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! 

The three delays

Preventing maternal mortality and morbidity is often looked at using the three delays model, it is thought that reducing/ preventing these delays will substantially reduce maternal mortality.  These are  delay in seeking care, delay in transportation to healthcare facility and delay in receiving treatment at the facility. The 3 delays are all closely linked, and all need to be targeted to reduce maternal death and disability.

I've just finished a busy 24hr shift and two mothers stick in mind as perfect examples of this. 

The first mother was at a health center, she had been fully dilated at 9 am in the morning,  4 hours later they decided that she should have delivered by now and so referred her to us ( you can say that this is delay no.1- as it should take about an hour in those who have had babies before to deliver ), it then took a further 3 hours to transport her to us as there was no transport available.  So on arrival she was dehydrated, and was now fully for 7 hours!  When we listened to the babies heart is was beating very slow so we really needed to deliver fact.  The babies head was low and also showed signs that it had been there awhile, unfortunately it was in an awkward position  but we managed to do an instrumental delivery with difficulty.   Unfortunately the baby did not survive. 

The  second mother went into labour at home and delivered a baby at 11am without complications- however the placenta would not deliver and so eventually she went to a health center (3pm).  After assessment  they realised that she had twins (she had not attended antenatal visits so this was undetected) and the second baby was yet undelivered, on top of this the umbilical cord had prolapsed ( this is obstetric emergency as the pressure on the cord prevents oxygen reaching the baby causing fetal death- at this point the cord was still pulsating indicating the baby was alive.  ) And to prove bad things happen in threes she was also bleeding heavily as the first placenta was detaching, she was referred and reached us at 7pm- again transport being a problem.  It was clear at this point that she had lost a lot of blood, her clothes were soaked, her Bp was low and pulse high and we started resuscitating her with fluid.  Unfortunately the cord had now stopped pulsating, but luckily she was still fully dilated  and we could do a quick breech extraction to deliver the baby, followed by the placenta which settled her bleeding.   She still looks pale this morning but is doing well- it wouldn't have taken much more bleeding before the outcome would have been much worse.   So delay in self referral to a health center, delay in appropriate care- she did not receive fluids and no measures were taken with the cord prolapse, and delay in transport  caused a fetal death and could have caused another maternal mortality. 

Perinatal mortality

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Every morning we have a handover where the last 24 hrs statistics are reviewed for every ward and special cases discussed both as a learning point and also to help in patient management.  I am always surprised by the postnatal ward summary- it normally goes something like this:  on the postnatal ward we have 70 mothers 40 of whom have their babies with them.  My immediate thought is -what happened to the other 30 babies, they go on to say 15 babies are in the nursery/ nicu- and run threw the stats e.g 3 for birth asphyxia, 4 for prematurity etc. but there is still always a percentage unaccounted.  These are the babies that have died fresh still birth, macerated still birth and early neonatal deaths and its easy to see why these occur.

 It is too late to do anything about the macerated still births once they reach the hospital, the mum presents and already there is no fetal heartbeat detectable and hasn’t been for a few days, sometimes this is because of the distance the woman has to travel to reach the health facility by which point it is too late, but it is also due to poor patient education and the women not knowing to be vigilant for reduction or changes in fetal movements which could indicate problems and lack of attending for antenatal care so early problems aren’t detected and addressed . 

The bigger problem however and one that we can do something about are those babies who die within labour.  Imagine carrying your baby for 9 months coming to hospital, going through a long labour only to deliver a stillborn baby and be told that your baby has died- it must be heartbreaking!   The guidelines are that the fetal heart should be listened to every 30 minutes in the first stage of labour and every 15 minutes in the second stage of labour- this is often not feasible with the large patient load and staff shortages and sometimes the fetal heart is only listened to once or twice in labour, and so fetal distress is missed and poor outcomes common! 

If anyone has any suggestions as to how to improve this with limited resources please comment below.  I have been using the student to help, which has worked a little but they aren’t always around.  I also bought a CTG machine with me which I thought could be used for high risk patients after some training and excitedly tried to use it once but came to plug it in only to realise the sockets were broken and didn’t work. I also need to think of ways to motivate the midwives as i'm sure more can be done within the same system, it must be difficult when you are over worked and payed so little and poor outcomes are so common to not get complacent and just take it as the status quo especially as there are almost no repercussions. 

Malawi is actually doing quite well at reducing its child mortality rates but   neonatal mortality still makes up 32% of the under 5 deaths and may hinder in achieving the millennium development goals.   A high Perinatal death rate is actually an indicator for poor obstetric care within a country and this is clearly seen here. 

On deaths doors.

She came with abdominal pain and bleeding, drowsy but rousable and a pulse of 130 she wasn’t looking too good!   She was 37 weeks pregnant and all was going well till the day before when she started feeling dizzy then the pain and bleeding started- I kept asking her how she was feeling and all she could tell me over and over was – I am not fine, I am not fine!  She wasn’t bleeding too heavily anymore but unfortunately we couldn’t find the fetal heart beat and confirmed by uss that the baby had died.  When we did her blood test we found she had a Hb of 4! For the non-medics normal is above 10.  So it was obvious she had lost a lot of blood and was probably anaemic to begin with as most women are in Malawi.   Her abdomen felt hard and I thought she had an abruption- this is when the placenta starts separating and can lead to catastrophic life threatening bleeding.  Thankfully we know these women deliver quite quickly when labour is stimulated so we started resuscitating her with fluids and were lucky to get some blood which we stated giving her during the labour.  We were prepared for a Post partum haemorrhage, which is also common in these scenarios and managed it quickly and actively so as to limit the amount of blood loss, this could have all ended very differently had she delivered at home or not got to the hospital in time. 

This is why it’s so important to deliver in a health facility with doctors and midwives experienced in emergency obstetric care, without which this woman would have surely died.  I went to see her the next day and she told me with a smile- I am fine :)

Queen Elizabeth Hospital

I am working at queens, it is a big tertiary referral hospital, and they receive patients from all the surrounding districts.  The delivery rate is around 12, 000 per year the majority of whom are high risk - this is unheard of in the UK.  With this number of women the department still only has 3 consultants ( 2 are leaving soon :( ) , 3 registrars and 5 interns- newly qualified doctors.  There is also a shortage of midwives and nurses on the wards which are often flooded with patients,  because of this shortage patient care is often compromised and maternal and fetal death are no strangers here.  As well as clinical duties the department also has to teach the incoming medical students who are the doctors of the future- this is the main teaching hospital in the country.