Autumn 2014 – Newsletter from Khristiya

Seva Niketan Hospital If you are called to any ward around mid-day, there will be few folk outside –

only the saris drying in the heat of the day, but as the cool of dusk approaches folk gather outside to chat and have tea, and compare notes on their loved one’s progress. KSN Hospital has been busier than ever in this last quarter. Usually it is only the maternity ward, which is full to overflowing, but the other wards have been fuller recently. The Childrens ward, which has 30 beds, has several times overflowed into the female ward. Many children and adults too, being admitted

with infectious diseases. As the children recover they really appreciate the outside space where Dr Tom

Lamb and Dr Vasu Verma built for them. But even when its raining, and you can’t play outside, other kind folk have provided toys for the children to play and learn with inside. We are very grateful to our nursing staff in the childrens ward particularly, because having a kind sympathetic nurse who is willing to play games is half the battle won on the road to recovery.

Independence day was celebrated on 15th August in the usual fashion and various posters could be seen including this one here. Did you know all these facts about India? Most people are aware “ zero “ was invented here, and there is much for India to be proud of. But just being the largest doesn’t always equate with quality. India may have the largest post office network in the world, but if I want to be sure a letter will reach its destination, I would never use the India postal service. In the same manner also, KSN Hospital may be dealing with an ever-increasing number of inpatients and outpatients,

but it is the quality of service rather than the quantity that counts. We are seeing over 200 women through the antenatal clinics weekly, and some come a long distance and wait several hours to be seen. Thus it is important to give them time to voice their concerns, time to explain what is normal and what is not, time to reassure them their baby is growing well or there is a potential problem…….

Many girls return to KSN to have their second and third babies because their KSN experience has been a good one. Even if they have lost a baby here, like this young girl, they still come back because they were treated with sympathy and respect when their baby died. This girl returned to KSN to have her second child, whom she is so grateful for, and has come back to book in her third pregnancy. Another wee one waits patiently with her grandma, as her Mum goes for her antenatal check-up.

Sadly we had another young mother who died in August due to a complication of a condition called eclampsia. This mother had a cardiac arrest about half an hour after Caesarean section, but after 7 minutes of CPR her heart returned. In spite of this she remained deeply unconscious, was transferred to a Medical College with ICU facilities and died there 8 days later. She never regained consciousness, and never saw her newborn son. She was only 19 years old and leaves behind a 3-year-old daughter. Her family wrote this girl off as “always having been a weak sort” but we believe her death was possibly preventable and feel we let her down. This picture shows Sitansu explaining gently to students and staff the importance of meticulous nursing care in the recovery area after surgery.

In August the delivery rate crossed 200, so the maternity staff were awarded a small bonus. At times they have to cope with 3 deliveries simultaneously which means (with only 2 delivery beds) some poor soul inevitably has to deliver in the courtyard. It also means if 2 babies need resuscitation at the same time, it can be tricky for Shubhro. Shubhro has been training and re-training the Nursery staff, so that nowadays they are quite

proficient in resuscitation and he can concentrate on one baby at a time. This photo was taken one morning in July, when 4 mothers delivered within moments of each other and two of the babies did not breathe at delivery. In both of these situations we need oxygen – ie in the resuscitation of an adult or a baby. You remember in our summer newsletter we told you of the generous gifts of oxygen concentrators for KSN Hospital. Well we were able to take delivery of the oxygen concentrators in late August. It was a Saturday evening when we picked them up from

Kolkata, and the company manager and his assistant from whom we bought them came with us to Sarenga, so that all the KSN Staff could have a tutorial the following morning. We started at 7.30 with the night staff who were going off duty, and carried on till the late staff who came around 1.15 pm. The photo shows the ambulance being packed in Kolkata. There was hardly room for us !!!

Resuscitation - two at once – and not twins !!!

You maybe recall from our Winter 2012 newsletter that we sponsored 2 young tribal girls to live and study in Marsal Duar – the children’s hostel bordering the hospital. If you have not seen it before we have a short video of Marsal Duar which you can see through the following website http://youtu.be/mvhsX28gqcM

Through the generosity of folk from different UK Churches we have been able to sponsor six children. The first girl we sponsored, Kakoli – whose picture appears in the winter ’12 newsletter, recently became a patient in the children’s ward here. One night around 1am, the hostel warden was woken by some anxious girls, who had been woken up by Kakoli who was having convulsions. The warden brought her straight through to the hospital and for half an hour the doctor on call gave her medicines to stop the fitting, but to no avail. Shubhro then spent the next 3 hours with her till she seemed settled. He was planning to do a lumbar puncture, since Kakoli had had a fever, but the next day she was fully conscious, as bright as a button and wanted to go “home” to her friends in Marsal Duar. She was persuaded to stay another day, by a bar of Cadbury’s chocolate (we had not long returned from Scotland ! ) and a visit from her best friend. Since then she has been fine, and never having had a convulsion in her life, we pray this shall be the first and last. I have included here two photos of Kakoli – the first when she was still the “baby” of Marsal Duar, and the second when she was in the children’s ward – now too big really for the cots there ! Thank you all the caring staff in Marsal Duar who help these children to grow so well physically, emotionally and spiritually. Sister Nirmala Ree Sadly Nirmala died in August. She had given her whole life in service to the people of Sarenga. She was amongst a handful of our senior GNM nursing staff who are working with us beyond retirement, since it is difficult to attract the younger generation of GNM Nurses. Nirmala, like others could easily have secured a lucrative nursing post in Kolkata, but chose instead to remain in Sarenga giving her service to the people of Sarenga and the surrounding villages. In her youth She was involved in the maternity ward, but her greatest love was the community, and she has delivered many a girl in the surroundings of her mud hut. She would go out day and night for her patients. She was not a person to complain, but in November 2013 she went to see a Medical Specialist in Bankura, complaining of pain in her left shoulder. Various investigations were done, but essentially she was told that as you get older it is not unusual to have aches and pains. She worked all her life with women and children, looking after the mothers in pregnancy, delivery and after their babies were born. Latterly she was given charge of the ANC and Under Five clinics

which run 4 days a week, but she was never idle, and used to come to the Maternity ward to help the staff on the other two days of the week. In her younger days she had conducted many home deliveries in and around Sarenga, and was now involved in the antenatal care of the children and grandchildren of her patients. She was highly respected by the local people. Nirmala carried on working full time until she was eventually admitted to KSN Hospital on 19th June. Several investigations done in Bankura suggested the possibility of tuberculosis or lung malignancy, but neither was certain. She gradually lost consciousness by the end of June and it is to the credit of our nursing students that in spite of being unconscious for 7 weeks before she died, she had not even the hint of a bedsore. Here we should like to gratefully acknowledge the help, which we received from Consultants and

Professors all over the world through the Swinfen Charitable Trust. We should like to name and thank them here – Professor Victor Patterson, Dr Adrian Morris, Dr. Don Perry- Keene, Dr Julie Matsumoto, Dr Abbi Lulsegged and Dr Giuseppe Barbesino. They are all busy people and gave up hours of their time literally agonising over the diagnosis and best care for Nirmala. In the end they came to the conclusion Nirmala had metastatic lung cancer, and she died peacefully, surrounded by her family, and nursed and cared for by her own colleagues in her own “home”. We want to say a particular word of gratitude to Lord and Lady Swinfen, who together run this amazing service available free to the medical profession all over the world. They work tirelessly and completely voluntarily to help and support doctors and nurses in the far-flung corners of the world. There were 59 correspondences to the Swinfen Charitable Trust regarding Nirmala, and I can vouch that sometimes a response would come in the middle of the night (GMT) This sort of involvement was a huge comfort not only to Nirmala’s “hospital family” but also to her own family – they knew she could not have received better care in the finest most expensive hospitals in Kolkata. Since Nirmala spent her whole working life looking after the women of Sarenga and surrounding villages we are dedicating the second of Jane Hope’s painting to Nirmala’s memory – you can see here – it depicts women in various poses around the hospital.

Sister Nirmala explaining something to patient March ‘14

There is the same percentage of infertility in India as the world over, but girls in India, especially in rural areas tend to be married in their early teens.

If she is not pregnant within 6 months of marriage, there is great pressure brought to bear on her, and we see

many such youngsters at the gynae. Outpatient clinic. The girls are brought to the clinic under various pretenses, and the mother-in-laws body language betrays it all !!! Elisabeth usually asks the protesting mother-in-law to go to buy the medicines and proceeds to have a quick private chat

with the girl on her own. It takes only 2 minutes to discover that whatever “symptom” she has presented

with is simply the result of the mother-in-laws demands to find a reason for her failure to conceive. It would be amusing, were it not so serious, that some of these teenage couples are not even living together……..usually because of work, the husband (or less commonly the wife) live 200 miles apart and get to see each other 2-3 times a year. But, if he is around I then call the husband in and from that point on, they will be seen and investigated only as a couple, never alone. If the mother-in-law prohibits her son from being available, then I simply explain nothing further can be done without him. The result of this is that women who are potentially fertile stop ovulating regulary due to stress, are investigated and treated ……and then years later, when they have given up hope of pregnancy, their stress levels drop and they get pregnant…and so again this month we had three women in their 30’s married for 15- 20 years and delivering their first child. Incidentally, anyone spot the diagnosis in the mother-in-law top right hand corner. When I asked her, she had apparently lived with this goitre for the past

10 years, “and she did not want to part with it “ In our winter 2013 newsletter we told the story of three women who had babies after many years. One of them, only 30 years old had waited 15 years for this child, and she came to the clinic in early September to proudly show us her daughter. Shubhro will often call me to his clinic to see extra special babies like

these.

Married at 14 - now 29 and delighted with her firstborn

Baby after 20 years !!

November '13 Happy first time Mum,

and now.....10 months on, tired but fulfilled

Another happy family

We are finding some interesting trends in presentations in the maternity ward. The rate of eclampsia has fallen, but we are doing many more inductions for moderate to severe pre-eclampsia, and many of those women have a healthy baby and no

stiches after a normal vaginal delivery.

Our episiotomy rate has fallen to 5%, and whereas up till 18 months ago one woman every week was having to be re-admitted for cleaning and re-suturing of episiotomy, we have not seen a single broken down episiotomy for

15 months. One thing, which is still prevalent, though is the high premature delivery rate. Things, which make this common, are the high rate of early teenage pregnancy, anaemia, recurrent urinary or other infection and poor nutrition of the mother. These issues can be addressed, but they require a change in cultural attitude so that young girls are not pushed into early marriage and immediate childbearing. The government of India has recognized this and marriage is illegal before 18 years. But it is no co-incidence that 80% of our girls come at “19” years of age, while many like the girl pictured here are actually only 14-15 years old at most. 99% of our premature and very low birth weight babies are born normally. They simply have to take their chances, since we do not feel it is ethical to put a scar on a Mum,

delivering her by Caesarean section, and putting her at risk for a tiny baby that may not survive. We always give these families the option to deliver in a better-equipped hospital with incubator and baby ventilation facilities, but the majority of families want to stay in KSN Hospital. The Caesarean section rate has settled down to between 10-14%. Around 70% of Caesarean sections are done because the mother had a previous section or maybe more than one section, sometimes in KSN, sometimes in another hospital. Since we do not have continuous fetal heart monitoring here, we tend to deliver by repeat C/S if mother had her first baby that way. But some mothers actually request a normal delivery (especially when the first baby was a girl) and in these instances, we will consider allowing her a trail of normal delivery, with recourse to C/S if there is any sign of fetal distress or of mother’s scar dehiscing. We are still having rain, almost daily as I write (now end of September) so we continue to be grateful for the proper cement road between the maternity ward and theatre – built for us from Fullarton Church friends. The road built in 2011 has made a huge difference to the speed with which we can get a mother to theatre

born too soon at 990grmas

one month later - ready for home at 1300grams

Teenage Mum with her tiny premature baby ready for home

Older Mum with 1300gram baby - at term Mum had severe pre-eclampsia

in the monsoon. The picture below shows the “sunshine after the rain” so Mum is going under a cloudy blue dry sky back to the maternity ward after Ceasarean section. We are so grateful to Fullarton friends, (but Mum’s are even more so). And although now 3 years old, the Fullarton path is in fairly good condition. There are still some small defects from the goat and cow droppings, (for it took us several months after the Fullarton path was built before we found a way to stop animal owners from encouraging their livestock to use the hospital grounds as free pasture) Sheena Kinmond (from Fullarton) will be visiting us again in November, and we hope she will be happy with the condition of Fullarton path. At present we have a goat in captivity which came as a baby kid, and after 5 weeks of Konika’s caring, feeding and company now seems to want to stay for ever. It doesn’t say much for its owner that the poor wee goat was never missed, and has never been claimed. Invitation to do some interactive hands on skills and drills training in Jharkhand Dr Lindsay Barnes (who runs a small hospital in Jharkhand asked Shubhro and I several months ago if we would be prepared to go and do some interactive training sessions with her staff. And so it was we went for a weekend in late August. But we think we learned more from them than we were able to teach. We had a great time, and the team there, including doctors, nurses and paramedics were all so happy and enthusiastic, and did not seem to mind staying late after evening duty, or even in the morning after night duty – so that we could have these sessions together. We also went out with Linsday to one of her clinics in a very remote area, and were so impressed by the nursing staff she has trained out in the villages also. These very poor people are getting an excellent service and they know it and just love Lindsay and her husband Ranjan who have dedicated their lives for the women of this tribal area. The name of their set up is

Jan Chetna Manch (which means forum for people’s awareness). Lindsay and Ranjan have lived (in their own mud house) there alongside the people for over 30 years. They know what it is to adapt to no electricity, no running water year in year out. But Lindsay’s dedication was recognised early this year when she was awarded an honourary FRCOG at the World Congress of Obstetrics and Gynaecology. The Indian Governemnt, (GoI), in conjunction with RCOG, through the Liverpool School of Tropical Medicine’s Maternal and Newborn Health Unit is about to launch the first “Skills and Drills” Course in Delhi next month. Elisabeth spent a few days in Delhi in August sitting on an interview pannel with representatives from GoI and LSTM, to appoint 30 Full time Master Trainers for the Course. The Master Trainers will run three 6 day ‘”skills and drills” courses per month, and in the 4th week they will travel to the Health Facilities from where

their trainees have come, to see if they are able to put into practice those skills which they learned on the course. GoI plans to give in-service training on a regular basis to all

government employed nurses and doctors working in maternal and newborn health. It is hoped that by regular practice together, teams of nurses and doctors will gain confidence in the skills which help to save the lives of mothers and babies.

Thank you to all who prayed for more nursing and medical staff to join us. In this quarter we have welcomed two part time doctors, one of whom has a postgraduate qualification in surgery. We hope to add a third permanent doctor next month, for when we are away, it is too much to expect the two permanent doctors to manage the hospital alone. We have also welcomed another senior qualified nurse. We thank God for the undeserved blessings He continues to pour out on this place. This comes with our love and gratitude to all. Shubhro and Elisabeth

Learning ventouse delivery by the "see one" "do one" method

Elisabeth in Delhi