Wednesday, October 24, 2007
Shortage of Hands
Today I walked into the labor ward to find Msiska alone with all 14 beds full and women lined up on the benches. She laughed, twirled her arms over her head and said, "Welcome, my friend." When I asked, "Who is working with you?" She said, "You are. Aren't you here?" Where to start?! Six of the 14 women had not been examined at all, a few others had been transferred from clinics due to prolonged labor but hours later they continued to moan and shift on the beds, their IV lines clogged. After the morning rounds finished the situation improved somewhat, the clinical officer, medical intern, nursing students, a medical student from Holland, and a general physician from Palestine joined the fray. By the time I left at 1:30 I had conducted one vacuum extraction, had assisted with two others, diagnosed an IUD (intrauterine demise), initiated the resuscitation of two babies, and examined a handful of patients. I had passed through the full range of emotions, walked several kilometers, discussed the effect of American/Bush's politics on the world with Ahmed, laughed with Elske about a patient calling her Oscar, and visited the quadruplets. Msiska said, "Some day I will write an article about working at Bottom - sometimes you cry, sometimes you laugh." "Sometimes you laugh so that you don't cry," I added (we all laughed). I told her this is not an article but a book. I had to leave for work at the Embassy in the afternoon but patients and referrals continued to arrive. I told Msiska we'd meet tomorrow, "I will have drowned by then," she laughed.
Monday, October 22, 2007
Angels
Sunday morning I went to Bottom. I don’t usually work on the weekends but Friday my friend Msiska said she would have to work 12 straight days because of the shortage of nurses so I volunteered to come in for her. Saturday she sent me a text at 5:30 saying it was a horrible day, at the end of the day they had a stuck breech and the baby died. The whole of last week was bad, I resuscitated several babies who died, there were several severely asphyxiated babies, and there were several very premature deliveries. A cord prolapse that I assisted with was the one significant happy ending – they were twins and the presenting little girl needed some resuscitation but her condition improved quickly.
Sunday morning I arrived at 7:35, grateful to see that the ward was not full. The clinical officer and nurse were busy doing a vacuum extraction and she quickly told me that there was a delivery in progress on the next bed. I rushed to put on gloves and found Yasintha lying on her back with her knees pulled to her shoulders and a palm-sized portion of her baby’s head crowning. I quickly noted the vacuum sitting on the corner of her bed and took it as a sign that this was either a very prolonged second stage or that there had been fetal distress or both but for some reason – probably the neighbor requiring urgent attention - the intervention was not done. I watched Yasintha struggle through two contractions without moving the head any further then grabbed lignocaine and scissors and cut a small episiotomy. Yasintha pushed her baby out into my hands at 7:42, I clamped and cut the cord and rushed him to the resuscitare.
The boy lies flat at first but then, after several minutes, he blinks and begins moving his arms in wide slow circles. When I tilt him upright his eyes open like a doll’s but he is not breathing. I ask the other nurse to draw up some glucose and I give it to him through his cord. I continue with the bagging. Other staff arrive and greet me warmly, “Mwadzuka bwanji?” “So, we’re together today, great.” No one pays much attention to the baby as I bag it. It is not an unusual scene, me standing at the resuscitare over a limp baby first thing in the morning. I am so tired of this. My heart is tired, and what about the mother? She is now silent behind closed curtains. This is her first baby; does she know what is happening? Is she fearful or exhausted? Does she realize now that her baby may die or that if he survives he may have severe developmental problems? I blink away a few tears and consciously pull my thoughts away. I think of Clement in Ghana, we talked last night, he said he is losing weight, his classes are far apart and they last all day, he is walking constantly and not eating much. His trousers fall from his hips even with the belt cinched to the smallest notch. The baby kicks at my hands. He is still not breathing. I hold him up to the heat, he blinks, I plead with him softly, he still does not breathe. I plead with God. Yesterday Effie and I went shopping for zitengi in the market. For a Malawian wedding the couple is supposed to select an African cloth and then people will buy the fabric and have clothes made from it for the day of the wedding. We chose three different cloths, next weekend when we visit Mangochi we will see which is most readily available there and make the final decision. It feels good to have accomplished something. We only have ten weeks remaining before the wedding.
The woman in the bed closest to the resuscitare calls to me in pain, I look up and she says, “Come here.” She can see me with this baby but her baby is close now, her entire body involuntarily contracting to push her out. She needs hands to catch her daughter. I am the only one she can see. The little boy’s heart beats strongly but he only takes an occasional gasp – nothing very hopeful. I think about when I should stop, it has been 40 minutes, I will continue for an hour. It is a horrible torture to be the one who must decide when to stop. One hour passes. I am not ready to stop, maybe two hours. The woman at the near bed has delivered; a midwife arrived just in time. Her daughter lies wrapped in a cloth in her arms, the mother is quiet. I hold the boy again to the warmer. Watching his abdomen I see shallow breaths, he blinks. I stand over him now, caressing his forehead he breathes like a sleeping baby. After a few minutes I take him to his mother. She is asleep and I wake her to see the baby and tell her I will take him to the nursery. She looks concerned, “He hasn’t cried?” “No, he hasn’t.” According to her chart, Yasintha was tranferred hours ago for prolonged labor. I place the baby in his own cart in the nursery and explain the situation to the nurses.
There are two nurses working in the nursery, they are the same experienced nurses who worked all week. They will retire soon. Tereza walks me around the nursery. She says there are now twelve babies depending on formula. There are the quadruplets, a set of triplets, twins whose mother died, a singleton whose mother is suffering from postpartum psychosis, and two others whose mothers are severely ill. She is changing and weighing the quadruplets as she talks, she says the father and an elder from the mosque came and held a naming ceremony. They are now Mohammed, Hussain, Hassan, and Hamida. Hassan smiles periodically in his sleep, Tereza laughs and asks him, “Are you seeing angels now and then?” She says they are losing weight but their condition is good the only problem is that the mother wants to return home. It is planting season and the garden is waiting. The four will not survive if she takes them now. Tereza tells me that the triplets are in the kangaroo room (where the mothers wrap their babies tightly to their chests) she says they are not gaining weight yet but they are strong and clever, she says they will survive.
At the end of the day I return to see the boy. I find his mother sitting on the floor watching other mothers express their breastmilk by hand into small medicine cups. Her baby is screaming, his hands clasped into tight fists, he kicks and punches with what would be fury if her were older. I pick him up and try to soothe him. I tell his mother he is hungry. I know this cry; it is the cry of a baby who has suffered oxygen deprivation. I hold him while she works at expressing her milk. The milk has not yet come in, she manages to catch only two or three drops. I place him back in the cart he now shares with a premature boy who lies quietly, his thin arm resting over his eyes like an old man. We all need more angels.
Sunday morning I arrived at 7:35, grateful to see that the ward was not full. The clinical officer and nurse were busy doing a vacuum extraction and she quickly told me that there was a delivery in progress on the next bed. I rushed to put on gloves and found Yasintha lying on her back with her knees pulled to her shoulders and a palm-sized portion of her baby’s head crowning. I quickly noted the vacuum sitting on the corner of her bed and took it as a sign that this was either a very prolonged second stage or that there had been fetal distress or both but for some reason – probably the neighbor requiring urgent attention - the intervention was not done. I watched Yasintha struggle through two contractions without moving the head any further then grabbed lignocaine and scissors and cut a small episiotomy. Yasintha pushed her baby out into my hands at 7:42, I clamped and cut the cord and rushed him to the resuscitare.
The boy lies flat at first but then, after several minutes, he blinks and begins moving his arms in wide slow circles. When I tilt him upright his eyes open like a doll’s but he is not breathing. I ask the other nurse to draw up some glucose and I give it to him through his cord. I continue with the bagging. Other staff arrive and greet me warmly, “Mwadzuka bwanji?” “So, we’re together today, great.” No one pays much attention to the baby as I bag it. It is not an unusual scene, me standing at the resuscitare over a limp baby first thing in the morning. I am so tired of this. My heart is tired, and what about the mother? She is now silent behind closed curtains. This is her first baby; does she know what is happening? Is she fearful or exhausted? Does she realize now that her baby may die or that if he survives he may have severe developmental problems? I blink away a few tears and consciously pull my thoughts away. I think of Clement in Ghana, we talked last night, he said he is losing weight, his classes are far apart and they last all day, he is walking constantly and not eating much. His trousers fall from his hips even with the belt cinched to the smallest notch. The baby kicks at my hands. He is still not breathing. I hold him up to the heat, he blinks, I plead with him softly, he still does not breathe. I plead with God. Yesterday Effie and I went shopping for zitengi in the market. For a Malawian wedding the couple is supposed to select an African cloth and then people will buy the fabric and have clothes made from it for the day of the wedding. We chose three different cloths, next weekend when we visit Mangochi we will see which is most readily available there and make the final decision. It feels good to have accomplished something. We only have ten weeks remaining before the wedding.
The woman in the bed closest to the resuscitare calls to me in pain, I look up and she says, “Come here.” She can see me with this baby but her baby is close now, her entire body involuntarily contracting to push her out. She needs hands to catch her daughter. I am the only one she can see. The little boy’s heart beats strongly but he only takes an occasional gasp – nothing very hopeful. I think about when I should stop, it has been 40 minutes, I will continue for an hour. It is a horrible torture to be the one who must decide when to stop. One hour passes. I am not ready to stop, maybe two hours. The woman at the near bed has delivered; a midwife arrived just in time. Her daughter lies wrapped in a cloth in her arms, the mother is quiet. I hold the boy again to the warmer. Watching his abdomen I see shallow breaths, he blinks. I stand over him now, caressing his forehead he breathes like a sleeping baby. After a few minutes I take him to his mother. She is asleep and I wake her to see the baby and tell her I will take him to the nursery. She looks concerned, “He hasn’t cried?” “No, he hasn’t.” According to her chart, Yasintha was tranferred hours ago for prolonged labor. I place the baby in his own cart in the nursery and explain the situation to the nurses.
There are two nurses working in the nursery, they are the same experienced nurses who worked all week. They will retire soon. Tereza walks me around the nursery. She says there are now twelve babies depending on formula. There are the quadruplets, a set of triplets, twins whose mother died, a singleton whose mother is suffering from postpartum psychosis, and two others whose mothers are severely ill. She is changing and weighing the quadruplets as she talks, she says the father and an elder from the mosque came and held a naming ceremony. They are now Mohammed, Hussain, Hassan, and Hamida. Hassan smiles periodically in his sleep, Tereza laughs and asks him, “Are you seeing angels now and then?” She says they are losing weight but their condition is good the only problem is that the mother wants to return home. It is planting season and the garden is waiting. The four will not survive if she takes them now. Tereza tells me that the triplets are in the kangaroo room (where the mothers wrap their babies tightly to their chests) she says they are not gaining weight yet but they are strong and clever, she says they will survive.
At the end of the day I return to see the boy. I find his mother sitting on the floor watching other mothers express their breastmilk by hand into small medicine cups. Her baby is screaming, his hands clasped into tight fists, he kicks and punches with what would be fury if her were older. I pick him up and try to soothe him. I tell his mother he is hungry. I know this cry; it is the cry of a baby who has suffered oxygen deprivation. I hold him while she works at expressing her milk. The milk has not yet come in, she manages to catch only two or three drops. I place him back in the cart he now shares with a premature boy who lies quietly, his thin arm resting over his eyes like an old man. We all need more angels.
Monday, October 15, 2007
Eid Mubarrak
Patuma sat on the bench outside labor ward Thursday afternoon along with other women waiting for ultrasound scans. As I motioned her inside the scanning room I noted that the midwife had written “multiple gestation??” on the line for her most recent prenatal visit. Like most other pregnant Malawian women, Patuma was thin and sinewy but as she lifted her dress the size of her belly was so impressive, and her skin over it so taught, that it seemed almost as though a balloon had appendaged itself to her front. When I asked, Patuma said she was only eight months pregnant and that this was her fifth pregnancy. She had 5 living children, two from the previous pregnancy.
Unable to palpate much, I rolled the transducer over the gel on her belly and peered through the window it provided - definitely multiple gestation. I moved slowly in irregular circles making sure not to count the same head twice. Hesitant to tell the mother until my finding was confirmed – I called in the medical intern. He agreed - triplets. I told Patuma she had three babies; she remained quiet and looked mildly shocked. I measured each head, abdomen, and femur to approximate the estimated gestational age and size. This process took me a while as I tried to sort out the kicking rolling bodies and ensure that this leg belonged to this head. I moved back and forth over her belly and Patuma sighed under its weight. According to my scan the babies seemed to be about 32 weeks and all weighed less than two kilograms. Patuma could not remember the specific date of her last period (which would enable a more accurate calculation of the gestation) but from my experience with the women at Bottom, as they approach term, their babies’ measurements fall away from the standard indices, so it was possible that Patuma was already 35 weeks (37 weeks is considered term).
Friday morning only a few women lay on beds in the labor ward when I arrived. On the high risk side of the ward Patuma sat quietly on one bed and across from her lay another woman crying with pain. Patuma was now draining amniotic fluid and apparently in early labor though no one had thought to give her Dexamethasone (a steroid injection shown to accelerate fetal lung maturity, given when women go into preterm labor). The other woman had arrived ten days previously complaining that her current and fifth pregnancy, was overdue (pregnancies passing 42 weeks gestation carry a much higher risk of stillbirth). Although not noted, the midwife added that she had been draining amniotic fluid since admission. Glancing over her chart I saw that she had had several vaginal exams and that no one had started antibiotics. An induction had been ordered Wednesday and the first dose of medicine had been inserted, however no one had documented hearing the baby’s heart since early Wednesday. I considered these two women and felt a wave of anger and despair wash over me. I placed my fetoscope on her belly. Silence. I moved it. Silence. I brought the ultrasound machine in and found the heart, no movement. I called the medical intern. He watched the still heart. He contemplated the reason the baby died and told the mother. I wanted to walk out, go home, and crawl under the covers. Instead, Lonnie, the nursing student with Patuma asked me to come help her make an assessment.
Patuma, though quiet and not appearing to have strong contractions, complained that she needed to push. I told her to go ahead and as she lifted her chitengi I saw a head with dark wet curls emerging. Lonnie rushed to grab a delivery pack and returned in time to catch the first baby boy at 9:20. I brought the ultrasound machine to her bedside and checked the other babies. I found two heads down and a third head in the fundus! Three little hearts beat reassuringly. Patuma said she felt some relief, although still uncomfortable; she could breathe a bit better and looked forward to eating. I examined her and felt the next head almost out of reach. Her contractions spaced out. I began stimulating her nipples (this releases oxytocin, the hormone that causes uterine contractions) and scanned the three heartbeats every few minutes. She worked and waited and now and then would loose confidence. She said, “I have already gone through so much and after this next one there will still be another, I can’t do this.” I told the student but did not tell her she still had three babies inside.
After about 40 minutes of anxious watching, assessing, encouraging, stimulating nipples, and silent praying, I felt the next head settle into her pelvis and we ruptured the membranes. At 10:30 the second little boy arrived. Again we dried her bed, I scanned and examined her. She laughed lightly and told Lonnie we would each have to take a baby home because she had only wanted one. When we asked about her husband’s reaction she said he hadn’t said much but she was not worried because he is usually able to provide for the children. At 11:25 I caught the third boy. As I gave the little one some oxygen, the student examined Patuma and said she could not feel the next baby. I repeated the exam and felt a hand and a foot floating high inside. I called Chikoti, one of the experienced clinical officers, and asked him to put on gloves. He instructed me to rupture the membranes, reach inside, and grab the feet. After explaining the situation to Patuma, I reached in, broke the bag and found a single foot, which I pulled down to where it was visible. Chikoti then helped bring it the rest of the way and as a small crowd of students encouraged Patuma, I assisted her little girl out. 11:55am. At the resuscitare I gave the girl some oxygen, examined her, weighed her and placed her among her brothers. They weighed 1.8kg, 1.6kg, 1.4kg, and 1.5kgs.
The nursing matron helped make the bed and dress Patuma, and then called the newspaper. Shortly thereafter a female journalist arrived at her bedside. I stood directly across with the other woman who still labored with her dead baby. No curtain hung in-between. Patuma and the journalist chatted and laughed softly. The other woman cried, “I’m sorry. I’m sorry. Please take me for a c-section,” moving from her back to her knees, pushing, straining, crying, pleading. I felt the head low in her vagina; her cervix was completely dilated. Her contractions were weak and infrequent but no one wanted to give her pitocin for fear of rupturing her uterus. I stimulated her nipples. We brought over the vacuum to assist, but the pressure gauge would not work and we could not maintain enough suction. At 4:15pm I called Chikoti he said he would come. A screen was located and placed between Patuma and the other woman. I walked to the nursery to see the quadruplets and to restore some joy, then exhausted I left.
This morning I stopped by Bottom to see the babies; they looked pink and peaceful in their single cart. Patuma was all smiles.
Unable to palpate much, I rolled the transducer over the gel on her belly and peered through the window it provided - definitely multiple gestation. I moved slowly in irregular circles making sure not to count the same head twice. Hesitant to tell the mother until my finding was confirmed – I called in the medical intern. He agreed - triplets. I told Patuma she had three babies; she remained quiet and looked mildly shocked. I measured each head, abdomen, and femur to approximate the estimated gestational age and size. This process took me a while as I tried to sort out the kicking rolling bodies and ensure that this leg belonged to this head. I moved back and forth over her belly and Patuma sighed under its weight. According to my scan the babies seemed to be about 32 weeks and all weighed less than two kilograms. Patuma could not remember the specific date of her last period (which would enable a more accurate calculation of the gestation) but from my experience with the women at Bottom, as they approach term, their babies’ measurements fall away from the standard indices, so it was possible that Patuma was already 35 weeks (37 weeks is considered term).
Friday morning only a few women lay on beds in the labor ward when I arrived. On the high risk side of the ward Patuma sat quietly on one bed and across from her lay another woman crying with pain. Patuma was now draining amniotic fluid and apparently in early labor though no one had thought to give her Dexamethasone (a steroid injection shown to accelerate fetal lung maturity, given when women go into preterm labor). The other woman had arrived ten days previously complaining that her current and fifth pregnancy, was overdue (pregnancies passing 42 weeks gestation carry a much higher risk of stillbirth). Although not noted, the midwife added that she had been draining amniotic fluid since admission. Glancing over her chart I saw that she had had several vaginal exams and that no one had started antibiotics. An induction had been ordered Wednesday and the first dose of medicine had been inserted, however no one had documented hearing the baby’s heart since early Wednesday. I considered these two women and felt a wave of anger and despair wash over me. I placed my fetoscope on her belly. Silence. I moved it. Silence. I brought the ultrasound machine in and found the heart, no movement. I called the medical intern. He watched the still heart. He contemplated the reason the baby died and told the mother. I wanted to walk out, go home, and crawl under the covers. Instead, Lonnie, the nursing student with Patuma asked me to come help her make an assessment.
Patuma, though quiet and not appearing to have strong contractions, complained that she needed to push. I told her to go ahead and as she lifted her chitengi I saw a head with dark wet curls emerging. Lonnie rushed to grab a delivery pack and returned in time to catch the first baby boy at 9:20. I brought the ultrasound machine to her bedside and checked the other babies. I found two heads down and a third head in the fundus! Three little hearts beat reassuringly. Patuma said she felt some relief, although still uncomfortable; she could breathe a bit better and looked forward to eating. I examined her and felt the next head almost out of reach. Her contractions spaced out. I began stimulating her nipples (this releases oxytocin, the hormone that causes uterine contractions) and scanned the three heartbeats every few minutes. She worked and waited and now and then would loose confidence. She said, “I have already gone through so much and after this next one there will still be another, I can’t do this.” I told the student but did not tell her she still had three babies inside.
After about 40 minutes of anxious watching, assessing, encouraging, stimulating nipples, and silent praying, I felt the next head settle into her pelvis and we ruptured the membranes. At 10:30 the second little boy arrived. Again we dried her bed, I scanned and examined her. She laughed lightly and told Lonnie we would each have to take a baby home because she had only wanted one. When we asked about her husband’s reaction she said he hadn’t said much but she was not worried because he is usually able to provide for the children. At 11:25 I caught the third boy. As I gave the little one some oxygen, the student examined Patuma and said she could not feel the next baby. I repeated the exam and felt a hand and a foot floating high inside. I called Chikoti, one of the experienced clinical officers, and asked him to put on gloves. He instructed me to rupture the membranes, reach inside, and grab the feet. After explaining the situation to Patuma, I reached in, broke the bag and found a single foot, which I pulled down to where it was visible. Chikoti then helped bring it the rest of the way and as a small crowd of students encouraged Patuma, I assisted her little girl out. 11:55am. At the resuscitare I gave the girl some oxygen, examined her, weighed her and placed her among her brothers. They weighed 1.8kg, 1.6kg, 1.4kg, and 1.5kgs.
The nursing matron helped make the bed and dress Patuma, and then called the newspaper. Shortly thereafter a female journalist arrived at her bedside. I stood directly across with the other woman who still labored with her dead baby. No curtain hung in-between. Patuma and the journalist chatted and laughed softly. The other woman cried, “I’m sorry. I’m sorry. Please take me for a c-section,” moving from her back to her knees, pushing, straining, crying, pleading. I felt the head low in her vagina; her cervix was completely dilated. Her contractions were weak and infrequent but no one wanted to give her pitocin for fear of rupturing her uterus. I stimulated her nipples. We brought over the vacuum to assist, but the pressure gauge would not work and we could not maintain enough suction. At 4:15pm I called Chikoti he said he would come. A screen was located and placed between Patuma and the other woman. I walked to the nursery to see the quadruplets and to restore some joy, then exhausted I left.
This morning I stopped by Bottom to see the babies; they looked pink and peaceful in their single cart. Patuma was all smiles.
An Encounter
Two weeks ago as I was walking up the street from Bottom I noticed a woman also walking in the same direction struggling with her two year old who fought in her arms kicking and screaming. I gave her a small smile and as we walked side by side for a pace she held him out to me saying, "Mzungo, tengani mwana ali mavuto kwambiri." (Take this child he is such a problem.) She passed him to me and I carried him on my hip a few paces. Startled mute he stared at me in shock, everyone around us broke into laughter, and he remained quiet even after I passed him back.
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