Labor ward

I had a patient die on Tuesday. "Pass away" seems a gentler way to write it, but to bluntly write "die" represents better the violence and shock of it. She wasn't just my patient, per se, but I had helped others with her. When I saw her laying out on the bed, so unnaturally not-alive, I felt self-conscious closing her eyes and covering up her naked breasts, like I was in some kind of movie, even though no one was watching. It was the first time I've experienced a maternal death as a midwife. 

She was only 39, the mother of eight living children, and had crossed over from the Mozambican borderlands for care at the hospital. It is possible she had first labored for one or two days with a traditional midwife in her village, but the details are hazy, and there's realistically no way to recover them now. 

Tuesday was my first of ten days I will spend working in the labor ward at the district hospital. In order to be licensed in Malawi, I must spend five days in each of the various maternity wards (antenatal clinic, antenatal ward, postpartum, nursery), and ten days in the labor ward. Monday was my last day in antenatal ward, which is where women - who are high risk and/or live far enough away to need to camp out at the hospital for a month - await the start of labor, sleeping on the floor, spilling out into the hallways, waiting patiently to be assessed each day. It's where we manage patients in early labor, then transfer them to the labor ward once they're in active labor (5-6 cm dilated). 

With something as unpredictable as birth, the lines are fuzzy and I did deliver one baby myself because everyone casually ignored us when I walked the patient over: ignored my verbal report that she was about to give birth and ignored me when I yelled out, "Hey, she's crowning here!" By the time someone appeared at her bedside, the baby was on her chest. I've spent a decent amount of time in the labor ward transferring patients and thought I knew what to expect. It looked a little crazy, sure, but not much more than the antenatal ward.

Did I say the district hospital wasn't like a refugee camp, in the end? That was silly. I'm back to saying that's exactly what it's like, at least in the labor ward. The chaos, the noise - oh, the noise - the necessity for urgent resourcefulness, the do-or-die mentality (but literally). Tuesday's shift was like nothing I've experienced. The only grace was that, I do not say this lightly, God gave me a premonition about the death in the days leading up to it. When I kissed the kids goodbye before jumping on Rex's motorcycle to go to work, I asked them to pray for me, for courage, for ability. I knew in my gut something was going to happen. 

It did - and quickly. Within minutes of my arrival, before I'd had even the most basic orientation to the unit or the staff, a Mozambican woman, 39 years old, in her 9th pregnancy, was transferred to us from antenatal ward. I know her first name but I'm not going to use it. She'd been there since the day prior, apparently having contractions. Her papers showed that a fetal heart rate had not been heard on night shift, but nobody did anything about it. There was no ultrasound tech at night  anyway. Then she came to us right at shift change.

A young male midwife named Aubrey went to admit and assess her. He called me over for a minute because he couldn't hear a fetal heartbeat. There was no doppler to be found (of course) and it was very hard to hear anything with the fetoscope because at least three of her neighbors were screaming very loudly. (The beds are about 2 feet apart and separated by only partial curtains, which are held in place with locking forceps. Those women finally stopped their continuous screaming 4-5 hours later, after they had raised the tension in the ward by 1000%.)

Fetoscope

Locking forceps

Initially I couldn't hear a heart rate either. Moving slowly around her belly, concentrating, I suddenly heard a strong thump-thump. "Hold on," I told him. "I can't tell if it's her or the baby." After counting carefully for a minute, I raised my head and reported to him: 130, a good fetal rate. I hadn't been told anything about her history yet, so I had no reason to double-check it against her wrist. Aubrey leaned his ear over and confirmed it. 

I then went back to my patient, a girl I wanted to keep a close eye on. I had sent her for an ultrasound the day prior (her only scan of the pregnancy) and the report showed that she was having twins - but much too early, at only 29 weeks. Third trimester scans are very unreliable: she looked further along than that, even with twins. John (the antenatal ward-in-charge, who is wonderful) was certain the scan was wrong. I hoped so, to give them a better shot at survival. Now joining her on labor ward, I saw that someone had randomly written down that she was 39 weeks, which was probably what her fundal height was measuring and definitely wrong. Both babies were breech and the plan was for a vaginal delivery, which is common here. I wanted to be present for that and make sure she wasn't overlooked in the hubbub of the ward.

In the meantime, I tried to make myself useful. There were people everywhere, staff and patients alike, and a big pile-up of women in active labor waiting for open beds, all standing or sitting in the same small area, everyone on edge because of their own discomfort and because of the Screamers. My attempts to provide doula-like comfort to the Screamers seemed to only made things worse: they were begging me for things I couldn't understand and couldn't provide and there simply were too many people to attend to. The way people cope with labor pain is very cultural - especially while laying flat on hard delivery tables without pillows, without medicine, and mostly being ignored. I just wasn't understanding it and couldn't calm them down. One seventeen year old girl - who was there on her own - kept grasping me firmly by the wrist and begging me not to leave. (I did spend a lot of time with her and eventually delivered her baby. It went fine and I think I may have christened her baby Mathews - the Malawian way to say Matthew - but I'm not 100% sure.)

In the midst of so much chaos, I suddenly sensed something was going on two beds down. I walked over and the 39-year-old Mozambican patient was on the floor, not convulsing in an eclamptic seizure but clearly not okay. There were two other midwives trying to pick her up, so I grabbed one leg and we shuffled her to a triage area. When we released her onto the floor, she was unresponsive; then the third midwife left so Aubrey and I heaved her up and onto the bed together. I turned her on her side and could see she was breathing but not fully-conscious. I lightly slapped her cheeks, trying to get a response. Her eyes came into focus and she started responding in Chichewa and was apparently coherent. "What is she saying?", I asked Aubrey. "What is going on??" 

He peered down at her, then guessed: "I think she got up to ambulate, then got dizzy and fell?" Other people had taken over her care by then, so I returned to my patient with the twins. Later I saw an ultrasonographer come on the ward to scan the woman who fell and when he was done I begged him to check the fetal heart rates on my gal, too, because I didn't feel confident about what I heard using the fetoscope, nestled as we were between the Screamers. Also people were barfing on the floor. 

Maybe 30-60 minutes later, I wandered over and asked Veronica how the Mozambican woman was doing. "She's dead," she replied in a scared whisper. "WHAT?!", I exclaimed, stunned. "When? How?" Sometime after the ultrasound, apparently, but no one knew exactly when. It gets weirder: the ultrasound scan showed there was no fetus in her uterus. 

WHAT!??!

A whole crowd of people then arrived in the ward: hospital administrators, John the charge from antenatal ward - because someone on his team had transferred to us a woman who was contracting and seemingly at 5 cm dilatation, but who must have already delivered at home with a traditional midwife but no one knew or asked?? - and everyone involved in her case gathered in a side room. The 130 heart rate we heard must have been maternal, I offered, her body going into shock. Everyone was confused. No one was doing any normal labor care anymore. There was a growing crowd of patients needing admission and labor beds.

Then the woman's elderly mother showed up, was told her daughter had died but we didn't know why, and she began to grieve and wail at her bedside for the next several hours until the patient's body was moved to the mortuary. Two of the Screamers were still waiting for the OR to open up so they could have their recommended cesareans but they never tired of their shrieking. One of them wandered out of her bed, repeating herself loudly and rapidly, over and over, in Chichewa, losing her mind, not coping at all. She threw herself over my shoulder and tried to pull me with her into the hallway, taking me who knows where, until I asked a ward attendant to save me and help disentangle her from my neck. The pregnant women waiting for labor beds stood in a group watching, wordless, patiently, but with deep alarm in their eyes.  

I texted Matthew: "I feel like I'm in a horror movie."

But it wasn't that. It really wasn't. It was everyone making-do the best they knew how. Things happen. Women die in childbirth, especially in low-resourced countries like Malawi, but even in America they do sometimes. This was my first encounter with that. On some deeply merciful level, I had been prepared for this day, so I was doing okay; but I was helping people in a sort of shocked dream state. I had never seen the labor ward like this; it was a lot for a first day. 

Then I went to check on my patient with twins who had seemed close to delivery, and to my surprise, the first breech twin had just been born! A sweet midwife named Tadala, 23-years-old at most, was standing at her bedside, quietly doing the work. While she clamped the cord and handed the baby over to be brought to the warmer, I caught the second baby, who was so tiny she simply slid into my open hands feet-first, like on a warm, gentle waterslide. I brought her to join her sister at the warmer, where Aubrey was struggling to resuscitate them all by himself. 

"Shit, shit, shit, shit, shit!", I thought to myself, trying to remember the skills I learned in September at a training for just this scenario. Baby 2 needed deep suctioning, there was so much amniotic fluid streaming out of her nostrils and mouth, but the suction machine was broken. There was only one oxygen machine and nasal cannula, not two. No one was helping us. "WHERE IS THE PENGUIN SUCKER?", I yelled and someone pulled one out of a bucket where it was being disinfected and handed it to Aubrey, who started removing large amounts of fluid from the tiny babies. I was giving breaths with an Ambu bag to the second baby. I flipped on the O2 machine, though when I asked a passing clinical officer (like a doctor but less trained) what rate to put the oxygen on, she admitted she didn't know and walked away. I felt very panicked. The first baby was breathing okay without it at least and someone had now taken her to the neonatal nursery. 

Ambu bag

Then someone dropped off a third tiny baby, their sister: because my twin patient was actually having very-preterm breech/breech/breech triplets, though the ultrasound had not visualized that third baby in either of her scans. Tadala the midwife, God bless her for eternity, had remembered to palpate for another baby "just in case" and then this one slid out too.

(I later went to John and told him he'd been spot-on. He had said she looked too big to be only 29 weeks, and the reason was because she had three babies in her, not two.)

Baby 3 was now at the warmer beside baby 2, soaking wet, and neither were breathing well despite drying, stimulation, and alternating breaths with the Ambu bag. Aubrey and I looked at each other. "Aubrey, can we please just run with them to the nursery!", I begged. We each grabbed a baby, drowning in the stiff chitenge wraps their mother had packed, and we raced down the long corridor, past all the quiet women in labor who followed us with their eyes. 

"So help me God, these sisters are not losing any of each other. NOT TODAY!!", I shouted. Aubrey just laughed as we turned into the neonatal nursery, where nurses trained to handle this sort of thing were already stabilizing baby 1. We plopped them down together, into a warmer that now held five tiny preterm babies in a small row. I was so glad they could all feel each other, their arms and legs splayed and askew, in each other's space. It seemed especially helpful for the two other very ill-looking babies who were with them. We need each other, I thought, my mind racing. I need you. You need me. I need Aubrey. There's death, there's life. My brain is going to explode. 

I breathed a huge sigh of relief when the neonatal nurses took over. I finally stepped out, found a sink, rinsed my hands with water, and slowly trudged back to labor ward, where I still had a few more hours in my shift. How was that possible?

There had been news in my absence: The dead patient had been ultrasounded again, but this time they called in a different tech to do it. Doubt had been cast on the findings of the first scan, which had showed an empty uterus, leading to much speculation and self-doubt for everyone. This time, the ultrasonagrapher found a dead fetus and a uterus that had ruptured open, fatally. This can especially happen to someone who has been pregnant nine times, as she was. When it happened is unclear. Possibly it started when she was laboring in her village, before walking or being driven on the back of a motorbike to our hospital - especially since the night shift nurse had detected no heart tones. Or maybe it happened sometime after Aubrey and me had heard a heartbeat at 130 beats per minute. Or maybe that was her own heart rate, as we had speculated. In any case, now both mother and baby were dead. There were eight children back at home in Mozambique who had yet to hear the news, to find themselves now motherless. 

I had snapped a photo of the triplets together, looking so alive, and brought it to their young mother. She and her mom, their grandma, were still sitting on the hard delivery bed. The Screamers had been taken away at last; the ward was quiet. She was trying to hand-express colostrum into tiny plastic cups. When I pulled up the picture of the babies on my phone, they both smiled and started to cry at the same time. "Ana ali bwino", is all I could say, "the children are good" - but they could see that for themselves. I stood holding it for several minutes, hoping it would help her milk to flow. (They do not have a phone so I will print it and give them a hard copy this week.)

(Jenny at Mercy in Action: this one is for you.)

Holy shit, y'all. I mean it, really: There was shit that day, but there was a holiness to it, too.

Riding back home with Rex at the end of the day, I closed my eyes instead of taking in the human scenes around me, instead of watching the mountain. I felt the thrill of fear pass through me for a second, that disorienting letting-go that has to happen, the need to trust that the motorcycle would not crash even if my eyes were closed. Or maybe it would - we're not all carried safely, are we? Whether my eyes were open or closed it would not change the outcome. I let Rex transport me away, blindly, only feeling the cool air rush by and smelling the woodsmoke from nearby fields.

I realized I felt eager to get back to the labor ward, not tomorrow, good Lord no; but next week, as scheduled, after resting. I gave such thanks for that. 

My Malawian coworkers - Aubrey and Veronica and John and Tadala - would have no such break, no such choice in the matter. 

Rex brought me home safely, and I thanked and paid him. "See you Monday," I said. 

"See you," he replied, and with a rev of his engine, disappeared behind the banana trees.