28.01.2020 Good things comes in threes (Part 2)

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 rateabout 71 cents!!!)  For this price I think I could buy about 5 litchis in Germany 😊

Litschis!

Returning after a short time away, work continued in labor and delivery (L&D).  We had one patient transferred to us from an external ‘clinic’ because of ‘problems during delivery’.  This case was more difficult because for the first time I was dealing with a patient who had not done all of her antenatal care here.  It turns out this is a huge difference.  Patients that come here get screened for some basics like age of the pregnancy with expected delivery date, previous history and risk profile.  The document this patient brought was anything but useful.  No expected delivery date! Or any other information for that matter.  I was informed that a common belief here (among midwives and clinicians) is that if the baby is still too small, it must not be at term.  This basically means there is no regard for any baby that may be small for gestational age (SGA) or have an intrauterine growth restriction (IUGR)!  The same by the way is true that a baby having reached normal size (Malagasy normal) of around 2500g must be at its due date and will often be induced, nevermind that this baby may actually still be premature.  Teaching the staff here that pregnancy age is determined early in pregnancy and adjusting this only if there is discrepancy of a week or more between expected calculated delivery date and measured delivery date at this early stage was already a huge step in education.  Our coordinator was proud when she realized her trained midwives recognized that the documents from our external patient were not helpful and that there was a problem.  None of the information in this document were any bit useful.  What we got from her anamnesis was that she had been induced already the last two days due to increased vaginal bleeding.  The cervix was still completely posterior and minimally opened.  What kind of induction was done was unclear but we did not continue this. We began to piece together the information as best we could, meanwhile we took the patient to the delivery room for CTG control, rest, fluids and yoghurt (she was emaciated due to malnurishment and completely exhausted).  During the afternoon the CTG began showings signs of pathology, we had no accelerations and a loss of variability with long silent phases.  Glucose 5% over the i.v. helped intermittently but produced no major changes.  Baby movements on the kinetogram were sparse and vaginal bleeding picked up.  We decided this baby would be too week for vaginal delivery and opted for a primary C-section with suspected IUGR and pathologic CTG.  Normally this kind of case would be done at a clinic with a pediatric ward as it is expected that this baby will have difficulty with adaptation (breathing, hypoglycemia, intestinal bleeding).  This does not exist here in the form that many of you will be familiar with.  I was told there is such a ‘ward’ but to summarize: they may have a CPAP, one only and if this is in use you are out of luck.  Then again if it is used there is a pretty high chance of infection.  Thanks to generous donations we have a lot of equipment including an incubator to help stabilize those tiny babies.  A consulting pediatrician in Germany was on call to guide us as soon as the baby was born.  There were a lot of considerations, especially for this unborn baby, as we went into the operating theater for my fourth C-section just this week.  The operation went smoothly.  The baby (who appeard to be around 36+ weeks) was being cared for with respiratory support and warmth.  By the time I had finished operating the mom, the team had already moved to our intensive care room.  The only thing still missing was an i.v. line for infusions.  Our anesthesia nurse (most experienced of us) didn’t have any success.  I was asked if I could.  Well I guess there is a first time for everything but I was pretty anxious about putting a needle in the hand of a tiny premature baby.  The first attempt was ok but unfortunately the vein ruptured.  After a short time I decided to give it another try knowing that if it didn’t go in there wasn’t necessarily anyone there at the moment who could.  So concentrated and calm I attempted it a second time and hallelujah it worked!!! Our pediatric consultant was on the line and instructing our further steps, so glad internet is working today.  We got the glucose infusion running and followed her protocols with CPAP, eventually starting also antibiotics.

C-section #4: Premature baby boy Valimbavaka

Cuddeling with handmade octopus

Our two other patients were kind enough to wait with their deliveries until after we had finished operating and stabilizing our newborn.  A fourth time mom two days over term had a quick uncomplicated delivery.  A second time mom at 35+2 weeks of pregnancy who sadly lost her first baby at 3 days old last year (likely premature and malnourished) was being monitored for vaginal bleeding and given bed rest earlier today.  The cervix was closed but vaginal ultrasound showed a cervix shortening of 1,8 cm (we like to see these above 2,5 cm).  We hoped to prolong the pregnancy but she started developing rapid contractions at about 8 pm and dilated completely within an hour and delivered a 2550g baby with APGAR 9/10/10.  Again this size would be equivalent to a 3400g baby in Germany, which is good for one so premature.  However, this can be trouble because it can give the impression the baby is fine (its big enough) when extra special care (regarding feeding, warmth and observation) needs to be taken because of the premature status. 

Baby boy Daniel 3032g

We did give him a bigger hat and cleaned him up ;) We just didn't take a picture then.

And

Premature baby boy Fandresena 2550g

Note: natural prostaglandins work as we later found out from the patient ;) If you don't know what I mean feel free to ask!

Summary:  3 boys – one IUGR baby born by primary C-section, one healthy spontaneous birth at term and one born premature.