This article is about how to recognize obstructed labour and deal with it in a way that preserves the life and health of mother and child. It is for midwives and others who work in maternity care and is based on our experiences in Yei, South Sudan. Obstructed labour means that the baby is too big to pass through the birth canal. It can be associated with prolonged labour. Prolonged labour can sometimes be treated, resulting in a normal delivery but a woman in true obstructed labour should be delivered by Caesarean section.
Pathophysiology
Inhalation of Mycobacterium tuberculosis leads to one of four possible outcomes:
• Immediate clearance of the organism
• Latent infection
• The onset of active disease (primary disease)
• Active disease many years later (reactivation disease).
Among individuals with latent infection, and no underlying medical problems, reactivation disease occurs in 5 to 10 percent of cases [1]. The risk of reactivation is markedly increased in patients with HIV [2]. These outcomes are determined by the interplay of factors attributable to both the organism and the host.
In a recent article in this journal [1] I discussed the question of poisoning in South Sudan in an attempt to generate information about the size of the problem. As I pointed out from my experience in Uganda I was concerned about the occurrence of, and mortality from, poisoning with organophosphates. Seventy-one cases of poisoning from organophosphates were reported from forty hospitals and health centres over a six months’ period with a 27% mortality. No other agent was associated with a death in this series (Table 1).
World Health Organization and Global Malaria Programme
During the last few years, WHO has observed a slowing of efforts to scale-up intermittent preventive treatment of pregnant women (IPTp) for malaria with Sulfadoxine-Pyrimethamine (SP) in a number of countries in Africa. While there are several reasons for this, confusion among health workers about SP administration for IPTp may also be playing a role. For this reason, WHO is clarifying its recommendations, and urging national health authorities to disseminate these recommendations widely and ensure their correct application.
17-year male student presented with vague constitutional symptoms and jaundice. His clinical chest findings initially suggested a discord with radiological findings. It turned out that the patient had a rare congenital disorder in addition to a seemingly common condition that brought him to the hospital.
The purpose of this case presentation is to share some challenges of a clinical-radiological discord in a teaching hospital in Zimbabwe. It shows a flow of teamwork from House Officers to the Consultants as well as radiological back up.
Below are two more of the nine checklists from the Maternal, Newborn, and Child Survival (MNCS) Initiative, which was developed and is being implemented countrywide by Massachusetts General Hospital and the Ministry of Health. These two checklists illustrate the basic steps that community-based providers can use to diagnose and manage the danger signs of labour, and heavy bleeding. For more information, please contact: Dr Thomas Burke, tfburke@partners.org.
Examples of checklists for community-based frontline health workers in South Sudan.
Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune inflammatory disorder targeting diarthrodial synovial lined joints, usually in a symmetric distribution. The lungs, pericardium of the heart, skin, and eyes may be affected in up to twenty percent of patients. If uncontrolled, RA leads to joint destruction, disability, and a significantly shortened life span.
Pericardial effusion is fluid in the space between the heart and the pericardial sac. There are many causes of pericardial effusion, with infection (viral and TB) as the most common. If fluid rapidly accumulates in the pericardial space, like in chest trauma, this fluid can compress the heart (cardiac tamponade) and cause circulatory failure. With slow accumulation of fluid, the pericardial sac will stretch to accommodate the fluid. However, if fluid continues to accumulate, tamponade will eventually occur. This is an emergency situation requiring aspiration of pericardial fluid (pericardiocentesis).
Mental illness has a profound and often underestimated impact on the health and functioning of individuals and communities in post-conflict societies. Part I of this series provided an overview of depression and post-traumatic stress disorder (PTSD); Part II focuses on anxiety and substance use, including alcohol withdrawal.
It is generally believed that ischaemic heart disease and the serious consequence of myocardial infarction is uncommon in indigenous South Sudanese. This belief may be misplaced as evidenced by this case report.
We are pleased to publish the article ‘Post-Conflict Mental Health in South Sudan: Overview of Common Psychiatric Disorders’ by Maithri Ameresekere and David C. Henderson. This outlines the disorders commonly seen and suggests ways of diagnosing and managing them
Mental health is “a state of well-being in which every individual realizes his or her own potential, can work productively and fruitfully, and is able to contribute to her or his community.”(1) Mental illness often attracts a lower priority than physical illness in post-conflict and low and middle-income societies but the two are inextricably linked
The prevalence of asthma is highest in ‘developed’ countries and lowest in developing and emerging countries. The prevalence increases as development progresses and is higher in urban compared to rural areas in developing countries. This increase may be a result of several factors including:
Dengue fever is caused by dengue viruses (DENV). Transmission of DENV has increased dramatically in the past two decades making DENV the most important human pathogens among arthropod-borne viruses. About 50-100 million dengue fever infections occur every year in tropical and subtropical countries
This is a common problem among young children. In a study reported in this journal (1) it accounted for over half of the children with all forms of poisoning admitted to 20 health units in Uganda. This problem usually seems to arise from kerosene being kept in an unlabelled container (e.g. a cola bottle) and within reach of the child.
Improving maternal, newborn, and child health is a leading priority worldwide. It is a particularly urgent issue in South Sudan, which suffers from the world’s worst maternal mortality and among the worst newborn and child mortalities
Examples of checklists for maternal, newborn and child health workers
Faced with the magnitude of health care challenges in South Sudan, one could argue that epilepsy is a minor problem and that resources should not be diverted from more pressing needs. Yet epilepsy is a common and often devastating condition which in South Sudan burdens the lives of more than 100,000 sufferers and their families. In most cases it could be effectively and cheaply treated if resources and systems were available
Charts 7 and 8. How to give IV fluids to children without and with severe malnutrition from ‘Pocket Book of
Hospital Care for Children - Guidelines for the Management of Common Illnesses with Limited Resources’ WHO
2005. See the whole book at http://www.ichrc.org/. Charts 1 – 6 were reproduced in previous issues of this journal.
The overall responsibility for health research in South Sudan falls under the Division of Research, Monitoring and Evaluation and has been the remit of the Directorate of Planning and Coordination in the Ministry of Health, Republic of South Sudan. The existing structure of the research department includes the research data hub, the ethical committee and the research secretariats.
Wherever we are in the world there never seems to be enough money for healthcare provision. So the key is to make what resources we have go as far as possible. Any laboratory test that we request should always be preceded by the questions “Why are we making the request, what are the possible results and what decisions might those results lead us to make?” Then we should ask “Have we gained all possible information from that test?”
Onchocerciasis is an insect-borne disease caused by the parasite Onchocerca volvulus and transmitted by blackflies of the species Simulium damnosum. It is often called ‘river blindness’ because the blackfly lives in fertile riverside areas, that frequently remain uninhabited for fear of infection. Onchocerca volvulus is almost exclusively a parasite of humans. Adult worms live in nodules in the body where the female worms produce large numbers of first-stage larvae known as microfilariae. These migrate from the nodules to the sub-epidermal layer of the skin where they are ingested by blackflies. The microfilariae develop in the body of the blackfly and are transmitted to humans when the fly bites them (1).
We thank the Director of Nutrition, Ministry of Health, Government of Southern Sudan for permission to publish the Ministry’s Interim Guidelines on the Integrated Management of Severe Acute Malnutrition. These cover all aspects of the modern management of acute malnutrition including community outreach, outpatient and inpatient care and monitoring and reporting.
Chart 6. How to position the unconscious child from ‘Pocket Book of Hospital Care for Children - Guidelines for the Management of Common Illnesses with Limited Resources’ WHO 2005. See the whole book at http://www.ichrc.org/. Charts 1 – 5 were reproduced in previous issues of this journal.
You can use these charts in different ways. For example, you can print them and display them in relevant wards or clinics (laminated if possible), or use them as a ‘memory aid’ in your pocket, as handouts or as training aids.
We thank the WHO for permission to reproduce these charts, and Dr O’Hare who gave us the idea of making the charts more widely available.
In the February 2011 issue of SSMJ we covered the pathophysiology, and clinical and laboratory diagnosis of malaria (1, 2, 3). In this article we deal with the treatment of uncomplicated malaria. Management of malaria among pregnant women and children, and treatment of severe malana will be published in future issues of this journal.
The previous article described the clinical features and diagnosis of malaria. However, for a definite diagnosis, the malaria parasite must be seen in a blood film. In this article we cover laboratory tests used to diagnose malaria...
In Kenya we are trying to focus on confirming the diagnosis of malaria using microscopy or rapid test diagnostic kits (RDTs) rather than just treating a presumed clinical diagnosis. Many health staff in dispensaries and health centres still believe that every fever is malaria and that malaria tops the list of diseases even in non-endemic area. This belief is strong particularly among those who have had training in IMCI (Integrated Management of Childhood Illness). One result of this belief is that many patients are given artemether-lumefantrine treatment (AL) unnecessarily with the additional risk that other causes of fever go untreated. I wonder if it is the same in South Sudan?
The previous article, ‘Introduction and patho-physiology’, reviewed the mechanism of transmission of malaria, the types of parasite and the life cycle of the malarial parasite. In South Sudan, 90% of malaria is caused by Plasmodium falciparum (P. falciparum). This article focuses on the clinical features and diagnosis of P. falciparum but for completeness will also discuss the other main species of malarial parasites.
This is the first in a series of articles on malaria. It is intended for everyone in South Sudan who diagnoses and treats malaria, and advises on how to prevent it. This article gives an overview of the epidemiology of malaria, the parasite’s lifecycle and the pathophysiology of the disease. There is more information in items listed at the end of the article. Also in this issue of the journal are two articles on the diagnosis of malaria. Treatment and prevention will be covered in future issues.
This is the second in a series of articles that aim to help readers to understand and interpret recordings of the surface ECG. The first article introduced the basic principles of the ECG including the electrophysiology of the heart and the features of a normal ECG (1). This one describes some of the common abnormalities of electrical conduction which can be seen on the ECG.
we reproduce Chart 4. How to manage the airway in a child with obstructed breathing from ‘Pocket Book of Hospital Care for Children - Guidelines for the Management of Common Illnesses with Limited Resources’ WHO 2005 – see the whole book at http://www.ichrc.org/. We published Charts 1, 2 and 3 in previous issues of this journal (vol 3 nos 1, 2 and 3) and plan to publish more in future issues.
You can use these charts in different ways. For example, you can print them and display them in relevant wards or clinics (laminated if possible), or use them as a ‘memory aid’ in your pocket, as handouts or as training aids.
We thank the WHO for permission to reproduce these charts, and Dr O’Hare who gave us the idea of making the charts more widely available.
Over the last few years I have visited Rwanda many times working at a beautiful but remote rural health centre (Kirambi, about 100km south–west of Kigali). The “Land of a thousand hills”, as Rwanda is sometimes called, is a land that is difficult to cultivate needing a lot of hard work. The people there attend the health centre at Kirambi with a wide variety of complaints but, at my recent visit in July, the striking fact was...
Chart 3. How to manage the choking infant and child is from ‘Pocket Book of Hospital Care for Children - Guidelines for the Management of Common Illnesses with Limited Resources’ WHO 2005 – see the whole book at http://www.ichrc.org/. We published Charts 1 and 2 in previous issues of this journal (vol 3 nos 1 & 2) and plan to publish more charts in future issues.
This short review was inspired by an article in "Hospital Medicine" . The availability of plasma liver function tests (LFTs) to monitor hepatotoxicity (liver [hepatic] damage) is uncommon in many resource-poor countries. Even so we must be aware of and not ignore the risk of hepatic damage from many commonly used drugs. It is important to realise that drugs are the commonest cause of liver failure.
Like doctors and other healthcare professionals worldwide, many of us see children with injuries caused by physical violence and girls who have been raped. Sometimes we know that a child is malnourished, sick or traumatised because of abuse or neglect.
The aim of this article is to raise the issue of child abuse and neglect and to start a dialogue on how healthcare and other professionals can better protect South Sudan's children. So please send us your views and suggestions for tackling this problem.
Leprosy is the oldest disease known to man. The earliest written records describing true leprosy came from India around the period 600 BC. Leprosy is caused by Mycobacterium leprae; the Norwegian, Dr Amauer Hansen, isolated the bacterium in 1873. Leprosy is also called Hansen’s disease after him. Although it is the first human pathogenic bacterium to be defined, M. leprae is the only bacterium causing disease in man that has not been cultured in the laboratory.
There are no recent international guidelines for the management of moderate malnutrition in spite of the fact that it: Increases the risk of death from common diseases and may result in severe acute malnutrition and/or severe stunting (both life-threatening conditions)...
In the last issue I covered the use of PubMed to retrieve primary sources of evidence (individual research studies). However, if you need quick or more definite answers to your clinical questions you may prefer to start with secondary sources - where individual studies have already undergone analysis and have often been compared with others to provide a summarised, more definitive conclusion...
The electrocardiogram (ECG) is one of the simplest and oldest cardiac investigations available, yet it can provide a wealth of useful information and remains an essential part of the assessment of cardiac patients.
With modern machines, surface ECGs are quick and easy to obtain at the bedside and are based on relatively simple electrophysiological concepts. However junior doctors often find them difficult to interpret.
This is the first in a short series of articles that aim to...
This is the second chart from ‘Pocket Book of Hospital Care for Children - Guidelines for the Management of Common Illnesses with Limited Resources’ (WHO 2005). This is ‘Chart 2. Triage of all sick children’ [page 4-5].
We plan to publish more charts from this book in future issues of the Journal. We hope you will find them useful.
The Prevention and Treatment Guidelines for Primary Healthcare Centres and Hospitals was produced by the Ministry of Health, Government of Southern Sudan (MOH/GOSS) in 2006.
The management of alcohol dependence consists of psychological, social and pharmacotherapeutic interventions aimed at reducing alcohol associated problems. This involves detoxification and rehabilitation...
Chest drains are commonly used in the treatment and management of various acute and chronic conditions in many different clinical settings, especially when respiratory function is compromised. Whilst it is usually the responsibility of the doctor to insert the chest drain, it is the responsibility of both the nurse and doctor to maintain the drain and monitor the patient...
The prevalence of alcohol related illness in the Southern Sudan is unknown, though there is anecdotal information that alcohol related violence, marital discord, absenteeism from work and road traffic accidents which are related to the use of alcohol are common.
Humans have drunk alcohol for at least twelve thousand years. It has been used in religious rituals, in ancient cultures as diverse as Samaria, Babylon, Egypt, China and Anglo-Saxon Britain. According to the World Health Organisation (WHO) 1.8 million people worldwide died in 2000 from alcohol related causes, 3% of all deaths worldwide...
At a time when food is in short supply it is essential to have a simple method of identifying malnourished young children. The mid upper arm circumference (MUAC) of children aged 6 – 59 months gives an indication of the degree of wasting and is a good predictor of mortality. Research shows that it is equally good, if not better, than other measurements for screening young children and selecting those needing therapeutic feeding...
Assessment includes the following:
Confirmation of hypertension,
Risk factors for cardiovascular disease,
Underlying cause(s),
End organ damage,
Indications and contraindications for anti-hypertensive drugs.
History: A thorough history is essential - note particularly...
Anaemia, often due to iron deficiency, is one of the most widespread causes of mortality and morbidity in Southern Sudan, which probably has probably one of the highest rates in the world...
Microbial Keratitis, also referred to as Suppurative Keratitis or Corneal Ulcer, is a potentially sight threatening condition that may present to doctors and nurses working in State hospitals and eye units in Southern Sudan.
Delay in treatment can result in development of complications that may lead to loss of sight or destruction of the eye...
Many newborns, especially in developing countries, die unnecessarily because health staff have not had the opportunity to learn how to give simple resuscitation. Birth asphyxia (fail ure to establish breathing at birth) ac counts for about 900 000 deaths each year and is one of the primary causes of early neonatal mortality. However resuscitation can be successful in low-resource settings...
Undernutrition occurs when people do not eat (or absorb) enough nutrients to cover their needs for energy and growth, or to maintain a healthy immune system. Micronutrient deficiencies are a sub-category of undernutrition and occur when the body lacks one or more micronutrients (e.g. iron, iodine, zinc, vitamin A or folate). These deficiencies usually affect growth and immunity but some cause specific clinical conditions such as anaemia (iron deficiency), hypothyroidism (iodine deficiency) or xerophthalmia (vitamin A deficiency).
When our bodies do not get enough food, or the right foods, we become weak and cannot develop or function properly. Healthy and balanced nutrition means eating the right type of food in the right quantities. People with HIV have higher than normal energy needs (see Box 1). So a healthy diet is especially important if you are infected with HIV. Food cannot cure HIV infection, or treat the virus, but it can certainly improve fitness and quality of life. Eating enough and a balance of different foods helps
More than two million children under age 5 years die each year from pneumonia. This is more than the combined mortality from HIV, malaria and measles: an astonishing and not widely realised fact! Appropriate vaccination could prevent half of these deaths. Inexpensive antibiotics (about $0.27 for an average course of treatment) are available for treating most cases yet only...
This article is an attempt to give the reader guidance how to read a chest Xray and below are two methods. There is no perfect way to read an x-ray. However, the important message I would like to give is, to adopt one or the other approach, and to use the chosen approach consistently.
On all Xrays check the following...
Gonorrhoea is caused by the sexually transmitted bacterium Neisseria gonorrhoeae. The incubation period ranges from two to 30 days. The risk of infection differs between the sexes: Males: 20% risk after sexual contact with an infected female. Females: 60-80% risk after sexual contact with an infected male. During childbirth an infected woman may transmit gonorrhoea to her newborn and cause ophthalmia neonatorum...
All health professions should be practising 'evidence-based care'. This is defined as the "integration of the best research evidence with our clinical expertise, and our patient’s unique values and circumstances"...
Among the under 5-year-olds worldwide there are about 156,000,000 cases of pneumonia each year. This causes about 20% of all deaths in this age group. Effective implementation of the WHO Integrated Management of Childhood Illness (IMCI) reduces this morbidity and mortality. The recommendations for treating pneumonia for first-level health facilities were made over ten years ago although there was an update in 2005
Handwashing at critical times – including after using the toilet and before eating or preparing food – can reduce diarrhoea rates by almost 44 percent among children under 5.
More than 5,000 children every day – 1.7 million children every year – under the age of 5 die from diarrheal diseases. Diarrhoea is the second most common cause of death in children, accounting for...
1. Use oxytocin 10 iu im alone for prophylaxis, with delayed cord clamping (especially in settings with high anaemia rates)
2. If oxytocin is not available, use misoprostol 600mcg orally.
Acquired Immune Deficiency Syndrome (AIDS) is the leading cause of sickness and death among young adults in developing countries. The introduction of highly active anti-retroretroviral therapy (HAART) has changed the epidemiology of AIDS from being a universally fatal illness to a chronic debilitating infection attended by multi-organ complications. Improved survival as a result of HAART has lead to increase in systemic and ocular complications...
Feeding from birth to 6 months:
The way a HIV+ mother feeds her baby affects the child's risk of:
Becoming infected with HIV,
dying from other infections.
Table 1 shows that the risks to the baby of exclusive breastfeeding...
Western countries are experiencing an explosion in the prevalence of type 2 diabetes (T2DM) linked to increasing obesity and a steady year on year rise in the incidence of type 1 diabetes (T1DM) in children. However, for reasons that are not currently understood, the situation in Sub-Saharan Africa is less clear. Many factors contribute to this. Problems reported in other African countries include:
Oncocerciasis is a parasitic disease that primarily affects economically disadvantaged communities in Africa and Latin America. It results from infection with filarial nematode Oncocerca volvulus, transmitted to man through the bite of infected black fly of genius simulium. It is the second commonest infectious cause of blindness responsible for an estimated 340,000 cases of blindness and one million cases of visual impairment
Undernutrition among mothers and children is the underlying cause of a third of all child deaths and more than 10% of the total global disease burden. The situation is probably worse in Southern Sudan where rates of undernutrition are high. The immediate causes of undernutrition are a nutrient-deficient diet and frequent infections. Here we describe vitamin A deficiency, future articles will cover other types of malnutrition.
The risk for H1N1 influenza transmission through breast milk is unknown. However, reports of viraemia with seasonal influenza infection are rare. Also unknown is the specific protection to the baby of the antibodies the mother passes through her breastmilk. However the strong recommendations from Centres for Disease Control and Prevention (CDC)1 and the UK National Health Service2 are that mothers with swine flu should continue to breastfeed
Arterial hypertension is a common and preventable cardiovascular risk factor, leading to about 1.7 million deaths/year worldwide.
Previously1 we have discussed the diagnosis, classification and prevention of diabetes mellitus. In this article we provide an overview of management of glycaemic control in diabetes mellitus as well as managing hypoglycaemia. We also look at the management of diabetic complications and provide a basis by which to run a diabetes clinic.