It has been quite busy on the wards, this week especially. I believe Jan has written about some of the crazy days we've had so I think I'll will write about the first stillbirth I attended.
When we came in Tuesday morning Georgia would not find a fetal heart on one women. By the way, here we use the pinard horn or and Allen fetoscope to monitor fetal hearts--no such luxury as the doppler. Anyway, so many of us listened and nobody could hear a fetal heart. The woman was sent for an ultrasound and it was confirmed that the baby had died. It was really sad for all of us to hear this news nad I image heartbreaking for this mom who had carried her baby to term and though she was coming here to birth her baby. The mama also had a fever by now. A blood smear was done to test for malaria which came back negative. Her membranes had only just ruptured the day before, but I guess the most likely cause of this baby's death was an infection (chorioamnionitis).
We put up an oxytocin drip to bring on contractions. This was in the late afternoon. She was also started on antibiotics. She evenutally started pushing spontaneously and by 5:30 she delivered a beautiful baby girl. She was perfect. There were no defects--nothing else to explain her passing away. Grace was with me and incredibly supportive as I did the catch and then brought the babe up to her mom's chest, which is what she had requested. I helped the mom hold her baby there for some time. I told her how well she had done and how strong she was and how sorry I was for her loss, and just stayed with her for some time. I then brought the baby to be weighed after which I gently placed the baby's limp arms across her chest and carefully wrapped her in a large forest green cloth and offered for the grandma to hold her but she declined, so I placed the baby on one of the tables on the ward and then went to say goodbye to the mom. Both she and her mom expressed thanks for our care.
As emotionally difficult as this birth was, both Grace and I were thankful that we were able to be there with her.
Friday, June 20, 2008
silver lining and birth on the wards at Masaka Regional Referral Hospital
So it has definitely been a busy week in Masaka. There is so much to say and share, where to begin...
So one of the things I wanted to add, is about my ray of hope with regard to the birthing practices here. Jan and I met two fabulous students who are doing their nurse-midwifery training. They are only just beginning the midwifery stage of their training and so they have been popping in on their spare time to the ward trying to absorb as much as they can. There have been a few students but Winnie and Carol are our favourites and so we've tried to take them under our wing to teach them what we know in exchange for them translating for us for the women who only speak Lugandan. I have found spending time with them and teaching them what I know to be so incredibly rewarding. Also, they are so keen and impressionable. This is where I feel there is the greatest hope for impressing upon them that treating a woman warmly, compassionately and respectfully in labour can accomplish so much more in a labour and delivery than being unkind. It has already been so amazing and rewarding watching them with women. I have turned around many a time from something I am doing in another part of the ward to see them holding a woman's hand, speaking kindly and gently to them or wiping their brow. I was attending a woman with Winnie earlier in the week and the labouring mama was in a fair bit of distress. At one point I saw Winnie holding her hand on woman's belly and rubbing it gently. Later Winnie told me the woman had asked her to do so. It was truly heartwarming to see. I have decided that besides modeling respect towards labouring women on the ward in general, I want to work with these students as much as I can as I feel this is where there is great potential to plant seeds that will most likely germinate and flourish.
So besides the silver lining of these students, I wanted to share what life of the ward can be like. I will do my best to describe it although it may be difficult to believe as it is so far from the reality that I have come to know in Canada.
To begin with,as some women travel from far away villages to come birth their babies here and they may be in labour for days before they deliver, they bring at least one female attendant with them who can look after them by bringing them food and drink (as neither is provided by the hospital) doing their laundry, helping them wash etc. The attendants and other family members "camp out" on the hospital grounds awaiting the delivery of the baby. It can be days before that happens or up to a week or longer at times before this happens. As a result, there is often some washing to be done in the meantime and so walking on the grounds we'll see clothing and sheets strewn about out on the grass, drying in the sun.
So the labour ward had 3 beds. There are green curtains strung up on thicker wire that is attached at each end of the room in between the beds. There is and another curtain strung behind the desk (which is literally a desk, not a nursing station) and this is virtually the extent of the privacy women get. As I mentioned in an earlier blog, some of the windows have broken glass and others broken screens. As the building in ground level, I often how much people on the outside can see in, particularly at night when the lights are on. Anyway, this ward is an all-in one type of ward. There are no toilets or showers perse, however, the women either squat directly on the floor to do their business or use a basin that then gets poured into the floors drains that line the perimeter of the room.
The matresses in labour and delivery are covered with a thick canvas and on top of that sits another piece of canvas that covers the bed. Women are supposed to bring another long piece of plastic with them that covers the bed. They labour and birth their babies on this plastic. They are also supposed to bring cloths that we use to dry the babes off with when they are born and then to wrap them into to keep them warm. In terms of supplies for a straightforward birth, we use 2 pairs of gloves (which in Kampala women are expected to bring with them), 3 ends of latex gloves (the rolled rim at the wrist) to tie off the cord and a razor blade to cut the cord with. We often scurry around trying to find oxytocin and a syringe so we can do active management for the placental delivery. We use paper left over from glove wrappers to wipe away any bowel movements that are passed during birth. Cotton that comes of a big roll is used to wipe the baby's face if need be, to inspect the perineum for tears and a larger piece is torn off and rolled to be used as a pad for the women postpartum. After women birth their babies we pour cool water (because that's all we have) into plastic basins, give them some soap if they haven't brought any with them and they wash themselves on one side of the room by the drain (no curtain) either on their own or with the assistance of their attendant on one side of the room beside the drain. We then accompany them to the postpartum ward where there are 40 beds, where we settle them in and check on their vitals and bleeding before we leave them in the care of the staff (and their attendants) there.
For labours that are more complicated and require and IV or a urinary catheter, we are often running around trying to find all that we need. This is particularly frustrating when time is of the essence. Sometimes, the supplies we need are not available and so attendants are asked to go and buy IVs, saline solution, administration sets, urinary catheters or even medication! When we feel we don't have the time to wait, or know that fa miles cannot afford the supplies we run to our stash and use some of the emergency back-up supplies we brought.
In terms of wards, there are 2 wards of 40 beds each (one if early labour/antenatal, the other is postpartum) and then the first stage room and labour and delivery room. These are more often then not full and, on some days they are staffed with as few as 2 nurse-midwives to cover all these areas. It's wild! No wonder so many of them are burned out. At times it seems like assembly line work with all the women there are to care for--because the wards aren't staffed adequately. It sure brings different meaning to staffing shortages. Oh and if I have heard correctly the midwives here get 150 USD per month!
So one of the things I wanted to add, is about my ray of hope with regard to the birthing practices here. Jan and I met two fabulous students who are doing their nurse-midwifery training. They are only just beginning the midwifery stage of their training and so they have been popping in on their spare time to the ward trying to absorb as much as they can. There have been a few students but Winnie and Carol are our favourites and so we've tried to take them under our wing to teach them what we know in exchange for them translating for us for the women who only speak Lugandan. I have found spending time with them and teaching them what I know to be so incredibly rewarding. Also, they are so keen and impressionable. This is where I feel there is the greatest hope for impressing upon them that treating a woman warmly, compassionately and respectfully in labour can accomplish so much more in a labour and delivery than being unkind. It has already been so amazing and rewarding watching them with women. I have turned around many a time from something I am doing in another part of the ward to see them holding a woman's hand, speaking kindly and gently to them or wiping their brow. I was attending a woman with Winnie earlier in the week and the labouring mama was in a fair bit of distress. At one point I saw Winnie holding her hand on woman's belly and rubbing it gently. Later Winnie told me the woman had asked her to do so. It was truly heartwarming to see. I have decided that besides modeling respect towards labouring women on the ward in general, I want to work with these students as much as I can as I feel this is where there is great potential to plant seeds that will most likely germinate and flourish.
So besides the silver lining of these students, I wanted to share what life of the ward can be like. I will do my best to describe it although it may be difficult to believe as it is so far from the reality that I have come to know in Canada.
To begin with,as some women travel from far away villages to come birth their babies here and they may be in labour for days before they deliver, they bring at least one female attendant with them who can look after them by bringing them food and drink (as neither is provided by the hospital) doing their laundry, helping them wash etc. The attendants and other family members "camp out" on the hospital grounds awaiting the delivery of the baby. It can be days before that happens or up to a week or longer at times before this happens. As a result, there is often some washing to be done in the meantime and so walking on the grounds we'll see clothing and sheets strewn about out on the grass, drying in the sun.
So the labour ward had 3 beds. There are green curtains strung up on thicker wire that is attached at each end of the room in between the beds. There is and another curtain strung behind the desk (which is literally a desk, not a nursing station) and this is virtually the extent of the privacy women get. As I mentioned in an earlier blog, some of the windows have broken glass and others broken screens. As the building in ground level, I often how much people on the outside can see in, particularly at night when the lights are on. Anyway, this ward is an all-in one type of ward. There are no toilets or showers perse, however, the women either squat directly on the floor to do their business or use a basin that then gets poured into the floors drains that line the perimeter of the room.
The matresses in labour and delivery are covered with a thick canvas and on top of that sits another piece of canvas that covers the bed. Women are supposed to bring another long piece of plastic with them that covers the bed. They labour and birth their babies on this plastic. They are also supposed to bring cloths that we use to dry the babes off with when they are born and then to wrap them into to keep them warm. In terms of supplies for a straightforward birth, we use 2 pairs of gloves (which in Kampala women are expected to bring with them), 3 ends of latex gloves (the rolled rim at the wrist) to tie off the cord and a razor blade to cut the cord with. We often scurry around trying to find oxytocin and a syringe so we can do active management for the placental delivery. We use paper left over from glove wrappers to wipe away any bowel movements that are passed during birth. Cotton that comes of a big roll is used to wipe the baby's face if need be, to inspect the perineum for tears and a larger piece is torn off and rolled to be used as a pad for the women postpartum. After women birth their babies we pour cool water (because that's all we have) into plastic basins, give them some soap if they haven't brought any with them and they wash themselves on one side of the room by the drain (no curtain) either on their own or with the assistance of their attendant on one side of the room beside the drain. We then accompany them to the postpartum ward where there are 40 beds, where we settle them in and check on their vitals and bleeding before we leave them in the care of the staff (and their attendants) there.
For labours that are more complicated and require and IV or a urinary catheter, we are often running around trying to find all that we need. This is particularly frustrating when time is of the essence. Sometimes, the supplies we need are not available and so attendants are asked to go and buy IVs, saline solution, administration sets, urinary catheters or even medication! When we feel we don't have the time to wait, or know that fa miles cannot afford the supplies we run to our stash and use some of the emergency back-up supplies we brought.
In terms of wards, there are 2 wards of 40 beds each (one if early labour/antenatal, the other is postpartum) and then the first stage room and labour and delivery room. These are more often then not full and, on some days they are staffed with as few as 2 nurse-midwives to cover all these areas. It's wild! No wonder so many of them are burned out. At times it seems like assembly line work with all the women there are to care for--because the wards aren't staffed adequately. It sure brings different meaning to staffing shortages. Oh and if I have heard correctly the midwives here get 150 USD per month!
Fundraising Enquiries
I have to describe the frustrations we have with the lack of supplies. Basic necessities like IV cannulas, administration sets, normal saline, oxytocin, antibiotics, and urinary catheters are SOMETIMES available. Each day is different as to what supplies are available. On Thursday, we were using the IV cannulas we brought, but there were no administration sets, or antibiotics, or foley catheters. We try to save the foleys we brought for those women heading to theatre, otherwise you improvise, eg pediatric feeding tubes are used as catheters - does that ever take a long time to empty a bladder! When you have a sick woman, or when you might want to do something quickly, often you can't because there are no supplies. So then we have to find the woman's attendants plus someone who can speak Lugandan, to tell them that they must go to the pharmacy to purchase the drugs or supplies that are needed. Often people don't have the money, so then they are calling on friends and relatives. Often women don't get the antibiotics they need. Somedays we have hibitane in a bucket for cleansing - other days we don't. So on the days we don't, we are cleansing with plain water. We are running out of the oxytocin we brought with us.
Lydia and I have had long discussions about fundraising. We have had a number of email enquiries from friends and family about how to contribute the work we are doing. For those of you who are able and feel inclined to donate to this cause here is a list of needs:
- 12 mattresses to be replaced/recovered - $30 each
- 4 hospitals in need of an infant bag and mask ~ $200 each
- oxytocin, catheters, IV cannulas, administration sets are all available to be purchased locally.
If you are interested in making a donation please contact Lydia or Jan through the blog or email.
Thanks for all the support you are giving us. Hearing from people back home makes our day. - Jan & Lydia
Lydia and I have had long discussions about fundraising. We have had a number of email enquiries from friends and family about how to contribute the work we are doing. For those of you who are able and feel inclined to donate to this cause here is a list of needs:
- 12 mattresses to be replaced/recovered - $30 each
- 4 hospitals in need of an infant bag and mask ~ $200 each
- oxytocin, catheters, IV cannulas, administration sets are all available to be purchased locally.
If you are interested in making a donation please contact Lydia or Jan through the blog or email.
Thanks for all the support you are giving us. Hearing from people back home makes our day. - Jan & Lydia
Thursday, June 19, 2008
Busy Times and Harsh Realities
We had quite the day Monday at the hospital. I was there with our instructor Grace and Celina. We each conducted 3 births before lunch with the last 2 babies being born at 12:00 (mine) and 12:01 (Celina's). It was crazy. I started with a gravida 6, then a gravida 5 came in and Sal (Celina) took her on. While we were dealing with those two, the Sisters kept bringing more women into the room. There are only 3 beds, so we put one of them in a bed and the other 3 stood around the desk moaning and contracting. The first was born at 10 am (Sal's), then my G6 at 10:30 (with a prolapsing cervix and shoulder dystocia - that baby was huge 4.3 kgs!), As we were trying to clean beds and assess women the next one delivered on the floor (Sal attended her). We did have her on a bed but even though she was fully and pushing, the Sister told us to move her off the bed as she was a PG (primagravida). That floor birth was at 10:45. One of the new women on a bed we were told to prepare for section, as she had had a previous section for cephalopelvic disproportion and a subsequent vaginal birth where the baby had died in the delivery. She had come in fully and pushing and we could see bulging membranes on the perineum. I took a fetal heart; it was 100 bpm. I examined her and the head was low with no caput and her pelvis seemed adequate, so I asked my instructor "Shouldn't we just get her pushing?" The answer was in the affirmative. Her baby delivered at 11:15 - a live newborn male. He too had a shoulder dystocia and I'm glad Grace was there to help me with the manoeuvres. We used our delivery set on that birth for a quick cord clamp and cut rather than the usual tying the cord with the rims of our gloves and cutting with a razor blade. We took the baby to the resus area and gave him 20 - 30 secs of PPV then he started crying. Meanwhile, the woman who had delivered on the floor was now having a postpartum hemorrhage and we turned a bed around quickly to get her in it and stabilized with IV oxytocin in normal saline. We had a few minutes to clean beds and assess a few more women then we were catching the last two of the morning. We cleaned up again, took a few moments to say "WOW!" and decided we had earned lunch at the canteen. We came back to the ward with the intent of checking over all the moms and babes we'd attended that morning and then calling it a day. I saw two of my mom/baby pairs then was called into the labour room. A woman was brought in from home where she'd been labouring for a couple of days. Actually she was carried in by her friends. Part of the story was that she'd been pushing and was obstructed and that she should be prepared for the theatre. I examined her and her cervix was 7cm dilated, not swollen as I'd expect with a history of pushing for a long time. Her pelvis seemed adequate. She was a G3 P1 A1. With a previous vaginal birth, we decided to tell her to not push and set up an IV with oxytocin as her contractions were very infrequent. Her 2 friends stayed in the labour room and I was okay with it was one of them spoke English well and said that she was a student nurse. The translation part was good, but the student nurse part was a pain. She had her fingers in everything, including sticking them in the woman's vagina while I was doing a vaginal exam. I repeatedly told her "don't do that". Eventually the woman was fully dilated and I told her she could push and I was horrified by what her friends did next. The largest one clamped a hand over the woman's mouth - to keep her from making noise I suppose. I was seriously concerned that she couldn't breath and again said "No - no , we don't do that to women. We respect them." Then the student nurse friend was pushing on her fundus - again I had to chase her hands away. I was concerned that this woman might run out of steam and the Sisters were questioning why I hadn't sent her to surgery, so I wanted to get her delivered sooner rather than later. I got her friends to get her up in a squat on the bed and she brought the baby down nicely. I said they could let her lie down for the delivery but as soon as this woman was on her back and pushing she gave up again and her friends were up to their tricks again. I think they thought they could squish the baby out of her. I made them get her in a squat again because they couldn't do anything to her when she was squatting and I was tired of fending them off. The next contraction the head was crowning and then she was slowly lowered to the bed. A very nice delivery at the end. Throughout the labour, the student nurse friend was translating and telling me that the woman was asking for a c/sec and then an episiotomy. After the birth, I teased her "You asked me for a Caesar and I said 'No', then you asked me to cut you and I said 'No'. See you could do it! Aren't you glad I didn't say 'Yes'?" She and her friends laughed and laughed. She then went on to bleed more than I was happy with, so I emptied her bladder with a catheter and she stabilized, but then minutes later they asked to go home, as all 3 of them had other kids at home. I told them not after that bleed. I told them they could ask one of the Sisters to reassess after the IV oxy had run through, but suspected they might have just disconnected it and left when they wanted to. That is our current record for births in one shift - 8!
At the end of the day one of the Sisters called us to come and help with a woman who was very sick and anemic. She'd been brought in by taxi. Grace told Sal and I to stay and finish charting. She returned moments later for her stethoscope. The woman, with what looked like a near term pregnancy, was dead. We were told later that she'd gone to another hospital. She needed a blood transfusion, but they had none so she was she to Masaka Hospital. She was driven directly to the blood bank but when they saw that she was pregnant, she was sent to the Labour Ward. She died in transit, and was probably already dead when they reached the blood bank. This would not be the last death of the week.
Tuesday, I assisted Cathy and Mickey at the ALARM International Training with the local doctors and midwives. It was good to review the ALARM program again, and to see the adaptations for International obstetrics. Lydia was on the Ward with Georgia. It was not quite as busy but there was a term stillbirth to deal with it. Georgia was the first person to assess her, and was unable to find a fetal heart. The fetal demise was confirmed by ultrasound. The UBC students and Grace supported this woman through her delivery. I think Lydia will post more about that experience.
On Wednesday, I was at the Labour Ward with Lydia. (With 4 students here, we have set up a rotating schedule for the Labour Ward, Antenatal Clinic and assisting with the ALARM program which runs all week.) It was not quite as hectic as Monday was, but each of Lydia, Grace and I had two catches that day. The most interesting was the last birth of the day that Grace did. We had been at the canteen for lunch and one of the doctors informed us that there was a Gravida 8 in the case room, fully dilated with a breech presentation, and maybe twins. This was definately one for Grace, but Lydia and I were excited to assist her. We set up an IV quickly, reviewed breech deliveries and watched as the presenting part slowly dilated the perineum. As more was visible, we were trying to figure out just what we were looking at ... was it labia? was it the butt cleft? Then as few more millimeters were visible and we all reached the same conclusion at the same time - it was a FACE presentation! Once we were all oriented the birth progressed quickly. Grace delivered the vertex and the body soon followed. A not so little girl, 3.6 kgs, with a very swollen face. We checked for a twin, which the doctor had suggested, but she just had a big bulky uterus - I guess Gravida 8 will do that to you. Again as we were attempting to clean up and leave for the day, I was approached by a woman in the hallway. She spoke English well and told me she had come from the post-cesarean ward. A woman there was in bad shape and there was no Sister on the ward. I thought to myself that there wouldn't be much that I could do, other than find a Sister. I convinced one of the Sisters from the postpartum ward to come. She was very busy and didn't want to, but she did come. Eventually, Grace came as well. When I saw the woman she was thrashing on her bed while others tried to keep her from falling off. A nursing student tried to get a BP on her, but couldn't. Grace eventually got a BP of 70/40. A doctor did come to see her and ordered blood. We found out the next morning that she died during the night. We don't know if it was blood loss, or sepsis or ?
Thursday all students and instructors were at the ALARM course to assist with the ALARM exam and OSCEs. I have to say that I enjoyed assisting with OSCEs much more than I did participating in them last January. It was interesting to note that the experienced midwives were all as nervous as the students had been, which was understandable as they were learning a lot of new content.
We finished with the exams around lunchtime. Sal wasn't feeling well so she opted to have a quiet day back at the hotel. Grace, Georgia, Lydia and I went to the Labour Ward to spend a few hours. When we got there, the Sisters told us that it had been quiet. It seems that the universe was waiting for us to arrive, because it was anything but quiet that afternoon. Lydia and Georgia were attending two women who looked like they might deliver soon. I was triaging patients in the First Stage room. One of the doctors called me to admissions to set up an IV on a very, very sick woman. She had malaria and wasn't conscious. I set up her IV with 5% dextrose and the doctor added quinine. I checked on her a couple of times before we left. I was not sure that she would make it through the night. I've asked Georgia to follow up today, but I'm not hopeful she's alive. Then we had 3 women arrive on stretchers within 20 minutes. The first one I bumped into in the hall, on my way back from admissions. She's fully and pushing I was told. I helped them move the stretcher to the Ward and called in that I had someone for the last available bed. I asked the attendants if the woman could walk and they said no, the baby's almost out. My heart skipped a beat, and quickly pulled up her skirts, fearing to see a head out, but it wasn't that - but it was ugly. She'd been pushing for 6+ hrs at home. She was grossly edematous and someone had cut her in an attempt to get the baby out - a "do-it yourself episiotomy when the baby was no where near the perineum - gross. Grace managed the assessment of this woman. She was febrile, we set up an IV and asked for antibiotics. A catheter drained 750+ mls from her bladder, pushing was given a short trial, but it was apparent she need to go to theatre. The fetal heart was good when assessed, around 120 - 130. Grace followed this woman to the OR to be there to resuscitate the baby. Grace told us later it was another hour wait to get into the OR. The baby was flat when delivered. Grace did the resus, and said the baby always had a heart rate of 120 - 130, but never breathed on its own. She bagged the baby for over an hour, (eventually the anesthetist brought over a pediatic laryngoscope so the baby could be intubated), then brought the baby to the nursery (in her arms while bagging) to get one of the Sisters to place an IV and give the baby dextrose. The baby had not only a huge amount of moulding and caput, but you could see that the head was very swollen. One of the Sisters called the baby a "Cabbage" - I'm not sure if that term has the same connotations for Ugandas as it would for Canadians, but at the time, I was sure that's what she meant. Once given some glucose, the baby seemed to rally some; and was extubated and breathing on his own. However, he expired within the next hour. It is harsh and sad, but perhaps it was a blessing for that mother as it appeared that he had some significant brain damage.
We sent 3 women to theatre that afternoon - lots of IV and catheter experience. Lydia and Georgia had gone back to the hotel and I was waiting for Grace to finish with the baby. I went into the labour ward to do some notes and noticed that one of the women we'd been attending was pushing and head was visible on the perineum. There were no Sisters in the room, and this woman did have an oxytocin drip. I gloved up and prepared for the birth as there was no one else around. Grace came in a few minutes later and we decided we would attend this last birth then go home. There are many more detail about this birth, but I'm running out of internet minutes, so I'll cut to the chase ... a shoulder dystocia. We'd had a number through the week, and Grace had taken over on those and delivered. This time she said, Jan, you are going to deliver this one. I tried the manoevres, but could not budge that baby. I told Grace to take over and she couldn't move the baby. Grace asked me to get help. I called the Sisters and one came and pulled the baby out by its head. He needed resus, but he did slowly come around. We are worried about a brachial plexus injury, but at least he's out and breathing.
That was our busy, eventful week. Maternal and fetal mortality is a harsh fact of obstetrics here. We leave the hospital every evening feeling quite exhausted. We have a debriefing over a quiet dinner in the evening, then try to catch up on journaling and fall into bed to rest up for the next day. Lydia and I will have a few days off to rest and recouperate. We will be visiting traditional birth attendants in a nearby village on Monday. There are some loose plans for the weekend, but we might just enjoy some quite time.
Thanks for all the emails. - Jan
At the end of the day one of the Sisters called us to come and help with a woman who was very sick and anemic. She'd been brought in by taxi. Grace told Sal and I to stay and finish charting. She returned moments later for her stethoscope. The woman, with what looked like a near term pregnancy, was dead. We were told later that she'd gone to another hospital. She needed a blood transfusion, but they had none so she was she to Masaka Hospital. She was driven directly to the blood bank but when they saw that she was pregnant, she was sent to the Labour Ward. She died in transit, and was probably already dead when they reached the blood bank. This would not be the last death of the week.
Tuesday, I assisted Cathy and Mickey at the ALARM International Training with the local doctors and midwives. It was good to review the ALARM program again, and to see the adaptations for International obstetrics. Lydia was on the Ward with Georgia. It was not quite as busy but there was a term stillbirth to deal with it. Georgia was the first person to assess her, and was unable to find a fetal heart. The fetal demise was confirmed by ultrasound. The UBC students and Grace supported this woman through her delivery. I think Lydia will post more about that experience.
On Wednesday, I was at the Labour Ward with Lydia. (With 4 students here, we have set up a rotating schedule for the Labour Ward, Antenatal Clinic and assisting with the ALARM program which runs all week.) It was not quite as hectic as Monday was, but each of Lydia, Grace and I had two catches that day. The most interesting was the last birth of the day that Grace did. We had been at the canteen for lunch and one of the doctors informed us that there was a Gravida 8 in the case room, fully dilated with a breech presentation, and maybe twins. This was definately one for Grace, but Lydia and I were excited to assist her. We set up an IV quickly, reviewed breech deliveries and watched as the presenting part slowly dilated the perineum. As more was visible, we were trying to figure out just what we were looking at ... was it labia? was it the butt cleft? Then as few more millimeters were visible and we all reached the same conclusion at the same time - it was a FACE presentation! Once we were all oriented the birth progressed quickly. Grace delivered the vertex and the body soon followed. A not so little girl, 3.6 kgs, with a very swollen face. We checked for a twin, which the doctor had suggested, but she just had a big bulky uterus - I guess Gravida 8 will do that to you. Again as we were attempting to clean up and leave for the day, I was approached by a woman in the hallway. She spoke English well and told me she had come from the post-cesarean ward. A woman there was in bad shape and there was no Sister on the ward. I thought to myself that there wouldn't be much that I could do, other than find a Sister. I convinced one of the Sisters from the postpartum ward to come. She was very busy and didn't want to, but she did come. Eventually, Grace came as well. When I saw the woman she was thrashing on her bed while others tried to keep her from falling off. A nursing student tried to get a BP on her, but couldn't. Grace eventually got a BP of 70/40. A doctor did come to see her and ordered blood. We found out the next morning that she died during the night. We don't know if it was blood loss, or sepsis or ?
Thursday all students and instructors were at the ALARM course to assist with the ALARM exam and OSCEs. I have to say that I enjoyed assisting with OSCEs much more than I did participating in them last January. It was interesting to note that the experienced midwives were all as nervous as the students had been, which was understandable as they were learning a lot of new content.
We finished with the exams around lunchtime. Sal wasn't feeling well so she opted to have a quiet day back at the hotel. Grace, Georgia, Lydia and I went to the Labour Ward to spend a few hours. When we got there, the Sisters told us that it had been quiet. It seems that the universe was waiting for us to arrive, because it was anything but quiet that afternoon. Lydia and Georgia were attending two women who looked like they might deliver soon. I was triaging patients in the First Stage room. One of the doctors called me to admissions to set up an IV on a very, very sick woman. She had malaria and wasn't conscious. I set up her IV with 5% dextrose and the doctor added quinine. I checked on her a couple of times before we left. I was not sure that she would make it through the night. I've asked Georgia to follow up today, but I'm not hopeful she's alive. Then we had 3 women arrive on stretchers within 20 minutes. The first one I bumped into in the hall, on my way back from admissions. She's fully and pushing I was told. I helped them move the stretcher to the Ward and called in that I had someone for the last available bed. I asked the attendants if the woman could walk and they said no, the baby's almost out. My heart skipped a beat, and quickly pulled up her skirts, fearing to see a head out, but it wasn't that - but it was ugly. She'd been pushing for 6+ hrs at home. She was grossly edematous and someone had cut her in an attempt to get the baby out - a "do-it yourself episiotomy when the baby was no where near the perineum - gross. Grace managed the assessment of this woman. She was febrile, we set up an IV and asked for antibiotics. A catheter drained 750+ mls from her bladder, pushing was given a short trial, but it was apparent she need to go to theatre. The fetal heart was good when assessed, around 120 - 130. Grace followed this woman to the OR to be there to resuscitate the baby. Grace told us later it was another hour wait to get into the OR. The baby was flat when delivered. Grace did the resus, and said the baby always had a heart rate of 120 - 130, but never breathed on its own. She bagged the baby for over an hour, (eventually the anesthetist brought over a pediatic laryngoscope so the baby could be intubated), then brought the baby to the nursery (in her arms while bagging) to get one of the Sisters to place an IV and give the baby dextrose. The baby had not only a huge amount of moulding and caput, but you could see that the head was very swollen. One of the Sisters called the baby a "Cabbage" - I'm not sure if that term has the same connotations for Ugandas as it would for Canadians, but at the time, I was sure that's what she meant. Once given some glucose, the baby seemed to rally some; and was extubated and breathing on his own. However, he expired within the next hour. It is harsh and sad, but perhaps it was a blessing for that mother as it appeared that he had some significant brain damage.
We sent 3 women to theatre that afternoon - lots of IV and catheter experience. Lydia and Georgia had gone back to the hotel and I was waiting for Grace to finish with the baby. I went into the labour ward to do some notes and noticed that one of the women we'd been attending was pushing and head was visible on the perineum. There were no Sisters in the room, and this woman did have an oxytocin drip. I gloved up and prepared for the birth as there was no one else around. Grace came in a few minutes later and we decided we would attend this last birth then go home. There are many more detail about this birth, but I'm running out of internet minutes, so I'll cut to the chase ... a shoulder dystocia. We'd had a number through the week, and Grace had taken over on those and delivered. This time she said, Jan, you are going to deliver this one. I tried the manoevres, but could not budge that baby. I told Grace to take over and she couldn't move the baby. Grace asked me to get help. I called the Sisters and one came and pulled the baby out by its head. He needed resus, but he did slowly come around. We are worried about a brachial plexus injury, but at least he's out and breathing.
That was our busy, eventful week. Maternal and fetal mortality is a harsh fact of obstetrics here. We leave the hospital every evening feeling quite exhausted. We have a debriefing over a quiet dinner in the evening, then try to catch up on journaling and fall into bed to rest up for the next day. Lydia and I will have a few days off to rest and recouperate. We will be visiting traditional birth attendants in a nearby village on Monday. There are some loose plans for the weekend, but we might just enjoy some quite time.
Thanks for all the emails. - Jan
Thursday, June 12, 2008
labour ward experiences in Masaka
So we are now in Masaka, which is quieter and less polluted though I would not call it rural. The walk to work is much more enjoyable and we are less likely to be run over by cars or boda-bodas (scooters). On Monday's walk there we stopped to watch curious monkeys swinging in the tress-both adults and baby monkeys. It was very sweet. And besides, how often can you say you see monkeys on your way to work.
So once we arrived at the hospital and began our day we were in for even more of a rude awakening. It happened to be a holiday after a weekend and there was lots going on. So much that it is difficult to keep track of all that happens through the day. The facility is even older and more basic than at Mulago Hospital in Kampala. Here the window screens are broken as are some of the windows, so shooing away flies is now part of our care for women in labour. The delivery ward has three beds and as there is no high risk ward, so all cases are brought to this room. It is somewhat disorganized, and unfortunately there is no method to the madness here. Assessments on women appear to be somewhat sporadic. There is no partogram used. And so there can be women in labour for days before someone realizes they have an obstructed labour and need a consult or help. There is no such luxury as 1 to 1 care in the public hospitals in Uganda. Here you get what you get and it depends on how busy things are, how many directions the staff are pulled in and whether the supplies you need are available when you need them. Although basic supplies such as urinary catheters, IV cannulas, oxytocin for active management, IV fluids, disinfectant wash and other such supplies should be readily available, it is amazing how often they are not. It is also exhausting and incredibly frustrating trying to track them down when you need them ASAP. At times, we have ran back to our packs to grab a few of these supplies we brought with us just in case. Thank goodness we have them with us. Although we do not have an endless supply and we have already run out of the oxytocin we brought with us.
Such is the reality of working in an under-resourced public hospital here in Uganda. It makes everyone's work so much more complicated and what contributes to the increased infant and mortality rate here. On Monday when we toured the ward, on a small concrete shelf lay wrapped bodies of babes and fetuses that had died the night before. Thankfully we have not witnessed a death of a mom or a babe yet ourselves although there have been a few that we were not sure would make it.
Today I went to the "theatre" (OR) with Cathy (instructor) to receive the infants of two of the mothers we had attended in labour who had an obstructed labour. It was such a contrast to what the ORs are like at home. My heart was pounding as I watched the procedure, just hoping all would be fine with the mom and babes. We set up our resuscitation area in anticipation of the newborns needing assistance breathing. We fund a bag with a mask attached that was more suitable for a toddler. The table we were working with was significantly slanted and we decided if the babies needed assistance we would place them across the table to avoid the incline. That still made for an uneven work surface for us, which made the resuscitation that was needed for both babes a challenge. However, Cathy has been here many times and resuscitated many a baby and so she knows the ropes and works with what we've got and then we just hope for the best.
Here after a baby is pulled out of the incision (feet first, not head first as as home) he or she is hung upside down, held by the ankles and bounced a few times, until its cord is cut. Perhaps this is done because it is believed it will expel some of the amniotic fluid--I am not certain but it is difficult to watch. Although Cathy asked for them not to do this for the first baby, it was still done for the second. Change takes time, I suppose, as well as education. So anyway, the amniotic fluid of the second baby was filled with a pea-soup like meconium and as I received the baby on a towel in my arms I smelled a foul odour. In addition to the meconium, this baby had an infection. Although in Canada we would have intubated and suctioned the meconium, there are no such supplies here. So we used the bag and mask on the babe and eventually, after a long 7 minutes, he took his first breath. Apgars were 2, 4 and 7 on this little one. He was still rather limp but at least he was breathing. He would certainly need antibiotics if he was going to stand a chance. Cathy advocated for this although the staff in the OR were not on board for Cathy to bring this baby to get treated immediately, they said they would do this in time.
So that is just a snip-it of some of the adventures and obstetric culture shock I have been experiencing. There is so much to share but so little time. I will do what I can over e-mail and fill in the rest upon my return home.
So once we arrived at the hospital and began our day we were in for even more of a rude awakening. It happened to be a holiday after a weekend and there was lots going on. So much that it is difficult to keep track of all that happens through the day. The facility is even older and more basic than at Mulago Hospital in Kampala. Here the window screens are broken as are some of the windows, so shooing away flies is now part of our care for women in labour. The delivery ward has three beds and as there is no high risk ward, so all cases are brought to this room. It is somewhat disorganized, and unfortunately there is no method to the madness here. Assessments on women appear to be somewhat sporadic. There is no partogram used. And so there can be women in labour for days before someone realizes they have an obstructed labour and need a consult or help. There is no such luxury as 1 to 1 care in the public hospitals in Uganda. Here you get what you get and it depends on how busy things are, how many directions the staff are pulled in and whether the supplies you need are available when you need them. Although basic supplies such as urinary catheters, IV cannulas, oxytocin for active management, IV fluids, disinfectant wash and other such supplies should be readily available, it is amazing how often they are not. It is also exhausting and incredibly frustrating trying to track them down when you need them ASAP. At times, we have ran back to our packs to grab a few of these supplies we brought with us just in case. Thank goodness we have them with us. Although we do not have an endless supply and we have already run out of the oxytocin we brought with us.
Such is the reality of working in an under-resourced public hospital here in Uganda. It makes everyone's work so much more complicated and what contributes to the increased infant and mortality rate here. On Monday when we toured the ward, on a small concrete shelf lay wrapped bodies of babes and fetuses that had died the night before. Thankfully we have not witnessed a death of a mom or a babe yet ourselves although there have been a few that we were not sure would make it.
Today I went to the "theatre" (OR) with Cathy (instructor) to receive the infants of two of the mothers we had attended in labour who had an obstructed labour. It was such a contrast to what the ORs are like at home. My heart was pounding as I watched the procedure, just hoping all would be fine with the mom and babes. We set up our resuscitation area in anticipation of the newborns needing assistance breathing. We fund a bag with a mask attached that was more suitable for a toddler. The table we were working with was significantly slanted and we decided if the babies needed assistance we would place them across the table to avoid the incline. That still made for an uneven work surface for us, which made the resuscitation that was needed for both babes a challenge. However, Cathy has been here many times and resuscitated many a baby and so she knows the ropes and works with what we've got and then we just hope for the best.
Here after a baby is pulled out of the incision (feet first, not head first as as home) he or she is hung upside down, held by the ankles and bounced a few times, until its cord is cut. Perhaps this is done because it is believed it will expel some of the amniotic fluid--I am not certain but it is difficult to watch. Although Cathy asked for them not to do this for the first baby, it was still done for the second. Change takes time, I suppose, as well as education. So anyway, the amniotic fluid of the second baby was filled with a pea-soup like meconium and as I received the baby on a towel in my arms I smelled a foul odour. In addition to the meconium, this baby had an infection. Although in Canada we would have intubated and suctioned the meconium, there are no such supplies here. So we used the bag and mask on the babe and eventually, after a long 7 minutes, he took his first breath. Apgars were 2, 4 and 7 on this little one. He was still rather limp but at least he was breathing. He would certainly need antibiotics if he was going to stand a chance. Cathy advocated for this although the staff in the OR were not on board for Cathy to bring this baby to get treated immediately, they said they would do this in time.
So that is just a snip-it of some of the adventures and obstetric culture shock I have been experiencing. There is so much to share but so little time. I will do what I can over e-mail and fill in the rest upon my return home.
Friday, June 6, 2008
An Update from Masaka - we're not in Kansas anymore
At the end of the first week, I had yet to do my first catch and I was envious as Lydia had 3 and Georgia has had her first 4-handed catch. The first day on Ward 14, I tried to open a vial of oxytocin and the whole thing shattered between my thumb and forefinger. I had two very minor punctures, but Cathy sidelined me from the labour ward until it's healed. Probably wisest, but disappointing nonetheless.
Instead I went to the antepartum clinic with Sal. The clinic sees approximately 150 - 200 women a day. Just the number of women seen per day is overwhelming. At first Sal and I managed the blood pressure post. Honestly, I think that each of us took 75 - 100 bps that day. I was moved to one of the exam rooms with one of the midwives. Visits are quick. Each woman brings her piece of plastic to lay on the worn and torn mattress on the exam table. Fundal height is measured in fingerbreadths from the sternum. Fetal heart tones are listened to with a pinard horn. The rate is not measured, just the presence/absence of a fetal heart is recorded - few nurses or midwives have watches or clocks. Women have 4 prenatal visits during their pregnancy. I'm not sure when the first one is, but there are 2 after 14 wks, so that they can be given antimalarial treatment and immunized against tetanus. They are also treated for parasites and given iron supplements. The last visit is shortly before they are due.
This last weekend we spent at Mburo National Park. We stayed in very rustic bandas - had my own gecko beside my bed- which un-nerved me a bit. Perhaps it was the getting stuck in the mud when our driver chose a shortcut and we had to get out and stand by the vehicle while the van was unstucked. It was night time and our driver assured us "Don't worry, there are no lions." Okay - I was feeling close to nature and didn't sleep much that night and the lizard beside my bed didn't help. I kept thinking about Jennesse and how much she likes geckos, but I wasn't feeling the gecko love. We went on a Game Drive, on a boat in Mburo lake and on a Game Walk over the weekend and saw many animals - we have a list of over 50 animals and birds we sited. It was an amazing experience. We are now in Masaka while Georgia, Sal and Grace are back in Kampala. Both Lydia and I are looking forward to being in one place for a while.
We have spent 4 days on the labour ward in Masaka and well - Toto, we aren't in Kansas anymore. I had 3 catches this morning - two within 10 minutes of each other. There seems at times to be an endless stream of women in labour. We have seen several women with 2nd trimester losses. Two were delivered on the ward while we attended them. One had a PPH and retained placenta and Cathy successfully removed it. The other woman also had a retained placenta and needed to have it removed in the procedure room. The scarcity of supplies has been hard to deal with. We save all glove wrappers because its paper that we can use to wrap placentas in, clean away feces, etc. There are no extras here and sometimes there isn't what you need. There is no anesthetic for women in labour or for other procedures. Cesareans are performed under GA. I am amazed by how strong the women are here. Within minutes of birth, they are up having a cold water wash from the tap in the labour ward. They then walk to one of the postpartum wards - noprivate or semi-private rooms here. Both wards have 40 beds.
There have been so many experiences, it's hard to pick what to write about. Thanks to everyone who's left a comment - it helps to feel a little closer to home. The internet cafe experience here seems to be hit and miss. We would love to post and email more, but sometimes it's just too frustrating.
We are all well - so far everyone is healthy. Hopefully we can post more on the weekend. - Jan
Instead I went to the antepartum clinic with Sal. The clinic sees approximately 150 - 200 women a day. Just the number of women seen per day is overwhelming. At first Sal and I managed the blood pressure post. Honestly, I think that each of us took 75 - 100 bps that day. I was moved to one of the exam rooms with one of the midwives. Visits are quick. Each woman brings her piece of plastic to lay on the worn and torn mattress on the exam table. Fundal height is measured in fingerbreadths from the sternum. Fetal heart tones are listened to with a pinard horn. The rate is not measured, just the presence/absence of a fetal heart is recorded - few nurses or midwives have watches or clocks. Women have 4 prenatal visits during their pregnancy. I'm not sure when the first one is, but there are 2 after 14 wks, so that they can be given antimalarial treatment and immunized against tetanus. They are also treated for parasites and given iron supplements. The last visit is shortly before they are due.
This last weekend we spent at Mburo National Park. We stayed in very rustic bandas - had my own gecko beside my bed- which un-nerved me a bit. Perhaps it was the getting stuck in the mud when our driver chose a shortcut and we had to get out and stand by the vehicle while the van was unstucked. It was night time and our driver assured us "Don't worry, there are no lions." Okay - I was feeling close to nature and didn't sleep much that night and the lizard beside my bed didn't help. I kept thinking about Jennesse and how much she likes geckos, but I wasn't feeling the gecko love. We went on a Game Drive, on a boat in Mburo lake and on a Game Walk over the weekend and saw many animals - we have a list of over 50 animals and birds we sited. It was an amazing experience. We are now in Masaka while Georgia, Sal and Grace are back in Kampala. Both Lydia and I are looking forward to being in one place for a while.
We have spent 4 days on the labour ward in Masaka and well - Toto, we aren't in Kansas anymore. I had 3 catches this morning - two within 10 minutes of each other. There seems at times to be an endless stream of women in labour. We have seen several women with 2nd trimester losses. Two were delivered on the ward while we attended them. One had a PPH and retained placenta and Cathy successfully removed it. The other woman also had a retained placenta and needed to have it removed in the procedure room. The scarcity of supplies has been hard to deal with. We save all glove wrappers because its paper that we can use to wrap placentas in, clean away feces, etc. There are no extras here and sometimes there isn't what you need. There is no anesthetic for women in labour or for other procedures. Cesareans are performed under GA. I am amazed by how strong the women are here. Within minutes of birth, they are up having a cold water wash from the tap in the labour ward. They then walk to one of the postpartum wards - noprivate or semi-private rooms here. Both wards have 40 beds.
There have been so many experiences, it's hard to pick what to write about. Thanks to everyone who's left a comment - it helps to feel a little closer to home. The internet cafe experience here seems to be hit and miss. We would love to post and email more, but sometimes it's just too frustrating.
We are all well - so far everyone is healthy. Hopefully we can post more on the weekend. - Jan
Wednesday, June 4, 2008
The First Few Days
We are now in Kampala and had an orientation to some of the wards and areas in the hospital yesterday. Cathy and Grace really want to ease us in slowly and not overwhelm us, so we just had a 2 hour orientation yesterday and today we only worked on Ward 14 this morning. So yesterday was a bit overwhelming as we visited the high risk ward where they do about 60 plus deliveries a day. Of course there is no room for all the women needing help and treatment, so the halls are strewn with women lying down on mattresses. There were about 15 women sitting on benches waiting to get assessed and apparently, some labour so quietly they may come to the point of needing to push while sitting there. So the midwives get other women to turn their heads to try to attempt some privacy for the labouring mom and they catch the baby right there. The same goes for the women on the mats on the floor awaiting a bed. Often they need to have their babies before a bed is available and so someone hopefully comes in time to catch the babe. There were about 13 women in the hallway, some with their tops off moaning and groaning in labour, next to other women doing the same. The staff are gracious enough to accept anyone who comes to the door, unfortunately there aren't enough midwives and supplies to provide the standard of care. There are no friends or family allowed in to offer support (there's literally no room for extra people). It's definitely sad, and certainly far from our reality in Canada. We truly are very blessed to have resources we have back home. So anyway, this ward is full of women who have more complications, like high blood pressure, twins, breech babies, anemia, malaria, ruptures membranes etc. Apparently there are about 6 to 7 babes who die on this ward daily and one mom passes on every other day. The services are free here at Mulago hospital and I think this is one of the reasons it's so crowded.
Ward 14, the low risk unit, is where we will spend most of our time while in Kampala. There are between 12 to 30 deliveries per day here. Two of which we had the privilege of attending today. We, Grace, Jan and Lydia, were just finishing up with a birth at one end of the labour ward and there was a woman moaning loudly at the other and so Grace asked us to go assess her. Lydia double gloved, a standard of practice here, and did a vaginal exam to find her fully dilated with a big bag of bulging membranes. Lydia was a bit caught off guard. This was her 5th baby so we knew it would be quick. There was no delivery tray in the room yet so Lydia asked one of the midwives to get one for her. Jan in the meantime, was going to get Grace. Lydia broke the waters and the baby came shortly thereafter. It was overwhelming because we didn't have all that we needed in front of us. It was also frustrating because we could not communicate with this woman. ALthough we have a cheat sheet of words it wasn't practical at the time. All went well medically, the mom and babe were well, and Lydia had her first catch. Our internet minutes are running out. Hope to post more later. - Lydia and Jan
Ward 14, the low risk unit, is where we will spend most of our time while in Kampala. There are between 12 to 30 deliveries per day here. Two of which we had the privilege of attending today. We, Grace, Jan and Lydia, were just finishing up with a birth at one end of the labour ward and there was a woman moaning loudly at the other and so Grace asked us to go assess her. Lydia double gloved, a standard of practice here, and did a vaginal exam to find her fully dilated with a big bag of bulging membranes. Lydia was a bit caught off guard. This was her 5th baby so we knew it would be quick. There was no delivery tray in the room yet so Lydia asked one of the midwives to get one for her. Jan in the meantime, was going to get Grace. Lydia broke the waters and the baby came shortly thereafter. It was overwhelming because we didn't have all that we needed in front of us. It was also frustrating because we could not communicate with this woman. ALthough we have a cheat sheet of words it wasn't practical at the time. All went well medically, the mom and babe were well, and Lydia had her first catch. Our internet minutes are running out. Hope to post more later. - Lydia and Jan
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