Jan 15, 2021

Gynecological Training to ANMs of Benirorang Rural

HHC had discussion with the District Health Office in regards to expansion of the training to Benighat Rorang Rural Municipality after HHC was approaced for such a training. HHC had conducted similar training in Ruby Valley and Gajuri Rural Municipalities in 2019 and 2020. Benirorang RM also has health posts in isolated remote village sites and helping the midwives with gynecological training was a continuation of HHC’s support to this rural municipality as well as improving services to the women patients of the region.

Benighat Health Post where the training was conducted is three hours’ drive from Kathmandu and one hour from the Dhading District HQ of Dhadingbesi and is the center of the region but the participants had to travel for several hours and bus ride to reach this center from other village sites which are spread out in the region. HHC Officer Mr. Nabin M escorted the specialists from Kathmandu for the training. The training was held from 16 to 19 November, 2020 for 11 Auxiliary Nurse Midwives (ANMs). The trainees were diving into two groups and one was facilitated by Dr. Richa J and another one by Dr. Rakshya U. Both the trainees worked at Paropkar Indra Rajya Laxmi Maternity Hospital Thapathali, kathmandu. The chief consultant of Obstetrics and Gynecology of Paropakar Maternity and Women’s
Hospital, who helped HHC find the expert trainers, also decided to join the team and
observe the training for future support and while she was there provided training on the

First day of training: History taking, introduction, chief complaint, menstrual history, obstretic and contraseptic history, past or present medical history, occupational/family history etc.

Second day of training:
Types of vaginal discharge

1. Physiological- reproductive age, menstrual and hormonal
2. Pathological - infected and non-infected
Infected: Sexually infected- TV, Chlamydia, Gonorrhea, Syphilis, HSV Non sexual infected- BV,
Candida (mostly below 25 Years)
Non-infected: Foreign body, atrophic (dryness) and
3. Malignant Diseases
Major Causative Agent and Nature of Discharge:
1. Candida fungal agent with curdy discharge with itching
2. Bacterial vaginitis causes by chlamydia bacteria with grayish white discharge
3. Trichomonas protozoal agent with greenish discharge with frothy nature
4. Gonorrhea bacteria discharge Fishy odor
5. Syphilis bacterial ulcer on vagina

Third day of training:

Definition of PPH:
Types of PPH: Primary / Secondary
Estimation of blood loss
Management of PPH:
Pharmacological: Oxytocin, misoprostol, tranostat, mothering
Non Pharmacological: Aortic compression, uterine compression and condom tamponade
Identification and treatment of jaundice, fever, and kangaroo mother care

Fourth day of Training:
Participants were interested to know about hypertension complicating pregnancy.Therefore they were given basic information that would help in diagnosing it:
Gestational Hypertension
Preeclampsia/ Eclampsia
Chronic Hypertension
Chronic Hypertension with superimposed preeclampsia
Discussion on how to properly counsel patient, revision of previous day’s topics.
A total of 6 patients were checked while conducting practical training

Closing program
During the closing program six officials of Benighat Rorang RM participated and thanked
HHC and the trainers for the effective training provided to the participants. The closing
ceremony was carried out ensuring Covid-19 protocols were followed.

Finally, the chairman  handed out certificates and health check kits (table right) to all the
participants provided by Himalayan HealthCare.


Attachments:
Sep 18, 2020

One Home One Toilet Campaign

As part of one home one toilet campaign, Himalayan HealthCare installed 50 new permanent toilets with septic tank in Sertung and Tipling villages, directly benefiting 250 and indirectly 5,000 villagers thus reducing diarrhea and other deadly infectious diseases in community. As part of the toilet construction, HHC trained all beneficiaries/head of family in use and care of toilets, integral public health step as toilets need to be functional and clean at all times.
Outcome: 250 trained, more than toilet recipients as neighbors also participated. Toilets brings health benefits immediately, other outcomes are long-term; HHC has observed positive changes after 600+ toilets built in the region, increase safety for vulnerable members (e.g. children, elderly, physically disabled); avoid risks such as falling, heavy monsoon rains, wild animals/snakes in forests

Change community norms - Toilets uplift community members who value themselves more in class-driven cultures

Outcome: As toilet is built it’s an instant matter of pride for the family

Toilet for a family has an immediate impact and brings instant benefits and improved quality of life. Firstly, there is no rush to the forests in the dark early hours of the morning, no danger of slipping and falling, or wild animals and heavy monsoon rains. Vulnerable community members, such as children, elderly and those with physical challenges benefit the most. Families can go to the bathroom at leisure, in comfort and with pride. It is so convenient.

Secondly, children do not defecate around the yard or on the nearby trails, which is immensely important health wise but probably less apparent to community members. ‘Open defecation’ means flies transmitting diarrhea, dysentery and other deadly infectious diseases. No open defecation means food and water are less likely to be contaminated as feces are not carried into water sources and into farms and so or fecal transmission of diseases are curtailed.

The overall impact of the toilets goes beyond health and safety. Family saves critical resources such as money and time. A rural family relies on hands in the field and healthier and less sick people means more hands dedicated to food production. There is less money spent on medicines and even expensive visits to cities for protracted treatment when money is hard to come by to begin with and sometimes loans with steep interest have to be taken. Children who are less ill help more around the house with rural chores and miss little classes in school and find more time to play and be happy. Parents especially mothers have less to attend to sick children and find more time for chores and additional income. Overall less illness means better life.

As with all our projects in this region since 1992, our partnership with the community and the local administration is the main reason for successful and durable program and projects. The community is the main partners who make the change happen while we are the catalyst.

Challenges: For the recipients, toilet building in these isolated, remote and roadless villages is challenging and time-taking. It requires months of commitment which takes time away from important farm work, their livelihood, but they are committed and want a toilet.


Attachments:
May 21, 2020

Gynecological Follow-Up Training Camp, Feb 2020

GYNECOLOGICAL FOLLOW-UP TRAINING OF 10 MIDWIVES

 Date:   Feb 18th to 21st, 2020 First cohort of 5 midwives
             Feb 23rd to 26th, 2020 - Second cohort of 5 midwives

Place: Gajuri Primary Health Centre, Gajuri Rural Municipality (RM), Dhading District, Central Nepal

 Participants:10 AMNs from village health posts and primary health center of Gajuri RM

 First Follow-Up Training: 18th – 21st February 2020

Trainer: Dr. Sunita T, Patan Hospital, Lalitpur

 Participant           Station/Health Post            Designation

1. Ranjana S         Pida,                                    ANM
2. Sarita R             Gajuri PHC,                         ANM
3. Radha P            Gajuri PHC,                         Staff nurse
4. Amrita Pa          Gajuri PHC,                         ANM
5. Anju C               Dolbhanjyang Sec. School  Staff nurse

 Second follow-Up Training: 23rd – 26th February 2020

Trainer: Dr. Sunita Thapa, Patan Hospital, Lalitpur

 Participant           Station/Health Post            Designation

1. Ambika K          Gajuri PHC                           ANM
2. Amrita P            Gajuri PHC                           ANM
3. Saradha S         Pida HP                                ANM
4. Rama R             Pida HP                                ANM
5. Sarita C             Kiranchok                             ANM

First day Follow-up Training

HHC supervisors reviewed women patient reports of 45 days after the first training, submitted by the trainees. They discussed experiences and challenges that each one faced during those 45 days. They were also briefed about the importance of the follow-up training. The ob-gyne specialist began an interactive class with discussions about patient history taking.

History taking:Introduction of patient; Chief complain; History of present illness (HOPI); Menstrual history; Obstetric history; Contraceptive history; Past medical & surgical history; Personal history; Occupational history & family history

 Doctor's note:Participants were encouraged to actively participate and discuss about history taking for gynecological patients stressing on the importance of different aspects of proper history taking in the management of diseases. During the outpatient hands-on training, they were asked to take history and examine patients. At the end of the sessions, they were confident in patient history taking and examination.

 2nd Day  Follo-up Training Steps of physical examination: GC (general condition): fair, ill looking, conscious or unconscious, Vitals: T, PR, RR, BP (temperature, pulse, respiratory rate & blood pressure); PILCCOD: (pallor, icteric, cyanosis, clubbing, edema, dehydration); Chest examination: B/L normal vesicular breath sound and equal air entry, crepitation and wheeze; CVS (cardiovascular system): s1 s2 or any added sound; A/P (per abdomen): any mass feel and tender; P/S (per speculum): polyp, discharge, erosion on cervix and its position; P/V per vaginal: feel any cyst or mass and motion tenderness on cervix; Breast examination: standing and hands on waist, press by palm on the breast as quarterly on both breasts.

 Types of vaginal discharge: Physical: reproductive age, menstrual and hormonal; Pathological: infected and non-infected; Infected: Sexual infected - TV, Chlamydia, Gonorrhea, Syphilis, HSV; Non sexual infected- BV, Candida (mostly below 25 Year; Non infected: foreign body, atrophic (dryness) and malignant.

 PID (Pelvic Inflammatory Disease): cause by ascending infection from the endocervix or may from descending infection from organs and 25% cause by Chlamydia and gonorrhea.

 Doctor's note: Focused on physical and breast examination of patient. The trainees were also explained about nipple discharges and breast mass. During the outpatient practical training, the trainees directly examined patients under my supervision and now they are confident in physical and breast examination. Also briefed them about breast suppressant agents.

 3rd Day of Follow-up Training

DUB (dysfunctional uterine bleeding): Defined as abnormal uterine bleeding in absence of pregnant, genital tract pathology or systemic infection. 

Signs:Abdomen exam usually normal. If uterus enlarged,fibroids are likely. Anemia +
Symptons: Heavy or prolonged p/v bleeding, dysmenorrhea (on/off)
Investigation: UPT, CBC, TFT, Blood Gp. & cross match, endometrial biopsy
Management: Tranexamic & mefenemic acid useful to decrease loss during periods, OCP to regulate irregular cycle ( if no cardiovascular risk).

Menorrhagia ( 80 ml or 7 day bleeding) is the commonest and age below 45 Y

Hyperemesis dravidarum: Trained to carry out urine acetone test. Inj. RL III pint, Inj 5% dextrose 1.5 ltr IV over 24 hour. Inj Metoclopramide 10 mg IV TDS; Inj. Ranitidine 50 mg IV BD and Pyridoxime 10 mg PO TDS
Preterm labor: inj Dexona 6 mg 6 hourly 4 doses or 12 mg 12 hourly 2 doses to make mature lungs of baby but caution to be taken while giving to GDM (Gestational Diabetes Mellitus) mothers.

Doctor's note: Explained about primary management prior to referral to higher center as theyhad encountered many cases of hyperemesis gravidaraum and Gestational Diabetes Mellitus.Taught in detail including diet on screening during pregnancy (GCT and OGT T). PT/INR,Ectopic pregnancy (organized and ruptured ectopic) GCT (glucose challenge test). Trainees presented on history taking, physical exams and managemet of infectious diseases.

 4th Day of Follow-up Training

PPH (post partum hemorrhage):any amount of blood loss that threatens a woman’s hemodynamic stability and estimated blood loss of >500 ml from the genital tract at vaginal delivery & >1000 ml in Caesarean section or 1500 ml at caesarean hysterectomy; Types: Primary: 3rd stages of labor to 48 hours of delivery; Secondary: 48 hours to 6 weeks of delivery; Cause of PPH is 77%, 4 Ts (tone, trauma, tissue, thrombin); A 10% drop in hematocrit, or the need for blood transfusion in first 24 hours; Inj Oxytocin 20 units in each drip, tab misoprostol 800mcg per rectal, inj. Tranexamic acid 1gm iv stat if bleeding doesn't stop apply bimanual compression, proper inspection if there is any trauma associated with bleeding. If bleeding doesn’t control inj. methergin to be given stat, if bleeding persists, apply condom tamponade and refer to higher center.

The condom tamponade: if medical intervention failed, then use this procedure. Counselingabout procedure, prepare instruments; Procedure of condom tamponade - Inflate 250-500 ml saline & bleeding stops in 0-15 min in most cases.

Doctor's note:The last day of the training focused on post partum hemorrhage (PPH) includingcause and management. Importance of condom tamponade in the management of PPH was explained and a demonstration was given on how to prepare and apply condom tamponade.

Trainees practiced the procedure on their own.

 13 patients were asked to be subjects for the 1st Follow-up training

 Patient                 Age/Sex           Diagnosis               Solution

Mina T                   49 Y/F          ervical polyp                 Refer to KTM
Sita T                     35 Y/F         Cervicitis                       Infa V (Metro+Clotrima+Lactobacillus)
Maya S                  27 Y/F         Cervicitis                       Infa V (Metro+Clotrima+Lactobacillus)
Jamuna M             46 Y/F          Menorrhagia                 Tranexamic acid 500mg
Junamaya S          50 Y/F          Menorrhagia                 Tranexamic acid and vitamin
Mithumaya S         42 Y/F          Cervicitis                       Infa V (Metro+Clotrima+Lactobacillus)
Kalpana S              30 Y/F          UTI                               Ciprofloxacin 500 mg
Pratima B               20 Y/F          Dysmenorrhea              Mefenamic 500mg, Ranitidine 150 mg
Sushmita S            20 Y/F          Preterm labor of 35w     Inj Dexona 12mg stat                                Kanchhimaya T     56 Y/F          Vaginitis                         Azithromycin 500mg
Bishnukumari R     36 Y/F          Cervicitis                       Infa V (Metro, Clotrma, Basillos)
Susana A               20 Y/F          Vaginitis                        Cefixime 200 mg
Sabitri M                36 Y/F          Prolonged labor            Inj. Oxytocin and normal delivery done

 17 patients were asked to be subjects for the 2nd follow-up training session

 Patient              Age/Sex           Diagnosis              Solution

Santoshi U          32 Y/F               DUB                       Mefenamic acid 500mg, Tranexamic acid                                                                                                 500mg & Ranitidine 150mg
Lalita M               20 Y/F               VDS                       Cefixime 200mg, Azithromycin 500mg &                                                                                                    Tinidazole 500mg
Sangita BK         18 Y/F               DUB                        Mefenamic acid 500mg, Tranexamic acid                                                                                                  500mg & Ranitidine 150mg
Gayatri A             28 Y/F               Cervicitis                Ciprofloxacin 500mg, Metronidazole 400mg                                                                                               and Fluconazole 150mg
Maili T                  36 Y/F               Failed MA               MVA and medication
Bhawati K            57 Y/F               UVP                        Ciprofloxacin 500mg and counselling
Maiti T                  36 Y/F               Failed MA               MVA and medication
Shanti T               30 Y/F               Postpartum HTN     Amlodipine 5mg
Krishnak R           35 Y/F               Menorrhagia            Mefenamic acid 500mg, Tranexamic acid                                                                                                  500mg
Pramila C            27 Y/F Incomplete miscarriage          MVA, IV and oral medication for one day
Parbati U             32 Y/F               Vaginitis                    Cefixime 200mg, Tinidazole 500mg and                                                                                                    Azithromycin 500mg
Sirjana B              27 Y/F               Varicose vein          Counselling provided
Urmila P                   28Y/F                UTI                      Ciprofloxacin 500mg
Nira BK                    26 Y/F               Miscarriage          MVA, Azithromycin 500mg
Sarita S                    27 Y/F               Candidiasis         Ointment Clotrimazole and Fluconazole                                                                                                     150mg
Mina S                     28 Y/F               Chlamydia            Infa V (Metro+Clotrim+Lactobasilus)
Jyoti N                     30 Y/F               MA                        Metron 400mg, Cefixime 200mg and                                                                                                         Ranitidine 150mg

Closing program

18 local leaders and government officials were present during the closing ceremony including the Chairman, Dr. Sailesh K, acting chief of Gajuri PHC; Chief Guest: Mr. Rajendra BB, Chairman of Gajuri RM; Special Guest: Dr. Ramhari R, incharge of Gajuri RM; Special Guest: Mr. Yuwaraj A, admin officer of Gajuri RM and 14 other guests from PHC and nearby villages.

Final Words from the guests

Chief Guest (Rajendra B. B.):Personally and on behalf of the municipality, I thank HHC for such a useful and practical training which will help the entire women population of this region. We are expecting more support from HHC in the future too. We need a gynecological camp and training for more midwifes who have recently been appointed in this region. I also advise all health staff who participated in this training to make good use of what they have learned and work honestly in their work place. Special Guest (Yubraj A): I have observed HHC work for several years when I was in DDC as a program officer and as usual HHC has done such a wonderful job in Gajuri. I thank HHC. I hope and request all participants to use their new knowledge wisely for their patients. We are hopeful that the patients get better quality of care from you.

Radha Pa (one of the trainees):This gynecological training gave us more knowledge and ideas (techniques) about women issues. This training has helped us revise what we learned during our time at the teaching institute and has allowed us practical lessons which will allow us to independently deal with cases and help solve them. We expect more training from HHC thank you to HHC from Gajuri PHC and all participants.

 
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