Our resuscitation workshop started today despite only being able to rouse 2 midwives for the lectures. The positive side to this was that I was able to give them nearly one on one instruction. The negative side was that one of them was on duty and got called away to an imminent delivery, and the other one got called in to the district health office for some unknown reason. Rather than sitting idly in the classroom, I decided to attend the delivery to see what it was like. The patient who had just arrived was a woman having her 8th child. Most women do not give birth at health centers, preferring to give birth at home with a traditional birth attendant because of the cost of transport and the costs of the materials required at the health center. There is no charge for public healthcare in Uganda, but those who give birth at health centers are meant to bring mama kits, made up of things like a plastic sheet, a razorblade, clean cotton cloths, and ties for the umbilical cord. I have no idea what they do to substitute for these items if they give birth at home.
The midwife was a strong woman with a commanding voice. I had met her on a previous visit to the health center, when she politely requested an update in every aspect of emergency obstetric care. I liked the fact that she was so open to learning new things, and she also had a very entertaining way of using the Lusoga exclamation “eeh!” as she made stinging indictments of the Ugandan healthcare system. “No soap, no medications, eeh!” She said derisively. “At times we are just like a TBA.” (Traditional Birth Attendant) The midwife put on an apron, large white rubber boots, and gloves. I got the feeling that she was nervous that I was observing her.
The patient crawled onto the bed, which had a plastic mattress and metal frame and no further covering. She crawled clumsily. She was fully dilated. She didn’t make it into good position on the bed, and her head was propped up on the bare metal bar at the head of the bedframe. A plastic sheet like a garbage bag was laid underneath her. Her eyes were squeezed shut and she appeared uncomfortable, but she made no sounds except breathing heavily. The midwife grabbed her thighs and pulled them up towards her head, shouting “push!” in Lusoga. I grabbed a thigh, assuming the ‘husband position’ in American obstetrics and held the patient’s hand. The midwife continued to shout as she ruptured the membranes and tried to help the baby’s head down. “Push! Push more!” Her tone sounded like a drill sergeant’s. A few other patients peeked their heads around the screen to watch. The fluid from the ruptured membranes splashed everywhere. “You see the conditions that we are dealing with.” The midwife said, angrily looking at her wet arms. “She is a victim, eeh!” Meaning that the patient has HIV. The baby’s head got close, and the midwife grabbed onto it and started maneuvering it out. The cord was loosely around the neck. The midwife’s shouting reached a fevered pitch, and then she reached over and whacked the patient in the thigh as she yelled. The baby slid out, looking blue and limp. The midwife turned the baby upside down and gave it a little shake to get fluid out, then put her finger in the baby’s mouth and tried to sweep out anything remaining. I looked at the bulb suction sitting next to the bed, unused, which the midwives had told me they no longer utilize due to infection risk if it is reused. After some vigorous drying, the baby ‘pinked up’ and started crying, though not lustily. Perhaps he sensed that the circumstances in the room were less than joyous.
The baby was wrapped in a cotton cloth and placed on a nearby bed. The onlookers from the other part of the ward were still watching. The woman finally sat up and took her head off the metal bar it was resting against as she climbed out of the puddle in her bed to get dried off. The whole thing had taken about fifteen minutes. As I walked back to the classroom, I thought of my Ugandan teammate’s pronouncement that “women have to be strong, because they must endure labor.”
The midwife cleaned up and returned to my workshop, having sent the mother and baby to a bed in the maternity ward. “How was my technique?” She asked politely. “Can you give me feedback?” She has been a midwife for something like twenty years, and I felt a bit ridiculous, but I ran through what I had seen, starting with her protective gear, mentioning the Apgar score and what she had done after the baby was delivered. “One thing I would like to emphasize, though – please don’t hit your patients.” I said carefully.
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