A week on a Norwegian labour ward
‘Go in and learn!’ said the midwife in Norwegian as she pushed me through the door. It was my first night on the delivery ward during my Women’s and Children’s health elective in Oslo, Norway. I had read the textbook chapter entitled ‘Normal Labour’ that morning and attended the lectures on the physiology and anatomy underlying the birthing process. As I looked around the darkened room and greeted the diaphoretic primigravida lying heavily on the bed I realised again that there is an abyss between the academic and clinical faces of medicine. Those small hours of darkness taught me not only about the practical side of obstetrics but also the Norwegian approach. I will take you through my first week on the labour ward at the Oslo University Hospital and the reflections it engendered.
The first labour scene I saw taught me about being lost in medicine without language. I was comfortable with basic Norwegian phrases but could resort to English with most doctors and nurses. At the bedside of this labouring woman, however, was her Hispanic mother, who spoke neither Norwegian nor English. The daughter spoke Norwegian but was obviously becoming unable to translate. When the progression of the labourslowed, the tension mounted. An obstetrician whirled in creating a flurry of confusing clinical activity. As the snap of the episiotomy rang out and the patient screamed, her own mother became distressed, which the next stage of the Ventouse cap only compounded. The mother insisted on watching her daughter’s procedure without understanding it and became increasingly anxious while for me it was fascinating education. I tried explaining it in my limited Spanish then walked her gently back to the head of the bed for a kinder viewpoint. She relaxed, no doubt helped by the delivery of a healthy baby girl. I realised how daunting it is to not understand what is happening in a medical situation, let alone actually give birth. Reassurance and sensitivity are vital when confronted with irresolvable language barriers.
That my first delivery was the birth of a Hispanic‐ Norwegian became no surprise on reading the rate of immigration. Immigrants comprise 8% of the Norwegian population . Language difficulties inevitably arise but regardless of your origin or tongue, the Norwegian healthcare system will ensure you are treated to the same exacting standard. Equality in healthcare is a tenant of the Norwegian medical system, particularly in obstetrics where there are no private obstetric hospitals. The Queen of Norway has even been delivered of her royal offspring in our teaching hospital by our course coordinator. In addition to a consistently high standard throughout the nation, this translates to ample opportunities for teaching as well as an unsurpassable medical record database.
Immigration brings not only languages but cultural practices. The second birth I observed that night was eyeopening to the trauma inflicted by members of one’s cultural group. The 23‐year‐old African woman was writhing on the bed in agony in the second stage of labour. The midwife directed my gaze to the young woman’s external genitalia. I said it looked unusual and she explained that this young woman been circumcised prior to immigrating to Norway. I was quite shocked that a woman born only in the late 1980s had undergone such a process. It was presumably labour pains which caused this woman to tell me intrapartum to not have children. Regardless, it showed how far we have still to go to ensure women worldwide are treated with dignity and that reforms isolated to our own nations are arguably insufficient.
The first sight of female circumcision prompted me to research how Norway is improving this situation withinand beyond its borders. The WHO estimates 300 million girls in Africa are at risk of FGM annually . Norway has in fact fought against the practice for decades; it adopted laws against female circumcision in 1986. As the problem became increasingly visible with rising immigration, they developed an international approach and the Norwegian Government’s International Action Plan for Combating Female Genital Mutilation was launched in 2003 . This is an inspiring effort coupling cultural sensitivity and grass‐roots action with a Norwegian passion for women’s rights.
The third birth I observed brought me back from the developing world to the acclaimed achievements of modern medicine: reproductive technology and assisted delivery. This mother‐to‐be was 43‐years‐old with a history of miscarriage and other nefarious risk factors. IVF had given her another chance but pre‐eclampsia was putting this opportunity at risk. The week prior I had visited the IVF clinic marvelling at the technique and now I was using a Pinnard and the SFH to monitor her baby: a curious juxtaposition of such simple tools with the complexity of the medical procedures to create and support a new life. Oslo medical students are still taught to use the Pinnard although I failed to see it used beyond our OSCE! The patient underwent an elective caesarean soon after. Her husband was present in the requisite white scrubs like a medical astronaut and the delivery of a baby boy relieved his ashen‐faced tension. Watching the paediatrician in his well‐equipped surroundings manage the premature infant with a poor Apgar score reduced mine. Modern medicine had managed to overcome the obstacles to bring that couple their greatest wish.
Clerking this patient touched on Norway’s dual approach to obstetrics: technologically advanced yet back‐tobasics where possible. One way Norway differentiates itself with less intervention compared to other developed nations is its lower rate of caesarean sections: 12‐14% of all deliveries are caesarean, of which 40% are elective . For comparison, in Australia in 2008 31.1% of deliveries were caesarean . Norwegian obstetricians prefer vaginal deliveries for themselves with 98% in one survey selecting this as the preferred method for their own uncomplicated pregnancies to term . Over 50% of American obstetricians personally opted for a caesarean . Mode of delivery debates are contentious and require much elucidation but my teaching and reading in Norway certainly highlighted a preference for vaginal deliveries when safe.
My first week in the labour ward in Norway was insightful, moving and of course somewhat exhausting! Much of my obstetric experience in hindsight was neither unique nor specific to Norway but the Norwegian approach still shone through in the equality of medical care, the dedication to improving maternal health worldwide and as a leader in both obstetric technology and non‐interventional clinical skills. What added to the Norwegian flavour was the fact that the staff cross‐country‐skied to work and on my weekend off I climbed a glacier!
- G Daugstad. Preface. Immigration and Immigrants. 2008. p. 2. [article on the Internet]. [cited 18/03/11]. Available from: http://www.ssb.no/english/subjects/02/sa_innvand_en/sa104/introduction.pdf
- WHO. Female genital mutilation and other harmful practices. 2011. [article on the Internet]. [cited 18/03/11]. Available from: http://www.who.int/reproductivehealth/topics/fgm/prevalence/en/index.html.
- E Solheim. Norway’s international effort against female genital mutilation. Ministry of Foreign Affairs. 08/08/2007. [article on the Internet]. [cited 17/03/11]. Available from: http://www.regjeringen.no/en/dep/ud/Whats‐new/Speeches‐andarticles/speeches_development/2007/Norways‐international‐effort‐against‐fem.html?id=477191
- B Backe, K Å Salvesen, O Sviggum, Norwegian obstetricians prefer vaginal route of delivery. 359: 9306, 16/02/02. The Lancet. [article on the Internet]. [cited 19/03/11]. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140‐6736(02)07733‐4/fulltext.
- UNSW Perinatal and Reproductive Epidemiology Unit. Australia’s Mothers and Babies 2008. [homepage on the Internet]. [cited 19/03/11]. Available from: http://www.preru.unsw.edu.au/PRERUWeb.nsf/page/ps24.
- SG Gabbe, GB Holzman. Obstetrician's choice of delivery. Lancet 2001; 357: 722. [article on the Internet]. [cited 19/03/11]. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140‐6736(02)07733‐4/fulltext.
Demographic details have been changed to ensure anonymity of the patients described.