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GO MOMS Nicaragua June 2017 Report


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GO MOMS Nicaragua June 2017 Report

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GO MOMS Nicaragua June 2017 Report

  1. 1. GO GYNS / GO MOMS Trip HEODRA Hospital, León, Nicaragua June 5-9, 2017 Introduction León is Nicaragua’s second-largest city, with a population of 210,000. It is a university city, housing the National Autonomous University of Nicaragua (UNAN), and thus has a long history of serving as the political and intellectual capital of the country, with a prominent role in the revolution. HEODRA is the public government hospital in León, which is affiliated with the UNAN medical school and residency programs. The hospital serves as a referral hospital for northwest Nicaragua, and serves all patients free of charge regardless of insurance. HEODRA has a busy labor and delivery floor, with over 5,000 deliveries per year. While the hospital benefits from the presence of a relatively large number of well-trained OB/GYN attendings and residents, the care is limited by financial and institutional constraints: the blood bank has approximately 4 units of blood for the entire hospital and is often empty, many medications and supplies are not provided by the Ministry of Health or are inconsistently stocked, and laparoscopic surgery is only just starting to be introduced to the OB/GYN department and is currently limited to occasional small cases. The Stanford OB/GYN department is involved in global health activities around the world, and in recent years has been expanding the opportunities for resident involvement in these activities. In 2013, the department received an APGO grant in for global health, and in July 2013 a team of OB/Gyn attendings from Stanford and Kaiser traveled to León, Nicaragua to conduct a needs assessment. From this needs assessment the GO MOMS program was developed; this is an educational program utilizing didactics, videos, and simulation to teach obstetric skills, with a focus on postpartum hemorrhage, hypertensive disease, active management of the third stage of labor, shoulder dystocia, and vacuum-assisted delivery. Rather than service delivery, the philosophy behind GO MOMS was one of ‘teaching the teachers’— equipping the attendings and residents not only with clinical skills that they can utilize in their practice but also with educational methods and materials that they can continue to impart to future generations of learners. In 2014 and 2015, teams returned to León to conduct these training sessions. In 2015, the team also conducted a needs assessment for areas of need within gynecologic training. The needs assessment identified that many attendings and residents expressed a desire for additional training in urogynecology. The assessment also identified that only 7% of all hysterectomies were completed vaginally, with the remaining 93% being completed abdominally as laparoscopy is very recent and is still confined to minor gynecologic procedures. Based on these findings, the GO GYNS program was developed with a plan to focus on vaginal hysterectomy training as well as patient selection for vaginal hysterectomy, and also to provide pessaries and pessary training. The decision was made to defer training in more complex urogynecologic
  2. 2. procedures and to focus instead initially on the more fundamental skills of clinic evaluation, vaginal hysterectomy, and non-surgical management with pessaries. In 2016, the first GO GYNS trip to León took place, and introduced the vaginal hysterectomy didactics, videos, and simulation models. In 2017, this trip was planned with the goal of reviewing the previous didactics/simulations, assisting the attendings and residents in the clinic with evaluation of surgical candidates, and providing support in the OR for attendings teaching residents vaginal hysterectomy. As a second-year resident, I had the opportunity to go on this trip as part of my urogynecology rotation. My goals were to be involved in the above urogynecologic components of the trip as well as to complete a project evaluating the previous GO MOMS training that had taken place on previous trips. In this report, I will first present the findings from my survey evaluating the GO MOMS project, then I will discuss the GO GYNS component of the trip, and I will conclude with a few other impressions from the trip. GO MOMS: B-Lynch and UBT See Powerpoint for additional results Background: GO MOMS trips have been teaching the techniques of B-lynch and uterine balloon tamponade (UBT, using condoms and foley catheters) at HEODRA through simulation since 2014. We had received informal feedback that the B-lynch technique had been picked up well and was being used frequently in HEODRA, where it had previously not been used at all. To further investigate this, we performed an IRB-approved study to learn about the experiences of attendings and senior residents with using these techniques. We modeled our study on a similar study that had been performed in Sierra Leone to learn about provider experience with UBT.1 We also obtained IRB approval for a second study—a chart review to look at cases of PPH both before and after the GO MOMS training, identify cases where B-lynch was used, and hopefully show a decrease in the Cesarean hysterectomy rate after the introduction of B-lynch—but this study could not be performed during the week of the trip. We are continuing to work on this second study with the help of our colleagues at HEODRA. Methods: Surveys were conducted by one interviewer with either one or two respondents at a time, using semi-structured interviews. These interviews were conducted in Spanish and were recorded, and answers to closed-ended questions were also recorded on a survey sheet during the interview. Subjects were selected via a convenience sample of residents and attendings who had some personal experience with either B-Lynch 1 Natarajan, A., Kamara, J., Ahn, R., Nelson, B.D., Eckardt, M.J., Williams, A.M., Kargbo, S.A. and Burke, T.F., 2016. Provider experience of uterine balloon tamponade for the management of postpartum hemorrhage in Sierra Leone. International Journal of Gynecology & Obstetrics, 134(1), pp.83-86.
  3. 3. or UBT or both—we only included participants who had performed at least one of these skills. Interviews lasted approximately 15-20 minutes each. Subjects received an informed consent form prior to the interview, and did not receive any compensation for their participation. Results: A total of 11 surveys were completed, including three attendings and eight residents. Additional results, including more detail on qualitative results and quotes, are included in my powerpoint presentation  While all attendings reported having learned both UBT and B-Lynch from Stanford simulation (though two also mentioned other sources of learning as well), all residents reported that they had learned B-lynch directly from HEODRA attendings, suggesting the simulation model of ‘teaching the teachers’ worked in this case. For UBT, however, the results were more mixed: 3/8 residents learned from Stanford alone, 3/8 from HEODRA attendings, and 2/8 from both  7/11 respondents stated that they feel comfortable performing B-lynch without supervision, while 4/11 feel comfortable performing it with supervision. For UBT the numbers were reversed, with 4/11 comfortable without supervision and 7/11 comfortable with supervision  3/3 attendings and 3/8 residents reported having taught others to perform B-lynch; however, only 1 respondent (an attending) reported having taught others to perform UBT  Pooled, (but excluding one of the respondents, see below) gave a total of 25 B-Lynch sutures performed. 23 of these were at time of C-section, 2 were after vaginal deliveries. In both vaginal deliveries, UBT had been tried first and was unsuccessful. 21/25 B-lynch sutures were successful. 4/25 were unsuccessful and hysterectomy was performed  One attending’s responses were excluded from above for a few reasons: she has performed the most B-lynch sutures, was unsure of the exact number but estimated between 10-15, and could not accurately recall numbers of all the outcomes. We also were unable to do a taped interview with her as she unfortunately had a death in the family during the trip, so the information was collected later via email and was less detailed. Additionally, there was the concern that some of the B-lynch sutures reported by different participants may have been ‘overlapping’ or referring to the same event in which multiple providers participated—by excluding her answers we aimed to at least partially address this problem, as many of her experiences were shared by a resident. She estimated that about 20 total B-lynch sutures have been performed at HEODRA since the technique began to be used after the GO MOMS trip in 2014, which is overall consistent with our finding of 25.  There was significantly less experience reported with UBT. Pooled (including all participants), only 8 cases of UBT were reported, which were reported by only 5 of 11 participants--the remaining 6 had never performed the procedure, and these 5 had only performed it 1 or 2 times. 6/8 of these cases
  4. 4. were successful, while 2/8 were unsuccessful (both went for B-lynch as above, one of which was successful and the other of which failed and ended in hysterectomy). All UBT were performed after vaginal deliveries, with none at time of C-section.  Fewer challenges were reported with B-lynch than with UBT. For B-lynch, lack of appropriate suture was the most common concern (mentioned by 4/7 interviews), followed by concern about losing time in the setting of rapid blood loss (3/7), as well as procedural difficulties (3/7—2 mentioned difficulty with uterine compression by the assistant, 1 mentioned difficulty with suture tearing through thin inferior edge of hysterotomy). Only 1/7 mentioned provider inexperience. Anecdotally, respondents report a dramatic increase in utilization of B-lynch since the GO MOMS simulation  For UBT, many reported that this has not yet been incorporated into their routine practice. Major barriers to utilization include the time involved with setting up the condom and foley (mentioned by 6/7 interviews, with concerns about blood loss specifically mentioned by 5/7), lack of Bakri balloons (5/7), provider inexperience (4/7), and uncertainty about the method’s efficacy (2/7). 4/7 also mentioned that that PPH after vaginal deliveries usually resolve with medications. Additionally, lack of available blood transfusions and strict government oversight of maternal health were both cited as reasons why doctors feel reluctant to try a new technique which may take time and which may not be effective. Discussion: These results suggest that while the GO MOMS program has given equal emphasis to these two techniques for managing postpartum hemorrhage, one has been adopted enthusiastically by the OB/GYN department at HEODRA while the other is used much less commonly. The quantitative aspect of these surveys demonstrated this discrepancy, and the qualitative aspect-- the semi-structured discussions--provided insight into why the discrepancy exists. The attendings and residents interviewed painted a picture of a labor floor with no room for trial and error, a place where blood loss has to be stopped quickly and effectively. With no blood available for transfusions, the tolerance for bleeding is much lower than what we are used to in the U.S. The B-lynch suture is fast, it happens in the OR, and if it delays the decision to perform a hysterectomy, it does so by about half a minute. UBT, performed with condoms and foley catheters, takes longer. All participants who were asked to estimate the amount of time it takes to gather supplies and assemble the catheter for UBT said that it would 5-10 minutes--relatively short, but too long when a woman is losing 500cc of blood per minute. Yet despite these concerns, UBT is successfully used in other low-resource environments that lack access to a blood bank. Also, HEODRA recently developed a rudimentary PPH box, but the UBT supplies are not stocked in this box, suggesting low motivation to perform this technique. One of the more interesting responses, which may partially explain this, is that providers at HEODRA don’t use UBT because they haven’t seen the results
  5. 5. from it and they can’t be sure that it will work. Essentially, it hasn’t been done enough to have earned the trust of the providers as a reliable technique, and between the empty blood bank and a national health system that punishes doctors for adverse maternal outcomes, they aren’t willing to try something they can’t fully trust. However, with 6/8 of the reported UBT cases being successful, perhaps this will gradually gain acceptance as a viable intermediate step after uterotonics and before laparotomy and possible hysterectomy. GO-GYNS: Urogynecology and Vaginal Hysterectomy On the first day of the trip, we accompanied the head of gynecology, Dr. Pozo, and two residents in the gynecology clinic. Patients had been selected in advance as possible vaginal hysterectomy candidates, and were asked to come to this clinic for final preoperative evaluation in conjunction with the visiting GYN surgeons in preparation for going to the OR during the week of the trip. The clinic was held in a small room with a desk and two gynecologic beds separated by curtains; normally, the room was used for colposcopy clinic. At first it seemed like there were plenty of patients to fill our OR time for the week, yet as we began evaluating the patients, we realized that it would be more of a challenge than we thought. One patient had overactive bladder with no prolapse, and we recommended oxybutynin and vaginal estrogen cream if it was possible for the patient to buy these medications, as they were not available through the hospital pharmacy. Another patient had an adnexal mass, fibroid uterus, and two prior Cesarean sections, and was deemed to be a better abdominal hysterectomy candidate. Two patients would have been excellent candidates except that they needed cervical biopsies. The first of these was an elderly woman who had Stage IV uterine prolapse with ulceration. She did not desire future sexual activity, and we discussed colpocleisis with her. She was amenable to this plan; however, she had never had a pap smear, and when we did a colposcopy, there was an area of acetowhite change that we thought was likely scarring but that we could not rule out as possible dysplasia. We took a biopsy, which would not result for 4-6 weeks. We would have done a pap as well but there were no supplies—patients have to buy their own and bring them to the hospital. Another patient would have been an excellent vaginal hysterectomy candidate, however she had had a pap showing carcinoma in situ and had not had a colposcopy. We performed colposcopy and biopsies for her as well, with plan to delay her surgery until biopsy resulted in order to plan whether or not she would need referral to oncology and radical hysterectomy. Of course, our other goal was to teach the use of pessaries for patients who either did not desire surgery or were not good surgical candidates, or until surgery could be performed. The patient with the complete procidentia was fitted with a donut pessary, which worked well for her. A different patient presented with stress incontinence, and desired surgery. However, the best surgical option for her would have been a midurethral sling, and these are only occasionally available from a visiting urogynecologist. This patient was fitted with a ring pessary, but it fell out the next day, and the patient decided to wait and undergo surgery at a later time.
  6. 6. There was another patient who had had a transobturator sling placed previously by the urogynecologist in his private practice, who now presented with mesh erosion. She was examined in clinic and found to have a small area of mesh erosion of one of the arms of the sling, with good continued function of the sling (no further incontinence). She was scheduled for the OR for excision of the exposed part of the sling arm. We had one additional surgical candidate—a woman with pelvic organ prolapse with no contraindications to vaginal hysterectomy. She was scheduled for later in the week on the same day as the mesh excision case. When that day arrived, she was brought into the operating room, and on her way in she gratefully clasped the hands of the two vaginal surgeons from our trip who were going to be observing the surgery and providing teaching support as Dr. Pozo took a resident through the case. Yet when she was seated on the operating table, with the surgical instrument tray opened, Her surgery had been bumped by an emergency C-section,. Our team spent a significant amount of time debriefing about this experience and about the overall disappointment that we did not achieve our goal of coordinating vaginal hysterectomies during the trip. One possibility that likely contributed at least in part was a failure to organize and preoperatively assess the patients far enough in advance of the trip. We had suspected that this may happen, as several emails prior to the trip asking about how many patients had been lined up for surgery had gone unanswered. In a resource-poor setting where the hospital can’t employ administrative surgery schedulers, where patients are more difficult to track down and may live far from the hospital, and where something as simple as a pap or cervical biopsy prior to surgery can be prohibitively expensive or time consuming, it is certainly understandable that it would have been more difficult to arrange and preoperatively assess a week’s worth of surgical candidates. While the aim of the trip was largely to teach, we tried to emphasize in all of our communications with the HEODRA doctors that we truly viewed these trips as an exchange, where we have the opportunity to learn from them as much or more than they learn from us. While this sounds in some ways like a platitude or nicety, I was actually surprised to find how true it was, and the below ‘other impressions’ detail a few of the things that we have found that we can learn from our Nicaraguan colleagues. Yet despite our attempts to emphasize this, the underlying discomfort from this imbalance of power may have contributed to the difficulty we had with achieving the surgical goals of the trip. Finally, another thought we discussed was that the real interest that had been communicated to our team during the needs assessment was an interest in learning urogynecology procedures, and our previous needs assessment had made the decision that the first step of this would be to strengthen the vaginal hysterectomy skills, for patients with prolapse as well as other indications for hysterectomy who were good vaginal hysterectomy candidates. Thus, the goal of our trip was slightly
  7. 7. different than the goal that HEODRA doctors had communicated to us. We saw this in the patients who were sent to the clinic—almost all were urogynecology patients, and some did not even need hysterectomy, like the patient with overactive bladder and the patient with isolated stress urinary incontinence. Our team expressed concerns with teaching or performing advanced urogynecologic proceduresin that setting: mesh complications would be more difficult to manage, high uterosacral ligament suspensions have an 11% ureteral injury rate and the gynecology department at HEODRA does not have access to cystoscopy. Given this, we also discussed whether it would make sense to help teach Burch procedures, which is something that Dr. Pozo talked about performing, as they perform a very high percentage of abdominal hysterectomies and are requesting help with learning more urogynecologic surgery. Yet even if the HEODRA physicians were not directly requesting help with increasing their vaginal hysterectomy rate and decreasing their abdominal hysterectomy rate, I do think it is reasonable that that was one of the main goals of our trip. While I agree with the ethical global health principles of only going where one is invited and providing the help and services requested by the host community, I also think that once a group has a working relationship with a host community, if we observe things about their practice that we believe we may have room for improvement, we should be able to bring that up. Part of being in a low-resource environment is lack of access to the most current or updated practices or guidelines, so sometimes what we can offer is something that they haven’t specifically requested themselves (we also did this with vacuum-assisted delivery). This situation is not quite that clear-cut, as they did ask for help with vaginal hysterectomies as well, but I do think that the slight difference in goals (increasing vaginal hysterectomy rate vs. increasing comfort with urogynecologic surgery) makes this an interesting example of the above tension. We hope that with our lectures on patient selection, our discussion of the benefits of vaginal hysterectomy, and the simulations we did with the residents, we helped to increase interest in and comfort with vaginal hysterectomy. On our last day, we had a meeting with the chair of the department to discuss our the trip . We made a plan that if we go back for a trip in the future, we would like to have a list of all the patients in advance, with their names, the time of the scheduled surgery, their medical information, and their preoperative evaluation. This document sounded familiar to me—as a second-year resident I spend a lot of time preparing these ‘pre-op’ documents for our Gyn, Urogyn, and Gyn Onc rotations—so I sent a copy of our template to Dr. Daniels to be translated and sent to the HEODRA leadership. If nothing else, we have shared one aspect of U.S medical care with them—pre-op! Other Impressions: Labor and delivery:  For early labor, their partogram is divided into two different curves based on whether the patient is lying in bed or walking around. They explained that everyone knows that patients who are walking around progress more
  8. 8. quickly in labor because it puts more pressure on the cervix and allows it to open more quickly. Almost none of their patients have epidurals for vaginal deliveries, and almost all of them walk around until they are in active labor, as long as their membranes are intact  They perform intermittent fetal monitoring in active labor and during the second stage of labor. They calculate contraction strength by sitting and measuring contractions manually over 10 minutes and calculating the strength of the contractions with a complicated calculation by hand that involves long division. If inadequate contractions or cervical change, they start oxytocin and measure by counting the number of drops per minute.  For the second stage of labor, they allow 30 minutes for multiparous patients and 1 hour for primiparous patients. If they have not delivered in that time period they go for C-section. They also routinely cut mediolateral episiotomies for primiparous patients. They use a sterile field for deliveries and give everyone antibiotics after delivery. They also use fundal pressure during delivery. They delay cord clamping for 1-3 minutes, do immediate brief skin-to-skin, then move the baby to an isolette for evaluation. During one delivery that I observed, the baby from a previous delivery was in the room in the isolette during the delivery.  They do have a high C-section rate, about 40%, and anecdotally are beginning to see more and more cases of placenta accreta  While they do inductions for various indications, the majority of their patients are low risk and present in spontaneous labor. They have recently started to induce for ‘over the due date’, but they start these inductions at 40+0 rather than 41+0. When asked why, they mentioned that sometimes the patient doesn’t arrive on the recommended day, or the induction takes some time. Dr. Pozo reported that most women do not go past 40 weeks, and usually go into spontaneous labor around 38 or 39 weeks. When asked why he thinks that is, he said that women have sex through their due date, and if one of his patients hasn’t delivered near her due date he advises her to have sex three times a day.  Kenia (one of the UNAN attendings) reported that their chorioamnionitis rate is very low, maybe five cases per year, which may possibly be related to overall shorter labor courses and fewer inductions  Additionally, their postpartum hemorrhages after vaginal delivery may be less severe than ours, as multiple people mentioned in the B-lynch/UBT survey that most PPHs after vaginal delivery resolve with uterotonics  They also noted that the national medical system is very strict about maternal and neonatal outcomes; they said that they are ‘not allowed’ to have a stillbirth, that all maternal deaths are investigated by the government, and that doctors sometimes lose their jobs over these incidents, even when it may not have been a medical error that caused the outcome Family Planning:
  9. 9.  Most common method of contraception is injections (most commonly a combined monthly injection, though Depo Provera is also common). Pills are relatively common as well. They have implants but they don’t use as often as they are expensive, and the residents have never placed them as HEODRA is a public hospital. Copper IUDs are relatively common and are available for free in HEODRA. They do not have hormonal IUDs.  A 20-year-old delivered her second baby and I watched Kenia counsel her on contraception while she was in labor. The patient said that she wanted sterilization, and Kenia counseled her that the Paragard might be a better option for her. To help convince her, she told her that the tubes carry blood to the ovaries, and if she had a tubal ligation, she will age faster and look older sooner. The patient agreed to get an IUD, which was placed immediately postpartum.  The residents told me that abortion is illegal under all circumstances, even to save the life of the mother, and they described cases of previable PPROM and chorioamnionitis where patients are sick but they still have to continually listen with Doppler until fetal heart tones are no longer audible before they can evacuate the uterus. They were strongly opposed to these laws, with one male resident getting especially emotional as he spoke to me about it, saying “it’s stupid, it’s so stupid! Don’t you agree that it’s stupid?” They also told me that women can buy misoprostol from pharmacies at only $1 per pill, but only a few doctors offer clandestine surgical abortions which cost at least $250 or more, and these doctors run the risk of losing their license and facing criminal charges. Residency training:  The residents worked extremely hard—they did 36-hour shifts every four days. On post-call days they seemed very tired—one was almost falling asleep retracting in the OR, another fell asleep toward the end of a simulation session  Many wanted to do fellowships, most of which are only available in Mexico  Before starting residency, they had each completed a one-year internship and two years of social service, practicing general medicine in a rural area of the country. OB/Gyn residency itself was 4 years.  Most of the OB/Gyn residents were women. I asked them if it was possible to have a baby during residency and they told me that occasionally people did but that it was very difficult and you were looked down on, people thought you would be ‘slow’ and not committed to your work