Time to do a bimanual massage, while lifesaving, is also quite painful for the patient. Obstetricians and midwives sometimes have to cause pain to save a life, and we understand that, but often the patients do not realize it until after, when they see how much they bled.

In total, we calculate a 1 liter blood loss. I realize that we never emptied the bladder, and a full bladder can contribute to hemorrhage, so I ask for a bladder catheter, and we insert it and then remove it. I look at the young midwife and tell her she did a great job. 

The team sits together, and each member of the team recounts the event from their perspective. Then, everyone is given the opportunity to identify both positive observations (what we did well) and areas for improvement. I have found debriefing to be both cathartic for the providers and essential to quality improvement.

In this debrief, the team is at first confused. Why recount something that we all just witnessed? I explain that it is just to discuss and to learn. The nurse reviews what happened. Then I ask what we did well, and what could have been improved. We all agree that generally, the hemorrhage was handled quickly, and that the teamwork was solid. The massage, the injected medication, the insertion of the IV, and the checking of vital signs were all handled expediently.

I remark that I should have remembered the urinary catheter, and that next time I won’t forget. I emphasize that the purpose is not criticism of others, but self-critique. Although the concept of debriefing seems new and slightly confusing to most of the staff here, they generally respond well to it, and appreciate the opportunity to review.

Just then, the nurse arrives with the tray of instruments and supplies. The nurse moves to help the mother with the baby, and the midwife clamps and cuts the cord. The nurse injects 10 units of oxytocin intramuscularly, in order to prevent postpartum hemorrhage.  The placenta delivers soon afterward, and we perform a quick massage of the uterus to prevent bleeding. It is firm and contracted.

Next, we check the perineum for lacerations. There is a small tear that needs to be repaired, so we decide to move the patient to the actual delivery room, now that the emergency is over, for better positioning.

Bimanual massage. That means that she inserts one hand into the vagina and the other hand on top of the abdomen, and squeezes the uterus between her two hands. Both hands then move in aggressive circular motions to literally massage the uterus. This simple maneuver is one of the most lifesaving actions performed in obstetrics.

She hears me, but panics a little. She is wearing non-sterile gloves, and backs away from the table to go find sterile gloves. Meanwhile, the woman has already lost 300cc of blood – the equivalent of a can of coke.

This is one of those times when it’s really difficult to not be allowed to touch patients here. This woman needs intervention now. In a postpartum hemorrhage, a woman can lose 1 liter of blood in 1 minute. She can lose her entire blood volume, 5 liters, in 5 minutes. That is how quickly this patient is bleeding right now. Sterile gloves don’t matter when someone is bleeding to death. The young midwife, who is just being taught all the rules of medicine – including hygiene and sterility – has the right instinct but doesn’t yet know enough to ignore this instinct and just stop the bleeding.

Things running through our minds during these times are,

"Is it:  (a) Ergometrine, which will help contract the uterus more. 

   (b) whether the uterus is firm (contracted) or soft (atonic)

   (c) if the uterus is firm and there is still bleeding, needs to think about other causes of bleeding, like a laceration of the cervix. probably the biggest hemorrhage 


One last thing I want to share is that I couldn't fully communicate with the patient, and that’s frustrating. We can smile at each other, and I can use the few words I know. In the delivery room, though, when I was holding her hand, we made an intense connection in a time of crisis. It is in those moments that I see most clearly the humanity in each patient.

I feel like I know her now. I think back to how rapid her hemorrhage was. She lost an entire liter of blood within minutes. If she had delivered at home without anyone to perform a bimanual massage or inject medication, she no doubt would have died. And finally, I realize, this is why we are here.

People do not magically stop getting pregnant during a conflict; fertility works the same, war or no. And when they are pregnant, they need to deliver safely. That is why MSF opens Maternity projects. If this woman had stayed home out of fear that she could not pay – or worse, where the health infrastructure has been decimated – she would have died.

Training eager midwives to be independent practitioners, who will provide safe deliveries to women long after we leave. If we do our jobs correctly, these midwives will continue to work for MSF even when there are no expat midwives or obstetricians.