Soon to say farewell

It's a Wednesday evening, our last week working as midwives here in Kampala, and I think Anne-Marie and I are both feeling ready for a break. I am feeling the need for time to integrate, to mull, to write, to hunker down and process all that we've seen and learned in our 5 weeks here in Uganda. Being in the midst of it, up to our elbows in amniotic fluid, meconium, blood, and feces every day, I've found it hard to really contemplate how maternity care in Uganda impacts women, babes, and the people who work as midwives, doctors, and nurses in this system. You know, it's been very easy to focus on the ways that maternity care here could/should improve, but we were also acknowledging today that here in Kampala, there are many things that are being done well. Almost all the women we see have been for at least one antenatal appointment, where they've been screened for HIV and determined to be high or low risk. If they are HIV positive, they have access to treatment. If they're considered low risk, they are sent to Ward 14, Upper Mulago, to have their babies. And this screening seems to be quite accurate. In our week and a half working in Ward 14, we've yet to see a woman with gestational hypertension present in pregnancy, twins, breech, or any other complex care needs come through our door. Those women have been screened out and sent to the high risk ward at New Mulago. So almost every birth we've seen on Ward 14 has been straight-forward, normal - no postpartum hemorrhage, no seizures, no malpresentations. So that's something that here in Kampala, seems to be working relatively well.

The question is, what sort of care do the high-risk women get at New Mulago? We occasionally walk past the high risk ward and see the women lining the halls, throngs of people outside the entrance, many of them attendants for the overwhelming numbers of women inside. Today we thought we would spend an afternoon on the high risk ward to try and get some resuscitation experience as we haven't had much opportunity to resuscitate babies on Ward 14. There is a resuscitation room where babes are brought after birth if they are having trouble getting started. Cathy had suggested, on taking her leave from Uganda, that if we were to return to the high risk ward we should restrict ourselves to doing resuscitation only, as you never know what you might get sucked into on that ward. The need is so great, the staff obviously too few, and many of the cases fairly complex. There was no guarantee that if we were suddenly faced with a difficult case that we would be able to find someone to back us up. So after checking in with the "in-charge", we ensconsed ourselves in the resus room, with a copy of the ALARM manual (emergency obstetrics manual) to pass the time, and waited for a baby. It didn't take too long. Shortly after our arrival, a babe was deposited on the vinyl-covered pad by a nursing student who quickly took her leave. We were left to assess this wee boy. He was limp, not breathing, was dusky, meconium was obviously present, and he had a strange smell about him. The smell reminded me of the smell of the macerated still-born babe I caught in Masaka - a smell that isn't healthy, shouldn't be associated with a normal birth. But this babe was alive, with a heart rate of 110 - he needed a little jumpstart. So we ventilated him and his heart rate remained stable, but he wasn't really making any effort to breathe himself, so we carried on with ventilation - "breathe little baby, breathe little baby" - the mantra of Neonatal Resuscitation running through my head. Eventually he started making some breathing efforts but he was still so limp and sounded really mucousy. The wall suction didn't seem to be working so I used a bulb syringe (never seen in Canada any more but the main resuscitation aid here in Uganda) to try to clean some of the muck out of his mouth and nose. Finally Anne-Marie got the wall suction working, but there was no flexible tubing to attach to it in order to suction out his pharynx so we did the best we could with the rigid plastic attachment. Looking back on it, perhaps we should have suctioned his mouth before starting ventilation, but I think if he'd started crying or coughing or sneezing with the ventilation, he would have cleared his own lungs. I certainly felt my lack of experience during this resus but he did eventually come around, and after about 2 minutes of ventilation, plus the suction and some more stimulation, his tone was better, his heart rate was 130, and he was breathing on his own. But I'd give that baby an apgar of 7 at 5 minutes. But what about the smell that I mentioned? I think his mother was probably infected and that babe most likely should have IV antibiotics.

As we were trying to arrange for him to go to the special care nursery for further monitoring, we discovered that his mother (and the midwife and students attending her) were waiting for his twin to be born. It's so hard to describe the chaos of New Mulago. The attending midwife comes in, takes a quick look at the baby, says he's fine and doesn't need to go to special care. Our comments about infection, ongoing gurgly lungs, seem to fall on deaf ears as she heads back to attend to the mother. We're told to wrap the babe up in another cloth and leave him in a cot. As this is transpiring, Anne-Marie hears a woman calling for a midwife. She walks by the cubicle where the woman is labouring. The woman is obviously pushing. Then the head is visible. There's no midwife in sight. Anne-Marie calls for an attendant. No one comes. We weren't going to catch babies at New Mulago but if Anne-Marie doesn't put on her gloves and catch, this babe will have no hands to receive it as it makes its entrance. So Anne-Marie catches. And the woman has a postpartum hemorrhage. And we're not sure if the blood is coming from the uterus because it's well contracted but the blood keeps gushing out. She definitely has a second degree perineal tear but that's not where the blood is coming from. Cervical tear? By this time, there are a couple of interns also on the scene, trying to figure out where this blood is coming from. We hang normal saline with oxytocin. The blood slows but gushes whenever you massage her uterus. The interns don't think there's a cervical tear and in the end decide it was uterine blood. It seems to ease after 15 minutes or so and we leave the interns to repair her tear. We head back to the resuscitation room.

In the end, we didn't have any more resuscitations but Anne-Marie catches yet another baby due to absent midwives. How strange, that in a second stage room, with five beds, each containing a labouring mother, there is no midwife. How can that be? Are they so short-staffed? Are they ignoring the calls of help from mothers? Are they so over-worked, underpaid, and apathetic that their work no longer holds any reward or joy? I could see it happening but it still just seems so bizarre that women are left to labour and birth without the benefit of caregivers.

As for the wee babe we resuscitated, well, his mom was sent off for a C-section for delivery of the second twin. Apparently the second was presenting his face (deflexed head) and not coming down so she went for cesar (as they're called here). I doubt that he'll get antibiotics but I hope that someone assessed him after we left to make sure he was still holding his own.

Two days to go.

Heather