Thirteen Babies

I just completed my five days of orientation in Labor and Delivery. Orientation is not quite the right term for this period, basically a nurse took two minutes to show me around the room, pointing out where meds are kept, gloves, suture, IV, etc. and then turned me loose. There is no practice of assigning particular women to a particular nurse. Everything is done on a first come first serve basis or, more accurately, on a whoever-is-walking-by basis. Someone is moaning or calling for help, go there, a head is crowning, glove up and run to make the catch. At the moment, this place represents the antithesis of true midwifery. True midwifery being . . . staying with a woman throughout her labor, offering constant support, encouraging movement, protecting privacy, and in general working in partnership with the women. But, there is hope for change.

The scene: there are eight beds on one side of the labor room (the low risk area) and six on the other side (the high risk area). The beds are simple metal frames high off the ground (too high to get up and down without the use of a step ladder, but still not high enough to protect the backs of those catching the babies) with bare mattresses. Among the items a woman is required to bring to L&D is a plastic sheet (they look just like large black garbage bags and aren't much bigger than that, they don't cover the entire mattress). Once a woman is in active labor, she enters L&D carrying all of her things and is told to find a bed. Finding an empty, and hopefully clean mattress, she spreads out the plastic sheet, puts a chitenge on top, undresses, climbs on to the bed, and covers herself with another chitenge. Those of you who have either experienced a birth or seen one, know how messy it can be and you can imagine that often times the chitenges are soaked not far into the process, leaving the poor woman lying in a cold puddle - the plastic sheet doing nothing to protect the larger mattress on which it rests. The mattress is cleaned and dried only after the delivery and an hour observation period. It is really hard to keep the women warm and dry since there are no sheets or blankets and only a few cleaning rags. Most women are so eager for their shower/bucket bath, which of course is cold but is a better alternative to lying on those mattresses. The women get up, bathe, wash their chitenges, and go to the low risk postpartum room for 24 hours. I'm still not exactly sure how that works since there are fewer beds in that room than in L&D. A lucky few get beds or mattresses on the floor and the rest . . .?

Over the past two weeks the visiting Scottish midwives and OBGYNs did a fabulous job of putting a new face on L&D. They scrubbed from ceiling to floor, painted the walls, cleaned the curtains, had new cupboards made for materials, and donated a bunch of useful stuff like shower curtains to use instead of the plastic - which can easily changed and washed - and sheets. So it's looking much better. Hopefully the improvements will last, and the curtains, sheets, and other items will not walk out too soon. One of my Malawian friends suggested writing, "Stolen from Bottom Hospital," on all the sheets. I laughed, but apparently it's already being done at many institutions and it's still not a strong enough deterrent for theft. Theft is such a complicated issue. Everyone is poor. Who is stealing? employees? patients? guardians? Is it just poverty? A sense of entitlement? Are people earning money by selling stolen items? I have been told that so many people and organizations have donated things over time but the items never stay long, slowly and inevitably they all disappear. I recently heard an interesting theory, "Poverty and wealth both have an equal ability to corrupt." I have many jumbled thoughts about development work, poverty, and charity but perhaps I should come back to them later, on to the births . . .

I caught 13 babies in five days (3, 3, 4, 1, and 2), 8 boys and 5 girls. I was a bit nervous the first day, since almost a year had passed since the last birth I had attended, but it all came back. Everyone left the labor ward in their mother's arms within an hour or two of their birth, even though I did have to resuscitate one little boy who was born blue and floppy. This time I managed to find a bag and mask quickly, warded off all those who wanted to suction, and he was breathing, crying, sucking, and kicking within minutes. I suppose (I hope) each time will be a little easier and that soon, even with the surge of adrenaline, I will be calm, gentle, precise.

I feel good about the care I provided this week, sure it could have been better - especially if I spoke Chichewa - but I did my best, and the moms seemed happy and the babies healthy. On my first day, one of the laboring women was rattling away in Chichewa to me and when I called a nurse over to find out what she was saying, the nurse told me that she just wanted to talk to me as a distraction. I asked if she wanted someone else to be with her since I couldn't understand and she pointed at me and said "Ayi, awa" (No, her). That was nice and she continued talking to me in Chichewa.

All in all it was a good week. Exhausting but good. I am being forced to learn my limits, and recognize when I really physically can't give any more before I've had a break. I've helped convince a few people to change their practices (i.e. no suctioning, less episiotomies, and starting with a lower dose of miso for inductions (they are using 100-200mcg of miso in one dose for induction?!)). And, of course I'm learning a ton too; so many lessons are packed into each day.

This week did also have its tragedies. Friday morning I came in to find one of the visiting OBGYNs resuscitating a baby. The mother had a long difficult labor, an infection, and was delivered by an emergency c-section. The baby had been left for sometime before he was found by the OB who started the resuscitation. In the end, after 50 minutes with a heartbeat but no respiratory efforts (and no other life sustaining options available), the OB stopped the resus and we stayed with the baby until it died.

This morning one of the interns came by the college, where I'm planted doing emails, to return a book and told me that last night they had a maternal death. Apparently the woman had seized at home and was taken to a few traditional healers before being brought to the hospital. On L&D she was given Hydralazine to lower her blood pressure and MgSO4 to prevent more seizures, she was then left alone for about 10 minutes and when people returned to check on her they found that she had died. She may have died from her eclampsia but she may have died from the medication (MgSO4 causes respiratory depression at high doses), no one will ever know.

Bottom Hospital?!