While we were at the Kafountine clinic, two laboring patients were transferred to the Ziguinchor Hospital for complications that were beyond the clinic’s ability to handle. One pediatric patient (7 months) was also sent to Ziguinchor. The first illustrates the reality of working in a “low resource setting” and it was through this client, my first client, that the full meaning of a working in a low resource setting became fully clear to me.
Mrs. B, a short, petite, 16 year old, was here to have her second baby; she has the smallest feet. Her first baby died within a few hours of its birth and weighed less than 3 ½ pounds. When she arrived at 9:00 a.m. she is 3-4 cms dilated and the baby is very high and the mother has a very narrow pelvic inlet.
She is frightened, dehydrated and hungry, but does not want to eat or drink because she has been vomiting. Throughout the day her family brings her food and with constant coaxing she eats and drinks a little. Her female family members are practicing the “tough love” form of labor support that so characterizes birth here. We walk her and give her breaks to doze—she has no energy; a tired and pacing mother. We have ORS available for dehydration, but keeping it down is still an issue.
Throughout the day we have discussed and tried various options to get this labor to progress and for the baby to descend. We have used a wide variety of the comfort techniques and strategies to move the baby lower into the pelvis, but her pelvic inlet is very small and narrow. Her contraction pattern remains irregular all day. We have focused our attention and commitment on changing the baby’s position in the uterus (yes, I took my rebozo and “Happy Puppy” glute moves to Senegal).
We have no IV with dextrose to give her some energy. The clinic does not carry dextrose IV and it would have to be purchased at the pharmacy. The pharmacy is closed and the client does not have the money with which to purchase and IV. We volunteer to pay for it but with the pharmacy closed the issue is moot.
We have no Benadryl to give her a nap.
The baby is still too high for a safe rupture of the bags of water.
We have no homeopathics or herbals except for parsley tea for contraction stimulation.
By 7:00 p.m., her cervix has dilated only 3 cms. —to 7 cms. The baby is still very high, the heart tones no longer reassuring and the baby, and scalp stimulation is only a temporary improvement method. Despite our day-long rigorous activities to get the baby to descend and to re-position itself, the baby has not done so.
We discuss options for getting this baby out now. Recommendation—immediate transfer.
But as I was to learn, the decision to transfer involves three levels of decisions:
- The medical recommendation that a transfer is the only available solution in this situation;
- The family’s agreement on this recommendation—which involves getting a complicated set of approvals from various family members and money with which to pay for the transfer; and
- Access to transfer—collecting money to pay for the ambulance and the ability to get the ambulance here from Ziguinchor
The matrone is not convinced that all available options have been tried yet and takes management of this client. Her solution—pitocin by intra-venous injection and internal version. When this failed she recommended transfer to the hospital in Ziguinchor to the family.
We were unaware (and naïve) that in making this decision, the issue of money was the pivotal factor. It was not until the next morning that the ambulance arrived.
In Ziguinchor, Mrs. B. had a c-section and her second fetal demise.
From this event we took the issue of money out of decisions to be made by the family members of the clinic’s clients. We paid for ambulance rides, formula, water, food, etc. —life or death would not turn on the issue of money for our Sisters while we are here.
On Thursday Feb. 4 we were called to check on a mother. We arrived to find a mother who is 6–7 cms., dilated, with the baby entering the pelvis in an assynclitic position, with a deflexed head, and a brow and nose presentation.
There is universal agreement to immediately transfer this mother to the hospital in Ziguinchor. The family agrees to the transfer and we agree to pay for the ambulance (Senegal $20,000). An IV is placed while the ambulance makes the drive from Ziguinchor; one of the midwives accompanies the mother on the ride.
As the ambulance arrives, the mother’s family members and some of the clinic’s post partum mothers come out to wish her good luck.
We sit down to give ourselves a “Job Well Done” pat on the back and a taxi cab speeds up to the clinic door, with a home birth mom and her twin girls.