When I walk into the labor room, things look messy already. The patient – a pale, freckled woman whose headscarf has come off to expose her dark curly hair pulled back into a ponytail. She has hurled herself backward on the bed, grabbing the upper rail and yelping in pain. The Jordanian midwife has just performed a vaginal exam, and announces to me that the patient is fully dilated and the baby is about to come out.
Normally, we move fully dilated patients from the labor room into the delivery room, which has a bed that is better designed for delivery, and is stocked with supplies. But that requires getting the patient into a wheelchair, rolling her through the waiting room, through the triage room, and into the delivery room. From the way that the midwife is holding her hands over the patient’s perineum and the patient is launching herself backward on the bed, it seems moving is not an option.
“Is it crowning?” I ask the midwife.
She confirms that it is. Once the head is crowning, we can’t move anywhere else, because we don’t want to deliver in the wheelchair in the hallway. The nurse thinks fast and runs to the delivery room to grab the tray of supplies that we need. We are between contractions and the patient is calm, so the midwife and I shift her into a better position for delivery (this is not the ideal bed), and wait for the next contraction.
Ob/Gyns (obstetricians/gynecologists) and midwives are do-ers. We are people who like to jump in, get our hands dirty, and fix the problem. We make decisions quickly, take action, and solve the problem. Unlike internal medicine, neurology or pediatric rounds, which can be hours of talking, we will round for only a few minutes, then jump into action.
Here in Irbid, Jordan, the expat midwife, Liz, and I are learning to take a step back. MSF opened a maternity and pediatric hospital inside of a private hospital here in Irbid to serve registered and unregistered Syrian refugees.
The maternity (labor ward and antenatal clinic) is already open and running, while the pediatric service has not yet opened.
Although maternity is open, Liz and I still cannot get our hands dirty. This is because our role here is not as service providers, but as trainers and supervisors. We do not have permission to practice medicine in Jordan, so we have hired national staff to do the actual work. Many of them are young, recently graduated from school, and require training before they can practice independently. In addition, we need to make sure that the practice conforms to MSF protocols.
I put on gloves so that at least I can hand the midwife necessary supplies for the imminent delivery. With the next contraction the patient arches her back grimaces and pushes. It’s not ideal, but I guess it’s working. The baby comes out easily, and we still have no instruments or supplies. But the baby is already vigorous and crying, so we are OK. The midwife takes a breath, then places the baby on the mother’s abdomen. The mother looks the way many women do just after delivery – half relieved to no longer be in excruciating pain, half stunned into catatonia. We help her put her arms onto the baby to hold her there, so that we can focus on the placenta, which she does halfheartedly. I grab a draw sheet to cover the baby and keep it warm until we can get a towel to dry it.
Just then, the nurse arrives with the tray of instruments and supplies. The nurse moves to help the mother with the baby, and the midwife clamps and cuts the cord. The nurse injects 10 units of oxytocin intramuscularly, in order to prevent postpartum hemorrhage. The placenta delivers soon afterward, and we perform a quick massage of the uterus to prevent bleeding. It is firm and contracted.
Next, we check the perineum for lacerations. There is a small tear that needs to be repaired, so we decide to move the patient to the actual delivery room, now that the emergency is over, for better positioning.
We put the baby in a bassinet, the mother in a wheelchair, and roll them to the delivery room. The baby is placed in a warmer, doing well. As the mother moves from the wheelchair, I notice that she is bleeding a little more than I would like. As she lies down on the delivery bed, she suddenly starts to bleed very, very fast. The midwife is taken aback. She is young and eager, but also inexperienced, so Liz and I have been working on training her. I can see that she is not sure what to do.
I tell her what she needs to do, which is a bimanual massage. That means that she inserts one hand into the vagina and the other hand on top of the abdomen, and squeezes the uterus between her two hands. Both hands then move in aggressive circular motions to literally massage the uterus. This simple maneuver is one of the most lifesaving actions performed in obstetrics.
“Do a bimanual massage!” I instruct.
She hears me, but panics a little. She is wearing non-sterile gloves, and backs away from the table to go find sterile gloves. Meanwhile, the woman has already lost 300cc of blood – the equivalent of a can of coke.
This is one of those times when it’s really difficult to not be allowed to touch patients here. This woman needs intervention now. In a postpartum hemorrhage, a woman can lose 1 liter of blood in 1 minute. She can lose her entire blood volume, 5 liters, in 5 minutes. That is how quickly this patient is bleeding right now. Sterile gloves don’t matter when someone is bleeding to death. The young midwife, who is just being taught all the rules of medicine – including hygiene and sterility – has the right instinct but doesn’t yet know enough to ignore this instinct and just stop the bleeding.
If I could touch the patient, I would do the bimanual massage myself.
The midwife has already grabbed the sterile gloves but she is putting them on slowly and carefully, so I urge her to hurry up. She jumps to attention and speeds up. At this point, the woman has lost half a liter of blood. The midwife performs the bimanual massage, and even more blood pours out. As she continues to massage, it slows down. The nurse has gotten extra oxytocin, which she injects into the patient’s muscle. The patient does not have an IV, so one is placed. Her blood pressure is checked, and it is normal. We also give her another medicine, ergometrine, which will help contract the uterus more.
I ask the midwife whether the uterus is firm (contracted) or soft (atonic), but she is too focused on what she is doing to think clearly and answer. She says yes, and then she says no, neither of which answers the question. I want to teach her that if the uterus is firm and there is still bleeding, she needs to think about other causes of bleeding, like a laceration of the cervix. But I realize that this is probably the biggest hemorrhage she has seen, and she is trying to keep up, so I figure I can always review this with her later.
If I were able to practice, I could examine the patient for myself, or take over for the trainee to let her breathe, but I can’t. For now, the bleeding seems OK, so I let her continue the massage.
Through all of this, the patient has been extremely uncomfortable. Bimanual massage, while lifesaving, is also quite painful for the patient. Obstetricians and midwives sometimes have to cause pain to save a life, and we understand that, but often the patients do not realize it until after, when they see how much they bled.
I have been trying to help by holding the patient’s hand, and showing her how to breathe in and out. I don’t know how to say “breathe” or “it’s OK” or “I’m sorry” or “we just need to control the bleeding” in Arabic. So all I can do is hold her hand, maintain eye contact, nod, and breathe deeply with her. I can see that though she is in pain and terrified, she understands that I am with her. Her mother is also by her side, and encouraging her to bear with us.
The hemorrhage has finally stopped, and we have a few minutes to observe the bleeding and take stock of the damage.
In total, we calculate a 1 liter blood loss. I realize that we never emptied the bladder, and a full bladder can contribute to hemorrhage, so I ask for a bladder catheter, and we insert it and then remove it. The patient takes some deep breaths and lies back on the delivery table, overwhelmed. Her IV is running, she is OK, her baby is OK, and the emergency is over. I look at Liz, who has been watching us but also directing the nurse caring for the baby, and we both breathe a sigh of relief. I look at the young midwife and tell her she did a great job.
She smiles, temporarily exhausted but proud.
After the episode is over, the patient is cleaned up, the baby is dressed, and everyone has calmed down, I ask the nurse and the midwife to debrief with me. I am a big fan of debriefing. I do this when I work in my hospital in New York, and I have instituted it here. The team sits together, and each member of the team recounts the event from her perspective. Then, everyone is given the opportunity to identify both positive observations (what we did well) and areas for improvement. I have found debriefing to be both cathartic for the providers and essential to quality improvement.
In this debrief, the team is at first confused. Why recount something that we all just witnessed?
I explain that it is just to discuss and to learn. The nurse reviews what happened. Then I ask what we did well, and what could have been improved. We all agree that generally, the hemorrhage was handled quickly, and that the teamwork was solid. The massage, the injected medication, the insertion of the IV, and the checking of vital signs were all handled expediently.
I remark that I should have remembered the urinary catheter, and than next time I won’t forget. I emphasize that the purpose is not criticism of others, but self-critique. Although the concept of debriefing seems new and slightly confusing to most of the staff here, they generally respond well to it, and appreciate the opportunity to review.
Afterward, I check in with the woman herself. She is now calm and smiling, holding her baby, with her mother by her side. Her mother takes my hand, kisses my cheeks, and we both say “Hamdillilah” – which is what you say in Arabic after the baby comes out. The patient takes my hand too, and says something in Arabic that I don’t understand. The nurse translates: “She is asking God to bring you good things.”
I can’t communicate with her, and that’s frustrating. We can smile at each other, and I can use the few words I know. In the delivery room, though, when I was holding her hand, we made an intense connection in a time of crisis. It is in those moments that I see most clearly the humanity in each patient.
I feel like I know her now. I think back to how rapid her hemorrhage was. She lost an entire liter of blood within minutes. If she had delivered at home without anyone to perform a bimanual massage or inject medication, she no doubt would have died. And finally, I realize, this is why we are here.
Although there are plenty of hospitals here in Irbid, the Syrian refugees are in an awkward limbo. Registered and unregistered, they represent a burden on the system, even though they are just people with needs like the rest of us. Through no fault of their own, they were forced out of their country. Often they have no resources to pay for services in Jordan, which has quite a strong currency.
People do not magically stop getting pregnant during a conflict; fertility works the same, war or no. And when they are pregnant, they need to deliver safely. That is why MSF opened a Maternity project here in Irbid. If this woman had stayed home out of fear that she could not pay – or worse, if she had stayed in Syria, where the health infrastructure has been decimated – she would have died.
Although it is hard for me to work in a delivery ward and not be able to touch patients, it is well worth it.
The war in Syria does not seem like it will end anytime soon, and Syrians will be in limbo for a long time to come. We are training eager midwives to be independent practitioners, who will provide safe deliveries to women long after we leave. If we do our jobs correctly, these midwives will continue to work for MSF even when there are no expat midwives or obstetricians.
We will pass on MSF’s commitment to providing care to people caught in crisis, regardless of race, religion, or political affiliation.
Image shows a staff member checking on a child in the maternity unit. This is not the child mentioned in the blog post.
Veronica wrote this post in December 2013. In January 2014, five our colleagues were taken in Syria and we had to suspend all communications around the conflict for their safety. Now, our staff are safe and back home with their families. We are publishing Veronica's blog, and others from Syria and surrounding countries, retrospectively as we feel their stories should be shared.