Work work work work work...(in my Rihanna voice)

Sorry guys it's been a while....not that there was nothing to write about, there is always something to share but for these experiences I needed time. Time to deeply reflect, time to internalize and analyse before I could really find a proper way to bring across what goes on in health care systems across this country. Even the time I spent reflecting seems barely enough to assimilate the experiences here. For the purpose of making it easier to visualize I will describe the trajectory a woman might follow within the system.  

A little background info: So we are in the Borgu region, within this region there are 3 main health care centres (centres de senté). Nikki is the largest followed by the one in Kalalé and third is the center in Pèrèrè (which is currently inaccessible due to the state of the roads caused by rainy season). Nikki has the only hospital in the region and it's located right alongside the healthcare centre. The hospital serves A huge population consisting of a vast mix of ethnicities. A great deal of people come from Nigeria seeking medical care as in that part of Nigeria closest to Nikki there are NO hospitals. Historically speaking the borders of Borgu did not end at the modern day border and extended well into Nigeria. 

 A health care centre can be likened to a miniature hospital which deals with triage of patients. They take care of low risk and sometimes medium risk cases and all (medium) to high risk cases are referred to the hospital including pregnancies and childbirth. After visiting the facilities what I've learned is that the main issues plaguing health care facilities are : Accessibility, roads may be in poor conditions some patients simply don't have the means to reach a health care centre. No means of transportation centers lack working ambulances so patients are transported by motorbike or if they have the means to pay someone by car. Another problem is unreliable water and electricity supply. At times both just cut off and staff is left to work in the dark or without water or they can wait it out. The hospital does have back up generators but only 2 and they serve only a small portion of the hospital. They try to counter water shortage by creating reservoirs for times of need. 

So on my shift one morning there was a young lady of 20 years old (looks like 14 to me). She came in during the night at about 38 weeks of gestation. Her mode of transport from her village about 15 km away to the hospital was by taxibike. You have to imagine being in labor then crawling on the back of little motorbike and stay on it for 15km on bad roads. Not very comfortable.

 The young lady belongs to the Bariba tribe and does not know any French at all.  Pregnancy seemed to have evolved normally, no complications noted. Uterus is contractile but she refused vaginal examination.  As I see her lying there I notice she has been circumcised. Female circumcision or what we call female genital mutilation is the practice of removing the female clitoris and labia. It is a cultural practice which has no health benefits, on the contrary it often time causes many health complications. Most times it is believed that women should not enjoy orgasm nor have sexual pleasure so the organ that gives a woman pleasure is removed. Many times it is performed by traditional healers with questionable tools. In some countries female circumcisions are performed bij medical professionals. In most nations this practice is illegal. There is a beautiful movie called "Desert flower" based on a book written by novelist Waris Dirie for those interested in understanding what it means to be a young girl in a country that accepts this practice. 

So when the gynaecologist in training arrives on the floor he decides that it is time the lady got a vaginal exam. He gently tries to examine her, she squeezes her legs but he manages to complete examination. Fully dilated head engaged! He ruptures the amniotic sac, fluid is moderate and clear. It is obvious that the girl is in distress, she is in labor pain and sweating profusely. Without making a sound she looks around wide eyed like a captured deer and scans the room. She often makes eye contact with me as I think I am the constant calm focal point amongst the hectic back and forth of midwives, nurses, aides,students, doctors. All babbling loudly in a language she has no notion of. The midwife would go and "stimulate" the uterus by violently digging into the girl's abdomen with her fingers. "The contractions are too far apart!" I hear someone yelling, it sounds like the doctor. In the mean time young mom squirms on the table getting up each time the pushing reflex overpowers her.  He commands to start a ptocin drip. This is an artificial version of the hormone naturally made by the body called oxytocin. The hormone causes the gravid uterus to contract as to expell the baby. After birth it also aids in the let down of mothers milk for the baby. The same hormone is also a key factor in all human bonding relationships especially mother and child, lovers....

The student prepares the IV to start the drip. No pump is used, the drop rate is done by counting drops which in itsself is perfectly fine. All this time I notice nobody is listening to the baby's heartbeat. I ask the sage ( sage is the nickname for the midwife from the French "sage femme" it means wise woman) on duty if they do that on occasion, she says yes by "Pinard". The pinard is a tube like instrument which allows one to auscultate fetal cardiac rhythm and frequency or listen to the baby's heartbeat. I have not seen anyone listen by Pinard as yet. They do have doppler devices but they cannot be used because the batteries died and can't be replaced because.....they don't have a screwdriver! Incomprehensible and sad.  

I hear the doctor asking the nursing student to prep for surgery cause this isn't working. The young girl isn't able to push correctly so labor is stagnant. No one actually gave her any proper coaching in her language, nobody took the time to reassure her. Emotional wellbeing of the women is not on top of the priorities list. Granted she didn't make a sound but her body language and eyes told it all.....

We prep her by bathing her, shaving the abdomen, stop the drip and replace it by saline etc....basically what we would do at home. The OR block is about 2 minutes away from the delivery room so we put the young lady in a wheelchair and head over there. On the way passing many visitors or guards of the ill hanging out in the hallways. These guards are family members or friends who travel to the hospital with the person who needs medical assistance. They bring food and clean linen and clothing for their loved one. Many come from far away so they stay on the compound untill their family member is discharged to take them home. The sick are rarely left alone. There's always someone "guarding" them. These guards have designated areas to cook and wash linen and to sit, they are called pavilions. Yet they choose to roll out their mats in the passage way and take a nap. Even though it has something to it, seeing all these people together caring for others, it does obstruct mobility. The girls' chaperones notice us leaving, they quickly grab their belongings and follow us.  Once we reach the OR the laboring woman gets up and walks  to the operating table. She is told to climb on but there is nobody to assist her. Midwife disappeared, student disappeared. Both went to change for OR.

The anesthesiologist starts to disinfect her back (prep for the placement of anesthesia) without notice so she startles. Her response is met with someone yelling oh no you have to sit still you might fall! Good that they notice but she didn't understand one word that was said. During the puncture our young lady got scared as she didn't know what they were doing to her back so she jumped again. More yelling! Hey stay calm! Unfortunately nobody was able to explain anything to her. Thanks to the exceptional skills of the anesthesiologist the puncture went well without any calamities. They lay her down and start installing her for the surgery. All she does now is just stare around her with those big shiny eyes. We install the catheter disinfect the abdomen and add  the draping. Her hands are tied with pieces of a bandage. Hands have to be tied to prevent the patient from contaminating the sterile field. Finally the surgeon gets started after a few minutes the amniotic sac is ruptured, I noticed it's no longer clear but stained with meconium (the baby's stools). The  more of the fluid comes out the darker it looks, the thicker it seems. A huge wave of dark green fluid is oozing out of the amniotic sac. This is usually a sign of fetal distress. I'm on alert I move a bit closer to the resuscitation table. The midwife has arrived in the meanwhile. I check the clock 10:57, the baby's head is being born and the rest of him follow quickly. Our little prince looks like something the cat dragged in. Completely limp, devoid of any tonus covered in green fluid. He makes no sound nobody moves any faster. I look for the pediatrician but then I remembered that's not common practice to have him present at any birth. The midwife receives the baby and puts him in a surgical table and dries him off. I'm looking at her like I'm the only free player on the field close to goal waiting to score wanting her to hand me the baby. She takes her time, likes him a bit and since he's not moving she comes to the table. At this point the baby has gone pale and is staring straight ahead. He's making attempts to breath but his tonus is weak. The midwife and student start doing their thing so I step back. Their thing ( by no means do I want to make it seem as if these ladies don't know what they are doing, just describing what I observe) includes drying the baby off some more, looking at him and poking him and squeezing his nipples. His poor little belly has been pulled in so far by now that his ribcage is pretty much the only thing prominent. His skin is blotchy and little baby is craving for air. Midwife decides it's time to suction his airways. Good call but should have done before all the poking and probing in my opinion. There is quite some green liquid coming out of the oral cavity so she goes deeper and deeper each time. The baby is just there grimacing and stating around. Midwife keeps aspirating and more of the green liquid comes out I check the reanimation clock but nobody has turned it on. By this time I notice blood is coming into the aspirating tube. And she goes for one more round. Now the nasal cavity same story she continues untill I see blood coming out of the baby's nose. Finally it stops. Babe is still not fully of this world. I ask please do you have any oxygen. I can barely stand doing nothing. She says ah no we don't have any. In my mind I'm thinking let's go to the neonatal block and stabilize this child. She takes up the balloon to blow some air in his airway. From all the manipulating and handling the baby he is in no proper position to receive air. I want to pull my hair out at this point. All I hear is the air escaping from the mask. I'm afraid to ask her if she has the appropriate mask because I already know the answer. My eyes want to well up with water but I fight the tears. This child is suffering and all this has been going on way too long. It is now 11u13!! I say excuse me do you mind if I help you position the baby maybe it can help. The student who was doing nothing just poking gives me the side eye. So I show the midwife how to put the baby in a symmetrical position, elevate his thorax perform chin lift I help her to secure the mask but it's to no avail and she knows it too. I say to her softly shall we take him to the neonatology? She said yea. But first she starts to take his measurements! This baby is on no state to be without proper oxygen exchange. You can tell it's hard for him cause all now I haven't heard his little voice. His breathing is still irregular, his color has not really changed and his tonus is still the same. I check his pulse and good thing it's normal. The student grabs the baby and puts him on the metal scale which has the wrapper from sterile gloves as cover. It's one of those old scales where you move the weights around untill it balances. She's not sure so keeps meddling with it untill she gets it. Ok all the measurements taken now let's go! 11:20 I'm moving at a rapid pace towards the newborn block. The student follows with the baby wrapped in a green cloth from the OR. Then only good thing about the long trip to the block is that outside temperature is about 33 degrees way warmer than in the OR where the cold air was on. Visitors from all over are hanging around even the sick who come outside for some air are here coughing and spitting. We pass sick children on the floor leaning against the wall covered in flies. I don't know why all I notice now is how germ infested this place seems. Other times it had something charming about it....now I'm just worried. When we arrive we enter the newborn reception hall. It's the place where the one "deposits" the new baby. The nurse is not there and the student calls out to her up to 3 times. I hear some clogs dragging. Oh hello! The baby has been lying on the cold tile counter for a good 2 minutes. Let's check his weight again! Same ritual with the metal scale, the nurse verifies the weight to the student and she takes off. She did not tell her anything about the baby's background or situation. The student says she will bring the file. I stay to observe the nurse. Little man is put in a warm bed and she hooks him up to the monitor his sats (% of available oxygen in the bloodstream) are on the low side but more than I had expected his is in the low 90's. We prefer a number closer to 100% but it usually climbs if the baby is oxygenated properly. Brains need oxygen and sugar to function properly. After she reads the monitor and writes it down nicely she goes looking for something I hear noises coming from the other room. All I can do I stare at the child who is craving air. His skin is still pale but his tonus seems better. There are locust in the bed next to him and i see spiders crawling around. The walls look like they haven't  been cleaned in a decade, draws are open and everything is a mess, sheets have been used so many times that they are no longer white. Subconsciously I take a step back... So unsanitary in here, I might be having an OCD (obsessive compulsive disorder) moment......By this time he has closed his little eyes in an attempt to find some rest. I feel so overwhelmed..... After a few minutes I see her rolling in an oxygen device. Hallelujah! My heart jumps for joy. First she goes to get another monitor for continuous measurement of his vital signs, puts his IV in his little hand and then starts his oxygen therapy. I look at the clock: 11u40! That's way too long. No blood samples are taken no Xray of his thorax...nothing.  I ask when is the pediatrician coming to check the baby? Oh on his evening tour because its not a high risk situation.

As I take in the events and put my personal judgements aside. I realize that this situation would have been handled a bit differently at our facility.  The staff  here lacks proper equipment and because these situations occur on a daily it makes absolutely no sense to get upset over things. You just do what you can and that's where it ends. Although we might overdo things in Belgium I realize it's because each life is deemed precious. The overall feeling I get is that ok we do what we can but if the baby doesn't make it the mom can have another baby. And in reality it's true but does that ideology take away from the preciousness and sanctity of life? Or is it it a defense mechanism to help one cope with sorrow and powerlessness?Something to think about.....

Our young man is finally left alone. Literally he will be separated from his mother for 48 hours as mom recovers in intensive care (standard protocol here after c-section). After 2 days she will move to maternity and they will be reunited with her son. That is also when they will negotiate the baby's name. He will receive a glucose drip with some electrolytes and minerals. If he shows sign of hunger sugar water is on the menu. Nobody goes to mom to express colostrum (First milk) for him...it is what it is.  I can't wait to get out of there. I felt so powerless and I rarely feel this way. Especially in my work, I usually feel confident and adopt the African mindset of do what you can and that's that. I'm not sure why this is even an issue for me. Maybe because I realise that where and how we come into this world is such a determining factor for our entire life path....I can't help but think about the little man's future and what if he has suffered oxygen deprivation? How will his young mother cope? In the grand scheme of all calamities this is not an extremely bad situation and chances are everything will be fine but it could have been different......if he was not born here.