Another delivery

Monday, Christmas eve, was a clinic day and I have to be honest, I had really thought it would be a quiet one. I had actually even asked myself if there would be any patients at all. If only. Early in the day two women came within 20 minutes of each other both in active labor. The first was dilated to possibly 6 and having contractions rather close together but was adamant that she did not want to go to the hospital. The only reason that she came is that she heard that I gave away baby sweaters. The second lady was a primip and not dilated very  far. But she told me she had been having hard pains since Sunday morning. We took tea together and she was indeed having long contractions about 3 minutes apart but seemed to be tolerating well. She wasn't sure she wanted to go to the hospital (very few village ladies do) and I didn't want to force her so when she suggested she go back home I didn't disagree but gave her husband my number.  Oh, meanwhile a lady came in covering her eyes saying she had been attacked by a spitting cobra and the snake had gotten some in her eye. The right eye was seriously swollen and tearing constantly. If I understood correctly it took them more than 30 minutes to walk from the garden to the clinic because she couldn't see anything. I gave pain meds and flushed the eye as well as I could with saline while the other nurse arranged transport. She told me that because the sight was already gone there was no reason to rush and they could take public transport.  No one complained and they quickly headed off on the back of a passing truck.
But back to my laboring patient. I just had a feeling about her. She seemed strong and I've found very few ladies that complain here about labor pains. And 24 hours already seemed long. But FHTs were good, BP was good, I had no reason to be concerned and chalked it up to first pregnancy worries. But it didn't surprise me at all when they called me at 10:00 pm asking if I could please come and help them. I arrived in the village and had a terrible time assessing her as it was really dark and my flashlight quit. They lit a candle for me but when I suggested we just go to the hospital everyone was quick to agree. They got all of their stuff together and we set off. We arrived just before 11 and discovered the ward was overflowing (20 beds full and people sleeping on the floor), there were 5 ladies pushing, three babies in the lone incubator and one stressed nurse (and a partridge in a pear tree) . It was obvious my patient didn't take precedence.  The nurse did a quick exam while I monitored her other patients (HA!) and declared her dilated to 3 and fine. She was to go walk around outside and she would be checked again in 4 hours. As there were no open beds anyway it didn't seem to matter that it was 11:30 at night.  I checked that Winny (the laboring mom) and Johnathan (the soon to be father) and Dina (their very young attendant who was 16 and brought along to fetch water, cook, and do the wash) didn't need anything. They discovered they didn't bring any mats to sit outside on and didn't have anything to eat. So I ran home and grabbed some things for them and brought it all back. At this point I decided there was little I could do for them so headed back home to bed. At 7 the next morning (Christmas) I stopped back in the hospital hopping for a baby. But no luck. Johnathan didn't have a phone so couldn't call me but they had never been checked again. They had been waiting outside all night. I got a bit assertive and asked the nurse to pay attention to my patient. She did an exam and told us she was to 4 cm. She also broke her water at that time which I thought was a terrible idea but did it before I knew what she was doing. I checked FHTs and they were still good but it was very obvious Winny was exhausted. Contractions were few and far between and externally felt much weaker than 24 hours before. We were sent back outside and I tried to get her to lay down and sleep for a bit.

Winny in a "labor room" at the hospital.

She said she felt too painful lying and wanted to sit. While talking, her husband mentioned that she had been feeling like this since Friday. Like what? Not laying because of contractions. Only sitting or walking. I asked Winny to clarify, knowing she told me Sunday. She said the contractions had gotten stronger Sunday but she had been  feeling them very regularly since Friday. I felt so out of my element. I knew something wasn’t right but clinically didn’t really have any indication except the long labor. Around mid-morning we decided to leave the hospital (as they were doing NOTHING for us anyway) and went to my house. I coaxed Winny into a hot shower (she had never had a shower before, let alone one with hot water) and then she laid down on my couch an seemed to doze off when her contraptions seemed to really pick up again. Several minutes long and quite painful. Everything seemed good, FHTs good, she lost a lot of amniotic fluid on my couch, had some juice, and labored for a few hours. It seemed time to head back to the hospital. They didn’t even notice she had been gone.  The nurse checked again and told her 4 cm. Seriously?! I asked for her to be examined by a doctor. She was crying during contractions and not moving at all between them. Once again they were very ineffective and slowing down. Finally, after asking for hours (literally, it was late afternoon by now) a doctor came. He started pitocin which she immediately lost control during contractions, thrashing, yelling then practically catatonic between. She was making me really worried. I didn’t have my stethoscope and the nurses were not checking FHTs but at least only an hour went by before the doctor came back. Actually he was checking on another patient but as Winny was in one of 5 labor beds all in the same room he had to pay attention to her too. He finally seemed to listen to me and examined her again and said maybe she had Cephalopelvic Disproportion as she was still not progressing at all. Her hips were wide and it didn't seem right but I was in no position to argue with him. I pointed out she had not progressed since arriving almost 24 hours before and had possibly been in labor for 5 days. He was doing a vacuum extraction on another laboring patient that was going very poorly so as the decision to head to surgery with that one was made he told me that if Winny was still unchanged he would take her to surgery next. Having no idea another solution I agreed (and immediately reached over and turned the pit off). I know this story is already too long but I have to put this in too. While one nurse and doctor were 20 minutes away (the surgical theater is nowhere near the delivery room) another patient began crowning with contractions  She was alone (most woman are- the staff hate it that I stay with the ones I come with!) and calling out in ateso. I stuck my head down the hall and told the other nurse she was crowning to which I got an eye roll and "I'm coming." I pulled gloves on from my pocket and tried to encourage the patient to pant. Yeah right. I yelled again for the nurse but within seconds the head came with an obvious nuchal cord so I slipped it off and the rest of the baby and placenta immediately followed. The mother had been laboring in nothing but a towel so I laid that on her chest with the baby. Still no nurse.  The patients have to bring their own ties and razor blade so they were right there. I tied the cord and cut- still no nurse.  I was looking around for something, anything to wrap the baby up with and put the placenta in.  Finally the nurse arrived and immediately started screaming at me. She was already mad that I was demanding so much attention for my patient and now more pissed about me messing with another one.  Whatever lady!
But back to Winny, She looked terrible. I went and got a gurney and loaded her up myself and headed over to surgery. It took him an hour and a half to finish the first patient (sections are NOT quick here!) and it was 10:00pm that he finally took her back.

30 minutes later we had a 5.8 pound baby. He was  clearly full term and healthy but tongue tied (ankyloglossia) and small! No indication of why the terribly prolonged labor. By 11:00 she was back on the ward and in bed. It was a really, really long day leaving me wishing for some midwifery training in the not so distant future.
Anyone want to weight in with things I could have done better, ways to help the patient, any ideas for next time? I'd love to learn from this...