Vector Issue 12 - 2011

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 2011
35