A busy last day on the ward in Baglung

April 23, 2018

On our last day at the Dhaulagiri Zonal Hospital we went in at 6 am because the nurse on night shift had called us to say that a woman was in labour. When we arrived there were two women in labour. One was in active labour and the other was still in the latent phase of an induction using misoprostol for cervical ripening. The protocol they use here is 25 mpg vaginally (PV) every 4 to 6 hours up to 4 doses. The nurses I spoke to said that most women will be in labour after the second dose.

The gorgeous view of Mt. Dhaulagiri from the hospital in Baglung

Our plan for our last day on the ward was to pair up with an SBA and do 4-handed deliveries with them. We were excited to continue working closely with these SBA students who had been a part of our refresher workshop.

When the woman who was in active labour went into the delivery room Emma and Cathy went with her. When her membranes ruptured there was meconium present so we made sure to prepare the warmer in case we needed to resuscitate the baby.

The mother and was coping very well and together with the nurses we moved her onto side lying position to deliver her baby. It was a bit awkward conducting a four handed catch for the first time in the role of the teacher. She easily delivered a healthy baby girl with a nuchal cord. The baby was vigorous and the exhausted mother relieved.

Jenny stayed in the delivery room to monitor the two women in labour. One of the women had arrived while we were taking the first women over to the delivery room. We had seen her every day for the past two days and she arrived in what appeared to be active labour. As we knew the doctor was coming in and would likely perform a vaginal exam on all of the women, we had not examined her. When the doctor examined her she was fully dilated and the baby's head was on the perineum. We moved over to the delivery suite where Emma was suturing her client.

Although she was fully dilated she was not having strong enough contractions to push well, so the decision was made to hang an IV with 5 IU oxytocin in it to give her stronger contractions. We ruptured the membranes and there was meconium present so one of the nurses brought the suction machine over to bedside.

She delivered very slowly with the support of Jenny and an SBA. The baby appeared to be undernourished and of a gestation age that was not concordant with the dates on the mother's antenatal record. We kept the baby skin to skin for a short time and then she was moved to the warmer for a closer look.








Once we got both mother's settled in the postpartum ward we had a quick cup of milk tea and some biscuits. They were delicious!

Our day finished with a difficult cesarean delivery. The woman had been labouring quietly all day with some support from family members, as our team were busy supporting other birthing women. Unfortunately after being in labour all day, and reaching full dilation, her baby's head never descended. In addition to this there was thick meconium when her membranes ruptured. Meconium can be a sign of fetal distress or fetal maturity in addition to putting babies at risk of meconium aspiration syndrome.

The obstetrician assessed her and decided it was time to deliver via cesarean section. Cathy and Emma went into the OT to continue supporting the mother and to resuscitate the baby as needed. It was a difficult delivery for the doctors involved due to lack of resources and maternal health. After several hours in the OT a vigorous, healthy baby was born and we were all relieved. Emma felt very privileged to have the opportunity to witness the skill and patience of care providers working in low resource settings. Both mother and baby are thriving.