For reference: Technical notes on obstructed labour and assisted delivery in rural Tanzania

Obstructed Labour and Assisted Delivery in rural Tanzania

Notes for professionals – and the technically-informed curious.

The puzzle of obstructed labour in rural Tanzania

The strange facts needing to be reconciled are:

1.      1. Most of the emergency CS’s in the UK are due either to a CTG diagnosis of fetal distress, or to a long, slow, seemingly dysfunctional labour; or both. Long slow labours are typically the product of induction of labour, or are primips in labour where the diagnosis of active labour was made too early. Fetal distress mainly comes from CTGs.

Where we have no induction, nor CTG, nor anxious primips coming in too early, the CS rate in Berega should therefore be much lower than the UK. However, it seems, if anything, to be higher – more than 30% of deliveries. This is presumably because we are skimming off the caesareans from a much larger population than just those who give birth at Berega.

2.       2. Obstructed labour is far and away the most common indication for CS. A few CS are done for eclampsia, twins, breech, post-dates with very high head, etc. However, far and away the most frequent indication for CS (90% in my two months here) was obstructed labour.

This is wildly different from the UK, where although the CS rate is more than 25% of pregnancies, only very few of these – 1 or 2% of deliveries if that – have full-blown obstructed labour.

3.       3. You may conjecture that this might be due in part to over-diagnosis of obstruction. However, when women get obstructed labour in Berega, the diagnosis is typically barn-door. The head is very high abdominally: often 3-4/5 palpable despite eg 14 hours or more of active labour – even in multips with several previous normal deliveries of seemingly similar-sized babies. In the UK, obstruction can be difficult to diagnose, as the head is often well down, and the diagnosis is less obvious.

4.       4. In obstructed labour in Tanzania, caput seems to be an important sign. They also have the classical signs, (see below). However, the heads seem to get more severe caput than they do in the UK – perhaps just a feature of longer labours not dealt with earlier? Or something to do with the traditional medicines taken?

5.       5. When reviewing antenatal women, the head just about never engages. It is either free or 5/5 palpable right up to labour.

6.       6. Obstruction is almost always in the first stage. In two months here, I have seen around 70 CS, but only three second stage obstructed labours. Two were an easy Kiwi rotations, in the presence of a tired mother, and an OT or oblique OP position, where there was minimal caput and moulding, and decent descent of the head with contraction. The other was the opposite – lots of caput, (difficult to determine position), and stuck right at the outlet. In this one, a Kiwi pull failed, and CS was needed. The baby was born in poor shape with a very sausage-shaped head.

7.       7. I did one other successful Kiwi – for eclampsia, a delightfully easy delivery, making the Kiwi rate around 2% in my time at Berega. (3 of them successful, one not.) I did no forceps, nor (surprisingly), did I see an indication.

Again, this is in sharp contrast with the UK, where the combined vacuum + forceps rate is often 15% or more of deliveries. If we are indeed dealing with the problems arising from a much bigger population, then we should have a higher instrumental delivery rate than the UK, not a lower one.

It is true that many instrumental deliveries are done for CTG problems in the UK, but many also are done for failure to deliver, often associated with malposition. Even when the baby is OA, the need for forceps to deliver because of a tight fit is common. Here I did not see it once.

8.       8. In Berega, fetal distress is rarely an indication for CS or assisted delivery – probably related to the lack of CTGs. FH auscultation is done badly. Nevertheless, for all that, when the baby was actually born vaginally, it was rare during my two-month stay, (possibly once or twice a month), for it to need resuscitation.

However, I did run an intensive update on resus, and I have no idea what the death rate from vaginal delivery was before I came.

9.       9. According to the Berega records, the death rate of babies in obstructed labour was horrifically high before I arrived. The combined perinatal mortality rate over the 7 months 1^st Dec 2012 to 30^th June 2013 was 9% of deliveries. In the UK, it is below 1%.

Some of this was poor resuscitation of babies born in poor condition, often after a GA caesarean*. (Despite annual resuscitation updates from a highly skilled paediatrician, the skills obviously waned without constant reinforcement – a salutary lesson.)

In other cases, a few babies died, even when I was there, from being un-resuscitatable after CS for obstructed labour. This presumably relates either to late presentation, or, more commonly, to failure to pick up profound fetal distress early enough.

10.   10. The huge majority of women with obstructed labour admit having taken local medicines.

11.   11. This all represents a hugely different pattern of obstruction in Tanzania from my previous observation of Zulu labour – also a Bantu race. (I worked in a rural hospital in KwaZulu-Natal for four years.) There, outlet obstruction is far more common, and first-stage obstruction is rare. Vacuum delivery was a common need – sometimes with symphysiotomy, (which was preferable to what would otherwise have been a dreadfully difficult CS, with the head crowning but undeliverable vaginally).

Zulu women in general have much more of a sticking-out bottom – rural Tanzanian women are often flat by comparison. (They are also thinner and less female-shaped than their urban sisters.) Zulus are also considerably taller, and often stocky. Rural Tanzanian women are typically below 160cm, and are almost always slender – sometimes markedly so.

Reflection

The differences in body-type between KwaZulu-Natal and rural Tanzania may be due racial differences – eg Tanzania includes Nilotic tribes who are traditionally slimmer. However, Zulus are Bantu, and their antecedents originated in East Africa just a few centuries ago. It may therefore be that malnutrition in puberty in Tanzanian girls causes failure of development of the full gynaecoid pelvis, perhaps related to insufficient oestrogen.

A second conjecture relating to the markedly different pattern of obstruction on Tanzania, is the common consumption of labour-enhancing local drugs. 

Clearly, when a primip not in labour is given such a drug, it may readily cause distress before it causes delivery. Similarly, in a multip given such a drug inappropriately in early labour, she may end with rupture.

However, I wonder whether these drugs also interfere with the natural mechanism of labour? We have already established that as many as 90% of women referred in from the community have already taken these substances. Some of these women should not have developed obstruction – eg previous quick normal deliveries of a similar-sized baby. Do these local medicines somehow cause a type of contraction which has all the harm of squeezing the baby and exhausting or rupturing the uterus, but without the enhancement of natural labour? Is the cervix or pelvis or pelvic floor somehow not ready?

Finally, we know that for every delivery we do in the hospital, at least ten occur in the community. Perhaps our obstructed labour workload comes from the arrival at hospital of those women from the villages who get stuck. Most other causes of problems in childbirth – eg fetal distress, breech – would not cause a woman to travel a long way on bad roads on a motor-bike. Obstructed labour, however, means that she will not otherwise deliver in the village, and so the only other option is to die.

An interesting mathematical conclusion thus arises: We could examine our CS indication rate over a long period, and then compare the rates of ‘eclampsia’ and ‘obstructed labour’. We could then compare this ratio to that in a major city. 

Assuming that most village-based eclampsias do not arrive at hospital, (a long way to bring a fitting lady on a motor-bike), but that most obstructed labours do, the comparison of the two rates may allow us to infer how many extra obstructed labour cases we are doing, by comparison with eclampsia.

It would thereby give us an rough idea of how many women are delivering in villages in our territory, from which we could calculate how many common problems must be occurring there – eg breech, twins, eclampsia, fetal distress, etc.

Suggestions for the management of labour in Tanzania

1.       1. The diagnosis of labour is critical. The partograph is meaningless if the woman begins it many hours too early, or many hours too late. Therefore staff should not only be taught but also tested and checked within in-service training, (IST), on the diagnosis of labour.

2.       2. Using cm of dilatation to diagnose labour can produce considerable inter-observer variation. Nevertheless, the midwife needs to be clear that the os is not just a multip’s os, but is in fact at least 3-4cm dilated. More important however, than trying to tell the difference between 2cm dilated and 3cm, the midwife needs to be absolutely clear that the cervix is fully effaced; and that contractions are coming regularly, at least every 5 minutes. They need physically to feel the entirety of the contraction with their hand.

At full-term, a working definition of active labour is the combination of:

·  

- cervix open at least two fingers; plus

- cervix fully effaced and thin; plus

- regular spontaneous contractions each lasting 40 secs or more, coming every 5 minutes or more 

3.  Once labour is diagnosed, the woman should be entered on a partograph. Use of the partograph also needs IST. Ideally, a woman should not be left alone once active labour is diagnosed. However, that is impractical, so a bare minimum of observations need to be insisted upon, to ensure that the woman at least is seen and checked every half an hour in the first stage. (And every 5 minutes in the second). 

Most importantly, at these times, the FH needs to be auscultated – after a contraction. This again needs both in-service and classroom-based updates.

The normal observations of pulse, BP, and contractions can be recorded at appropriate intervals, depending on clinical circumstances.

4. In addition to in-service training, midwifes need regular in-service checks to ensure that they are able to tell the difference between a normal FH, and an abnormal one.

5. Whenever a labour is abnormal, the doctor needs not only to be informed, but to come and check the woman.

6. If second stage has not occurred by the transfer line, the woman should be transferred.

7. If no second stage has occurred by the action line, but the FH is still good, then the whole situation needs assessment. However, pay particular attention to the station of the head. If it is still 2/5 palpable or more in rural Tanzania, then obstructed labour is extremely likely. If the labour has been long, with good contractions, but the head is still high in the abdomen, then a vaginal examination should be done, but will probably just confirm the diagnosis of obstruction, and a CS should be ordered. (Rather than augmentation and/or giving time for the obstruction to become impacted.)

8. Membranes should only be artificially ruptured when not to do so would probably deny the woman the chance of a normal delivery. The typical situation in which ARM would be appropriate would be a slow labour in a multip, where contractions could be better; where the FH is good; where the head is not high abdominally; where the presentation is definitely uncomplicated cephalic; where the position is probably OA: and where plenty of time has already been given for SRM, so the next step would otherwise be to call the doctor.

Even then, ARM should not be performed in someone about to be transferred, as labour will get stronger. Hypoxia of the baby secondary to obstruction does not occur if the membranes are intact. Intact membranes also protect against cord prolapse, when the presenting part is ill-fitting.

Suggestions for the diagnosis of obstructed labour in Tanzania

When the doctor is called, s/he has to decide whether the labour is obstructed. A suggested guide is:

1. In rural Tanzania, it seems that the head stays high in the abdomen in obstructed labour. The combination of a long labour, (where diagnosis of labour had been good); plus good contractions actually palpated; plus high head abdominally, is very likely to mean obstruction.

2. As mentioned above, caput seems commoner and more severe in obstructed labour in Tanzania.

3. Additionally, the accompanying factors are typically: on vaginal examination there is an empty pelvic curvature at the back of the V/E, even though at the front of the vagina the head is easily palpable; no descent with a good contraction; moulding should be present, (if sutures can be felt); poorly applied swollen cervix; and eventually vulval oedema and haematuria.

4. Once the labour is actually obstructed, the baby will increasingly get hypoxic, and previously clear liquor will become increasingly meconium-stained.

Suggestions for the use of Kiwi Omnicup and Forceps in Tanzania

The Kiwi Omnicup has an important place in Africa, where it may not only prevent caesarean section, (and therefore problems in future pregnancy), but may save life. However, it use should be considerably more limited than is normal in the UK. My suggested rules are:

1.       Certain rules should be as for the UK: Fully dilated; Head not palpable per abdomen; head comes down with contraction; placement of the Kiwi on the flexion point; no other contra-indication to Kiwi such as HIV; etc.

2.       Kiwi Omnicup should never be used for (relatively) obstructed labour in OA position, I believe. A technical reason for saying this is that in OA position, the tendency of the omnicup is to increase deflexion, whereas in OP position, it corrects deflexion.

However, more important than this is the balance between risk of good and risk of harm. To do an omnicup delivery for slow progress in OA position (ie when trying to overcome a tight fit), would be to suggest that even though the head is correctly placed, by traction on just a small area of the baby’s scalp, you would hope to succeed in the large majority of cases, and only rarely get unfavourable consequences for the baby. That does not usually make sense to me.

I think that too often, the rural Tanzanian pelvis would be fooling you into thinking that vaginal delivery was possible, whereas in fact, the mother had only just made it to full dilatation. You would therefore fail too often, and the baby in these circumstances might have suffered from the intervention – eg cephalhaematoma, or even cerebral haemorrhage. Additionally, a failed Kiwi in such cases would make the CS more difficult, and therefore the baby would be more hypoxic.

3. The Kiwi omnicup comes into its own for correction of malposition – OP or OT, with or without asynclitism and/or deflexion. In prolonged second stage – or earlier if the baby is distressed – the Kiwi will very often turn the baby readily on the first pull.

Thereafter it will come quickly, as long as the pull is correct, the pushing is maintained, and the contractions are satisfactory. Such Kiwis will save unnecessary CS. Despite a small risk of cerebral bleed, they will often help prevent severe hypoxia in the baby, and the balance is therefore very much in their favour.

This is particularly the case, as there are some mothers where delivery should be easy, but malposition prevents it from being so – eg twins, grand multips. Nevertheless, such indications probably do not amount to much more than 1% of deliveries.

4. Remember that the first pull especially must pull the head into the levator ani, and into the woman’s perineal body. If the baby's head is pulled into the woman’s pubis bone, clearly it cannot advance. The perineal body, by contrast, is soft, and the levator ani naturally assist in the turning of the head. PULLING THE HEAD TOWARDS YOUR CHEST, YOU MEET HARD PUBIS. PULLING THE HEAD TOWARDS YOUR GROIN, YOU MEET SOFT MUSCLE. SO PULL DOWNWARDS!

The Kiwi should not be pulled above the horizontal until the head is half-born!! (It’s just physics – with less than half delivery of the head, if you pull above the horizontal, the fulcrum is passing through the pubic bone.)

5.The other important place for the Kiwi is when a quick delivery is required in the absence of prolonged labour – eg eclampsia; fetal distress; second twin; abruption. Such indications currently probably do not add to more than 2-3% of deliveries in rural Tanzania, but with better fetal monitoring, the diagnosis of fetal distress would increase. (And with CTGs, it would increase too much!).

In such situations, especially in multips, a Kiwi can be quick and simple, and will often save at least the brain, if not the life, of the baby. A CS for mother can also be avoided – eg distressed second twin with high head, eclampsia with poor maternal effort; etc.

In such a real crisis in a multip, you may get a good Kiwi delivery even at 8cm. In a grandmultip, she just needs to be in good labour, and you can push the cervix away!

6. I suggest that non-rotational forceps currently have little place, though this may change. They need the head to be OA, and they need good analgesia and a decent episiotomy. In the UK, one cautious and judicious pull with (eg) Neville-Barnes forceps can make the baby deliverable where this was uncertain. By contrast, it can confirm the diagnosis that the baby is stuck and CS is needed. In this case, the forceps can be used to disengage the head before they are taken off.

However, stuck OA head in second stage seems very rare in Berega – I have not seen one. Furthermore, where it does occur, I conjecture that it would be common for the head to be truly stuck and vaginal delivery impossible.

The place for Neville-Barnes forceps is thus very limited – for a woman who needs vaginal delivery to be expedited; where the head is OA; she is fully dilated with no head palpable abdominally and no other signs of obstruction, (in particular, be wary of caput); she has sufficiently good analgesia or does not need it; and the operator is skilled with the instrument.

Effectively, this amounts to certain clearly-defined situations: fetal distress not caused by obstruction; eclampsia; after-coming head of breech; abruption; poor maternal effort; the need to protect the mother – eg in heart disease; needing to avoid a Kiwi – eg HIV; etc.

In such circumstances, the availability of skilled forceps delivery is vital, so forceps still have an important place.

It is likely that as obstetrics improves in rural Tanzania, these indications will become more common.

*Post script

In Berega, GA CS is far too common. The typical reasons were either because of having run out of spinal lignocaine, or because of a cautious anaesthetist not wanting to give a spinal to a mum with a low Hb, in whom the ward staff had omitted to give an IV fluid bolus on the way to theatre.

The GA is done with a variety of induction agents, often added together ad hoc until she is asleep, then halothane plus mask. There are no facilities for intubation, and no antacids are given. Post op, patients are left alone, on their back, often deeply asleep for many hours, untended, with an airway in. 

When visitors ask what they can bring, one idea is battery-driven pulse oximeters and BP monitors, and then put them right in the hands of an anaesthetist you trust. Insist on their use when you do a CS. And regularly without embarrassment ask "What are her vitals?" 

08. Imperfect Instruments

08. Imperfect Instruments
11th August 2013

In the small hours of the morning of Thursday 8^th August 2013, I saw what I expect will be my last womb, (barring, perhaps, when I am finally put into Fort Semolina Retirement Home, getting allocated the bath chair opposite a naturalist with procedentia).

It was a blessing that my last ever action as a doctor was an operation; and that my last ever operation was assisting a caesarean. Like the seasoned night-club bouncer on the door of The Wonky Innards, I have grappled far too often with unwelcome visitors, bustling them to the abdominal door, and thence into the hands of the waiting pathologist. How much nicer to find that the ruckus was due to a little baby crying with joy at the prospect, finally, of meeting the outside of his mum.

A wriggly boy, who had struggled to be born in a long labour, responded heart-warmingly to being vigorously dried and wrapped, and thereafter greeted his weary mother with one of life’s most beautiful sounds. Welcome to the world, little baby.

Hizza was the surgeon, and it was to be our last operation together. The operation was performed, as always in Berega, with imperfect instruments – needle-holders that, in an irony lost on them, no longer hold needles; old-fashioned sutures; torn drapes; gowns with one cuff missing; over-tolerant scissors that only cut after three final warnings; a catheter the size of a hose. The surface on which the game was played, instead of being softly-surfaced memory-foam, was an ancient, hard table, rudely covered with an even more ancient rubber sheet. Nevertheless, Hizza made a good fist of it. He did a horizontal incision instead of his previous vertical; he remembered to make a double-bite stay on each angle; to leave these knot-ends on a clip; and all traces of Cornish-pasty-ness had been eliminated from a precisely-executed double-layer closure of the uterus. Nice job.

I am sure that he will not mind if I say that not long ago, he also was an imperfect instrument; the product of his circumstances. He had had sparse, if any, one-to-one supervision in his surgical training, and what he knew was what he had gleaned and inferred. His eagerness to entice every last tip and nuance of surgery out of me before my final day, was touching and humbling. I felt that if he in his life now performs as many thousand caesareans as have I, then it will truly have been my privilege to have been there for him; there in his early days. This alone was worth crossing a few continents for.

Of course, he is not yet perfect. The fact that perfection is an unattainable goal means that both he and I will always be imperfect instruments. (Although I am surgically less imperfect now than at my first abdominal operation in 1976. It was an appendicectomy. I remember it vividly, not just because it was my first; nor because it took so long that I could barely remember life before it began; nor due to the resultant stress perhaps being the origin of the challenge to my scalp which has blighted my barber’s life ever since, and is perhaps the reason why surgeons wear hats; but principally because in those days you learned by watching rather than by being taught. (As Hizza did.) And so when I asked if I could do this appendix, the senior registrar said, “Have you done one before?” “No.” “OK. Well you can do this one, but I’ll wait in the coffee room so that I don’t put you off”. True story.)

Since then, I got better, but never perfect. There must be a book or two in there, (or more probably already out there, as are most of the stories that I otherwise would have written), on the paradox that purposefulness is the pursuit of the unattainable, and futility is the taking of your foot from the path.

It is for the purpose of making doctors less imperfect that the new regulations of appraisal and revalidation are currently being implemented. I fully concur. When my revalidation date comes up soon, I will not have the evidence of 250 hours of ongoing education in the last five years; nor the organised reflections of patients and colleagues on my work; nor the five annual appraisals of my strengths, weaknesses, needs and plans; nor the plethora of filled-in forms. Apart from the last of these, the other elements are truly are good, and the day that I start to believe that my experience makes me exempt, is, (was), the day that I should retire. (The world is a better place because of Lord Lister, without whom many millions would have died of peri-operative sepsis. But if he were alive today, aged 186, I wouldn’t let him within twenty stretcher-poles of me if I were to need an op.)

And so, 41 years, 10 months and a few days after stepping up to Liverpool Medical School, eager and young and bursting with possibility and a strong liver, I now hand in my scalpel and exchange it for a pen – which, to be honest, is less likely to cut my hand.

The week that ended with a life-saving operation had begun with the tragic absence of one. Sion and I were on-call last weekend, and a twenty-three year old woman was brought in from afar with abdominal pain and collapse. White as death, she died in front of us, before we had a chance even to begin the search for a donor of blood. She might have had a ruptured spleen secondary to malaria, in which case she would have been difficult to save. But it was harrowing to think that it might have been as simple as a ruptured ectopic pregnancy, instantly curable by a simple operation, if we had seen her earlier.

The rest of the weekend brought many other challenges. Perhaps the most spectacular success was Sion’s clinical diagnosis of massive lung pathology in a child of eleven. Xray showed a complete white-out of the right side. Subsequent repeat pleural aspirations over the next few days, (tolerated with impressive and characteristic courage), eventually eliminated 1.3 litres of pus from the boy’s grateful pleural cavity. He is doing very well, but hides when Sion approaches.

During the weekend there were other deaths as well – one from cancer at one end of life, and one from meningitis at the other. But yet others were rescued by Sion, sometimes impossibly so – a baby with pneumonia whose oxygen levels were under 60% is now recovering well. (The mum’s comments will be one for the appraisal folder.) (I hope that this still counts under ‘Annexe 4B: Comments from Patients’, even though it is from the mother. You could imagine that sometimes maternal comments are inadmissible, like when I gave my ‘Annexe 4C: 360-degree Assessment – Comments from Colleagues Form’ to my mum. We came from a collegiate family, was my argument.)

Anyway, Sion - you made a difference. Not to the totality of suffering in the world, but to its sum.

Regular blog-readers will know that I like to ooze effortlessly from paragraph to paragraph, forging unlikely links with literary dexterity. And so it is with suction cup extraction.

I brought Kiwi suction cups to Africa, wondering whether the twenty that Nicholas nobly fast-ferried from Cardiff would be enough. As it was, I only used four in two months, during which time I performed or assisted at 70 caesareans for obstructed labour. Their use in these cases still emphasised their irreplaceable importance in Berega-like settings, but I am perplexed by the rarity of need there. I brought forceps, but did not use them once. Furthermore, I did not see a single case of PPH, (post-partum haemorrhage), the world’s number one killer of mothers. By contrast, first-stage obstructed labour was a daily occurrence. I shall annexe a page of musings on this for the childbirth professionals and the curious.

I can talk with despot-like confidence of annexing, because I am writing this from Dar-es-Salaam. Not only does my computer now say that I have internet, but, much more importantly, it also behaves as if I do. (Note for future African Internet providers: one out of two, though technically a pass-mark, is simply not enough.) Soon you will be able to see our house, the hospital, and the environs, through the inestimable wonders of You-Tube and the World-Wide Web.

One of the joys of the net, besides being able to read my emails more than one word at a time, is that I have finally been able to check out Kofia! (Google Kofia + Berega if you don’t know it.) Blanché, Debbie, and the worthies of Guildford, I salute you!! Starting with just good will, knitting needles, and a wireless router, you have begun a process which has the potential to enhance the outcomes of childbirth for people who have never known anything other than fate. Just the babies’ hats would be a wonderful and welcome intervention. Getting cold is the biggest threat to a baby struggling to adapt to its first few minutes outside the womb. Berega cannot afford proper baby towels, and the knitted hats will send a message of loving warmth from one world to another.

More importantly still, (no pressure!), I am hoping that Kofia can be a powerful instrument helping us to begin to reach out to those current beyond access. On my last day at the hospital, the key players met, and we have a plan for the first year of outreach to the community. I will write a separate page, with the details and map, with photos, and with links to a video of the road that leads there. Working alongside Hands4Africa and their plans for community development and transport, I believe that we have a real chance of starting something inexorably important. We will begin cautiously, and take each step gingerly. We will seek first to understand. We will try to measure. The purpose is not to do things to people, but to create harmony of purpose. Synergising the efforts will be slow. Traditional Birth Attendants making a hard-won and inadequate living from bringing the next generation into the world, need to be our local partners, and that will take time. However, I won’t listen, and nor should you, if Caution wheedles: “Don’t start! Go back! Relax! The distance isn’t going to look at itself, you know!”

A journey, once begun, will always lead to somewhere more interesting than your front room.

Nowhere was this more true than my last journey from Berega. (A better link this time?) Leaving the hospital after two months was strange.  We set off at 6.30, just in time to see the new moon rise for Eid. (I can only hope that the joy with which it was greeted will encourage a more regular attendance in future.) For a while at least, I had my last powdered milk cup of tea. Our last banana breakfast. The last “News of the morning?” greeting to the gateman, (the answer to which is always “Good!”, even if one of the Four Horsemen of the Apocalypse had stabled at your home the night before). My last time to hear “Shikamoo!”, (a greeting of respect to elders), from children on the long walk to school. No more caesareans at which the mother calls her child after me, (even if she spelt it ‘Rollent’).

I have four more days in Dar to finish putting things on the web, and to put on some of the lost two stone, (assuming that the current population of protozoa in my intestines can be eliminated when the pharmacies open tomorrow). It feels unsettling to be unleashed back into the other world, but it is a very welcome unsettlement.

I will be continuing the work, and a pithier blog, for up to five years, (if I manage it. But if I stop writing it, you can stop reading it). Five years to see if the hopes and dreams for rural Tanzania can become more solid.

We have a good start. The meeting of senior staff and management with the leads of the clinical areas introduced to them the idea of agreed minimum standards of the hospital. I had anticipated a bloody battle, and a long, hard meeting. Well the meeting was certainly long, (and all in Swahili), but that was because the staff themselves punctuated every point with their own tales of how vital it was to build that standard into established practice. Rules are important in Tanzania, and lack of their being explicit has, it transpires, been unwelcome to many. The entire document got through with just a few additions, and no deletions. The uploaded draft is the final version. 

Berega has a charter.

A final reflection: You may have been surprised the first time that I discussed Berega Hospital’s flaws as well as its challenges? There is so much good in the hospital: sound lead clinicians, many dedicated and talented staff, and excellent managerial leadership. I myself wondered then, if it was acceptable to reflect on inadequate responses, and even to hint at what sometimes seemed too much like neglect. However, I decided that I needed to give you the story as it really is. However much better Berega is than it has been in the past; however much it is head-and-shoulders above many of the district hospitals in the rural areas; nevertheless it is true that bad outcomes in the hospital sometimes owed as much to its inadequacy as to its inaccessibility to those in distant communities.

Berega has been, like me, an imperfect instrument.

I hope you will continue to travel with us both as we seek the unattainable.

Laurence Wood

email.lozza@gmail.com

This is a post-script on the death of the young woman. For the faint-hearted, don’t read it. I add it because, more perhaps than anything else I have written, it evokes a picture of what needs to change in rural Tanzania.

The tragedy of the death of this young woman was shocking enough. But what illogically unnerved me more even than the death, was that the body was taken home by the grief-stricken family on a motor-bike, because that was all they could afford.

07. Yellow chuck-chucks pics

NB: Downloading these pics at one Byte per decade has meant that the scenes depicted may be of a bygone age.

Happy to see the Mzungu

The long weight

Our territory goes almost as far as you can see

Nhembo church / parish hall / clinic / community centre / everything else

The Long Drop Saloon

The wonderful Community Health Worker - a local man who makes it happen

07. B Charter of Expectations and Standards for Berega

BEREGA MISSION HOSPITAL

A caring, teaching hospital, where no-one will die of neglect or misconduct

This guideline is intended for any clinical staff dealing with patients

EXPECTATIONS – GENERAL

1.       Staff should be present in the hospital when rostered. When on break, or on call at night, they should be easily reachable – eg able to arrive within 10 minutes. Chai break is 30 minutes in total, from leaving to arriving back.

2.       Admissions should have had a good history, examination, provisional diagnosis, investigations, good record-keeping, and management according to national guidelines, with particular attention to getting it right in the first 24 hours. Beware of drug interactions.

3.       Nurses should perform vital signs twice daily on non-emergency cases – or as directed by the doctor – eg in post-op cases. They should report any concern to the First-on-call or Second-on-Call.

4.       All staff should have a caring attitude to patients, as illustrated by:

a.       Good and sensitive explanations to satisfy the patient;

b.      Knowing the names of patients

c.       Nurses ensuring that investigations reach the lab, and that abnormal results are followed-up

d.      Patients not being left alone uncomforted in frightening or dangerous situations – eg complicated labour, waiting for surgery, critically ill.

EXPECTATIONS – EMERGENCY CASES

1.        Complex/Sick patients should be reviewed promptly in OPD / Labour ward, where there should be a good history, examination, provisional diagnosis, investigations, record-keeping, and management according to national guidelines.

2.       Laboratory investigations on emergency /sick patients, (eg caesarean, meningitis, severe trauma, severely ill), should normally have the result back on the ward within 30 minutes. These results should be communicated by the nurse to the doctor, who should act on them where appropriate.

3.       Complex/Sick patients should be discussed promptly by the First-on-call with the Second-on-Call, and reviewed by the Second-on-Call at the time if needed, and a plan made.

4.       Second-on-Calls should be around the hospital between 07.30 and 14.30, easily available to review worrying patients. They should have done a morning round to identify and record who is sick or at-risk.

5.       A final check of the sick, at risk and in-labour patients should be made before going off-duty by the Doctor in charge of each ward, and these should be handed over to the Second-on-Call.

6.       Nurses should check vital signs every 2 hours for seriously ill ‘sick’ patients. They should keep the record of sick patients up-dated, and should know the plan for these. All observations and plans should be carried out well. This should be recorded in the end-of-shift report in a Ward Report Book.

7.       Any First-on-Calls coming on or off duty, plus all Second-on-Calls, should be at the morning report and weekly meeting, if not on leave. Sick/Complex patients should be handed over at this meeting, stopping to discuss each individually. Thereafter the night First-on-Call should accompany the Second-on-Calls to the ward to hand over any particularly sick patients.

8.       At the weekend, the night First-on-Call should review the sick/complex admissions with the Second-on-Call before going off duty, at 07.30, accompanied by the First-on-Call coming on duty.

9.       When an emergency attendance is required – eg an emergency Caesarean for obstructed – all staff should be present and ready to begin with 30 minutes. The patient by that time should have been fully prepared – eg IV fluids, drugs, Hb, X match, consent.

10.   When a nurse calls a doctor, she should enter this in the record, along with how and when s/he called the doctor. When a doctor sees a patient, a date, time and signature should accompany the entry in the notes.

EXPECTATIONS – LABOUR WARD   

1.       Midwives should see and assess any admission within 30 minutes of her arrival. In every case, the midwife needs to assess and record in the notes:

a.       Is the woman in labour?

b.      Is she normal? If not, the Second-on-Call needs to be informed, and needs to see the woman within 30 minutes - or more quickly where needed.

c.       Certain conditions are emergencies and need to be dealt with immediately by the midwife, and reviewed promptly thereafter by the Second-on-Call: eg obstructed labour; PPH; eclampsia; fetal distress; haemorrhage.

2.       When a woman is in active labour – ie more than 3cm dilated with good contractions coming at least every 5 minutes – she should be entered on a partograph. When the partograph becomes abnormal, the Second-on-Call should be notified right away.

3.       A woman in active first or second stage of labour should have a midwife with her at all times, even during tea breaks, although in busy times a single midwife might need to be covering more than one woman in labour. (The aim is eventually that, in normal circumstances, there would be two midwives per shift, plus one other nurse or attendant.)

4.       The fetal heart should be listened to every 30 minutes in the first stage, and every 5 – 10 minutes in the second stage. In both cases, this should be done immediately after a contraction.

EXPECTATIONS – EDUCATION AND TRAINING

1.       Opportunities should be taken by all staff to teach and learn appropriately – eg teaching of the First-on-Calls and nursing students on the job.

2.       There should be a programme of on-the-job training for all staff eg monthly.

3.       Where vital educational needs are identified, these should be dealt with appropriately.

4.       There should be a mechanism for learning from deaths and from serious incidents.This guideline is intended for any clinical staff dealing with patients.

07. Yellow chuck-chucks

07.  Yellow chuck-chucks
4th August 2013

Yesterday, Mama Liz told me off for throwing a few old bottles and empty tin cans into the rubbish pit. Of course rural Africa has no mechanisms for dealing with waste, so, until now, in a system akin to A&E triage, we have had a three-way disposal plan for garbage:

-          Combustible materials that don’t produce a pall of rancid smoke choking the life out of Mother Earth, we burn mercilessly.

-          Plant waste - the 2kg of tomatoes you never got round to using; peelings of wizened sweet potato, (peeled with a knife, to leave behind Lowry-sized remnants for cooking); the inedible parts of the bruised papaya you bought cheaply last week; the edible parts of the bruised papaya you bought cheaply last week;  mango stones and peel, plus all the bits of flesh that aren’t inextricably woven into your incisors; the outsides of guacamole; yellow things that you never knew what they were and didn’t dare eat – these, and the like, we put on the compost heap, in the ridiculously optimistic expectation that in two years, compost will magically appear from what was not eaten by the monkeys, ants, termites, chickens, rodents, fruit flies, and what I take to be anti-compost beetles. (Indeed, an enterprising bushbaby has actually set up a small market stall next to the pathetically penetrable walls of the would-be compost mountain.)

-          Non-degradable waste – old washing-up liquid bottles, (the contents of which, in this country by the way, only leave your hands as soft as your face if you have previously dipped your face in bitumen then dried it with a heat-lamp); glass; tin cans; etc – we have been in the habit of throwing into the pit, where they await the inevitable.

Not so inevitable, Mama Liz says. In Africa, things have many uses, and, (if not living), many lives. In the UK, everyone’s cupboard-under-the-sink is full of the bottoms of Tupperware containers and the tops of different-sized ones. In rural Tanzania, however, there are no Pound Shops, and no plethora of containers. If you want somewhere to store your old bits of soap, what better than a recycled tin can? A glass peanut butter jar is a candle stand. Beer bottle tops become an abacus. If you make sunflower seed oil (out of, as it turns out, sunflowers), then old water bottles are perfect for storage. Even the washing-up liquid bottle has an unlikely future, as a squeezy container for zapping termites as they try to gnaw into the tired door frame of the family home. Waste not, want not. OK, then, this is Tanzania – perhaps just waste not. Africa re-sets your thermostat.

It is not only detritus which has multiple potential uses, but also everyday possessions. Chickens, for instance. They can turn pecked-at used-corn-cob into egg; they can warn you of danger; they can remind you that it is dawn; they can remind you that it is only one hour until dawn; they can remind you it is only two hours until dawn; they can turn chicken soup into actual chicken soup; they can add a clucking, chooking, scratching back-beat to the rhythm of rustic African life; and they can be used as currency by the poor, to pay, for instance, for a traditional birth attendant. Today’s chicks are tomorrow’s birth-price.

This came home to me powerfully on Tuesday’s visit to Nhembo. (Pronounced ‘Nhembo’). The previous night we had had a rainstorm of sorts, and so the road was damp and slippy. (Old folks here say that in the days when all between these mountains was low forest, we would often have rain in winter. As the trees left, so did the rain.) We took the back road out of Berega, into the big beyond. Small mud villages slipped by, with antiquity only momentarily challenged by our passing. After five or six kilometres, we found a side-turning, and tossed and tumbled down the slope to a river crossing. Women were washing clothes, somehow not swapping new dirt for old. The dry-season rain had left just six inches of water, but the semi-vertical banks challenged even our trusty ancient Land Rover. Abdallah, driving, told me that recently he had got stuck in this river, and the nurses had got out and pushed. They had thereafter conducted the clinic with one eye on the sky, but eventually arrived home safely.

Arriving home safely, however, is surely not a reliable turn of events on the other side of this river. We drove for an hour in all, and eventually pulled in by a dilapidated bare building, which turned out to be the local church for half a dozen villages around. The tin roof rattled gently on the red clay-brick walls. Inside, a couple of dozen home-made benches were not much more than rough planks on stubby legs. The only other furniture, a rickety kitchen-table altar, had been commandeered as the nurses’ station. The glass-free windows, all of different shapes and heights, looked out on straggly patches of crops assailed by the inevitable bush, with the mountains distant yet impressive. A tiny shed stood off at a respectful distance in a field, ready to be of service in longer sermons.

Outside, I had expected a trickle of women and children to arrive for their antenatal checks, immunisations, and growth-charting. In fact, more than a hundred women, plus their (mainly thriving) offspring stood around, chatting, laughing, milling. A few women sat under the acacia tree selling bananas and mandazi dough balls. I bought a bunch of small bananas with a 20p (TSH500) note, and the woman later dashed after me with the 16p change.

It was an awesome tribute to some unknown community health warrior that immunisation and growth-charting was clearly so deep-rooted. But what of childbirth? Where did they deliver? Who did the deliveries? How did they get to hospital if it rained? Abdallah began talking to some of the mums: Six children. All delivered here by the TBA. And you mama? Four children. Delivered in that small village over there. And you mama? Three children, all quick deliveries. The Traditional Birth Attendant barely had time to arrive and claim her chickens.

But what if there are problems? Then we come to Berega. How much does it cost? TSH 5,000 on a piki piki (motorbike) is the normal price, but when you are in trouble in labour, and need to go with your sister mounted behind you, the price is TSH 20,000. What if it rains? You come back. What if you don’t have TSH 20,000? You don’t go. We didn’t have the heart to ask the other questions.

Nhembo is only half-way to the edge of our territory. Chagongwe is the furthest point, another 20km on a worsening road, and then up the mountain. Our ambition is to reach out to villages like Chagongwe, and begin the conversations that might eventually lead to maternity care at last being available to their women. It will begin by sending out a (Maternal-Child Health) Community Health Worker for talking and listening: What happens at the moment? What do they feel that they need? Who are the leaders? Who the potential health workers? We need to meet the TBAs and get their view on the past, the present and the future. There will be no blueprint that tells us how to engage, how even to begin, except simply to start the conversations.

We can promise nothing as yet, but we have hope. Chagongwe, for instance, is one of the communities that Hands4Africa is intending to reach, ultimately with economic opportunity, transport and education. If we can gradually blend health into the mix, then perseverance might lead us to local solutions. If, at the same time, we begin a Clinical Officer training programme at Berega, then we stand a chance of being able to deal with the wave of work we unleash.

The Clinical Officer training programme raises for me an important philosophical question. How much do we bring in wazungu? (Europeans are called ‘Wazungu’. Originally a term of mixed respect and awe, it now means something between ‘people in shorts who forget to greet you, and then ask to take a photo’; and ‘people who turn up to meetings on time, in a bad mood’.) Post-colonial Africa gradually realised that the popping in and out of wazungu could do more harm than good. Deeply caring figures of authority dictating the right way; intolerant tolerance; creation of dependence; blurring of identity; cajoling by the culturally insensitive yet well-intentioned; then suddenly an exasperated absence, and a regression to the mediocre. The culture clash has not been all one-sided, and of course those oppressed in the past by colonialism have sometimes exaggeratedly resented the intrusion of the erstwhile oppressor.

But are we emerging into a new day? Post-post-colonialism? A generation has passed, and it seems to me now that we both know who we are. I look at the wealth of talented, healthy Baby Boomers in England, the very ones who marched streets in their youth to protest at the colonialism of their fathers. Or at the very least listened to music that their parents disapproved of, whilst under the influence of things their parents disapproved of. Are we not now all on the same side? Well, that may be a little naïve, but I’m OK with naivety. When we have the Clinical Officer training, then, can wazungu of various disciplines take it in turns to come over and enhance the training, as long as the base is solidly Tanzanian? Here, they really want it. Can English-speaking primary teachers not come and help in Mama Liz’s school for a month or two? She really wants it. I think we might be ready for a spot of post-postcolonial-wazungu-ism.

With regard to this particular mzungu, however, my impact, as measured by body weight, is now once more on the decline. Having been boosted by the culinary dexterity of Dan the Mighty, I am now thrown on scarcer resources. Thankfully, Sion is still there, and last night conjured an impressive lentil stew from the unlikely ingredients of lentil, and stew. But he works very hard and cannot always be looking out for me. As I sit at the desk all day writing this, I am painfully aware that my ischial tuberosities are protruding through my flesh, and impaling themselves on the chair. Let me have bums around me that are fat. Sleek-bottomed bums, and such as pad the seat. My buttocks have a lean and hungry look. They ache too much. Such bums are dangerous. (If you don’t understand that last bit, ask someone who went to school when they still had inkwells.)

On Wednesday, then, having missed early breakfast, I came back late morning and decided to whip up a Spanish omelette. Well, let’s say something in between English and Spanish. A Santander Ferry omelette, may be. Anyway, it had some onion in it, as well as other traditional ingredients such as egg. I was proud of myself, and served it up on our last piece of brown bread.

I particularly needed the nutrition on Wednesday, because we had the follow-up meeting to last week’s, on making a Charter of Expectations, to set standards for working in the hospital. I have said that I am naïve, but even I do not believe that a magic new day will dawn tomorrow, and dissolve the problems of the past like morning mist. A charter of standards will not create excellence overnight. But what is surely true is that without it, we will remain in the dark. There were too many examples this week of the nocturnal insufficiency of current practice: delays; casualness; tolerance of the unacceptable; death as a travelling companion. And, on the other hand, there were many other examples of diligence, caring, and dedication in sometimes the most depressingly desperate of circumstances. As I write this on Saturday night at 8 o’clock, more of the senior staff are in the hospital than are at home.

The excellent news is that on Wednesday we agreed, including all of the management, that we would indeed  take a charter of standards to the staff. We would indeed sign up to a charter, however battered and tattered, of minimum standards. The amazing Sion, I hope, will gently, warmly and persistently be trying to make the children’s ward a showcase.  I cannot imagine anyone more suited for the job. (Aided by another worthy mzungu – David Curnock, who comes next month!)  We need plenty of others as naïve as we are to see it through.

(For posterity, I will load a copy of the draft document onto a separate blog page. It still needs to be modified by staff. Much more, it still needs to have any effect. But at the worst, a future mzungu coming here in a decade or two might be saved the trouble of writing another one.)

The final mzungu to mention is Marjan, who arrived on the scene from Belgium, via four months in Ethiopia. Marjan is a lab person, and in just a few days, has opened up for me a whole new vista: lab staff on ward rounds, who help, advise, and then quickly give you answers to the questions you might have had. What a resource. Like Dan, she is just here for three weeks, but is shining like a light.

The future then, is beginning to take more shape. A hospital where death is unwelcome. Caring wards where good work leads to fewer problems. All joining together, including wazungu, in the shaping of this, and in the development of clinical officer training, to root deeply a culture of learning and striving.

Then, for mothers and their babies, we will begin outreach to the unreached villages, and invite cooperation. We will invite them to deliver more safely in our safer hospital. We will go back with them into the community, and help ensure that their babies grow into healthy children. Within five years, we hope that the mothers of those villages will have other uses for their chickens.

PS apols for the delay and lack of pics, which will follow – the internet link is 1KB/century

Laurence Wood

email.lozza@gmail.com