They say a picture is worth a thousand words......

one of my many deliveries

new born

me with a great aneathetist

operating

waiting for post natal checks

neonatal unit

there are still lots of very sick babies being admitted

prematurity is one of the biggest problems

kangeroo mum- born at 29 weeks because of severe pre eclampsia- weighing only 900g at birth but doing well

labour ward bed

on the job training- neonatal resus with baby natalie

records room...hmm

my leaving present- now i am really malawian

with my postnatal nurses

health centre training day

I mentioned i my older posts that i was often surprised by the referals tat we got from the health centers, patients with pre-eclampsia sent without blood pressures ever being taken, eclamptics being sent without receiving magnesium sulphate which helps stop the fitting, patients never getting basic antenatal testing like heamoglobins or HIV tests and  patients in labour being referred far too late. 

So we decided on having a training day for the local health centers and 3 midwives attended from each center.  We taught them the importance of basic antenatal care, refreshed their knowledge on pre-eclampsia and eclampsia, the use of the partogram and neonatal resuscitation.  But more importantly we listened to their problems and what difficulties they face, lack of equipment including bp machines, lack of hb testing equipment, transport taking far too long to arrive in an emergency and being too short staffed to accompany the patients as it would leave no staff at the health centre. 

Early in the year Ammalife fundraised for BP cuffs and other essential equipment and these BP cuffs were given to each health centers so that they could carry out their work.  They were ever so grateful and when i did a follow up visit at the health centres several weeks later i saw them in again :)

 Discussing examples of partograms in groups

 Practicing taking of blood pressure in groups with the donated cuffs

 Neonatal resuscitation with our friend baby annie.

 Follow up visit to the health centers with on the job training- very basic conditions

The donated Bp cuff and emergency book with a midwive/ husband in a health center

post natal sepsis

Firstly sorry for the very long period of no blogging, a combination of being busy and rubbish internet got the better of me!

So this post is dedicated to one of my patient who i looked after for a month before she lost her life to sepsis.

She had a normal delivery, slightly prolonged labour but not too bad, a few days after she started complaining of abdominal pain, distension and vomiting- she was seen by another doctor and diagnosed with bowel obstruction, i saw her 2 days after that and thought she had endometritis- for the non medics that an infection of the uterus- i started her on strong IV antibiotics and observed 2 days later she was no better.  I have learnt by being here that you have to be quite aggressive in the management of these patients if they are to survive so i booked her for theater.  During her operation she had thin pus in her abdomen and a very infected, uterus that was starting to undergo necrosis- so we had to remove her uterus.  she has a few babies and this baby also survived but i have has some really young first time mums with very lengthy obstructed labour who end up having a c-section, after which their baby dies and then they get severe sepsis followed by a hysterectomy- it breaks my heart! But as my consultant says better alive without a uterus then dead with one.  Anyway back to my patient after her hysterectomy she was a little better but a few days later her abdomen was starting to become distended again despite being on antibiotics.  5 days from the hysterectomy she was still getting worse so it was time for another operation... this time she had accumulated an abdomen full of pus again, a washout and 2 large drains later she was back on the ward.  we sent some pus for microbiology and it grew klebsiella and group a strep resistant to pretty much everything except ciprofloxacin - we weren't winning here!  The drains became blocked and stopped draining and she started having high temperatures again, and a week later we were back in theatre with an abdomen full of pus again!  After this operation she started having intermittent seizure, we looked at all the common causes and she had none of these- so we fought for an MRI which showed a clot in the brain- thats a bit of a life sentence in malawi coupled with her still being very septic we werent going to win :(.  She was so lovely may she rest in peace, my thoughts are with her family, her three young kids and new born baby.

Purpural sepsis is still one of the leading causes of maternal mortality world wide, a combination of non sterile conditions, lack of antibiotics, long labours all play a part.

We don't always loose though- another of my patients finally went home after 2 months following a ruptured uterus,  c-section and hysterectomy, neonatal death, sepsis, laparotomy and wash out X2, Vesico Vaginal Fistula from the obstruction which caused the rupture,   VVf repair and now shes gone home in great condition :)

 

Happy mothers day

Happy mothers day to all the mums out there.  Becoming a mother in some parts of the world is tricky if not very dangerous business- it is said that is is the most dangerous thing a woman can do in Africa is give birth!   For all the mothers out there who survived, this day is a celebration of you and all the wonderful things you do!  And for all those Mothers  or women trying to become mothers who sadly died we mourn your loss and hope and pray for a future where this is a thing of the past! 

The forgotten victims of maternal mortality

Blantyre has been wet and miserable recently so we've been trying to find things to do in the city instead of traveling out.  

We found a great orphanage called open arms that we've been volunteering at, playing with the children, helping to feed them etc/  the orphange take in newborns till the age of three some have lost both parents, some just the mother but the father is unable to care for the child for the first few yrs and so the orphanage will look after them and then help to reintroduce them into their community and extended family if they have any. 

It got me thinking what happened to their mothers- and yes although not all of them died during child birth a significant proportion had- leaving the baby defenseless.  The statistics are that if a mother dies during child birth her new born baby is up to 10 times more likely to die in the first two years of life!  And lets not forget the other children that the mother leaves behind of varying ages.  

                                          What a cutie- i want to bring him home!

                                                Malnourished- drink up little one

3 months reflection

So I've been here for just over three months now, most days Ive really enjoyed it and other days I've just wanted to run away and wondered what I'm doing here- overall its been pretty tough going but I've loved it!

Malawian women are some of the nicest i've met (the patients not always the staff), their smiles will light up the room and their gratitude is plain to see and the level of poverty is unmistakable and being able to offer help however small in this settling is so rewarding.   

Its difficult to work under these conditions, the level of staffing is so low and resources scarce.  It would be better if the same things was missing then you could work around it and just do without but its the constant change that makes it difficult, no antibiotics today plenty tomorrow, lots of blood today none next week, cant operate today because -( insert any of the following) no gauze, no sutures, no gowns, lights are broken, tables broken.......On the wards its bp machines broken, no thermometers, no urine bags ( its amazing how many ways u can use a glove),  no pregnancy tests, no urine dipsticks, no gloves!  I thought it was just inefficiency at first- and wondered why they didn't just order things before they ran out- but after digging its a far bigger problem- the central medical stores that supply the hospitals have also run out! Partly because of corruption theres talk of some of it being sold off to private clinics and partly poverty the government just cant afford any!

Then there's the staff- when i first got here i thought they were all lazy and unmotivated, i was frustrated because when ever i asked for observations to be done or medicines to be given or babies to be monitored on labour ward it doesn't happen.  They would complain that they were tired and it would be 10 am, and by lunch time they are napping at the desk!  But these nurses often have to get two jobs to make ends meet and still find it difficult, some have to get two mini buses to get to the hospital and  when you consider that the government hasn't paid them ( again no money) for the last two months i wouldn't want to do any work either, and yet they still turn up!  I still think more can be done with the little that available if every one was just more motivated  and pulled their weight but i'm not sure how without better working conditions this will change. 

Although i've not worked in O&G for that many years, in the UK I had never seen a mother die, i have only seen 1 baby born dead and its heart breaking how many die here unnecessarily!  It really is hard to stomach or even get your head around- you come in to hospital not because you are sick but just to have a baby- something normal and natural but then u never leave- it just shouldn't happen. 

Now here comes the sales pitch to all my medical friends:
What they need here among other things is doctors and although a system cant survive purely on volunteers in the interim while they train their own doctors and specialists it works! 
As well as being hugely rewarding and teaching you about global maternal health, u will leave really appreciating the NHS, the hours and be motivated on your return.  Its a great learning opportunity, i've delivered vaginal breech's, twins, delivered two sets of triplets in two months, done numerous c-section-most pretty difficult.  You learn to rely on your clinical skills and examinations because you cant order a CT, MRI or even simple blood tests like LFT's ( well u can when they have reagents but you will get the results in a week so whats the point)   If gyne is your thing the operating opportunities are also vast.  So if you want to annoy the deanery by asking for an oope and come out you wont regret it- get in touch and i can give you more information! 

Its been a bad 10 days!

Its true what they say- bad times come in waves. we had 3 maternal deaths in the last 10 days alone :(

The first had been refered from a health center having been fully dilated for 2 days!!  2days!! when she got to us she had a macerated fetus still inside, a necrotic vagina and most probably a vesico-vaginal fistula which is a devastating complication of obstructed labour where the pressure of the babies head erodes a hole between the mothers bladder and vagina, causing her to leak urine constantly, be prone to lots of infections not to mention the social implications.  A rapid c-section was done, but the mother died of the complications and sepsis.

The second arrived having already ruptured her uterus,  Im not too sure of her history as i wasn't involved but i heard the tear in her uterus was very extensive and tore down into her bladder, she had lost a lot of blood, we did a hysterectomy and she went to ITU but died the next morning.

The third patient died while i was oncall- it was very sad as it was the first patient who has died that i was directly involved with.  she  was on her 5th pregnancy, she came from home already fully dilated and delivered in the admissions room a fresh still born baby.  she was taken to a bed and then had a massive postpartum hemorrhage- when i was called she already looked like she was in shock, had an unrecordable bp and was lying in about a liter of blood.  w started aggressively resuscitating her, took v\blood tests and gave her lots of fluids. on assessment her uterus wasn't contracted and we thought this to be the cause - we started massaging it to help it contract and giving her medication to do the same- in the uk there are about 4 different drugs you can use here there is only 2 so we are already disadvantaged.  All this helped to slow down the bleeding but it did not stop, we decided then to transfer to theater, to see if there were any products and possible do a hysterectomy if the bleeding didn't settle soon.  we also ordered blood but was told only one unit was available.
in theater the bleeding didn't improve and we couldn't find her pulse - we started chest compressions and she came back, wed called the consultant who arrived and we decided to operate on opening her abdomen it was clear why she was bleeding- her uterus had ruptured- straight into the broad ligament and there was massive bleeding into the retro-peritoneal space.  Id never seen anything like it- we quickly removed her uterus and with the help of a general surgeon we stopped the bleeding.  In total she probably lost 6 L of blood which is almost all the blood she has!  With out more blood she was surely going to die- we managed to find 2 more units but no more :(  I remember a similar case who survived but blood was more available and she had 8 units in total.  blood is a strange thing here sometimes its plentiful and other times very scarce, although there is a blood donation drive in Malawi. 

My consultant the next day asked why she died and i said lack of blood- his reply was no- lack of family planning and in this case he may have a point!  After 5 pregnancies the uterus becomes tired and thin, is less likely to contact properly after delivery and more likely to rupture.

Family planning in still very underutilised in the developing world, there are many teenage pregnancies ( a major cause of death of girls in this age group) and many women who have more than 5 or 6 babies which put them at risk of great obstetric compications. 

Heres hoping thats the bad patch is over for awhile.

see one, do one, teach one.

The interns here run the show- so they are newly qualified doctors at Fy1 level equivalent in the uk- they are a lot more hands on as medical students but still don't have much experience.  They will look after labour ward, do c-sections and see new patients all with little or no senior input.  The senior interns ( 3 months into the job) will often teach the new interns how to manage patients and also often how to operate, so i have been trying to teach while on labour ward and help them with c- sections as well as just generally supervising them a little more so that bad habits aren't passed from one intern to the next.  They also have no organised/ planned teaching sessions. 

So i've been thinking of organising intern teaching sessions and had one today which went well :) Iam basing my teaching sessions on the Life saving skills- essential obstetric and newborn care course run by the liverpool school of hygiene and the RCOG.  We started today with Basic life support/ resuscitation- basic but hopefully these skills and future sessions will help save lives :) It would also  be good to get the midwives involved too- if we learn together we may work better together as this is a real problem.   Here's hoping they find it useful and that future sessions go well! 

pre-eclampsia

Pre- eclampsia and eclampsia account for 10% of maternal deaths in Malawi.  The prevalence in the hospital i'm working in is very high and i see the worst cases as its a referral center so on several occasions they come after they have already had a fit- my old consultant who is a pre-eclampsia expert would love it here! 

For the non medics amongst you - pre eclampsia is a condition in pregnant women ( thought to be related to the placenta) which presents with high blood pressure, protein in the urine ( caused by problems in the kidney) and oedema.  It affects both mum and baby and at its worst can cause fits/ seizures in the mother and even death.   It also affects baby, sometimes they stop growing, and the fluid around them is reduced.  when and how severe preeclasia strikes varies- sometime it can be very early and very difficult to control so the only cure is delivery and this can lead to very premature babies being delivered.  There is also a condition called abruption which can be linked with pre-eclampsia- this is when the placenta detaches and the mother can bleed very heavily and the baby can die inside.

I have seen all the complications of pre-eclampsia here,  fetal growth restriction and still birth, abruption and eclampsia which is very rare in the uk.

Although you cant predict who will get it there are certain risk factors which put you at greater risk like older mums, first time mums and those with multiple pregnancies.  Pe-eclapsia often doesnt have symptoms until it is severe so we have to depend on screening tests to detect this condition.  During every antenatal visit we are meant to  measure the blood pressure and dip the urine so that we can detect it early and start treatment before it becomes severe.   I noticed that this wasn't really being done, so decided to have a closer look.  I went through all the antenatal notes of the mothers on postnatal ward all 50 of them and looked to see if their bp had been checked.  Only 3 women had their bp checked at every antenatal visit, 5 had their bp checked once and the rest didn't have any despite the average no of antenatal visits being 3-4.  of these mothers 5 presented with severe  pre- eclampsia on admission and 3 with eclampsia. 

A simple thing such as checking bp could have detected problems earlier which would have resulted in much better outcomes for mother and baby!.  However im told that some of the health centers don't have bp machines or they are broken and even in this big hospital we  are always running out of urine dipstick and there isn't a bp machine for the postnatal ward and they have to keep borrowing the one on labour ward so the bp's are not checked as often as needed and so some people have a seizure after transfer to the ward.  Its often simple things that can make the biggest difference!



simple life saving equipment.

Happy new year!

A Belated Happy New Year to all my readers.  May 2013 see mothers everywhere have a safe happy pregnancy and delivery.  May maternal mortality be a thing of the past!