last few weeks in Masaka--reality check

So now, Jan and I are in Masaka , under the supervision of local midwives. It has been busy and challenging. Over the last 2 and 1/2 days between Jan and I we have conducted 14 deliveries and resuscitated 6 babies who needed considerable help breathing. We've also prepared many women for c-sections and done our best to monitor the other labouring women, which at times it not realistic because there's so much else going on. Here is a snapshot of the crazy cases we've observed or participated in.

1. There was a woman pregnant for the 11th time with partial placenta previa (placenta partially covering the opening where the baby is born through) who was being prepared for a c-section when it was apparent that she had bulging membranes visible at the introitus and was going to deliver her baby. The membranes were ruptured and there were two loops of cord hanging out of her vagina. Major emergency! At this point the only option we had was to get her to push like stink and get her baby out. Thank God this woman pushed out several babies prior and was able to push this babe out within a few minutes. He was preterm (34 weeks) and needed some help breathing but considering what the potential consequences could have been, he did well. When we examined the placenta and membranes, we saw lots of vessels in the membranes and big succenturiate lobes throughout. Wow, how lucky was that baby!

2. A woman came in who had been assessed as being full-term and 8 cm dilated. The recommended plan was to rupture her membranes and deliver the baby. So when I went to assess her, the baby's head was too high to rupture the membranes, the head seemed very small for a term baby and I could not hear the fetal heart. I consulted with a midwives who suggested not rupturing the membranes and just waiting. An hour or so later Jan heard her waters break and as she was putting on gloves, she saw a small baby surf out with the waters. The woman had polyhydramnios (excess amniotic fluid) and so although her belly looked term the baby was actually only twenty some weeks old. She had a heart beat when she was born but she was clearly to young to breathe on her own. She died a few minutes later.

3. A woman rolls in on a stretcher, brought in from the village where she was trying to deliver. We uncovered her to find a another a large loop of cord and the baby's foot sticking out of the vagina! One of the midwives did a smooth breech extraction and the baby was thankfully fine. Miraculously, no resuscitation was needed.

4. One morning when we came in, there was a woman who was supposed to be prepared for a c-section because her labour was obstructed. Of course everything takes time here with everything else going on, so by the time we got around to preparing her another vaginal exam was and it was decided the baby's head had come down enough and she would deliver vaginally. No fetal heart could be found on the baby. I put on gloves to do the delivery and the baby's head came shortly thereafter followed by thick, dark, pea-soupy meconium. Jan and I lost hope of this baby being alive when we saw that. The delivery of the baby's shoulders took a few shoulder dystocia manoeuvres to get out, likely because the baby had no tone. Unfortunately when the baby was born, we confirmed what we feared, that there in fact was no heart beat.

5. A woman had come in from her village with an obstructed labour. The doctor decided to try a vacuum in the operating theatre so that if it failed a c-section could be done. The vacuum failed and so a c-section was done. The baby died minutes after delivery.

6. I followed a woman who was expecting her first baby all day Tuesday. She spoke great English and so throughout the day we had made a good connection. She needed to be augmented with oxytocin as her contractions were infrequent. Her baby's heartbeat was strong throughout her labour, but unfortunately when we ruptured her membranes an hour or so before she delivered, they were dark brown--meconium. When her baby was born, Jan and I resuscitated her for 12 minutes before she breathed on her own. Her breathing remained laboured. Although she received medication and dextrose before we left, she died around midnight. This was the first time I had cared for a mother in labour whose baby dies shortly thereafter. It was really sad and difficult to process.

7. The same day I learned the baby died, there were 2 more babies who needed significant resuscitation. With the first, the power went out just as we were bringing the baby to the nursery so we could continue the resuscitation under a lamp, so the baby would be warmer. Then it was decided the baby needed oxygen so Jan and I ran around the hospital compound from the emergency to paediatrics to the operating theatre--Jan holding the baby and me walking briskly beside her continuing to breathe for the baby with the bag and mask. We were not successful in getting oxygen for the baby as as the oxygen system here relies on electricity and the generator in the OR wasn't working either. No oxygen for this baby nor the next baby who needed resuscitation. We don't know if these babies made it or not. We'll know when we return to the hospital tomorrow.

8. The same day at the 2 above resuscitations, another woman rolls in on a stretcher. She delivered a baby in her village and then the placenta wouldn't come. She bled a lot and was transferred in. When she arrived the midwives determined that the baby she delivered was one of 2 babies--she was having twins. When she arrived, the placenta was partly out of the vagina and the 2nd twin was yet to be born. She no longer had effective contractions so needed to have a line of oxytocin put up. It took a while to deliver the second babe who came out sunny-side up/OP with no heartbeat. The mother's placenta had abrupted.

So that's just a snip-it of the last week. It's intense and it's hard to keep straight what happens when. At home if we were faced with any one of these cases, we would have the time and space to process what happened. But here, it's non-stop and you have to pick yourself up and move on to the next woman and/or baby who need care. There are only 2 working days left for us and then we are making our way back to Kampala this weekend and catching a flight home Monday. It has been an incredible though challenging learning experience. However I have no regrets doing a placement here. I have seen more than I could have imagined, and, in these 6 weeks I have almost done what would be a year's worth of catches for a midwife practicing in BC. Looking forward to connecting with some of you upon my return home.

Lydia

The last couple of weeks

It's hard to believe that we will be home in a week. We have been back in Masaka for a week and a half. As Lydia wrote, all four of us students were all back in Kampala for the last week of June and spent time on the High Risk ward with Cathy, Mickey and Grace. Our instructions left that weekend and the four of us decided to spend our last weekend together in Jinja - the headwaters of the Nile. We travelled by Matatu to the Kingfisher Safari Resort, which was an oasis. We swam in the pool all afternoon, enjoyed a great meal and a peaceful sleep on comfortable kingsized beds. We said our goodbyes, as Lydia and I were headed back to Masaka; Celina to Kampala and Georgia to Entebbe as her flight home was on Monday. Celina leaves tomorrow, Wednesday, and Lydia are flying out on the following Monday.

Lydia and I survived our travels back to Masaka by Boda-boda, then by Matatu, then by Costa. We were happy to arrive back at the Zebra Hotel where we were warmly welcomed back with a heartfelt "Well be back!" from the hotel staff.

We worked the following Monday through Friday on the Labour Ward. We planned to meet Celina at the Equator for lunch on Saturday and to search the craft shops there. On Friday our Ugandan preceptors asked us to work the weekend as they were short-staffed. We compromised and said we would come in on the Sunday. It is now Tuesday afternoon. Our shifts these 3 days have been crazy. So much happens that its hard to remember what happened the day before.

Last Friday was pretty wild too. I had 4 deliveries including one womant we were told to prep for the OR as she had a grade II placenta previa. The Doctor went to insert a catheter and the membranes and head were visible at the introitus. He called me to deliver. One of the Sisters told me to break the membranes and as I did so I remember saying I'm not sure this is a head presenting. Soon as the membranes were gone we saw a cord prolapse. Fortunately, she was a Gravida 11 and we had her push like crazy. Lydia and I were calling for preparation for resus, for a hypovolemic baby and a hemorrhage from the mother. We didn't need to resus and the mother didn't hemorrhage, but he was early about 32 - 34 wks and was grunty. The placenta had a huge lobe so that the entire placenta covered from fundus to cervix. There were vessels between the lobes and the baby had delivered between two large ones without rupturing them. I went through the frustration of trying to get oxygen for the baby, but couldn't. Eventually an IV was placed and he had fluids, glucose and antibiotics. By the end of the day he seemed to be doing okay. The next birth I had was another preterm but very preterm. She had been assessed her as term, 38/40, 8cms dilated with instructions to perform AROM and deliver. Lydia found that the presenting part was so high she wouldn't break the membranes. Also she couldn't find a fetal heart. Lydia was busy with another delivery and I was available when her waters broke on their own. A ton of fluid (polyhydramnios) and a very small preterm baby surfed out on the fluid. She had a heart beat but made no respiratory effort and I did not attempt to resus. She expired shortly after delivery. Fortunately the other births I had that day were uneventful.

Since Sunday, Lydia and I have had 14 deliveries between us (and we only worked until noon today). I think we have conducted 6 resuscitations. So far 5 of the 6 babies are alive. One of the ones we resuscitated yesterday died during the night. We have had many challenging moments. I seem to have had a run of primagravidas who refuse to push. One of them was said to have a mental illness by her family. The fetal head was visible on the perineum but she refused to push. She kicked and hit anyone who went near her. I dodged blows to check the fetal heart rate, and it was consistently below 100. I enlisted the help of one of the Sisters to speak to her in her own language but even with explaining the need to deliver her baby she refused. Oxytocin was hung. Why she let me insert an IV - who knows? The oxytocin worked and she started pushing. I tried to protect her perineum but she kicked me away. Her attendant was her grandmother and gran gave her a couple of good smacks for kicking me. We enlisted the help of another family member - one on each leg. The fetal heart rate was still below 100, and the Sister with me suggested that I would need to cut an episiotomy. Anticipating the need to resus this baby, I had pulled out one of our delivery kits so that I would have instruments to clamp and cut the cord. Skeptically, I pulled the scissors out of the kit, thinking that I would not be able to get close enough to cut an epis, or if I did, I'd lose teeth. As soon as this young woman saw the scissors her legs were flying again. I put the scissors down and said that I was NOT going to attempt an epis. I was sure we were going to deliver another FSB - a fresh stillborn. With the efforts of her family and the oxytocin running she did deliver her baby and his Apgar scores were something like 1, 4 and 7. Lydia and I worked really hard to bring that baby around. I did return to the mother and managed to inspect her perineum without getting kicked, although it took a lot of time and reassurances. She had a 2nd degree tear - no surprise. Again no surprise that she refused suturing - and I wasn't going to volunteer.

These days have been so full, and the last 2 evenings we have left the hospital after dark which is something we really don't like to do. This morning started with another primagravida referred in, who had been pushing for 9 hours; again head visible at the perineum. One Sister said send her to theatre; another said the head is so low get her to push it out, if she goes to theatre, she'll just end up with a dead baby and a scar. I think her meaning was there wasn't much chance for the baby anyway, and it's better not to have a scar, especially here in Uganda where women have 5, 6 ... 11 pregnancies. The rest of this story is pretty much the same as the one I've just written about. Except that I can say for this birth, I was reluctant to take it on, knowing that the cards were stacked against a good outcome. This baby too was a tough resus. After we'd been bagging this baby for 10 minutes we decided to see if we could get oxygen. Which meant that Lydia and I bolted for the Emergency Department, because there is no oxygen in the labour & delivery ward or the nursery. I carried the baby while Lydia bagged. We got to emergency, where there was oxygen, but no power. I'm not sure how the oxygen is delivered, but apparently it needs power. We repeated the same efforts at Ward 1 and at the Operating Theatre, only to find that there was no power; therefore no oxygen. There was nothing to do but return to the nursery. Baby was breathing on his by then, but was in rough shape. The supportive measures are limited to IV saline + glucose, Vitamin K, and antibiotics. He was alive when we left; we will see how he is doing tomorrow.

I am looking forward to coming home and seeing everyone and I think when I get there I don't want to discuss birth or babies for 6 weeks. See you soon - Jan

back on the high risk ward...

Last week we all headed back to Kampala to spend some time on the high risk ward. This is the place Jan and I described in one of our first e-mails where women are labouring on mats in the corridors because there is not enough room to accomate them in the labour and deliver ward. This is also the ward where a woman dies every other day. We were blessed not to have any losses of mamas while we were there for a couple of days. There were unfortunately stillbirths. It seems these are much more common than we see at home. Every week, there are a few women with stillbirths we either care for or hear about. Definitely a sad reality here.

The first day on the ward, the hallways were lined with women labouring on mats on the floor just as was the case when we visited the ward the first week. We got there in time to partake in morning rounds, where residents and obstetricians come to review how every woman on the ward is doing. It was impressive to see how many women they actually assess.

As the beds were full in labour and delivery, there was a woman who had to give up her bed during the rounds assessments and she was relegated to the floor where she lay on her plastic sheet until the rounds were finshed (about an hour later). During this time her (meconium stained) waters broke all ofer thr floor, which she was lying in. But here, where there is so much going on, getting her out of her the puddle isn't a priority, so she waited until the assessments were done to have a bed back, where she delivered her baby shortly thereafter.

Not too long after wrapping up with this birth, I heard a cry in the hallway, so I went to see where it was coming from. It was a young woman who I learned was 17 years old and having her first baby. I wanted to examine her to see how close she was, but when I gently approached her with my gloves on, she adamantly refused-- kicking her legs, pushing me away with her arms--and the look of terror in her eyes was heartbreaking. I learned from one of the local midwives who walked by, that she cannot hear or speak (due to a bout of malaria at age 3 that impacted her hearing and speech). How sad! Her mom was with her as her attendant and she tried to calm her so that I could check her but to no avail. The midwife who walked past told me that this young woman reacted similarly with other midwives and suggested I just leave her. My sense though was that she was petrified--she can't hear or communicate, this was her first labour expereince and on top of that, I suspect she has a history of sexual abuse.

Despite the recommendation of the midwife, I decided to stay with her. I felt that more than anyone there she would benefit most from continuous support. I used touch and facial expressions to try to comfort her and to let her know she would be fine. I touched her forehead a lot and smiled. It was amazing how quickly she calmed down and tuned into her body's cues. As I waited and watched through a few contractions, I knew her baby was near as I could see wisps of her baby's hair in the perineum with her contractions. Her mom had left by now and so it was just her and I for quite some time--well amidst the hallway of labouring women-- but on her mat it was just her and I. Once she calmed down she also really tuned into her body's cues. Early on when pushing she decided to squat, and, as her baby's head came down she moved herself into a semi-sitting position where she propped herself up on her elbows and watched her baby's head emerged slowly, slowly with every push. It was amazing to watch her expressions--ones of amazement, intensity and joy. It was also incredible to be reminded that when given the space, women intuitively know how to birth their babies. I had no words to offer her. All I really did was create a safe space for her to birth her baby.

Eventually the baby's head was born, and at that moment I looked at her, and she threw her head back and smiled. Not long after, the rest of her baby was born into my hands and I placed her on her mom's chest. She was so elated. I was so touched, I wanted to cry. As I was delivering her placenta, I noticed her hand on my knee and her smiling at me. I think this was her way of saying thank you. I wish I could have somehow conveyed to her how incredibly privilged I felt to have wintessed her strength and the beaufitul birth of her daughter.