#with pics from day 1 day 2 day 3 and after the sutures were removed on day 5 | Explore Tumblr Posts and Blogs

midwifebeth · 5 years

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Day 2: Labour Ward

Today was my first day in the hospital, and the last day for one of my housemates, Miriam, (a 4th year medical student/volunteer), so we went to labour ward together. It was good for me, as she was familiar with the environment, and good for her as I was able to explain what was happening.

They are apparently quite strict at this hospital about volunteers only observing, and due to our last minute change of country (I’ll explain in a later post), we do not have a visa that allows us to be hands on. My style of practice is very different to what I saw today, so I think that is for the best.

The Ward.

See the picture for my rough drawing of the layout of the ward. Between each bed there was a curtain, this was left open until the woman was delivering, then it would be pulled halfway, so the woman next to her wouldn’t have a clear view, but the staff around the room could see what was happening. A curtain would also be slightly pulled at the end of the bed so the women opposite couldn’t see ‘everything’.

Staffing

The ward is staffed by a number of nurses and midwives, a few healthcare assistants (that do the cleaning and sorted equipment), and a sister. The nurses and midwives wear green scrub knee-length tunics, or short-sleeved scrub gowns that go over clothes/uniform like a theatre gown does (this is what volunteers and students wear). Shoes are supplied, with the role of the wearer written on them. They are white leather cloggs. I will try to get a picture when I return. Today there was also a male SHO present at all times on the ward, and a couple of female medical students (I think).

Routine Care

As far as I can tell, all women are kept on a CTG, Synto infusions are routine (5iu, I couldn’t read the amount of dilutant). Infusions are given through a bottle, rather than a bag (which is what I’m used to) and if drugs are added, a needle is stuck into the airspace at the top of the bottle. I think I also saw the active management synto dose given IV, there was about 5mls in the syringe they were using, I am not sure. All babies are given Vitamin K IM, it did not seem that maternal consent was required. The women are alone on the ward, with no birth partners allowed.

It is difficult to ask questions as very few of the staff speak any English, and those that do, speak only basic English. The doctors learn in English, so they will be my source of information when I can catch one having a free moment.

The Experience.

We were on the labour ward for 3 hours, and witnessed 3 births within an hour (2 within a minute of each other!), then another just before we left. The main thing I learned today is that at least in the hospital I’m based at, (I’m not sure if it’s country-wide), all women have episiotomies, this is done during second stage, when vertex is visible. Most, but not all, were done with a contraction. None were done with anaesthetic.

When we arrived there were 3 women labouring, and one postnatal, her baby was on a resuscitaire across the ward while she waited to be sutured. Only doctors do the suturing here. The SHO did the suturing, with me and the other volunteer, and the 2 medical students, observing, and a nurse/midwife assisting. The suturing method was the same as in the UK, commencing with infiltration of local anaesthetic (through a needle manually bent by the doctor). I have to say I’ve never seen someone suture so quickly! It was textbook style.

Afterwards, the mother was handed her baby, and she lay with her for a while. They were concerned about bleeding, so a tampon swab was left inside her vagina for about an hour. The doctor came back and removed it, and a few clots, then she was dressed while on the bed, and left to rest, with the baby back on the resuscitaire.

Soon after the suturing was completed, the lady in the middle bed on the left (see pic) was given an ARM with a pair of surgical scissors. Synto was commenced. All three labouring women were occasionally vocalising in pain, but were mostly left to it. When the staff feel that a woman is reaching second stage (they did not always do VEs), they get them into the ‘birth position’. This is like McRoberts, but with the legs held out to the side, and the woman holding her feet in a particular way to keep the position. It looks quite uncomfortable, and having tried it myself (at my host house) I know I would not be able to hold it for very long. They are then left to push with each contraction. Once vulval gaping is seen, or the staff feel birth is soon, the woman is attended by 2 midwives/nurses, one on each side. An episiotomy is given, baby delivered, covered in a small sheet, while one midwife gives the active management dose via IV (who then takes the baby to the resuscitaire), and the other palpates and massages the uterus, delivering the placenta quickly (I think the longest 3rd stage I saw was max 4 minutes). She then changes the sheet under the woman and takes the placenta, any swabs used, and the used linen out to the sluice/back room. Meanwhile, the midwife caring for the baby weighs it, measures length, head and chest circumference, gives Vit K, then dresses it in about 3 layers before swaddling and leaving on one side of the resuscitaire with a temperature probe attached to the resuscitaire.

While the first woman was pushing as described above, the two that delivered simultaneously had their bladders emptied with a catheter into a steel kidney dish that was then rinsed.

While the other 2 women were reaching second stage and starting to push, a 5th woman was brought into the ward on a wheelchair. Hearing the noises the ladies were making, and observing the environment, her fear was visible and Miriam and I both noticed her attempting to hide her tears as she climbed onto the bed. The woman pushing on the right was opening her bowels frequently, this was left exposed for most to see until each movement had finished.

The two women delivered within a couple of minutes of each other, directly opposite one another. The one on the left was given an epis, and we could see the scar tissue from her previous birth (P2), they have the bent episiotomy scissors here, with the guard on the side that goes inside the perineum, which we don’t have in my hospital in London (we use standard surgical scissors). Her perineum was then guarded with a swab, and the midwife encourage her right leg into McRoberts position. Once the head was delivered they did nuchal cord cutting.

The SHO assisted in the delivery of the lady on the right, doing forceful fundal pressure, which I have only seen once before and not to the same extent. Miriam and I were concerned as after the baby was born the right shoulder seemed lower than the left, and the arm floppy (indicative of Erb’s Palsy or another injury), however the baby was moving her right arm around freely by the time we left.

Soon after they delivered a 6th lady was admitted. The consultant came for his round soon after. He did a VE on this lady (with minimal if any communication with her), conveyed his findings to the SHO and promptly left. A couple of minutes later the lady started to haemorrhage, so all the nurses and midwives worked together to get her onto the gurney and rushed to theatre (which is in another building, up a ramp). I estimated about 600mls on the bed.

Reflecting on the experience

It was an interesting, and rather uncomfortable experience for me. I felt like I wanted to help. I have been trained and work with a woman-centred approach, and my team specialises in women with previous birth trauma, which I was concerned all these women could experience. Particularly when they were calling out in pain I wanted to be there with them to provide at least a little comfort. But I had to be careful, as I’ve said previously my role here is mostly observational, and I can only provide minimal assistance, and it has to be when given permission by the midwives or doctors.

After the first woman was left on the bed to wait to be sutured, with her baby by the resuscitaire, being examined and dressed by the midwife, she caught my eye, she looked so worried I went over to her. I said your baby boy is beautiful, to which she showed she understood by repeating ‘beautiful’, I said he looks big, while making hand gestures, and she said ‘big boy!’ with a smile. She then reached for my hand and held onto it tight until a midwife came up to the bedside to get her ready for suturing. It was one of those ‘warm midwifey feeling’ moments, a ‘this is why I do this’ moment. Just by giving this woman a smile, and holding her hand, I hope I’ve made the experience a little more positive for her. It was heartwarming to see the look of love and pride on her face as she cuddled with baby after her suturing had finished.

Picture key:

1: Drs/Sister in charge office

2: Labour bed

3: Resuscitaire

4: Staff desk

5: Door to sluice/back room

#midwife

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