EXCELLENCE IN PEOPLE


three midwives on each shift, there was clearly a lot of work to do.


To work So, we set about creating a bit of order and familiarity. Bed numbers, drug charts, admission sheets, blood forms, clipboards and, of course, a handover white board, without which I think any British obstetrician would struggle to survive. The sterilisation and disinfection systems were overhauled and a stock-checking and controlled medicine system was introduced. We worked with the Ministry of Health,


which recognised the need to increase our staffing levels in order to open the operating theatre; with our new ward nurses, we were able to institute six-hour observation checks and have some confidence that it was safer to administer MgSO4


than not. We began


operating and introduced the concept of a swab check, as well as a few essential guidelines to harmonise management of the most common clinical scenarios. We cleaned, created, re-organised and often


felt more like Blue Peter presenters than obstetricians. Remarkably, the majority of the staff took our frenetic activity in their stride and adopted the changes as they were made. Nobody likes to run out of essential medicines or watch a patient convulse unnecessarily, and the benefits of our interventions were easily and rapidly visible.


Oh, and clinical work Of course, there was also clinical work to do and training to deliver. What is remarkable is how many women did not need our assistance. Most mothers passed through the labour ward rapidly, barely stopping long enough to make it worth writing their names on the board. Just as well really, as with 6,000 deliveries a year and major understaffing, even a small percentage of the total represented plenty of work: eclampsia, heart failure, malaria, asthma, sepsis, obstructed labour, malpresentation, abruption and, of course, postpartum haemorrhage. We are taught that postpartum


haemorrhage is the leading cause of maternal death worldwide. I no longer believe this to be true. During my time in The Gambia, I treated dozens of women with life- threatening postpartum haemorrhage of the terrifying ‘good Lord, we’re not going to be able to stop it’ variety. Nearly all had had abruptions secondary to unmanaged pre- eclampsia. They were usually admitted pale,


O&G November 2015


tachycardic and hypotensive. Their babies were usually dead and their conjunctiva were often ominously pale. There then followed a frantic effort to get hold of some fresh blood before the delivery. If our efforts failed, the delivery saw disseminated intravascular coagulation combine with atony, and we were left chasing our tails. A couple of fresh units before delivery and the story could be different. Later, after herculean intervention, when the patient was stable, up would go her blood pressure and we would then be reaching for the hydralazine and MgSO4


. Medicine is all


about pattern recognition, and after some time we had the patients loaded on MgSO4


before


this happened and were rarely caught out with an unexpected convulsion. Our trainees, having initially been frustrated


by the lack of order, operating and training, have progressed impressively over the last year. They have benefited from a high case- load, small trainee numbers and proactive supervision. I am proud to be able to trust them to run the unit and manage most high- risk cases with limited oversight.


The future We have grand plans for the future of the maternity unit and the training programme. We envisage transforming our district maternity centre into a model unit and cooperating with the teaching hospital in Banjul to transform our one-year programme into fully-fledged specialist training.


Dreams are necessary I think, but in the meantime we do have the more modest short-term aim of continuing our one-year programme for a further four trainees, this time with the involvement of a Gambian obstetrician. We also plan to support the unit staff in consolidating and building on the changes made this year, and have plans to introduce a basic maternity dashboard, to affiliate to the World Health Organization maternal death review system, and to introduce neonatal care training for our ward staff. We would also like to increase our cooperation with the teaching hospital and the University of The Gambia and look forward to developing new relationships with both institutions. There is plenty of work to do, and it isn’t easy, but in the end it does feel worthwhile.


Alice Clack MRCOG


Alice completed her specialist obstetric training in the London deanery in 2013. Since


then she has worked for Maternal and Child-health Advocacy International, (MCAI), initially in their task shifting project in Liberia and, since October 2014, in the project described in this article in The Gambia.


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