Maternity Matters in Madagaskar

This was my first urogynecology patient. She has a total uterine prolapse grade IV. I was able to reposition it and then prodeeded with the usual urogynecology exam. From the anamnesis I understood that the urin loss was occasional from time to time (the prolapse probably helping to reduce this). The stress test was positiv. Urin examination surprisingly showed no signs of infection. This patient is 65 years old! And pretty short. For clarification, Dr. Lovatina standing next to her looks tall in this photo but she is about my height (160 cm). I know at home we would have the ability to offer both a surgical option and a conservative option. Here I can do neither, at least not at the moment. A pessary inserted into the vagina could keep the uterus repositioned. Right now we are trying to find out if something like this can be found here. I suspect not. It would however be a good solution for this very fit and mobile patient.

Just saw my patient Voahirana, my C-section patient from last week for follow-up today.  I removed the steri-strips and was pleased to find that the wound was healing well.  Uterus was well below the navel and the post-partum bleeding was all physiological.  I was quite relieved to see everything healing well, especially compared to the wound care case we have been managing from a C-section done somewhere else.  Below is a picture of my patient and her wound followed by the wound we are hoping will secondary heal despite poor adaptation.  The lower section of the wound is sutured into the subcutaneous part of the upper section so the skin is not adapted.  We are checking it regularly for signs of infection but are hoping this will heal without further intervention.  If she ever has a C-section again, the scar tissue can be removed during this procedure.  For anyone who has a tendency to get queezy please take caution when scrolling past the firs...

Today the day begins with routine scans in the ultrasound room for first trimester pregnancies.  The doctor I’m meant to be teaching is out sick today so its up to me to work with the IT and a different ultrasound machine to determine the date of delivery.  With the help of one of the nurses, communication with the patients flows smoothly.  All this morning seemed to be around the same time somewhere in the 10 th week of pregnancy.  Troubles were had with the program the clinic uses to save the scan information (I’m sure a well written program but my technical skills are well not the best!) After some back and forth things got sorted.  The afternoon was used for a food run to the local market vegetable stands.  We were out of some basics like potatoes, carrots, tomatoes and fruits.  Its not the big market from last week, but we got everything we needed.  My personal highlight was the 1 kg of litchis purchased for 3000 ariary (current exchange r...

Happy birthday dad!  Today you turn 66 years old.  I’m glad we had a chance to talk today (internet and Whatsapp calls do work depending on the weather and given the rainy season it can be difficult).  You are about 20 years beyond the average life expectancy of people here in Madgaskar – it is 47.

While attending the local church for service, Tanja and I were notified by our midwives at the hospital of a patient who came in with strong vaginal bleeding near term.  This patient was not seen in our hospital before so we had no previous history.  Because of the strong bleeding and the fact that we do not have a blood bank here we transferred this patient by ambulance nearly 2 hours away to a larger clinic in hopes that she remained stable and makes it and that the staff and equipment necessary were present at that hospital today (this can be a hit or miss situation).  Hours later we got a message: it had been a placenta previa (not previously diagnosed) with a placenta accreta.  The patient received blood transfusions and required many working hands.  Our team was relieved knowing we had made the right decision and thankful that the blood bank had blood and the staff there were not out sick (they don’t always have replacements, there is simply no one there...

Sometimes the little things remind me that it is indeed a different place than home!  These guys do a good job, I hope they receive good salaries like our garbage men do. I suppose though they prefer payment in food nonetheless :)

Since I have already spent sometime in the operating room, I think it is a good time to introduce you to some of these faces and places Here we are making preparations prior to surgery This includes counting all the equipment and documenting this on our wipe and write board With counting complete, it is time for anesthesia to start The steady hand of Nosy, our nurse anesthesia Behind the screen of our anesthesia work space.   Note to self: I should remember my posture while operating more:) Or ask to have the table turned up (those shipwheel look alikes just under the head of the patient need to be turned to mobilize the table)

This was how my Friday began today at 3am. I was called for a IG 0P at 38+4 who is 154 cm tall and had a baby with an estimated  weight at about 3100g. Not large for European standard but when the average weight of a baby at term here is 2500 g it puts it into perspective. The above partogram is what the midwives use to see the progress of delivery. In the image a line is crossed that suggested a stagnation in the birth process (not what I would consider stagnated but ladies here proceed very quickly so anything taking longer than 4 hours is suspicious) We started with Oxytocin to help along. By 6 am we had 9 cm dilation. The head presenting in anterior asynclitism or naegele obliquity. Using change of position, stopping of oxytocin and rotating the lady on the side the baby had a chance to turn into a more convenient position before restarting oxytocin. Success. Finally a hard delivery and then shoulder dystocia! Gaskin maneuver (patients are extremely mobile) and del...

This Wednesday night started with a primi para at one day over term (40+1) and a very prolonged delivery. She had been induced since the day before with signs of preeclampsia and her water broke in the evening. It was green. Given there were no further signs of infection (temperature or a tachycardic baseline) we waited as she developed contractions. Towards midnight dilation had come to a standstill and oxytocin was started. She fully dialed by the early hours of the morning but the CTG started showing signs of fetal distress. The indication to do a c-section with a pathologic CTG was made and off to operating theater we went. Operation went well but the baby showed signs of infection already at delivery and needed ventilation, CPAP as well as chest compressions for some minutes. My highest respect to our nurse anesthesia, Nosy, who took care of the mom while I operated.  Nosy also managed to put a tiny i.v. in this newborns hand that needed antibiotics, fluids and glucose. We d...

This is how we spend lunch time. Every day the cooking staff at the clinic prepares a meal for us. There is always a big pot of rice in combination with vegetable and meat cooked over an open fire.  Lunch with my colleagues including 2 volunteers from Germany. Anna on the left (an operating room nurse) and Elena on the right (a dental assistant). It's always plenty of rice for everyone so nobody leaves hungry.

Tonga soa, welcome!  My name is Lisa and I am gynecologist currently spending a few months in Madagaskar to volunteer in a small clinic in Ambovo with an organization called Mobile Hilfe Madagaskar.  I have a wonderful team and a kind boss I work with at the Donauklinik Neu-Ulm that have enabled me to take some time off from my job to do this project. For more information on the organization and the work that is done here you can visit the website and their facebook profle here: http://www.mobile-hilfe-madagaskar.de/index.php/de/ https://fr-fr.facebook.com/pages/category/Women-s-Health-Clinic/Mobile-Hilfe-MadagaskareV-137530603016376/ It has been a wish for a while to do such a project and so I will try to share a little piece of my experience here from time to time.  I work with local midwives and some general doctors as well as other volunteers to take care of the patients that come here.  My main job is in the obstetric department, acting as a guide...