Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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90 Surgery and Healing in the Developing World
and organized was a challenge. I sewed a folding table-sized mat with pockets for
holding a stethoscope, BP cuff, note papers, pens, paper clips, patient registery, etc,
each pocket was velcro-closed. It opened out on the hood of the car, providing an
instant nurse’s desk. Disposable hand wipes for village work are quick, effective, and
won’t mold like wet washclothes.
Care of the Infant and Child
Care of the premature infant is an acute challenge in a nontechnical setting.
Great efforts and planning are required to provide adequate prenatal care to support
full-term babies. If the government doesn’t have a standardized prenatal visit card
for following the pregnancy, one can be easily created and copied. Treatment of
existing conditions such as STDs, malaria, anemia, parasites, and TB should begin
as early as possible, even prenatally if the woman presents herself to the clinic.
During prenatal visits, in addition to the usual monitoring, the waiting time can
be used to great advantage to include teaching of public health measures
(handwashing, oral rehydration therapy, use of latrines, safe drinking water, prevention
of AIDS), care of the Mom and newborn, and safety issues. Stressing an alcohol-,
drug- and smoking-free pregnancy can make the difference between a viable
and a lost pregnancy. Alcohol is the leading known teratogen. As the initial contact
with the healthcare system for many women is during pregnancy, planning is needed
to make this experience user friendly and helpful to her. Prenatal care includes prevention
of infections, malaria prophylaxis (Chloroquine 250 mg base weekly is effective),
iron supplements, prenatal vitamins, iodine replacement (1 ml Lipiodol
IM) if she is in an iodine deficient location. If the mother hasn’t been immunized
against tetanus, she can receive the tetanus-diptheria (Td) vaccine at seven months
gestation and a booster at eight months (a month between the first and second
injection). This schedule will provide the newborn with transplacental antibodies to
prevent neonatal tetanus if born out of asepsis. Also, Hepatitis B vaccine can be
given during pregnancy, and at birth for the neonate. Temperatures greater than
39.5˚ are associated with pregnancy loss and CNS anomalies in the first trimester
and preterm labor in the last trimester; many of these febrile episodes can be avoided
with malarial prophylaxis and treatment of infections.
Careful obstetric histories often reveal very sad outcomes, many of which could
have been prevented. For a history of spontaneous abortions early in the second
trimester, an incompetent cervical os may be diagnosed. This can be easily treated,
even in outlying clinics, with a cervical cerclage, enabling the pregnancy to continue
to term.
Care of the premature infant in a low-technology environment can be successful.
Maintaining an adequate body temperature of 37˚ can be accomplished with a
warm water bottle, or if that isn’t available, warming some bricks at the edge of a
fire. These, of course, have to be wrist-tested to ensure they are a safe temperature
for the infant, then wrapped in a baby blanket and placed alongside the infant. They
are particularly useful for the cold tropical nights. The family enjoys learning and
following through with this technique. One day a young mother with a seven pound
baby greeted me at the maternity, having walked for over 50 miles to show me her
“newborn”. The baby had been born prematurely in the village, many weeks before,
and she had kept the tiny preemie warm with the heated bricks—she was so pleased
the villages’ talking drums had passed on this new idea.
Premature neonates, under 1650 grams usually have to be gavage fed, aiming for
120 kcal per kilo per day. I have found the 15" Fr. 5 tube to work well, gravity