A Travellerspoint blog

Neonatal care

sunny 26 °C
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Neonatal care is somewhat different to our model!

Firstly, here we are often not knowing what to expect when the baby arrives. There is no such thing as a CTG and the baby is monitored in labour using a doppler (assuming it is working, otherwise a good old fashioned pinnards!) Meconium is common, although it seems more related to the high incidence of post-term (yes, actually post-term and not post-dates) rather than fetal distress. Despite this, relatively few babies come out flat and rarely do they require active resuscitation. The commonest intervention is suction with a most unusual plastic apparatus. I couldn't find one today to photograph but this is the 'resus cot':

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The baby is generally delivered onto the mother's abdomen; but really only for convenience rather than any attempt at 'bonding'. There is no delayed cord clamping, although I have seen the occasional midwife strip the cord towards the baby which I guess has a similar effect. It is whisked off to be checked, weighed, given Vit K and then has tetracycline ointment rubbed into its eyes to prevent a gonorrhoeal or chlamydial infection. It's wrapped in a colourful blanket and given to a family member until it's mother is back in her bed on the ward. I'm thinking this type of practical management would not appear in one of our extensive birth plan at Murdoch?

Despite all this, the baby is usually on the breast within 1/2 hour and generally seems to suck happily from the outset. I will talk about breastfeeding in a future post. The baby is then cared for by the mother and family members, although the midwives keep an eye on it, do regular obs and assist with breastfeeding if necessary. The baby stays swaddled and sleeps in the bed with its mother. They all co-sleep!

I've fortunately not been so far involved in many neonatal resuscitations. The equipment is basic and there are no facilities to provide ongoing care for sick babies. These babies are shipped out to the nearby government hospital which I'm told also doesn't have much to offer.
Recently we had a baby born initially healthy but required oxygen to stay pink. The mother's 2 previous babies had died at 4 and 5 days of age from an unknown cause. We sent the baby off and it lived at least 5 days before we lost contact with the mother. Obtaining any ongoing information is very difficult.

As most women are discharged after 6 hours, there is little followup for the babies. I gather the mothers are encouraged to return on 'vaccination day' and then the babies can be checked if necessary. Small babies such as my 1.7kg twin will not be discharged until breastfeeding is established and the baby has gained weight. Sometimes babies are brought back for checking if they are at risk. I am rarely consulted with regard to neonatal issues (which is probably a good thing!).

Sorry not many photos today. But here's a horse that happened to be wandering up the street as I walked home:

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On a personal note......last night on my way home from the restaurant, I tripped and covered my newly washed (and ironed) trousers in mud. Not happy Jan!! So, I have made use of the sun today, boiled the kettle and found some Omo........who is impressed?

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After a lot of creative investigation, I have discovered that some of my friends were on the right track with the Facebook issue. I will not go into it here but, suffice to say, I seem to have got around the problem (at least for now). Sadly, my other issue (cold shower) is not solved. I'll keep you all posted but I'm not expecting a miracle!

And so endeth my first week alone in Barhirdar! I have survived relatively unscathed. Although the hospital has been overall busy, my services have not been greatly needed and there have been no major disasters. I admit there have been some stressful moments and times I would have loved some advice or reassurance. But, overall I am coping well and feel confident about the coming week. Having said that, I'll be very relieved to see Marjolein return on the 18th!

Posted by gunny64 11:06 Archived in Ethiopia Comments (3)

A quiet Saturday


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It has not been a good day. I awoke to no power, no hot water and no Facebook! The electricity returned in time for me to at least get my morning coffee fix but the other 2 essentials are still absent. The Facebook issue is particularly mystifying. I have internet access and every other application on my phone works fine. I've updated, reinstalled, turned my phone on and off and tried to login directly from the website to no avail. Jenny is able to still access the account so I'm thinking it must be somehow a local issue. The major implication is that I can't link this blog post to my Facebook account. It is possible Jenny may be able to do it from her end, however otherwise you will be reading this directly via travellerspoint.com. This will be a brief post just in case nothing works.

It was otherwise a glorious day here in Barhirdar. The sun was out, a light breeze was blowing and it was around 25 degrees. I did a quick round this morning and the hospital has been quite peaceful (although there were 13 deliveries in the previous 24 hours).

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I have finished my 2nd book....a somewhat strange but interesting story of survival in the Australian outback. It has the same feel as one of my favourite books 'Only Ever Yours' and won the author this year's Stella Prize. Worth reading if you enjoy not quite knowing the full story!

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A few days ago my wonderful housekeeper did some washing and removed an enormous amount of mud from my clothing. Some of you will know of my obsession with crease-free clothes. I have been psyching myself up to don the clean but wrinkled garments. Today, to my great delight, I discovered an old but somewhat functional iron. It's the simple things in life that make me happy!

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To make up for my cold shower and absent Facebook, I decided to splurge and go out for dinner. There are 2 exclusive lake side hotels so I chose the closest. The Kuriftu is very posh and it felt really strange walking in to this oasis; so different from my current reality. And there were white people!

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How could I resist beef fillet? And a glass of South African wine? Even fresh home made bread! Cream of corn soup. Ahhhh.....

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All did not go smoothly. It is Ethiopia afterall! The power went out! There was surprisingly only a short time of darkness but I did wonder how rare my beef would end up! As it happened, I needn't have worried as it came out 'well done'. Not how I would normally like beef but it still tasted like nectar!

The second power outage gave me an opportunity to watch the impending thunderstorm make it's way over the lake and to lament the fact that I had forgotten to bring an umbrella! Oh well, a little more cold water won't hurt me (but fresh mud on my newly ironed trouser will)!

Posted by gunny64 10:11 Comments (1)

HIV testing


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I have a few things to say at the start of today's post!

Firstly, thanks to all of you who have sent me feedback on the blog. It was mainly designed for me to have as a record of my experiences so I can look back in the future. However, I am pleased that others are enjoying it and I hope it has opened your eyes to those who are struggling outside our very sheltered western civilization.

I have also received many public and private messages congratulating me for doing this work. I am thankful for your support but also feel somewhat embarrassed and uncomfortable with the attention. I am such a tiny cog in the incredible wheel that runs this hospital in Barhirdar. I have left my comfortable home and well paid job for only 1 month to be a small, temporary help for the staff who actually do all the hard work. Behind this place is an obstetrician (Andrew Browning) who now lives in Africa and has dedicated his whole life to improving the health of women in developing countries. I can't imagine the time and effort it must have taken to get this hospital off the ground; let alone the others scattered throughout Ethiopia and Tanzania. He is the one deserving of our praise.

I am also in awe of the 'career' volunteers (such as Marjolein) who choose to travel the world for many months or years at a time, providing their incredible experience and expertise for little or no salary.

But the real heroes are the local staff. The midwives are hard working, dedicated Ethiopians who deal every day with the risky business of childbirth in their country. They provide an amazingly high standard of care in these very basic conditions with great skill, love and a sense of humour. Each of these midwives has been directly responsible for improving the obstetric outcomes for their fellow countrywomen. I hate to think how many lives have been save by these remarkable people.

Secondly, yes, doing this blog is quite time consuming! My laptop doesn't have Internet access so I have to write each post on my phone. I try to write some during the day and then finish it off at night. However, there will come a day when I am too busy, too tired, have no internet access or can't be bothered. So, please be patient and don't harass me if you miss out on your daily read. Surely the election updates are just as fascinating?!

Today the staff had an Inservice on HIV testing. All pregnant women are tested at their first visit (and then again later in the pregnancy if they are at high risk). Up until now, the test has only been for HIV 1. Recently a whole new batch of kits arrived and these test for both HIV 1 & 2. One of the midwives has been to a training program for the new kits and today taught us how to perform the testing. There is an initial 'screening' kit. If this is positive, a more expensive confirmatory test is then performed. For the sake of demonstration, the midwife was supplied with some artificial HIV positive blood so we could see the various patterns of reactivity.

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I am still trying to get statistics for the prevalence of HIV in this area. It seems to be low and I am yet to see someone who is positive in labour. We had 2 women diagnosed this week, but it is a little artificial as the kits haven't been available and the staff are trying to catch up on testing now that the new kits are here. I will investigate further or find out from Marjolein when she returns.

I will end on a lighter note with a cute anecdote.....

As you have no doubt worked out, this hospital is here to provide high quality free care for the very poor women of Barhirdar. However, there are actually no real restrictions on who is allowed to attend. Most women we see are obviously in a low socioeconomic group, have no idea of their due dates, speak minimal English and are dressed in the typical Ethiopian loose clothing.

Today, out of the blue, in walked a supermodel! She was 6ft, stunningly beautiful, dressed in tight fitting fashionable clothes and high heels. She knew her dates, spoke English and came with an equally elegant female friend. They watched the ultrasound giggling and then thanked me profusely for the consultation. During the entire time, the midwives were eyeing her off and exchanging 'glances'. The moment the 'supermodel' walked out the door, my assistant midwife jumped up, arched her back and strutted up and down the ward wiggling her hips to the riotous laughter of staff and patients. It was hilarious!!

Posted by gunny64 09:55 Comments (4)

Hard labour


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We all know labour is tough but in Ethiopia it is tougher!

The hospital has 12 beds. 10 of these are in one room. Antenatal, postnatal and labouring women are all intermingled. Midwives, students, cleaners, family members and visitors share the small space. There is rarely privacy. If an internal examination is to be performed, the security guard ushers out all the visitors and a small screen is put up to provide some semblance of privacy for the woman. Women labour away in this room day or night until they start to push.

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At this point they are quickly shuffled down to the 'birthing suite' which contains 2 delivery beds. After birthing, they are returned immediately to their bed on the ward to make way for the next patient.

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During labour, the women have no pain relief. It is neither offered nor asked for. Family members provide support (rarely the husbands) and the midwives give care as required. Long labours, vacuums, forceps, manual removals are all stoically accepted by these amazing women. Local anaesthetic is however given for episiotomies and perineal repairs. The ONLY indication for a spinal block is Caesarean.

After a vaginal birth, the women are generally expected to discharge in 6 hours (and most do!). If the birth is particularly difficult, the baby low birth weight or there is some other complicating issue, the women will stay longer but rarely more than 2 days. Yesterday afternoon I assisted a delivery. It was difficult and the woman had a postpartum haemorrhage. She collapsed on her way back to the ward and could not get out of bed overnight. This morning she could barely walk but her loss had settled and she was breastfeeding well. She wanted to go home and was therefore discharged to her extended family with iron tablets. Blood transfusions are rarely considered.

A warning to my midwifery colleagues......you may not like hearing this next bit!
So much fuss is made in our western culture of the importance of an 'active' labour and childbirth. Women are strongly encouraged to be mobile, upright and participatory during labour. The Ethiopian women here (without input from antenatal classes or instruction from well paid Doulas) do none of this! They all lie curled up on the bed for hours on end during their labour and rarely stand up or walk around. When it comes time to push, they almost all lie flat on their back and draw their legs up to deliver in the way we obstetricians in Australia are told is 'unnatural'. And they usually have uncomplicated vaginal births.......interesting!!

On a lighter note, I bravely decided tonight to go out for dinner. Marjolein gave me a list of 'safe' restaurants so I picked one nearby and went out early so I wouldn't have to walk home in the dark and risk getting lost. There was an extensive menu of western and Ethiopian food but the thing that caught my eye was a 'normal burger'. Sadly the waiter informed me that there were no rolls left, although if I wished to wait, he would rush off and buy one. I decided instead to go with a pizza and fries. It was surprisingly good!

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It actually had got dark by the time I finished but I (obviously) managed to find my way home. Walking through the streets at this time was a very sensory experience from the smells, sights and sounds of families preparing their evening meals in ramshackle open houses along the way. It was nice to have my 'whiteness' hidden by the night so I could take in the atmosphere without attracting attention. A wonderful end to another fascinating day in Barhirdar.....

Posted by gunny64 10:39 Comments (1)

Caesarean experience


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OK a warning to my non medical/nursing friends.....I am going to start describing more of the obstetric details in upcoming posts. I'll do my best to keep the language simple but it will be too difficult and time consuming to explain complex medical issues or expand on common abbreviations. If you are really that desperate to understand, consult Google or hunt out a friend who can translate.

I did my 1st Caesarean 2 nights ago. The woman had been in labour for over 24 hours and finally reached fully dilated but the head remained high. There was thick meconium. The midwife attempted a vacuum but was unsuccessful. I then tried with forceps to no avail so the decision was made for her to have a caesarean. This is a major undertaking! The anaesthetic technician and scrub nurse are called. Sometimes the 'ambulance driver' needs to be called first to drive out and pick them up. The technician then does the spinal block. The entire process takes over an hour and there is no point stressing as this is how it is! In fact, one of the memories I hope to retain forever occurred in that hour it took for the Caesarean.

The Caesarean happened to coincide with nursing handover. One of the night midwives had made some fresh shiro wat (a bit like dahl) and brought it in with injera. A huge platter was set out on the table and the food was spread on top. All the staff gathered in the handover room chatting, laughing and sharing the meal. I was welcomed to join them and they explained the food and how to eat it appropriately. One of their interesting customs is to feed each other! They will gather up a parcel of food and offer it to someone else; not necessarily the person sitting next to them. It can be a very messy business! Everyone was so happy and friendly and relaxed. It was one of those 'pinch yourself' moments that I will cherish forever.

Finally we were ready to start the caesarean. There is only one scrub nurse who is on call 24/7 and rules her theatre with an iron fist. She was certainly not shy in telling me what to do (which made it easy for me!).

The operating theatre is a small separate building with absolute basics. Everything is reuseable including the masks and hats. No sign of those awful disposable, environmentally unfriendly surgical drapes! I scrubbed up with lavender scented Palmolive soap which they had to retrieve from a locker. If the soap is left out in the open overnight, it will be devoured by rats!

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I had minimal light (I'll never complain about the crappy theatre lights at Murdoch again), no diathermy and no assistant. The scrub nurse, however, was a very capable assistant who tried to take over several times when I wasn't doing what she thought I should. Fortunately there was good suture material and it did not seem to be in short supply (no doubt I would have been chastised if I'd used more than my quota!). Despite all this, the procedure was uncomplicated and out came a very grumpy but totally healthy little cherub.

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Postoperative care is somewhat confronting. The patients are simply popped back on their bed in the open ward with everyone else. They are not offered (and seemingly don't ask for) ANY pain relief. They are out of bed the next day and expected to be ready for discharge 48 hours later (although it seems this can be negotiated out to one more day if there is no bed crisis). Of course, they have a family member with them all the time to look out for them and care for the baby.

I did my 2nd Caesarean this afternoon. I'm almost at my quota for the month! Jokes aside, I'm told the caesarean rate is less than 5% at our hospital. I'll double check this and get back to you with an accurate figure. They are mostly done for failure to progess and it is this indication that saves women's lives and prevents devastating fistulae. My caesarean today was one of these! The woman had been in labour for 36 hours with the babies head in a transverse position and wedged in her small pelvis. Without our ability to provide her a safe caesarean, it would have been a terrible outcome. This is what it's all about!

Posted by gunny64 09:01 Comments (2)

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