Verge of Tears

I spent the majority of today on the verge of tears. I’m so thankful this week was my second so that I was mildly prepared for the insanity.

The clinic was in absolute chaos upon our 8am arrival. 10 babies overnight, 5 labourers, and the most staff I’ve seen together at one time all yelling, dusting and changing bed sheets like we might return them if not used immediately. Out of habit I peered into the delivery room and saw a lone swaddled bundle on the resus bench. During handover, I caught a glimpse of the tiny bluish baby being put skin to skin with mum to combat prematurity as the doctor explained. As lungs are one of the last organs to develop, premies often suffer respiratory distress and even from the end of the bed we could hear the baby gasping for air. It’s routine here for all small babies to be pumped full of antibiotics to prevent infection and was to be transferred to the Neonatal Intensive Care Nursery at Mt Meru. Sounded like a good plan to me but in the meantime I asked if the clinic had oxygen to assist bub’s breathing.

“Yes, of course we have oxygen.”

“Can we give some to this baby?”

“We will at Mt Meru.”

So off we go I assume. I should have realized that even in urgent situations, Tanzanian time still prevails. Handover continued for over an hour, midwives answered social phone calls and the floor was mopped before we finally prepared to transport.

Keen to experience the NICU, Anika and I bundled into an ambulance with the schoolgirl mother and baby and waited for another 20minutes before realising another passanger was coming – a mum 10cm dilated on the verge of pushing. Holy moly I thought, something must be seriously wrong to risk delivery in transit. When I found out the diagnosis was “caput” (swelling of the fetal head which I think rarely results in complication and resolves itself) I was so frustrated.

No attention was paid to the flashing lights and sirens as people ambled across the street whilst mama was gripping Anika for dear life and yelping. The midwife meanwhile was demanding she resist pushing until arrival. The teenager was gripping her gasping baby and sliding all over the place. To top it off, her five relatives had come along for the ride. When we finally arrived, I escorted the pushing mum to labour ward where she was given 30mins to deliver or c-section poor thing.

Then came the NICU where these miniscule fighters were laid out in open, rusty cribs. Multiple babies shared beds and in place of incubators for warmth, the room is instead heated. Babies are given nasal oxygen only with no sign of nasogastric tubes so not quite sure how they’re fed. Our premie looked glowing and healthy compared to the frail creatures surrounding him including 30 week twins and a 26 weeker. The fact they are alive is miraculous.

Back in the clinic, the delivery room was buzzing. Two women each occupied a bed; one was attempting to deliver and the other was being whisked away minutes after deliver by the midwives to clear her bed.

The aforementioned young women was pushing and pushing with no progress. In Aus we might suggest a position change (off her back for goodness sake!) or consider vacuum extraction. To my absolute horror, the midwife roughly stretched the skin to the point of tearing and reached her hand inside to physically grip the head and pull. Not surprisingly, bub was born unresponsive with poor tone, grey in colour and no respiratory effort.

Hands down the most frustrating part of this whole experience is witnessing simplistic care when effective equipment is available! Back home, the policy for an unresponsive baby is to first stimulate, and then assess and clear the airway. Whilst the clinic has working suction some midwives aren't familiar with it and prefer not to use it. For 4 excruciating minutes I watching the midwife rather gently pat the baby on his mothers stomach, and only when his nose was cleared did a weak cry escape him.

I was shaken and about to walk out when another woman flopped onto the second delivery bed to begin pushing. Whilst Anika conducted that delivery, I was cradling and monitoring the first baby. His poor mama aged 20 had a fear of needles and was refusing to let the midwife repair her second-degree tear. I felt tears in my eyes as the midwife shoved her legs apart yelling how she must obey. The needle of local anaesthetic was waved threateningly as the mum desperately tried to bat her away.

The new mum could not be convinced – and by this point who could possibly blame her – and was allowed to return to bed. No pain relief administered. No education on care of tears. No ice to reduce swelling. Everything I value in midwifery care, especially fostering a trusting relationship based upon woman centred care was stripped from this woman. It's definitely a cultural experience I am trying to come to terms with.

Before leaving for the day, we asked to observe a tubal ligation as part of the clinic’s free family planning service. Having never seen one back home, I can only assume it’s a laparoscopic procedure. Everyone seemed very concerned about our footwear, although I found the brief hand-washing to be a bit more frightening. The doctor was so friendly, and made such an effort to talk us (and the mama who was wide awake and flinching) though the entire procedure. We got a shock when out flops a fallopian tube onto mum’s abdomen! It was hand tied with a piece of thread, snipped with those rusty scissors and finally poked back inside. Simple as that.

Night duty tomorrow, may our babies be many and healthy!