Tuesday: Obstetrics

The UN Millennium Goals were devised in order to try and tackle some of the really pressing problems occurring in the middle/lower income countries. 

One of the eight which anaesthesia is very much a part of is goal number 4: Reducing child mortality and 5: Improving Maternal Health.

                                    http://www.un.org/millenniumgoals/maternal.shtml

The MMed programme and ZADP programme has been key in helping set up, run and teach the SAFE Obstetric courses (the third one is due next week) alongside Zambian MMed trainees who will become the teachers of the future and will continue to run the courses long after us ‘foreigners’ have left! This teaching is key to the on-going safety of anaesthesia to pregnant women and reducing maternal and neonatal deaths especially out in the rural areas of Zambia where the only anaesthetist might be a non-docotor, non-nurse practitioner. Which is just as well as currently the Neonatal Mortality Rate is 34 per 1,000 live births (compared with 4 per 1,000 in the UK) and the Maternal Mortality Rate is 591 per 100,000 live births (12 per 100,000 in the UK). 

Helping with teaching with the MMed trainee Hazel at the first SAFE Obstetrics course

  However the courses are a total team effort but are totally indebted to the sweat, blood and tears of one key man in particular: Dr David Snell, who is in his second year out here running the Zambian end of the Mmed programme on behalf of Prof Kinnear in Southend. David and I started at UTH on the same day and we laughed, cried, shared frustrations and successes over a six month period when I was last out here.  However he and his wife Kaly (who is also making strides with palliative care out here) and two boys have made the amazing commitment to staying here for two years which has brought great continuity of care to the programme and they will be really missed when they leave in July.  A truly selfless couple.

So the SAFE Obstetrics course is going strong, and long may that continue but what is currently interesting to me right now is how are we doing at UTH? So, Tuesday saw me mosey on down to the Obstetrics theatres to see what was what!

Not too much has changed:

Porter folding'sterile' swabs

The nurses and porters are still busy washing and folding the linen to be used as sterile drapes as well as folding the swabs neatly into piles before they get sterilized – which is why often, there is a shortage of swabs or drapes at the end of the week. And often why there is such an infuriatingly long wait for the patient to arrive if the porter is busy folding swabs!

  

Folding 'sterile' linen in the corridor

 The patients relatives also still do their washing and hang the colourful chitengi outside to dry when the rains stop. And inside the airway equipment is still reused and soaked in a bucket full of chlorine to disinfect before they are scrubbed and reused on the next patient due to poor resources. 

The recovery is still too small. It has the capacity really for one person though it usually has two women in there side by side being momitored just with the use of one pulse oximeter donated by Lifebox (which I am sure I will talk about in later blogs – but basically a machine that reads the oxygen levels in the blood and gives the pulse rate too, which is really the very least amount of monitoring you’d expect after an caesarian section. 

Recovery room

 But the surgeons are very quick – they have to be when you see that there is a board full of names of people that need urgent operations and only one theatre….

4 names on the board indicating two women that are failing to progress well in their labour (one lot are twins) which generally means by the time they come to theatre there is foetal distress. There is another that has documented foetal distress - basically the baby's heart was very low and then another who needs a caesarian because of a large baby secondary to the mother having diabetes of pregnancy (but also having pre-eclampsia too)... A board of women that would be fairly urgent to do back home - likely to have to wait a few hours here...

But other things have changed for the better: 

We now actually have not only 2 and 5ml syringes but also 10 and 20ml syringes which makes drawing up drugs so much easier. There is a dedicated cupboard for the storage of equipment for anaesthesia in the back of the neonatal resuscitation room (started my colleague Rachel who followed me in the ZADP programme and consolidated by Emily – the current ZADP registrar). This makes restocking and getting and finding stuff in an emergency so much easier. The Mmeds are working really hard and are making good decisions of when to operate and when they need to ask for different tests to be done/blood to be brought before they start. All of which is certainly contributing to safer maternal health. And also my colleague Emily has recently been involved with some of the MMeds and also the Obstetric team in a multidisciplinary approach to writing new guidelines for pre-eclmapsia and major obstetric haemorrhage.  All great strides for improving the service offered to mothers at UTH.

Anaesthetic storage area in the neonatal resuscitation room

  
However my day was pretty eventful as would be expected. Two very urgent cases with the first one a placenta praveia which was severe and likely to bleed a lot – sporting to say the least when there is only 1 unit of blood available to transfuse in the event of a major haemorrhage.  Thankfully the surgeons were incredibly swift in their operating and the blood loss was minimal – still it would have been good (and less stressful) to have had a few more units at the ready.

 The second was an extremely urgent case due to foetal heart rate being very low. In fact it was so low when the baby was born that she needed resuscitation. The midwife recognized this very quickly and thankfully asked for help early, so it was a good opportunity to show and talk through and teach some neonatal resuscitation as my fellow MMed trainee was looking after the mother. Luckily for us the baby was resuscitated with some rescue breaths (5 big breaths to open the lungs) and some help with her breathing until she decided that she was going to join the party and do it herself! I’ve never been so relieved as unfortunately here the special baby care does not have the ability to ventilate little babies like this and even if I had placed a breathing tube  (if she’d needed it) unless her relatives sat by her bed and breathed for her pressing the bag she wouldn’t be able to survive.

 And her survival instincts must be high as after we had managed to resuscitate the baby I returned to the operating theatre to check on the mum and left her in the capable hands of the midwife (or so I thought!). On wandering out a bit later I found the baby lying – swaddled in the thickest of blankets in the heat of the day (30C!) with oxygen propped up against her via a ventilating bag. No sign of the midwife anywhere, but at least I guess the baby was kept warm and that she had considered the use of some oxygen, despite its delivery method not really working! However the good news is that the mothers and babies of both cases did well and went home two days later.

 So all in all I think that there are some very positive aspects coming from the Obstetrics theatres. There are many that need further input and others that are still frustratingly difficult to change. But I do see that we are making progress even if it is pangono, pangono…. Slowly slowly (Nyanga!)