The other side of midwifery (by Natalie)

Sadly Angela left us last Wednesday to do a workshop in Kampala, so we had a few days off. Yesterday was our first day back on the wards, and I was wondering how it would go without her. What would I get today? Would I be able to manage on my own? As I have learned already, sometimes the world has a funny way of listening.

As soon as Quinn and I stepped into the ward, the head nurse tells us, “Gloves on! We have two women in second stage!” Thankfully, they are side by side, so Quinn and I can be close together if we need each other. As my 16 year old mom is getting close to crowning, Quinn lets me know she is a first time mom who has been in labour for many days. I also notice by the shape of her stomach something that looks like a fibroid - both of which are risks for extra bleeding postpartum. Many mothers here have differently shaped pelvises from having babies young (their pelvises have not fully developed) or from inadequate nutrition (their pelvises don’t develop in a normal way). I can see this baby needs some help coming out, likely from a differently shaped pelvis, and it’s a very tight fit. I do what I can, and the head comes out...but the shoulders do not.

I am doing all the maneuvers I have learned and practiced at school, but I now have many students looking at me, and two senior midwives telling me to do fundal pressure and pull on the head, and if I just pulled on the head, the baby would be out by now (we don’t do these technique anymore). Quinn backs me up while we stick to our guns and try to quickly explain we don’t pull on the baby’s head; the baby comes out in 3 minutes (you have 5-7 minutes) and needs some resuscitation. As Quinn does the resuscitation (and is still monitoring her other mom!) my mom starts to have a postpartum hemorrhage. I get the bleeding under control with wonderful help from the Ugandan medical students. Her baby is now breathing, but clearly needs further monitoring. Minutes later, Quinn’s mom has her baby, and then her baby needs resuscitation too. Her baby comes around well, and I really begin to appreciate how hard the nurses work - often one nurse to six patients; and I am running off my feet to keep good care of my mother and her baby as well as Quinn’s recent baby, while Quinn is finishing up. We take the baby to acute care, and from within, I sadly hear the unmistakable cry of a mother who had recently lost her child.

I then follow one of the interns as he reviews a mother having her fourth baby. She is “nearly” (means almost fully dilated) when the senior obstetrician has advised that she should have her waters broken to help with the head coming down. As the interns break her waters, he discovers a cord prolapse (when the cord comes down first - you need to lift the head off the cord so blood can continue to flow to the baby instead of getting squished by the head). I change places with him to keep the head elevated so he can prepare for surgery, and they are able to get in quickly. Thankfully, the baby comes out crying and doesn’t need any help.

The day is filled with more moms to assess. As more senior students, Quinn and I have lots of Ugandan nursing students and two medical students following us around. In some ways it is wonderful, because it really tests my own knowledge, and makes me so proud of all that I have learned. And in other ways, it really(!!) makes me admire my preceptors, because teaching is incredibly hard work.

It starts to get late, but after a chaotic day, all I really want is a non-dramatic catch and without a million pairs of eyes staring at me. There are a few moms labouring, and the mom’s labouring voices sound like puppies crying out to each other. I am monitoring two in particular: one who is a 16 year old first time mom and in the bed beside her, a 32 year old mom of 6. Very sweetly, as the night progresses, I noticed the 16 year old steal glances at the more experienced mom, and begin to echo her noises and movements, as if she is learning the art of coping with labour. Quinn and I both finish the night with straightforward catches and beautiful babies.

I swing by acute to see how the baby from earlier is doing - and when we look at the baby, we see that it is having seizures. We ask the nurses what will be done for the baby, to which they explained they will have to wait for the doctor to come in order for the baby to be assessed. Unlike home, acute care is just a room full of mothers holding their babies. No monitors, no one-to-one nursing, no doctors right away when you call them, no immediate diagnostic tests to tell us what is happening to the baby. Often all you can do is hold the mothers hand and give a tender squeeze, a smile, and just hope for the best. Today when I went by, the mother had left with her baby, so I don’t know how the baby will do.

Today was the first time I really missed home. First, it is extremely challenging to have to manage complications while defending yourself. I have so much to learn from these women and midwives; but it is so difficult to go up to a midwife who has been practicing since I was born to gently explain why their management technique is not right. Second, the condition of the first baby I caught really hit me hard. I know that I did all that I could and I delivered the baby in a reasonable amount of time, and I have no idea how this baby had coped with many days of labour or if there had been any underlying conditions. I hate the lack of resources to find out why and not understanding why some babies have a harder time than others. I hate that a doctor will likely not see the baby for many hours, and no one will be able to monitor the baby closely. I hate knowing that the difference between life and death for this baby could be so simple, but is so far out of reach in a health care system that is so under supported and under valued. And even with all the resources, tests, and care, the outcome may be the same and I still may never know the answers. But I guess that this is also what it means to grow into myself as a midwife - to come to terms with the other side of life, and all that it means.