Well, okay, I didn't literally ride on any rollercoasters, at least not the sort that you find at the PNE and suburban carnivals. But some of the minibuses (matatus) that I ventured forth in across the Ugandan countryside perhaps shared some characteristics with the traditional rollercoaster. Sure, they look different, they only have four wheels, they don't do loop-de-loops (if you're lucky) but they can very effectively evoke that freaky feeling in the pit of your stomach that rollercoasters tend to elicit when you're hanging suspended upside down forty feet above the ground. The minibuses that transport people (and goods, don't forget the goods) around Uganda are designed to carry 14 passengers. In Kampala, that's generally the case - 14 people plus the driver. Not too squishy. Room to reposition your legs, ensure some blood flow to the extremities, shift your bum when it starts to go numb. The countryside is a different story. When it comes to matatus, more people means more money for the driver and conductor. And often the matatu you're in is the only one that will be through that area for a number of hours. The local people who live in that area have no other means of transportation so the conductor does his best to get everyone in who needs a ride. You quickly learn that to get anywhere in a rural region of Uganda, you'd best be prepared to get cozy with your seat mates. I was commonly in matatus with 22-24 people, plus livestock (chickens, no goats), produce (pineapples, matoke, onions, jackfruit), and belongings. Some of the buses have racks on the top for the myriad mattresses, bags, and shopping. Some don't. I spoke with a traveller who had been in a matatu with 32 people. This basically means that a third of the passengers are sitting on top of the other passengers. Fun way to meet new people. Generally these hardy vehicles are travelling on dirt roads or paved roads that haven't seen new asphalt for quite some time - lots of potholes, lots of washouts. The terrain definitely contributes to the sense of riding a rollercoaster, as does the somewhat erratic driving behaviours of many matatu drivers. But you know, pretty cheap carnival ride, compared to what you'll pay at the PNE. Once I managed to silence (or at least generally ignore) that little voice in my head making comments like "no seatbelts", "trapped inside", "when were the brakes last serviced?", I found myself thoroughly enjoying the chaotic nature of transportation in Uganda. A comraderie seems to develop among the passengers as we shift and shuffle to take on yet another person, children on laps, adults sitting on one bum-cheek, chickens squawking from beneath our feet.
I'm on another sort of rollercoaster ride now, that of readjusting to life at home. This ride is more emotional than physical, more theoretical than tangible. I arrived home in Victoria on August 6, having flown into Vancouver International Airport and then hopped aboard BC Ferries for the ever-beautiful crossing to Swartz Bay, where I was met by my lovely Mom. I am happy to be home. I'm so pleased to have much of the month of August to readjust to life in Canada before starting my fourth and final year of midwifery school. But I am certainly feeling the confusion and imbalance that comes with shift of place, shift of reality, shift of economics. Our privilege and wealth (on a general scale, as a society) is at times overwhelming, at times comforting. It's going to take some time to find my balance.
There's more to come.
Heather
Friday, August 10, 2007
Wednesday, August 8, 2007
Some photos at last!
A Ugandan mama and baby of the pachaderm tribe in Queen Elizabeth National Park.
Signpost at the entrance to the Masaka Hospital
Entrance way into the maternity ward at Masaka Hospital
One of the four beds in the delivery room
This is me with one of our mamas in Masaka - this baby was the woman's fifth. We had expected a fast pushing stage because she was a gravida 5, but the baby's head was asynclitic - he was born with a lot of moulding on the right parietal bone. Came through in a very difficult position. What a strong mama and baby!
The view from our hostel in Kampala - looking out over the slum/shanty town towards Mulago Hospital. The heavy pollution is standard in Kampala. Most of the vehicles run on diesel, and it's common to see heavy black exhaust pouring out of the tailpipes of vans, trucks, and boda boda (motorcycles).
Anne-Marie on our walk home from the hospital. Coffin makers are a common sight in Uganda - there's a steady demand for their merchandise.
Sarah, me, and Florence. Sarah is the Senior In-Charge midwife at Upper Mulago and was incredibly welcoming and encouraging. Florence was one of the regular midwives on the ward.
Boda boda drivers on Kampala streets. While we were wearing light t-shirts, they were dressed in down jackets. These motorcycle taxis are a common mode of transport in the city and the fastest way to get around during "jam" (daily morning and evening traffic snarls) because they never hesitate to weave their way through the bigger vehicles on the road.
Selling matoke at Owina Market in Kampala. Matoke, made from these green plantain, is the staple starch food in Uganda.
Women selling spices at Owina Market.
You just can't imagine how excited I was to see giraffes, up close. They're so amazingly cool! This was in Murchison Falls National Park.
Saturday, July 14, 2007
Farewell Mulago
It's Saturday morning, the sun is finally making an appearance, the grey clouds that dropped some rain on us earlier having headed off for other parts. Anne-Marie and I are spending the weekend in Kampala, each of us with various errands to complete, before we head our separate ways for our remaining time in Uganda. Anne-Marie is taking off for the Seese Islands in Lake Victoria and I'm going to go to the southwest of the country to spend some time at Lake Bunyonyi. We are both looking forward to some time spent relaxing, reading, thinking, sleeping, and exploring Uganda.
Our final two days on Ward 14 were challenging and rewarding, with some joyful and difficult outcomes. On Thursday, a baby died. Most likely from meconium aspiration. We weren't at the birth but had been attending the mother during labour. I had ruptured her membranes when she was about 9 cm dilated to find thick meconium in the fluid. (Meconium is the baby's poop - sometimes babes poop before they're born. It can at times indicate fetal distress and thick meconium can be a warning sign that the babe will have difficulty breathing after birth.) The babe's heart rate was incredibly normal and reassuring throughout labour - I heard no decels. I don't know what resuscitation steps were taken at the birth, but they don't have the capacity to intubate babies on Ward 14 so most likely he was suctioned and then ventilated. When we saw him, he was under the warming lamp, an oxygen tube in his nose, with poor tone, waiting for transfer to New Mulago. According to the midwife who took him down to the special care nursery, the doctor there "did everything" but he still died. We were surprised. Though he didn't look well when we saw him, he was breathing and his colour wasn't terrible. I've been thinking a lot about this loss, for a few reasons. We've caught a lot of babes here with meconium stained fluid. They've all done well, often with no more resuscitation needed than routine stimulation after birth. I think I had let my guard down regarding the potential seriousness of meconium. I am reflecting on this birth, wondering if when the thick meconium was noted, we could have transferred the mother to New Mulago before the babe was born. Would she have received better care there? Would a pediatrician have seen him sooner? Would they have intubated him shortly after birth, suctioned the meconium from his lungs? I don't know. New Mulago is an insanely busy ward. There's no guarantee that he would have received pediatric care there any sooner than he did being born on Ward 14 and then transferred down. So I think I'm feeling some remorse and responsibility for this babe's death, wishing that I'd responded to the meconium with more urgency when it was first noted. I can't know whether it would have changed the outcome, but I can't help wondering.
Late Thursday afternoon I attended an 18 year old woman having her first baby. Her name was Rose, a woman who could have been 15 or 16 in looks and demeanor. She had a slow second stage, pushing on her back, on her knees, in a squat, on her side. She pushed out her babe, a normal delivery, though she had a second degree tear. Well, every outcome is a learning opportunity, so I got to suture, a skill that I still don't feel really confident with. And you know, it went well. It was a straightforward tear and I think I sutured well. Continuous sutures for the muscle and then subcuticular stitches for the perineum.
Apparently the sun that I mentioned at the beginning of this post high-tailed it out of here in the face of an approaching rainstorm. The water is pelting down from the sky outside, it's dark and wet and windy and I'm glad that I haven't yet left for my journey down town.
Yesterday we spent our final day on Ward 14. We took in some cake and cookies to share with the midwives who have been so generous in allowing us to catch babies on their turf. The morning was busy - three babies caught in the first hour and a half. As we walked on to the ward, one of the midwives called to us, saying "come and help, there's three babies coming!" Anne-Marie caught two - one multigravida, one primigravida. Both straightforward, uncomplicated deliveries. I caught one - the woman's third babe. There was a double nuchal cord (meaning the cord was wrapped around the babe's neck twice), which I was unable to unwrap before the babe was born. He ended up somersaulting out, sort of. The woman had a small tear, not too bad but given that she was a multip, probably heading home to chase after her other babes the next day, I thought that suturing it would probably help it heal faster. She was reluctant. I wonder whether she'd been sutured before without any anaesthetic? It's pretty common here for midwives to suture a second degree tear using no lidocaine. And they wonder why women are "uncooperative", and "non-compliant"?! Sarah, the in-charge midwife, told us that in Uganda, there's an erroneous belief that using anaesthetic when suturing will prevent the tear from healing as well. After repeated assurances that I would use freezing, she agreed to the suturing. It was straighforward and didn't take too long.
After lunch, we had two final births. Both births happened in the same room, the women separated by a pink curtain. Anne-Marie attended one birth, and I the other. These births, somehow they summed up what we've learned and taught while here in Uganda. Anne-Marie attended Cate, a woman in her fourth pregnancy, 26 or so weeks along, who arrived at the ward crying out that her baby was coming. She was escorted into the assessment room, where Anne-Marie tried to find the fetal heart but wasn't sure that she could hear it. The babe was definitely coming - in fact coming breech. It was clear as soon as the body was out to the umbilicus that the babe was already dead. There was no pulse in the umbilical cord. Anne-Marie assisted the babe's body out with the breech manoeuvres; the legs and arms came easily. But the woman's cervix was not yet dilated enough to allow the head to come. Her contractions stalled and the babe's head was trapped behind a tight cervix. In some ways, it was a blessing that the babe had already died, as I think our adrenaline and anxiety would have been much higher if this live baby's head was trapped. It most likely would have died anyway as we had to put in an IV, hang normal saline with oxytocin to stimulate more contractions, and dilate the cervix enough for the head to be born. It took about 15 minutes for the mom to start getting contractions again and with a strong urge to push, Anne-Marie was able to assist the birth of the head. Her third stage was uncomplicated, the placenta came out complete, and she had little bleeding after the birth. Perhaps the saddest part of this birth was the mother's question, after the babe was born, "is my baby okay?" Anne-Marie had tried to communicate during the delivery that it was too early for the babe to be born and that it had already died but perhaps the mama had been too distressed to understand what Anne-Marie was saying. Anne-Marie handled this birth with such professionalism, such grace and skill, it was heartwarming, despite the sad outcome, to watch her attend this woman and comfort her afterwards.
On the other side of the pink curtain, I was standing with a primigravida, 20 year old Lilian, who was pushing out her baby. She had a beautiful 45 minute 2nd stage, a slow crowning of the head, an uncomplicated delivery of her baby girl. The wee one was a little slow to start but she came around with stimulation, coughing out the mucus that had been plugging up her airway. Lilian's perineum was completely intact, not a graze. What dichotomies, these two births. On one hand, a complicated breech delivery of a preterm stillborn infant, managed calmly, with skill. On the other hand, a new mother supported respectfully during her normal delivery, not cut, not berated to "push push push", her wee one gently welcomed into the world. I feel like these two births epitomize much of what we've learned and shared while we've been here. We've seen and begun to manage complex cases, births that we would rarely or never attend in Canada. We've also brought a different way of managing second stages to the midwives here, showed them that births can be slow and safe, that episiotomies are rarely indicated, that first-time mothers can come through birth without injury to their bodies. It was an emotional end to our last day. It felt like an appropriate ending.
That's enough writing for today. I don't know when I'll next have access to internet, but I'm sure there will be future posts to 'Birth in Uganda' at some point as I mull over all that I've seen and done while here. I'm missing home and looking forward to sharing in person with my friends and family once I'm back.
Love and light,
Heather
Our final two days on Ward 14 were challenging and rewarding, with some joyful and difficult outcomes. On Thursday, a baby died. Most likely from meconium aspiration. We weren't at the birth but had been attending the mother during labour. I had ruptured her membranes when she was about 9 cm dilated to find thick meconium in the fluid. (Meconium is the baby's poop - sometimes babes poop before they're born. It can at times indicate fetal distress and thick meconium can be a warning sign that the babe will have difficulty breathing after birth.) The babe's heart rate was incredibly normal and reassuring throughout labour - I heard no decels. I don't know what resuscitation steps were taken at the birth, but they don't have the capacity to intubate babies on Ward 14 so most likely he was suctioned and then ventilated. When we saw him, he was under the warming lamp, an oxygen tube in his nose, with poor tone, waiting for transfer to New Mulago. According to the midwife who took him down to the special care nursery, the doctor there "did everything" but he still died. We were surprised. Though he didn't look well when we saw him, he was breathing and his colour wasn't terrible. I've been thinking a lot about this loss, for a few reasons. We've caught a lot of babes here with meconium stained fluid. They've all done well, often with no more resuscitation needed than routine stimulation after birth. I think I had let my guard down regarding the potential seriousness of meconium. I am reflecting on this birth, wondering if when the thick meconium was noted, we could have transferred the mother to New Mulago before the babe was born. Would she have received better care there? Would a pediatrician have seen him sooner? Would they have intubated him shortly after birth, suctioned the meconium from his lungs? I don't know. New Mulago is an insanely busy ward. There's no guarantee that he would have received pediatric care there any sooner than he did being born on Ward 14 and then transferred down. So I think I'm feeling some remorse and responsibility for this babe's death, wishing that I'd responded to the meconium with more urgency when it was first noted. I can't know whether it would have changed the outcome, but I can't help wondering.
Late Thursday afternoon I attended an 18 year old woman having her first baby. Her name was Rose, a woman who could have been 15 or 16 in looks and demeanor. She had a slow second stage, pushing on her back, on her knees, in a squat, on her side. She pushed out her babe, a normal delivery, though she had a second degree tear. Well, every outcome is a learning opportunity, so I got to suture, a skill that I still don't feel really confident with. And you know, it went well. It was a straightforward tear and I think I sutured well. Continuous sutures for the muscle and then subcuticular stitches for the perineum.
Apparently the sun that I mentioned at the beginning of this post high-tailed it out of here in the face of an approaching rainstorm. The water is pelting down from the sky outside, it's dark and wet and windy and I'm glad that I haven't yet left for my journey down town.
Yesterday we spent our final day on Ward 14. We took in some cake and cookies to share with the midwives who have been so generous in allowing us to catch babies on their turf. The morning was busy - three babies caught in the first hour and a half. As we walked on to the ward, one of the midwives called to us, saying "come and help, there's three babies coming!" Anne-Marie caught two - one multigravida, one primigravida. Both straightforward, uncomplicated deliveries. I caught one - the woman's third babe. There was a double nuchal cord (meaning the cord was wrapped around the babe's neck twice), which I was unable to unwrap before the babe was born. He ended up somersaulting out, sort of. The woman had a small tear, not too bad but given that she was a multip, probably heading home to chase after her other babes the next day, I thought that suturing it would probably help it heal faster. She was reluctant. I wonder whether she'd been sutured before without any anaesthetic? It's pretty common here for midwives to suture a second degree tear using no lidocaine. And they wonder why women are "uncooperative", and "non-compliant"?! Sarah, the in-charge midwife, told us that in Uganda, there's an erroneous belief that using anaesthetic when suturing will prevent the tear from healing as well. After repeated assurances that I would use freezing, she agreed to the suturing. It was straighforward and didn't take too long.
After lunch, we had two final births. Both births happened in the same room, the women separated by a pink curtain. Anne-Marie attended one birth, and I the other. These births, somehow they summed up what we've learned and taught while here in Uganda. Anne-Marie attended Cate, a woman in her fourth pregnancy, 26 or so weeks along, who arrived at the ward crying out that her baby was coming. She was escorted into the assessment room, where Anne-Marie tried to find the fetal heart but wasn't sure that she could hear it. The babe was definitely coming - in fact coming breech. It was clear as soon as the body was out to the umbilicus that the babe was already dead. There was no pulse in the umbilical cord. Anne-Marie assisted the babe's body out with the breech manoeuvres; the legs and arms came easily. But the woman's cervix was not yet dilated enough to allow the head to come. Her contractions stalled and the babe's head was trapped behind a tight cervix. In some ways, it was a blessing that the babe had already died, as I think our adrenaline and anxiety would have been much higher if this live baby's head was trapped. It most likely would have died anyway as we had to put in an IV, hang normal saline with oxytocin to stimulate more contractions, and dilate the cervix enough for the head to be born. It took about 15 minutes for the mom to start getting contractions again and with a strong urge to push, Anne-Marie was able to assist the birth of the head. Her third stage was uncomplicated, the placenta came out complete, and she had little bleeding after the birth. Perhaps the saddest part of this birth was the mother's question, after the babe was born, "is my baby okay?" Anne-Marie had tried to communicate during the delivery that it was too early for the babe to be born and that it had already died but perhaps the mama had been too distressed to understand what Anne-Marie was saying. Anne-Marie handled this birth with such professionalism, such grace and skill, it was heartwarming, despite the sad outcome, to watch her attend this woman and comfort her afterwards.
On the other side of the pink curtain, I was standing with a primigravida, 20 year old Lilian, who was pushing out her baby. She had a beautiful 45 minute 2nd stage, a slow crowning of the head, an uncomplicated delivery of her baby girl. The wee one was a little slow to start but she came around with stimulation, coughing out the mucus that had been plugging up her airway. Lilian's perineum was completely intact, not a graze. What dichotomies, these two births. On one hand, a complicated breech delivery of a preterm stillborn infant, managed calmly, with skill. On the other hand, a new mother supported respectfully during her normal delivery, not cut, not berated to "push push push", her wee one gently welcomed into the world. I feel like these two births epitomize much of what we've learned and shared while we've been here. We've seen and begun to manage complex cases, births that we would rarely or never attend in Canada. We've also brought a different way of managing second stages to the midwives here, showed them that births can be slow and safe, that episiotomies are rarely indicated, that first-time mothers can come through birth without injury to their bodies. It was an emotional end to our last day. It felt like an appropriate ending.
That's enough writing for today. I don't know when I'll next have access to internet, but I'm sure there will be future posts to 'Birth in Uganda' at some point as I mull over all that I've seen and done while here. I'm missing home and looking forward to sharing in person with my friends and family once I'm back.
Love and light,
Heather
Wednesday, July 11, 2007
Soon to say farewell
It's a Wednesday evening, our last week working as midwives here in Kampala, and I think Anne-Marie and I are both feeling ready for a break. I am feeling the need for time to integrate, to mull, to write, to hunker down and process all that we've seen and learned in our 5 weeks here in Uganda. Being in the midst of it, up to our elbows in amniotic fluid, meconium, blood, and feces every day, I've found it hard to really contemplate how maternity care in Uganda impacts women, babes, and the people who work as midwives, doctors, and nurses in this system. You know, it's been very easy to focus on the ways that maternity care here could/should improve, but we were also acknowledging today that here in Kampala, there are many things that are being done well. Almost all the women we see have been for at least one antenatal appointment, where they've been screened for HIV and determined to be high or low risk. If they are HIV positive, they have access to treatment. If they're considered low risk, they are sent to Ward 14, Upper Mulago, to have their babies. And this screening seems to be quite accurate. In our week and a half working in Ward 14, we've yet to see a woman with gestational hypertension present in pregnancy, twins, breech, or any other complex care needs come through our door. Those women have been screened out and sent to the high risk ward at New Mulago. So almost every birth we've seen on Ward 14 has been straight-forward, normal - no postpartum hemorrhage, no seizures, no malpresentations. So that's something that here in Kampala, seems to be working relatively well.
The question is, what sort of care do the high-risk women get at New Mulago? We occasionally walk past the high risk ward and see the women lining the halls, throngs of people outside the entrance, many of them attendants for the overwhelming numbers of women inside. Today we thought we would spend an afternoon on the high risk ward to try and get some resuscitation experience as we haven't had much opportunity to resuscitate babies on Ward 14. There is a resuscitation room where babes are brought after birth if they are having trouble getting started. Cathy had suggested, on taking her leave from Uganda, that if we were to return to the high risk ward we should restrict ourselves to doing resuscitation only, as you never know what you might get sucked into on that ward. The need is so great, the staff obviously too few, and many of the cases fairly complex. There was no guarantee that if we were suddenly faced with a difficult case that we would be able to find someone to back us up. So after checking in with the "in-charge", we ensconsed ourselves in the resus room, with a copy of the ALARM manual (emergency obstetrics manual) to pass the time, and waited for a baby. It didn't take too long. Shortly after our arrival, a babe was deposited on the vinyl-covered pad by a nursing student who quickly took her leave. We were left to assess this wee boy. He was limp, not breathing, was dusky, meconium was obviously present, and he had a strange smell about him. The smell reminded me of the smell of the macerated still-born babe I caught in Masaka - a smell that isn't healthy, shouldn't be associated with a normal birth. But this babe was alive, with a heart rate of 110 - he needed a little jumpstart. So we ventilated him and his heart rate remained stable, but he wasn't really making any effort to breathe himself, so we carried on with ventilation - "breathe little baby, breathe little baby" - the mantra of Neonatal Resuscitation running through my head. Eventually he started making some breathing efforts but he was still so limp and sounded really mucousy. The wall suction didn't seem to be working so I used a bulb syringe (never seen in Canada any more but the main resuscitation aid here in Uganda) to try to clean some of the muck out of his mouth and nose. Finally Anne-Marie got the wall suction working, but there was no flexible tubing to attach to it in order to suction out his pharynx so we did the best we could with the rigid plastic attachment. Looking back on it, perhaps we should have suctioned his mouth before starting ventilation, but I think if he'd started crying or coughing or sneezing with the ventilation, he would have cleared his own lungs. I certainly felt my lack of experience during this resus but he did eventually come around, and after about 2 minutes of ventilation, plus the suction and some more stimulation, his tone was better, his heart rate was 130, and he was breathing on his own. But I'd give that baby an apgar of 7 at 5 minutes. But what about the smell that I mentioned? I think his mother was probably infected and that babe most likely should have IV antibiotics.
As we were trying to arrange for him to go to the special care nursery for further monitoring, we discovered that his mother (and the midwife and students attending her) were waiting for his twin to be born. It's so hard to describe the chaos of New Mulago. The attending midwife comes in, takes a quick look at the baby, says he's fine and doesn't need to go to special care. Our comments about infection, ongoing gurgly lungs, seem to fall on deaf ears as she heads back to attend to the mother. We're told to wrap the babe up in another cloth and leave him in a cot. As this is transpiring, Anne-Marie hears a woman calling for a midwife. She walks by the cubicle where the woman is labouring. The woman is obviously pushing. Then the head is visible. There's no midwife in sight. Anne-Marie calls for an attendant. No one comes. We weren't going to catch babies at New Mulago but if Anne-Marie doesn't put on her gloves and catch, this babe will have no hands to receive it as it makes its entrance. So Anne-Marie catches. And the woman has a postpartum hemorrhage. And we're not sure if the blood is coming from the uterus because it's well contracted but the blood keeps gushing out. She definitely has a second degree perineal tear but that's not where the blood is coming from. Cervical tear? By this time, there are a couple of interns also on the scene, trying to figure out where this blood is coming from. We hang normal saline with oxytocin. The blood slows but gushes whenever you massage her uterus. The interns don't think there's a cervical tear and in the end decide it was uterine blood. It seems to ease after 15 minutes or so and we leave the interns to repair her tear. We head back to the resuscitation room.
In the end, we didn't have any more resuscitations but Anne-Marie catches yet another baby due to absent midwives. How strange, that in a second stage room, with five beds, each containing a labouring mother, there is no midwife. How can that be? Are they so short-staffed? Are they ignoring the calls of help from mothers? Are they so over-worked, underpaid, and apathetic that their work no longer holds any reward or joy? I could see it happening but it still just seems so bizarre that women are left to labour and birth without the benefit of caregivers.
As for the wee babe we resuscitated, well, his mom was sent off for a C-section for delivery of the second twin. Apparently the second was presenting his face (deflexed head) and not coming down so she went for cesar (as they're called here). I doubt that he'll get antibiotics but I hope that someone assessed him after we left to make sure he was still holding his own.
Two days to go.
Heather
The question is, what sort of care do the high-risk women get at New Mulago? We occasionally walk past the high risk ward and see the women lining the halls, throngs of people outside the entrance, many of them attendants for the overwhelming numbers of women inside. Today we thought we would spend an afternoon on the high risk ward to try and get some resuscitation experience as we haven't had much opportunity to resuscitate babies on Ward 14. There is a resuscitation room where babes are brought after birth if they are having trouble getting started. Cathy had suggested, on taking her leave from Uganda, that if we were to return to the high risk ward we should restrict ourselves to doing resuscitation only, as you never know what you might get sucked into on that ward. The need is so great, the staff obviously too few, and many of the cases fairly complex. There was no guarantee that if we were suddenly faced with a difficult case that we would be able to find someone to back us up. So after checking in with the "in-charge", we ensconsed ourselves in the resus room, with a copy of the ALARM manual (emergency obstetrics manual) to pass the time, and waited for a baby. It didn't take too long. Shortly after our arrival, a babe was deposited on the vinyl-covered pad by a nursing student who quickly took her leave. We were left to assess this wee boy. He was limp, not breathing, was dusky, meconium was obviously present, and he had a strange smell about him. The smell reminded me of the smell of the macerated still-born babe I caught in Masaka - a smell that isn't healthy, shouldn't be associated with a normal birth. But this babe was alive, with a heart rate of 110 - he needed a little jumpstart. So we ventilated him and his heart rate remained stable, but he wasn't really making any effort to breathe himself, so we carried on with ventilation - "breathe little baby, breathe little baby" - the mantra of Neonatal Resuscitation running through my head. Eventually he started making some breathing efforts but he was still so limp and sounded really mucousy. The wall suction didn't seem to be working so I used a bulb syringe (never seen in Canada any more but the main resuscitation aid here in Uganda) to try to clean some of the muck out of his mouth and nose. Finally Anne-Marie got the wall suction working, but there was no flexible tubing to attach to it in order to suction out his pharynx so we did the best we could with the rigid plastic attachment. Looking back on it, perhaps we should have suctioned his mouth before starting ventilation, but I think if he'd started crying or coughing or sneezing with the ventilation, he would have cleared his own lungs. I certainly felt my lack of experience during this resus but he did eventually come around, and after about 2 minutes of ventilation, plus the suction and some more stimulation, his tone was better, his heart rate was 130, and he was breathing on his own. But I'd give that baby an apgar of 7 at 5 minutes. But what about the smell that I mentioned? I think his mother was probably infected and that babe most likely should have IV antibiotics.
As we were trying to arrange for him to go to the special care nursery for further monitoring, we discovered that his mother (and the midwife and students attending her) were waiting for his twin to be born. It's so hard to describe the chaos of New Mulago. The attending midwife comes in, takes a quick look at the baby, says he's fine and doesn't need to go to special care. Our comments about infection, ongoing gurgly lungs, seem to fall on deaf ears as she heads back to attend to the mother. We're told to wrap the babe up in another cloth and leave him in a cot. As this is transpiring, Anne-Marie hears a woman calling for a midwife. She walks by the cubicle where the woman is labouring. The woman is obviously pushing. Then the head is visible. There's no midwife in sight. Anne-Marie calls for an attendant. No one comes. We weren't going to catch babies at New Mulago but if Anne-Marie doesn't put on her gloves and catch, this babe will have no hands to receive it as it makes its entrance. So Anne-Marie catches. And the woman has a postpartum hemorrhage. And we're not sure if the blood is coming from the uterus because it's well contracted but the blood keeps gushing out. She definitely has a second degree perineal tear but that's not where the blood is coming from. Cervical tear? By this time, there are a couple of interns also on the scene, trying to figure out where this blood is coming from. We hang normal saline with oxytocin. The blood slows but gushes whenever you massage her uterus. The interns don't think there's a cervical tear and in the end decide it was uterine blood. It seems to ease after 15 minutes or so and we leave the interns to repair her tear. We head back to the resuscitation room.
In the end, we didn't have any more resuscitations but Anne-Marie catches yet another baby due to absent midwives. How strange, that in a second stage room, with five beds, each containing a labouring mother, there is no midwife. How can that be? Are they so short-staffed? Are they ignoring the calls of help from mothers? Are they so over-worked, underpaid, and apathetic that their work no longer holds any reward or joy? I could see it happening but it still just seems so bizarre that women are left to labour and birth without the benefit of caregivers.
As for the wee babe we resuscitated, well, his mom was sent off for a C-section for delivery of the second twin. Apparently the second was presenting his face (deflexed head) and not coming down so she went for cesar (as they're called here). I doubt that he'll get antibiotics but I hope that someone assessed him after we left to make sure he was still holding his own.
Two days to go.
Heather
Saturday, July 7, 2007
Apparently the title bar isn't working on the blogspot site at present so this will have to be a title-free posting. I've spent the day walking into downtown Kampala, enjoying pots of African tea while writing in my journal. I then met up with a new Ugandan friend, Favor, who is the daughter of Prossy, one of the midwives we worked with in Masaka. I had a fun afternoon talking with Favor and a couple of her friends about Ugandan economics, politics, gender dynamics - it was enlightening and great to just sit down and chat about something other than birth with some local folks.
I loved reading Anne-Marie's impressions of our week at Mulago. It's so great to compare our different perspectives, writing styles, highs and lows. I'd also encourage you to check out Brynne's family blog if you haven't yet (there's a link from this page) - Brynne's eloquent words capture so well her (our) experiences in Masaka.
Our final birth on Friday afternoon was so rewarding. Stella was a primigravida whom Anne-Marie had assessed in the late morning when she was 7 cm dilated. Around 3:30, one of the Ugandan midwives checked her and told us she was fully dilated. Anne-Marie was just finishing up with another birth and so we figured we'd have one more quick birth (remember, average Ugandan primigravida pushes for 20-30 minutes) before we headed out for the weekend. Over the next half hour, A-M attended Stella while I checked in with a few other women, monitoring fetal heart tones and checking dilation, waiting for the call from A-M that she was ready for backup. But that wee babe just wasn't coming down - after half an hour, A-M rechecked Stella's cervix to find that she wasn't fully dilated; there was an anterior lip, not swollen but definitely present. We encouraged Stella to lie on her side, try to resist the strong pushing urge, and allow time for the last of the cervix to melt away. As we stood at the bedside, we talked about what homeopathic remedies we might try if we were at home to help disappear this cervix. We both thought gelsemium, perhaps alternated with caulophyllum. But, this is Uganda, not Canada, and there weren't any homeopathics at hand so we resorted to the age-old, tried and true method of physical and emotional support to help Stella through this painful transition to fully dilated.
Another half an hour, the pushing urge was still irresistible, another vaginal exam found the cervical lip still stubbornly present. So we thought we'd try to slip that lip out of the way manually so that the babe could come down. Slipping a cervical lip involves using your fingers to push the lip up past the babe's head as the mom pushes with a contraction. Anne-Marie slipped the lip, the head came down, some but that feisty lip came back once the contraction was over. After a few more contractions, I tried slipping the lip. This time, the head really came down and the lip stayed up. But Stella was tired and overwhelmed, her contractions were spacing out, the head still wasn't visible at the perineum so we thought we'd better consult our Ugandan colleagues. It was decided that we'd hang normal saline with some oxytocin to encourage her contractions, get her some tea, and give her some more time. By this point, she'd been pushing for almost 2 hours. The babe's heart had been a solid 130 beats per minute (normal range 110-160 bpm) throughout second stage so we knew the wee one wasn't feeling the strain her mother was. Well, it wasn't long after the oxytocin was hung that we started to see this babe's black hair peeking out at us. We had two of our Ugandan colleagues standing by as Anne-Marie received this 3.5 kg baby over an intact perineum. Stella was thrilled. We were thrilled. How lovely to stay with this mom, see her through a tough second stage, to see her cuddle in with her beautiful baby girl after a long "birth" day.
This birth inspired a really interesting conversation with a couple of our Ugandan colleagues. Grace and Sarah observed the birth and the discussion of episiotomy came up yet again. Grace told us that in nursing/midwifery school, students are taught that indications for episiotomy are primigravida, premature baby, big baby, multiple pregnancy (e.g. twins), and breech. We discussed some of the research that indicates that routine episiotomy is unnecessary and harmful and that the main indication for episiotomy where we work is fetal distress. To which Grace replied, "Well, it was people from the West who came to Africa and taught us to do episiotomy in the first place. How come no one has bothered to tell us that it's no longer considered the appropriate thing to do?" Good point.
My time is short - I've got lots of thoughts on the subject of medical/cultural imperialism and changing practice but they will have to wait. Wishing you all a pleasant and joy-filled day, wherever you are in the world.
Heather
I loved reading Anne-Marie's impressions of our week at Mulago. It's so great to compare our different perspectives, writing styles, highs and lows. I'd also encourage you to check out Brynne's family blog if you haven't yet (there's a link from this page) - Brynne's eloquent words capture so well her (our) experiences in Masaka.
Our final birth on Friday afternoon was so rewarding. Stella was a primigravida whom Anne-Marie had assessed in the late morning when she was 7 cm dilated. Around 3:30, one of the Ugandan midwives checked her and told us she was fully dilated. Anne-Marie was just finishing up with another birth and so we figured we'd have one more quick birth (remember, average Ugandan primigravida pushes for 20-30 minutes) before we headed out for the weekend. Over the next half hour, A-M attended Stella while I checked in with a few other women, monitoring fetal heart tones and checking dilation, waiting for the call from A-M that she was ready for backup. But that wee babe just wasn't coming down - after half an hour, A-M rechecked Stella's cervix to find that she wasn't fully dilated; there was an anterior lip, not swollen but definitely present. We encouraged Stella to lie on her side, try to resist the strong pushing urge, and allow time for the last of the cervix to melt away. As we stood at the bedside, we talked about what homeopathic remedies we might try if we were at home to help disappear this cervix. We both thought gelsemium, perhaps alternated with caulophyllum. But, this is Uganda, not Canada, and there weren't any homeopathics at hand so we resorted to the age-old, tried and true method of physical and emotional support to help Stella through this painful transition to fully dilated.
Another half an hour, the pushing urge was still irresistible, another vaginal exam found the cervical lip still stubbornly present. So we thought we'd try to slip that lip out of the way manually so that the babe could come down. Slipping a cervical lip involves using your fingers to push the lip up past the babe's head as the mom pushes with a contraction. Anne-Marie slipped the lip, the head came down, some but that feisty lip came back once the contraction was over. After a few more contractions, I tried slipping the lip. This time, the head really came down and the lip stayed up. But Stella was tired and overwhelmed, her contractions were spacing out, the head still wasn't visible at the perineum so we thought we'd better consult our Ugandan colleagues. It was decided that we'd hang normal saline with some oxytocin to encourage her contractions, get her some tea, and give her some more time. By this point, she'd been pushing for almost 2 hours. The babe's heart had been a solid 130 beats per minute (normal range 110-160 bpm) throughout second stage so we knew the wee one wasn't feeling the strain her mother was. Well, it wasn't long after the oxytocin was hung that we started to see this babe's black hair peeking out at us. We had two of our Ugandan colleagues standing by as Anne-Marie received this 3.5 kg baby over an intact perineum. Stella was thrilled. We were thrilled. How lovely to stay with this mom, see her through a tough second stage, to see her cuddle in with her beautiful baby girl after a long "birth" day.
This birth inspired a really interesting conversation with a couple of our Ugandan colleagues. Grace and Sarah observed the birth and the discussion of episiotomy came up yet again. Grace told us that in nursing/midwifery school, students are taught that indications for episiotomy are primigravida, premature baby, big baby, multiple pregnancy (e.g. twins), and breech. We discussed some of the research that indicates that routine episiotomy is unnecessary and harmful and that the main indication for episiotomy where we work is fetal distress. To which Grace replied, "Well, it was people from the West who came to Africa and taught us to do episiotomy in the first place. How come no one has bothered to tell us that it's no longer considered the appropriate thing to do?" Good point.
My time is short - I've got lots of thoughts on the subject of medical/cultural imperialism and changing practice but they will have to wait. Wishing you all a pleasant and joy-filled day, wherever you are in the world.
Heather
Friday, July 6, 2007
All in a week's work...
hello to all you sweet blog-treaders...
i've not been posting personally to the blog so far, but it's been lovely to hear about some of your thoughts and responses to heather's posts. it adds a new dimension to our processing to share things with cyber-folks!
i've been meaning to get posting here and since it's the end of a special week at mulago hospital, ward 14, it's as good a time as any!
monday - i was stabbed with a pen and spanked a few times by a crusty local midwife; i would have spanked her back if i wasn't struck still by my disbelief. heather got a spank or two as well, so we suffered together. the day was so frustrating, as we got into true baby catching sportsmanship. we were playig defence, catching babies with elbows out, fending off midwives coming in to cut episiotomies in women's vaginas who certainly didn't need the cut, or pulling women's hair to make them push harder! i appreciate that we work within different birth cultures, and i appreciate that a colonial history is what fueled the episiotomy train in the first place, but i couldn't help but leave feeling sickened. i felt like i wouldn't be able to face this everyday; women abusing other women. violence in birth just ain't going to make the world a better place.
tuesday - a rainy afternoon. i listened to babies fast little heart beats through big bellies in a quiet labour ward. the calmness was a gift.
wednesday - i chat with a local restaurant owner who shivers when i tell him that i am a student midwife. i ask why. he tells me that midwives are ruthless and violent. this reply rings familiar with the local belief that the midwife is a woman's worst enemy. i go into work in the afternoon and have a chat with the head midwife on the ward and her mother who is also a midwife. she's so rad and she is totally supportive of learning more gentle approaches to birth. we talked about tonnes of stuff...midwives' dissatisfaction with their work, poor pay, stress, power trips over women, modelling behaviour, ideas about how to motivate women, lack of educational opportunities, religion and birth... she really wants heather and i to do some teaching with the midwives and we're both super stoked for that opportunity!
thursday - incredible. it's a slow day on the ward, permitting some time for teaching and disussion. we started by talking about the importance of administering oxytocin with normal saline, rather than dextrose, and we pulled out the alarm manual to justify our case. we talked about using oxytocin rather than ergot for the management of third stage. we then demonstrated shoulder dystocia and breech birth management, as if we were a bunch of pros. then i went off on a big ol' rant about midwives being privileged to do the blessed work that we do. most of these women are christian, so i talked jesus talk and ranted about the incredible responsibility we have as god's servants to invite new human beings onto the planet in peace and without violence. i talked about sisterhood between midwives and the women we support, and the need to make one of life's most challenging experiences as pleasant for women as possible. the few nods of agreement that i saw were enough to make me swell with bubbles of joy. even if they are a little kinder to one or two women this week, that's important.
and by friday... - the midwives are stepping back and watching. they are interested in the differences between how we catch babies and the midwife who stabbed us on monday now has given me her name and calls us sisters. she likes the little knit dolls that we brought from canada and she keeps trying to breastfeed them; kinda creepy, but it's better thank spanking! we attended 6 lovely births today and left smiling!
peace...a-m
i've not been posting personally to the blog so far, but it's been lovely to hear about some of your thoughts and responses to heather's posts. it adds a new dimension to our processing to share things with cyber-folks!
i've been meaning to get posting here and since it's the end of a special week at mulago hospital, ward 14, it's as good a time as any!
monday - i was stabbed with a pen and spanked a few times by a crusty local midwife; i would have spanked her back if i wasn't struck still by my disbelief. heather got a spank or two as well, so we suffered together. the day was so frustrating, as we got into true baby catching sportsmanship. we were playig defence, catching babies with elbows out, fending off midwives coming in to cut episiotomies in women's vaginas who certainly didn't need the cut, or pulling women's hair to make them push harder! i appreciate that we work within different birth cultures, and i appreciate that a colonial history is what fueled the episiotomy train in the first place, but i couldn't help but leave feeling sickened. i felt like i wouldn't be able to face this everyday; women abusing other women. violence in birth just ain't going to make the world a better place.
tuesday - a rainy afternoon. i listened to babies fast little heart beats through big bellies in a quiet labour ward. the calmness was a gift.
wednesday - i chat with a local restaurant owner who shivers when i tell him that i am a student midwife. i ask why. he tells me that midwives are ruthless and violent. this reply rings familiar with the local belief that the midwife is a woman's worst enemy. i go into work in the afternoon and have a chat with the head midwife on the ward and her mother who is also a midwife. she's so rad and she is totally supportive of learning more gentle approaches to birth. we talked about tonnes of stuff...midwives' dissatisfaction with their work, poor pay, stress, power trips over women, modelling behaviour, ideas about how to motivate women, lack of educational opportunities, religion and birth... she really wants heather and i to do some teaching with the midwives and we're both super stoked for that opportunity!
thursday - incredible. it's a slow day on the ward, permitting some time for teaching and disussion. we started by talking about the importance of administering oxytocin with normal saline, rather than dextrose, and we pulled out the alarm manual to justify our case. we talked about using oxytocin rather than ergot for the management of third stage. we then demonstrated shoulder dystocia and breech birth management, as if we were a bunch of pros. then i went off on a big ol' rant about midwives being privileged to do the blessed work that we do. most of these women are christian, so i talked jesus talk and ranted about the incredible responsibility we have as god's servants to invite new human beings onto the planet in peace and without violence. i talked about sisterhood between midwives and the women we support, and the need to make one of life's most challenging experiences as pleasant for women as possible. the few nods of agreement that i saw were enough to make me swell with bubbles of joy. even if they are a little kinder to one or two women this week, that's important.
and by friday... - the midwives are stepping back and watching. they are interested in the differences between how we catch babies and the midwife who stabbed us on monday now has given me her name and calls us sisters. she likes the little knit dolls that we brought from canada and she keeps trying to breastfeed them; kinda creepy, but it's better thank spanking! we attended 6 lovely births today and left smiling!
peace...a-m
Thursday, July 5, 2007
Creating space
Well, after four days working on Ward 14 at Mulago Hospital, I really feel like we've created a niche for ourselves. I think most of the midwives now trust that we know what we're doing, that we can manage births independently, and that we have good outcomes, in spite of the fact that we manage births very differently than they do. There even seems to be an increasing interest in the high number of intact perineums that we have, especially in the "P.G.s" (primigravidas) we've been attending. The head midwife on the ward, Sarah, is so eager to talk about skills and techniques that we've brought with us from home - she was thrilled today when we gave her a copy of the Canadian ALARM textbook that we'd brought from home. She is a woman with an warm heart who wants to provide good care to the mothers that they serve at Mulago. This public hospital maternity ward (and the midwives who work there) have a poor reputation among the general public - if women can afford to go elsewhere they do. I think Sarah is aware of this and wants to change it and is recognizing that how women are treated impacts their own experience and public perception of maternity care at the hospital. Today we had a really good teaching session with the day-shift midwives - Anne-Marie is going to post about this soon so I won't go into it in any detail except to say that it was gratifying and encouraging to talk about birth with the midwives we work with on a daily basis.
I attended a lovely birth at the end of the day today. A-M had already gone home because she'd been feeling a little "off" but I decided to stay out the day. A P.G. who had been on the ward since mid-morning was sounding quite active so I checked her to find her 8-9 cm dilated. Shortly afterwards, one of the Ugandan midwives, Grace, checked her again as she was feeling the urge to push. She was fully dilated so Grace ruptured her membranes. I asked if I could catch the baby, and Grace asked me if I could suture an episiotomy. I assured her that there would be no episiotomy if I was catching and that there was a good chance of no tear. I don't think Grace really believed me (she has been working evening shift and so hasn't seen us catch yet) but I told her that if there was a tear I would suture. I guess in Canadian terms, her pushing stage was pretty short (15 minutes) but Ugandan midwives are used to telling women to push like stink once they have reached full dilatation, whether they are having a contraction or not. I think Grace got a little impatient as I was telling this woman to rest and breathe between contractions so the head didn't pop out within five minutes of pushing. Grace asked me to call her once the head was crowning so she could see how I "delivered" the head. The head crowned, I told the mama to stop pushing, she breathed her baby out nice and slow, and then the shoulders and body came easily and babe was up to mom's tummy. No tears, no episiotomy. I'm quite sure that had Grace attended this delivery, this mom would have had an episiotomy. As we inspected the perineum together, I asked Grace what she thought about the delivery. While know she was happy there was no tear, she was sure to tell me that it was only because it was a small baby (2.7 kg). Ah well, whether it was a small baby, a stretchy perineum, a slow and controlled delivery of the head, I'm just pleased that this mama can settle down to loving her baby with an intact vagina.
It seems amazing that we have only 6 days of work left here in Uganda. At first, as we adjusted to a new birthing culture, lack of supplies, a different language, the days passed so slowly, each day full of rich new experiences. But as inevitably happens when one becomes more comfortable and settled in a new place, the time speeds up. Suddenly we're facing the end of our placement. Some days I feel ready for a break, ready to travel and experience Uganda from a perspective other than that of a maternity care worker. But other days, like today, I feel like I'm just getting into the groove, just finding my place here - I can't be nearly finished. It's just been such a privilege to experience birth in another country, to care for Ugandan women. We have been so lucky to been given independence to catch babies the "Canadian way" in the midst of this big public hospital. The low-risk ward where we're working has an average of 30 births per 24 hours. Down on the high-risk ward, they're welcoming 60-70 new babes into the world every day. It is so completely different from the midwifery care environment in Canada. But working here has given me so much more confidence in my skills. Catching baby after baby, day after day, really has reassured me that most of the time, birth works, often in spite of poor health, lack of antenatal care, rudimentary supplies.
Brynne will be leaving Masaka next Wednesday as she and her family travel home to Bowen Island. I had an email from her today - it sounds like she has been entrusted with the management of most of the deliveries in Masaka since we left. She is, I am sure, attending those mothers with grace and skill, while enthusiastically teaching the many nursing students that seem to be continually present in labour and delivery at Masaka. I think she and her family are feeling really at home in Masaka - it will be difficult for them to leave after such life-changing experiences for all of them.
Until next time,
Heather
I attended a lovely birth at the end of the day today. A-M had already gone home because she'd been feeling a little "off" but I decided to stay out the day. A P.G. who had been on the ward since mid-morning was sounding quite active so I checked her to find her 8-9 cm dilated. Shortly afterwards, one of the Ugandan midwives, Grace, checked her again as she was feeling the urge to push. She was fully dilated so Grace ruptured her membranes. I asked if I could catch the baby, and Grace asked me if I could suture an episiotomy. I assured her that there would be no episiotomy if I was catching and that there was a good chance of no tear. I don't think Grace really believed me (she has been working evening shift and so hasn't seen us catch yet) but I told her that if there was a tear I would suture. I guess in Canadian terms, her pushing stage was pretty short (15 minutes) but Ugandan midwives are used to telling women to push like stink once they have reached full dilatation, whether they are having a contraction or not. I think Grace got a little impatient as I was telling this woman to rest and breathe between contractions so the head didn't pop out within five minutes of pushing. Grace asked me to call her once the head was crowning so she could see how I "delivered" the head. The head crowned, I told the mama to stop pushing, she breathed her baby out nice and slow, and then the shoulders and body came easily and babe was up to mom's tummy. No tears, no episiotomy. I'm quite sure that had Grace attended this delivery, this mom would have had an episiotomy. As we inspected the perineum together, I asked Grace what she thought about the delivery. While know she was happy there was no tear, she was sure to tell me that it was only because it was a small baby (2.7 kg). Ah well, whether it was a small baby, a stretchy perineum, a slow and controlled delivery of the head, I'm just pleased that this mama can settle down to loving her baby with an intact vagina.
It seems amazing that we have only 6 days of work left here in Uganda. At first, as we adjusted to a new birthing culture, lack of supplies, a different language, the days passed so slowly, each day full of rich new experiences. But as inevitably happens when one becomes more comfortable and settled in a new place, the time speeds up. Suddenly we're facing the end of our placement. Some days I feel ready for a break, ready to travel and experience Uganda from a perspective other than that of a maternity care worker. But other days, like today, I feel like I'm just getting into the groove, just finding my place here - I can't be nearly finished. It's just been such a privilege to experience birth in another country, to care for Ugandan women. We have been so lucky to been given independence to catch babies the "Canadian way" in the midst of this big public hospital. The low-risk ward where we're working has an average of 30 births per 24 hours. Down on the high-risk ward, they're welcoming 60-70 new babes into the world every day. It is so completely different from the midwifery care environment in Canada. But working here has given me so much more confidence in my skills. Catching baby after baby, day after day, really has reassured me that most of the time, birth works, often in spite of poor health, lack of antenatal care, rudimentary supplies.
Brynne will be leaving Masaka next Wednesday as she and her family travel home to Bowen Island. I had an email from her today - it sounds like she has been entrusted with the management of most of the deliveries in Masaka since we left. She is, I am sure, attending those mothers with grace and skill, while enthusiastically teaching the many nursing students that seem to be continually present in labour and delivery at Masaka. I think she and her family are feeling really at home in Masaka - it will be difficult for them to leave after such life-changing experiences for all of them.
Until next time,
Heather
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