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November 2007

TU DU HOSPITAL

A typical day in the labour room

A RNSH OBSTETRICIAN'S VIEW OF TU DU HOSPITAL

Jane Hirst, Senior Registrar, Obstetrics & Gynaecology Royal North Shore Hospital

During November 2007 I was fortunate enough to spend three weeks in Tu Du Maternity Hospital Ho Chi Minh City. Being the year of the Golden Pig it was particularly auspicious to have a baby, and there were 5150 babies in November alone. This provided a fantastic opportunity to see how a system manages so many patients, and left me with great admiration for the staff who never seemed flustered. Whilst I was there I collected data on the perinatal outcomes for preterm perinatal rupture of membranes. With ten postnatal wards and often two patients in a bed and not a lot of English this was no easy task, but I was greatly assisted by midwives Ha Thi Thanh Lieu and Phan Thi Phuong Trinh, both of whom were recipients of AusAid/Hoc Mai fellowships in 2007. During the data collection period there were 46 cases of PPROM, 3.5% of public deliveries, which is consistent with previous research at Tu Du looking at causes of preterm birth. The results of the study showed that whilst almost all women received antenatal corticosteroids to aid fetal lung maturation, only a minority were given sufficient time for the steroids to optimally work. Repeated digital vaginal examinations were also performed, and this has been shown to be associated with shorter latency times to delivery and increased incidence of infection. As no vaginal microbiological swabs are performed after the membranes have ruptured it was difficult to comment on their choice of antibiotic, cefotaxime, and maybe this may be an area for future research. My recommendations for practice improvement, based on current evidence based medicine, were to only use a sterile speculum examination to diagnose PPROM, to allow 24-48 hours after the first dose of corticosteroids before looking at expediating delivery (unless there are obvious signs of chorioamnionitis), and that prior to 34 weeks gestation expectant management is better for neonatal outcomes provided the mother is monitored for signs of chorioamnionitis.

Birth Rates per month for 2007, the taller columns represent total births.

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As well as research, I was also fortunate enough to spend time in the gynaecology operating theaters, and I learnt many new tips and techniques particularly in laparoscopic surgery. I found the Vietnamese surgeons to be very proficient and enthusiastic about laparoscopic surgery and I was able to assist in 15 laparoscopic hysterectomies in my time there, which is more than I have been able to do in an entire year at RNSH! Clearly though there are a lot of other areas, particularly medical decision making and communication, where practice could be improved. One of the more obvious areas where practice significantly differed was neonatal resuscitation. Hopefully in the future Hoc Mai may be able to consider running a SCORPIO workshop to make sure all practitioners are aware of the correct steps in neonatal resuscitation, particularly the importance of bag and mask positive pressure ventilation. Antenatal inpatient care was also very different to Australian practice. With 260 antenatal patients understandably a "ward round" would be too much for one doctor, so the junior doctors worked through the ward whilst the senior reviewed the notes and looked at any patients they were concerned about. Standard management included contraction stress testing, which involves stimulating the uterus with a small amount of oxytocin prior to labour whilst monitoring the baby on CTG, to see whether the baby will tolerate contractions. As the Caesarean rate was 40% I suspect for this and other reasons (including maternal request) many unnecessary caesareans were performed. Inductions were also by insertion of a modified Foley catheter through the cervix, which has the risk of dislodging the fetal head and causing a cord prolapse. Hopefully in the near future they will have prostaglandins available for induction agents, however these too can be dangerous if not used and monitored correctly.

In favor of the Vietnamese clinical management, they did have extremely good post partum haemorrhage protocols in the delivery room. The assessment of blood loss was very accurate, there was widespread active management of the delivery of the placenta and misoprostol was commonly used as a second line agent. The reality of a being in a developing country was apparent in the high stillbirth rate >28 weeks gestation (1.9% in the data collection period of my visit,) and also seeing the late terminations which were done up to 28 weeks. The lack of privacy for the patients and the lack of consultation with the patients about management options was also striking, but perhaps unavoidable with the number of patients being seen. It was interesting to talk to the Hoc Mai fellows who were out in Australia earlier in the year. Lieu is an oncology midwife who after coming to Australia has designed a set of patient information brochures on the side effects of chemotherapy, and also has started making IV poles with wheels! The doctors who came to RNSH have also tried to put some of their projects into practice, and Dr Quy Khoa is looking at the interpretation of doppler studies in high risk pregnancy. Seeing how the doctors work has certainly given me ideas and insight into what would be useful to teach them when more fellows come to Australia in 2008 and beyond. Overall it was a fantastic experience, and I am grateful for the chance to experience a very different medical system and a very exciting city. Probably the most valuable thing I learnt was to question and justify nearly all areas of my clinical practice, and certainly I feel my education and hopefully clinical management is the better for it.

TU DU 2007

Hoc Mai fellows, past and potential future, came to see me off at the airport after I was escorted by ambulance

Dr Phan Viet Thanh, hospital director was welcoming and hospitable throughout my stay. I extend sincerest thanks to him and the doctors and midwives who made me feel so welcome in Ho Chi Minh City. I hope I get the chance to visit and work with my new friends again in the future.

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