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.

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

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

Less than 24 hrs now

Lydia, Georgia and I leave tomorrow ... Oh my! Everyone asks me if I am excited, but honestly, I've been too busy to be excited. I think though that I just might want to scream with excitement once I'm on the airplane tomorrow evening.

I checked in online this evening; managed to get the seats I wanted, but discovered that my flight home from London to Vancouver has been cancelled and I haven't been booked on an alternate flight! Guess what I'll be trying to sort out tomorrow before I leave?

My dear friends, Tina and Jalana, gave me a "flight care package" yesterday. An armload of trashy magazines, a couple of good novels and a bag of trail mix. Who luvs ya?

Lydia, Georgia and I have each picked up a large suitcase full of supplies from UBC. Lydia tells me that she has another suitcase full of donated baby clothes collected by friends in Squamish. We have a last minute meet tomorrow to collect a couple of blood pressure cuffs and then we are off!

Thanks to everyone who's helped collect supplies and who have wished us well. I hope we will be able to update our blog often. Celina, Lydia & Georgia have yet to add their voices to this blog, but I'm going to make sure that they post too! - Jan

21 days and counting!

Departure day is fast approaching. We've all been to the travel clinic to get the necessary vaccinations; we've scrounged, borrowed or discount purchased the white scrubs/uniforms that we are required to wear when we are in the Ugandan hospitals; and we are busy trying to organize and pack everything else that we will need to bring for 6 wks in Uganda. Can I mention that we are all currently in clinical placements in the meantime?

Lydia, Georgia and I are booked on the same flight leaving Vancouver on May 31st in the evening. We will arrive in London on June 1, some 9 hours later. We have 7-1/2 hours to chill out at Heathrow before we take the 2nd leg of our journey to Entebbe - another 8-1/2 hours of flight. We will arrive in the morning of June 2 and our instructor, Cathy, will have arranged to have a driver to bring us to Kampala where she promises to let us sleep before orientation.

Sal (Celina) will repeat the journey a few days later.

We've also been trying to collect supplies to take with us. We have had some generous donations. I would like to thank Fort Langley Midwives, Natasha and Shelley, for donating a pediatric laryngoscope. Many thanks to the Midwives of Ridge Meadows Midwifery who tucked a box of sterile gloves, and a box of 100 needles and syringes under my arm as I finished my practicum with them. Special thanks to my preceptor Jennesse who has been so helpful organizing donations from local hospitals; she's been an incredible help. Many thanks to the RNs and aides at the local hospitals who have thoughtfully collected items for us. It is so inspiring to have our community support us in this journey.

I'm excited to have this blog to be able to keep in touch with everyone at home. Please read the paragraphs below to find out more about our global placement. Stayed tuned and enjoy this adventure with us! - Jan