Time and space

It is Saturday morning, the sky is hazy with low clouds, the air is warm but not muggy, and my eyes are heavy with fatigue; my stomach grumbling, rolling over in protest over the two tomato slices I ate yesterday afternoon. It's been a slow morning, dozing in to 9:30am after a night of little sleep. I am sharing rooms with Brynne's family, the Purcell's, at the Hotel Zebra. Isa and Canaan, Brynne's daughters, and I are sleeping in the same room and last night found Canaan and I both awake intermittently, tossing about under our mosquito nets. My protesting stomach was not conducive to resting well, so I spent the night with pictures of Ugandan mama's rolling through my mind. Occasionally I'd slip into sleep, dreaming of women pushing out their babies, their voices calling out in pain and prayer, only to wake and find that Canaan was crying out in her restless sleep beside me.

On Thursday evening, Cathy and Mickey hosted a pizza party for us all at a cafe that supports a Ugandan/Danish NGO. Two of our Ugandan colleagues, Prossy and Teddy, joined us and we had good chats about Ugandan culture, language, HIV prevalence and treatment, and programs to reduce HIV transmission from mother to child. Prossy is a midwife and worked closely with Cathy and the UBC students last year - this year she is working with Uganda Cares, a government- and internationally-funded program that provides HIV testing, counseling, medication, and support to Ugandans. Prossy says that at the centre here in Masaka they see over 450 people per day. Despite Uganda having been quite successful in reducing the transmission of HIV, the need is still incredibly great. In the last year, HIV testing of pregnant women has become mandatory, so almost every woman who accesses antenatal care is tested, and if found to be positive, is counseled, given medication for the duration of her pregnancy, and provided with medication for her newborn babe to try and prevent vertical transmission between mama and babe. Women are counseled about feeding - if they can afford formula, they are encouraged to exclusively formula feed. If they can't afford artificial feeding, they are encouraged to exclusively breastfeed for 6 months and then to wean their babes and start them on solids. While there is a risk of HIV transmission through breastmilk, for women who can't afford proper formula and clean water, the risk of infant mortality due to gastrointestinal disease is higher than the risk of HIV transmission. It's been found that mixed feeding, breast and bottle, further increases the rate of transmission. So it's exclusive bottle or exclusive breast.

After dinner, Mickey, Cathy and I headed back to the hospital to do a second curettage on the woman whose babe was stillborn on Wednesday morning. Mickey had done a curettage Wednesday afternoon but an ultrasound on Thursday had shown there were still some retained products in her uterus. Given that she had been febrile and in shock the day before, he wanted to be sure that her uterus was completely empty to prevent reinfection or a late postpartum hemorrhage. We brought her into the labour and delivery room, where she placed her plastic sheet on this rickety half-size table and then climbed up, Cathy and I helping her to place her legs in the awkward stirrups which we couldn't adjust to make it more comfortable for her. Here in Masaka, they rarely have access to any sort of sedative or analgesia for these sorts of procedures, so the best we could offer was me holding her hand and shoulder, looking into her eyes, while Mickey inserted the speculum, grasped her cervix with ring forceps, and cleaned out her uterus with the curette. It was a quick procedure, less than five minutes probably, and she was so brave but cried out in pain several times. When it was over, we took her back to the postpartum ward where she was to receive another dose of flagyl and some more IV fluids through the night. Cathy spoke with her mother-in-law, through the nurse who translated, telling her how brave this young woman had been through the very painful procedures to save her life. Perhaps this will make a difference as to how her family treats her and views her when she goes home, perhaps not. It's hard to know. She's most likely back in her village now - I wonder if she's back to work or will be able to rest for a couple more days before resuming her responsibilities?

We spent a half day at the hospital yesterday morning. Cathy and Mickey headed to Kampala as they had to pick up some paperwork. So it was Brynne, Anne-Marie, and I alone on the labour and delivery ward. It was a quiet morning, one woman being prepped for C/S, another woman in active labour, another waiting for a curettage procedure following an incomplete miscarriage, and a fourth who came in for labour assessment. We had seen this woman in the early labour ward the day before, though none of us had examined her. Brynne started the assessment, finding her at about 4 cm dilated with fairly regular contractions. But she was unable to find the fetal heart. Her chart said that the fetal heart had been heard that morning, around 5am, but none of us could find it, nor could the in-charge midwife Teddy, nor could Doctor Doreen who came in to assess. As it was a week-day, we were able to send her to ultrasound for a scan. The scan found that her babe was dead, and in fact probably had been for some time, given the amount of moulding of the skull, something that apparently happens once a fetus dies. The ultrasonographer told us that there was no way the fetal heart could have been heard that morning, which left us wondering whether it was truly heard the day before when she was on the ward being monitored. Though it can be difficult with pinard fetoscopes, it is awful to think that whoever was assessing her wasn't really listening thoroughly and that her babe had been dead since she'd come in. The doctor ordered an oxytocin drip to speed up her labour and Brynne attended as a second, not catching the baby but holding this woman's hand as she birthed her stillborn babe. Another sad morning, with no apparent cause for this fetal death, except the late realization that her membranes were already ruptured so perhaps there had been an infection. It's so hard to know.

My time is short...I will post again soon. Thanks to all who have posted notes of support and love. We so appreciate knowing that people are reading our blog and steppinginto Ugandan maternity care through our words.

With love,
Heather