First Days in the Labor Ward

During our time in Nepal, Kimber and I will be visiting the Paropakar Maternal and Women's Hospital in Kathmandu. For our first couple days we spent time in the low risk labor ward observing nurses perform deliveries, talking to them about how the manage labor and go through their decision making process, and just getting more familiar with the staff.

One of the nice differences we noticed in the labor ward at PMWH as compared to Sevagram was that the staff is much more focused on the type of care the mother receives. Each woman gets her own cubicle like area for delivery that can be made private with portable room dividers. Nurses work with the mother to try their best to facilitate a normal vaginal delivery, such as by encouraging alternative birthing positions, delaying episiotomy until necessary, and actually using lidocaine before performing said episiotomy. 

The unit is run entirely by nurses, all of whom have received two months of Skilled Birth Attendant  (SBA) training. This course teaches them how to manage labor, perform normal vaginal deliveries, and perform vacuum assisted delivery (VAD). SBAs in Nepal are not allowed to perform forcep deliveries. 

The yet to be used manual vacuum pump

While watching the nurses perform deliveries and talking to them, we learned a lot about how often women are examined while they are in labor, how nurses can tell if a woman is progressing properly, how nurses know when alternative methods of delivery need to be considered, and how confident they feel performing VAD. Though the labor ward has a VAD device, it has a manual pump, meaning two people are necessary to operate it, and the nurses are unsure how to tell if they have reached the appropriate pressure for use because they aren't sure how to read the pressure gauge. They used to have an electric pump that had a red zone and green zone delineating what the proper amount of pressure is, but that broke and they now only have the manual pump one available. 

3rd year medical student demonstrating how VAD
is performed using a pelvic model and a fetal skull

We were also able to attend a lecture about the indications for use for forceps and VAD and at the end were able to talk to the 3rd year medical student who lead the lecture. We asked him about how VAD is trained for at the facility and he said they currently use a pelvis model and a fetal skull to practice but he prefers to practice on delivering women because on real cases he can't accidentally skip steps and there is a whole team of doctors and nurses to help make sure that he is attempting the VAD properly. He also told us that he thinks a more realistic simulator would help him feel more confident about the skills he can learning while training.

At the Jhpiego office in Lalitpur we were also able to talk to Dr. Kusum, our in country advisor, about the need for a better VAD trainer. She said more of the models they have are not realistic and are not designed with teaching VAD in mind. A lot of time she has to use workaround to demonstrate certain features or scenarios, but these workarounds are not very realistic and generally don't last long.

We hope to learn more about the simulators they use and watch some training in the next couple days!