#3- Maternity care and clinic week

July 18th, 2018 by edwardchristiansen

I like delivering babies…there I said it.  So much so, I did an obstetrics track in residency and delivered as many babies as I could.  One of the major wishes I had when I arriving was to have the opportunity to see the differences in obstetrics here in comparison to “the states.” To start, all the vaginal deliveries here are done by the midwives/nurses.  Every single one!  Instrumentation is hardly used and the “ceasar” rate(remember that means c-section) is higher than one might think!  What did this mean to me; no experience actually delivering any babies aside from c-section.  Instead, my week was full of other teaching moments!

 

The first day began with some surprises.  I arrived and met up with Dr. Myeni.  A soft spoken, brilliant young physician who had done much of her training at Mseleni Hospital.  I asked where we would start rounding and her response was in the neonatal ward.  Neonatal ward?  This hospital had a neonatal ward?  In fact, they have the capacity for 3 incubators and 3 neonatal beds.  They manage babies 25 weeks old and later here!  They have capabilities I was not expecting.  I saw a 29 week old IUGR(intrauterine growth retardation- AKA a small baby even for being born so early) that weighed 800g when born.  For all my American friends who refuse to switch to SI/metric units, that’s 1lb 12oz.  Over that week, the baby was gaining weight and was being weaned slowly from O2.  Another sick baby was one with sepsis from an unknown source.  The baby had been on the normal antibiotics(ampicillin and gentamycin) and had worsened.  The neonate was placed on imipenem and had been improving.  Throughout all the acuity, the gadgetry, and foreign doctors surrounding these young mothers of severely ill children, it was joyous to see them ALL breastfeeding and doing kangaroo care.

 

After we would round on the ill neonates, we would head to the next ward where ill antepartum(still pregnant) patients were being housed.  The normal pre-eclamptics, possible early gestation SROM’s were there and stable.  The last female was not anything like I had experienced prior however.  If my nonmedical friends and family will indulge me a few sentences, I promise to explain in better terms following the medical jargon. 🙂  She was a 17 yo G1P0 at ~29wga PMH RVD on HAART, hx of cryptococcal meningitis s/p treatment who presented back to clinic with worsening headache and found to have a re-exaccerbation of cryptococcal meningitis.  Dr. Myeni and I looked over her chart finding her to be relatively stable with a normal daily NST. NONMEDICAL TRANSLATION AS FOLLOWS: A young woman with her first pregnancy, with HIV on medication to control her disease, and in her 3rd trimester has a serious infection in her central nervous system requiring heavy duty anti fungal medications! Now back to the story…Dr. Myeni said she was on amphotericin IV and would need to finish 14 days.  Amphotericin?  The only thing I remember about this horribly strong medication was a mnemonic device from med school; this medication is “ampho-terrible” with side effect reactions during infusion!  It turns out with the rates of RVD, this medication in combination with fluconazole is commonplace! By the way, amphotericin is Cat B! 🙂

 

The following day, we arrived to the neonatal ward to find all the babies oxygen sats falling.  As I was looking for reasons, I made the discovery the O2 outlets were not working.  Constant power outages plague the developing world and we had multiple that morning.  I quickly asked if we had extra O2 tanks and a few of the nurses went out to attempt to find some.  They returned with 1 large metal tank and 2 nonfunctional smaller ones.  After finding these were faulty, I asked for the nurses to continue searching for some while I hooked up our sickest baby(our aforementioned 800g neonate) to O2 and quickly stabilized him.  This was done successfully and eventually, the nurses returned with some workman rolling O2 tanks to set up.  It felt good to get things done!

 

Following rounds, Dr. Myeni and I left for clinic.  Only about 20-30 minutes away, it was still lovely to see some of the countryside. As we arrived, we went to a back consultation room where patient after patient opened the door.  They all carry there own medical records!  There we 3 cases which stood out throughout the week and I will mention them here:

 

• 45yo female with newly diagnosed RVD and not yet on ART has had 1 month history of mild abdominal pain, some nausea/vomitting, and non bloody diarrhea.  She was back for a check up following a stool culture.  This revealed necator species or hookworm!  Treatment is mebendazole 100mg PO BID x3 days and iron.  That’s because these creepy-crawlies deplete your ability to absorb iron from your diet.  That’s not one you see everyday in the US!

 

• 28yo male with no PMH who was hospitalized following MVA/hit and run in Durban with no noted fractures found presents in a wheelchair for continued inability to move his right leg and pain.  He brought his hospital X-ray where a mid-femur and knee X-ray were done of the R leg.  These were negative.  I asked if they’d done a pelvic X-ray and the patient said no.  I did!  Hmmmm, I wonder what we found.

 

• 7 month old female presents with mother with bumps on feet that are pruritic(itchy) for 1 month.  The mother notes she saw a doctor and was given a cream which she has used.  She does not remember the name of the cream. Records indicate it was hydrocortisone cream.  The baby is well otherwise.  Physical exam revealed the following…

 

A few data points for those who might be interested:

• Total deliveries in 1 month:  160
• c-section rate:  24%
• HIV rate of mother’s giving birth:  36%

 

*Please note per the CDC in 2016, the U.S. c-section rate was 31.9%.

 

All in all, a great week filled with meaningful experiences and medical/life lessons. Of note, I finally convinced some of my previous flat mates to let me ride along for an outing on the weekend.  They were going to Maibibi beach.  They agreed and off we went in a fellow physician’s 4×4.  Approximately 1 hour later we pulled into a heavily and densely forested area.  We saw some signs that said “Beach” and followed it.

We began walking down some wooden stairs for what seemed like an eternity.

And then….

 

 

 

The water was a bit chilly but I waded in.  Checked out the tidal pools which were rather absent of life.  Beautiful nonetheless. A couple of hours here and I was recharged!  We headed back and later watched France beat Croatia in the World Cup.  A great end to a great week.