Friday 10^th July 2020

Today I was lucky enough and the doctor, with whom we led the first waterbirth, arranged for me to go to have a shift on the maternity ward of one of the largest state maternity hospitals in Colombo. De Soysa maternity hospitals has 6-8 thousands babies a year, in four maternity wards. I wanted to take a look and see how it went there. I was preparing for a lecture for their medical staff and I wanted to identify practices that needs to be brought to attention in favor of quality improvements, which I will use as a basis for discussion.

At 8.00 I found myself in an old building that looks like the one we see in the post-war movies. White tiles on the walls from top to bottom, the ground looks dirty, because the tiles are old and destroyed, but it is clean – to the Sri Lankan standard. Lots of people everywhere, nurses and helpers too, but most of them doing nothing. I was the only white woman there. The doctor came for me and took me to the maternity ward. The nurse in charge greeted me, I gave her a box of tea and wafers for the nurses, and she gave me a theatre gown. I changed my shoes (I have shoes that I only wear to the maternity hospital), I put on a home-made name tag and I immediately found myself standing by a woman, who was lying on a bed and whining, calling her mother and God. I introduced myself to her, I asked her if I could be with her, she understood a little English. I don’t even know how long I whispered in her ear, how strong she is, how well she manages to listen to her body, to trust her baby and not to be afraid, holding her hand. I had rapeseed oil with lavender aromatic essential oil, so I massaged her back for a while. She gave birth and was happy – like any mother holding her baby, suddenly she forgot about the pain.

Then another woman gave birth right next to the first woman, so I was with her and did the same. The two of them then told each other independently that they would pray for me. I hope I helped them at least a little. At around 1 pm I tool a break for food and a sit down.  A doctor ordered me lunch and a drink (fried fish rolls and a strong sweet cold coffee). I gave it to the nurses.

In the afternoon, I went from one woman to the other, gave them a massage, tried to breathe with them and encourage them. Unfortunately, both ended up with a caesarean section at 8 p.m. One lady got stuck on 5 centimeters and the other lady had pathological CTG and echoes. One of them told me I was like her mother. She did not want a caesarean at any cost, that her husband and his family had told her that if she gave birth vaginally, they would give her whatever she wanted!

The labour room also looks like a post war hospital. One big long room, with dirty windows and old dirty curtains. 4 old rickety iron delivery beds by the wall separated / not separated by curtains / hangers.  No privacy, no dignity, all women like in a shop window and staff walking around them like in a shopping mall.  

What did I observe?

• All are connected to CTG, a machine that captures heartbeat and the frequency of labour pains (in the UK it is only used for women with high risk pregnancies)
• Everyone lies flat on the bed all the time
• They all have a cannula inserted and an intravenous solution into their veins
• Clear fluids are given (water or tea)
• Catheterization (emptying bladder) to everyone every 2 hours, instead of giving them a bed pan (there is only one bed pan for the labour ward)
• Women give birth in a supine position with active pushing
• Episiotomy for all women, unless it is their third baby
• The baby is taken from the mother about a minute after the birth and is returned to be breastfed after episiotomy is performed by the doctor and she is in a clean environment
• They had only one hose to the Entonox cylinder today, however, it didn’t work, so no one could use it
• The only possible form of pain relief was Pethidine or epidural (none of the women used this option that day)
• I saw good teamwork with doctors, early identification of problems and timely escalation to doctors
• Women were alone; they were not allowed to have a birth partner with them (Covid)
• Women lay on green or white cotton sheets; they do not have incontinent pads for single use
• Sterile gloves are available for all health personnel
• The air conditioning worked
• I was glad to be able to spend my shift with a very skilled midwife as I needed to understand more of the environment and system in which they work; accordingly, I will prepare a presentation and I will keep the nurses at the centre of my talk
• Nurses in a state maternity hospital have more power/autonomy than in private, because in the latter a doctor/consultant takes responsibility and leads the birth as a named professional to whom the woman will pay
• The woman has to pay both the hospital and the professional separately if private
• Hierarchy is very strong in Sri Lanka and especially in healthcare
• Doctors start in state maternity hospitals / hospitals on the periphery and as their number of years of experience increase, they may be transferred to the city and can work as a consultant to set a private practice once experienced enough
• Sometimes a doctor works 10 hours in a state maternity hospital and then goes to a private maternity hospital for 5-6 hours, has a pregnancy clinic or is called to the maternity hospital, has a pregnancy clinic or is called to lead the birth. That’s why cesarean sections are more convenient as they are done in 45 minutes and they can be planned

Quite a lot!

Rennie