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From the FieldThe following are narratives from NRP instructors and advocates in the field. Their work is a testament to the Neonatal Resuscitation Program. We hope you enjoy their stories.
Armenia | Iraq | Nigeria | Zimbabwe |Guatemala FRANCISCO JAVIER VEGAS RODRIGUEZ MD MEXICO
Figure1. Mortality rate in Puebla, México 2005-2008
Karen Moore, RN, CNNP I am a recently retired neonatal nurse practitioner, and I am a regional NRP trainer. I also do volunteer work in the northwest highlands of Guatemala with a small grassroots organization called Casa Colibrí (www.casacolibri.org). This area is a 15-hour truck ride from Guatemala City and is populated by indigenous Maya who have little or no medical care. At the request of Marcia, the area public health nurse, Linda Eastman and I started teaching newborn care, including very basic neonatal resuscitation, to village midwives. The majority of these traditional birth attendants are illiterate. They learn on the job from another midwife, have little or no equipment, no formal education, and only speak Q’anjob’al, a Mayan dialect. To date, we have given midwife seminars in August 2008 and April 2009, and we are planning to hold a third training in January 2010. In the previous courses, we have encountered a few male midwives. These men are literate, and besides speaking Q’anjo’bal, they can read and speak Spanish. In addition to the hands-on training, any participants who can read Spanish are given a copy of A Book for Midwives by Klein, Miller and Thomson. In addition to normal newborn care, we taught hand washing, “sterile” technique, physical assessment, instruction and practice of mouth-to-mouth resuscitation, and some obstetric tips. We also gave each of the midwives a kit with useful supplies. Prior to these classes, the midwives did not even have so much as a bulb syringe. These classes are an involved process because I speak little Spanish. My English is translated into Spanish by Linda. Marcia then translates the Spanish into Q’anjob’al. The midwives are incredibly grateful for any information we give them. They take pride in doing a good job. We have very involved discussions, and the midwives are eager to share what they know. These women and men perform an invaluable service in areas where backup medical care may be a five-hour truck ride away. A public hospital is under construction in Barillas, closer to our clinic site, but progress is slow. When the hospital is completed, I have offered to give the entire NRP course to the staff. I am eagerly awaiting the release of the Helping Babies Breathe materials, to help me and others teaching resuscitation in developing countries. There is still much work to do in Guatemala.
Dr. Maysoon Jabir C.A.B.G.O. Although I am an obstetrician, my vision is that the presence of a neonatologist is sometimes a luxury in some places in Iraq (like faraway district hospitals). Therefore, every birth attendant - an obstetrician ,a midwife or otherwise - should know how to apply the basic steps of neonatal resuscitation to save so many lives as the 98%of newborns mentioned in NRP textbook (5th ed.) I have been involved in teaching NRP courses in Iraq since March 2004, after I got my first provider and instructor courses in Baghdad under exceptional circumstances. Courses were held in Risafa Health Directorate hospitals and the Centre for Training and Development in the Ministry of Health. We were 5 instructors; 2 left Iraq, one had her instructor certificate expired and 2 certified instructors remained in the country struggling to keep their instructor certificates valid to maintain NRP teaching in Iraq By 2006 and 2007, the security in Iraq deteriorated. Going to work and coming home safe became a real challenge. Courses were temporarily stopped until August 2007 when I resumed teaching NRP courses but in another hospital this time. I directed and taught 2 courses with my other remaining certified colleague, Dr. T. Fadhil for 28 obstetric and pediatric residents. I found out that the teaching material needed to be updated as new obligatory chapters were added as well as new slide presentations, test papers and improvements on the Megacode test to make life easier for the instructor and more precise for the trainee. I started to look around me or inside my e mail box to find someone who may sponsor this issue. Don't ask me about money because it's a most difficult thing to transfer foreign currency in a formal way from my country outwards. I sent some e mails to my neonatologist friends and colleagues; some gave me suggestions, others did not bother themselves to answer and one gratefully sent me his own updated power point presentations to chose whatever I needed to present in teaching my courses, and I did. To the surprise, my problem became hers rather than mine and she started thinking of some way to provide the teaching material that I requested. In a few weeks' time I received an e mail addressed "NRP material -on the way" and in a matter of one week the teaching material was shipped from the United States to my place in Baghdad. I received the” treasure" that enabled me to resume my courses again; now with the new updated textbook, post-test questions , key answers , slide presentations and others. I made the necessary preparations and held another course last August. Most importantly is that I did not pay a cent to buy any teaching material. The price I'm paid in return is the gratitude that I see in the eyes of my resident trainees and the lives of newborns saved by applying the principles of neonatal resuscitation learned during the courses. Thanks to those who initiated the training in Iraq and donated the teaching mannequins and other practical teaching aids; namely Colonel Dr. Kelly Murray of the US Army, without the efforts of whom, all this article would never have existed. The NRP is still viable in Iraq, thanks to the AAP/NRP .
Dian Ruder, RN, BS, MA I was excited to read in the November (2007) newsletter about the NRP Global
Implementation Task Force. I would like to report my experience in
teaching NRP in Zimbabwe, Africa this October. I am a NICU RN and NRP
instructor at Lucile Packard Children's Hospital in Palo Alto, CA. My husband and I went for three weeks,
during which he taught music to children in orphanages and programs for
street children. I went alone to Karanda Mission Hospital, in the rural
north, which has become a referral center for the country due to severe
nursing and doctor shortages around the country. The hospital situation
in Zimbabwe is under crisis, given the current economic woes there.
This hospital has a high-risk program, where mothers come to live in a
compound outside the hospital grounds for a few weeks before their
anticipated delivery, so they don't have to walk for miles to get to
the hospital when in labor.
Karanda's nursing school program has had NRP taught once before, and they were interested in having it taught again. In eight teaching days, we covered lessons 1 through 6 of the NRP textbook, and aspects of 7, 8 and 9. Each day involved practicing skills with dolls I brought and equipment that they will use. Sequentially, we added skills each day, with daily testing and successful megacodes performed on the last days. Fifteen nurse-midwife and nursing students participated, and additional regular staff came after work several days to review recent NRP changes and to practice skills. I left them with teaching materials for future classes, and the instructors excitedly planned to share them with a nearby hospital. I was also able to leave other equipment which had been donated for the hospital's use. I hope this small beginning will help advance NRP in the country for the good of the babies born there. Lloyd Jensen, MD, FAAP Elizabeth Disu, MD
These course were held in conjunction with the Pediatric Association of Nigeria national Conference in Lagos, Nigeria. We had representatives from 60 different organizations that attended the training. Among those organizations were 20 Federal Medical Centers and 15 University Teaching Hospitals in Nigeria. LDS Charities donated 24 sets of SBA teaching sets and 24 set of standard NRP teaching equipment. The course was supported by the Ministry of Health (Dr Grange is the Minister of Health in Nigeria - former International Pediatric Association president) and the Pediatric Association of Nigeria.
In March of 2006, we team-taught two NRP courses in Goris, Armenia, with four physicians who had been trained the previous week in Yerevan. On Tuesday morning we were setting up the breakout tables and preparing for the course when Dr. Astghik Gabrielyan, a neonatologist at Goris Hospital and one of our team teachers, rushed in to us exclaiming "I saved a baby, I saved a baby!" She went on to explain that about an hour before she was to be at our meeting she had delivered a baby girl who was not breathing... "The child was depressed as the result of difficult delivery. It was the 3rd pregnancy and the second child. The baby was born without cries, breathing, muscle tone and was cyanotic, with no meconium. She was immediately put under the heat, positioned properly, suctioned (mouth, then nose), dried and stimulated. Wet blanket was removed and changed, the baby was repositioned. After additional stimulation the baby still didn't breathe, heart rate was less than 50, still blue and no muscle tone. Positive pressure ventilation was done with Ambu. The baby still didn’t breathe. The 2nd resuscitator performed chest compressions; after 30 seconds the baby started breathing, the ventilation was continued without chest massage. Very soon the baby took several breaths, after which spontaneous breathing was restored. The baby started moving. Ventilation was stopped. After the evaluation – adequate heart rhythm, skin still remained blue, breathing spontaneous. The doctors provided oxygen. Now the baby is doing fine. I would like to share my happiness with all those who would know about this case and express my gratitude to all the doctors who came to Armenia and taught this wonderful course. Thanks to the new principles mentioned in the algorithm we were able to resuscitate the depressed newborn in a couple of minutes. We are honestly grateful for this project and will start using our knowledge immediately. When we were following the algorithm we were sure of the positive results. We strongly believe that this project will save many, many babies of Armenia and again want to thank those who developed, organized and implemented this project in our country." We were thrilled to hear Astghik’s experience and George asked her to stand and tell her story to the participants in our class – they were all so proud of her; I saw her several times during the day obviously retelling exactly the steps she had taken to save this baby girl. Before this session began Astghik was nervous and insecure about participating as a teacher; suddenly she was smiling and animated – it gave her the confidence she needed and her confidence spilled over to the rest of the doctors who were participating. When our day was finished we went to visit the mother and baby and Astghik dictated her story to Anna Babakhanyan, who then translated this story into English for us. This was wonderful in every way; a baby was saved first of all, but Astghik was a real inspiration to all the other doctors who participated. We know that she and all those who taught with us that day as well as the participants in the course will be inspired to continue teaching all those who work with them to deliver babies.
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