My African Midwifery Adventure – Day 8 – Two Baby Girls and Fundal Pressure

So, as I mentioned before, week two was the week it all got a bit more intense out there. The first week had been intense in it’s own way, but in no way had I been expecting to get quite so hands on as I did in this second week.

Just as a bit of disclaimer:
1.  I did witness some of the darker and sadder sides of midwifery out in tanzania, including a neonatal death, so this is a bit of a warning for that too 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.

N.B. Please think before posting negative or confrontational comments on these posts or where they have been shared. I am simply sharing my experience and have no control on the overall set up or running of the hospitals out there – as such I will not be responding to any such comments.

The Midwives on the labour ward were so very friendly out there – obviously pleased to have the extra hands on deck and happy to help with anything we needed – that said, they were also happy to let us get on with it if we seemed to know what we were doing.
As a result, we ended up carrying out several deliveries completely unsupervised, which was a really good learning experience – and we knew the midwives were nearby if we needed anything, but they weren’t monitoring everything we did, letting us be independent and get on with it.

As a bit of context, the labour ward is one large room, with flimsy curtains, and so us and the midwives were walking up and down the room, and when you saw that a woman might be pushing, or in some cases when you walked past and saw a bit of the baby’s head emerging, you headed over and pulled on your gloves. This meant you didn’t know much about the woman before you helped her baby into the world – a quick “Unaitwa nani?” to ask her name and “Naitwa Rosie” to introduce myself was about as much as there was time for – no medical or even obstetric history, just straight in!

Within 15 minutes of our arrival, one of the other student midwives from the UK (I’ll call her L for confidentiality! headed over to a woman who looked like she was pushing, asked me to assist, and after just a few minutes of supporting the woman (and protecting her perineum – something they don’t really do out there) her baby had been born, caught by L and passed straight up onto the mother’s chest.

The women are so unbelievably grateful out there, just repeating “Asante, Asante Sana!” over and over (Thank you, Thank you very much!) after their babies are born. It’s not that the women in the UK aren’t grateful, but out there they have none of the inherent British-ness here in the UK, they just want to tell you over and over how grateful they are! It’s really moving actually, particularly when you compare the care they get to the care we give in the UK and the differences in dignity and lack of pain relief…

I didn’t have much time to help out with the clean up after delivery, however, as another woman across the room had started pushing and as I looked over I saw a patch that I recognised as the top of a baby’s head. I headed over, and the woman looked at me saying “Asante Nursey, Asante” as I introduced myself and pulled on my gloves. She seemed like she was exhausted, and though she was getting the urge to push, she needed more power behind the pushes to bring her baby into the world – “Sacuma, Sacuma” (Push, Push) I told her, in as encouraging a manner as I could (limited swahili meant I only knew a few choice words to help with deliveries but it didn’t seem to stop the women understanding what I meant).

That seemed to do the job as with just a few more contractions she was crowning and with my hand and a swab protecting her perineum her baby girl was born just a minute later at exactly 8.30am. It was only after delivery that I found out that this baby was only 36 weeks – thankfully, it was absolutely fine, despite being a little preterm and weighed just under 6lb 10oz.

They have very minimal paperwork out there, with only a small folded piece of paper for each woman, where you write time of birth, gender, weight and condition of the perineum, and then a large book for the hospital records, where you write the date and time of birth, gender, weight and who “delivered” the baby – so it was really exciting to be able to write my own name as the catching midwife for that baby – the 992nd baby born there that month!

The women out there are all very happy and even excited to have you take pictures with their babies – so I managed to get photos with each of the babies I caught out there; so special considering it isn’t really done in the UK. In each case I also got permission to share the images, so I can share them on here for you guys to see!
So this is the first baby I helped into the world out in Tanzania, a beautiful baby girl:

After the speedy tidy up that is expected after every delivery, within minutes of the bed being empty, another woman filled it – as it goes all day, every day out there – one-in-one-out = but it needs to be to accommodate for the number of women delivering on the ward every day.

The next lady was already starting to feel the urge to push, so I stood with her and supported her as much as I could. Within 20 minutes however, the midwives came over, expecting her to have delivered already. It’s all very quick out there and so anything more than 15 minutes of pushing, the midwives start intervening. The midwife came over, and using the blade I described in one of my posts from the first week, gave the woman an episiotomy (with no local anaesthetic – they don’t have it). As the baby still wasn’t born with the next contraction, the midwife placed her hands on the top of the woman’s uterus, her hands in a CPR grip, and with the contraction pressed her whole body weight through the top of the woman’s bump. I was desperately trying to protect the woman’s perineum (even with the episiotomy, with no time for stretching the risk of tearing is huge), and with the next contraction, with even more weight through the top of her bump, the baby flew out. Honestly, it was one of the most brutal things I’ve ever seen. I didn’t know that was something people did, and it was something I’d happily never see again – the matter-of-fact way of doing it, and with no pain relief at all…. just really hard to see.

The midwife left me to deliver the placenta, which came away nicely (every women gets oxytocin injected to get the placenta out as quickly as possible and clear the bed – and it reduces risk of PPH too) and then she came back over to carry out suturing. The woman had torn in addition to her episiotomy as I had expected (and tried to avoid, but with that pressure going through her perineum, there was only so much protection I could offer). Again, there is no local anaesthetic for the suturing, but the women out there seem somewhat hardened to it, with no cries of pain or flinching, just letting the midwife get on with it and being so unbelievably grateful throughout.

I suppose birth is so much more high risk out there with the higher rates of maternal death, neonatal death and stillbirth, so they are simply grateful that all parties are alive, but compared the care we give in the UK, it seems amazing that they are so grateful.

As soon as the suturing was done, she was up and out of the bed, into the showers and then dressed and ready to move on – it amazes me how quickly these women are expected to be up and about…I don’t think I saw anyone stay on the bed more than 25 minutes after delivery, even with suturing, the whole time I was there.

I was just thinking about getting a sip of water once everything was sorted from that lady’s birth, and another lady called me over. She seemed quite young, maybe 20/21 years old, and just looked so scared. She kept crying out for her “mama” and I could just tell she was scared and exhausted, and with the midwives going around and telling the women to be quiet when they cried out in pain, she was obviously struggling. I held her hand and tried to reassure her.

This is a moment I will never forget; she looked straight into my eyes and said “Saidia” which means “help”. I didn’t know what to do, I wanted to make her feel safe, to tell her what to expect, to tell her it would all be ok, but I suppose that is part of the challenge out there – it tests your core midwifery skills, and your ability to communicate in ways other than language, and to reassure women with your presence, your skills and your touch. I held her hand and squeezed it, and she seemed to understand. “Asante” (thank you) she said.

I stayed with her, wanting to provide some intrapartum care to this woman who was clearly feeling particularly vulnerable. About 15 minutes later, still holding my hand, she started making a few stronger noises and I heard that familiar guttural sound that women make when they feel the urge to push. “Sacuma?” she asked me (push?) and I nodded. She started to push and I caught a glimpse of her baby’s head. I encouraged her as much as I could, and as she came to crowning I looked her in the eye and said “Si Sacume, Hema” (Don’t push, breathe) and she grabbed my hand and imitated the panting breathing I was showing her. One hand holding hers, the other protecting her perineum, the baby’s head was born, slowly and controlled, and with one final push, her baby was born into my waiting hands.

It was nice to feel that I’d given proper care to a woman in that situation; that I’d created some kind of bond with her and helped her when she was feeling so vulnerable. They are so stretched out there, they just can’t offer than kind of care to every woman, but being an “extra” pair of hands, I was able to do that, and give her the time and compassion she needed to feel safe in such a vulnerable time.

As we had managed such a gentle and controlled delivery of the head, and I’d been protecting her perineum, I was really pleased to check and find that she had no tears at all – and she was so grateful, standing by me as I cleaned up the bed and holding my arm or my hand every few minutes saying “asante, asante”.

Another baby girl welcomed into the world, and caught by me – a challenge, but I really felt that I was able to use my core skills to help her, even without all the resources and pain relief we have in the UK, and that is something I will never forget.

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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