Fly on the Wall....

My recent experience in the Tamale Teaching Hospital, more specifically on the labour and delivery (L&D) ward, was very mind-opening. Having only been exposed to L&D care for one day last year at Kelowna General Hospital, I felt like I had walked onto a ward where I was only qualified enough to be a fly on the wall. Luckily, for the first day that’s all my partner and I were – flies on the wall. Huge-eyed, stunned-looking flies as our brains were trying to take in and process as much as our eyes could let in at once. 

Labour & Delivery Ward

Garbage Bins

The delivery room is empty when we first arrive, which is apparently quite rare. We find this to be true in the subsequent hours and days as they average 25 births per 24 hrs (both vaginal and cesarean deliveries). The “Stage II” room (active labour/delivery room) has six beds in it, each only about three feet from its neighbor. The room is hot despite all of the windows open and the two old ceiling fans twirling. The air is thick and I can feel it on my skin, but maybe this is just in my head. The smells vary depending on how many soon to be mothers, women currently becoming mothers, already mothers, or recovering mothers there are. It’s not hard to imagine though, since each bed has a garbage basin sitting at its feet that collects (or at least tries to) all of the less romantic part of the birthing process: amniotic fluid, broken water, urine, stool, meconium, and blood. The room is not air-conditioned and they say it never gets below 30 degrees Celsius here this time of year, today it’s 39C outside.  

Needless to say, it’s a bit different here than in Canada.

We meet, and befriend, a couple of midwifery students on the ward. This is appreciated because I feel less intimidated to ask them questions about what’s going on and their English is great. Actually, all of the staffs’ English is great, but sometimes it’s hard to understand their beautifully thick African accents when they are speaking quickly and with purpose. Everyone’s first language is that of which is spoken in their region (or tribe) and their second language is English which they learned in school. Different regions have slightly different accents when speaking English and it makes my brain go into overdrive throughout the day trying to understand what is being spoken around me. I think it’s so cool that everyone has a mutual secondary language they communicate in.

A woman dressed in a brightly patterned dress-wrap waddles into the room, carrying her own IV bag in one hand while the other is holding her lower back. Her face shows pain that she’s never felt before and yet she doesn’t make a sound. Being stoic is highly valued here and laboring mothers are often given grief if they are making too much noise while pushing a new life into this world. Sweat is dripping off her chin onto the bed as she tries to figure out how to get on top of it and over onto her back with the feeling of something the size of a softball between her hips. The midwife who is preparing to help the mom deliver the baby is getting her gloves on and opening the catheter to insert without any explanation, urethral cleaning, or lube. She is wearing Crocks that are two sizes too small with bare feet inside – the most common footwear in the hospital. The mother was sent down to this room because she is fully dilated and the baby is on its way. It doesn’t take long for me to see the baby start crowning while mom continues to quietly push with the exhausting contractions. The further down the baby comes, the more pain the mom is in and she starts grunting or screaming with her mouth still closed. At one point she holds out a hand in hopes of someone grabbing it, but instead another midwife comes over and moves mom’s hand down to the bed and tells her to quiet down and keep pushing. By observing other people in the room, I started to understand that this wasn’t emotional abuse, but rather just part of their culture; being independent and stoic. Did I mention that 99% of these women give birth without any pain medication?

Needless to say, things are a bit different here than in Canada.

The baby is pushed out and flopped onto a soaker sheet on mom’s chest – almost skin-to-skin, but not quite. The new mother is exhausted and can hardly bother to hold her baby. Sylvia, the nurse who had us under her wing, came in and right away spotted that the baby wasn’t skin-to-skin and took the sheet out from between babe and mom. There, that’s better. This gives baby recognition of who mom is, introduces immunity to the newly extra-uterine human, allows him to be colonized by the same bacteria as mom, and helps with temperature and heart rate regulation. It also gives mom a rush of oxytocin to stimulate uterine contractions to expel the placenta, helps with clotting and reduces bleeding, and tells mom she’s got to get her breastmilk ready for babe. The midwife takes the same

catheter as before out of the basin of (now bloody) water and re-inserts it into the mother, again, with no cleaning or lube. Mom is now ready to get a bit of lidocaine and get her 3^rd degree tear sutured up. Watching this made me flinch too, it almost looked more painful than the birthing process. Baby is wrapped up and placed in a basin along with other newborns under the window.

I quickly notice that after delivering, the mothers are either told to walk down to the recovery room to wait or they are kept here for observation if a post-partum hemorrhage (PPH) is anticipated. Delivering babies is a bit like a fast food place down here; they’re ushered in and out as quickly as possible. It’s efficient and resourceful, seeing as how they are often short on staff and are trying to do the best they can with what they have.

Needless to say, things are a bit different here than in Canada.

Sylvia tells us to check out the Theater, the operating room where back to back c-sections are done throughout the days. We need a face mask and hair net to get in and join the other 20 people in the room. The door is often left open and many of the masks I see are not covering either the user’s nose or mouth. Two staff members are sporting bare feet in flip-flops. A few flies are playing around the large brown belly sticking up from a sea of turquoise cloth on the operating table. The baby hasn’t been taken out yet. Despite the lack of resources and equipment, the surgeons do their best to practice sterility once they are scrubbed in. Boiling water is being used to rinse tools, one of the surgeons is wearing eye protection, and four students suddenly jump out of the way to semi-avoid getting doused by a projection of amniotic fluid and blood when the uterus is entered. Three minutes later the baby’s feet stick out – I piece together that mom is having a cesarean because the baby is breech. The surgeon pulls on the baby’s feet, then legs, then reaches up inside to scoop out the head. The baby is very pale and almost grey-tinged. I naively wonder if this is the color that most Black babies are in their first minutes of life, the first one I saw was only a few minutes ago. The babe’s head has a funny shape to it, a shape that I thought was only common with vaginal births because it has to squeeze through the small birth canal. There is no crying, even when the midwife is drying him off and stimulating him. There are a few whispers from the other students as we all watch the midwife feel for a pulse. After a few seconds she takes a cloth and wraps the cold tiny body up to show mom.

My three days at TTH went by quickly and I experienced and learned a lot more than I could have asked for. I saw into some women’s (potentially) most difficult moment of their lives after losing a child before even being able to hold him or her. I also saw some precious moments where mom looks into her newborns eyes for the first time and smiles. There were ups and downs to each day I was there.

Here are some of the things I was privileged enough to witness. (I use the word privileged carefully. I don’t mean to say I was lucky to see these things, but on a global, mind-opening, world-understanding scale, I believe myself to be privileged to now have this insight.)

·       12 vaginal deliveries and the traditions and cultural aspects that come with these.

·       5 cesarean births and the rituals, chaos, and composure of the OR.

·       3 term stillborns and how the mothers and staff deal with this. I was surprised to see that the body and placenta are placed in a cardboard box (typically an empty equipment box) and left on the floor of the room until mom is ready to leave. She will then take this box home and give both her baby and placenta a proper burial when she is ready.

·       A spontaneous abortion of 15-week-old twins fetuses.  

·       A post-partum hemorrhage (PPH) where the mother was getting cleaned out of many clots and what appeared to be a lot of blood. This process also looked more painful than the delivery itself. Blood products are not abundant here so it’s up to the nurses and midwives to do the best they can.

·       A PPH that was being managed by inserting four condoms full of water into the vagina to apply pressure to the bleeding sites to assist with clotting. The mother was to lay there for 24 hours with the four metal clamps hanging out from inside her.

And here are only some of the things I learned:

• How resourceful the staff members are; they need to be due to a severe lack of supplies, equipment, and financial aid.
• How the ball can get slowly rolling by continuous advocacy – skin-to-skin!
• Culture is a beautiful thing. I really appreciate learning about it and find it so fascinating, although sometimes hard to witness. But, just because it contradicts my own culture and beliefs does not make it wrong. It just makes it different. And makes all of us different. And unique.
• How welcoming everyone is here and willing to share what they know.
• How to be left alone with my school partner to keep a brand-newborn alive while they are suturing up mom’s belly right beside us. Oxygenating, suctioning, warming up, and stimulating baby for about 45 minutes until he finally gained enough energy to start to fuss and eventually even cry (probably the happiest I’ve felt to hear a baby cry).
• That babies are cute. But I guess I already knew this…

Posted by Janelle Greer, UBCO 4^th year nursing student.