Bring healthcare to thousands in rural Nepal

GYNECOLOGICAL FOLLOW-UP TRAINING OF 10 MIDWIVES

 Date:   Feb 18th to 21st, 2020 First cohort of 5 midwives
             Feb 23rd to 26^th, 2020 - Second cohort of 5 midwives

Place: Gajuri Primary Health Centre, Gajuri Rural Municipality (RM), Dhading District, Central Nepal

 Participants:10 AMNs from village health posts and primary health center of Gajuri RM

 First Follow-Up Training: 18th – 21st February 2020

Trainer: Dr. Sunita T, Patan Hospital, Lalitpur

 Participant           Station/Health Post            Designation

1. Ranjana S         Pida,                                    ANM
2. Sarita R             Gajuri PHC,                         ANM
3. Radha P            Gajuri PHC,                         Staff nurse
4. Amrita Pa          Gajuri PHC,                         ANM
5. Anju C               Dolbhanjyang Sec. School  Staff nurse

 Second follow-Up Training: 23rd – 26th February 2020

Trainer: Dr. Sunita Thapa, Patan Hospital, Lalitpur

 Participant           Station/Health Post            Designation

1. Ambika K          Gajuri PHC                           ANM
2. Amrita P            Gajuri PHC                           ANM
3. Saradha S         Pida HP                                ANM
4. Rama R             Pida HP                                ANM
5. Sarita C             Kiranchok                             ANM

First day Follow-up Training

HHC supervisors reviewed women patient reports of 45 days after the first training, submitted by the trainees. They discussed experiences and challenges that each one faced during those 45 days. They were also briefed about the importance of the follow-up training. The ob-gyne specialist began an interactive class with discussions about patient history taking.

History taking:Introduction of patient; Chief complain; History of present illness (HOPI); Menstrual history; Obstetric history; Contraceptive history; Past medical & surgical history; Personal history; Occupational history & family history

 Doctor's note:Participants were encouraged to actively participate and discuss about history taking for gynecological patients stressing on the importance of different aspects of proper history taking in the management of diseases. During the outpatient hands-on training, they were asked to take history and examine patients. At the end of the sessions, they were confident in patient history taking and examination.

 2nd Day  Follo-up Training Steps of physical examination: GC (general condition): fair, ill looking, conscious or unconscious, Vitals: T, PR, RR, BP (temperature, pulse, respiratory rate & blood pressure); PILCCOD: (pallor, icteric, cyanosis, clubbing, edema, dehydration); Chest examination: B/L normal vesicular breath sound and equal air entry, crepitation and wheeze; CVS (cardiovascular system): s1 s2 or any added sound; A/P (per abdomen): any mass feel and tender; P/S (per speculum): polyp, discharge, erosion on cervix and its position; P/V per vaginal: feel any cyst or mass and motion tenderness on cervix; Breast examination: standing and hands on waist, press by palm on the breast as quarterly on both breasts.

 Types of vaginal discharge: Physical: reproductive age, menstrual and hormonal; Pathological: infected and non-infected; Infected: Sexual infected - TV, Chlamydia, Gonorrhea, Syphilis, HSV; Non sexual infected- BV, Candida (mostly below 25 Year; Non infected: foreign body, atrophic (dryness) and malignant.

 PID (Pelvic Inflammatory Disease): cause by ascending infection from the endocervix or may from descending infection from organs and 25% cause by Chlamydia and gonorrhea.

 Doctor's note: Focused on physical and breast examination of patient. The trainees were also explained about nipple discharges and breast mass. During the outpatient practical training, the trainees directly examined patients under my supervision and now they are confident in physical and breast examination. Also briefed them about breast suppressant agents.

 3rd Day of Follow-up Training

DUB (dysfunctional uterine bleeding): Defined as abnormal uterine bleeding in absence of pregnant, genital tract pathology or systemic infection. 

Signs:Abdomen exam usually normal. If uterus enlarged,fibroids are likely. Anemia +
Symptons: Heavy or prolonged p/v bleeding, dysmenorrhea (on/off)
Investigation: UPT, CBC, TFT, Blood Gp. & cross match, endometrial biopsy
Management: Tranexamic & mefenemic acid useful to decrease loss during periods, OCP to regulate irregular cycle ( if no cardiovascular risk).

Menorrhagia ( 80 ml or 7 day bleeding) is the commonest and age below 45 Y

Hyperemesis dravidarum: Trained to carry out urine acetone test. Inj. RL III pint, Inj 5% dextrose 1.5 ltr IV over 24 hour. Inj Metoclopramide 10 mg IV TDS; Inj. Ranitidine 50 mg IV BD and Pyridoxime 10 mg PO TDS
Preterm labor: inj Dexona 6 mg 6 hourly 4 doses or 12 mg 12 hourly 2 doses to make mature lungs of baby but caution to be taken while giving to GDM (Gestational Diabetes Mellitus) mothers.

Doctor's note: Explained about primary management prior to referral to higher center as theyhad encountered many cases of hyperemesis gravidaraum and Gestational Diabetes Mellitus.Taught in detail including diet on screening during pregnancy (GCT and OGT T). PT/INR,Ectopic pregnancy (organized and ruptured ectopic) GCT (glucose challenge test). Trainees presented on history taking, physical exams and managemet of infectious diseases.

 4th Day of Follow-up Training

PPH (post partum hemorrhage):any amount of blood loss that threatens a woman’s hemodynamic stability and estimated blood loss of >500 ml from the genital tract at vaginal delivery & >1000 ml in Caesarean section or 1500 ml at caesarean hysterectomy; Types: Primary: 3rd stages of labor to 48 hours of delivery; Secondary: 48 hours to 6 weeks of delivery; Cause of PPH is 77%, 4 Ts (tone, trauma, tissue, thrombin); A 10% drop in hematocrit, or the need for blood transfusion in first 24 hours; Inj Oxytocin 20 units in each drip, tab misoprostol 800mcg per rectal, inj. Tranexamic acid 1gm iv stat if bleeding doesn't stop apply bimanual compression, proper inspection if there is any trauma associated with bleeding. If bleeding doesn’t control inj. methergin to be given stat, if bleeding persists, apply condom tamponade and refer to higher center.

The condom tamponade: if medical intervention failed, then use this procedure. Counselingabout procedure, prepare instruments; Procedure of condom tamponade - Inflate 250-500 ml saline & bleeding stops in 0-15 min in most cases.

Doctor's note:The last day of the training focused on post partum hemorrhage (PPH) includingcause and management. Importance of condom tamponade in the management of PPH was explained and a demonstration was given on how to prepare and apply condom tamponade.

Trainees practiced the procedure on their own.

 13 patients were asked to be subjects for the 1st Follow-up training

 Patient                 Age/Sex           Diagnosis               Solution

Mina T                   49 Y/F          ervical polyp                 Refer to KTM
Sita T                     35 Y/F         Cervicitis                       Infa V (Metro+Clotrima+Lactobacillus)
Maya S                  27 Y/F         Cervicitis                       Infa V (Metro+Clotrima+Lactobacillus)
Jamuna M             46 Y/F          Menorrhagia                 Tranexamic acid 500mg
Junamaya S          50 Y/F          Menorrhagia                 Tranexamic acid and vitamin
Mithumaya S         42 Y/F          Cervicitis                       Infa V (Metro+Clotrima+Lactobacillus)
Kalpana S              30 Y/F          UTI                               Ciprofloxacin 500 mg
Pratima B               20 Y/F          Dysmenorrhea              Mefenamic 500mg, Ranitidine 150 mg
Sushmita S            20 Y/F          Preterm labor of 35w     Inj Dexona 12mg stat                                Kanchhimaya T     56 Y/F          Vaginitis                         Azithromycin 500mg
Bishnukumari R     36 Y/F          Cervicitis                       Infa V (Metro, Clotrma, Basillos)
Susana A               20 Y/F          Vaginitis                        Cefixime 200 mg
Sabitri M                36 Y/F          Prolonged labor            Inj. Oxytocin and normal delivery done

 17 patients were asked to be subjects for the 2^nd follow-up training session

 Patient              Age/Sex           Diagnosis              Solution

Santoshi U          32 Y/F               DUB                       Mefenamic acid 500mg, Tranexamic acid                                                                                                 500mg & Ranitidine 150mg
Lalita M               20 Y/F               VDS                       Cefixime 200mg, Azithromycin 500mg &                                                                                                    Tinidazole 500mg
Sangita BK         18 Y/F               DUB                        Mefenamic acid 500mg, Tranexamic acid                                                                                                  500mg & Ranitidine 150mg
Gayatri A             28 Y/F               Cervicitis                Ciprofloxacin 500mg, Metronidazole 400mg                                                                                               and Fluconazole 150mg
Maili T                  36 Y/F               Failed MA               MVA and medication
Bhawati K            57 Y/F               UVP                        Ciprofloxacin 500mg and counselling
Maiti T                  36 Y/F               Failed MA               MVA and medication
Shanti T               30 Y/F               Postpartum HTN     Amlodipine 5mg
Krishnak R           35 Y/F               Menorrhagia            Mefenamic acid 500mg, Tranexamic acid                                                                                                  500mg
Pramila C            27 Y/F Incomplete miscarriage          MVA, IV and oral medication for one day
Parbati U             32 Y/F               Vaginitis                    Cefixime 200mg, Tinidazole 500mg and                                                                                                    Azithromycin 500mg
Sirjana B              27 Y/F               Varicose vein          Counselling provided
Urmila P                   28Y/F                UTI                      Ciprofloxacin 500mg
Nira BK                    26 Y/F               Miscarriage          MVA, Azithromycin 500mg
Sarita S                    27 Y/F               Candidiasis         Ointment Clotrimazole and Fluconazole                                                                                                     150mg
Mina S                     28 Y/F               Chlamydia            Infa V (Metro+Clotrim+Lactobasilus)
Jyoti N                     30 Y/F               MA                        Metron 400mg, Cefixime 200mg and                                                                                                         Ranitidine 150mg

Closing program

18 local leaders and government officials were present during the closing ceremony including the Chairman, Dr. Sailesh K, acting chief of Gajuri PHC; Chief Guest: Mr. Rajendra BB, Chairman of Gajuri RM; Special Guest: Dr. Ramhari R, incharge of Gajuri RM; Special Guest: Mr. Yuwaraj A, admin officer of Gajuri RM and 14 other guests from PHC and nearby villages.

Final Words from the guests

Chief Guest (Rajendra B. B.):Personally and on behalf of the municipality, I thank HHC for such a useful and practical training which will help the entire women population of this region. We are expecting more support from HHC in the future too. We need a gynecological camp and training for more midwifes who have recently been appointed in this region. I also advise all health staff who participated in this training to make good use of what they have learned and work honestly in their work place. Special Guest (Yubraj A): I have observed HHC work for several years when I was in DDC as a program officer and as usual HHC has done such a wonderful job in Gajuri. I thank HHC. I hope and request all participants to use their new knowledge wisely for their patients. We are hopeful that the patients get better quality of care from you.

Radha Pa (one of the trainees):This gynecological training gave us more knowledge and ideas (techniques) about women issues. This training has helped us revise what we learned during our time at the teaching institute and has allowed us practical lessons which will allow us to independently deal with cases and help solve them. We expect more training from HHC thank you to HHC from Gajuri PHC and all participants.