|Tu Du Hospital
Ho Chi Minh City – Vietnam
I completed four weeks of my elective term at Tu Du hospital. Tu Du is the largest maternity hospital in Vietnam. It is situated in Ho Chi Minh City and plays a major role in the education of local medical and nursing students as well as midwives from the remote, minority tribe regions. On average 100 newborns are delivered each day at the hospital. In addition to obstetric services the hospital also offers gynaecological, fertility, NICU, genetic testing and pathology services.
The activities that I undertook during my time at Tu Du hospital were based on my learning objectives. As such I spent the majority of my time in the delivery department. This department consisted of a large room separated into six smaller rooms, each containing two lithotomy beds (see photo). The typical process of entry into this room begins when the labouring woman presents to the emergency department at Tu Du. Due to difficulties with transport and the scarcity of ambulance services, she will usually present early in the first stage of labour and remain at the hospital for the entirety of her labour. This ensures that emergency transport to the hospital, due to unexpected complications or fast progression of labour, is not required. The pregnant woman is then admitted to the maternity ward which is a large room containing approximately 40 haphazardly arranged beds, without privacy curtains. When delivery is imminent the woman is moved into the delivery room.
The activities I undertook in the delivery room included observing the obstetric practice of the doctors, the midwifery practice as well as hands on obstetric procedural training. I delivered several babies personally as well as observing the birth of up to 80 others. I was privileged to participate in the management of obstetric emergencies and complicated deliveries including twin delivery, footling breach presentation delivery, external cephalic version, first, second and third trimester miscarriages, premature deliveries, HIV positive and hepatitis B positive women delivering and assisted vaginal deliveries (episiotomy, vacuum and forceps delivery).
I was able to have a high level of hands on experience with patients. The opportunity to perform physical examinations each day, including vaginal examinations, was particularly helpful in improving my practical obstetric skills. During my Perinatal and Women’s Health block in Australia, I was restricted in the number of vaginal examinations I was able to perform due to patient preference and less exposure to labouring women. Even with the language barrier I was still able to compare my interpretation of dilation and presentation with that of the examining doctor or nurse. I accomplished this using hand gestures, reading the numerical information in the patient notes (in Vietnamese) and learning how to count to 10 in Vietnamese (with the assistance of a Vietnamese medical student).
My chief learning outcomes were mainly procedural in nature. The language barrier restricted my learning in this instance. I gained increased knowledge and expertise in obstetric procedures in particular normal vaginal delivery. I also perfected my ability to examine a woman in labour. During my time at Tu Du hospital I developed a clearer understanding of the Vietnamese healthcare system. The government run hospital system in a developing country is obviously very different from my previous experiences in Australia. One of the most notable differences in the obstetric setting is the availability of pain relief. Epidurals were not generally administered because the cost to the patient of $20US made them unaffordable. In comparison to Australia where about 33% of primiparas elect to receive epidural analgesia during labour (1). The delivery of care in Tu Du hospital was not only lacking in analgesia but in the availability of privacy, something Australians regard as their right rather than a privilege.
The incidence of miscarriage at Tu Du was quite surprising to me. The rate of stillbirth in Vietnam is reported to be about eight times greater than in Australia.(2) Unfortunately I witnessed many miscarriages while completing my elective. I did not observe any in Australia during my Perinatal and Women’s Health block. There was also a higher incidence of premature births and low birth weight babies. The obstetricians informed me that the normal birth weight for a Vietnamese baby is 2000g to 3000g compared to 2500 to 3500g in Australia. It was difficult to engage in conversation with the doctors because of the language barrier and possible gap in knowledge due to the limited specific evidence based medicine.
During my elective at Tu Du hospital I was also fortunate enough to observe many caesarean section operations. The main differences I observed were a greater percentage of emergency caesarians compared to Australia. As I was only permitted to observe the public patients, it must be acknowledged that the proportion of elective caesarians in the private setting is similar to in Australia. I was able to observe an alternative surgical technique. In Australia the usual approach is a transverse incision through the lower uterine segment. At Tu Du the surgeons often performed a vertical subumbilical incision to provide better exposure and minimise blood loss in emergency situations.
The most valuable learning activity during my time at Tu Du was when I was able to deliver a healthy newborn. I performed all the elements surrounding the birth unassisted. This included performing serial vaginal examinations, interpreting the CTG monitoring, injecting lignocaine in the perineal area, performing an episiotomy, delivering the newborn’s head, ensuring restitution, delivery of the anterior and posterior shoulders and delivery of the placenta. The opportunity to perform all the elements in the delivery of a baby was not available to me during my Perinatal and Women’s Health block in Australia. I believe it is important to learn and subsequently practice the entire process, in a particular procedural element of medicine. Participating in one part of the process is far less beneficial and can result in future medical errors due to the omission of an important step.
The least valuable learning activity was observing the education session run by the Kangaroo Care doctors. During this session the fathers were taught how to massage their premature babies. Although there is evidence that massage of newborns is effective in treating colic, aiding settling and facilitating bonding, when performed correctly, the purpose of the massage was not properly explained to us. Maybe this was because of the language barrier or maybe there is no equivalent English explanation. The demonstration was quite lengthy and conducted in Vietnamese. Although it was entertaining I don’t feel that it was a valuable learning activity.
The repair of an episiotomy incision or high grade perineal tear was something that I had not attempted or observed during my Perinatal and Women’s Health block in Australia. I was fortunate enough to observe and perform many repairs during my time at Tu Du hospital. At times I was troubled by the ethical appropriateness of my role as a foreign medical student in a developing country. The patients did not speak English and as previously mentioned, neither did most of the midwifery and medical staff. The nature of health care in Vietnam and the importance of status in the Vietnamese culture lead to a lack of informed consent. Patients were more likely to be told how they would be treated or examined rather than asked for their consent. As a medical student I asked permission before performing any procedure on a patient but on most occasions the patient didn’t speak English. I then asked a nurse, either in English or if they didn’t speak English I would use a series of hand gestures to try and convey my meaning. On many occasions I felt that the nurse told me the patient had given consent when the patient had in fact not been asked. This put me in an awkward position.
It was difficult for me to experience taking patient histories because on most occasions the patients didn’t speak any English at all and unfortunately my Vietnamese is very limited. When the Vietnamese medical students were present they assisted with translating so we were able to take a proper obstetric history. In hindsight I should have learnt more Vietnamese phrases relevant to history taking. I believe the patients would have responded well to my attempts to question them in Vietnamese. I was able to say a few basic phrases in Vietnamese including telling the mother the sex of her baby and that her newborn was handsome or beautiful. The women were greatly amused by my attempts at their language and responded positively.
During my elective at Tu Du hospital my activities in the delivery room were supervised at all times. The department is a well established educative environment with a sea of local medical and midwifery students. As such there were experienced midwives, obstetricians, and obstetric registrars present at all times. During all the procedures I performed on patients, I had a doctor or midwife at my side, ready to assist if required. In most instances the language barrier precluded direct tutorials but in the area of obstetrics, much instruction can be relayed using hand gestures.
I learnt a great deal during my time at Tu Du hospital in Ho Chi Minh City and I would like to thank the Hoc Mai Foundation for making my elective possible. Not only did I increase my knowledge of obstetric procedures but I was also fortunate enough to be immersed in the healthcare system of a developing country. I have gained a new perspective on what it must be like to live and work in an environment that is often far more challenging than the world of Australian medicine. I believe that my time in Vietnam has equipped me with many of the skills required to be an efficient doctor. For this I am very grateful.
Johansson, A., Hoa, H.T., Lap, N., Diwan, V. & Eriksson, B. (1996), Population policies and reproductive patterns in Vietnam, The Lancet, v. 347, pp1529-1532
Hirst, J. (2009) Reducing Stillbirth in Viet Nam, Hoc Mai foundation annual report, Hoc Mai Foundation, Camperdown, NSW.