Friday, April 5, 2013

Day 6- Teaching NRP

It has become apparent that many of the Haitian midwives are not adequately skilled in neonatal resuscitation (and yes, that is indeed an understatement). From an outsider's perspective (who has now had the opportunity to see several different reuscitation scenarios here) there are a few issues that are adding to the inadequate resuscitaion efforts. First- and an obviously glaring problem- is the lack of foresight and planning ahead in anticipation of delivery and the possibility of a resuscitation occuring. It seems that nothing is ever set up in the dleivery room. Nothing is organized or easily obtainable. This of course presents quite a chaotic environment when something is needed STAT and you have no idea where the item is, or if you even have it. Imagine a mom who just delivered. She starts to hemmorhage and you decide she needs pitocin, yet not only is there none drawn up at the bedside, but there's no vial or needle and syringe. Or, as I've seen this past week, there's a vial of pitocin and no needle or syringe. Um, hmmm...useless. Oh, and you have no idea where those supplies are, to boot. Doesn't make for a good outcome. And yet this situation was easily preventable with some foresight and planning accordingly.

The midwife I trained under as a student midwife was (is) diligent in set-up. If you are anticipating someone coming in, you get the room ready. This includes checking stock of supplies, turning on heating pads, making sure instruments, suction, and resuscitation equipment are readily available, oxygen tank is within reach and the tank is open, and the anti-hemorrhagic meds drawn up and readily available in the delivery room. Everything you need, for every situation, is immediately available. No messing around. Because this was pretty much pounded in me, I am OCD when it comes to birth set-up.

I know that the midwives here have been (theoretically) trained in NRP, but it seems apparent that the skill training, assessment, and continuous practice has not occurred. NRP is not something that you can become competent at from reading a book or sitting in a lecture. It's continuous practice, continuous honing of the skill, and the gain of confidence in doing it correctly.

NRP can be intimidating. Having a compromised baby (one that is essentially in danger of being damaged forever or dying), is the most nerve-wracking, scariest thing. Take the lack of skill, lack of confidence, and compound that with the lack of resources here (high volume hospital, under staffed midwives, no assistants, unsanitary conditions, and lack of supplies), and is it that difficult to understand why so many babies are dying? No. I get it. And even as much as it pisses me off that a baby was just left to die on a counter, I'd like to think that whoever did that just simply didn't understand that the baby needed help. Or just didn't know HOW to help and panicked.

These are good midwives and I know we can do better.

With that said, Glen, Liz, and I hosted a neonatal resuscitation class this morning here at the Midwives for Haiti house. We had a great group of prior graduates of the program. IT WAS FANTASTIC!

NeoNatalie dolls

We opened up the class by discussing the most important thing in helping to ensure a good outcome: PREPAREDNESS.

Prepardness was the biggie for me. It's a simple fix, requiring only minimal effort, utilizing whatever they already have. I opened up this discussion by speaking of the unpredictability of birth. What about the primip who comes in and is 2cm and we think we have a while before birth, yet she precips and we have a baby less than an hour later? Been there! What about the mom that shows up pushing? Been there! These things happen, so why not anticipate and plan for them?

"Always be prepared."

What does 'preparedness' mean? It refers to having the delivery set up out- gloves, delivery instruments, pitocin drawn up, alcohol wipe, resuscitation equipment, and a towel and hat for baby. We also discussed the importance of having a 2nd midwife once birth is imminent, as this midwife's role should be to care for baby and assist with resuscitation, if needed.
A set up for birth.

Next, Liz discussed the basic NRP sequence, emphasizing the importance of proper ventilation. Glen then did several demonstrations of the proper way to ventilate. We then took the pressure off of the midwives and put it on us. We told them to give a scenario in which neonatal resuscitation would be needed. Glen and Liz then ran a full resuscitation, based on the scenario that the students made up.
Glen demonstrates the proper way to ventilate.

After they were able to see it demonstrated a few times and the ice was broken, the midwives came to the front in sets of 3- one was mom, one did compressions, and one did ventilation. They alternated so that each person got a turn.

We repeatedly told them how much we were learning as well from this class. Again, NRP is not a skill that can just be read and never practiced. The more you practice, the more comfortable and confident you get, and the better your skill gets. I really think this put the Haitian midwives at ease.

After we practiced, we went to the kitchen table and I showed everyone proper suction technique. This is also something we have noticed- bulb syringes being put in baby's mouth, and THEN compressed, or the midwife simply not being aggressive enough and not able to suction anything out.
Lastly, almost all of the midwives had never used a DeLee manual suction. This is partly a problem of resources and the lack of available supplies, but I have seen a few here. This is something that I really hope to see them get, and a simple piece of equipment that every midwife should be able to use.
Our table to practice suction
Glen, Liz, and I wrap up the class and feel confident that we have provided a good foundation for the midwives to build on, and for now, we have strengthened their understanding of the importance and process of neonatal resuscitation. This feels damn good. The midwives leave with smiles on their faces and we all take a picture outside of the house.
Our class
With a morning of work completed, we eat lunch and then take off for an afternoon of adventure! We are joined by one of our translators, Gladious. We are going swimming at a waterfall! It is a perfect day for it. (Though, most days in Haiti are a perfect day for swimming.) I have officially re-phrased the saying, "It's hot as Hades." It is now, and will forever be, "Hot as Haiti." Definitely appropriate.

We get to the waterfall and it is gorgeous! We take a hike up to see the top and explore the cave. We are accompanied by a dozen Haitian children. We are told that they are here to "assist" us and will expect reimbursement of one American dollar at the end of the tour! Ha! I gladly accept the help of two young brothers. I find myself very grateful for their help about halfway through our upward hike, as I am slipping and sliding in the mud and water. These little boys are literally holding me up and preventing me from falling flat on my face.
Who knew we would have an entourage?

Glen's tour guides

My tour guides

Getting ready to swim!

After our hike, we got in the water, climbed on the rocks, and let the waterfall pound on our backs. It was better than any expensive hydrotherapy massage you could buy! In the water, there was a massive tree trunk that was floating. We were climbing and trying to balance on it with the kids. Funny how a tree trunk could be used as though it were an inflatable pool toy. But even better!

And that was the extent of our day.

Tomorrow brings a night shift at the hospital...

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