Neonatology part 2

by Jenn Harling

In February I wrote a blog describing what our neonatal unit looked like in our new pediatric building into which we moved at the end of 2021.  I mentioned in that blog that I had attended a neonatal conference a few months prior (Oct 2022).  I had the lovely opportunity to attend that conference again this year.  This is not an ordinary neonatal conference, but rather one to bring together those who care for and treat neonates in Africa. I'll state the obvious in case it's needed - taking care of neonates in LMICs (Low and Middle Income Countries) in Africa is not the same as practicing neonatology in HICs (High Income Countries).  This conference focuses on educating and training as well as sharing up-to-date information regarding neonatal care around the world, and also (and possibly more importantly) innovative ways to treat neonates when all the technology and resources are not available.  

Not only is there a huge opportunity to learn, it's also a place to network and make connections as well aso talk to others who are also trying to find innovative solutions to challenges faced in a low-resource setting. I've met numerous people who are in similar settings and it is so helpful - "oh, do you have this challenge too? this is how we navigate this situation without _____ (insert resource that may not be available in LMICs like blood cultures, electrolytes, intubation, ventilators, IV pumps, arm boards, paging system, caffeine...). 

I have left this conference each year thinking "there is SO much to do at our hospital to improve the care we provide..." but then I looked back and realized we have already started the process!

Below are a few things that changed in our unit after attending last year's conference:

-Trying to keep a cadre of nurses in the unit who do not rotate out.

-Hand hygeine 

-Keeping a particular generalist doctor mostly in the unit when a specialist was not available to round.

-Updated feeding protocol with fortification of breastmilk

-Transfusion protocol to know when to transfuse neonates

-New neonatal ward manual in French being written

-more kangaroo mother care (skin to skin care), with hopes to increase even more this year

-humidification of oxygen

-patient tracking white board

-updated fluids management protocol

-hats for every baby in the unit

This year I hope to expand bubble CPAP and medical air and blenders amongst many other improvement projects. My hope is to write another blog next year to tell you all the things God has allowed us to accomplish! 

There is hand hygeine signage all over the unit now

There is a steady supply / stock of hand sanitizer in the pharmacy now.

Patient tracking board 

One of our nurses washing his hands before touching the baby on the warmer. 

COTW: Postpartum Complication

 by Rachel

Well, we often see strange and bizarre cases at Kibuye, that has not changed!  But it's been awhile since we've posted our old blog standby of Case of the Week.  FAIR WARNING that if you are squeamish about medical things, this might be a post to skip.  But for all the rest of you, I'm curious if you can figure out the problem.  Also, we could use some advice on how to best fix this patient, so contact me after if you have ideas.

This lady came to the maternity service about 4-5 days after a spontaneous vaginal delivery of her 3rd child at a different hospital.  She had no previous medical or surgical history (no previous C-sections).  She was transferred to us with a suspected small bowel obstruction, with some nausea and vomiting, but was passing gas and stool.  Bleeding was minimal.  She had not passed urine for several days.  She had a low grade fever but otherwise vital signs were normal.  Her belly was significantly tender and distended.  Hemoglobin was normal with a very mild leukocytosis.  

Now, this presentation is not terribly uncommon after C/S.  Many women are transferred to us with peritonitis after a C/S done at an outside hospital, and they end up with frank pus in the abdomen and usually a necrotic uterine incision that needs debridement.  This all causes an ileus, not an obstruction.  We see this at least once a month.  But, this lady had not had a C/S.  Also not uncommon is a diagnosis of uterine rupture after vaginal birth, due to trauma or fundal pressure given during second stage of labor.  But, this lady didn't seem to have the classic signs of uterine rupture.  No bleeding, no fluid wave in the belly, and a normal hemoglobin.

On ultrasound, nothing was visible due to a massive amount of gas in the pelvis.  So, we ordered an abdominal X-ray.  And saw this:

I know that it's not a great image (and remember we have no CT scans here) but that's a giant collection of air/gas in her bladder, and in real life we could see a very tiny amount of free air under the diaphragm.  So, we placed a Foley catheter and got out a large amount of gas and around 600cc of cloudy urine.  Strange.  She was started on antibiotics for a UTI and improved significantly within 24 hours of placing the Foley.  We discussed with surgery the need for an ex-lap, but given the patient's significant improvement decided to send her home with the foley for 7 days, and then have it removed at the first hospital.

She came back two weeks later.  After the Foley had been removed, her pain had returned and continued to increase.  She was unable to pass urine, and once we replaced the catheter, cloudy yellow urine came out, but the pain did not improve.  She was taken to the OR, where the surgeons found this:

You can see her urethra with the foley in place.  The small tubes on either side are her ureters.  But the bladder was just a necrotic pile of mush.  Best as we can figure, during her delivery her bladder had ruptured (??), but the uterus remained intact.  Given the late diagnosis, the bladder was not repaired immediately, and perhaps developed an infection, but regardless all bladder tissue died.  She's currently hospitalized with drains and a foley catheter, but there's no awesome urologist to send a case like this to, to create an artificial bladder.  Any ideas?