Right

Thursday morning began with a woman named Clara whose distressed baby was emerging feet first; slipping through a partially opened cervix (footling breeches must always be delivered by c-section because, although bodies may slide through before the cervix is completely dilated, the head will most likely become entrapped). I went to theatre to receive the baby. An hour passed between the minute when I heard the alarmingly slow heart rate and the minute when the struggling baby was placed in my hands. I resuscitated her for about 20 minutes before her breathing became regular but even then her lips remained an ominous shade of purple.

I took her to the nursery and returned to the labor ward to find the nurses preparing magnesium sulfate for an eclamptic woman who had just arrived unconscious. Apparently Jessy was on her way to the hospital complaining of a severe headache (a symptom of preeclampsia) accompanied by her mother when she seized. I helped the others prepared and administer the magnesium and then she seized again. We had no medicine to help lower her blood pressure. She seized again. She looked to be less than 30 weeks pregnant (i.e. very premature and barely viable in Malawi) but the only cure for eclampsia is delivery and you must deliver to save the mother's life regardless of the baby's gestational age. The baby’s heart rate sounded strong so I returned to theatre. Lying unconscious, outside the theatre, waiting for a cervical repair to finish, Jessy seized again. Once the section started, I stood to the side with my sterile cloth, expecting to be handed a creature so small and unprepared for extrauterine life. I was please to meet a pink beautiful little girl with a hopeful weight of 1.6kg.

I took her to the nursery and then returned to the labor ward. In a calm voice Msiska called me, “Joanne, can you help?” and I, slowly and calmly walked over to where she stood. My gaze landed on the horrific sight of a baby’s body dangling freely with the head still inside his mother. I ran for gloves and asked Msiska if the baby was still alive, she said that it had been but that it had died. I quickly delivered the head and then felt a slow but strong pulse and ran with the limp baby boy to the resuscitare. While I was resuscitating him another woman began delivering a footling breech on the bed 10 feet behind me. She had come in just moments before; no warning or time to prepare for a section. I handed over the resuscitation and ran to help deliver the head. The little girl needed just a breath or two with the bag and mask to encourage her. Chipeta delivered her twin sister and placed them side by side.

I don’t remember the flow of events for the remainder of the day. I remember eating an apple. I remember assisting a student manage the care of a woman with a moderate hemorrhage. I remember attending a normal birth. I also checked on the babies in nursery periodically throughout the day. Clara’s baby looked distressed and pale despite the oxygen. Jessy’s baby was lovely. The breech boy held steady although his posture suggested damage to the nerves enervating his right arm. Friday was similarly hectic. I assisted with two shoulder distocias, delivered one baby via vacuum and attended a couple normal deliveries as well.

For almost the whole of last week there was no pethadine at Bottom. In other words there was NO pain medicine. Women delivering at Bottom never receive pain medicine during their labors (except in a rare case when it is given to a mom delivering a dead baby). Usually the precious pain medicine is reserved for women who undergo surgeries, but for a week even they received nothing. Women were anesthetized during the surgical procedures but once in the recovery rooms they received nothing, despite the fact that they had been cut through their skin, fat, muscle, and uteruses. Dr. Meguid often talks about these shortages (other common shortages include antibiotics and suture material) in terms of human rights. I think it's appropriate to frame the situation in this way. We have international documents on human rights and women's rights but what does this mean in a practical way? Certainly it is INhumane to use inappropriate suture material on women and increase their risk for abdominal rupture. It is INhumane to withhold antibiotics and risk peritonitis and the not uncommon subsequent hysterectomy. And it is INhumane to withhold pain medication after surgery. Although this is a situation of absent resources and not withheld resources, is it not in actuality withheld when we consider the global picture? We know what is necessary to treat women humanely on a mundane level. We know practically what is involved to provide adequate maternity care. So, where is the commitment?

I went to Bottom on Sunday just to check on all my babies. Clara's baby had died Saturday night. Jessy's baby, the twins and Esmilo's breech boy were doing well. Jessy was also doing great. I recognized her name but looking at her did not recognize her face. I could not remember how I was involved in her birth until I read the baby's file. Just a couple days before she was swollen and unconscious, Sunday she was laughing, walking, and nursing her baby.

Today I spent my usual half day at Bottom (the morning at Bottom, the afternoon at the Embassy). I walked in and did two deliveries within 15 minutes, the first was an undiagnosed stillborn anencephalic baby; the second was a nice normal girl delivered by a 15 year old. Anencephaly is a rare event, according to my perusal of various sources the incidence lies somewhere between 1 in 100,000 to 1 in 70,000. I have seen 5 since coming to Bottom. Considering that Bottom has only 12,000 births a year and I am only present for a fraction of these, this number is incredibly concerning. I am going to start keeping a log. I checked in the nursery again and was devastated to learn that Jessy's baby died unexpectedly last night. The nurse said Jessy breastfed the baby and then the baby had an apneic attack from which she never recovered. I did not see Jessy but I can only imagine her heartbreak. Just before noon I attended 19 year old Elena's delivery, it was a beautiful birth and she had a boy.