needed to inject (IM)large doses of Magnesium Sulphate to prevent convulsions a truly dangerous complication of pre eclampsia carrying a high risk both to the life of the mother and the baby. This medication needs to be mixed with local anesthetic otherwise it is an extremely painful procedure. I knew we had been running down our stocks for the past 4 days but were now completely without it. I was aware that the midwives had been suturing the women’s perineums without it, which is totally unacceptable, but assumed that either it was ‘on its way’ or I could ‘borrow’ from another ward. But NO there was no stock in the hospital nor in the pharmacy. I made calls to the Medical officer in-charge who was in a meeting and would call later. The question was now whether I should give the Mag. Sulph. without anesthetic and risk the possible consequences or cause the mother intense pain? I gave the IV dose and waited. Before I left to go home 10 bottles were supplied and I was able to give the medication. I wonder how long that lasted and whether there will be any tomorrow?
Physically and emotionally exhausted by 3pm on Friday afternoon I was further challenged by the admission of a woman in advanced labour carrying a twin pregnancy complicated by a previous c/section scar. Our protocol advises that in our circumstances these women should not labour as the risk of rupturing her uterus and causing death of the child and possibly of the mother is very high. I had just sent another mother for c/section so knew that the theatre would be occupied for some time. I decided that in view of the fact that she was almost ready to push her babies out I would attempt a vaginal delivery. The first twin I delivered quickly and easily assisting with a vacuum extraction to prevent unnecessary strain on the uterus. The second twin decided to put its hand alongside its head making the whole process much more difficult. The little one was born, also with the help of a vacuum extraction 30min. later needing intensive resuscitation which was successful .Even though I gave the necessary medication to prevent hemorrhage the mother still bled excessively , but these are strong women and the outcome for both mother and twins was good.
I went home exhausted…..I burst into tears ….I had a warm bath and a cup of tea… then danced and partied until 3 o’clock in the morning!
It was just another day at Bwaila……….
Today is Monday so I went to check up on my twins from Friday. The little boy(number 2) is still in nursery but doing really well. I am always amazed and humbled to recognize the great power and strength of our instimct to survive. I also visited mum and first twin(big sister) on postnatal ward. I was greeted by huge smiles and hugs. The mother was so happy to have avoided a second c/section making her so much more able to care for her twins.
The toilets are still blocked since Friday and we are running out of local anesthetic again but life goes on at Bwaila and I am happy to be here.
As you may well imagine it’s an attractive proposal for any would be donor. It looks good on paper and sounds convincing…but…
Over the past year I have been actively involved with an expert team as they worked on creating the appropriate software. Funding became available for the setting up of a simple registration system to suit the needs of the unit and provide the necessary hardware. For this we are grateful. Latterly more funds became available to expand the project, meaning that I have needed to dedicate more of my time to attend meetings and aid with preparatory work. I trust this time away from the clinical situation, away from labour ward has been well spent…but…
Inevitably there will be some resistance from the staff at first until they become familiar with this new method of record keeping but we hope that it will lead to far greater accuracy and therefore better care. Leaving paper behind and changing over to electronic recording should ease the constant challenge we face daily when paper is not available for photocopying. We are assured that it will prove to be easier and quicker but at present I doubt it!
I arrived on labour ward last Friday at the usual time (7.15am.) I found the ward full of laboring mothers with many women sitting on the floor outside the Admission Room waiting to be assessed. On enquiring as to how the night had been I was informed that for the second time in one week there had been just 3 midwives on duty…. Three midwives to attend 27 births.
My first job is to take a look round the ward and receive the ‘hand over’ from the night staff. I must make a quick assessment of the situation and start to prioritize. I am usually the first to arrive much to the relief of the tired and overworked night staff. The arrival of my daytime colleagues is generally delayed and sporadic, meaning I often find myself alone or with one other midwife for the following hour. It has always been a difficult time as I try to sort out the problems left over from the night performing vacuum extractions on prolonged labours and subsequently resuscitating babies that should have been born hours before.
The morning report in the conference room attended by the clinical staff, in-charge midwives and matrons begins at 8am. It is an important time when we get together as a team to discuss the events of the previous 24 hours and the plans for the day. Very often I am not able to attend as there is no one else to cover the labour ward.
At 9.30am I was called to a meeting with the matrons of the Family Health Unit ( antenatal clinic, immunizations, postnatal clinic, etc. …all out-patients) We were to meet with those involved in the development of the new ICT program. I left instructions with the student midwife as to the plan of care for the mother with prolonged labour in Room1 and asked a more qualified midwife to cover her. ‘ If she has not delivered in the next hour please assist with a vacuum extraction or send her to theatre’ I always feel uneasy leaving the more difficult cases but I was needed in the meeting. One and a half hours later I returned to labour ward. The baby had just been born and needed resuscitation and the mother was bleeding. I quickly performed the necessary resuscitation and as soon as I felt able to leave the baby went to assist the midwife who was attending the mother. After controlling the hemorrhage I left the student to suture and document.
So I was in a meeting with the aim of improving care, whilst a baby nearly died and a mother nearly bled to death!
How difficult it is at these times to appreciate the possible benefits of a computerized system when we are having such huge challenges just performing the basic care.
The day continued to be hugely busy with many complicated and demanding situations. I was due to attend a further ICT meeting at 1.30pm. but this was just impossible. I could not leave labour ward at this time, especially after my experience of the morning. Lunch breaks range from 12.30 until 2pm when we work with just a minimum staff. I have always chosen not to take a lunch break preferring to work during this critical time but aim to leave a little earlier. As you can imagine leaving a little earlier does not often happen! Two women with severe pre-eclampsia ( high blood pressure etc.) were admitted during this time. Finding myself without a clinician but now totally familiar with the protocol and treatment of this very serious condition I go ahead and administer the appropriate drugs and care. The challenge then became apparent…… I needed to inject (IM)large doses of Magnesium Sulphate to prevent convulsions a truly dangerous complication of pre eclampsia carrying a high risk both to the life of the mother and the baby. This medication needs to be mixed with local anesthetic otherwise it is an extremely painful procedure. I knew we had been running down our stocks for the past 4 days but were now completely without it. I was aware that the midwives had been suturing the women’s perineums without it, which is totally unacceptable, but assumed that either it was ‘on its way’ or I could ‘borrow’ from another ward. But NO there was no stock in the hospital nor in the pharmacy. I made calls to the Medical officer in-charge who was in a meeting and would call later. The question was now whether I should give the Mag. Sulph. without anesthetic and risk the possible consequences or cause the mother intense pain? I gave the IV dose and waited. Before I left to go home 10 bottles were supplied and I was able to give the medication. I wonder how long that lasted and whether there will be any tomorrow?
Physically and emotionally exhausted by 3pm on Friday afternoon I was further challenged by the admission of a woman in advanced labour carrying a twin pregnancy complicated by a previous c/section scar. Our protocol advises that in our circumstances these women should not labour as the risk of rupturing her uterus and causing death of the child and possibly of the mother is very high. I had just sent another mother for c/section so knew that the theatre would be occupied for some time. I decided that in view of the fact that she was almost ready to push her babies out I would attempt a vaginal delivery. The first twin I delivered quickly and easily assisting with a vacuum extraction to prevent unnecessary strain on the uterus. The second twin decided to put its hand alongside its head making the whole process much more difficult. The little one was born, also with the help of a vacuum extraction 30min. later needing intensive resuscitation which was successful .Even though I gave the necessary medication to prevent hemorrhage the mother still bled excessively , but these are strong women and the outcome for both mother and twins was good.
I went home exhausted…..I burst into tears ….I had a warm bath and a cup of tea… then danced and partied until 3 o’clock in the morning!
It was just another day at Bwaila……….
Today is Monday so I went to check up on my twins from Friday. The little boy(number 2) is still in nursery but doing really well. I am always amazed and humbled to recognize the great power and strength of our instimct to survive. I also visited mum and first twin(big sister) on postnatal ward. I was greeted by huge smiles and hugs. The mother was so happy to have avoided a second c/section making her so much more able to care for her twins.
The toilets are still blocked since Friday and we are running out of local anesthetic again but life goes on at Bwaila and I am happy to be here.
Friday, 8 October 2010
SOMETIMES A STRUGGLE
The back-up generator broke down and the power went off on Sunday morning from eleven am. until nine pm.
The on call anesthetist just didn’t show up for duty
….but life went on at Bwaila.
These sort of situations are unimaginable in the developed countries but not with us here at Bwaila, one of the busiest maternity units in the whole of Southern Africa.
So what happened?
38 babies were born during that time.
6 mothers were transferred to the new referral unit it the central hospital for emergency c/sections and 2 babies died. Fortunately we didn’t lose any of our mothers.
I arrived on labour ward on Monday morning unaware, at that time, of the difficulties that had been faced by our staff the previous day and night. The only evidence was the half burnt candles still present around the ward. Many babies will have been born by the light of those few candles and many will have been born in darkness. I was approached by the clinician who had been on call that night. ‘How’s the night been?’ I enquired. ‘Bad, really bad!‘ he replied and proceeded to explain the situation. He asked me to come and see the woman in room 1. It was her 3rd pregnancy. She was fully dilated and had been pushing since 1am. That was over six and half hours ago! The clinician had tried to extract the baby with the aid of a vacuum extraction somewhere around 2am. but without success. He tried in vain to send her to the referral unit but was told that they were too busy. Unable to make any other arrangements and without the anesthetic necessary to perform the emergency c/section, she was still in her room contracting and pushing when I examined her at 7.30am. The fetal heart beat was still present but inevitably showed signs of severe distress. It was immediately apparent that there was no way this baby could be born vaginally. Time was running out for the baby and possibly for the mother, who after so many hours of obstructed labour was in danger of rupturing her uterus which would result in the need to remove the uterus and could lead to severe haemorrage and possible death. I quickly made sure that she was prepared for theatre and asked the clinician to find out if theatre staff could take her in immediately. Fortunately the anesthetist on duty Monday morning had just arrived. Our voluntary obstetrician from the UK was also present and surgery was commenced. It was a risky and complicated procedure due to the time that she had been obstructed needing the help of our German consultant obstetrician. Having extracted a dead baby they then went on to remove her uterus which had been on the point of rupturing with uncontrollable bleeding.
Today she is recovering in our high risk postnatal ward, she is not in danger of losing her life and that is a good.
Of course this is not acceptable. Of course this brings feeling of anger and frustration but we are in one of the poorest countries in the world. The whole health system is inadequate for its people. We are understaffed, under skilled and poor equipped in every way. As clinicians and midwives at Bwaila we are improving, the care and attention to the patient is rarely consistent and the infrastructure does not always support us but we must keep positive and enthusiastic as we aim for excellence.
The new Ethel Mutharika Maternity Wing has now opened at the central hospital. Bwaila will slowly change its function to becoming the District Maternity Unit. All the high risk patients will be sent to the new wing where they can be cared for by a larger medical team and backed-up with an intensive care unit and improved neonatal services.
We will continue to be extremely busy as we the care for the women and babies of the ever increasing and expanding population of the district of Lilongwe. We will still receive referrals from the health centres and villages as well as caring for the pregnancies, babies and young children of the area. Dealing with emergencies, stabilizing patients for transfer and maintaining our own operating theatres will continue to be a huge task. We will lose our doctors to the central hospital leaving the unit to be staffed by Clinical Officers and midwives. The need for more highly skilled midwives will be greater than ever. Midwives able and ready to use their knowledge, make accurate assessments, good decisions and follow through as skilled practitioners is my aim.
I continue to do classroom teaching twice a week and bedside teaching on a daily basis. It’s tiring and often frustrating but it’s slowly making a difference and I am proud of the way some of our midwives are responding.
At the beginning of the year I was able to find funding to present a ‘midwife of the month award’ as a means of encouraging good practice. At that time it was very clear who would win the award as those few clearly out-shone all others. I am pleased to say that we are now finding it very difficult to select just one person each month. This is a sure sign that there are now many outstanding midwives. I find this extremely encouraging…..and you should too!
Last week was a quiet week. Just 25 to 30 births each day. We continued to keep busy but without the sensation that many of the women were receiving less than adequate care.
Today is Monday. I arrived on labour ward soon after 7am. 18 babies were born before 12midday. Just 5 midwives reported for duty this morning. We then lost 2 of them to meetings which left 3 of us to cover the ward, admission room and theatre. There are always problems to solve from the night and also things left over from the weekend. Inductions, prolonged labours, fetal distress, referrals, all needing our time and skills. This generally means that the easy ones end up birthing alone, calling out for the midwife as they push their babies out onto the bed. We enter the room just to clamp the cord delivery the placenta and move on. The babies get weighed, later…. if we find time, the documentation is scanty and the after-care often non- existent. I must have delivered more than 10 babies myself but did not have time to take even one blood pressure. In an attempt to avoid un-necessary c/sections I assisted two women with vacuum extractions and successfully delivered a breech on a very young primigravida. The baby needed resuscitating and the mother suturing. The outcome was good for both, but extremely time consuming, meaning that other mothers just had to wait. The midwives seem tired and demotivated today which I always find distressing. We very quickly ran out of delivery packs meaning that for each and every birth I had to search the ward for some way to improvise. The cupboards were almost empty as they had not yet been restocked after the weekend. I could not find any suture material or cord clamps. It was a hard day for me both physically and emotionally.
Last Thursday we had a visit from a team representing the Nursing Council. They came to inspect the ward and the care and attention we are giving to the mothers and babies. The meeting this morning, which I would like to have attended but could not due to shortage of labour ward staff and heavy workload, was to receive the feedback from their visit. Later this afternoon I found time to hear from one of my colleagues the contents of the report. It was highly critical. The infection prevention standards are not being met. The documentation was poor. The care was not up to standard. The midwives had a very defensive attitude. I was angry and disappointed but not surprised. No account was taken of either the huge lack of staff or materials. This report in my opinion served only to decrease an already low morale. So much of my time at Bwaila is spent in raising morale, keeping the atmosphere happy and positive, giving praise for simple tasks done correctly and celebrating good outcomes. I truly believe that although some official appraisal and control of standards is vital it must be done in a realistic and positive way. I wonder how long it will take to get back the enthusiasm at Bwaila?
Just to end on a happier note…..
Fiona has just celebrated her 21st Birthday in Leeds. I was sad not to be able to be with her but will have a special something with her in December when I am in UK.
Katy and Nick’s wedding is getting nearer (Dec.30th) Invitations are being sent and the dress fittings will start soon. It’s all so exciting I can’t wait!
Alasdair is on the lookout for a good job now that he is a fully qualified vet. He was recently interviewed but hasn’t heard yet if he has been successful …….
Lucas is fit and well again after having being diagnosed and treated for Bilharzia. (A nasty little bug picked up in the lake.) He took part in his 1st fishing competition last weekend. He was delighted to win 4th prize.
Sometimes we have to struggle…..sometimes not. The issue is not the struggle: the issue is who we are as we engage in it.
The on call anesthetist just didn’t show up for duty
….but life went on at Bwaila.
These sort of situations are unimaginable in the developed countries but not with us here at Bwaila, one of the busiest maternity units in the whole of Southern Africa.
So what happened?
38 babies were born during that time.
6 mothers were transferred to the new referral unit it the central hospital for emergency c/sections and 2 babies died. Fortunately we didn’t lose any of our mothers.
I arrived on labour ward on Monday morning unaware, at that time, of the difficulties that had been faced by our staff the previous day and night. The only evidence was the half burnt candles still present around the ward. Many babies will have been born by the light of those few candles and many will have been born in darkness. I was approached by the clinician who had been on call that night. ‘How’s the night been?’ I enquired. ‘Bad, really bad!‘ he replied and proceeded to explain the situation. He asked me to come and see the woman in room 1. It was her 3rd pregnancy. She was fully dilated and had been pushing since 1am. That was over six and half hours ago! The clinician had tried to extract the baby with the aid of a vacuum extraction somewhere around 2am. but without success. He tried in vain to send her to the referral unit but was told that they were too busy. Unable to make any other arrangements and without the anesthetic necessary to perform the emergency c/section, she was still in her room contracting and pushing when I examined her at 7.30am. The fetal heart beat was still present but inevitably showed signs of severe distress. It was immediately apparent that there was no way this baby could be born vaginally. Time was running out for the baby and possibly for the mother, who after so many hours of obstructed labour was in danger of rupturing her uterus which would result in the need to remove the uterus and could lead to severe haemorrage and possible death. I quickly made sure that she was prepared for theatre and asked the clinician to find out if theatre staff could take her in immediately. Fortunately the anesthetist on duty Monday morning had just arrived. Our voluntary obstetrician from the UK was also present and surgery was commenced. It was a risky and complicated procedure due to the time that she had been obstructed needing the help of our German consultant obstetrician. Having extracted a dead baby they then went on to remove her uterus which had been on the point of rupturing with uncontrollable bleeding.
Today she is recovering in our high risk postnatal ward, she is not in danger of losing her life and that is a good.
Of course this is not acceptable. Of course this brings feeling of anger and frustration but we are in one of the poorest countries in the world. The whole health system is inadequate for its people. We are understaffed, under skilled and poor equipped in every way. As clinicians and midwives at Bwaila we are improving, the care and attention to the patient is rarely consistent and the infrastructure does not always support us but we must keep positive and enthusiastic as we aim for excellence.
The new Ethel Mutharika Maternity Wing has now opened at the central hospital. Bwaila will slowly change its function to becoming the District Maternity Unit. All the high risk patients will be sent to the new wing where they can be cared for by a larger medical team and backed-up with an intensive care unit and improved neonatal services.
We will continue to be extremely busy as we the care for the women and babies of the ever increasing and expanding population of the district of Lilongwe. We will still receive referrals from the health centres and villages as well as caring for the pregnancies, babies and young children of the area. Dealing with emergencies, stabilizing patients for transfer and maintaining our own operating theatres will continue to be a huge task. We will lose our doctors to the central hospital leaving the unit to be staffed by Clinical Officers and midwives. The need for more highly skilled midwives will be greater than ever. Midwives able and ready to use their knowledge, make accurate assessments, good decisions and follow through as skilled practitioners is my aim.
I continue to do classroom teaching twice a week and bedside teaching on a daily basis. It’s tiring and often frustrating but it’s slowly making a difference and I am proud of the way some of our midwives are responding.
At the beginning of the year I was able to find funding to present a ‘midwife of the month award’ as a means of encouraging good practice. At that time it was very clear who would win the award as those few clearly out-shone all others. I am pleased to say that we are now finding it very difficult to select just one person each month. This is a sure sign that there are now many outstanding midwives. I find this extremely encouraging…..and you should too!
Last week was a quiet week. Just 25 to 30 births each day. We continued to keep busy but without the sensation that many of the women were receiving less than adequate care.
Today is Monday. I arrived on labour ward soon after 7am. 18 babies were born before 12midday. Just 5 midwives reported for duty this morning. We then lost 2 of them to meetings which left 3 of us to cover the ward, admission room and theatre. There are always problems to solve from the night and also things left over from the weekend. Inductions, prolonged labours, fetal distress, referrals, all needing our time and skills. This generally means that the easy ones end up birthing alone, calling out for the midwife as they push their babies out onto the bed. We enter the room just to clamp the cord delivery the placenta and move on. The babies get weighed, later…. if we find time, the documentation is scanty and the after-care often non- existent. I must have delivered more than 10 babies myself but did not have time to take even one blood pressure. In an attempt to avoid un-necessary c/sections I assisted two women with vacuum extractions and successfully delivered a breech on a very young primigravida. The baby needed resuscitating and the mother suturing. The outcome was good for both, but extremely time consuming, meaning that other mothers just had to wait. The midwives seem tired and demotivated today which I always find distressing. We very quickly ran out of delivery packs meaning that for each and every birth I had to search the ward for some way to improvise. The cupboards were almost empty as they had not yet been restocked after the weekend. I could not find any suture material or cord clamps. It was a hard day for me both physically and emotionally.
Last Thursday we had a visit from a team representing the Nursing Council. They came to inspect the ward and the care and attention we are giving to the mothers and babies. The meeting this morning, which I would like to have attended but could not due to shortage of labour ward staff and heavy workload, was to receive the feedback from their visit. Later this afternoon I found time to hear from one of my colleagues the contents of the report. It was highly critical. The infection prevention standards are not being met. The documentation was poor. The care was not up to standard. The midwives had a very defensive attitude. I was angry and disappointed but not surprised. No account was taken of either the huge lack of staff or materials. This report in my opinion served only to decrease an already low morale. So much of my time at Bwaila is spent in raising morale, keeping the atmosphere happy and positive, giving praise for simple tasks done correctly and celebrating good outcomes. I truly believe that although some official appraisal and control of standards is vital it must be done in a realistic and positive way. I wonder how long it will take to get back the enthusiasm at Bwaila?
Just to end on a happier note…..
Fiona has just celebrated her 21st Birthday in Leeds. I was sad not to be able to be with her but will have a special something with her in December when I am in UK.
Katy and Nick’s wedding is getting nearer (Dec.30th) Invitations are being sent and the dress fittings will start soon. It’s all so exciting I can’t wait!
Alasdair is on the lookout for a good job now that he is a fully qualified vet. He was recently interviewed but hasn’t heard yet if he has been successful …….
Lucas is fit and well again after having being diagnosed and treated for Bilharzia. (A nasty little bug picked up in the lake.) He took part in his 1st fishing competition last weekend. He was delighted to win 4th prize.
Sometimes we have to struggle…..sometimes not. The issue is not the struggle: the issue is who we are as we engage in it.
Tuesday, 24 August 2010
GOODBYE TAREK
Agnes was 22years old. She was married with one small child. She lived in a small, extremely poor village on the outskirts of Lilongwe.
Pregnant with her second child she went into labour prematurely at only 7months. Before the first pains of labour began she started having convulsions. The local gulewamkulu (witch doctor) was called as it was presumed by her family and the rest of the village that she had been bewitched. Steps were taken to find the person who was bewitching her. Five days later, after numerous fits she gave birth to a small dead fetus. By now her condition had deteriorated to such an extent that on day 6 post-delivery she stopped talking and walking. They continued to use the services of the gulewamkula and local medicines still believing that this was the only remedy.
Agnes was brought to us on Monday morning at 8.05am. 8 days after giving birth and 13 days after her first convulsion though we presume she must have had signs of her illness well before that. I was asked to go and see a woman in room10 who had arrived in a critical condition. My first impression on seeing Agnes was that she was only just alive. She was deeply unconscious and only taking gasping breaths. I called for help and assisted by a midwife colleague and a student we started to resuscitate Agnes. It was difficult to find a vein in which to insert an IV cannula but we managed to fix 2 lines and take blood samples. We started her on oxygen and quickly catheterized her bladder to check her urine for proteins. At some point I ran to the telephone to call for medical assistance. Whilst the intern doctor tried to get some information from her family so we could get a clearer picture of her condition she went into respiratory and cardiac arrest. It was now 8.15am. I sent for the anaesthetist to intubate and started CPR. We continued to resuscitate for more than 20minutes but with no response whatsoever. Agnes was pronounced dead.
The conclusion was that Agnes had suffered from undiagnosed Eclampsia. Untreated for 11 days she suffered a cerebral vascular accident (CVA) Complicated by puerperal sepsis she finally suffered septic shock, respiratory and cardiac arrest and she died.
This was a totally avoidable maternal death. This condition can be treated.
Of course she came to us far too late. We did everything we could but it was already too late for Agnes. Her family cried and wailed. This was the same family that delayed in bringing her to us for more than 13days due to their local superstitions.
How can this happen? Why are these people still so poorly informed in 2010? Why are these superstitious beliefs still so strong to the extent of allowing their loved ones to die? Why do the women not come to receive care in our hospitals?
Agnes was eventually brought to the hospital which means her death will become part of our Maternal Death Statistics. In Malawi around 900 women in every 100.000 will die in pregnancy, childbirth or immediate post natal period. (In Europe it will be 5-10 per 100.000) But how many young women are being buried out there in the villages without any record being kept?
Agnes was a beautiful young Malawian woman. A mother, a daughter, a wife, a sister and Agnes was very, very, poor….could this be the reason why she died?
Lucas arrived back from Europe yesterday after having been away from Malawi for the past 7 weeks. What a joy, what a pleasure to have him back with me. A house should always be filled with that special something that only a child can give. He has obviously had a wonderful time with his ‘papa’ doing all those things that mummy doesn’t do……fishing, catching birds, shooting everything in sight, watching the football at the bar, buzzing around on his motor cross bike and the new mini bike doing incredibly dangerous things and staying up all night! He has also been able to spend time with his big brother and sisters. I am so happy that he has such a close relationship with them all, that they love and care for him and that he in turn is so proud to be their little brother. He talks of them constantly and I know misses their company.
It’s been an interesting 7 weeks for me. Being on my own has been very different than usual both relaxing and liberating but sometimes lonely. I have been working hard and long. Arriving early in the morning and staying late without the worry and guilt of not being at home for my child is a feeling many working mothers will appreciate. I have also been playing hard. My social life has been rich and full. Starting with all the excitement of the world cup football which involved nights out several times a week to support whoever happened to be playing that day whilst remaining true to, first England, then when they ‘went out’ to Spain. We were only a small crowd of serious Spanish supporters which made us even more vocal and loud as we cheered them through to the final and then the championship. It’s amazing how nationalistic one becomes when away from ones origins! I have never been to so many farewells as I have during the past 2 months. This is one of the peculiarities of living in a developing country. Most of the ex-pats will be working on 2-3 years contracts which means making friends very quickly, enjoying them to their full and then moving on. I am lucky to also have very special friends who are Malawi residents which gives our life a little more continuity and stability. With no need of a ‘baby sitter’ I have seen the insides of the Lilongwe night clubs as well as playing a few rounds of Black Jack at the casino. There is really not much more to do in Lilongwe, no cinema, few nice bars or restaurants or places to dance so we make our own social life with private parties and ‘braiis’(BBQ’s) I have missed Lucas but I have been able to find my way without him too and that is good.
Tarek left Malawi last week. After working together in Spain for 3 years he left Acuario to take up his position in Lilongwe becoming head of Obstetrics and Gynaecology in both Kamuzu Central and Bwaila Hospitals. We have a very special relationship both in and out of work. His list of achievements during the 6 years he has been in Malawi is both admirable and extraordinary.
This is a part of what I wrote about him before he left:
……. Kamuzu Central Hospital is the main referral hospital for the whole of the central region of Malawi. It is the Teaching Hospital for the University of Malawi attending to the clinical placements of students from both the College of Medicine and the College of Nursing and Midwifery. Bwaila Hospital is the city of Lilongwe’s only District facility. Together they serve a population of over 5.5 million. Plagued by diseases of extreme poverty and social deprivation with all its incurrent and specific problems they carry a huge burden of severe pathology. Approximately 13,000 births are attended each year. The units are consistently understaffed and often deprived of essential drugs and equipment. Such severe working conditions are also exaggerated by poor discipline and low staff morale making the leadership such a huge undertaking. Dr. Meguid has consistently shown his full commitment
…… Teaching has formed a highly important part of his role. As an exceptional and experienced clinician himself, he has tirelessly shared his knowledge, teaching and guiding medical and nursing staff as well as national and international students
……With a vision for the future of the department, or more importantly, respectful and dignified care for the women of Malawi, Dr Meguid was the co-founder of The Chitenje Trust. Being its manager resulted in achieving the necessary funds for the erecting and subsequent opening of two new, modern, maternity units for both central and district maternal care at Kamuzu Central Hospital and Bwaila
…… It has been a privilege and a pleasure to have known and worked with Dr Meguid. His contribution to our hospital and more widely within the health sector in Malawi has been, without doubt, one that will be remembered for many years. His passion, enthusiasm, leadership, strength and persistence even in the most difficult of circumstances have all led to (this) list of outstanding achievements.
Tarek is a very special person. He has played a hugely important part in my life….because of him I am here. I shall miss him terribly.
.
Pregnant with her second child she went into labour prematurely at only 7months. Before the first pains of labour began she started having convulsions. The local gulewamkulu (witch doctor) was called as it was presumed by her family and the rest of the village that she had been bewitched. Steps were taken to find the person who was bewitching her. Five days later, after numerous fits she gave birth to a small dead fetus. By now her condition had deteriorated to such an extent that on day 6 post-delivery she stopped talking and walking. They continued to use the services of the gulewamkula and local medicines still believing that this was the only remedy.
Agnes was brought to us on Monday morning at 8.05am. 8 days after giving birth and 13 days after her first convulsion though we presume she must have had signs of her illness well before that. I was asked to go and see a woman in room10 who had arrived in a critical condition. My first impression on seeing Agnes was that she was only just alive. She was deeply unconscious and only taking gasping breaths. I called for help and assisted by a midwife colleague and a student we started to resuscitate Agnes. It was difficult to find a vein in which to insert an IV cannula but we managed to fix 2 lines and take blood samples. We started her on oxygen and quickly catheterized her bladder to check her urine for proteins. At some point I ran to the telephone to call for medical assistance. Whilst the intern doctor tried to get some information from her family so we could get a clearer picture of her condition she went into respiratory and cardiac arrest. It was now 8.15am. I sent for the anaesthetist to intubate and started CPR. We continued to resuscitate for more than 20minutes but with no response whatsoever. Agnes was pronounced dead.
The conclusion was that Agnes had suffered from undiagnosed Eclampsia. Untreated for 11 days she suffered a cerebral vascular accident (CVA) Complicated by puerperal sepsis she finally suffered septic shock, respiratory and cardiac arrest and she died.
This was a totally avoidable maternal death. This condition can be treated.
Of course she came to us far too late. We did everything we could but it was already too late for Agnes. Her family cried and wailed. This was the same family that delayed in bringing her to us for more than 13days due to their local superstitions.
How can this happen? Why are these people still so poorly informed in 2010? Why are these superstitious beliefs still so strong to the extent of allowing their loved ones to die? Why do the women not come to receive care in our hospitals?
Agnes was eventually brought to the hospital which means her death will become part of our Maternal Death Statistics. In Malawi around 900 women in every 100.000 will die in pregnancy, childbirth or immediate post natal period. (In Europe it will be 5-10 per 100.000) But how many young women are being buried out there in the villages without any record being kept?
Agnes was a beautiful young Malawian woman. A mother, a daughter, a wife, a sister and Agnes was very, very, poor….could this be the reason why she died?
Lucas arrived back from Europe yesterday after having been away from Malawi for the past 7 weeks. What a joy, what a pleasure to have him back with me. A house should always be filled with that special something that only a child can give. He has obviously had a wonderful time with his ‘papa’ doing all those things that mummy doesn’t do……fishing, catching birds, shooting everything in sight, watching the football at the bar, buzzing around on his motor cross bike and the new mini bike doing incredibly dangerous things and staying up all night! He has also been able to spend time with his big brother and sisters. I am so happy that he has such a close relationship with them all, that they love and care for him and that he in turn is so proud to be their little brother. He talks of them constantly and I know misses their company.
It’s been an interesting 7 weeks for me. Being on my own has been very different than usual both relaxing and liberating but sometimes lonely. I have been working hard and long. Arriving early in the morning and staying late without the worry and guilt of not being at home for my child is a feeling many working mothers will appreciate. I have also been playing hard. My social life has been rich and full. Starting with all the excitement of the world cup football which involved nights out several times a week to support whoever happened to be playing that day whilst remaining true to, first England, then when they ‘went out’ to Spain. We were only a small crowd of serious Spanish supporters which made us even more vocal and loud as we cheered them through to the final and then the championship. It’s amazing how nationalistic one becomes when away from ones origins! I have never been to so many farewells as I have during the past 2 months. This is one of the peculiarities of living in a developing country. Most of the ex-pats will be working on 2-3 years contracts which means making friends very quickly, enjoying them to their full and then moving on. I am lucky to also have very special friends who are Malawi residents which gives our life a little more continuity and stability. With no need of a ‘baby sitter’ I have seen the insides of the Lilongwe night clubs as well as playing a few rounds of Black Jack at the casino. There is really not much more to do in Lilongwe, no cinema, few nice bars or restaurants or places to dance so we make our own social life with private parties and ‘braiis’(BBQ’s) I have missed Lucas but I have been able to find my way without him too and that is good.
Tarek left Malawi last week. After working together in Spain for 3 years he left Acuario to take up his position in Lilongwe becoming head of Obstetrics and Gynaecology in both Kamuzu Central and Bwaila Hospitals. We have a very special relationship both in and out of work. His list of achievements during the 6 years he has been in Malawi is both admirable and extraordinary.
This is a part of what I wrote about him before he left:
……. Kamuzu Central Hospital is the main referral hospital for the whole of the central region of Malawi. It is the Teaching Hospital for the University of Malawi attending to the clinical placements of students from both the College of Medicine and the College of Nursing and Midwifery. Bwaila Hospital is the city of Lilongwe’s only District facility. Together they serve a population of over 5.5 million. Plagued by diseases of extreme poverty and social deprivation with all its incurrent and specific problems they carry a huge burden of severe pathology. Approximately 13,000 births are attended each year. The units are consistently understaffed and often deprived of essential drugs and equipment. Such severe working conditions are also exaggerated by poor discipline and low staff morale making the leadership such a huge undertaking. Dr. Meguid has consistently shown his full commitment
…… Teaching has formed a highly important part of his role. As an exceptional and experienced clinician himself, he has tirelessly shared his knowledge, teaching and guiding medical and nursing staff as well as national and international students
……With a vision for the future of the department, or more importantly, respectful and dignified care for the women of Malawi, Dr Meguid was the co-founder of The Chitenje Trust. Being its manager resulted in achieving the necessary funds for the erecting and subsequent opening of two new, modern, maternity units for both central and district maternal care at Kamuzu Central Hospital and Bwaila
…… It has been a privilege and a pleasure to have known and worked with Dr Meguid. His contribution to our hospital and more widely within the health sector in Malawi has been, without doubt, one that will be remembered for many years. His passion, enthusiasm, leadership, strength and persistence even in the most difficult of circumstances have all led to (this) list of outstanding achievements.
Tarek is a very special person. He has played a hugely important part in my life….because of him I am here. I shall miss him terribly.
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