Maternity Matters in Madagaskar

Though I have not spent much time talking about the situation here regarding the world wide impact of the COVID-19 virus on air travel we all know that most airports are closed at the moment and many airlines have cancelled flights. It is at this point still uncertain when air travel will go back to normal and the scheduled flights in the future will resume.  So far my return flight has not been cancelled but many of the volunteers that were meant to depart in the last few weeks are still here because their flights were cancelled and they have not been able to get home.  We have all placed ourselves on lists of the French Embassy for chartered return flights.  The German Embassy is collaborating with them regarding these repatriation flights that are Paris bound.  The airline hired for this job will be contacting us so we wait.  Last week one of the volunteers on this list got a slot and was able to return to Paris via an Air France flight.  Onward travel ...

Its been a very relaxing weekend and I've finally had time to catch up on my blog. Today Patrick and I had a chance to go on an extended hike into the surroundings.  We traversed some rice fields and passed through some small villages on our way to one of the mountains in the area.  The peaks are not super high because we are living already in the highlands at an altitude of 1300 meters.  All in all we did a 5 hour hike in flip flops :)  We were glad because as always, going through the rice fields tends to end sooner or later in slipping into some muddy areas.  That is usually quickly recovered in flip flops but tends to be a pain when wearing any other sturdy shoe.  And yes we managed to get muddy. Here some pictures from our day out and about: Panorama from the way up the mountain  Our day trip goal Local village along the way with outdoor gaming Rooftops and tree   T...

The day of the week starts off pretty generous.  My patient scheduled for her third C-section and tubal sterilization on Wednesday came in this morning at 8 am with contractions.  Thankful this didn’t happen this morning at 3 am!  The uncertainty I had in planning the operation with the question posed in the title dissipates because she has contractions and it’s the third C-section so we are off to the operating room.  I had some concerns as this was her third time to be operated and I was expecting a lot of adhesions and difficulty as some of my previous cases had shown.  To my surprise the scar was small not only on the outside but the inside showed a very orderly abdomen.  Going through the layers was almost as if she had not been operated before.  Delivery went without any complications as did the sterilization.  Unsurprisingly her previous uterine scar was very thin and with barely any pressure from my scalpel popped like a balloon spilling...

Well so these posts are coming at a daily rate.  I didn’t have the time in the last weeks to catch up here at all for all that has been going on so how fitting that after about a solid week of running with difficult cases my wrap up is an extremely large abscess of the breast.  By large I mean we drained about 300 ml of content after partial spontaneous rupture.  This one needed surgical care as opposed to the one I had dealt with last week so an incision and drainage was made at the lowest spot and a wick inserted to prevent closure and enable further draining.  Daily wound care and antibiotics will be necessary as the entire breast is diffusely swollen.  I have never seen one this big before but I guess I’m used to patients coming at the first sign of pain or swelling in the breast. This wraps up one week where we operated every day since Easter Sunday.  Only Easter Monday the operating room stayed closed but we had enough tough cases that day outside o...

Thursday mornings is our weekly trip to the supermarket to get supplies.  Its strange seeing all the military presence around and knowing normal routine has really come to a standstill here in the afternoons.  Back at the house I’m staying at I soon get a phone call that has be running to the ward.  A patient IIIG IIP with two spontaneous births has just come in with an unknown date of delivery and contractions.  Scan suggests somewhere between 34 and 35 weeks and in transverse position!  We decide to try to do an external maneuver in hopes to get the baby in a position for natural birth.  This we decide to do in the operating room ready for C-section in case we run into any complications.  The maneuver is successful.  Dr. Joselitto and I have just finished scrubbing in and are ready when a prompt rupture of membranes takes place with umbilical cord prolapse.  Midwife Tanja is prepared and pushes the head up until we can operate. We immedia...

Good morning we need you immediately are the words I’m greeted with as my phone wakes me once again.  This time it’s a patient, Volatiana, that came during the night with a rupture of membranes.  Contractions and dilation had been progressing continuously without any signs of worry.  In the early morning hours though the water turned meconial and green which was soon followed by signs of fetal distress in the CTG.  The inability to do micro blood analysis (MBU) but even more a suspicion for fetal infection is the reason the decision to deliver via C-section is quickly made.  We soon find out that this was the right decision.  The baby is born with APGAR 0-2-7 and has clear signs of infection.  The midwife team have to resuscitate and administer CPAP.  My nurse anesthesia leaves my patient on the table in the hands of the non-medical assistant to monitor the machines while he puts in the i.v line for antibiotics and I continue the surgery.  ...

The day began as scheduled with the two C-section patients we had planned during the Easter weekend.  The two procedures were a great teaching experience for me.  Dr. Joselitto performed the first case with was a re-C-section.  He did a great job.  We had some very difficult adhesions between Uterus and abdominal rectus muscle to get through which made the case a bit challenging.  The delivery went well and after I completed my first tubal ligation here, he finished up the case.  The next C-section was easier in comparison as the patient had not had any previous abdominal surgeries.  Again Dr. Joselitto did the procedure with me taking on the teaching responsibility. For the tubal sterilization part I took over again before handing the case back to him.  I was very proud of his work and feel happy that I was able to teach him some of my skills especially including intracutaneous suture but more importantly to carefully go through the abdominal ...

NOTE:  LONG POST AHEAD  We currently have a number of difficult cases we have been trying to manage.   Most of these were ongoing for the Easter weekend so I will present here a little overview of the 6 challenging cases we had in our labor and delivery.   We do have normal deliveries too.  These patients usuallly leave about 2 hours after delievery.  Our midwives take care of them and I am usualy not involved for those cases as they manage them quite well on their own. Interestingly enough these were the only patients this weekend and non of them fell in this category during this time.  Quick explanation for the non-medical readers.   G = number of pregnancies P= babies born A= abort   Ev= living children #1 3G 2P A0 Ev1 (Post C-section with intrauterine death of a 6 kg baby at term in 2017)   Diagnosis : Intrauterine death in the 32+0 week of pregnancy.  Blood group: O Rhesus positive Procedure : Exter...

My patient I have been treating conservatively for the breast abscess was back today.  She told me that she had milk coming out of the puncture hole every time she breast feeds.  I examined her again with Ultrasound and found a rather small remainder of presumable abscess close to the pectoralis muscle, deep in the breast tissue.  Palpation revealed that not milk but pus mixed with some serous fluid and a little blood exited the hole.  Upon applying more pressure, more drainage took place until finally only a bit of serous fluid came out.  Ultrasound showed a very small remaining cavity (4,3 mm) which given the possibility to drain externally should hopefully close on its own once completely empty.  The patient was very happy, fever free and had taken her antibiotics a full week after the last puncture. I scheduled her for a follow up in a week.  All in all I’m very content to have achieved a good result in 3 punctures and spared her an operation 😊 ...

Today I would like to take some time to reflect on the situation with Covid-19 and how it affects us here in Madagascar.  We have a complete airport closure that began on March 19 and is expected to continue until April 20.  It has been strange to hear absolutely no air traffic these last weeks.  About a week after airport closure the movement via landroute has also been curtailed.  Travel to and from the region Antananarivo (in which we live) as well as Tamatave (main harbor city on the east coast) is closed.  That means we are not able to leave the city/rural area around the city in which we live.  There is a big police and military presence on the roads, controlling all cars.  Medical convoys are excempted  We actually recently left town with the Ambulance to pick up stranded midwives in the bush so at least all of our staff is back!  All essential stores and food markets are open only until noon.  This means we have had to adjust o...