Maternity Ward Observational

During my two week stay at the maternity ward as a clinical instructor, I had the opportunity to note some interesting cultural observations.

Day after day, I'd arrive at the maternity center with students in tow to find a number of first-time mothers in labour. Usually, the first-time mothers laboured the longest, while the multigravidas (aka: women pregnant for the second or more times) came much later in labour.

One G2 (aka: mother for the second time) came striding in, calm as the sea after a storm, only to discover she was fully dilated. She delivered (to my and my students dismay) while we were out of the room. It took her less than five minutes from beginning to end.

But labours like hers were not the norm. Most of the women who laboured and delivered there were first-time mothers-to-be. They arrived after the first or second contractions and then stayed until the baby was born.

For some this was quick. However more often than not, they were there for the long haul. One young girl (having more than likely braxton-hicks contractions) had arrived three days before. She had not had contractions in over two days, but she was not discharged nor did she seem interested in leaving. For the life of me, I am not sure why.

Several women came in at 1 or 2 cms dilated and chose to stay. The maternity ward was bustling but they did not seem to mind. They waddled around and watched as others delivered around them one by one.

When it was their turn to push, they were watched as well.

A lot of the first-time moms had hypertonic (aka: abnormally strong) contractions even though they were only 2 cms dilated.

After talking with the staff about it, I discovered that it was common for women to try and induce labour by drinking traditional herbs. These herbs cause painful and frequent contractions that don't always dilate the cervix. I saw similar things in the Philippines.

One nurse tsked their use of herbs, explaining that usually the ineffective contractions led to exhaustion, an inevitable referral to the hospital, and an (avoidable) cesarean for fetal distress. 

I also saw things done by the staff that caused me to pause.

One nurse sutured a woman up without using local anesthetic. Naturally the woman cried out in pain with each stitch. Meanwhile the nurse yelled and berated her for making so much noise. I didn't stay to watch. I couldn't.

One day while evaluating one of the labours, I noticed her family had purchased cytotec. When I asked her about it, she informed me the nurse had insisted she buy it. The nurse denied this since she was already well advanced in labour. However when I inquired the woman's family about it again later, they presented me with the prescription the nurse had given her. I never saw what the nurse did with those drugs but they were certainly not for the woman who purchased them.

I also saw a nurse be given a 'gift' of a capulana (a traditional cloth) at one point. She hurriedly rushed to put it away in her purse as the gift-giver went back to her friend in labour. I had been told that such 'gifts' were expected by the nursing staff but I confess I was still disappointed to see it.

Labor of Love May 2015

   Labor of Love May 2015

On the Road Again!

For those of you who prayed and gave.... thank you! My car is in working order again. It took 3 frustratingly long weeks but my new mechanic, Luis, has finally returned her in excellent condition.

In fact, I don't think she's ever been working so well!

He had to put on a new engine head (as the one that I got fixed in Zimbabwe last year was in fact cracked) and all the valves, gaskets, and what-nots that usually go into such things.

Plus, he fixed my emergency brake (which was loose), replaced my starter (which was finicky), put in a new clutch (which was smashed to bits), and fixed the door handle on my trunk (which had been broken while I was on furlough)!

The man is magic. Magic! I say.

My engine now purrs as she bounces down the road.

Mind you, I still need new tires... but other than that, the car is better than ever.

Thank you for your precious prayers!

Stitches?

The third birth I observed seemed normal enough to begin with. The mother was 27 years old and expecting her second child.

When we arrived, her contractions were strong and frequent but she seemed to be handling them well. Within no time, her water broke displaying a yellowish puddle of meconium stained fluid.

The nurse set up the room for the birth (which means she got a bed pan, some non-sterile gauze, and a birth kit and placed it at the foot of the bed). The bed pan was slipped under the mother's bottom and she was told to push.

She pushed for only 5 minutes for the head to be born. But then the nurse reached in and wrenched him out. The mother stayed quiet while the nurse literally pushed and pulled and twisted and turned his little body every which way imaginable.

Two minutes later, the nurse lifted his body free of the mother with a gush of more mec-stained fluid.

The nurse then injected her with oxytocin to precipitate the placental detachment, then started massaging her uterus.

She massaged and pushed on it externally until 4 minutes postpartum it popped out in a gush of clots and blood.

She placed the boy in his mother's arms and evaluated her tear.

There was a tear but it was not deep. At most i would have put it at a shallow 2nd degree. However, as the nurse considered it, I overheard her worry how she was 'out of stock'.

I thought nothing of it, until a few minutes later I watched her suture her up with 3-0 acrylic (aka: non-absorbable) suture material.

She placed interrupted stitch after interrupted stitch, burying the deeper stitched beneath the more shallow ones.

My jaw dropped in surprise and my legs snapped closed in horror... but I didn't say anything. How could I?

We were guests there. I could not make those kind of calls... nor could I criticize them in their work. But I confess, I worry still what those buried sutures might do. Perhaps her body just rejected them and the string fell out as they healed.

That is my hope at least.

Fit To Be Tied.

The next birth happened a day or so later.

The young mother-to-be was alone but apparently unconcerned by this fact. Not all of the labours have companions.

So as she laboured, I taught the students how to evaluate her contractions and take her history. She was 20 years old and expecting her first child.

She readily admitted to taking traditional herbs to prepare her body for birth... and even to start her labour.

Since her contractions were strong and frequent, the nurse decided to do a vaginal exam at 10 am. The nurse was VERY aggressive during this exam, manually dilating her cervix despite the patient's vocal protestations.

Afterward the nurse informed us she was 90% effaced but only 6 cm dilated. But after such forceful manipulation of the cervix, I did not think it true for long.

Sure enough, an hour later her water broke and she immediately got pushy.

In fact, there was no stopping her. So we called for the nurse. 

The young mother was already fully dilated and wanting to push. The nurse tried to get her to focus and push effectively but she would have none of it.

All she wanted to do was scream. 

One scream was so piercing and so long, it could have shattered glass.

After some negotiation, we convinced her that screaming like that was not actually helping. In her defense, she did really try to push. But each time she did, she would close her legs and withdraw.

It was going no where. 

The nurse was not pleased and she argued with her.

She then tried to push again but ended up kicking the nurse and swatting her hands away.

The nurse was even less pleased with this behavior. 

After more negotiating, the young mother confessed that she needed help controlling herself and requested that two of the male medical students hold her down while she pushed.

Yes. She wanted them to forcibly hold her down so she would not hit or kick the nurse.

So they did.

Mind you, they seemed more than a bit surprised by this. I don't think either one of them woke that morning thinking that they'd have to tackle a pregnant woman while she pushed her baby out. But you know... some days are surprising like that.

I soon found myself out of my depths and stepped away from the melee to watch at the foot of the bed. The remaining two students shuffled a step closer to me with each new scream. One (who plans on being an obstetrician) was wide-eyed and mesmerized by the beauty of it all. The other (who is unlikely to choose obstetrics as a specialty) kept hiding her eyes and furtively glancing my way for assurances that the woman was not in fact dying.

Meanwhile the young mother continued to scream and abuse the staff while pushing. The nurse, more than likely frustrated with the abuse, decided to perform aggressive perineal stretching. The baby was born quickly but caused a significant 2nd degree tear in the process.

The placenta was pulled from her body within minutes of the birth with strong cord traction. It was so strong in fact, that the cord snapped, squirting blood all over the foot of the bed.

The nurse decided to suture the tear before presenting the baby to the mother. The young mother screamed and fought the sutures just about as much as she did the birth, despite being anesthetized.

When the nurse finished up the stitches, she reached down for the baby's ankles, lifted her high in the air and presented her genitals for the mother to see.

The young mother whispered, 'a girl' to herself and smiled.

Then the baby was taken off to be wrapped and weighed.

Normal?

Her contractions were strong and frequent when I first met her. She lay on the bed and her mother held her hand.

The pain contorted her face and forced the occasional groan, but she didn't seem to notice it much. For the most part, she was surprisingly quiet.

So quiet in fact, that I didn't think she was even close.

As a 17 year old G1 (aka: primigravida or woman pregnant for the first time), I expected things to go a little slower. But her body had other plans.

Shortly after we arrived, her waters broke and she started getting grunty. One of the students informed the head nurse, who started setting up the room.

She started pushing before the nurse was ready, so I encouraged her to breathe through contractions and taught her how to push effectively.

The grandmother, looking a mixture of exhausted-relief, excused herself to the corner of the room and said nothing. Absolutely nothing.

The mother pushed effectively despite the five extra medical student faces huddled around her bed. She didn't seem to notice or care in all the pain.

The nurse on duty expedited the birth by doing perineal stretching and the mother remained silent. She pushed only a handful of times before the head was born. The nurse didn't wait for the next contraction, she just reached inside and wrenched the shoulders free. Again, the mother made no noise.

The baby was out less than a minute when the cord was cut. She too made not a sound. Just like her mama.

The nurse grabbed the child by both feet and swung her in the air, presenting her upside down for the mother to see. The mother smiled when she saw it was a girl, then dropped her head back on the bed in a rush of exhaustion.

The nurse lay the child on her breast and it mewed quietly.

Within 3 minutes after the birth, the nurse aggressively massaged the mother's uterus and applied traction on the cord. The placenta wasn't budging. She forced it harder and massaged even more aggressively.

This continued until the nurse found herself with a torn placenta (only 5 minutes postpartum) and decided to do a manual extraction. Reaching her right hand in up to her elbow, the nurse extracted chunk after chunk of the placenta from the uterine wall. Each time she reached in, she came out with chunks, clots and membranes.

The mother made not a sound. 

Afterward, the nurse reached in repeatedly with non-sterile gauze to evacuate the uterus and vaginal canal of any remaining blood. But still the young, new mother remained silent.

Inside, I screamed for her. Inside, I cried out in pain.

For her.

How she remained so stoic... so quiet, I'm still not sure.

As I looked through the nurses' bloodied hands, several baffled expressions caught my eye. "What must these medical students be thinking?"

For many of them, this was their very first experience with birth. I shuddered to think that this was considered 'normal' in Mozambique.

Perhaps... it is normal. 

Multiparity

The last two weeks of May involved teaching at a maternity ward downtown. My job was to help introduce fourth year medical students to 'normal' birth. Much of our time was spent labour watching, timing contractions, evaluating fetal heart tones, and palpating fetal positions. However, we also got to do a number of newborn exams and assist in a few births.

One day we arrived to find a young woman occupying one of the labour beds. Naturally, we assumed she was pregnant (as her fundal height was marked), so I told two of the students to time her contractions. Ten minutes later when I came back to see how things were going, I was informed she was not in labour and that her babies were in the other room.

So I instructed them to get her obstetrical history instead.


The new mother explained that she was a 20-years-old mother of six. Earlier that day, she had delivered twins at home. She came to the maternity ward for the birth certificate but did not seem very interested in any other service. Since her babies (a boy and a girl) were cold and covered in sand, the nursing staff had taken them for evaluation and placed them in a warmer.

The mother explained that she had delivered her first child at the age of 11 and that her previous four pregnancies were simple. This was her first set of twins, however. 

She didn't want to talk much about the particulars, so we didn't press her for more information. Although I know 11-year-olds can get pregnant, my heart hurts to think that this mother has so many mouths to feed and so much responsibility...  at such a young age.

What were you doing at the age of 20?

Teaching

As I mentioned previously... during the months of April and May, I was invited to be a clinical instructor for a medical school in a neighboring city. The people I met and the opportunities this experience afforded me were equally wonderful and heartbreaking.

The first four weeks, I worked with nursing students doing clinical rotations in a busy hospital. The school gave me a white coat, a pen, and pointed me to the various departments. I was working in the pediatric department and the malnutrition center.

Needless to say, what I saw was...

Stressful: Each morning I had to rush from where I was staying (my commute was anywhere from 40 to 90 mins one-way) to get to the hospital in time for roll call. The hospital was crowded. The needs were overwhelming.

Disconcerting: The manner of teaching was very different from my own (educational) experience. I felt like I was wading eyebrow-deep in murky waters for the first few days. Every day brought new challenges with no cultural insider to ask if I was making a fool of myself or standing tall. Sigh.

Heartbreaking: No one forgets the gaunt and wasted face of a 8 year old boy dying of AIDS. It's hard to silence the wails of a mother who just watched her two year old die.

Fascinating: One day a 4 day old neonate was brought in to determine the sex. The genitals were ambiguous. After the examination the doctor explained the mother had an hermaphrodite. The news was not well received.

Overall, my time there was...

Exhausting: Most days turned out to be 10 to 12 hr days. Speaking all day in Portuguese was a challenge as well... mentally and physically.

Expensive: Though friends let me stay with them for free, the public transport was either cheap or inconvenient. Getting back and forth from work took an hour and a half in the morning if I went with 'cheap' (costing less than a dollar). But if I needed to get there quickly (30 minutes or so), it cost 8 dollars. Sigh.

Insightful: After two years of stories about policies and practices in governmental hospitals, I was finally able to see first hand that they are true. I saw corruption, neglect, abuse, and incompetence. But I also saw many who did not fit the mold and strived to do well.

Blessed: I was able to make lots of new friends and learn how the medical system works in this country. Often I was impressed by the caliber of medical professionals in this country despite the obstacles they must face to care for their patients.