Six Hours, Five Babies to Catch: CGHD’s Monica Onyango is a Midwife in Kenya

October 15, 2010

My most recent trip to my home country of Kenya was in September 2010. As I usually try to do on these visits, I took part in a few nursing and health-related programs while I was there. I do this periodically to update my clinical skills, keep in touch with the realities of the practice environment for nurses and other health professionals in developing countries, and generate case studies for my teaching. During this visit, I was privileged to take part in three events: 1) the first breast and cervical cancer walk in Kisumu city in Nyanza Province of western Kenya, which was followed by cancer screening for 140 women; 2) a ten-day training course for midwives on the use of obstetric sonography for pregnancy management; and 3) two days of volunteer work at the labor ward (delivery unit) at the Nyanza Provincial General Hospital (NPGH), Kisumu. All three events were unique experiences, but the third was the most memorable.

When I told the nursing director at the hospital that I wanted to hang out in the labor ward for two days, he gave me a very warm welcome and said that I could stay for as long as I wanted. “After all you will add an extra pair of hands, which is much needed,” he joked.

My first visit was for an afternoon shift which ran from 1 to 7:30 p.m. As soon as I stepped into the unit, I realized that I would be more than just an extra pair of hands. There were only two nurse midwives on duty that afternoon. I was puzzled by how small the unit was for a provincial hospital. I’ll describe the unit briefly: It was on the first floor and had three small rooms, each approximately one and half times the size of my small office at the BUSPH/IH department in Boston. They were divided into two rooms for the first and second stages of labor and a third room for acute cases. The first stage room is where women who are in active labor are admitted for management before they are ready to deliver. It had six beds with ten patients, each wriggling with labor pains. Four of the six beds in this room were shared by two women each. The second stage room had three delivery coaches and this was where the babies were delivered. The acute room had three beds with four patients. Acute room is where women with labor complications were admitted. For example, one of the patients in this room was HIV-positive with obstructed labor. Another patient was in early labor with hypertensive disease.

preparation for a deliveryThe first day that I was there, the head nurse asked me to help in the second stage room where one of the nurse midwives was stationed. After receiving report from the morning nurses, we got to work. We took over the care of two patients who were just about to deliver. I started to look at the notes on one of the women, and, lo and behold, as she began to push, it was a breech presentation — every midwife’s nightmare. For some reason, I had not realized that everybody who was standing around me at the time was a student. One of them screamed: “Sister, this patient is ready to push and it is a breech. Put on gloves quickly.” I put on gloves. But what they did not know was that I could not remember the last time I conducted a breech delivery. I have been living in Boston for the last ten years, for God’s sake! Of course, I did not tell them this. In any case, the woman was ready, the perineum was bulging with the baby’s butt, and somebody (me) had to catch the baby.

Fortunately, one of the nurses was passing by, saw me wearing gloves and, somehow nervous, said: “Sister don’t worry, breech is hands off.” It immediately clicked what she was saying. I relaxed and remembered what I was supposed to do. The baby was small and, before we knew it, the legs had come out and they were hanging. I just had to deliver the hands (very carefully so they didn’t fracture) and the head. There were no complications and the baby came out and gave a loud yell with the first breath of outside air! Phew, I sweated a little. What an experience! In the next two hours I conducted one other delivery and was also involved with routine patient care. I was told by the other nurses that I brought them luck. That was the best afternoon they had had in the labor ward: Only three deliveries, one breech with no complications? Hmmmmm, that was a very good day.

The joy of that first day did not last long. What happened the next morning left me stunned. I reported to the unit by 7:30 a.m. when the morning shift began. The most important case was that of a woman who had twin pregnancies and had delivered the first twin at a health center. She had been referred to the hospital because the second twin had died in utero and was lying across the mother’s uterus (transverse lie), with one arm hanging out (arm prolapse). She urgently needed a Caesarian section. She was taken within one hour of our arrival to the labor ward, which was very impressive.

That morning there were just two qualified nurses in the unit (if you count me). So I decided to take over the instruction of students as they examined and monitored the women in labor. This meant that they examined the women and I confirmed their findings. We had completed one examination, when a patient came into the labor unit ready to deliver. The student who was taking care of her told me to put on gloves (students cannot conduct deliveries alone). So I helped with the delivery, while at the same time attempting to give students an educational experience by demonstrating every step in the process.

I completed the first delivery, including the active management of the third stage of labor (delivery of the placenta, the examination of the woman for tears, bleeding, etc). After we cleaned the patient, but before we could take her to the room, another patient was brought in, ready to deliver. Again, I was told to wear gloves. After all, the other sister was busy elsewhere. The second delivery was somewhat difficult because the mother was delivering for the first time and the baby’s head was a little big. I needed to support her perineum very well to avoid her getting a tear. I was unlucky and she got a nick, which was then stitched. The baby came out alright and cried immediately. I finished with her, cleaned her, and was told yet another patient was ready to deliver.

This third patient was also a young girl having her first baby. The infant’s head was too large to easily pass through the birth canal and I had to get an episiotomy–there was no way that baby was going to come out without it, much as I hate giving episiotomies. Thank God, there was local anesthesia (Lignocaine), which I gave. Strangely, after giving her the anesthesia, I still was not able to make the cut. I gave the episiotomy scissor to whoever was assisting me and I closed my eyes (yes). She did it in less than a minute and the baby came out. Please note that this was baby number three! The routine of baby catching continued until 1:30 p.m. Over the course of the shift, I delivered six healthy babies (one mother got an episiotomy, one a small tear); examined all six placentas, ensuring they were all normal and nothing was retained in any of the women’s uteruses; and made sure all notes were well written.

By 1:30 I could not have conducted even one more delivery. I was thoroughly exhausted. I had not moved out of that small room, not taken a drop of water, and not gone to the bathroom. At 1:45 pm the sister in charge thanked me so much for being there–how would she have managed alone? She offered me tea; but I had to leave because I was supposed to be at my daughter’s school at 2 p.m. I thanked her and told her I had to run. As I rushed out of the labor ward, I wondered how the midwives work there on a daily basis and stay sane. I also wonder now, when we talk about the shortage of nurses in developing countries, do we really understand the magnitude of this shortage? Do these nurses ever have a minute to reflect on what they do? How are they expected to provide quality care under these circumstances? But I was too tired at the time to reflect too much on this experience. I shelved it for another day and went to my daughter’s school. There really is never a dull moment for a midwife in Africa.