Nurse training is a bit different here. From what I understand, the first level is an enrolled nurse (similar to an LPN or LVN in the US). This is a two year program. The nursing school in Macha is an enrolled program. Next one studies another year to become a nurse midwife. Most deliveries at Macha are done by nurses. Doctors are only called in for complications/c-sections. Then after another year of study, one becomes a registered nurse.
My first day in maternity I worked with Mrs. Simamba. She has been a nurse midwife for 20 plus years and gave me a thorough orientation to their processes and charting. The first patient was born the same year as me, making her 46 or 47. Though we didn't speak the same language, this gave us a bit of a bond. I was a bit surprised by her age, but they say it is not uncommon for women to have babies into their 50's here. Though there is an automated BP machine and digital thermometers, fetal heart rates were measured by the manual funnel shaped fetoscope put directly to the mothers abdomen, the nurses ear is then placed on the fetoscope and the heart rate is counted for a minute. There are no tape measures. She taught me the trick of counting fundal height and estimating gestational age with my own finger width. She also calculated the gestational age from the last menstrual period on paper (no handy wheel).
The maternity ward is housed in one building. There is the labor room on one end with four beds for laboring patients and two warming beds for newborns. There is an ultrasound room off to the side. At the other end is the antenatal and postnatal beds partially divided by a wall halfway down the room. The four beds closest to the door are reserved for surgical (theater) patients. There looked to be a total of 20 or so beds. I would say they were two thirds full. There are a few baby cots, but most moms seem to keep the baby in bed with them or in the bed next to them if it is empty. There is a door on the antenatal side that exits outside to the bathrooms. I have learned that a lot of the nursing care is provided by patients' families. Each patient can have one family member stay with them (sleeping on the floor under their bed, or with them). Nurses give meds, do dressing changes and other procedures, but the family, helps the patient eat, bathe, get to the bathroom, change linens etc.
In between the two ends are the nursing station, storage rooms, staff bathrooms, a procedure room, the cleaning closets/areas, a counseling room and a side ward for staff patients (this exists on all wards, the closest one can get to a private room). There also is a room for premature babies and their mothers. This room has heaters, a warming bed and no visitors are allowed. The door is kept closed and there is a window that looks straight into the nurses station. They usually stay until the baby is 3kg.
My second day in maternity I worked with Mrs. Bakasa. I learned about the discharging process. Most women with normal deliveries and healthy babies leave in less than 24 hours. I was happy to see there is a heavy emphasis placed on patient education. It's done in Tonga, so I can't understand it, but it seems pretty thorough. We had one young mother who said she was almost 15, but didn't look a day older than 13. She is the youngest by far that I have seen. After she left I found out that she was the second wife to an older husband. Polygamy is a tradition in Zambia that is less and less common, but still occurs. We also came across a baby with a 37.7 axillary temp (normal is 37). The baby was bundled to the hilt, but we decided it best to keep him for a few more hours of observation.
I also got a chance to connect with Mrs. Bakasa on PMTCT, the program I will be focussing on which she has been overseeing since it's beginning six or so years ago. We will connect in the future and sit down to talk nitty gritty, but it was nice to have a brief intro to each other. We had only seen each other in passing up till then. She explained all the logs they have there on the maternity ward (inpatient admission, delivery registry and PMTCT log).
When my job description was written, 40% of hiv+ mothers in our catchment area were not getting treatment to prevent transmission to their baby. That is down to 18% in just 4 years. This is good news. We hope to decrease this even more and figure out a system where less people are falling through the cracks. During my day last week in maternal-child health (MCH) outpatient department, I examined the records of all mothers receiving short course treatment. Short course is given to mothers whose CD4 counts are high enough that they don't qualify for full treatment. If their CD4 count remains high, they will go back off meds a week after delivery. The baby will take an antiretroviral medicine from birth until one week after weaning. During this time, the mom's CD4 count is checked every 3-6 month in case it drops low enough to start full therapy. The baby is tested at 6wks, 6mos, 1yr and 18 mos to make sure that the virus has not transmitted to them. It seems the medicine is getting dispensed, but according to the records, these follow up exams are not getting done as they should be. This is one area I hope to help reconcile over the next three years.
The ART clinic at Macha Hospital has done great things. It has grown so big though, with over 8000 patients enrolled, that the staff can't keep up with all the little details. On top of that funding has not kept pace, and is even getting cut. I really look forward to being able to participate in improving the care that is being given.
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