Settling in to Kampala

Hello to the many folks keeping in touch with our work through this blog. It's been so lovely to read your notes and warm wishes - your interest in our work here inspires me to keep posting regularly.

Anne-Marie and I have found cheap, convenient digs in Kampala, quite close to Mulago Hospital where we're working this week and next. We're staying at a university hostel, called Akamwesi Hostel. Generally university students fill up this hostel but they are on a break from classes at present so there is a room available for us for the next two weeks. There are even cooking facilities, which is wonderful, as eating out every day starts to get a little wearing.

Today was our first day working on our own without Cathy providing instruction and support. While I couldn't imagine managing births without Cathy's support when we first arrived, I think both Anne-Marie and I felt quite confident as we worked in labur and delivery on the low-risk ward today. We've become pretty confident with managing births Ugandan style and no longer have any qualms about tying cords with the cuffs from gloves or cutting cords with razor blades. It's also become really normal to attend women who are lying on a piece of plastic that they've brought themselves, layed out on an old vinyl-covered mattress. We clean up with pieces of cotton batting torn from a roll brought by the women; we also use this cotton to clean away clots of blood so that we can examine their perineums after the birth. The gloves we use, the razor blade, syringes and needles for active management, the basin - all of these items are provided by the birthing women. It's not ideal but it works. And you know, compared to a birth in a hospital in Canada, there's very little waste - the plastic sheet, some wet cotton batting, the used gloves. That's about it. All the amniotic fluid, blood, etc. from the birth gets wrapped up in the plastic. We use the cotton batting to wipe off the woman's body. She stands up, uses cotton as a pad between her legs, puts on her clothes, lays out another cloth on the bed, and lies down again with her babe. It always amazes me how quickly women go from the intense effort of birthing their babies to fully dressed, phoning their relatives on their cell phones (yup, some of them have cell phones - they're pretty ubiquitous in Kampala), while lying down nursing their babes. The transition just seems so quick.

One of the challenges that we seem to be frequently faced with is misuse of medications. All women birthing at Ugandan public hospitals are supposed to be offered active management of the third stage of labour. This means that within a minute of the birth of the baby, the mother is given an injection of oxytocin to help the uterus contract, the placenta separate, and to reduce postpartum bleeding. In a place where many pregnant women are anemic, more than 10% are HIV positive, and IV fluids and blood for transfusion is scarce, active management makes good sense and I've certainly embraced this policy. The problem that we've encountered, however, is that often labour wards don't have oxytocin. And so they're using ergometrine for active management instead. Ergometrine is a drug that is used selectively in Canada (if you can even access it) - it's second line treatment for postpartum hemorrhage and is only used if the placenta is out and is complete, oxytocin has failed to contract the uterus efficiently, and the woman is continuing to bleed heavily. It's contraindicated if the woman has high blood pressure. It also requires refrigeration to be effective. Here we see ergometrine used over and over for active management. It's given like oxytocin would be - intramuscularly within one minute of the birth. We've been providing oxytocin on labour wards in both Masaka and here in Kampala because it often seems that it's just not available. But more than that, it seems that many midwives don't understand that ergometrine isn't an appropriate drug to be using in this manner. While they know that oxytocin is better, the potential complications of using ergometrine aren't recognized. It feels like we're frequently discussing appropriate active management of third stage and encouraging midwives and students to use oxytocin. But what do you do when there's no oxy available? Is ergometrine, despite its problems, better than nothing? I really don't know. All we can do is keep bringing our own oxytocin so that the women we attend at least get appropriate management but there are obviously systems problems, supply problems, and miseducation. That seems like barriers that are too large for us to tackle in the short time we're here.

Today A-M and I each caught two babies. For the most part, all the births were uncomplicated, though the biggest challenge was trying to firmly hold our ground and manage the births in our style. We support women differently than the Ugandan midwives, especially during second stage when we encourage a slow delivery of the baby's head to allow the perineum to stretch and prevent tears. Most of the midwives we've worked with here get the women to push like crazy and episiotomies are much more common, especially with first time mothers. Today it felt as though we were frequently fending off well-meaning but inappropriate directions from our colleagues. We know how to catch babies. We've done a lot of it now. We have really good success with promoting intact perineums. And yet we have to continually defend the way we manage second stage. It's draining and sometimes hard to keep our sense of humour and a positive perspective. But we did have a lovely success today - Sarah, the head midwife on the ward, attended a birth with us. Anne-Marie was catching and encouraged a really slow delivery of the baby. Afterwards Sarah said that she really liked the way A-M managed second stage and admitted that midwives in Uganda tend to get scared if pushing takes a long time or the head stays on the perineum too long. She said that she thinks sometimes women tear who shouldn't because the head comes out too fast. I think we may have a convert!

There will be lots of babies on Ward 14 at Mulago. Overall I'm looking forward to the next two weeks. Lots of learning to be done, and perhaps some teaching as well.

Tunalabagana (see you later!)

Heather