Ward 14 – Learning to deliver

I finally found my way back to Mulago Hospital for my much anticipated rotation on Obstetrics and Gynecology. As instructed by the many international students who have rotated there before me, I requested to start out my rotation on Ward 14, the labour suite in Old Mulago for low-risk obstetrics patients, entirely run by a team of uber-experienced midwives, and a perfect learning ground for newbies like me.

I met with a cold welcome when I first presented myself to the sister-in-charge on Ward 14. The midwives there are really busy and overworked, and in their experience, most of the students who pass by stay for only a short while, disrupting the overall pace of work in order to gain experience and knowledge, and disappear before they are actually skilled enough to help lighten the workload. Thus, that you really have to prove yourself to be eager to learn and help out before they will pay you any attention. When I first told them that I was only planning on staying for 2 days, they scoffed. “But what can you possibly learn in 2 days? You must stay for at least a week.” Sister Florence, the in-charge, informed me. And by the end of my first day, I had already learned so much from them that I decided to stay for the whole week. They showed me the ropes in terms of how to deliver women in these low-resource settings, and how different it is from what I’ve been used to in the US.

The first delivery that I observed totally shocked me. These women have to bring their own delivery set, which includes, at the minimum, the following items: a large plastic basin, a small bottle of Jik bleach, at least 2 large plastic sheets, a huge roll of cotton, a few pairs of sterile gloves, a razor blade, 2 sheets for the soon-to-arrive baby, and a change of clothing for themselves. Why these items, you wonder. Well, allow me to explain.

The laboring mother who is found to be in the active stage of labour gets a bed in the labour suite, and she proceeds with her suitcase (presumably filled with the items of her delivery set) to the bed. She spreads the large plastic sheet on the bed, both to protect her against the nastiness of the bed and to protect the bed against the nastiness of her labour-induced fluids soon to be spread all over the plastic sheet. She also provides the sterile gloves for the midwives to use while doing vaginal exams and during the delivery. Then, if she is lucky, she may get checked once or twice before her actual delivery. If she is super unlucky, she may end up pushing out her baby on her own while the midwives are busy with other deliveries. Let’s say she’s lucky. She screams her classic second-stage scream (if you work in a labour suite for long enough, you learn to recognize the unique scream that soon-to-be mothers emit when their babies are crowning – it is a terrific combination of pain, anxiety, and anticipation, brushed with a hint of desperation and a tinge of hope – that directs you to the woman who needs your attention most immediately in a room full of laboring women screaming in agony, forming a strange cacophony of sweet but unbearable pain) and you rush to her side (after hopefully having had time to don a plastic apron to protect yourself against splashes, and if you’re me, you also wear goggles for eye protection, though I don’t always have time to put these goggles or the apron on before the baby starts popping out). You prepare your delivery “tray”, in case you don’t have an assistant by your side when the actual delivery happens. Note that this preparation precedes the checking of the mother to see if she indeed is in the second stage of labour, because we cannot afford to waste a precious pair of sterile gloves on the vaginal exam, which results in the not-uncommon tragedy of the mother pushing her baby out while the deliverer, in this case, me, is busy preparing the “tray” and does not even have gloves on to try and catch the baby before it pops out traumatically, ripping a nasty tear into the mother’s vaginal wall and perineum. Anyways, back to the “tray”. You first track down the plastic basin that all laboring women bring with them. You place it beneath the mother’s bed. Then, you find the huge roll of cotton, a necessary part of any delivery. You break off a big chunk and set it close to the mother’s perineum, ready to wipe off and push away poop that may get squeezed out as the baby’s head descends, to catch the amniotic fluid that may fly out as the membranes rupture, and to support the mother’s perineum as the baby’s head exits the vagina to prevent tearing. You open one set of sterile gloves, tearing off the rubber rings located on the wrist end of the gloves that are meant to provide some elastic traction to keep the gloves from sliding off your hands – these rings are used as ligatures to tie off the umbilical cord. You place the rings on top of the sterile-ish package holding your now not-so-sterile elastic ring-less gloves, and this serves as your delivery “tray”. You break open a glass bottle of Pitocin for use after the delivery of the baby to help the uterus contract and prevent post-partum hemorrhage, and fill a syringe with the drug (it is to be delivered as an injection intramuscularly), making sure to save the broken glass bottle in case you need to use it to rupture the membranes (if the membranes are not already ruptured). All these items are placed on your delivery “tray”. Lastly, you open the razor blade and add it to your “tray”. Finally, you search around the suitcase until you find the baby sheets, and place one of these sheets on the mother’s abdomen. You now open another set of sterile gloves, so that you can double-glove. You first don the not-so-sterile pair of gloves on the inside, and add the actually sterile pair of gloves to the outside. You do a vaginal exam and more often than not, the mother is in the second stage of labour just as you had expected, and is ready to start pushing. Good thing you already prepared your “tray” so you’re ready for the delivery.

If the mother is still dressed, you ask her to strip. Yes, these women give birth absolutely naked. Not a whole lot of dignity gets retained during this birthing process. The mother starts pushing, with shouts of encouragement from you. “Sindika! Sindika! Yongera! Sindika!” “Push, push,” you yell. You tell her to raise her head off the bed, and hold onto her legs with her arms. This goes on until the baby’s head is crowning. Usually, this process proceeds smoothly. However, once in a while, the mother demonstrates “poor maternal effort”. This basically means that the mother is not pushing effectively, either because she is tired, or because she doesn’t know how to push. Now, for outsiders like me, there is only so much we can do to encourage these women. But there comes a time when encouragement alone does not suffice, and some intimidation is necessary to get the baby out. Now, I have not yet fully adapted to the delivery process here, and so intimidation is not currently in the arsenal of tools I have at my disposal. So I call in an experienced midwife, usually Sister Sarah, the most experienced and intimidating of them all. She comes, screams at the mother, pushes her roughly into the optimal position for pushing (head tucked, legs pulled way open) and sometimes slaps her a few times on her thighs. Now, this may seem barbaric to some of you back home, and when I first witnessed this, I thought it was so unbelievably mean and unethical to treat women who are already suffering so much with so much cruelty. But it turns out that it is not cruelty, but the lesser of two evils, and I swear that it works like a charm. What I couldn’t get the mother to do with some 30 to 45 minutes of eager encouragement, Sister Sarah gets done in a matter of minutes, and when I say minutes, I mean usually less than 5. Suddenly, the mother is able and willing to push, and push effectively, and the baby pops out effortlessly. I have carefully considered this matter, and discussed it at length with both my American and Ugandan friends working at Mulago. As a result, I have drawn a tentative conclusion. I believe that Ugandan patients do not respond as well to encouragement as American patients do, and they certainly respond much better to threat and intimidation. I have seen and experienced this many times myself. For example, when I politely asked a patient’s attendants to leave the labour suite, they dragged their feet, and basically didn’t move. When a midwife came and ordered them sternly to leave, yelling at them, and shooing them away, they left immediately. So perhaps, when polite encouragement fails, threat and intimidation is the way to go. In fact, all of the mothers I’ve seen who were yelled at, and even slapped, were super grateful to the midwife who yelled at and slapped them, despite their apparent “meanness”. These midwives got the job done, and got the babies out before they became distressed, or worse. All of the mothers seemed to prefer a few slaps and rough words to a sick or dead baby. I know I would. Interesting food for thought, isn’t it? Where would you draw the line between ethical and humane conduct, versus doing everything you can to avoid a possibly terrible and tragic outcome?

Anyways, back to the hypothetically smooth delivery. The baby’s head is crowning, and you use cotton to support the perineum as the baby’s head pops out, and if you do your job well, the mothers generally do not tear. Once the head is out, you wait for restitution, and the shoulders to descend. Then, you deliver the anterior shoulder, followed by the posterior shoulder, and the rest of the body follows. You deposit the baby on the sheet on top of mom’s abdomen, and quickly dry the baby off. If all is going well, the baby is pink and feisty, and crying at the top of his/her lungs. You give mom the Pitocin injection, often without cleaning the skin with any kind of antiseptic, and hope the mother’s immune system will prevent her from getting an infection. You tie off the umbilical cord with the elastic ring ligatures, and grab the part of the cord between the ligatures with a piece of cotton to absorb the blood splashes before cutting it with your razor blade. You clean the baby off and show the sex to mom – “Muana ki, mommy?” Then you wrap the baby snugly in the second, clean sheet, and find a relatively clean area of the bed to place the baby. By this time, the placenta should have separated, and you use another piece of cotton to firmly grip the umbilical cord. You use firm traction to deliver the placenta, while applying pressure just above the pubic symphysis to prevent uterine inversion. As the placenta reaches the vaginal introitus, you let go of the cord and grab it with both hands, twisting as you gently pull to gather the trailing membranes into a stronger cord, so that hopefully no membranes will be left behind. You examine the placenta for completeness, and then drop it in the large plastic basin beneath the bed.

Now you get to the really nasty part – the cleaning. I’m telling you, I’ve never properly appreciated nurses and patient care technicians until I had to do the cleaning part myself. I will never again take any nurse or PCT for granted, I swear. The first few times I witnessed this process, I almost ran away. But I had to start cleaning as soon as I started delivering. You have to take charge of every part of the delivery, including the gross aftermath. So here’s what you do. The mother is now lying in a pool of nasty fluids such as amniotic fluid, blood, urine, feces, etc, atop the plastic sheet. You roll up this plastic sheet, trying to catch all the fluids in it, without letting any leak onto the bed underneath (not always a possible feat). You ask the mother to lift herself off the plastic sheet, which you then pull out from under her. You then drop the rolled-up plastic sheet into the basin. You take the basin with you to the instrument room, separating the placenta out from the rest of the waste, depositing it into the placenta bin, and then toss the rest of the contents of your basin into the biohazardous waste bin. You rinse the basin off, and fill a small tin bowl with Jik diluted with water by a factor of 6. You bring the now relatively clean basin back to mom, and drop her soiled clothing, sheets, etc into it. You ask the mom to get off the bed, and clean her with some cotton soaked with diluted Jik. She starts getting dressed as you wipe off the bed with more cotton soaked with diluted Jik solution. You dry off the bed with cotton (see the importance of cotton in all of this?) and then spread a new plastic sheet over it. If the mother has a bed sheet, you place it on top of the plastic sheet, and the mom gets back into her bed to recover. You then weigh the baby, and write your delivery notes. A job well done!

P.S. I am never giving birth at Mulago.