By Lt. Cmdr. Andy Baldwin, Family Medicine resident, Naval Hospital Camp Pendleton, Calif. Lt. Cmdr. Baldwin is participating in a month long rotation in Western Kenya as part of his Family Medicine Residency at Naval Hospital Camp Pendleton, Calif.
Lt. Cmdr. Andy Baldwin is participating in a month long rotation in Western Kenya as part of his Family Medicine Residency at Naval Hospital Camp Pendleton, Calif.
Hello again! I’ve been in Kenya for a couple of weeks now and wanted to provide you all with a progress report and give you an idea of the crucial work we’re doing over here. It’s been an eye opening experience for me so far and such a departure from everything I’m accustomed to in a military family residency back in the U.S. I think the story I am going to share with illustrate some of what I mean.
Just days after my arrival at the Chepaiywa Health Center in the Rift Valley Province, I was teaching the staff the Neonatal Resuscitation Program when a woman presented in labor with her fifth child. After delivering well over 100 babies at Camp Pendleton, Calif. over the past year in a controlled and highly monitored environment, the ensuing delivery showed me first hand a true “natural” delivery. Much of what I had learned, if not all, about the process of monitoring and delivery of a child went out the window.
The woman had no records, especially not an electronic medical record on the Armed Forces Health Longitudinal Technology Application (AHLTA). I had to rely on the size of her abdomen and doing what we call maneuvers to estimate the size of the baby and how many weeks along she was. By my estimation she had to be at least 37 weeks gestation which is term and a good thing. As any of you who’ve been party to a conventional birth in the U.S., whether as a mother, delivery doctor or nurse, or even as an excited father-to-be know, with a modern equipment setting this patient would be checked in and put on continuous monitoring of her fetal heart rate and the strength and frequency of her contractions. She also would have had screening for diabetes of pregnancy, anemia, high blood pressure, and bacterial infections. But this woman had none of these.
Her “sister,” in fact, insisted on doing the check of seeing how far along she was in terms of dilation, of which I promptly followed, and felt her four centimeters dilated and able to feel what I thought was the head of the baby. This was good but not incredibly reassuring since you never want to deliver a baby vaginally feet first (breech). Usually you rely on an ultrasound machine to prove that the baby’s head is down. Not in this case. I also relied on a “fetascope” to check the baby’s heart rate. This is basically a plastic horn shaped device that you put one end to your ear and the other to the woman’s abdomen and listen for the heart beat. I heard the heart beat, but there was no electronic monitoring here.
This woman was in active labor and having contractions every two minutes, and had no anesthesia. There is no such thing as an “epidural” in this part of the world. Yet, she was stoic as could be. After being checked for the status of her baby I watched as the woman put her sandals back on and walked down the dirt path. “Where is she going,” I shouted in bewilderment. “She’s going home, but hopefully she’ll be back,” said one of the nurses. This defines the overwhelming feeling here of “Hakuna Matata,” which if you’ve seen Disney’s The Lion King you know means “no worries, it’s all good.” If the mom delivers at home, it’s okay. If the baby doesn’t make it, it is sad, but it’s okay. It’s not our responsibility to deliver this baby. We are here to help if she wants it. I looked up and took a deep breath and tried to eliminate the first-world medicine mindset from my head.
The woman did return several hours later with even stronger and frequent contractions, yet she remained her same stoic self, not uttering a word, and just occasionally wincing in pain. I checked her status, and she was almost fully dilated and ready to start pushing. She had a colorful dress on and assumed a squatting position in the delivery room of the clinic which basically just had a table, scissors and some sterile gloves. There were no footrests, no sterile delivery area/sheets, and other than the occasional listen by the fetoscope, we had no idea what the baby’s heart rate was.
I asked the woman in Swahili whether she wanted a boy or a girl, and she replied girl. Only time would tell. Unlike in the U.S. where a second trimester ultrasound will let us know the sex of the child, this was surprise at delivery. If it were a girl, she would name her Joy. I had a presumption she would deliver quickly, and almost seeing the baby’s head crowning as she was doing a squat I urged her to get on her back on the table and for the others to get gloves on and be ready to help the baby if needed. The suction device for the baby looked like a large turkey baster. I delivered the head without issue, but with the woman’s small pelvis, I realized that we had a shoulder dystocia, meaning the baby’s shoulders were stuck. I used the skills I had been taught at Naval Hospital Camp Pendleton, Calif. and took the steps necessary to deliver the shoulders. For a second I thought I would have to break the baby’s clavicle to get the shoulders through.
The clock was ticking and none of us had any idea of whether the baby’s heart rate had been low and there had been a deprivation of oxygen to the baby. Joy it was! As the sex revealed a girl, I cut the cord, but noticed that baby Joy looked awfully pale and was not crying. The nurses looked at me not knowing what to do. The time for neonatal resuscitation was now! Using the suction, and tactile stimulation I was able to clear the airway and reaching for a ventilator bag-valve mask was able to give some rescue breaths. After what seemed like an eternity, Joy let out a cry.
I breathed a sigh of relief and continued to ensure she was breathing. Her mother by this point had delivered the afterbirth and was in a pool of blood, and I rushed over there and was able to do some massage of her uterus to get it to firm up and stop the bleeding. She smiled and got off of the bed in complete control, said “Asante” (thank you) to me, and picked up her baby and immediately started nursing her on the breast. She then proceeded to put her sandals on and walk home with her new baby. I looked at my watch. This had all occurred within 30 minutes, and now the mother and baby were on their way home.
A thousand things rushed through my head, “what if the baby had aspirated and would get a lung infection,” “what if she had trouble breathing,” “what if she couldn’t feed well?” This is the reality of natural child birth, which has been taking place since the beginning of time — only some babies and mothers make it through.
If you get pregnant 10 times, and five of the children make it, then this is the way it is. In many areas of Kenya, this is how it still happens. In the area of Kipkaren, with the Chebaiywa Health Center, we are working to change this, and in this case I am glad that things did not take place fully naturally, for if that were the case, baby Joy may not have made it. With basic education around neonatal resuscitation many more Joys will make it as well and I hope to help facilitate for the wonderful people and a truly beautiful culture.
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This is incredibly thought provoking and educational. I’m learning so much from Dr. Andy Baldwin’s medical mission- it is changing how I think.
@MayNBC
Just a few thoughts for Dr. Baldwin: I am a Family Doctor, just retired. You mention several times that in U.S. hospitals, we do continuous fetal monitoring during labor, routine ultrasounds, etc. etc. There is no evidence that continuous fetal monitoring is at all predictive of fetal outcome, and even ACOG states that intermittent monitoring(with fetoscope–a tool I used a lot when I trained and early on in practice) is quite acceptable. Determining position by exam is a good tool to have, as well. Our neonatal outcomes, despite all our technology, are not as good as many nations, even some that are not “first world”. Many of us our in the real world actually try to let women labor as naturally as possible(walking, positioning, etc), and let them choose the position for delivery. I rarely use the dorsal lithotomy position(unless the woman requests–a rare thing), I do bed deliveries, often on the woman’s side. Dystocia is usually not an issue in that position, and almost never in knee-chest position.
Your maneuvers to resolve dystocia are always good tools to have, but remember prevention as well. Congrats on the resuscitation–in almost all cases, a little oxygen is all it takes!!
Your experience must be eye opening and wonderful in Kenya!! Some of what you learn can be translated into US medical/obstetrical care, I am sure.
Sharon Dietrich MD
Very humbling to practice in the developing world. Thanks for sharing your experience. I saw some of the unlucky mothers in Sudan and Tanzania. People
Forget that natural and safe are not the same.
Andy,
Good story! I am working with a group seeing about electronic medical records in the underdeveloped world – read, most of the world! If you had that capability, what would you REALLY want and need – remember, you are not billing, and coding is different. Are there repeat visitors to the clinic? Could you create an identifying system for the patients – has to be yours since it is not important to the people. I have a telephone appointment Monday, October 31, and would appreciate some input. Thanks, Bob Landes