My African Midwifery Adventure – Day 4 – Life Put in Perspective & Neonatal Resuscitation in Theatre

My fourth day out in Tanzania was another eye-opener, and by this point I think I was realising that every single day was going to open my eyes in ways I had never anticipated – whether this was by something that happened or just by the attitudes and the way that it works out there…it’s just a completely different world out there.

As I’m sharing a bit more of the detail of my Tanzanian Labour Ward experience now, I just wanted to post a little disclaimer, as I know I’ll get comments, and I don’t want to get too much hate to sift through….

1.  I did witness some of the darker and sadder sides of midwifery out there, including a neonatal death, so this is a bit of a warning for that too (it’s in this post, so if you’d rather avoid that, this is the post to avoid), but I think it’s important to share an accurate representation of what I experienced out there so I didn’t want to omit it, despite it being a difficult time for everyone involved.

2.  I had been warned by other students I spoke to before going out there that it isn’t really a place that you can be strictly “Observational” so I took out additional Professional Indemnity Insurance before heading out there so I would be covered to be hands on. It’s a bit of an “all hands on deck” attitude out there so it wouldn’t have been entirely feasible to just observe – plus, I wanted to make the most of the experience!

3. I am sharing the experiences I had out there, and not judging in any way, so please don’t take offence or express your outrage at the way things work out there in a negative way; it’s just how it works and with the finances and resources out there, they really do make the best with what they have.

4. I had consent to take and share any images I post.

5. I am going to share the honest details, so if you get squeamish you have been warned.

Ok, disclaimer over!
(Sorry to be a bit dull in that way but I’ve started getting a lot of very confrontational messages over the past few months and I could just see them coming from sharing this experience….so thought I’d try to answer some of the messages I would be getting in advance! I don’t deal well with confrontation so I thought I’d try to avoid as much as possible!)

So, I started my fourth day out there by observing one of the doctors carrying out a suction “Kiwi” delivery and observed my first Tanzanian Episiotomy. In the UK, if you need an Episiotomy, you are given local anaesthetic and specially angled scissors are used to optimise recovery times. Out there, there was no anaesthetic, and the episiotomy was carried out with a sharp blade, simply pinched between two fingers (it felt like there should have been a handle, like those with a craft knife, but there weren’t any, so it was just pinched…) It was a very inaccurate art, meaning several cuts were needed to carry out the episiotomy, which made my stomach turn a little (sorry, I did warn you that I would be sharing the details!)

After the delivery, the woman was quickly sutured by one of the midwives and then was expected to get up and about as quickly as anyone else, within just a few minutes of delivery. It’s tough, but I can’t tell you how much admiration it gives you for the women; they are just so resilient and far from complaining, they are so incredibly grateful. I suppose they are aware that childbirth can be a dangerous thing out there, with so many fewer resources in the case of emergency, and so when they come out of it all safe and with a healthy baby, they are so so grateful. “Asante Sana, Asante Sana!” you hear across the ward after any delivery – “Thank you, Thank you so much!”

After this delivery, we were just helping clear up and saw a woman on the corridor between the antenatal and the labour ward delivering. It’s all so open, we were the other end of the room and could see the whole delivery. This baby was tiny and it became apparent pretty quickly that the baby was very premature – from how little it was, we estimated about 27-28 weeks. In the UK, this baby would have had a neonatal team ready to assist before the baby was even delivered, and would most probably have been whisked off to NICU for assessment and care immediately at birth. Out there, this baby was simply delivered and placed onto the mother’s chest and then just left there while the midwife tidied up around the woman on the bed.
We could see that the baby was hardly breathing and was obviously struggling, but it was moving and wriggling around…maybe the neonatal unit just don’t have the facilities to care for a baby that small so they were just seeing how it was, but it was never taken up to the neonatal unit, and by the time it was wrapped up, passed to us and weighed, it sadly died. At least the little baby was having a cuddle in it’s last moments, but it was certainly difficult to process, knowing that in the UK there would have been so much more support and so many more options for it’s survival.

These kind of incidents happen so regularly out there that the staff, although very sensitive (and much more caring to these mothers than the ones who they shout into silence in labour) appear to be a little hardened to it, or at least used to it, and so they simply carried on with their day. The couple of us from the UK who were on the ward were a little shaken but when the midwife in charge came over and promptly delegated jobs to each of us to be getting on with, we were quickly aware that we just had to get going again…it’s just part of the care out there and we had to be strong and carry on.

As the day went on, I found myself caring for a woman with obstructed labour, where her pelvis simply wasn’t allowing the baby through. She was fully dilated but the baby wasn’t descending at all. Whether this was a problem with her pelvic dimensions, or if she had a fibroid or something restricting the route, we didn’t know, but she was heading to theatre.
Before I headed to Tanzania, I wrote myself a little list of the things I really wanted to see out there if I got the chance, and one of these was a C-section, simply because they do a “classical” incision out there, where the incision goes from top to bottom, rather than horizontal across the bikini line; and they don’t do them in the UK unless there is a very unique medical condition or if the baby is particularly premature, so this was an opportunity to see one of these c-sections outside of a textbook.

This particular C-sections had been categorised as an emergency, so I was really really surprised that it took over 45 before we were wheeling her to theatre, and then another hour before the surgeon arrived and the team were ready to place the spinal for her anaesthetic. Even more surprising for me was the surgeon, as he arrived, took one look at me (as a white girl who stuck out like a sore thumb) and assumed that I was a doctor, stating “Ah, you have come to assist me in surgery!” at which point I very quickly corrected him and said that I was a student midwife from the UK, expecting to then observe the surgery…however he responded with “You know neonatal resus?”
Now we have done this at uni, on mannequins, and I passed my neonatal resuscitation exam first time, but I’d never had to do it on a baby before…I didn’t really know how to respond, so I replied with a hesitant “uummm….yes, but…” and he quickly replied with “Ok, you do the resus.” No question about my qualifications, or what stage I was in my training, no concerns that I’m a student and wouldn’t even write a note on someone’s chart in the UK without it having to be cosigned by a mentor, I was in charge of the resus!

I have to admit, I was slightly prepared for this as one of the other girls had told me that she had experienced the same thing when she went to theatre so I had already gone over the resus process in my head, but even so, way to send your heart into your mouth!!
I went to prepare the resuscitaire to find that they don’t really have one….just a flat surface with a lamp over it as a heat source….no oxygen, no suction, not even a stethoscope (they had a pinned for that part)….simply a “penguin” (like an upright bag-valve mask) and that was it.
I had to gown and mask up fully, and then I watched the surgery with my fingers crossed behind my back, wishing for the baby to come out screaming. When the baby boy was passed to me I was terrified, but everything I have learned in the skills labs came to me as if second nature – they really do know what they are doing when they drill it into you at uni – and I cannot tell you how relieved I was when, after what felt like absolutely AGES, the chubby little baby let out his first cry! It’s not a moment I will forget any time soon!

So much relief on my face!!!

I may have been petrified at the time, but I know now that if the moment comes when I am in the hospital at home, particularly once I’m qualified, I am ready to get hands on and resuscitate that baby. Definite confidence boost – and the mum consented to me taking a couple of pictures with her baby too! 🙂

Needless to say, after that mentally draining, and both tough and rewarding shift, we were in need of a bit of a wind down, so after a quick shower and a sort out, a group of us went to the market for a wander, a bit of a shop and an ice cream, which was lovely! We even managed a bit of a swim when we got back to the house before getting changed for the evening.

Thursday evening in the Work The World house in BBQ night and it was AMAZING! They had set up a huge, double-tied BBQ and made all sorts of extras to go with the VAST quantities of meat – seriously yummy! One of the guys staying at the house used to work as a mixologist (cocktail-maker) before he started training to be a doctor, so he had set up his own bar and was making cocktails for us all night (seriously strong ones) and the team even taught us some traditional African dance too! Such a good night and just what I needed after such a full-on day!

To read about the rest of my trip, see the “My African Midwifery Adventure” posts here, or click on the links below.

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