Friday, March 20, 2015

Maternity Ward

****DISCLAIMER: This blog may not be appropriate for young children.  There are no graphic pictures, but labor and delivery is discussed.****

No, the ship does not have a maternity ward.  However, the local hospital, Hopital Be, does.

There is one large hospital in Tamatave - Hopital Be.  Even its name means Big Hospital.  This is one of only four teaching hospitals in the country.  There is another smaller hospital in the area, but it offers very few services.  The majority of people needing a hospital go to Hopital Be.  As part of our capacity building programs, we partner with local doctors and nurses offering mentoring programs, education, evaluation of medical practices, and more.

We never go in and tell hospitals how they should run.  Instead, we let it be known that we are willing to partner with local facilities.  Hopital Be invited us into their hospital.  Medical teams went into the hospital, spending time in each ward, learning what resources are available and what practices are being followed.  In addition, our local nurse educator, Amy, surveys the nurses to find out what areas they feel could use improvement/education.

In Hopital Be, we have being focusing on one ward at a time.  Right now, I am working with the maternity ward.  There are about six nurses onboard with labor and delivery experience.  There are four local midwives involved in the exchange program this year.  The midwives here, or Sage Femmes, do everything.  There are no maternity nurses.  The Sage Femme admits a patient (though their history and physical is practically nonexistent), starts an IV, determines which medications are given, gives the medication, delivers the baby, performs newborn resuscitation, and makes any repairs to the mother.  There is a gynecologist that is consulted only for emergencies.

So, how can we have an exchange program when we have no maternity ward?  Well, the midwives spend time on the VVF/Gyn Ward.  In this ward, about 90% of our surgeries are vesicovaginal fistula repairs.  The other 10% are rectovaginal fistula repairs and gynecological surgeries, such as a hysterectomy or repair of prolapsed uterus.

Almost all VVFs and RVFs are a result of obstructed and prolonged birth.  The midwives see firsthand the damage that can occur.  I worked with a midwife, Evelyne, this past Tuesday.  She was surprised at how many ladies were on our ward - about twenty at the time.  She was even more shocked to learn that there are about 50,000 women living with VVFs in Madagascar.  She witnessed the beginning of the long process of healing.

Each Sage Femme will spend two days on our ward and another day following a single patient on the day of surgery, including observing the surgery.  Each Mercy Ship nurse will spend two days in the maternity ward at Hopital Be.  Yesterday, Thursday, I spent the day there.  I witnessed three births and observed one hysterectomy in the OR.

The health care system is so very different than any first world system.  The patient or their family must provide all the basic medical equipment and medication.  Women are given a list of recommended items to be purchased.  This list includes the following items: IV cannula, medical tape, IV tubing, IV fluids, several syringes and needles, Oxytocin (uterine stimulant), corticoid steroid, dexamethasone (anti-emetic), latex gloves (for the nurses to wear), alcohol (to swab areas of IV site and injections), cotton balls, linens (for the patient's bed), towels, laundry soap (for the nurses to wash their hands)...and it is possible that I have forgotten something from the list.  The equipment that the hospital has includes a baby scale, a suction machine (for vacuum and nasal suction), and a cardiotocograph machine.  The cardiotocograph machine measures fetal heart rate and contractions, though they do not have the paper to monitor contractions.  For an additional fee, the Sage Femme will listen to the baby's fetal heart rate with the machine.  If you do not have the money, which most patients do not, the Sage Femme will use a fetal scope.  This is a fetal scope:

I found this picture online of a suction machine.  The one on the left is very similar to what is on the maternity ward here.

The ward has outdated equipment, except for the cardiotocograph which is a newer donation to the ward.  However, if it breaks, there is no one who is trained to fix it and no easy way to get parts for the machine.  Also, many of the practices are outdated.  In some cases, this is due to ignorance.  In other cases, it is due to a lack of resources.  For example, the acceptable method for stimulating the newborn immediately after birth is pouring alcohol on the baby's chest so he will breath the fumes - sort of like a smelling salt.  Or the Sage Femme will hold the baby by the feet, upside down, and vigorously slap the feet several times.  Or a suction catheter is inserted deeply into the baby's nose and nostrils several times and wiggled around.  This are not practices recommend in the US.

Another example...The nurses expressed a lot of interest in learning neonatal resuscitation.  Twenty to twenty-five Sage Femmes, OR nurses, and pediatric nurses have attended our neonatal resuscitation class.  We will be holding another one or two classes in the next few weeks.  In the class, the Sage Femmes stated that they did not have a neonatal resuscitation mask or bag.  Mercy Ships was able to donate two bags and masks.  After one delivery, the baby was not breathing, and Franz, a Sage Femme who attended our class, used the bag and mask to revive the newborn.  It was awesome to see that she was putting into practice what she learned.

I look forward to continue working with the Sage Femmes and, hopefully, helping to provide education that will improve their practices within their resources.

I must say that the Malagasy women are amazing.  They have no epidural, no pain medication at all, yet they do not utter a sound during delivery.  I do not know if it is culturally inappropriate to do so or if it is because the Malagasy are a stoic people.  Even when the Sage Femme performed an episiotomy (cut the perineum), no sound was made.  When the Sage Femme was stitching a torn cervix, the mom grunted a single time.  They are so amazing!

To close, I want to share an interesting Malagasy custom I learned about yesterday...if a man sleeps with another while his wife is pregnant, it is believed that she will likely have a complicated labor.  However, if the husband wraps his clothes around his wife's belly during labor, it is said to ward off complications!

Sunday, March 1, 2015

Not Your Ordinary Plastic Surgery!

We have just finished almost two months of plastic surgery!
For those of you who are put off by the words "plastic surgery," do not be alarmed!  We are not performing tummy tucks or nose jobs.  Our plastic surgeon, Dr. Tertius Venter, helped many patients by performing a variety of surgeries.  With each patient, I will explain the types of surgery performed.

This is Ben Ali - he totally captured my heart!  He is a two-year-old boy who got burned over a year ago.  As the burn healed, the skin contracted.  Rigid scar tissue formed over the arm, elbow, and wrist.  His right arm contracted, and he was unable to straighten the arm due to the scar tissue.  In surgery, the scar tissue was removed and the arm straightened.  A layer of skin was removed from his thigh and placed over his arm over where the scar tissue previously laid.  The thigh, his donor site, and his arm, the graft site, are closely monitored to ensure that the wound is healing properly.  At a certain point in the healing stage, a physical therapist started working with Ben Ali to use and strengthen the muscle and tissue of his arm.
Once his wound was healing, Ben Ali was trying to use his arm more and more so physical therapy gave him a splint to keep his arm straight.  It was torture for a young boy!  He only took it off for his physical therapy (PT) exercises.
But he did not let the splint stop him from having fun!

The surgery to release a burn contracture has two purposes:
First, to restore function to a limb.  Ben Ali will have so many more options with two fully functioning arms.  One day, he'll be able to provide for his family.
Second, to restore normalcy to a person's look.  Dr. Gary Parker said it best - we believe that a person has the right to look human.

Meet Melina.  She had an extra digit on each toe, protruding at a 90-degree angle from her foot just below the big toe.  The only shoes she could wear were flip flops!  She was not able to hide her deformity.  This simple operation took away the extra toes along with any sense of shame she felt.  You can see the suture line on her right foot.

This little man is Finoana.  He is a five-year-old boy who was born with syndactyly.  This means two or more of his digits were fused or webbed.  In his case, the fourth and fifth digits (ring and pinkie fingers) on both hands were not separated.  In the OR, a small skin graft taken from his groin, the crease where his leg and torso meet.  The skin was placed in between the newly separated fingers.
He had a very big personality for such a little boy!
Florence is a nine-year-old girl who had spilled boiling water on her foot many years ago.  As she grew, the scar tissue remained stiff and prevented the foot from developing properly.  As the unburned tissue grew normally on the sole and sides of her foot, the burned tissue on top of her foot remained rigid.  She was not able to walk normally.  Like many people do when faced with a handicap, Florence adapted to her less-than-normal foot.  She could walk.  However, she was not able to bend her ankle much and her toes were fused together.  As she would continue to grow, the foot would continue to deform.  Perhaps later on she would have a pronounced limp, perhaps not.  Like the first patient discussed, Ben Ali, Florence also had a skin graft taken from her thigh and placed over the top of her foot where the scar tissue was removed.  She has been here on the ship for almost two full months now!  Her wound is healing slower than most, but recent reports are very positive.  She can go home soon...

This is Landrino.  He first appeared in the "Back to Work!" blog from November 2014.  Here he is waiting in line during screening.
Landrino was burned along the left side of his body.  During the operation to release the burn contractions to his hand and foot, Dr. Tertius also removed the keloids on his ear.  A keloid is a growth of scar tissue formed after an injury.  Landrino, his mother, and his sister have captured the hearts of all the nurses.  Here is Zuela, his young sister:
The Rakotoniriana twins each had extra digits.  One on the left hand and one on the right hand.
Here is one of the girls as she reaches for a toy during PT.  You can see where the surgeon removed the extra digit near her fifth, or pinkie, finger.

Below is a collection of photos from some more of our patients, both pre and post op.

Because the wounds take a long time to heal, our patients become good friends.  We have a lot of fun with them, both on the wards and outside.  Every day, the patients get an hour of playtime outside.