Back at work.

I am a volunteer in Pristina, Kosovo for 4 weeks with Project HOPE. All opinions stated are my own and do not represent the positions, strategies, or opinions of Project HOPE.

I mentioned at the end of last week that I had some ideas for what to do in terms of my work for Project HOPE. One goal listed online for the work at the University Clinical Center was to train all nurses, residents, and doctors in basic life support (CPR). When I arrived, it seemed this was not a very helpful goal for the current situation in the Obstetrics and Gynecology department. For one, there is no equipment to use to help train people. There are no projectors for powerpoint presentations or even any computers at all on labor and delivery. There are computers in many of the offices and internet (although it requires a username and password), but nothing really available for the teaching of BLS. In addition, many people don’t speak enough English to be able to ask questions. Many people understand English but don’t speak it well enough to ensure that the teaching was understood and therefore effective. Also, there are no mannequins to practice CPR on and their are no non-rebreather masks to use to practice safe CPR. Also, BLS teaches about the use of defibrillation which when you have access to it, is what makes CPR most likely to succeed in saving a life. I have not seen any defribillators on the unit. And, most people who require CPR will likely need a higher level of care following resuscitation - higher level of care meaning an ICU. Although I am certain there is an ICU within the University hospital, the hospital is a series of separate buildings and there is not an adult ICU in the obstetrics and gynecology division. I am not sure where it is or how patients would be able to move from here to there in a timely fashion. The only patients who seem to be able to receive higher level of care quickly are the neonates as the NICU is on the same floor as labor and delivery. 

The sterilization equipment on labor and delivery.

All record keeping is done on paper and there are no computers on the labor and delivery unit. Computers are not just helpful for documentation in an electronic record, they are also helpful as a source of information and learning for residents, midwives, and staff here at the hospital. Without a computer and without any textbooks, there is a deficiency in resources available for the staff to learn from. There is a lot of teaching that goes on especially from midwives to residents and the specialists to the residents and midwives and medical students, but there are no resources available while at the hospital to refer to for management questions or even just for learning to enhance knowledge. Many of the residents are learning German in hopes of going to Germany for further training and possibly to live. There are not as many opportunities here for them. I hope to at least help change the availability of education resources for them, and this is what I plan to work on through my time with Project HOPE. I have started by emailing some PDF files to one of the residents who speaks English. She has been very thankful for these and asked if it would be possible for me to send her more to learn from. Michael is hopefully going to be able to bring a textbook of obstetrics and gynecology for the residents to have to keep in the hospital. One of the residents owns a pocket manual of ob/gyn and another resident owns a book geared toward medical student education published in the UK in 1988. My co-Project HOPE volunteer and I are going to work on a proposal to get a computer on the labor and delivery unit which can be used for education. If they have a computer, PDF files and online textbooks could be accessed by all. We live in an era where so much information is available online and if people are guided where to look for good information, there is so much that can be learned. I hope to help provide some of these resources. 

In terms of practical experience, those who work at the University hospital are not lacking in deliveries. As I mentioned before, during the slow time of year, this hospital averages around 40 deliveries per day and up to 80+ during the busy time of year. They keep a record in a large ledger book of all the deliveries done during the day. Here are the numbers from the past week: 3/23: 40. 3/24: 42 (7 c-sections). 3/25: 21. 3/26: 15 (really slow day). 3/27: 15. 3/28: 25. 3/29: 36. 3/30 by 2PM: 25 (14 of which were c-section deliveries). 

The empty 4th floor operating room on L&D

Yesterday, I observed my first c-section delivery at the hospital. It was an urgent c-section for non-reassuring fetal heart tracing. The patient was fully dilated but the head was still high and there is not a lot of access/options for operative vaginal deliveries. She was taken for an “urgent” c-section. I’m not sure that an emergency c-section can really happen in an emergent manner here. Labor and delivery is on the 4th floor. The operating rooms are on the 2nd floor. There is an operating room on the 4th floor but there is no equipment or bed in the OR so it is basically non functional. Anesthesia was via spinal. Reusable cloth drapes are used. The glove sizes available are 7.0, 7.5, or 8.0. The technical parts of the c-section were the same as how we do it in the US. The most interesting part about the whole experience was that the operating rooms are adjacent to each other and all the doors were open - the door between our OR and the neighboring one (which also had a surgery going on simultaneously) as well as the door into the hallway. Betadine is used for skin prep prior to surgery and is used liberally. It is also poured on the dressing before it is applied at the conclusion of the surgery. The patient helps to move herself onto a transfer bed after surgery by pulling on a triangle attached to the top of the bed while the anesthesiologist and resident help pull the patient’s body (on a cloth placed beneath the patient prior to surgery) and legs. Per one of the residents, the infection rate is “high” after surgery. I’m not exactly sure what that translates to in terms of percentages. It was interesting for me to see the flow and see how everyone performs their job in a surgical setting. 

Cutting and folding bandages

My typical role during a delivery here in Kosovo is to provide support for the mother. As I have mentioned before, no family members are allowed on labor and delivery. I hold her hand, provide water to drink and a wet cloth for the forehead if desired, and talk to her. Even if she doesn’t understand what I am saying, I think she understands my tone of voice and a smile can go a long way. It is a different role than I typically have in the US, but a valuable one and one that helps me feel that I can contribute to the birthing experience for the women here in Pristina. I also helped fold gauze sponges today. Instead of having individually wrapped gauze, they have a large role that gets cut by hand into smaller squares than folded into individually wrapped pieces that are used in the delivery room. We filled two large metal containers with them to prepare for the upcoming deliveries. It was a good day’s work.