“Dan! Maternity! Now!”
The calm yet stern voice commands down the radio.
I place my water bottle on the table, turn on my heels and run in the direction of maternity.
I am not a midwife. I am a logistician.
I have always been interested in learning about all things medical. Yet, throughout the various training sessions I have received, be it my emergency medical technician or team medic courses, or in the UK as an NHS First Responder, very little detail has been given to the subject of maternal health.
As a result, back in the UK, one of my biggest fears has always been attending a birth, unaware of how to respond.
Even with my limited knowledge, it was clear to me that with our limited facilities it is unlikely the child will survive
After a few questions the evening before, which demonstrated my glaring ignorance on the subject, Luise the midwife kindly agreed to teach me the basics in preparation for such an event back home.
So, armed with a pelvic training model and a baby doll, we start from scratch…
Luise patiently teaches me the three possible presentations (how the baby might be laying), before demonstrating the mechanics of birth. And, it’s not long before the lesson leads onto the subject of more complicated deliveries.
Luise brought in some examples from her current work in Leer.
The day before, she had been concerned about a woman that arrived in maternity experiencing a condition that I would learn is called “placenta praevia”. This is where the placenta is preceding the child during birth and is obstructing the delivery by blocking the exit – the cervix.
Even with my limited knowledge, it was clear to me that with our limited facilities – no operating Theater and so no option of a caesarian – it is unlikely the child will survive.
I ask the question anyway and the answer is worse than I had thought – it is unlikely that both the mother and child will make it.
We sit in silence for a few minutes, reflecting on the difficulties of working in such a low resource environment, before moving on to the immediate care to be given to a child following a difficult delivery.
Truth be told, when I started teaching Dan the basics about childbirth and some of the more likely emergencies that might occur, I already had a thought in the back of my head:
- He had some basic medical training (check)
- He was sincerely interested in learning about obstetrics (check)
- He was always ready to help out anyway (check)
He could offer a pair of otherwise lacking extra hands in such a small project as ours.
Nevertheless, I hadn’t planned on turning his theoretical training from the previous evening into practice right away…
A tiny, important word
That morning, as well as the patient I had been concerned about the night before, we had received a seven-month-pregnant mother already in labour and a partial placenta praevia.
The addition of this tiny, yet important word “partial” gave her the possibility of actually surviving the delivery.
She had begun bleeding the night before and decided to make her way to us as soon as the sun was up. Thankfully, in general, women here have a very good understanding of what is normal during pregnancy. So, interpreting her dire condition accurately, she sought help at our health centre.
The fear on her face
Back home, in Germany, we would be well equipped to deal with a condition like this. We would have a huge team from various medical backgrounds – including a midwife like me – to take care of specific tasks that come up along the way.
We could clearly see fear written on her face once she had understood that both she and her unborn child might not survive the following hours…
Working out of tents in Leer, it’s a different story.
Despite having a very skilled and dedicated maternity team, I lack most of the resources available back home… I can’t perform a blood transfusion if the mother suffers a haemorrhage. I don’t have an incubator for a pre-term babies. I don’t even have running water!
The situation being as it is, my goal as a midwife here in Leer always has to be to prioritize the mother’s survival and unfortunately this might come at the expense of the child.
My team and I did our best to calmly explain the life-threatening severity of her condition to the expectant mother. We could clearly see fear written on her face once she had understood that both she and her unborn child might not survive the following hours…
One of those days
We set about our tasks and start preparing, as best as we can, for the pre-term delivery. At the same time, we start to speed up the mother’s labour in order to prevent her from losing too much blood.
At the beginning of that process, everything seemed to be working fairly well. So, the maternity team and I kept half an eye on her at all times while also caring for the multitude of other patients in the ward. Each with their own range of pregnancy-related complications – it was “one of those days”.
The call for help
To our surprise, and much faster than any of us had anticipated, the mother suddenly started pushing!
Sarah, one of the local midwives, only just managed to catch the tiny and very limp baby in her hands. No one had been prepared for any of this to happen so fast.
Sarah and I were alone in the delivery ward. It was all too obvious to us that we would need help – now – if we wanted both the mother and her tiny baby to survive.
So… what to do? Call for help!
OK… Who’s available? Dan, the logistician!
So that’s exactly what I decided to do: holding the still-attached-to-its-cord-newborn in one hand and using the other hand to operate the radio, I transmit only the essentials:
“Dan! Maternity! Now!”
Experience has taught me that, while speed is important when getting to an emergency, it is no good crashing in and making things worse.
I slow to a steady jog, then a brisk walk, and begin to catch my breath as I approach the entrance to maternity. I round the corner and loudly announce over the bedlam:
“Luise, I’m here!”
To my surprise, I am not greeted by a similarly loud response (as I am accustomed), but with a calm, collected yet authoritative:
“OK, first job, I need you to clear a table”.
“Done! What next!?!”
Again, I am met not with an order barked at me, but rather a calm yet firm instruction asking me to go to the maternity supply cupboard and begin collecting equipment.
I fight back tears and re-focus on the job at hand as Luise, a nurse and I ventilate the child, together
As I set about this new task, I find myself impressed on two separate fronts:
Firstly, I am impressed about my level of retention from the previous day. But, far more impressive, is how Luise is using nothing more than her voice to calm down what is a very loud and intense situation.
Before I know it, it is so quiet that I am able to hear myself breathe as I walk the equipment over to the cleared table.
Fighting back tears
On her instructions, I pass Luise a cotton cloth which she then wraps the child in before placing it on the table. Meanwhile, I begin setting up the oxygen concentrator and place the nasal cannula around baby’s face.
Suddenly, I am struck by a number of other thoughts:
Firstly, the child is so small that the small nasal prongs are almost too big for its tiny nostrils.
Secondly, I have no idea of the child’s sex but am feeling increasingly uncomfortable referring to it as “It”.
Thirdly, I remember the conversation from the night before and become overwhelmed by a sense of sadness. I nearly stop as I think about how unlikely survival is for this child.
I fight back tears and re-focus on the job at hand as Luise, a nurse and I ventilate the child, together.
Suddenly, Luise disappears behind the curtain, returning to the mother. The nurse is then called away to another emergency in another department.
As panic begins to set in, the same calming voice begins giving me instructions again…
“OK Dan, I need to be with the mother. Monitor the child’s breathing and keep it warm”.
Thanks to its speedy arrival into this world, I begin to think that this tiny newborn might actually stand a slim chance of survival.
But, also thanks to this fast arrival, I now find myself standing a bit helplessly. The child cupped in one hand, trying to force a glove onto the second, using only my teeth, while at the same time instructing Sarah, who looks as dumbstruck as I probably do, to get a delivery kit and cut the umbilical cord.
Thankfully, those few seconds of enforced standstill have helped me to lay out a plan in my head.
As Sarah is cutting the cord, Dan announces his arrival in the ward.
I immediately sense that Dan has been exposed to emergency situations before, and as soon as he enters the maternity ward, he announces himself:
“Luise, I’m here!”
A wave of relief washes over me: I now know that this will work.
The baby’s heartbeat slowly begins picking up; it attempts to breathe independently; it might just make it!
My first instruction is simple but essential. We are lacking a resuscitation table and I need a clean and sturdy surface on which to do CPR. I don’t really fancy using the only other surface available – the floor!
At first, I can’t see Dan as the delivery table is curtained off from the rest of the ward. He clears the table and peaks behind the curtain to receive further instructions – there is a look of almost comical incredulity on his face as he realises that the baby has already been born!
Despite this, he gathers himself right away and starts assisting us. By now, another nurse has arrived and the three of us start doing CPR.
I am relieved to see that my initial prediction seems correct: the baby’s heartbeat slowly begins picking up; it attempts to breathe independently; it might just make it!
A few minutes later, the nurse has to go. I feel confident to leave Dan alone to monitor the oxygen saturation and keep the baby warm. I know he will tell me immediately if something changes.
The mother urgently needs my attention. I hear an ominous and constant trickling of blood on the floor. The placenta is still inside her uterus and we desperately have to get it out in order to stop the bleeding.
Thankfully enough, after we take some necessary actions the mother stops bleeding.
Next, I have to focus my attention to a second woman, also in critical condition – knowing that Dan is still looking after the newborn.
Recalling the previous day’s lesson, I know that the biggest concerns for the child right now are its oxygen saturation dropping or its temperature falling.
Keeping one eye on the pulse oximeter – the device that measures a patient’s blood/oxyxgen levels – I place my hands on the child to keep it warm.
Unused to the South Sudanese heat, my Scottish hands have been perpetually (and annoyingly) warm since my arrival in country. Now, this irritation will finally come to good use!
Knowing that Luise not only has the mother of this child to deal with but another very seriously ill woman as well, the last thing I want her to do is to worry about the condition of this child.
Every few minutes I give her an update, and, to my very welcome surprise, the child is holding steady.
As time begins to slow, a very dangerous thought enters my head:
“It might make it, it might survive.”
I know this is not helpful and I try to shake this feeling. But, then the child’s eyes open!
I am taken aback by my own ignorance as, until this point, I thought children were unable to open their eyes for at least a few days after birth.
Looking into its eyes, I find myself in awe.
I’m so focused on the task that I lose all track of time, only becoming aware of my surroundings again when Luise emerges from behind the curtain and calmly re-takes control of the situation.
I begin shaking and, for the first time in many years, feel an overwhelming sense of fear
Opening the cotton cloth and thus revealing that “It” is a girl, Luise passes me an umbilical cord clamp and asks me to clamp the cord. I take the clamp and, with all my blacksmith strength, find that I am unable to close the clasp!
“Am I doing it wrong? Is it broken?”
No matter how hard I try, I am just unable to close it!
I pass the clamp to Luise and, in one fluid move, she effortlessly closes the clamp that had so effectively defeated me.
Having been moved aside, I now find myself in a practical position with a free pair of hands, so Luise passes me an open packet.
To my horror, I see that inside is a scalpel as she asks me to “shorten” the cord!
I begin shaking and, for the first time in many years, feel an overwhelming sense of fear.
“What if I cut her?!”
“You won’t,” comes the calm yet authoritative response.
I shorten the cord.
Luise picks up the now stable child and takes her to her mother, whom I help to sit up.
At this point, it is time to leave. Whilst I was needed before, I am not a midwife and this is no longer an emergency, now that things are returning to relative stability, it is no longer appropriate for me to remain.
As quick as the situation had begun, it is over. I wash my hands using the hand washing bucket outside and leave. However, instead of going back to the office and continuing my mounting pile of work, I walk aimlessly around for I don’t know how long… until Luise joins me.
In the seven years since quitting smoking, this is the closest I have come to wanting a cigarette
I have been involved in a number medical emergencies across the world, but none that ended so well. I am overwhelmed by a euphoric shock!
Finding it difficult to sit still whilst simultaneously needing to rest and come to terms with what has just happened, I look at Luise and try to ask the million and one questions I have. All at the same time.
However, all I am able to get out is an unintelligible noise.
In the seven years since quitting smoking, this is the closest I have come to wanting a cigarette. So, I just sit silently for several minutes fighting off this urge before my thoughts return to the child.
I know her chances of survival are still very slim, but I let myself be taken for a moment by the sheer joy of the situation.
A world away…
The next day, normality – if it can ever be called that – returns and staff are going about their tasks.
At breakfast, Luise asks me if I would like to come to the ward and observe the daily weighing of the child.
Peter, a local midwife as well as a skilled a passionate teacher, takes me through the theory of the process. He explains to me that the child will remain on the ward until she reaches a weight of 2 kg.
As she is placed down, the child screams in protest at the cold scale. Her small size not reflected in her voice, drowning out the other two children on the ward!
Peter diligently sets the scales and, as he records a weight of 1.7 kg, I look up and am taken completely by surprise when I see the mother…
The calm, smiling woman sitting up on the end of the bed, lovingly watching her child. She is a world away from the scared patient in the life threatening condition that she was yesterday.
I almost don’t recognise her.
As I find myself momentarily taken aback by the serenity of the situation, the crack of my radio reminds me that I am still a logistician:
“Daniel for Rial…”
I am snapped back to reality as my colleague Rial informs me that the generator has cut out and needs repairing. An otherwise simple task, made miserable by the rain which is now flooding parts of our compound.
Being one of only three international staff in this austere environment makes for a lot of work.
The mother and I exchange smiles, and I leave for the next job…
It would be almost two weeks before the baby reached 2 kg and both mother and daughter were able to go home.
In South Sudan’s Nuer culture, it is traditional for newborn children to be given a name that reflects an important factor at the time of birth.
Two months on, Nyakim – the Neur word for “clinic”and her mother are still returning for regular check-ups.