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