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Giving Birth in the Cordillera Mountains

It has been two years since I started attending the Regional Neonatal and Maternal Death Review in our region, the Cordilleras. I had been invited to be a panelist and as such, it is my duty to critique why such happened, and what should have been the intervention, and what could have been the possible problem that really transpired for such a death. But this forum is not only me and my fellow panelists giving our “expert opinions.” Rather, I in particular had so much learnings and realizations that makes the scenario surrounding each death very painful to accept and embrace as a health care provider. These are some of the few things I came to realize…

GEOGRAPHY

One of the problems identified in our region is the geography. Because of the mountainous terrain of Cordilleras, one pregnant woman would need to hike 45 minutes, some 1 or 2 hours from their house just to reach the road or access a vehicle that will bring them to the nearest barangay health station (BHS), or rural health unit (RHU). Imagine a pregnant woman in labor, walking this distance in between contractions, you would expect a longer time to access the road. Likewise, because of this terrain, some areas are infested with the rebels (New People’s Army) that deters them to go the the nearest health facility, no matter what stage or phase of health emergency they are already in. So if the mother is having post-partum bleeding, they will wait till sunrise before the go to the nearest BHS. And if the midwife at the RHU or BHS would not be able to address the problem, they will have to transfer the patient to the nearest district hospital, which might again take them a while to look for a vehicle that will transport them there.

Another problem that the geography poses is the lack of telecommunication network’s signal. While the nurses, barangay health workers may have mobile phones that would facilitate referral to their superiors for proper advise while patients are being transported to higher centers, the lack of communication signal deters such and thus are only addressed when the midwives or the receiving doctor in the district hospital sees the patient

LACK OF HEALTH CARE PROVIDERS

Another deterrence to full delivery of health care to every household in the rural is the lack of midwives. While there may be barangay health workers (lay people who are not necessarily midwives who can be first line to check on ailing residents), it is the midwives who supervise them and who will ultimately decide whether she can manage the scenario or refer the patient to higher institution. In one municipality alone in Ifugao with 18 barangays, they only have 5 midwives. ONLY 5 midwives. Again, consider the distances of each house, their distance from the BHS or RHU or district hospital. And they usually access these houses on foot. Midwives need to track women who are pregnant, follow them up at the RHU, refer them to higher centers if the pregnancy is high-risk, deliver their babies if unable to reach a birthing facility, follow them up to make sure the mother-baby dyad is in perfect condition, submit monthly report to their municipal health officers.

During the past administration, nurses (nurse deployment program, NDP) and doctors (doctors to the barrios, DTTB) were hired to augment this vacuum of labor force. The nurses were deployed to each barangay or two, to help and facilitate the work of the midwives. Definitely being novice in the community and public health, there are flaws and misgivings, that given more time and experience, these will eventually be addressed. Nevertheless, there was a noted decrease in the number of maternal and neonatal deaths because they were monitored.

Unfortunately, starting next year, these contractual employees will no longer have their contracts renewed, making again the workload of our midwives double, maybe triple or quadruple when the NDPs are gone. Thus a rise again in the number of maternal and neonatal deaths will not be a surprise.

LACK OF SKILLS

We the panelists are specialists and subspecialists. We talk of interventions appropriate to our settings, which is way far up compared to the birthing facilities that the NDPs, midwives and MHOs work at. For one our NDPs, who are mostly first time on the job, still lack clinical acumen to detect subtle signs of disorder in the newborn, or signs of high risk pregnancy. Thus they only become alerted when the severe complications have set in, and thus intervention would be late already. Recognition of these subtle signs and early referral would definitely make a significant difference in these conditions.

Not all midwives are skilled in performing episiotomy. Not a single midwife in the region is even skilled in performing full course of neonatal resuscitation. Even doctors at district hospitals are not specialists to correctly treat these problematic parturients and/or their babies.

CULTURE

One thing that I commonly noticed is the influence of the matriarch of the family or clan. Usually, especially in a place where the house of the parturient is far from the nearest birthing facility, a birth plan is laid out. They assign which (of the limited vehicle) will be used to transport in case she goes on labor. And after birth, how soon they will be visited by the midwive or NDP. In other instances however, the matriarch interferes and alter already the planned contingency. A first-time mother ought not to contradict what their “experienced” seniors dictate upon them. While our health workers are campaigning and encouraging health facility deliveries, some “experienced” matrons insists that their daughters deliver at home, with them helping out. Only then will they call for help when they encounter a major problem. One classic example was when a woman on her third pregnancy delivered at home, assisted by the family members. It took them several minutes attempting to deliver the placenta. And because the placenta was adherent to the uterine wall, as they were tagging the former, the uterus inverted. Only then was the midwife called. And because there was no “birth plan” it took them several hours before the parturient was brought to the hospital. There was massive hemorrhage, with the source not identified, that eventually lead to hemorrhagic shock and her death. Such useless loss of lives would have been prevented had it not been for the “usual practice” that these elder people enforced.

 

Many of these problems presented are often preventable but it takes interplay of so many factors to prevent one maternal or newborn death. Our region as a long long way to go…

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Posted by on November 29, 2016 in Deliveries, neonates, Pregnancy

 

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How Do I Tell The Mother?

I dont even know what to write, or how to start writing this… One thing for sure is that DEATH is inevitable… At the end of everything, DEATH is the only victor, it will conquer us all, no matter how much we try to avoid and evade it.


(Photo courtesy: http://thinkinlikegavroche.wordpress.com/2011/11/08/a-grieving-mothers-wish-pantoum-poetry-by-toni-cross/)

A mother on her fourth pregnancy was scheduled for emergency cesarean delivery as the fetus’ heart rate and activity is reflective of ongoing distress. Baby had immediate respiratory distress requiring her mechanical ventilatory support to breath effectively and with ease. Despite the assisted breathing, baby still showed progressive respiratory distress typical of preterm babies with deficient surfactant. Within hours, surfactant was administered affording slight relief. Baby’s response wasn’t dramatic as expected; perhaps due to delay from the ideal time of administration from birth. Few days after, when favorable response was expected and weaning from mechanical ventilator was expected to be quick, another problem arose, a patent ductus arteriosus. This now prevented us from weaning off the baby from the respirator. I administered an anti-inflammatory drug in an attempt to close it. After few doses however, the artery remained patent, otherwise baby was doing well. The next day saw poor blood gas status requiring appropriate adjustment of the respirator settings. I saw baby in the middle of the night as I had another baby born at the same hospital.

On the fifth day of life, everybody was surprised by the baby’s status: she was in severe shock. The right forearm to the hands changed in color similar to the hands of Dumbledore that destroyed the ring of Marvolo Gaunt. She was bleeding from her lungs, stomach and all puncture sites would take a long time to clot. Her skin was doughy dry and pulses were thready and barely palpable. Her abdomen and lower extremities were swollen. Blood gas were abnormal and needed correction. Medications were revised, blood products were secured for transfusion, respiratory settings were increased accordingly and cardiac drug support was added. Blood gas analysis had to be done serially but to no avail, she kept on having uncompensated mixed acidosis. Ventilator settings were increasing; urine output was decreasing signifying failing kidney as well. When she was “stabilized” (and so I thought she was), I went to other hospitals to round other patients and consult those at the clinic. Having a stable update at the end of the morning shift, I proceeded to my workout (this keeps me sane), while waiting for another possible preterm baby to be delivered. Then I went back to check on her after I was done, making sure she was stable. I then decided to go home and do my waiting there for the call to deliver the preterm baby. While waiting, I received a referral about the problematic baby, saying that color became worse. She immediately requested for blood gas analysis; the result made my intestines knot several times as the figure clearly spoke of death. The pH was 6.7! (In medical parlance, a blood pH of less that 7 or more than 7.7 is NOT compatible with life). I ordered for aggressive correction and while doing so, I got called to another hospital; it was time to deliver the preterm baby. It turned out that the baby was term. Upon making sure that the newly born baby was well, I went back to the other hospital where my problematic preterm is. Yes, I brought blanket with me as I expected to keep vigil and watch over her. She remained stable and early in the morning, I repeated the blood gas analysis. It was still below 7 at 6.8. I already knew that “Death” has already claimed baby with his scythe, and I was just waiting for exact time her heart will beat last.

(Photo courtesy: http://www.medscape.com)

I saw the mother… I was helpless, I didn’t know what to tell her but I know that she already had the feeling. Mother’s have instincts, they would know when their child isn’t doing well. I just didn’t want to underscore and concretize the fear that she was feeling inside. Was that the right approach? I don’t know. I just didn’t want to sound and appear mean to her that early hour of the day. So, in my attempt not to crack the bad news, I asked her religion and if she wants baby to be blessed/baptized while there’s still a chance. So far in my mind, this was an indirect way of saying she will not make it. She agreed and arranged for the minister to pay the baby a visit. Before I left, I told her that it is up to baby’s response where this treatment will go. Then I went home at around seven o’clock to have my breakfast and for few hours rest. I was anticipating then that I will be called during lunchtime when the baby’s heartbeat has ceased. I finished my clinic consultation and rounds at other hospital when I finally got THE CALL. When I saw in my phone’s LCD that name of the caller (the hospital where the problematic preterm is), I already knew it was TIME. True enough, even without me asking, the first sentence of the caller said “We can no longer appreciate a heartbeat.” So I rushed… checked on her, and called the time of death.

 
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Posted by on April 22, 2012 in Personal

 

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