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