56: Overseas Project #8, Malawi, day 6

No cases today, so spent some time looking over facilities and reviewing the surgical log.

There are two operating rooms; this is the larger, plenty of lights from tall windows and skylights, an air conditioner which we didn't really need.  Our nurse anesthetist didn't trust the anesthesia machine (for inhalation anesthesia) so she relied on spinal anesthesia: pt is awake but numb from the upper abdomen down.

Home for the afternoon, a long nap prompted by a combination of fatigue/jet lag and mild gastroenteritis. Just what I needed; I was okay the rest of the trip.

55: Overseas Project #8, Malawi, day 5

I spent the morning in the antepartum clinic for high risk pregnancies.

Two women both had hemoglobin levels of 4.9 (approx equivalent of hematocrit of 15), a severity of anemia simply not seen in the U.S. There is a biochemical adaptation to chronic anemia that allows these women to function, though neonatal mortality is high.  The following week one of these women presented with fetal demise.  Malaria, malnutrition, parasites, or more likely a combination of the three.

In the afternoon a 17 year old who delivered 20week twins at home was brought in for retained placenta.
A curettage removed the placenta from what appeared to be a bicornuate (heart-shaped) uterus.  Then another C/S for failure to progress, again working with one of the "clinical officers" (CO's or clinicians), the approximate equivalent of physician assistants who regularly perform C/Ss and other surgeries.  Their technique and knowledge of anatomy were good, and they were interested in seeing my technique, unlike their counterparts in Mozambique.  One newly graduated CO had not previously assisted on a C/S let alone perform one, so was excited to throw some stitches a tie a few knots.

And then the difficult re-repair of a third degree laceration (meaning the rectal sphincter muscles were torn) that occurred during a 17 year old's delivery at a satellite clinic.  An initial repair had broken down so the patient was brought to Nkhoma.

54: Overseas Project #8: Malawi, Day 4

After OpenOffice for Ubuntu crashed its presentation program for the third time, I decided to go low tech, using chalk and chalkboard for a talk at the Monday hospital staff meeting.  I promoted the use of aspirin for women with a history of preeclampsia, given recent findings suggesting that early abnormalities in placental vasculature that lead to preeclamapsismay may be prevented by aspirin. And I encouraged the use of misoprostol for postpartum hemorrhage, which is in their protocols but not in their pharmacy--at least it wasn't until I gave the pharmacist the 100 I had brought with me.

After the meeting, I was introduced to Labor and Delivery, where I was asked about a woman making poor progress in labor--the staff suggested a C/S.  The hospital has C/S rate of about 20-25%, comparable to the U.S.  Higher than I would have expected prior to the Mozambique trip where I appreciated that it is better to perform a few extra C/S's than to have vaginal deliveries of babies in need of non-existent resscitation.  As in Mozambique, the nursery here consists of a single warmer where newborns stack up waiting for their mothers' recoveries.

Although augmentation of labor with pitocin would an option for slowly progress, given the long labor so far(unexpected for someone with prior deliveries) and her request for a tubal ligation, I agreed with the C/S.  The baby was 3700 grams (over 8 lb), a probably cause for the stall.  Afterward, when one of our nurses asked the mom what name she planned, she said, "you name it."  The nurse suggested David, and David it was.