Part four of a small series: on nurses and midwives taking the lead in promoting the natural course of birth.
As a “western midwife”, I have been trained to interact with the doctors on a more or less equal basis. Since I am their eyes and ears on the ground, I often know better than they do what is really going on with a patient. As a result, I will equally contribute to discussions on the management of the patient. However, in Tanzania, that is not exactly how nurses and doctors relate. The fact that there is also quite a variety in nursing degrees is not helping either. The lower ranked nurses may feel that all they can do is to execute orders in the best way they can without too much critical and independent thinking.
At FAME however, they try to make it a standard policy for nurses to actively participate and contribute to the discussions with doctors and to bring in their particular expertise and insights on the condition of the patient. It is a process that takes time and works both ways. Doctors need to gain the confidence that they can rely on their nurses and the nurses need to be taken seriously by the doctors. I felt very proud of the nurses on several occasions when I saw them pleading for a different labor management, more focused on allowing the woman the time to give birth in a normal way, without too much unnecessary interventions.
Some of the challenges that midwives encounter, turned out to be the same everywhere. For instance, there were moments when I felt that some doctors took a skeptical view of our efforts to mobilize women and let them exercise in order to stimulate the right fetal positioning and the progress of labor, even though this is entirely evidence based midwifery. Seeing the nurses advocate for natural birth was really encouraging to me and there were several situations in which them standing up for it actually resulted in the woman having a natural birth.
At the moments I suggested a different management to the doctors, I felt supported and backed up by the nurses in trying our best to avoid a woman ending up with a cesarean. I remember one woman with a beautiful smile who told us from the beginning that she didn’t want an operation. Before she really went into active labor, I saw on an ultrasound that the position was not favorable yet. We encouraged her to do exercises. She really took that to heart. When returning from lunch, I saw her walking up and down the stairs at FAME and she really made me smile with her commitment. We nurses/midwives had the same level of commitment in supporting the best outcome for this woman. The design of the hospital at FAME, with a lot of outdoor paved pathways, works perfectly for women in the early stage of labor. This lady was strongly motivated to make full use of it and to do everything we suggested to have the birth she wanted.
It is not always easy to define when a woman is really in active labor. If you work with a partogram however, defining the moment of active labor is crucial because it will also define when the ‘action line’ is crossed and you are faced with a situation of “no progress in labor”, demanding additional interventions. I myself am pretty skeptical about the way the partogram is used in midwifery, especially in primes. I focus on observing the resilience of the mother and the baby and on interpreting all aspects and signs of that labor more than on the time passed. With this patient, us nurses, who had observed her well, took a stand and pleaded for a correction of the start of the partogram, allowing her more time. Our smiling lady went through the long hours of labor heroically, she kept doing exercises while we tried to stand by her and do everything we could do to support her in labor. At one point, she was really exhausted and I must admit, we as staff were equally exhausted. We were faced with a situation of no progress in labour and we really felt sad for leaving our shift knowing that our patient would probably get the caesarian she so badly hadn’t wanted.
Thinking back to this case, I can however smile. I had seen a great passion and commitment to stand by the woman in my Tanzanian colleagues. We gave it our best as a team and when I saw the mother the next day with a big smile, a beautiful baby boy and a shining husband, I knew that she was also okay with the inevitable outcome, knowing that all of us had tried everything.
* * *
Want to know more about my journey to Tanzania and the Foundation for African Medicine? Check my travel diary.