No meds, No doc, No problem

My drug-induced sleep prior to my first day at Chintechi Rural Hospital, is laced with dreams of emaciated children and my glaring inadequacies in caring for them. For once, my 5:30AM alarm is a pleasant reprieve. With trepidation I arrive, toting gloves, a stethoscope, a pen, hand sanitizer and a thermometer- a modern day Florence Nightingale? As I pass the dreaded pediatric ward, my breakfast of tea and peanut butter (that's right), threatens a re-visit. I am greeted by the medical officer, who tells me- "I am a Practitioner, you are a Nurse, today you will be with them." Never has such arrogance sounded so musical to my ears! With relief, I follow one of the nurses to triage- an environment that finally instills more comfort than terror. The nurses, all fully trained as midwives, with no reliance of doctors (closest one is over 40km away), are the image of poise and self-sufficiency. Among others, within two hours, we have seen, referred, drawn blood and medicated multiple malaria cases, a child with marasmus, two post-partum women with retained products, a dramatic case of cellulitis, a child with a fractured arm, and a man with a human bite to the chest wall (further details unclear). A second nurse soon beckons me, advising me that a woman is currently in labor, and questioning whether I was ready for delivery. Was this a joke? I hoped so!
Side note: Child birth in Malawi is simple, quick, and quiet. To scream is an embarrassment. The woman checks herself in when she feels contractions. She arrives alone, and is received in the L&D ward, which houses three steel cots separated by makeshift curtains, and an ancient infant-warming contraption. She brings her own sheets and materials for laboring and baby clothes. A female family member may come in and bring her food at any part of the birthing process. The nurse midwife assesses position and station of the fetus. First time breech delivery gets referred to the district hospital, an hour away. Multi-para breech gets delivered here, more often than not, successfully. The woman delivers naked, on her back, hands grabbing the bed railing behind her head. No medication aside from a post-partum intramuscular shot of pitocin to induce uterine contraction to help stop bleeding. No blood pressure monitoring available secondary to supply shortage. No mandatory antenatal rapid HIV screening available secondary to supply shortage.
But back to me! The midwife asks me to preform the “V” test. I'm sorry, what? Ah- insert your fingers into the vagina, spread them to a V, and estimate how dilated the cervix is. Ahhhh! Ummmm, ok. I tell her I feel something hard, and she states, “that is the baby's head, she is ready.” OMG! She is ready, but I am not! The midwife teaches me how to listen for the baby's heart rate and how to feel for contractions, sans technical assistance. I scream “PUSH” every times I feel her contracting, most likely NOT negating the stereotype of the loud American. I start pacing, doning the role of the absent father. After about 20 min, a head emerges. For the next several minutes, an eternity to me, the body fails to follow. I am panicky, and perhaps more diaphoretic than the mother at this point. I am staring at the bodiless head, believing that the baby, who has failed to take a breath yet, must be rapidly approaching brain death. OMG- why am I the only one panicking?! As my mental fog clears, I realize that until the cord is clamped, the baby is still receiving oxygen from the mother. PHEW! Within seconds the body follows, and I place him directly on his mom's chest. No crying. OMG! Has he swallowed meconium? What his APGAR score? Who has a watch? Should I initiate resuscitation?! PANIC! The midwife rubs down the infant, who then produces the worlds most beautiful cry (the baby, not the midwife)! With bloody gusto, the mother delivers the placenta (which will be protected and later burned out back with all the others of the day), and breast feeding is immediately encouraged. Still bubbling with adrenaline, I peel off my gloves, carefully avoiding the gaze of the young woman in the adjacent bed, who has just suffered a late-term miscarriage, and is awaiting manual, bedside evacuation.