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