Student Electives a world of experience whitney d o w n e s monash university welcome to www.ghn.amsa.org.au SAMOA 34 vector FEB <strong>2011</strong>
I recently undertook my medical elective at Tupua Tamasese Meole Hospital in Apia, Samoa, in the Obstetrics and Gynaecology Department. I was involved in providing ante- and post-natal care, as well as assisting in deliveries. My first day on the labour ward, I was confronted by a thoroughfare occupied by at least 15 pregnant bellies, each attached to a woman either uncomfortably waddling up and down the corridor or leaning against a vacant doorway, labour pains acknowledged only through the cessation of movement. I entered a delivery room (a 4 x 2m space with room for a bed and a bench for equipment) to find a woman lying prone with legs apart in the timehonoured position of birthing, husband pushing the crown of her head as if he could somehow increase the force of his wife’s straining uterus, midwife shouting encouragement in the usually dulcet tones of the Samoan language, and two Austrian doctors watching the perineum in anticipation, chatting in German as the baby calmly crowned. In minutes, a boy was delivered (their 5th, the husband informed us), syntocinon administered and 3rd stage of labour apparently in progress. Fundal massage to assist placental delivery raised an interesting question, was there perhaps a second baby, explaining the prolonged 3rd stage? Calm turned to chaos as I was ordered to get the consultant, the parents worryingly understanding the frantic tones but not the English or the German, as the midwife performed a completely unsterile vaginal examination in order to determine presentation of the latest surprise. The consultant calmly entered the room, delivered the second baby breech, and left after satisfying himself that both babies would survive, with just a cursory nod to the bewildered parents. The Austrian doctors turned to me and said, ‘Welcome to Samoa!’ My experience of Samoa continued in a similar fashion. Questions posed on ward rounds highlighted the dichotomy of ideal management versus that in developing countries, ‘How would you manage this condition, but how can we best manage it here?’ Antenatal clinics were conducted in an old ward room, curtains dividing the ‘cubicles’ and providing the illusion of privacy. The corridors are full of women waiting to see either midwives or doctors, most heavily pregnant but often on their first visit, with only unsure dates or late obstetrics scans to provide a rough estimate of due dates. Five doctors attempt to sift through the patients, assessing fundal height and blood pressure with one tape measure and one sphygmomanometer shared between them. The pitter-patter of foetal hearts is barely heard amongst the electronic whine of a Doppler probe struggling to operate on failing batteries. Any procedures are done with the supposed protection of XL gloves, which are probably a greater risk than help. Women in labour rooms who have been pushing past the limit of normal labour wait anxiously for one of the two cardiotocograph machines to be available for foetal monitoring. In these labour rooms, meconium liquor is often the first and only sign of foetal distress. However, despite the apparent lack of equipment, the hospital has surprisingly few maternal or neonatal deaths. The staff, used to not having equipment available, work incredibly well within the imposed limits, and the women accept the basic conditions in which they are required to labour. Delivery is perhaps returned to its natural state, with the parents not focused on ‘pethidine versus nitrous oxide’, ‘Coldplay versus Mozart’, but on having a healthy child. Having said this, I definitely missed the comfort of a reassuring CTG or maternal blood pressure, and learnt the hard way when I delivered a floppy baby and was chastised by the doctors for letting the delivery carry on too long, that if I was in the room with a midwife, I was assumed to be in control. My experience of Samoa was a welcome insight into the world of medicine in developing countries, of a beautifully strong culture and of people who are rich in ways we in the ‘developed’ world do not place enough value on. I look forward to my return, perhaps in a more senior medical role. www.ghn.amsa.org.au vector FEB <strong>2011</strong> 35
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