Obstetrics and Gynecology

Brief Overview

This past week I switched from surgery to the obstetrics and gynecology rotation. I was able to see some of the smaller clinics, as well as large hospitals. This gave me a better understanding of how the health system works here in South Africa, as well as the different services offered at each level of care. In addition, I learned more about the role of sisters in antenatal care specifically. I went on call one night, and only one baby was born the entire night! It was amazing to be able to watch the C-section. Lecture topics this week included biology of aging, anemia, adrenal gland physiology, mitral valve disease, biological effects of radiation, statistics, neonatal endocrine and metabolic abnormalities, trauma surgery, physiology of the eye, the district health system, and diagnostic imaging. There was also a guest speaker from the UK presenting “101 Things to Do While On Call.”

Clinical Rounds

My first day of rounds was at Pelonomi Hospital’s prenatal ward. In South Africa, pregnant women first go to their local clinic to be treated. When there is a complication, they must go to a more specialized institution, such as a hospital. Therefore, all of these women had some kind of complication or risk factor for which they were referred. The first thing I learned about OBGYN was the structure of the H-10 form. This is a form that all South African medical facilities use when treating a pregnant woman. The woman then keeps the form with her throughout her pregnancy, so that any medical provider can know everything important about the woman’s history. It includes demographic data, information about previous pregnancies, social situation, family history of diseases, blood work, past operations, current medications, plan for contraception after delivery, and the estimated date of delivery (EDD). The EDD is determined by a combination of the following: calculation of 40 weeks past the start of the last known menstrual cycle, sonar imaging, and SF measurement. It was actually quite complicated—especially when there was discrepancy among the different types of measurements. The doctor was very stern when the fourth years presented their cases, making sure they knew what each part of the H-10 form meant, what all lab results signified, what the diagnosis was, and what treatment was necessary. She was so thorough that it took two hours for one patient!

The next morning, I was at Heidedal’s prenatal clinic. We learned how to take patient history on the H-10 card, and were even able to practice on a patient! We learned specifics about the blood work that is done on each patient. They test each mother’s HIV status, hemoglobin, Rh factor, and for syphilis. We also observed a full physical examination on several women, and learned how to take the SF measurement that is used to determine gestation. Finally, we were able to locate and listen to the fetal heartbeat. A sister typically does all of this. The sister we were shadowing was very helpful and patient, even though the clinic was extremely busy, so we learned a lot.

Wednesday morning, we were assigned to observe sonar at National Hospital. However, the woman there would not let students watch her. This was a problem, since the students have to see a certain number of different procedures during their rotation, and sonar was included. We ended up going to Universitas to observe. This ward was for extremely complicated pregnancies and was very modern looking and sterile. It looked just like an ultrasound room in the US. We saw three sonars. The first case had a baby that was not growing properly. The woman was 24 weeks pregnant, but the baby was only the size of 20 weeks. The physician had to explain to her that she would most likely lose the baby, which was tough to watch. The second mother had a mitral valve replacement (which we had already learned about in lecture), so she was taking warfarin for that. The problem is that this drug causes defects. The doctor was checking to make sure the baby was still growing properly, and it was. The final sonar was a 4D scan, which was very cool. It was to check for defects due to a genetic trisomy condition. It was interesting to see how much could be determined from an ultrasound. We listened to the fetal heartbeat and determined gestation by measuring the length of the femur.

Thursday morning, I was at the prenatal clinic at MUCPP, located in the township. The consultation rooms were very crowded because there were nursing students there observing as well. Even though it was a little hectic, we were able to do some physical exams on a few patients. The medical student I was with said that the observations and rotations they do during their third years are important for them to understand what the health professionals do. For instance, sisters perform physical exams on patients; these students will not do that as a doctor. It’s important, however, that they are able to know what the sisters did and understand their notes when a patient is referred to them. It was very inspiring to hear of this dedication to collaboration in the workplace.

On Call

I was on call all night on Wednesday at Pelonomi labor ward. When we got there, two twins had just been delivered, so we were able to see them. Then, we were in the theater for a C-section. It was such an amazing thing to watch, and it was interesting that the mother only had a localized anesthetic so she knew what was going on during her operation. I was also impressed by how many people were needed to deliver the baby. There were doctors for both the mother and the newborn, as well as students or nurses to assist. After that, I couldn’t wait to see more, but it was a very slow night. We actually did not see anything else, so we got a good night’s rest in the on call room.

Lectures

The biology of aging lecturer did a fantastic job of highlighting the importance of gerontology. He gave statistics about the elderly in the Free State and around the world, showing that the elderly population is growing rapidly. This signifies a growing need for providers for this patient population. He also gave a general overview of aging, showing the difference in life expectancy for different organisms (ex: flies live 18 days, sea turtles live 380 years, and trees live thousands of years). He also showed how the human life expectancy has changed throughout the years, dating back to the life expectancy of Bible patriarchs. It was interesting to me to see the frequency with which religion is included as a part of the lectures. He concluded that diet and exercise are the most effective ways to age in a healthy way.

The anemia lecture was very informal, with the professor introducing himself by his first name only. He stressed the importance of looking for the cause of anemia, rather than simply diagnosing and treating the anemia. He also pointed out specific things to ask when taking history. For example, he wants the students to ask separately if the patient is taking any over-the-counter medications, since patients often do not report this when asked if they are taking any medications. In addition, he showed the importance of knowing the cultural and social qualities of the patient. He gave the example that families who drink a lot of tea are often anemic, since tea inhibits iron absorption and that alcoholics have lower folate levels. The following lecture on adrenal glands was presented through a case study of a real patient with Addison’s disease. She also reviewed a few concepts from the previous endocrine lecture. The final lecture on mitral valve disease was interesting because he talked about how mitral regurgitation has different causes in South Africa than in Europe. In South Africa, it is typically due to rheumatic endocarditis, which requires a valve replacement rather than repair. This lecture overlapped a lot with the aortic valve lecture the previous week.

The medical physics lecture was on the biological effects of radiation and radiation protection. She provided guidance on safe doses of radiation by comparing the amount of radiation one receives in different ways, such as smoking, cooking with natural gas, living near a nuclear plant, and getting an X-ray. She specifically argued that medical radiation is an acceptable risk if it is used cautiously, since smoking can shorten your life by seven years while medical radiation only shortens it by about 49 days. She then taught how to protect the patient from unnecessary radiation and precautions to take during pregnancy.

The statistics lecture was extremely interesting. He argued the importance of statistics as having the ability to identify a problem or public health issue, so that action can be taken to solve it. He used an interactive computer model to show various health statistics for South Africa and countries around the world. For example, he showed that the most global child deaths occur in sub-Saharan Africa. Through these statistics, WHO has gotten involved to implement programs to save newborns, such as tetanus vaccines, malaria prevention, kangaroo mother care, and breastfeeding.

The trauma surgery was a continuation from the one last week. Therefore, it was taught in a similar fashion, using situations to teach different emergency medicine procedures. After this, a guest lecturer from the UK came and presented “101 Things to Do On Call.” The students liked to see the similarities and differences between their system of education and clinical practice and that of the UK. We were also able to practice some when we were on call that week.

Thursday, the students wrote a quiz on the anatomy of the eye. It was very short, and then we had a lecture on the physiology of the eye. The lecturer did not make the powerpoint, so she skipped many irrelevant slides. She did include several demonstrations and videos, however, to illustrate the concepts.

That afternoon, we had a lecture on the district health system. The students were presented with a project in which they must use the National Health Act to back up a case study. The lecturer compared the structure of South Africa’s health care system to the US, explaining that South Africa provides health care based on geographical districts rather than who can afford the services. He also taught about the importance of getting the community to participate in health care service delivery. Another point he stressed was developing a system in which people at the grassroots level can have a voice at the top of the system in order to effect change. There was much debate among the students, making it a more dynamic lecture than most.

The final lecture was on diagnostic imaging of the liver. I’ll be honest and say that this lecture was more above my head than the others because it was mostly just images of radiological scans. Since I didn’t have the appropriate background at reading these, I found it a little confusing. The professor did provide a lot of advice, however, about how to avoid making mistakes when reading the scans and preparing a diagnosis.

Clinical Education Facts

The students received their final grades for their third year of medical school this week! Those that passed are now fourth years. If students did not pass, but were close, they have a chance to rewrite exams in a few weeks. However, any student below the rewrite score fails the year and must repeat the entire third year.

For the OBGYN rotation, the students have a book with a certain number of procedures or tasks they must observe or do. When they complete it, the doctor or sister signs it off. This, along with a report on a case study is due for marks at the end of the rotation.