A shift on Delivery Unit Government Hospital

These are just the facts of what I observed on one short shift at the Makeni Government Hospital.
I arrived having seen some of my students providing antenatal care. I asked to go to the delivery unit to see how things worked - there were none of my students working there at the time.
A woman had just given birth vaginally to twins. I was not present at the birth but was there to witness a haemorrhage following the birth of the placenta. The floor was covered in blood - I've not seen so much in all my time as a UK midwife. The woman was tipped head down on the rusty old delivery bed - an infusion of syntocinon was put up and an injection of something that I did not get to read the label of the phial. The newly delivered woman was lying on a blue plastic sheet and I worried that she would slip off the delivery bed. Her legs were propped up on the bed by means of a chair that was wedged ontop of a portable set of steps. The whole thing looked incrediably dangerous. The clots were being expressed manually as she continued to trickle - the bleeding was by now less. Her Hb was done and was around 6.4 having had a booking Hb of 9 - so she had probably lost a significant amount of blood. There is no banked blood transfusion service in Sierra Leone - so relatives had to be traced to see who had the same blood group as this woman - as she had been prescribed 2 units - relatives permitting.
I wondered about the twins - the first a girl had lived and was wrapped in a cloth and left at the side of the delivery room - which was also the office, and place where staff got changed, put their bags and washed their hands in a bucket as there is no running water in the Government Hospital. The second twin a boy - born by breech died during birth - he looked like a fresh stillbirth to me. There were no signs of maceration - only bruising to his legs as I understand he was a footling breech. He was wrapped in a cloth too - and put on a table where everyone who came into the delivery room passed by.
Through a small curtain there is another room about 10x10 foot square with 3 really old rusty birth beds - just metal the rubber mattresses have long gone. Very dirty and one sink without running water. There were 2 other women in this small progress room. One woman had been in labour for 2 days and had transferred from another area. It was her second pregnancy - the first baby was born by cesearian section (classical) and had died at birth. This pregnancy the decision was made that she required a cesearian section too. I went into theatre. A nurse did the epidural (yes epidural) and the doctor proceeded to do another classical cesearian section. I can't recall any written consent or explanation being given to the woman. I also do not recall any form of intravenous fluid being administered. The baby's body was delivered (no fetal heart was listened into prior to the cesearian section)then part of the placenta came out of the abdomen with what I could see - a snapped cord with the head still in the uterus. It seemed like forever before the head was birthed. It came out like a cork from a bottle. The baby was covered in meconium and was flacid. The many staff present in theatre started to clean down the baby but at this stage no attempt was made to do a full resucsitation. Eventually an old dirty bag and mask was taken out of a cupboard. At this stage I instructed the operator of the bag and mask to bring the baby's head backwards and lift up the chin to get a clear airway. (I know what I will be teaching). There were 8 people round the table where the baby was - no one came back to the mother to let her know they were having difficulty with the baby. I felt for a heart beat and told the personnel around the table that it was 40 beats per minute. At this stage I felt the need to leave - I went back to the delivery room. I could see this baby was not going to make it. The staff brought the baby back into the delivery room - where they all thought the baby had recovered. I explained that the baby was taking its last gasps before she died. The oxygen is only obtained by means of a concentrator and the electricity is only put on for operations - then it is switched off.
When I returned to the delivery room I found the twin woman still in the same place awaiting blood from her relatives. In the progress room all 3 beds were full. 2 women birthed in that room - no curtains or privacy - within minutes of each other. The first baby had a urinary catheter pushed down its nose and throat to 'clear the airways' that did not need clearing. I asked the midwife (the only midwife on duty) to stop - the so called resucistation was very rough - the baby being held by its feet and in my opinion being hit rather hard. The second baby only had the urinary catheter pushed down its nose and mouth and was not subjected to rough handling. Both babies were not given to their mothers but put on tables in the delivery room where the twin mother was.
The third mother in the progress room - it was her first birth - witnessed the 2 births and looked terrified - no one reassurred her - I tried but she did not speak english and just looked terrified knowing she would be next. I understood there were 2 more women waiting in the courtyard in labour waiting to come in.
At this point I left.
Now that there is free healthcare for pregnant women, lactating women and under 5's - many women are coming to the Government Hospital when perhaps previously they would have birthed at home with TBA's. This is one way of stopping TBA practice but with only 95 midwives in Sierra Leone, births are being done by nurses, aides and others. There is a new Government Hospital being built - which is great - but without the staff to support all the births and provide a safer outcome - it is all going to take time. 60% of maternal and child health care is now free and the remaining 40% is provided by charities/faith hospitals - but they charge a small fee. I understand that these charity/faith hospitals are not busy now and one I know of is closing for a short period. If the charity/faith hospitals were paid to provide care - centrally - this would alleviate some of the pressure the Government Hospital are currently facing. The staff said they were exhausted - they have been on the go since the free health care was introduced on 27th April.
I will follow up the outcomes of the twin mother and the cesearian section mother when I next go to the Government Hospital.
The midwifery students return to classes 7th June.

Antenatal clinic Government Hospital Makeni

I went to the Government Hospital in Makeni as an observer and to see how the student midwives I will be teaching are getting on in their placements. There were about 10 pregnant women all sitting on benches under a corregated roof with poles supporting the roof. The ages of the women were from probably about 11 or 12 to 30's. Some of the women do not know their birth date and so it is difficult to know quite how old some of the women are.
The antenatal clinic started with a short talk by one of the student midwives about looking after their health in pregnancy and caring for their baby afterwards. Looking for signs of infection, premature rupture of membranes, sexually transmitted diseases. The women are advised to plait their hair tightly - so as to prevent wee beasties making their homes.
This talk (no questions asked by the women)was followed by prayers - both christian and muslim - all women partook in both religous activities without any conflict.
The pregnant women had blood pressure taken and this was put on a small piece of paper, then the same happened regarding their weight - so by the time the women got to have their pregnant uterus palpated they had collected various bits of paper. These bits of paper with various recordings on them were then handed to a clerk who recorded the information in a large A4 size record book. Very scant information was held in the maternal records - which are held by the women.
The examination of the mother was I thought brusk - women are not asked permission to touch their bodies or thanked afterwards. No questions seem to be asked by the women - their abdomens are briefly palpated - many women do not know the date of their last period - so dates for when babies are expected - is quess work by using fundal height.
Twins are more prevelant here - but twins are not always seen as a joy as in the developed world. Sometimes a weaker twin does not survive beyond a few weeks if that long - many twins die at birth or one does not survive the birth - more about this in another installment.
Women are seen four times during pregnancy, they are tested for HIV, STI's and have tetanus and malarial treatment as a routine. Rhesus negative women are not given anti D and there is no test on the baby to see if it is rhesus positive.
Women do not appear to have any privacy, several student midwives, State Enrolled Child Health Nurses, nursing aides are all present whilst a women has her teashirt pulled up to check her breasts and her skirt pulled down to check presentation of the baby. Fetal hearts are listened into using a Pinnard's. A scan costs money - so generally women do not have scans. Most women are anaemic but at the moment I'm not sure of the uptake of iron tablets or how they are obtained.
Men do not figure in any of the antenatal care.
Women are however referred to medical care if there are any abnormal findings.
Urine is not tested unless there is a specific reason, blood pressure is taken and attention to hair, eyes, mouth and any lymph nodes around the neck are checked so too are the legs for any swelling. I'm not sure how much women know how to look for early pre-eclampsia signs in themselves.
Next installment - a day in the delivery unit.

I have moved house - again!

I have moved to my permanant address today! Two hours later than planned - but I am in Africa - at least the day was right. I was collected by 3 men in a pick up truck with all my stuff bundled into the back. Enroute we encountered a march through the street of primary school children complete with a brass band! The temperature that registered on some religous icon on the dashboard of the pick up truck said 46c - wow it felt like it too.
We went over some really rough terrain to get to my new accomodation. I don't even know the address of where I am living - I suppose it is over the back of the Midwifery School by the trees, pink house within a compound - that is walled with big metal security gates with coiled barbed wire all the way round.
The house is so much better than the previous temporary house - a distinct lack of cockroaches, no loud music that resonates through the walls, no constant smell of mariujana - which makes me feel sick!
I set to work cleaning the kitchen and bathroom to a standard that I can live with - it took all day - but I feel for the first time I can cook here.
I made a cup of 'instant' coffee - boiled the water in the shiny new kettle after I had put the gas connections together without blowing myself up!
There is limited furniture - I'm still living out of suitcases until a wardrobe arrives! There is a promise of some sort of bench/table in the kitchen to prepare food on and place the 2 burner hob on safely!
There is no electricty here but a need for a generator to pump water from the well into the storage tank - needless to say the water tank is nearly empty and I was looking forward to a day of washing clothes (by hand of course!) - but I will have to save the water for showers - as it is just so hot, damp and sweaty here.
I have bought a couple of small battery operated lanterns and have candles - that is my power supply. I can charge up my laptop, toothbrush and phone at the school - but only on week days - so if I use my computer too much - I am then without the outside world!
Tomorrow I will go to the market and buy some food stuffs now that I can cook on the 2 burner gas hob. I have got an African cookbook - all beans and rice - but it is very tasty stuff.
Who knows what I will eat tomorrow.
I worked in the Government Hospital Antenatal Clinic this week - I will tell you about this in another installment.

My first week in Makeni

I have been 'up country' as it is described in Selonian for a week. The climate is much hotter than Freetown which is on the west coast with atlantic seas. I have been at the Midwifery School since last Wednesday with my first teaching session on the female pelvis with 10 minutes to prepare!
The next day I worked with another midwifery tutor where we did some revision classes for student nurses doing their 'midwifery' module. We did the breast and the male reproductive organ - guess what I had to draw on the board!! Yep you guessed right.
I had a tour of 4 midwifery establishments and the Primary Health Department - which manages health for the Bombali district. Makeni is situated within this district.
Some hospitals are run by religious groups and some by the government. Government hospitals are providing free health care for women who are pregnant or lactating or both and children up to the age of 5. The faith based hospitals at present do not fall into the category of offering free health care - this may have some implications if women prefer to receive free health care in the government hospitals.
My accommodation is temporary and I am going to move to a bigger, cleaner house shortly.
I was woken at 4am by a cockroach hanging off my right wrist. I shone a torch on it and in its fear - it bit me - I have a wound to prove it. I sprayed it with insecticide - but it is not unusual to have 10 dead on the floor in the morning - I spray my room first thing in the morning. But this cockroach must have got into my mozzie net!!
I am learning to barter for goods/food in the markets. They are colourful and sell just about everything if you are prepared to take your time and ignore the crowds. There are really smellie fish markets and I have never seen so many flies!
I also get around using motorbike taxi's and as I have only once - aged 15 - been on the back of a bike - this is a bit of a novelty. I keep telling the drivers to go 'slow slow' but it does'nt make much difference. Still it saves a long hot walk to where I need to get to.
I have met a few other NGO's and VSOers and have been introduced to several other expats - all good fun!