Every Town I Lived In: Learning the Flow when Giving Birth at the University Hospital in Pristina (24-25 March 2016)

(I am a volunteer for Project HOPE for 4 weeks in Pristina, Kosovo. All opinions stated are my own and do not represent the positions, strategies, or opinions of Project HOPE.)

www.projecthope.org

I am always amazed every time I travel to a new place how welcoming and friendly people are. I don’t speak Albanian, I am an outsider coming in to learn and to find ways to help “improve” the provision of care, and I ask a lot of questions. I feel fully embraced by the staff that I have met in the Labor and Delivery department at the University Hospital and am so blessed to add them to my circle of friends. Sometimes when I get bogged down in the drudgery of my day to day work as a resident in Rochester, NY, I forget why I went into the field of medicine in the first place. Over the past three days, I am starting to remember again why I chose this profession and why I chose Ob/Gyn in particular. I am inspired by the women and men I have met here, their dedication to patient care, and their passion for learning.

The Obstetrics and Gynecology Clinic is 4 floors with each floor having its own area of focus. Pregnant women who plan to deliver at the University Hospital can come up to two weeks ahead of their due date to wait for the onset of labor. There is a ward in the clinic for these women to stay. There are also wards for gynecology, oncology, and “pathology” - the women who have complicated pregnancies (hypertension, pre-eclampsia, diabetes, etc.).

"Labor Corral"

When any of the pregnant women go into labor, they stay on their respective floors until they reach at least 5cm dilation and +/- broken water. At this time, they are moved to the top floor to the labor and delivery unit. There is series of three rooms with two beds per room that I call the “labor corral.” Women are here until it is time for them to start pushing. The labor corral is a cluster of three, three-walled rooms with large windows encompassing the majority of the wall between them, sort of like a fish bowl. The staff room is adjacent to these rooms and all the labor rooms are visible through the large windows. Sometimes there are more laboring women then there are beds available. The women are here alone - no family or friends are allowed on the labor and delivery unit. They bring a bag of supplies with them including clothes for during labor and afterwards, water and other drinks, wet wipes to clean themselves after delivery and for the cleaning of the bed, and clothes and blankets for the baby. The women are each other’s support throughout the labor process. There is a fetal monitor in each of the rooms and doptones are intermittently obtained.

Exam Chair

There is a specialist who checks the cervical dilation of each of the patients at prescribed times throughout the day. The women are walked to a nearby room with small steps leading up to a half table with stirrups. One by one, the women sit at the edge of the table and are examined. The resident sits at the desk to the side and records the exams on a labor curve and also records the plan (continue “passive” labor, stimulation of labor with oxytocin…). The other residents, nurse midwives, other specialists, medical students, and techs are all present for the examinations - sometimes as many as 15 people are in the room for each of the examinations. Once a woman has her cervical exam, fetal heart rate is obtained with a fetoscope and documented, she gets up and walks back to the labor corral. The tech removes the dirtied cloth and places a fresh one down on the table for the next patient.

Delivery Room

Patients are not just checked at the time of the specialist examination. While in the labor corral, the residents will also periodically check the patients. When a patient reaches full dilation, a resident and midwife bring the patient to a delivery room. The delivery room is already prepared for delivery with the bed broken in half and stirrups up. Pushing never seems to last for very long - the midwives are very active in helping the patient move towards delivery. For most women who are pregnant with their first child, an episiotomy is cut without local anesthesia during one of her contractions. The fetal heart rate monitor is brought into the room, if one is available, for doptones between pushing. If no fetal heart rate monitor is available, the fetoscope is used to assess fetal heart rate between pushes. After delivery of the baby, baby is immediately placed on mom for skin to skin. The cord is clamped and cut and an additional person in the room brings the baby to the scale and weighs it. Afterwards, the baby is wrapped in a series of blankets ending with a thick fleece blanket and either left on the warmer or given back to mom. In the meantime, the midwife administers 10 units IM oxytocin, delivers the placenta, and examines for lacerations. The resident is documenting throughout. After placental delivery, the resident brings up a stool and a light and repairs the episiotomy. 1% lidocaine is used for local anesthesia (approximately 4-5cc). There is only one size suture available for repairs, size 0 braided dissolvable suture. The episiotomy is repaired, the woman is cleaned off with the wet wipes she provided, the foot of the bed is replaced, and she stays with her baby in this room for approximately 2 hours.

Standard Delivery Cart: Top left jar with hand cut and folded mic pads, far left container with scissors for episiotomy, next to that is container with sterile forceps and needle driver, top right fetoscope

At the public university hospital, epidurals are not available. There are no options for pain management during labor. Although women have been delivering babies for centuries without analgesia, this is so removed from my usual day to day experience in the United States that I find myself in awe of the strength of these women as they deliver their babies with only the support of each other during labor and the support of the health care workers during delivery.

Over the past two days, nearly 90 women have delivered their babies at the University Hospital. This is the slow time of year.

The big question for me is how do I take the observations and experiences of the past few days and use them to contribute to improving the system to provide better care for patients, better health care administration, and better education? I have some thoughts on this, but for now, it is Friday and I am looking forward to exploring my new home.