Labor and Delivery at Mahamodara Hospital

The last rotation week in ob/gyn found me at Mahamodara Hospital, just off the coastal highway linking Galle to Colombo. The hospital itself was heavily damaged by the 2004 tsunami, leaving large parts of the facility abandoned. Though many died in the initial wave, the patients of the Mahamodara were evacuated just in time to escape the tsunami’s second, more powerful wave. Although the mothers and children survived, the hospital didn’t. The venerable Mahamodara had been Galle’s maternity hospital since the 1940s. Now that it was gone, mothers were forced to go to the Karapitiya Teaching Hospital, which quickly became overwhelmed and overcrowded. On the first anniversary of the tsunami, workers broke ground on the new inland hospital and quickly set to work laying the foundation of what the Germans promised would be a state-of-the-art hospital for the people of Galle. But now, more than 7 years later, a concrete slab is all that exists of the promised maternity hospital. Thanks to the mismanagement of the donated funds, miscommunication, and cost overruns, the project came to a crashing halt. Enormous cranes and construction equipment can still be seen at the construction site, but no work has taken place for several years. Thankfully, attention was returned back to Mahamodara where several new wards have been built in the past few years, equipment has been donated and the Sri Lankan and German Rotary Clubs have made sizable monetary donations to revamp the women's hospital. 

Most of our time was spent on the labor ward, where a dozen or so women on nearly bare cots with zero privacy would deliver the most beautiful little babies. Very different from my experience on L&D in the states. 




Differences: 
-no epidurals here! not even an option! 
-nearly every woman delivering her first child vaginally will have an episiotomy (OUCH!). The professors are trying to reduce the number of episiotomies, however this number is still rather high. 
-women are smaller here (smaller body and smaller pelvis) so many tear during delivery
-no husbands or family members allowed on the ward during delivery (b/c it's one large room with women laboring/delivering, and many women having their lacerations repaired --legs in stirrups with med students stitching).... though this is different at private hospitals where patients can have a husband or family member in the room 
-no peds team on standby in the room
-C-sections are reserved for emergency, not elective (unless in the private sector)
-breech deliveries are still delivered vaginally, as are twins (most of these would be C/S in the US)
-patients hold their own legs and no one is coaching them through their pushing or telling them how long to push

Similarities:
-women are screaming out their labor pains
-oxytocin is everywhere! 
-the little nuggets are so cute!!! 
-both labor and delivery experiences make me scared to own a uterus

Ambulance carrying a new mom and her newborn from the delivery ward at
Mahamodara Hospital across the street  to the newborn nursery and clinics.

Maternal mortality, however, is impressively low in Sri Lanka (39/100,000 – the lowest in the Asian region), no doubt thanks to the public health system. All women receive free care with regular visits at the community medicine antenatal clinics, with 99% having at least 1 prenatal visit during their pregnancy. (See my blog about the MCH clinic in Gintota for more on the antenatal screening and Public Health Midwives.) If there is any problem or concern the women are referred to Mahamodara for further investigations. 

A heap of medical students watching a twin breech delivery.
There aren't normally this many students watching a delivery,
but with the unique nature of this birth, everyone wanted to learn. 

Side note: 

Dr. Fernando in Community Medicine had told me a story of one of her patients she referred to Mahamodara from an antenatal appointment- a pregnant woman came to see her at the MCH clinic for her 36 week check up. The woman was so large from swelling, she could barely open her eyes or stand on her feet. Her bare feet were so blistered and swollen, they appeared like a large driver head of a golf club. She couldn't afford a tuk tuk nor did she have any mode of transportation. She had walked the 5 miles to the clinic, barefoot and 36 weeks pregnant. Without having to do any investigation (though she did) she knew there was a problem. Dr. Fernando pulled out some money and got her a tuk tuk to send her immediately to Mahamodara Hospital. A week later, a skinny woman with a newborn came to the MCH clinic to see Dr. Fernando. She had no idea this was the same patient she had sent off in a tuk tuk just one week prior. When the woman arrived at Mahamodara, she was immediately taken back to the operating theater where she delivered her struggling baby at 36 weeks. Mom and baby were so happy and healthy, thanks to Dr. Fernando.