The Body Knows

By volunteer Ann Marie Gilligan, Registered Nurse

Blog originally posted on the Every Mother Counts website here.

 

Hospitals are not only for the sick. It is essential that women receive skilled health care when they give birth. In Tanzania, the rate of maternal and infant mortality is one of the highest in the world. FAME-Africa encourages women, particularly those with a high-risk pregnancy, to get to the hospital for their birth, especially if they do not have access to a skilled birth attendant, even if it may require many hours for their journey.

In my two weeks training the staff at FAME, I assisted in many births. I was asked to come and facilitate training for the medical team in “Maternal Positioning for Optimal Fetal Positioning.” This is a specialized training that optimizes fetal and maternal well-being by helping the fetus move into the ideal position for birth through a variety of maternal positioning. It is a very safe and straightforward process.

The first step of this process is to view the pregnant mother’s abdomen while she is lying flat on the bed. You get down to the level of the bed and observe which side of the uterus the fetus is leaning towards. Next, you do what is called ‘Leopold’s Maneuver’ to determine where the back of the fetus is in relation to the maternal spine and where the head of the fetus lies in relation to the maternal pelvis. You might then do a sterile vaginal exam to determine the dilatation and location of the fetal head. Based on these observations, you will then instruct the woman, through demonstration and a thorough verbal explanation, which positions she might take to facilitate moving the fetus into a more optimal position: specifically, the fetus’s back on the maternal left.

Studies are consistent in the conclusion that if a fetus is in one of the many less optimal positions at delivery, this alone is associated with a higher risk of adverse neonatal and maternal outcomes. This is why I am passionate about what I do and why I want everyone to learn more about it.

A young primigravida (a woman pregnant for the first time) from the Maasai tribe was admitted to FAME at 5:00AM in labor. She was examined vaginally prior to my arrival at 8:00AM, and was found to be 2cm dilated and the baby had not yet descended into her pelvis. She reported that she had been laboring for 24 hours. When I met her, she was lying laterally in her bed. Each time her uterus would contract, she sang out in a high pitch cry while rapidly slapping her lower back.

With the help of Tanzanian nurses interpreting for me, I told her that I would very much like to see if I could help rid her of her obvious lower back discomfort. She immediately said yes, and we walked with her to the room in the back of the ward where two delivery beds occupy a room that also serves as a nursery. My Tanzanian RN peer asked permission to touch her body and we viewed her abdomen, then placed our hands on her baby in utero and concluded what position she was in. This little one had somehow decided that the maternal right side was her temporary home while her head was up against the maternal iliac crest (hip bone). If the labor continued with the baby in this position, it could present multiple problems.

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Her contractions were palpating strong and were frequent, occurring every three minutes. Our patient was visibly tired and appeared to be in a lot of pain. Our goal was to help the baby get over to the maternal left side, therefore decreasing the discomfort to the woman’s sacrum.

First up was a 5-minute warm shower. The water was aimed frontal and low in the abdomen. This can help relax the muscles and ligaments supporting the uterus. Next, she was instructed on how to do some yoga stretching to bring the respiratory diaphragm off the top of her uterus. The abdominal lift came next to help the infant into a chin flexed position that would enable her to rotate to the other side of the uterus. Our last maneuver is named the “side lying release.” She was assisted into this lateral position in bed and her top leg was brought over and off of the bed. This technique stretches the lower uterine ligaments to make more room for the infant to rotate.

Once her baby was determined to be in the optimal position, I instructed her to get out of bed. I told her to use her voice to help release the intensity of her powerful contractions that were now felt solely in the front of her uterus, near her cervix. She was encouraged to make noise through calm rhythmic breathing and noises that she could call her own. I told her to listen to her body, as it is wise, and will guide her through purposeful movements. Once I gave her this permission and guidance, she became very fluid and danced through her contractions in a way that I have not witnessed in a very long time. She arched her back, swayed her hips, squatted, lifted her arms and waved them in unison. Her voice could be heard throughout the unit and out onto the paved walkways of this open facility. At one point, a male doctor came to check on her and he joined her in dance. We, including the woman, thought this doctor was funny and so we all laughed and danced together.

I encouraged the woman to continue in the upright position, taking short moments to rest when she could, while sitting on the birth ball with her head leaning onto the bed. Food and tea was encouraged throughout her labor. Her mother was always by her side. 

The next morning, I did not attend the daily doctors’ meeting and instead looked for the woman so that I could find out the result of her amazing efforts in labor. Isdori, one of the male midwives on staff, had assisted in her birth. I had left at 4:00PM, and she had delivered 2.5 hours after that, at 6:33PM. She had pushed for as little as one hour and her daughter had an Apgar score (a quick method to summarize the health of a newborn) of 9/10.

I walked into her room, occupied by two other post-partum mothers. She was still shielded by her draped mosquito netting. Her body was turned towards the wall in a fetal position wrapped around her newborn. I called out her name and her face turned towards me. She smiled – a smile that told me, “I did it, I am proud.” I stroked her forehead and smiled back, telling her she was so strong and brave. Her expression, the one of ultimate self-satisfaction, made my long trip to Karatu, Tanzania all the more worthwhile.

 
Kathrine Kuhlmann
An Evening Shared in the Labor and Delivery Unit at FAME-Africa
 

By Volunteer, Ann Marie Gilligan, Registered Nurse

Blog originally posted on Every Mother Counts website here.

I have worked the last several nights with a team of nurse-midwives in the Labor and Delivery unit at FAME-Africa, a grantee partner of Every Mother Counts. A nurse-midwife is a Registered Nurse that has additional training in pregnancy, childbirth, and postpartum care. All of the nurses at FAME-Africa who work in the Labor and Delivery unit have the title of “Midwife.” They are an incredible team, and I want to honor them by writing my first blog about what it is they do, day in and out, with a smile on their face. In the US, my job as a Labor and Delivery RN is hard. At least, I used to think so. This Tanzanian team is responsible for phlebotomy, level 2 nursery, ICU (intensive care unit), OB (obstetric) patients, OR (operating room), Post-Partum care, gastrointestinal examinations, the pharmacy, AND they deliver 50% of the babies. They are not assigned a patient, they work as one. Their individual care is woven together in a seamless fashion, creating a layer of excellent care provided at FAME.

 
Evelyn, Ruhama, Agness and Jacob, nurse-midwives at FAME

Evelyn, Ruhama, Agness and Jacob, nurse-midwives at FAME

 

Yesterday, after an already trying day, a patient was brought into the unit after suffering a seizure at home, seven days post-partum. She had global confusion, no ability to speak and responded only to deep pain stimuli. When told she would be arriving soon, none of the team members were on edge or changed what they were doing to prepare for this patient’s arrival. “We have seen this many times,” was the answer when I asked about their calmness. This team cared for her in a way in which I will never forget. The patient was brought in with her newborn in her mother’s arms, wrapped in several colorful African cloths. She was placed in a semi-private room with two other patients. One was a twin pregnancy with premature rupture of membranes and the other a laboring young woman.

Agness, Jacob, Evelyn, and Ruhama were part of her team of care. Agness got her settled, took her vital signs and welcomed her family. Jacob restarted her infiltrated IV within seconds in a hand where I couldn’t begin to see a vein available for use. Mama Evelyn put in a Foley catheter and got labs as the others handed her supplies without the need to be asked. Ruhama put in an NG (nasogastric) tube and spoke to the physician on call for orders. You have to realize how critical this patient was – she easily belonged in an ICU in the States.

These nurse-midwives already had a full unit of women laboring, postpartum and antepartum. When orders were placed by the efficient Tanzanian physician, they included a very critically needed yet potentially heart-stopping medication. In the US, this is prepared by a registered pharmacist. Ruhama calmly broke open the vials, confidently drew them up into her multiple syringes and gave a very combative patient her anti-seizure meds via IV and IM (intramuscular). After the patient calmed down, porridge was prepared by yes, a nurse-midwife, and placed, warmed, down her NG tube with precision and respect, having made sure the temperature was just right by placing a droplet on her forearm before pushing it into her stomach. The nurse-midwife talked to her comatose patient each time she came in contact with her, checking her mental status but also knowing the importance of including the patient in their care. My role could have included assisting with a number of those skills performed last night but I knew in my nurse bones that I was witnessing a symphony. So, I stood and watched, taking note, and beaming with gratitude that I can be included in this group called Registered Nurses.

 
Salina, two days post presenting to FAME-Medical with a complication

Salina, two days post presenting to FAME-Medical with a complication

 

The next morning I arrived on the unit. This new mama was lying in bed, surrounded by her immediate family, nursing her newborn with a glowing expression on her face.

 
Kathrine Kuhlmann
It Takes More Than A Village
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There we were, with a sweet baby boy, who was barely a day old and suddenly an orphan. His Maasai mother had succumbed to eclampsia shortly following his birth. He was a small newborn and was placed into one of our incubators upon arrival, but he was strong, undoubtedly strong. One of FAME’s social workers, Kitashu, sprang into action as soon as he heard of the child’s current circumstances. He immediately contacted the family, who were far from FAME in a very remote village in the Ngorongoro Conservation Area. He knew to support this newborn, he would need to involve the family to find someone to breastfeed and to help care for this charming baby boy. At FAME, and throughout Tanzania, the nurses know formula feeding for babies is not a sustainable solution due to limited resources. For most cases of maternal mortality, nurses and social workers look for a relative or neighbor that has young children and is able to breastfeed an additional child. For this baby, it was a challenge for Kitashu to find someone. After communicating back and forth with the child’s village and relatives, they finally found a young Maasai woman a few villages over who had a small infant of her own that would be a great match for our new little one. She agreed to come to FAME for three weeks for our team to observe feeding and ensure this baby boy would continue to grow and have the same strength we noticed during his first moments of life.  

During their stay at FAME, Kitashu worked with the young mother to ensure she, her young child, and our little one received the attention they needed. He brought them baby clothes, soap, and “kanga” which is a common type of Tanzanian fabric many new mothers use. As the social worker on this case, he was able to develop a relationship with this newly formed family. He said he saw an opportunity to help and he was happy to take it. With a huge smile on his face, he then disclosed that on discharge day, the family chose to name this new baby boy Kitashu, because of all the support they had received.

 

Social worker Kitashu and his namesake still get to see one another for check ups during Well Baby Day in the Reproductive and Child Health Center at FAME. At three months old, he’s still doing well and growing stronger and stronger with each visit. As an observer, seeing Kitashu work alongside this family, ensuring the safety and stability of life for this new baby boy was incredible. The family clearly has a lot of respect and love for Kitashu after the support he’s provided. Additionally, the young woman who stepped up to care for a baby that prior to our phone call, she had no relationship to was inspiring. We were all in awe of this new mother who came forward, willing to travel to FAME for nearly a month to support baby Kitashu without having ever met his family and with a young child of her own in tow. They say it takes a village, but this case made it evident that, sometimes, it takes more than that. It takes deep kindness and unconditional compassion that transcends village boundaries.

Kathrine Kuhlmann
Back to School - Meet Hosiana!
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After working at FAME for two years as an Enrolled Nurse, Hosiana will be leaving us for a year to continue her studies and become a Registered Nurse! She is very excited to travel to Moshi to attend school, but is already missing her home at FAME. With two years experience at FAME under her belt, her favorite thing about working here is how free she feels, in her work and interpersonally. She’s able to connect with administration, voice her opinions, and feel heard. She says the way administration handles their staff makes her feel appreciated and understood. “It feels like home.”

Aside from feeling connected, the culture of learning she’s experienced during her time at FAME has made her really excited to go back to school. She knows she’ll return more advanced after her year of studies and is looking forward to bringing her new skills back to Karatu. She believes she’ll return more capable, improving how she works and relates with patients. She also has hopes that her advancement will allow her to begin helping our doctors in the operating theaters. Hosiana definitely wasn’t shy about her goals for her future at FAME.

“I already miss FAME,” she responded when asked if one year would feel like a long time away. However, she knows going back to school will help her in the long run, allowing her to set realistic, tangible goals. She was so appreciative of the opportunity to return to school and make her dreams achievable. When she first applied for the scholarship, she was unsure if she would be chosen or not, but she felt that FAME knew her position and how motivated she was. When she told her father she had been accepted to return to school, she said he was in complete shock and couldn’t believe the opportunity she had been given.

She ended our conversation with immense gratitude. She wanted to thank FAME’s staff; all of her coworkers, leaders, and administration. She is deeply appreciative of this opportunity and is already looking forward to her return to Karatu. Thank you to our donors who have made our Scholarship program possible and giving us the opportunity to support bright healthcare providers like Hosiana!

 
Kathrine Kuhlmann
"You Might Just See a Miracle"
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By Volunteer Pediatrician, Margreete Johnston

Today, a half a world and a year away from my last volunteer visit, while in an expert group of pediatricians in the US, I was reminded of how remarkable the care is at FAME Medical.

In my comfortable surroundings with coffee and brunch, we were given a few clues to solve our “study case”. Our study patient was a 14-year-old girl with eye hemorrhages, fatigue, and anemia. My peers are well-respected clinicians and specialists and I have been a practicing pediatrician since 1982, having volunteered at FAME on two month long visits. Cases similar to our “study case”, which took my colleagues and I over an hour to figure out, are every day occurrences at FAME. Here in the USA, differential diagnosis is pared down after doing multiple tests, finding results, performing more tests, procedures, and finally moving on. Very little today was said of a bedside patient exam, and a detailed, complete, history and physical.

It was an Ngorongoro Crater safari guide who mentioned casually to me on my first trip that you might just see a miracle at FAME. He was right.

It was just another September day in rural Tanzania when a hunter found a lost, unconscious boy who was about 14 years old and dressed as a student in the bush. The hunter somehow got him to FAME’s outpatient clinic. Word of mouth brought his father, who assured us the boy had been a well, healthy child just the day before. The boy could not be awakened, had a stiff neck, and difficulty swallowing. He could not seem to hear and responded slowly to pain. Our differential diagnosis included everything from trauma, to rabies, to meningitis. The FAME team supported the boy with intravenous fluids and antibiotics. Spinal fluid results returned suggesting encephalitis like illness. He was monitored as potentially a critical case and examined frequently.

 

Encephalitis is an inflammatory form of meningitis that can be catastrophic. Complications of encephalitis may include permanent brain injury, seizures, loss of language and purposeful movements. Some patients may even have brain swelling. After 36 hours with minimal improvement, our FAME team reached for the next line of therapy, including steroids and anti-viral medications. There was a global shortage of intravenous anti-virals, so we began to question if we should risk giving the medicine orally through a tube? It was risky giving liquids to a person in and out of consciousness. However, the answer became clear when we saw the pleading look on his father’s face.

Less than 24 hours later the lost boy was able to sit with help, swallow food, and ask his dad for his favorite music. Protocol requires treating encephalitis for a minimum of 21 days. By hospital day four, our patient got up from his wheel chair and told his father he would prefer to walk. What made this case a miracle for this experienced pediatrician was the confidence he had. To make my complete surprise even better, he stood up in front of American tourists visiting FAME to “find out what goes on here”. I smiled and said “miracles”.

Kathrine Kuhlmann