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An Insight into the Current State of Health Services

This excerpt is taken from a report by one of Family Care's short term trainers


Excerpts from a Report by Susan Burvil, Midwifery trainer (UK) . Maralik, September 2002

This is the account of a 40 year old women whom we transferred to Giumry maternity hospital from Maralik for emergency caesarian section.

She had 2 other living children, youngest now 9. She arrived at Maralik with history of prelabour rupture of membranes at term, following a good pregnancy. Her labour progressed well within 16 hours of Spontaneous Rupture of Membranes. The maternal and fetal conditions were satisfactory. Her labour slowed and I was called to advise. The midwife felt she was now fully dilated as she was spontaneously pushing. On examination of her abdomen, I found the baby to be direct posterior. The mother was labouring on all fours on the floor. Being supported beautifully by Sida the Maralik head midwife. I was not convinced she was fully dilated and advised on a vaginal assessment. They wanted me to do. The baby was high in the pelvis with moderate caput and a transverse asynclitic head. The cervix was swollen and 6 centimeters. This was a classic posterior long labour, with a classic posterior labour onset history - prelabour spontaneous rupture of membranes, slow to start, backache, premature pushing, labour slowing and stopping at 5-7 centimeters. Lots of midwifery tips given to provide support. Sida the midwife was quick to learn and implement ideas. The contractions slowed and we decided to wait 2 hours, reassess and if no progress to commence oxytocin. All agreed. 2 hours later oxytocin was started and we were called back. She was fully dilated and pushing within 30 minutes of the Oxytocin.

After an hour of pushing there was no obvious progress seen. She was reassessed abdominally - showed no descent and the baby in ROT position. Vaginally: deep transverse arrest, deflexed and asynclitic fetal head. Ludmilla confirmed my findings and I advised caesarian section ASAP. Ludmilla agreed. The staff at Maralik were fantastic, the fetal heart monitored, the partogram used, mother supported and relatives kept informed. This was good safe management with appropriate decision making.

Then the problems began. There were apparently not enough anesthetics to do C/S in Maralik. We had to transfer. The mother was now exhausted, frightened and in a lot of pain. I was concerned for uterine rupture and fetal distress/demise. The timings were like this:

12.30 am Decision for Caesarian section made

01.40 am We finally left Maralik in an old van, nowhere for the woman to lie. It was cold with no emergency facilities. Susanna and I took neonatal resuscitation and maternal resuscitation equipment. We were not sure we would get to Gyumri with the state of the van. To add to the fiasco the family of the woman had to pay for the petrol. There was an argument as normally an 'emergency-nurse' transfers, not midwives! The journey was cold and uncomfortable; there was no light source if an emergency had occurred. The FH remained normal the mother was very distressed constantly...I was very concerned for her well-being.

02.15 am Arrived at the Gyumri maternity. The woman had to walk off the bus and into the hospital. She was in agony and very frightened. Eventually a wheelchair arrived. The staff was not expecting us as no call had come from Maralik.

We entered the labour ward. The paint was peeling off both walls and ceiling. There was a row of rusting dirty gynae chairs standing a foot apart. There was no running water and the light was appalling. The staff was not friendly and frankly offish. We explained the clinical picture and time that had lapsed. Despite this, the male gynecologist 'ordered' the woman onto a gynae chair with a nod of his head. He spoke roughly to her. She complied passively to his silent orders. He washed his hands in a bowl of 'murky, water and proceeded without the mothers consent or knowledge to do a painful 15 minute long vaginal examination. He told the woman to keep still, that he was not hurting her. He called her 'Comrade' and expected her compliance. She yelled out in pain constantly and asked him to stop. He continued. We asked him to stop. He continued. He was ungloved and with what was considered clean water left him with unclean hands. He roughly palpated her with one hand and continued to try and adjust the position of the baby without consent, without analgesia and without skill that I could discern. Eventually he stopped after we insisted and demanded a caesarian section. Despite being a gynecologist he was not able to do a caesarian. We waited again for the appropriate gynecologist to come.

3.00 am, 45 minutes after we arrived. The fetal heart was satisfactory, the mother distressed. In the background a women groaned on a bed in 1st stage of labour in the adjacent room that had no door. It smelt of blood and had an air of oppression and suffering. The midwives were totally disempowered in this environment and unable to provide any type of midwifery care. They themselves looked visibly traumatized and de-sensitized to the conditions. The admitting gynecologist has no right to practice obstetrics if this is his approach.

03.30 am Eventually the anesthetist arrived and did a preliminary medical examination. The gynecologist for the Caesarian Section also arrived. The woman was roughly catheterized that made her yell out again. She was roughly strapped down. Her legs trapped under metal poles her arms spread-eagled, one arm was cannulised, the other attached to a BP machines. She was trapped and terrified. Her body was half naked, she was totally out of control and exposed to a room of strangers. No one spoke to her or comforted her, the treatment was both rough and in humane. We were unable to enter the room 'as we were unsterile'. Eventually I pushed passed and went to provide some comfort. When the surgeon arrived she asked the woman if she wanted tubal ligation. We pointed out that this was not the time to be talking about a woman's fertility control. She was frightened, exhausted, in pain and very vulnerable. Also her husband was not even asked on his views. We intervened again and said this was inappropriate and her fertility should be discussed at a later time if she wished, along with her husband.

She eventually was anesthetized and was released temporarily from her ordeal. The surgery it self was excellent although not surprisingly the baby came out very shocked. The neonatologist took the baby, smacked it very hard, injected it with adrenaline despite the baby going pink and sucked it out deeply even before the baby had chance to naturally recover. She was totally inappropriate with her aggressive 'resuscitation' techniques and didn't want us to interfere. The baby was then badly bagged and masked. The neonatologist had no idea about positioning of the baby's head and placement of the mask, which appeared to be the wrong size anyway. Thankfully the baby was strong and well anyway despite the neonatologists 'efforts' the baby recovered. They put him under a radiant heater in a dark and dingy neonatal room with an oxygen box. What appeared to be cursory observations were made. There was no plan of care made and Susanna and myself had to remind them that the baby would probably need antibiotics due to the history. The neonatologist had not taken a full history and was apparently unaware of the child's high risk factors for infection.

Speaking to the surgeon after she told us that she had to incise high in the abdomen due to the separation of the lower and upper uterine sector. The surgeon said she would have had a uterine rupture if left longer. The baby was so impacted in the pelvis by this stage she had to do a footling breech extraction through the uterine incision. One has to ask what would have happened if we had not been there to intervene and insist on surgery when we did. The admitting gynecologist had no intention of going to section.

Susanna and I were badly shaken by the experience. We discussed the care with the surgeon/head gynecologist. She apparently agreed with all our comments and 'appeared' supportive or what we are doing. Susanna and I could not understand why she had not influenced the approach to care. Neither of us felt she was sincere otherwise she would not tolerate the conditions we witnessed.

We spoke to the relatives who waited in a cold dark corridor, also confused and concerned. They could hear her shouts of agony from where they were. They like everyone else were helpless. The father got to see his son; he was not invited to hold him. The baby was obviously the 'property' of the hospital.

We left the hospital early in the morning at 5am. Maralik staff will request a short hospital stay for this mother and baby and will take over the care on her return.



Report completed by Susan Burvill, 22nd Sept 2002 for Family Care