The Labor Ward

   I've spent a few days now on labor and delivery, or the "labor ward," and being there reinforces that there are some things about obstetric care that are truly universal. A G0 (a woman who has not had any prior deliveries) who presents for her first labor evaluation, 9 times out of 10, is less than 1 cm dilated; on any given day, there's a decent chance that someone will deliver in the hall, or their car, or (gross) someone else's car; and things can go from boring to crazy in literally no time at all. Although, I have to say, the atmosphere is different here in a lot of ways. For one, crazy has a totally different meaning here than it does in the states.
    Earlier this week, while I was passing through on my way to the OR, they wheeled in a lady who had attempted to make it to L&D, but ended delivering in the hall on the way there, standing up. She simply wrapped her baby up, umbilical cord still attached and continued to make her way to the unit. I stopped and talked with her very briefly until one of the KCMC interns came to interview her. She told me that she was a pastry chef and wanted to make a cake for us because we were taking care of her. It seemed completely commonplace to her that she just delivered a few minutes ago, or that it seemed a relevant topic of conversation. It's common for women to deliver essentially out in the open here- the labor ward itself is a single room with 4 beds that are essentially separated by a half wall. While the volume isn't as high as it is at Duke, it's common to have multiple patients laboring side-by-side, with even a few in the hallways on busy days. It makes me smile a little bit thinking of patients at home, who complain about their small post-partum room, all of which are private and have an attached bathroom.

This cutie was delivered to a 19 year old girl earlier this week.
The mothers bring cloth from home to match their own outfits
so there are no mix-ups.

   Aside from spinals for c-sections, there also isn't any anesthesia. After the first delivery I saw on labor and delivery, they gave an IM injection, which I thought might be for analgesia (they use IM pethidine here frequently)... but no. It was pitocin. In fact, it is essentially considered shameful to cry out in pain during labor- patients are expected to be stoic in the face of significant pain. Labor is expected to be painful, and women are expected to grim and bear it. For this reason, the ward can be eerily quiet, with occasional muffled cries and rarely anything more than that. It's a start contrast from home as well, where patients frequently scream, lash out and yell at their partners (sometimes even with an epidural). I remember last year, I had a patient who progressed very quickly while waiting for an epidural (the anesthesia team was in the OR), and while she was pushing, began to scream for the anesthesiologist: "where's the guy, I want the guy!!" When it comes to women who aren't able to keep their cool, the nurses and midwives on the floor are considerably less nice and patient than in the US. If they do fight and cry out during labor, the widwives smack their legs and yell at them. To be fair, I can't speak Swahili, so I'm only able to pick out a little of what they're saying- they could be saying words of encouragement and praising them... but that would be incongruent with their tone. Partners also rarely attend deliveries, or are seem to be present at the deliveries, but more on that later.

One lucky woman gets a spinal... after 24 hours of labor, shortly
prior to her c-section.

    Lastly, the labor ward is full of heartbreaking stories. While KCMC is an advanced hospital considering their resources, they get complicated (and ill) referrals from all over the region. Also, while they have some advanced technology (for example, they have an US machine on the ward), they don't have electronic fetal monitoring (EFM), and still use a fetoscope to monitor fetal heart tones every 15-30 minutes. Over the last week, there were 2 fetuses that died during labor (IUFDs), and birth asphyxia is very common, because they are often unable to detect a problem without EFM until it is too late. In addition, patients present less for prenatal care, and preeclampsia is quite common as well. This week, a patient in her 20s was transferred for eclampsia (preeclampsia with seizures). On arrival to KCMC, her blood pressure was 220/140, and her fetus was noted to have died during her transit. While they were able to stabilize her blood pressure in the ICU, she was essentially unresponsive after several days of ICU care and was thought to have had a stroke and brain death. Even though she was unconscious when I met her on the ward, even hearing about how she was doing at morning rounds seemed overwhelming to me. I couldn't imagine how devastated I would be if something like this had happened to my mother, little sister or a friend. 

    Here, the doctors and nurses have to be a little callous to survive in the medical profession, but these events affect them as well. Many of the residents I've worked with are passionate about learning all they can in training any many of them have big plans to change healthcare in their home country for the better- whether they are staying in Tanzania or returning home to the Congo or Rwanda after they finish training. For instance, one senior resident is doing a fellowship in fistula repair before returning to the DRC to become the only fistula surgeon in the country, while a couple others plan to stay at KCMC to teach and continue clinical advances at the place they trained. It just reinforces to me that enormous advances and improvement in clinical care can be made with education alone, even in placed where advanced technology in unavailable. 

One of the senior residents performing a GYN ultrasound