EMMW

Hey everyone, hope you had a good week!

Suz and I wanted to keep you updated about what we have been doing the past week or so. As we mentioned before we made arrangements to get into the maternity ward, Ethel Mutharika (named after the late president’s late wife who died in 2007) here at Kamuzu Central hospital. This by far was what both Suz and I were the most excited about during our time here in Malawi. We finished our maternal/newborn nursing rotation this spring at Rex Healthcare in Raleigh and were really looking forward to seeing how obstetrical care is done globally. Unfortunately, our dreams were somewhat dashed after just a few short days on the ward.

                                                               Suz and I in front of EMMW

I started off on the antenatal and postnatal ward while Suzann was stationed in the labor and delivery ward. We figured we would each spend a few days on a ward and then switch so that we could both experience nursing care before, during, and after birth. While KCH is a government run hospital, we learned that the Ethel Mutharika Maternity Ward (EMMW) is a high risk, tertiary care center that only accepts patients referred from district hospitals or patients who can pay out of pocket for care. This means that the mothers who are at EMMW tend to have diagnoses of high blood pressure, preeclampsia, eclampsia, preterm labor with multiple gestation or other serious ailments. This also means that clinicians are very hesitant to let women labor for very long; therefore, c-sections aka caesars here in Malawi, (not to be confused with the salad dressing) are done quite frequently.  And this all depends on if there are any actual patients…which unfortunately there weren’t.

                                                                   Plaque outside the ward

During Suz’s 4 days in L&D there were approximately 3 patients total. TOTAL!  There were 4 nurses assigned to the unit each and every day, too. After the first day, she questioned the nurses about the lack of patients and they replied that you never know when a woman will go into labor, and so the ward has to stay staffed and doesn’t float down to other units. To pass the time, Suz ventured into the Theatre (aka the OR) to pass the time. There was a little more action going on in their two theatres, and so she got to see a ceasar, a hysterectomy, and a uterine fibroid removal and possible a D&C. While this is not a terrible way to pass the time, this averages out to seeing less than one procedure each day spent at EMMW – not exactly how we wanted to spend our time. 

                                                                 The patient board. EMPTY.

I on the other hand saw a bit more but still felt almost as helpless/unneeded. Each room on the ward holds 6-8 beds with a bathroom/shower at the end of the hall for all to share. Women are grouped based on their condition (or so I thought). There are some women in the antenatal rooms awaiting labor or c-section and then there are those who have already given birth and are staying for a day or so to recover. There is also a room similar to what we would call a PACU (post anesthesia care unit) in the US. This is where women who have had c-sections go to recover. There is a room devoted to women who are in need of more monitoring ie: women who developed a postpartum complication (although during my time on the ward these women were given no more attention than the others and possibly even less) and lastly there are also 2 private rooms which hold only 1 bed each with a bathroom in the middle. These rooms are for those patients who choose to come to EMMW and pay for the services.

During my time on the unit I spent a lot of time observing the nurses and midwives. I usually went on rounds each morning with the doctor, an intern, and a midwife and tried to gather what was going on with each patient so I could try and be helpful later in the day when they needed something, I soon found out this didn’t really happen. I also helped turn and clean patients although not much is done on this front because each patient has a guardian with them, usually their mother, sister, friend or husband who takes care of most of their hygiene needs. This guardian is responsible for providing some of the linen the woman sleeps on, bringing food while on the ward and notifying the nurse if something is wrong. As far as I could tell there was no regularly scheduled times for vitals or general check in. The patient is pretty much left alone until they need to be given medicine or something bad is happening. Then, because there were also a lot of first year nursing students on the ward as well, they were left to handle most situations, most of the time alone.

For example, a patient needed to given an IM shot. The nursing student asked me to come with her while she did it. Once in the room she turned to me and asked where and how she should give the shot and then informed me she had never given one before. I was a little blown away. At home, we practice for months giving meds to mannequins and going over each step of the process.  We are then are watched like hawks by our clinical instructors when we get the opportunity to actually give real patients meds. After realizing this was not the case I told the student we should ask the midwife exactly where the shot should be given and double check the dose as well. After doing so, the patient ended asking me to give her the shot, I think she was a little nervous about being a guinea pig for someone’s first attempt at an IM shot. This is just one of the differences I saw between how nursing students in Malawi and in the US work. More often than not they are left to their own devices to start IVs, give meds, and put in catheters with little to no supervision.

One of the most memorable moments for me while on the ward was with a young woman named Emily. I first came in contact with her when helping the students turn her. She was in the PACU room and was surrounded by other women who had recently given birth and were recovering. The difference was Emily did not have a baby with her. At first I didn’t think much of it, plenty of babies have to go to the nursery after birth and I just assumed because she was being treated like everyone else her baby must have been there too. I couldn’t have been more wrong. I discovered later when I went in to help remove an infiltrated IV line that Emily had in fact had a stillborn the previous night. She was the woman the doctors had talked about in morning report who was put on a fetal heart monitor in the L&D unit. She was monitored for a few minutes and it was discovered her baby had a few decelerations (a very bad indicator of a baby’s oxygen levels). Usually the baby’s heart rate is monitored for 10 or 15 minutes to see if there is a pattern to the decelerations. In this case, because the monitor ran out of paper, the baby’s heart rate was not monitored after the initial 2-3 minutes. She then was not checked on for over an hour, why I have no idea. By the time the problem was discovered, she was rushed to the theater for a c-section, this was approximately an hour and a half after the strip indicated there was a problem. To put this in perspective, in the US if there is a pathological fetal heart rate strip, women are rushed to the OR as soon as possible, usually within 10 minutes of reading the strip. Needless to say, the doctors delivered what they call a “fresh SB” or stillborn.

When Emily looked up at me and told me she lost her baby I did what they tell you not to do in nursing school. I cried. I sat with her, told her I was sorry, held her hand, and cried. I did the only thing I really knew how to do, and that was to be with her. I knew we really couldn’t communicate as she knew little English and I have very limited Chichewa and more than that I knew nothing I could say would make up for her insensible loss. I sat with her for about 30 minutes, holding her hand while she lay in the bed staring in to space while infants cried around her. It was the first of many emotional moments I was to have while here in Lilongwe.

Needless to say, my time at EMMW was a learning experience. While I didn’t put too many of my nursing skills to use, I did learn a lot. I learned about the nursing students and midwives and how they are educated and taught to care for patients.  I learned there are great deficits in care and resources and that often patients do not get the care they deserve or need due to many different circumstances. I also learned Malawi has the highest rates of preterm birth in the world (check out http://www.who.int/pmnch/media/news/2012/preterm_birth_report/en/index1.html for the full report) and that many of these preterm births would be preventable in other parts of the world. While it saddens me, I also am glad I have had these experiences in Malawi and continue to learn from all situations I am presented with.

-Jen