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