by Bartholomew Kondwelani Kamlewe, Registered Midwife
”Midwifery is one of the oldest professions in the world…Historically; midwives were the only caregivers for women in childbirth…” (Sellers Midwifery, 2nd edition)
On the 1st of June, 2018, Lubalilo [above] gave birth to her first child. Baby was born preterm at 35weeks 6days (calculated from Last Normal Monthly Period) following a long battle with pregnancy induced hypertension which had complicated into severe pre-eclampsia. She had previously been admitted to the hospital on 1st May, 2018 with severe pre-eclampsia , later discharged and readmitted again on 23rd May, 2018. Ultra sound was done on 24/05/18. Findings indicated single live intra uterine fetus with gestation 30 weeks 2days and weight of 1500g.
Her admission period proved to be a time of adjusting to the condition and preparation for
delivery. She was a mother who was willing to learn how to cope with pre-eclamspia and the various interventions and observations that had to be done while admitted.
Managing complications of pregnancy in maternity ward make wonderful interaction moments if a client is very inquisitive, cooperative and interested to learn. She was discharged on 22nd June, 2018
On the 6th of July, 2018, she came for review and baby weighed 2100g
On the 8th of March, 2018, we received at our facility, a referral unlike any other from our District Hospital. Baby of Cecilia, a 900g female neonate had been born at home during the 6th month of the pregnancy. The mother was neither prepared for the pregnancy nor the delivery; she also had no history of attending antenatal…
I happened to be on-call for this particular referral. Despite all odds seemingly against this neonate, they say, “hope is the last thing that we should lose” and this was the motivation needed to do the best we can for this baby to ensure its survival. On successful intravenous cannula insertion at 1st attempt, the surprise and commendation from the referring nurse reminded me that some of the moments we encounter at work we may take them for granted like it’s just work because we do them every day but may be a motivation to our fellow staff. It was also a reminder that as nurses and midwives trained in emergency obstetric and neonatal care (EmONC), we need to use our knowledge and skills in everyday situations to bring a positive impact in the lives of our patients, the parents and our fellow staff through mentorship.
On admission, the mother was skeptical about the survival of the neonate; she kept asking if baby was going to survive and initially seemed already discouraged in caring for her newborn baby. She stated the baby was too small to survive especially that she had had several incidences of apnoeic spells and was kept on oxygen therapy for almost the first two weeks of admission. (She was weaned off oxygen on the `17th of March, 2018.)
On-going involvement of the mother brought a sense of hope and responsibility towards the baby. When the neonate was stabilized, the mother was involved in tasks such as expressing breast milk, checking in on the baby to see if it is breathing, reporting if she sees anything abnormal, checking if baby has opened bowels and passed urine, bring nappy to change the baby and later on kangaroo mother care. Of course these tasks were not immediately done by the mother as she had to observe first and gradually be trained and encouraged with such tasks. The aim was to encourage her to start learning slowly but surely how to care for gross preterm neonates during hospital stay and prepare her for post discharge care. It was also an intervention aimed at fighting the boredom that comes with caring for neonates in the hospital which can take days to weeks or even months. By the way our hospital is rural based and has no diversional therapy like radio or television in the kangaroo mother care unit as we have no power.
Nothing brought more satisfaction at work than to see a mother who initially had no hope of seeing her baby born at 6months survive, seemed uninterested to participate in the care change her attitude and become fully participatory towards caring for her baby!
On the 15th-16th day around 4am, baby of Cecilia had ceased breathing and Heart Rate was less than 100 beats per minute. Mother reported, resuscitation was done, baby was kept warm, oxygen given and stabilized. This is one of the many moments to highlight vigilance on the parent which went a long way to save the life of the neonate.
How we care for neonates in our unit
Sacred Heart Hospital is rural based in Katondwe, Luangwa District. It is located about 300km East of the capital Lusaka. Until 2016, It was the only 1st level facility in the District of now about 29506 (CSO, 2018) people. Currently, it is the only facility offering comprehensive emergency obstetric and neonatal care. We do not have a designated special care baby unit (SCBU) or Neonatal intensive unit. All we have is a resuscitaire which is just used to admit babies for close observation and management during intensive care. It is not used fully due to lack of power. We also have a room next to the labour room that is being used as a neonatal intensive care unit (NICU). The room just has two beds where the mothers to the neonates are admitted and also it is here where Kangaroo Mother Care (KMC) is done.
KMC is the currently practiced technique of caring for neonates in our facility but could not initially be used for our new patient. She had to be stabilized and cared for at our resuscitaire first. She was kept warm by use of hot water bottles & containers, fed via nasal gastric tube and given intravenous fluids as prescribed. Also, she was covered on antibiotics and given oxygen therapy.
On 23rd March, baby of Cecilia weighed 910g. Weight gradually improved to 1060g (the highest we recorded) on April 1st and by discharge time had gone back to 1000g
Being in the rural, the facility has its share of challenges which range from infrastructure, human resource, equipment etc. These include lack of electricity as major, as most equipment like resuscitaire would require power to run. Also lack of adequate equipment, as well as lack of skilled manpower adds to the list. At our facility, we have 28 nurses and midwives (8 midwives, 20 nurses*). Only 4 are trained in EmONC.
*Of the 20 nurses, two just completed their training this June in midwifery which will increase the number of midwives to 10
What is going on well?
Currently, the Zambia under-five and infant mortality rates stand at 75 per 1000 live births and 45 per 1000 births respectively while neonatal mortality rate is at 24 per 1,000 live births as of 2014. Zambia’s target is to reduce the neonatal mortality rate to less than 12 per 1,000 live births by 2021. Our facility was one of those recognized in May 2018 for its efforts in contributing towards 46 percent reduction in maternal mortality ratio in the saving mothers, giving life
What is needed to do our job?
We have now made great strides to increase the number of skilled birth attendants at our facility. We have 8 midwives and of these, only 4 have been trained in emergency newborn care (EmONC). Therefore, increasing the number of staff trained in EmONC would probably result in much better care of the neonates as well as the mothers as the midwives will have enhanced skills.
We currently use solar power thus power to run equipment like resuscitaires which come with in-built heaters to provide combined heat source and oxygen is needed. We need television sets or radio for diversional therapy as Kangaroo Mother Care can be exhausting for the mother.
“the Bad moments”
The mother was admitted at our facility on the 8th of March and was discharged on the 13th of April upon her request. She had been away from home for that entire period and wished to go and see what is happening to the remaining children at home. The zeal to be in the hospital any longer had gone which we saw translated in reduction of the weight for the baby to 1000g. However, our recommendation was that she be discharged via the District Hospital for continuum of care since it was near her home. She accepted. We called and arranged for her admission and when ambulance came, she was picked up.
While at District Hospital, we were kept updated of the care and within a few weeks, we had seen a great improvement in the weight of the child. She was discharged with baby weighing 1900g.
A few weeks later, baby was reported to have died due to negligent care by the mother and brought to the facility already dead.
This was a sad time for the health care teams after all the care that was put in to see this neonate survive. We had also started writing a combined success story having resuscitated and managed a grossly preterm infant born at 6 months and discharged at 1900g for ongoing care at home.
In conclusion, the various interventions that had been put in place to care for this baby had proven how effective evidence based practice with faith could lead to better outcomes for the babies. This is one of the many babies that have seen better outcomes despite being born preterm and managed with limited resources reducing the need for referral for more specialized care in towns where life is expensive.
Through mentorship rounds, many suggestions to modify the room have been made which have since started to be implemented. Several facility and staff from other institutions in the District have been empowered with skills to help manage such neonates as they await training in EmONC.
On the 5th of July, 2018, a severely malnourished child aged four months died within hours of admission. He had been born prematurely weighing only 1000g in March and was discharged a month later. A lot of effort was put in to try and resuscitate the child but to no avail. It was painful to see all the suffering this baby had gone through while mother insisted child was only sick a day. Evening of the same day, switching on data on my phone I saw a post about our family dog having had died of babesia that evening. It was an emotional time having lived with the dog for over 8 years. It had lost weight and that image brought back the image of the baby back to mind.
There is only so much that one person can handle emotionally in one day…
Mother kept insisting child was okay until a day before admission and stated that child was indeed breastfeeding while at home despite all the signs that baby had been starving. All trace of emotion was not seen in the mother even in the last moments of the baby’s life.
Later that night, I felt the need to establish a vet clinic to help animal’s access better healthcare but I also realized we have a lot to do with regards to improving neonatal outcomes for babies born prematurely and especially in less educated mothers. The need for follow up home visits, vigilance and linkages cannot be over emphasized.
Also we need support systems to care for carers as the emotional burden that comes with caring for neonates when left uncheck can lead to so many other issues in the lives of staff.
ANNEX Permission for use of pictures
BARTHOLOMEW KONDWELANI KAMLEWE REGISTERED MIDWIFE
KATONDWE HOSPITAL LUANGWA DISTRICT +260978542385
BRIEF BIOGRAPHICAL Author is a nurse midwife and clinical instructor working from a Mission Hospital in rural Zambia about 300km East of the Capital Lusaka. He has been in service for 7 years as a nurse and 2 years as a midwife. He is Trained in EmONC & clinical mentorship and loves documenting experiences at work.
Resuscitaire in labour ward requires power to fully function
The room used as kangaroo mother care room. No modern equipment (heaters etc) or television or radio to keep mothers busy, room is also used for instrument processing