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