Shaking our ''sitting facilities'' to Jinja

We are finally finished in Kampala. We did our 4th half day in Mulago hospital today. Only Sarah caught a baby today. Another group of Ugandan students caught a dead baby with a mouth full of teeth and a brain but no skull to cover it (anencephaly)...One woman has been waiting for 3 days to go to the operating room to get a vaginal tear sutured- it was too deep to do on the ward. She had no food- Alix gave her a granola bar and Angela (one of our instructors) bought some formula for her baby since she had no milk... Oh and yesterday a breech baby's head got stuck and it died.

Alix went in the operating room for 4 ceseareans in case any babies needed resuscitation. Cathy and Lyanne had noticed that one mom was bleeding more than she should have been prior to delivery and suspected a low lying placenta. They had pointed her out to the doctor and it was a good thing- that mom went straight to c-section and sure enough the placenta had been low lying. The baby needed only 4 puffs of air but was well enough to go to postpartum with mom. The second woman had been diagnosed as postdates, breech with polyhydramnios (too much amniotic fluid)- turns out the baby was head down, large and stillborn. It smelled worse than anything Alix had ever smelled even though it was dead less than 24 hours- it was covered in tiny blisters and Alix wondered if it had died from syphillis. The third baby came out screaming and robust. The fourth baby was supposedly coming face first and labour was therefore obstructed, but when the doctor pulled it out it was actually breech. They thought it was term but really it was only about 34 weeks and needed 4 min of resuscitation.

Needless to say we are not sad to be leaving. Though on a positive note, the Ugandan students at this hospital have been great to work with. Keen to learn, aware of what they don't know, and friendly, working alongside them was a positive experience. Carolyn today enjoyed mentoring one of the students who completed her first birth and another who wanted to learn how to use the partogram.

Last night we took our instructors out for dinner to a great Indian restaraunt and then we went to see a wonderful performance of traditional music and dance. We were so glad to finally get to hear some live music- it's a shame that there isn't more of the marvelous local drumming to be had. At the end we got up and shook our booties (or as the emcee put it our "sitting facilities") on stage with the dancers. Tonight the instructors took us out for dinner at the Indian place. They leave for Entebbe tonight and fly out tomorrow. We will miss their support, guidance and company greatly.

Tomorrow we will be heading back to the amazing resort on Lake Victoria in Jinga, source of the Nile, to spend Canada Day together drinking banana gin by the pool and eating delicious 'Ryan's chips' with avocado- these are fries smothered in some ketchup/chili sauce mixture with red onion and green pepper. Yum!  We have a Canadian flag t-shirt and tie that we were planning on giving away but perhaps we'll wear them with our swimsuits first. It will probably be our most patriotic Canada Day ever.


Lyanne delivering a placenta




Us with the inspiring Dr. Mirembe, renowned Uganda researcher of maternal mortality and champion of midwives.



Human (read female) suffering

Today was one of the hardest days for me so far here in Uganda. The four of us, as mentioned before are in Kampala; we have been spending our time in 'lower Mulago' the high-risk ward. Basically what this seems to mean is that approximately half of the women are waiting for c-section. Put another way, what this means is a large group of women are out of their minds in pain, moaning and screaming, terrified that they are going to die or that there baby will die. It is a cacaphony of suffering, and suffering with no end in sight.  This is not like in Canada or like any other developed country where waiting for a c-section means maybe an hour. If you are lucky, it will maybe take you 4 hours but realistically, you might be waiting for day or longer. There is also no such thing as an epidural for a long obtructed labor. Imagine being at the very limits of what you think you can handle, and yet you have to go on, and you have no idea, none, of how much longer you will have to continue experiencing the worst pain that you have had in your life. 
As a careprovider it is a helplessness that is so profound. You get so drawn in to the suffering around you. It is so draining. Today, there are no inspiring moments, just anger and sadness that this ward is only a sliver of what most women in the world experience. Actually I take that back, the strength of these women is even beyond compression. It is amazing what one can survive when you have to.

Carolyn

The last 4 days of safari and the first day in Kampala

We left fort portal and drove down to Queen Elizabeth National Park for Wednesday/Thursday nights. We stayed at the simba camp= simba is swahili for lion. The rooms were great but the food was expensive- one night they tried to serve us potato curry with roast potatoes as the vegetarian option!  It was here that we discovered the local banana gin called Warugi- or ugi for short. Tastes just the same but costs $0.55/shot. With a little tonic water or bitter lemon we were set. 

 

On Wednesday afternoon we decided to add an evening game drive to the itinerary. This cost an extra $35 each for park entry and gas but was worth it because we saw two lions- a young male and a female lying down about 10 feet from our car. Wow! They are beautiful. We also saw elephants (up close) and warthogs and many antelope. On Thursday morning our game drive was quieter but we glimpsed a leopard-incredible! Thursday afternoon we went on a boat ride on the Channel that connects Lake Albert to Lake Edward. We saw many hippos, numberous birds including the saddle beaked crane, we saw a crocodile who had tried to eat a python but the python's fang pierced the croc's lip making swallowing impossible- so he swam dragging the dead python with him. We also saw a fish eagle catch a Nile perch. Take that National Geographic!

 

On Friday morning we drove to Lake Mburo. On the was in we were thrilled to see a harem of zebras! Once inside we went for yet another boat ride with many fish eagles and hippos. We got too close to one hippo and had to race away as it lunged up out of the water to attack our boat. We saw how the local fisherman fish- they use floating papyrus reeds weighted with rocks to suspend the nets. We ate dinner at the open air canteen by the lake and we had a great view of hippos and warthogs. The next morning we left at 6:30am for a brilliant game walk and learned that the most dangerous animal is the buffalo who does not like to be surprised. We saw a new breed of antelope called a Topi. That afternoon we went on a game drive and Sarah spotted a mongoose (I missed it) and we saw a new breed of antelope- the Elan.

 

We are now in Kampala. Today we went to Mulago hospital and began with rounds. We heard about the extremely high volume of cases (sometimes labour admissions numbered 120 in 24 hours), the many successes but also a few tragic stories of deaths due to anaesthetists not showing up for their shifts, refusing to anesthetize a patient who was too sick only to have them die anyways, a broken oxygen set up and lighting in one of the ORs.  Several ruptured ectopic pregnancies were delayed in getting surgery because the gynecology OR was being used for cesearean sections. We heard about a woman who had had a failed abortion at 20 weeks at a local clinic- they tried 5 times to remove the products of conception- perforated her uterus and let her go septic before finally referring her... I have great admiration for the hospital staff and the great volume of women they serve despite shortages of staff and a lack of functional equiptment. Did I mention there was a grave shortage of sutures?

 

After rounds the BC team hit the  high risk ward today in full force- good things- in only 3.5 hours we caught 6 babies between us. Carolyn 1, Sarah 1, Lyanne 2, Alix 1, Cathy 1. Mickey and Angela helping all. All were happy endings but 1- Alix's catch was a macerated still birth.  We left work in hopes of finding the fabric market but our driver took us to a craft market instead- no worries- the gals happily dove in.  Delicious samosa and rolex for dinner tonight- best $0.50 dinner ever.

 

Posted by Alix

Things We Learned on Safari

Hello!

We haven’t had internet access for several days – I hope you haven’t all been hitting “refresh” every 5 minutes in the hopes of an update!

The rest of our safari we spent at Queen Elizabeth Park, and Lake Mburo. Many more hippos (including one very angry one), impalas, lions, more elephants, crested cranes, a saddle-bill (bird), a very shy leopard, and many, many zebras. We also all ended up falling a little bit in love with the warthogs.

We were back on the ward today, all together in Lower Mulago’s high risk labour ward. To wrap up our safari story, we figured we would share a list of things we learned on safari. So!

Things We Learned on Safari

* Kampala, the capital city of Uganda, was originally called “Ka-impala,” meaning “here there are impalas.” Impalas used to live there, but moved south thanks to climate change and human development. The colonial Brits decided to shorten the name (maybe it sounded too Klingon?)

* A group of zebras is a 'harem,' a group of hippos is a 'school,' and a group of vultures is a 'committee.'

* Buy your own avocados from roadside fruit stands, and bring them into the restaurants. The chef will turn them into guacamole for free, and avocados are (literally) 200x more expensive if ordered from the menu.

* ”Pumba” is Swahili for “warthog.” “Simba” is Swahili for “lion.” We don’t know for sure, but have a pretty strong suspicion that “Timon” is Swahili for “meercat.”

* Never give a monkey a roll of toilet paper.

* Carolyn is the fasted reader.

* Check the price on the menu before you order tea.

* “It’s okay” or “I’m okay” means “yes” in Uganda, not “no.”

* Never cross a hippo.

* Never cross a buffalo.

* Never cross Alix if she has access to a moldy frying pan.

* Do not pack a half-empty (i.e. open) container of jik (bleach) in the same bag as your clothes.

* Do not eat too much fruit if you’re going to be driving from Murchison Falls to Fort Portal.

* When the guide closes his car window, it might be a good idea to also close yours, especially if you’re about to be passed by a large truck on a dry, dusty road.

* In addition to “White person,” “muzungu” can also mean “wealthy person,” especially if referring to someone who receives money from white people.

* Do not try to do a safari game drive in a Corolla on dirt roads after a night of rain.

* Sit on the left on the boat rides.

* Stand further back on the squat toilet than you think you need to.

* Check for wasps nests before you say your hotel room/banda is fine.

* If the souvenir shop is painted like a zebra, there are probably cheaper prices elsewhere.

* Never eat a banana in front of a warthog.

Posted by Lyanne, Sarah, Alix, and Carolyn.

Murchison Falls Boat Ride

Why did the elephant cross the what?

Lake Mburo Boat Ride

One foot in each hemisphere...




Breasts vs Icicles

Yesterday we slept in (well some of us did-others wake up at 7 no matter what) and then headed to the Toro Botanical gardens. We were lucky to have an herbalist as our guide who had a very impressive vocabularly of female reproductive anatomy words and a comfort discussing them. He showed us many of the local medicinal herbs for childbirth. There were plants to prevent a miscarraige when a woman has bleeding in early pregnancy, plants to ease labour pain for first time mothers, plants that treated syphilis and candida, plants that helped create a swift birth, helped with the delivery of the placenta, helped with fibroids, fallopian tube problems etc. Like us they prescribe fennel to increase milk supply and sage to dry up milk. On the wards we noticed that very few women tear during birth-despite their great strength when pushing, sometimes poor nutrition and their choice of birth position (often on their backs). When we asked the midwives about this they explained the women soaked their perineums in an herbal bath before labour to prevent tears but they didn't know which herbs are used. Today we learned that a plant called waruncha and potato runners and boiled briefly and then used in said herb bath.
We  saw many species of indigenous plants including several endangered species that are being cultivated. There were also herbs and spices, traditional dye plants and even a specimen of purple sticky punch! We spotted a black and white colobus monkey and at a pale purple/green tree fruit that looked like a mini eggplant, had the internal colour and texture of a tomato and tasted like a salmon berry-yum! Our guide Dominic came along and we got a kick out of the fact that he bought a stevia seedling which he then carried with him on our excusions for the rest of the day so it didn't wilt in the car.
After the gardens Dominic drove us to visit the Amabere caves and 3 crater lakes. The caves are made of limestone and contain both stalictites and stalamites. These are formed when water seeps through the porous limestone causing a chemical reaction that results in the release of C02 and drips of calcium carbonate that form rock icicles from above and spears from below that eventually meet in the middle forming columns. Ambabere means breasts...If you have ever seen a stalictite you would agree it bears more resemblance to an icicle than a breast, and Lyanne pointed out that stalagmites bear a strong resemblance to penises...but we know that men all over the world are breast crazed and so Amabere it is. The local myth is that there was a king Bukuku who had an extremely beautiful daughter Nyinamwiru. One version of the story holds that the king had heard a prophecy that Nyinamwiru would give birth to a boy who would kill him and take over as king. In the first version of the story the king cut out oneof Nyinamwiru's eyes and one breast-throwing the breast into the caves and creating the first stalactite. He was too late though- Nyinamwiru was already pregnant. She gave birth to a boy who Bakuku kidnapped and threw into the caves also. There he was found by a potter collecting clay. The potter fed was too poor to feed the baby and so fed the prince with the milk that dripped from the stalactites. Eventually the boy prince grew and killed his grandfather, fulfilling the prophecy.
Another version has it that Nyinamwiru had many unsuitable suitors. King Bukuku had his daughter's breasts cut off to deter suitors. This failed and so he banished her to the limestone caves. There she was impregnanted by the King Isaza and gave birth to a boy prince, Ndahura. Having no breasts she fed Ndahura, future king, with the limestone milk from the stalictites.
Then off to visit 3 crater lakes. The scenery was beautiful- grassy green volcanic hills, grazing cows and the Rwenzori mountains in the distance. One crater was reputed to have quick sand in it! Viewing the 3rd crater involved a short climb up a very steep hill- the first cardio any of us has had in 4 weeks. We were all panting by the time we reached the top and we were grateful today was slightly overcast and cool. The view was well worth it. On the way down we stopped by a tiny store in a mud hut for beer which we ate sitting on a bench in what appeared to be a 5'x5' goat pen...the goats were tied up outside. Dominic told us about sugar daddies, sugar mommas and the difficulties of divorce in Uganda. He confirmed that a marriage is not legally binding until children are produced (we thought Benon was joking) and if the your parents don't consent to your marraige the church won't marry you.
We finished our day at a wonderful pizza restaraunt run by an Italian expat. We had thin crust pizza with mozza, gouda, tomato, olives, pineapple, garlic & eggplant and shandies. It was scrumptious! And they had a Canadian flag hanging in the centre of the restaraunt to boot. Dominic rested his stevia plant in a windowsill while we ate. We found a wonderful craft shop after dinner and have now settled in to read for the night. All four of us are reading a fabulous series about witches that Sarah has gotten us hooked on- The Witches of Eileanan by Kate Forsyth.
Today we drive to Queen Elizabeth National Park for another game drive.

PS- we apparently double posted...

A beer stop after climbing up to view the crater lakes

Part 2: Fort Portal

Yesterday (Monday) we spent most of the day on the road, driving to Fort Portal. It was about 300 km, but it took most of the day, because most of the drive was on narrow, dirt roads, filled with potholes. The sun was hot, and the dust from the road blew in through the windows. As usual, we were sharing the road with many boda-bodas, and people cycling with more on the backs of their bikes than I'm comfortable squeezing into the trunk of my car. Incredible.

We made two stops along the way for food, and at both stops, we recognized the same tourists that we'd run into at Murcheson falls the day before -- clearly, there are specific "muzungu-friendly" restaurants that all of the tour guides end up using. Our guide/driver, Dominic (of www.assuredugandasafari.com) was joking that the reason the ride was so bumpy was that he was lonely driving with all four of us sleeping, so he picked out the best potholes to jolt us awake. :)

We also passed through a town called "Kyejojo," which translates, literally, as "It's elephants!" It seems local farmers were finding that an animal was destroying their fields at night, so the villagers stayed awake together one night to solve the mystery of the disappearing crops. As the name might suggest, the culprits turned out to be elephants, so the town was named in honour of the farmers' started exclamations when they first noticed the animals galumphing through their fields.

Fort Portal itself is clearly a relatively well-off town. The roads are well-paved, there is very little garbage in the streets, and even our "budget" hotel has comfortable beds, hot showers, and soap in the bathrooms. The town is surrounded by tea plantations, which probably goes most of the way to explaining the town's relative economic security.

Most people come to Fort Portal to see the chimpanzees, but our budget didn't permit us that particular excursion. Instead we spent the morning at the local botannical gardens. When the guide asked us what our particular plant-interests were, and we mentioned herbs involved with pregnancy and birth, he excitedly found one of the female gardeners who had worked as a birth attendant, and she told us all about several of the local plants. We also toured the arboretum, saw a few monkeys, and sniffed many of the wonderful-smelling herbs. Our Dominic ended up buying a stevia plant for his kids back home (like in Canada, stevia is used as a sweetener here) and he took great care of the plant for the rest of the day, moving it to the shade, watering it, even bringing it into the restaurant with us where we ate dinner because he was afraid his plant wouldn't be safe in the car. We've named the plant "Steve."

We spent the afternoon at some local caves and volcanic hills. The walk to the cave was muddy and slippery, but the caves were interesting enough, and we saw another waterfall. The local name for the caves translates to "breasts," because the stalactites apparently resemble breasts. The local legend is that a king removed his beautiful daughter's breasts and threw them in the cave, because he had heard that his grandson would steal his kingdom -- as most similar stories go, he was too late (she was already pregnant, and still very beautiful) and the breasts continued to grow in the cave, and fed her infant son when her father banished him to the caves as well. We also climbed up the volcanic hill, and were treated to a beautiful view of the surrounding area.

There's a song with a line "You never know 'til you reach the top if it was worth the uphill climb" but here, the opposite seems to be true. The uphill climbs, tiring though they may be, tend to end in spectacular views -- today the top of the 1093 metre hill also featured hundreds of beautiful, colourful butterflies. It's the downhill climbs that tend to end in less spectacular sights -- and the problem with that is that they are also the ones where you have to climb up on the way back!

We went to a local pizza restaurant for dinner. We haven't made much of a point of seeking out Western food here, but after a long day with minimal food since breakfast, pizza has never tasted so good! Fresh pineapple on the pizza was a particularly special treat!

We head for Queen Elizabeth Park tomorrow. If it's anything like Murcheson, we won't have internet access there, so we'll update whenever we can.

Posted by Lyanne, Sarah, Alix, and Carolyn

Part 1: Boomu women's co-op, Murchison Falls

Our vacation began 3 days ago and we have packed a lot in 3 days. We were picked up from Jinga by our tour guide and we spent the day driving to Masindi. On our way there we stopped at the rhino sanctuary where we saw...we know the suspence is killing you...rhinos. So awesome! An interesting fact is that when the mama rhino gives birth she rejects her previous baby and sends him or her to live with other rhinos. It just so happens that a mother just gave birth, though we weren't able to find her as she is too aggressive right now to be around humans. The sanctuary is not like a zoo. The rhinos are in the wild over a very, very large kilometrage and you have to go and find them. This is also the first time that we feel like tourists. It's almost like culture shock. We were appalled when we saw a woman with short shorts and a tank top. We know that we are tourists, but where we are working there are basically almost no other foreigners, plus we are working all day. After the rhino sanctuary we arrived in Mapingi and stayed at the  BOOMU women's cooperative. Basically it is a co op run by women for women. The work they are doing is amazing. They have a crafts store where 85% of the proceeds go back to the artist and 15% goes to the co op. They have a guesthouse, and a restaurant and provide workshops on basket weaving and food making. They also provide a guided walk around the villages where you stop at 3 different locations and learn about ancient hunting practices, birth practices, and ancient marriage practices. When we arrived we had dinner there and Edna the woman who runs the co op sat down with us and described the story of the co op as well as how it is for many of the local women. It is heartbreaking and unbelievably inspiring to hear about how much she has accomplished as well as the challenges they face. For example, they have bees and make honey, but have no money for jars. They don't have money for electricity so people often drive by not realizing that there is a guesthouse that they could stay in. The next morning we went to the basket weaving workshop which was very interesting and heard a horrific story about Edna having a sore tooth, went to the "dentist" who pulled out two rusty nails, decided that her tooth wasn't so bad so went back home. She then returned the next day because it hurt so much and was told to go home since she refused his services the first time. She returned again and had her tooth pulled with the two nails and she "almost cried"! Have we mentioned that women here are much stronger than woman in Canada? Afterwards we went for the guided walk and here are some of the more salients bits of info that we learnt:

1. Traditionally men hunted with double ended spears. They had 3 hunting methdods. They would dig a large pit for the animal to fall in, construct a huge net and chase the animals into the net or simply chase they animals towards men waiting for to spear it. The first man to spear the beast (usually a buffalo) gets to claim the hindquarter. However, if the beast does not die right away the hunter makes a deal with the beast. If the deast lies down to die the beast can claim the life of the first person to taste it's meat. In this case the first cursed bite is offered to a neighbour in the village rather than a family member.
2. During childbirth a woman will kneel holding onto the central post in her house and her sister-in-law will provide a hip squeeze while she pushes. After the birth the husband will bury the placenta outside the house, marking the spot with an arrow. He will also place a spear at the corner of the house so that passers by will know a baby has been born. Baby boys remain indoors for 3 days, girls 4. On the day of their emergence the old women from the village come and they are served millet and soughrum ground ceremoniously while the grinder sings a birth song.
3. In the past, when a man loved a woman he would approach her 3 times. Each time she would reject him. On the fourth time she would agree she loved him but insist that he marry her. The man would tell his father who would befriend her father. After the 6th or so meeting of the fathers, the boy's father would express his son's interest in marrying his friends daughter by saying he wanted one of the man's "hens". The father would deny that any of his daughters would want to marry and so the girls mother was called. The mother would call all her daughters before her and ask which wanted to marry the boy. After several inquiries the girl would admit her interest. Then an introduction would be planned. The girls family would visit the boys family and give the boy an envelope with money (a "cock") and list of things for the bride price. The boys family agrees to pay and he girls family goes home.  The whole community of the boy would contribute to the bride price (cows, goats, money, alcohol). On the wedding day the boys family would come to the girls with the bride price, new clothes for the bride and a floral necklace. Once the bride price is counted an approved they dance. Then they look for the bride. A row of younger girls is presented first and when the groom doesn't recognize any of them he must pay their transport home before assessing another row-same thing. Finally he pays a friend to bring a third line before him which contains his wife. He place the floral garland around her neck and they dance again. The woman is then asked if she accepts the man. If she does they feast and dance again. The mans family then goes home, the bride accompanied by 3 aunts who carry her the whole way. Upon their arrival the bride & groom together plant a handful of seeds and then hoe together. Three days later the aunties return and if the seeds have germinated the marriage will be fruitful. The woman is then gifted with 2 knives, 2 pots and plates and must cook a feast for everyone. After this the woman spends the next 3 weeks indoors.
4. Some tribes bury their dead in their house.
5. When a woman has twins and they die the twins are each placed in a pot, the lid is sealed and they are kept in the corner of the kitchen for 40 days. Each day their mom puts the cooking ashes on them. After 40 days the fathers family and mothers family walk to meet by a tree marking a halfway point- they throw small green tomatoes at each other, place the pots under a tree, exchange meals, eat and return home.

Afterwards we headed to Murchinson Falls which were beautiful and then made our way to our accomodations. We spent the night sweating like crazy and awoke to thunderstorms; however this was made up for by having a wonderful day of a game drive and boat trip down the Nile! The Nile! Our safari guide was terrific and managed to not get us stuck in the multitudes of ditches that were there unlike several other cars and their unfortunate inhabitants. So today we saw: giraffes, elephants, baboons, monkeys, bufallo, dozens of antelopes, hippos, crocodiles, warthogs, and many birds. So cool! All of them quite up close. We were amazed by the gallantry of the giraffes, the speed of the elephants, the wallowing of the hippos, and the playfulness and jumping ability of the antelopes. We were surprised to learn about how many male species of animals reject their male young in order to maintain dominance. We were all really adorable in our geediness and gleefulness. Oh Africa! Such a country of extremes.

Lyanne, Sarah, Carolyn, and Alix

A day in the life of a rural Ugandan woman

Imagine...
You wake up at dawn and restart the fire. There is no electricty.
You begin to heat up the water. There is no plumbing. This water comes from the well that perhaps you or your daughter went to the day before. You have most likely carried 10 Liters of water on your head, in the heat, for over a mile.
You begin to make breakfast over the fire. Everything should be ready before your husband is awake. Once he is awake you will serve him first, then your children, and yourself last. Afterwards you will clean up.
You will spend your morning and the rest of the day doing various tasks. You might go to the market to buy your food for the day. You may bring your grain to the grinding machine or if you cannot afford to,you will need to grind it yourself. You may cut some firewood as this is always needed. You will work on the crops, hoeing the field, planting seeds, harvesting vegetables or fruit. If you are crafty you might go picking banana leafs and other plants in order to make baskets.
Because you are so busy, it will take 4 days to make 1 basket, which you will sell to tourists for 4 dollars.
If you are lucky your husband has been in the field working as well; however it is likely that your husband has been to town spending the money that you have made on the baskets.
You will begin to make dinne. Once you have warmed the bread you will put it in a basket to make sure it stays warm  for your husband who expects a warm meal as soon as he enters the house. Many men will come home drunk at 1am. You must get up, kneel at his feet, wash his hands, wait while he eats and then prepare warm water for him to bathe. Then you will clean up and using a kerosene lamp you will continue to work on your crafts until your hands and eyes hurt. Then you will go to bed, and the day will start anew.

If you are a girlchild, your day will start early also as it is expected that you will help your mother with the chores. You may or may not go to school depending on how money your parents have. You will go to the well and fetch the water, stunting your growth and contracting your spine. One day you will be 15 or 16 and it will be time for you to get married. Once you get married it is expected that you begin producing within 6 months. You will begin to do all the work of your mother before you in your new village as you are expected to go to your new husband's villlage once you get married. This work you will do until you go into labor, hopefully 9 months later and not earlier. Hopefully your baby is still moving inside of you. You will go into labor and most likely stay at home. If you are lucky, a traditional birth attendant will be with you, though sometimes what is thought to be helpful is harmful and she will have no supplies to help you with if there is a problem. You will know that childbirth is dangerous. Every girl born in Uganda has a one in 16 chance of dying in childbirth. Hopefully you will not labor for days and will birth a live baby. You know that the death of baby is common. The neonatal mortality rate is 30/1000. The years will go by and you willl continue to produce children. Over a decade may be spent either being pregnant or breastfeeding. The years will go by and you may decide to leave your husband because he mistreats you. If you do so, you will return to your mother's village with your children until you get married again. You will leave your children with her when that happens.

A mother's day , a woman day, never ends.

Carolyn

Mbale: a few days late

So this post is way behind and is my post about my couple of days in Mbale. There is not a whole lot to say but I wanted to post something. It was an interesting experience to work in a different hospital. The hospital in Mbale seems to be busier what with me attending 3 births, Alix 2, and Lyanne 2. It is also way more organized with easily accesible charts for every woman which was a total pleasure. It is unbelievably exhausting to try to find missing charts. Two of the 3 births were uneventful but the third one was an intense experience. Everyone had gone to a c-section and I was left by myself in the ward. A woman began to crown just as Alix arrived. The baby needed resus and then mother began to have a massive PPH at the same time. I began to resuscitate while Alix began to deal with the PPH. Luckily Angela arrived soon after and was able to bring some medication. This was a scary experience for me and was a lesson in humility. The first two births of the day had been straightforward and because everyone was busy I basically acted as the 1st and 2nd midwife with no difficulties. This last one was not a birth that could be handled on its own and I shudder at what would have happened had Alix not come when she did. There were of course local midwives around, but they too, were busy. Lesson learnt: make sure you find someone that can act as your 2nd.

The next day I decided to take the day off and went to Mt. Elgon using public transport. Public transport here is always an adventure as the drivers will cram as many people as possible in their car and will stop every couple of minutes until the car is full. I arrived and found a guide to take me around to the falls through the little villages. It was a very pleasant day. The Mt. Elgon area is also known for its male circumcision rituals. The people there are open to tourists coming and watching, but this wasn't my cup of tea. In any case, the ritual goes something like this, the boy decides between the ages of 16 and 26 to get cirumicised. By doing this, he is announcing his intention to marry. Before the ritual begins, the villagers get together and basically have a free-for-all orgy. Seriously. Then the boys line up while others dance and get circumcised by a man using the same razor blade for everyone. It is important to not cry out as this will shame your family. It should come as no suprise that the rate of HIV increases exponentially 3 months later.

Carolyn

Full circle with postabortion care

On Saturday Caroyn and I travelled to Mbale so I could do 2 days of interviews on postaboriton care. *Just a reminder that postabortion care is usually post-miscarraige care, but may also include care after a botched illegal abortion* The trip was pretty, and when we arrived we went to an awesome Indian restaraunt for dinner with Sarah, Lyanne, Angela and two male clinical officers who then took us clubbing- you can read about this in Lyanne and Sarah's previous post. 

On Sunday I worked on the wards during the day (caught 1 baby, managed 1 large postpartum hemorrhage  ~3L blood loss, and obseved 1 cesearean and tubal ligation. I then did two interviews. One with the incredibly lovely Dr. Paddy, a GP who is just on his obstetrics internship. He is renowned for his boyish good looks and the compassion he shows to the labouring women. He kindly volunteered to show me around gynecology and introduce me to people I could interview.

On Monday we started off with maternity rounds- rather uneventful. We then headed to gynecology for rounds. At 10am, before rounds began,  I watched a mother of 3 die at 10am after a septic abortion- there was a crowd of students watching and the nurse only did 9 chest compression then gave up- once a person requires chest compressions there is little hope of reviving them. There were no tears, no last rights. Sometime during rounds the body disappeared and by then end of rounds the bed was filled with someone new. My stomach churned.

I then met a man who's wife has a brain tumour which has resulted in paralysis of half her body and has left her in a coma for 8 weeks. She is 20 weeks pregnant. He requested a termination. The doctor explained that ending the pregnancy wouldn't help the tumour- but I couldn't help but wonder if he was requesting the termination because a child without a mother doesn't stand much of a chance here and it would be terribley hard to lose them both. However, abortion is illegal here unless it is to save a woman's life- and so the pregnancy continues.

I then  interviewed a doctor about the barriers to women receing post abortion care. So many! They talk about the 3 delays

1. Delay in the decision to obtain treatment
2. Delay in transport to the hospital
3. Delay in receiving care at the hospital

There is a lack of supplies and medcations, lack of diagnostic tools, a delay in sterilization of equipment, a lack of human resources, stigma, the lack of integrated family planning services...

When women arrive in the morning they are alreay quite delayed in receiving treatment. Then then must wait for the doctor to complete rounds, and for the more urgent women to be triaged. When it is finally their turn there are only 2 sets of equipment for D&C- these must then be sterilized-another delay. Oh- and there is not light in the MVA room, so women can only be treated until 6:30pm when the daylight is gone. On average 5 women a day present with postabortion complications and only 2 can be treated.  The untreated then leave- maybe they seek help elsewhere, maybe they don't.

Thankfully, 3 MVA sets were donated to Mbale hosptial last week and we finally got a hold of them on Monday.  So after rounds were completed and triage was done Dr. Paddy set to work. He did 3 D&Cs and then a midwife quickly gave him a crash course in how to use the MVA equipment. I helped to fill in the blanks in the theory of MVA use. Halfway through the first MVA we began to lose daylight so I lent Dr.  Paddy my headlamp to finish. There were 2 more women waiting. I wanted to call it quits for the day because I was emotionally exhausted after the death, already an hour late for dinner,  I didn't want to walk home in the dark alone and I had to pack but Dr. Paddy insisted on helping the last two women since he had the headlamp- if he didn't- he said they would have gone home and maybe returned septic several days later. So Dr. Paddy, a student clinical officer and I attended the last two women in the dark with only a head lamp and the light of a cell phone.

Our last case was a woman who had been admitted to hospital after being bitten and beaten by her mother-in-law. The blunt abdominal trauma caused her to miscarry. It was terrifying- I was trying to draw up and give painkiller injections in the dark. The room was black, the woman was black, the procedure table was black...all I could see where the whites of her eyes, wide and glazed over with trauma and the shadow of the surgical instruments on the wall. It looked like a scene from a horror movie, Saw perhaps, like my worst nightmare- but rather than torture her the three of us were trying to help her.

That was the hardest day I've had here.

When we finally finished Dr. Paddy and I walked to the dorm where the gals are staying and we ate the rolex (rolled omlett & chappati), samosas and beers that they had bought for us hours earlier. We had worked a 12 hours shift. Afterwards everyone walked me home.

And so I have come full circle and I am reminded of why I am pro-choice and why I mustn't ever become lacadaisical in my attempts to reduce maternal mortality as a result of unsafe abortion.

Posted by Alix

The Turkey in Mbale

Today's blog post title is brought to you by Angela, in honour of the turkey who lives near the dorms. It seems he's a rather angry turkey -- he doesn't like when people wear red, and he lets them know that by chasing them and snapping at their heels -- so he's always tied up to various fences and trees, unlike all of the free-range turkeys who also live nearby. He always says hello when we walk by, in his turkey way.

Anyway.

Today was our last day in Mbale for a little while, before we head to Jinja for the rest of the week. We had another busy day on the ward -- Sarah and Lyanne in maternity, Alix on the gynecology ward, where she did more interviews for her research, and watched some MVAs done by Dr. Paddy (post-abortal care using manual vacuums). Sarah coached a student clinician through his very first catch, and both Sarah and Lyanne resuscitated a wee little premature baby (between 30 and 32 weeks, we think) until she was breathing on her own. When we left the ward, she was still doing very well; hopefully she will continue to improve!

We finished off the evening with a lovely rolex-and-samosa dinner with Dr Paddy, who was able to work well past dark because Alix lent him her headlamp. This meant that they were able to offer care to several women who otherwise would have had to wait until morning, so we were happy to treat Dr Paddy to dinner. He's an excellent doctor, and very hardworking, so we really enjoyed getting to know him better. For Sarah and Lyanne, the highlight of the trip so far has been working with the wonderful staff at the hospital in Mbale. The midwives, nurse-midwives, doctors, and consultant doctors (Ob/Gyns) have all been incredibly warm, friendly, and welcoming to us, and they are wonderful teachers. They obviously face many challenges (the hospital's ongoing shortage of suture materials and IV cannulas is one of the more obvious challenges, along with always being under-staffed and very busy), but they work hard, they have incredible clinical skills, and they are kind and compassionate to the mothers and babies.

Sarah and Lyanne are excited about our next adventures, but leaving is bittersweet. We look forward to returning to Mbale in July. 

Making Friends

Alix and Carolyn arrived in Mbale yesterday, and the four of us have very much enjoyed our time being reuinted! We had arranged to meet two of the student clinicians for dinner, and Alix and Carolyn agreed to come along -- it probably didn't hurt that we were going back to our favourite Indian restaurant, which has several wonderful vegetarian options. :)

Denis and Paul, the two clinicians who were instrumental in setting up our lectures last week, braved the rainstorm to meet up with us, and they both tried Indian food for the first time. We had a lovely dinner together, and then they announced that because we had treated them, they were taking us out to say thank you. The group of us walked to a nearly empty dance club -- it turns out that 8:30 is too early to go out in Uganda, just as it is in Canada. :) Several more of the student clinicians were also at the club, and we had a lot of fun even though the place was mostly empty -- Angela, our instructor, was probably the best dancer of the lot of us! Among other things, we learned that the only Canadian musician that people in Uganda seem to know is Celine Dion. Before we parted ways, Denis and Paul asked if we would like a tour of their school, so we decided to meet Sunday (today) after work.

All five of us (four students plus Angela) spent the day on the ward. Alix was just planning on doing her interviews for her final project, but she brought along some sterile gloves "just in case" -- good thing she did, as she and Lyanne each caught two babies (another retained twin for Lyanne!), Carolyn caught three, and Sarah resuscitated three babies. Interesting things on the ward today included: a retained twin who came out crying, but deteriorated rapidly after his first few minutes of life (he had quite the heart murmer, so we suspect he has a patent ductus arteriosis, for those of you who speak midwifery); a very large PPH, that Carolyn and Alix managed expertly; a manual removal of a placenta; and a woman who spoke neither English nor Lugandan, with sickle-cell anemia, a history two previous cesarean sections and a vaginal delivery of a stillbirth, who had an obstructed labour. Sarah and Lyanne stayed with that woman through several long, frustrating hours, feeling utterly incapable of offering her any kind of comfort or reassurance, wishing we could offer her an epidural, and more than anything feeling the divisiveness of the language barrier in a more frustrating and poignant way. The woman ended up with a cesarean (and her baby needed resuscitation) and not a moment too soon, as a "Bandl's ring" appeared on her abdomen -- the dividing line between the upper and lower uterine segments, which is a sign that uterine rupture is imminent. The lady was really very sweet, and the whole situation, though heartbreaking and frustrating, certainly had its lighter moments -- as when Sarah and Lyanne had to communicate "empty your bladder" through sign language and gesture.

It was a tiring day, and we were almost late for our tour of the student clinicians' school. Like many things in Uganda, the school is in a beautiful setting -- on the lush, green hospital grounds, with a beautiful view of the mountains, lovely trees and flowers everywhere -- though as our guides pointed out, the buildings themselves are old and have not been renovated in a long time. We were invited into Paul's dorm room -- with Angela along, don't worry -- that he shares with three other students. The room has a single desk, and two sets of bunk beds with about 1m between them, and although it's small, it's remarkably clean given that it's inhabited by four men in their early 20s. It made the "bunk and loft" triple rooms at McMaster seem like the height of luxury!

All of Paul's roommates, and a few other student clinicians, dropped by, so that there were about 10 of us in the room in the end. Our hosts had thoughtfully picked up some soft drinks for us ('Stoney' -- Uganda's gingerale, and "Miss Angela"s favourite) and we discussed the differences between our medical systems, and the student clinicians' future goals. There was an aspiring obstetrician, an aspiring neural surgeon, and an aspiring cardiologist in the room -- it seems many Ugandans become clinicians so that they can work for a few years at a relatively good wage to save money for med school. They had a lot of questions about becoming a doctor in 'Canada' (by which they seemed to mean 'North America,' since one of them hoped to go to Johns Hopkins, and last I checked Baltimore hasn't defected).

It's certainly clear that medicine in Uganda is a very competitive field, and that student clinicians work very, very hard to gain the skills they need to get good jobs and build futures for themselves. Several of the clinicians also mentioned wanting to train in North America or Europe in order to bring their skills back home to their people -- certainly a noble goal, but it's not clear that they really understand how different it is to practice medicine with access to so much technology, how easy it is to become dependent on the technology, and how hard it might be to transition between the two. We certainly wish them all the best.

the humble and the haughty

Alix: No births today. At least not directly. The ward was quiet when we arrived. A woman was pushing with a Ugandan student attendent. After 45 min with seemingly no progress I gently inched my way in- taking blood pressure and pulse, listening to the fetal heart. I had asked the woman's history but the student just shrugged. It is delicate because I didn't want to undermine the local student. I finally did a VE to find what I had expected- the poor woman had been pushing on a lip of cervix which had begun to swell.  I had her lie on her side and not push. After an hour the cervix was gone. After another 40min the head had only come down 1/2cm.  I had discussed the dystocia with the student who continued to shrug- I had asked her if the pelvis was adequate, if she thought oxytocin may help, if she thought the head was low enough for a vacuum. Finally I announced I was calling the doctor for a consult because I suspected the baby's head was too big for the woman's pelvis and the student told me that the doctor had already come in early this morning and said that was the case and the woman was scheduled for cesearean.  Why she had not told me earlier I don't know. When I asked he why she hadn't shared this info hours earlier or charted it, she left the room in a fit of laughter. I was so upset I missed the IV twice when preparing the woman for the OR. Thankfully the doctor came in at that moment and kindly helped me with the IV and did the catheter himself.

 This was one of the most frustrating moments of my life. This isn't the first time that we have assessed women before having a chart. Its not the first time that we didn't know a woman had been obstructed for many hours before we arrived. I am not sure why this particular instance was so frustrating.

Upon closer examination of the chart I realized that at 11pm the night before a doctor had suggested a cesearean. I had written in the chart several times but found the first entry illegible and hadn't tried to decipher it, not to mention that she was pushing when I came in so I jumped into action anticipating a delivery soon. Had I read the chart I could have spared the woman the wait & see. She still would have waited just as long for the OR to be ready for her cesearean though. Thankfully, she and her baby were well in the end.

I have now learned my lesson. Handover/debriefing from one shift to another does not happen here. We always assess the supplies when we first arrive on the ward and now we will check the charts too-no matter what action is ongoing when we first enter. I now know that I mustn't give up on illegible writing on a chart. Thankfully this student was the exception, most are wonderful and we will miss the current batch, whose rotation on maternity ends tomorrow.

Carolyn: Alix mentioned an indirect delivery...I was doing some charting, I don't remember what I was charting, when someone rushed into the room to say that someone was delivering in the antepartum ward. I prepared the oxytocin and ran to the other room; when I got there, the head was already delivered, but unfortunately the baby was obviously stillborn. I gave some suggestions to the midwife who was delivering and and I also delivered the placenta. Despite the sadness, it was also a satisfying moment for me to feel that I actually knew what I was doing!

Today we heard some rather unsettling news. We have long known that Ugandans do not accept blood from foreigners and we didn't know why. It appears that many Ugandans, including educated ones, believe that blood from the Muzungu tribe is weaker than Ugandan blood, and is therefore not good for Ugandans. I'll let all of you to decide what to make of that.

Some of our days here are so positive, enriching, and inspiring. (Ie. yesterday's post) and other days are disheartening beyond belief. Disheartening, frustrating, where you want to leave the ward screaming. Today was more of the later.

We are off to Mbale tomorrow- the journey will take the whole day. Alix willl then do interviews on Sun/Monday. We are very excited to be reunited with Sarah and Lyanne. We will miss Cathy and Mickey. We are humbled.

The week finishes with a bang...

Between the two of us, Lyanne and I assisted four mothers to birth their babies in two hours this morning. The first was lovely enough to name her beautiful baby daughter after us - Sarah Lillian (no one here can pronounce Lyanne's name). Unfortunately our first mother also went on to have a PPH. As Lyanne and I were working with one of the sisters to resolve the bleeding, I heard a call from the woman next door (and I should clarify that there are no doors anywhere - here in Mbale women are quite lucky actually, in that they have a half-wall partition and curtains between most of the beds which block sight, if not sound). This woman was having her second baby and was clearly well on her way to pushing baby out! I let Lyanne know what was going on and thankfully our first mom's bleeding had resolved and Lyanne was able to gather instruments and umbilical cord ties (otherwise known as the elastic cuffs off our sterile gloves). I caught baby, Lyanne arrived in time to be second attendant and I helped mom clean up. Just as I was preparing to chart, Lyanne was ready to catch yet another baby, and it was my turn to play second attendant. This baby needed some ventilation to get going, and as second that task fell to me. Thankfully baby came around with four minutes of PPV. I had just wrapped this baby up after weighing her and doing the newborn exam when YET ANOTHER woman began pushing out her baby on the bed closest to the infant warmer. This mother was having her first baby, but only took about half an hour to push out her baby. So we had:

Baby 1: born 09:30
Baby 2: born 09:50
Baby 3: born 10:30
Baby 4: born 11:20

With hardly any time to think and certainly none to chart in between! We are taking this afternoon off as well as tomorrow, and are looking forward to spending the day at the pool tomorrow, followed by seeing Alix and Carolyn tomorrow evening and sharing a meal with some of the student clinicians who we have gotten to know over the past couple weeks.


Posted by Sarah

Head and shoulders, hands & knees!

Carolyn had her first delivery on the ward today on hands and knees. This is exciting news as all women here are encouraged to birth on their backs with their legs up by the face. It is a challenge to get them out of that position and on their side. This really makes us reflect on the effect of "the gaze" on pushing positions. This lady was left alone until the head was basically showing and during that time she instinctively changed positions, none of which included her back. As soon as we would walk towards her, she would move to her back. It is my theory, and I'm sure it's not an original one, that women left alone will change positions frequently and will not birth on their back. I also think that as soon as attention is paid to them they become 'patients' which means on the bed and on their back. One of the benefits of homebirth, I believe, is that women feel less like patients.

This same birth also made us so, so thankful for rescucitation. The baby was born with no heartbeat, but within 1 minute of reses, the heart rate was good, and a few minutes later, began breathing. It's amazing!

Another woman came in today with the head already outside of the vagina still in the caul (or still being in the amniotic sac). Cathy received this baby. It needed a little help, but did fine.

Alix also had one delivery today with a women who was HIV + and symptomatic (she had fungal infections on her arms and kaposi sarcoma on her legs). Saying how sad it is to see these young HIV + women is the understatement of the year. Most seem well supported, but some women are highly stigmatized and kicked out of the family.

Every perineum this week was intact! Our greatest success was that we cleared the labour ward before we left.






We cleared the ward!



My ethics approval came through! Mbale on Saturday!

Today was another national holiday- Heroes Day. I have reflected on our local heroes. Particularly Prossy, who takes care of women so they don't die over the night shift and saves babies that are born weighing under 1kg with only shoestring supplies. Cathy and Mickey have built lasting relationships in Uganda, Nepal and Nicaragua. They train Canadian students, offer CMEs abroad, and support midwives from around the world to attend the ICM. Today's photographs feature these heroes.


Prossy proudly posing with a premature baby on discharge day- 3 weeks old. The baby weighted less than 1kg at birth and Prossy nursed it to health with only shoestring supplies.



Mickey standing outside the maternity building in Masaka



Cathy and Prossy working together on a difficult IV


 

Routine

Sarah and I are starting to fall into the routine here in Mbale. Tuesday was a very quiet day, though unfortunately it started off with the news that three mothers died Monday night, two of post-partum hemorrhage, and one while waiting for surgery for her ruptured ectopic pregnancy (the operating room was in use for another cesarean). The hemorrhages were both complicated by the lack of resources -- the labour and delivery ward was out of I.V. equipment, and unfortunately it's very difficult to re-stock in the middle of the night. It was very sad to hear the news, and our hearts went out to the midwives who had been on night shift -- they did their best with what they had available, and obviously they were grieving the loss.

Wednesday made up for the slow day on Tuesday! Sarah and I were running from one woman to another all morning, not even having time to chart one birth before another baby turned up! We also did a number of resuscitations before noon, and we finished the day off with a "palpation and early labour assessment" lecture for the student clinicians -- this time 45 students turned up for our "class"! We've learned that the student clinicians have had a rough term, with their instructors going on strike for 3 months -- no wonder they're eager to catch up before their exams. One of the more hardcore clinician students has been showing up at the ward by 6:00 every morning, hoping to observe as much as possible, taking breaks only to attend class, and he still showed up to learn about palpation from the two of us at the end of the day. It was a bit funny trying to teach about pelvimetry, because in Canada we tend to assume that women have "adequate" pelvises to push out their babies, but we did our best!

One of the student clinicians was kind enough to give us a Lugandan lesson, which is fabulous for working with the 15% of women in Mbale who speak Lugandan. :) One thing we discovered is that we were mis-pronouncing the word that we thought meant "contraction" -- and the word we were using actually means "pubic hair." Whoops! No wonder we were getting some funny looks!

Some interesting things we've seen this week include:
- A face/brow presentation -- the baby was trying to come out face-first!
- Two "retained twins" -- one twin was born at home, and the woman transferred to hospital to deliver the second -- this happened twice the same day!
- A cesarean section for a woman with a "didelphic" uterus -- a heart-shaped uterus with a septum down the middle -- she had a cesarean, so we were able to see the uterus up close
- A beautiful ginger-coloured cat hanging out in the post-partum ward
- A baby with a significant hydrocele
- The "family planning" unit of the hospital -- they do really amazing work there, including screening for cervical cancer by visual inspection (because pap smears aren't available)



Things we miss:
- Friends and family (of course!)
- Soap and running water in the hospital! Hand sanitizer just isn't the same!
- Toilet paper, toilet seats, and hot showers -- did we mention that our dorm is a bit rustic? :)
- Being able to communicate with labouring women by talking. Some of the women have excellent English, but with most, we have to rely on body language and gesture, which isn't always the most effective way to get a point across or gain consent for a procedure.

Things we love:
- The rain! It's rained almost every day here, often huge, dramatic thunder storms that come on quickly and end ten minutes later. Often it means a power outage, but the rain storms are so powerful, and the lightening so dramatic, that they're really beautiful to witness
- Laundry. It's weird, but both Sarah and I have found some sort of strange zen moments through hand-washing our laundry every morning and hanging it out to dry on the line. It's possible that the novelty will wear off soon.
- The food! Cheap, delicious Indian food, 5 cent samosas, and fresh, cheap fruit for sale within a short walk of the hospital.
- The women here are incredibly strong and stoic. It's just amazing to watch them labour and birth with such grace, and they and their families are clearly very grateful for the care they receive.
- All of the beautiful, beautiful babies.

Posted by Lyanne

A Quiet Day

Today Carolyn went to the village to visit the wife of one of the hotel's staff who delivered the other day and then joined me on the ward. On the ward we had one birth each and another woman delivered outside.  Late lunch at the Danish NGO and then I went down to print out my research papers. Keep your fingers crossed that my ethics approval comes through tomorrow night! If it does then Carolyn and I are off to Mbale on Saturday. We are really looking forward to re-uniting with Lyanne and Sarah and to travelling to Jinga and then we are off on our Safari.

What is this? This is a blog post!

Today we had a pleasantly slow start due to a torrential downpour.  We arrived at the hospital around 10:30am and the delivery room was calm and nearly empty, there were plenty of supplies and there was a clipboard holding the charts of the women present!  Alix successfully started an IV (2 for 2) and attended a perfect mutlip birth of a healthy baby girl born to a healthy mum. We augmented a woman with ruptured membranes, prepared a woman for cesearean and observed as Mickey managed two miscarriages- one with misoprostol and the other D&C (2 prior doses of misoprostol had been unsuccessful). Finally, Carolyn attended a very precipitous birth- the mom progressed from 4cm to birth in 10 minutes! Thankfully both mom and baby were fine, though mom's bleeding was a little worrisome so Carolyn gave misoprostol. Normally, IV oxytocin would be the medicine to start with, but since IVs are in such short supply and the bleeding was slow this was a better use of resources.

Cathy and Mickey treated Prossy, Carolyn and I to a lovely dinner at the Danish NGO. Nancy, a nursing instructor from UBC who is here finding placements for nursing students for 2012, joins us in Masaka tonight and has brought us peanut butter and bug spray. Just in the nick of time too-we ran out of peanut butter and Bailey's this morning. While Bailey's is a luxery we can live without peanut butter is an essential!

We are finally getting used to a unique figure of speech here. Ugandan's will tell you something by stating a question and then answering their own question. E.g. "What are we learning today? We are learning the partograph. What do we chart on the partograph? We chart the contractions." Whenever this happens we are puzzled as we feel we are expected to answer the question but you haven't a clue. Alix mastered it this evening when visiting the Masaka Hospital staff accomodation. She said, "This is the accomodation for who? The staff of  the hospital."  Carolyn in particular has mastered the Ugandan way of speaking, with pauses and figures of speech, as evidenced by her role playing a Ugandan midwife while Alix practiced her MVA interviewing.

The first birth of the day,  Alix (in her new uniform), Cathy

Carolyn and the mother who laboured in 10 min

"Slip, I hate you"

Monday morning found us back in labour and delivery in Masaka.  Alix finally figured out the trick to the ungainly IV cannulas. In the morning both Alix and Carolyn "received" (Benon coined this lovely term) first babies, each requiring a minute of bagging to help them expand their lungs. The mother Alix attended had hypertension (seizure risk), meconium (the baby pooed in utero- the poo can then be inhaled) and the umbilical cord was inserted into the edge of the placenta and ran through the membranes (very risky when the water breaks)- I feel like we dodged several bullets given that the baby only needed a few puffs of air.

The back of Alix's uniform became soiled after an IV mishap and Prossy scolded her, "Alix, why did you soil yourself?" After several midwives had a laugh, Alix was loaned a teal nurses dress in the local style (Carolyn got one to match). On our lunch break Alix let Carolyn know she was thrilled to have the opaque teal dress because it meant she could go without the polyester slip that sticks to loins her for the entire sweaty shift. "Slip, I hate you," she declared.

After lunch there was a retained placenta that could not be manually removed because the cervix had closed too much to allow Carolyn's (or anyone else's) hand to fit in the uterus. She had to go to the OR. Alix then delivered a 22 week breech stillbirth. These are tricky because the tiny body is delivered before the cervix is fully dilated and there is a risk the larger head will get trapped. Thankfully that didn't happen this time but the woman did have some small bits of placenta that were retained. Luckily they could be removed from the cervix by hand.

As we arrived home some young North Americans were checking out the cable channels in the room next door, hoping to stay up all night to watch the Stanley Cup Finals. We listened through the door as they decided that the hotel didn't have the right ESPN channel and left. Many a Canadian would be thrilled to find some countrywomen/men next door to watch the Canuks with at 3am, but we are no such Canadians. We were grateful to hear them move on so we  could get some much needed sleep. This got me thinking about the things we do and do not miss.

Things we miss:

-People: partners, family, pets & friends

-Food: pickles, cheddar cheese, leafy greens (especially salads), whole grains, toast with almond butter & honey

-Medical Supplies: self capping IV cannulas, blue pads, charts

-Misc: guitar, cooking

Things we don't miss:

-hockey &TV in general

-the rain

-the waste (disposable birth supplies)

Our friend at the hospital canteen

Posted by Alix & Carolyn

Mount Elgon and Monday

On Sunday, Sarah and Lyanne went hiking at Sipi Falls, near (on? we're not entirely clear) Mount Elgon, about an hour outside Mbale. The scenery was breathtaking; the area is primarily a farming community (growing San Arabica coffee, and Matooke 'bananas'), so it was very lush and green. The hike was "at times strenuous," but we made it -- even though at one point, as we huffed and puffed up a hill, we were passed by a couple of girls who looked to be about 10 years old, both walking barefoot, both carrying giant bags of corn on their heads. :)
Monday we were back on the wards. Sarah had two quick catches while Lyanne stayed with a lady who was having her first baby. It was Lyanne's first time doing an episiotomy, but our tutor, Angela, kept reassuring her that the prompt delivery probably saved that baby's life. The baby needed a little bit of resuscitation, but was doing well within a few minutes. The two of us also did a resuscitation for a cesarean all by ourselves -- a milestone for both of us!

We had offered to do a quick course on neonatal resuscitation for some of the clinician students who we've been encountering at various times on the ward. One of the more outgoing students, Denis, had asked Angela if we could teach him how to resuscitate a few days ago, and Angela offered that we could do a quick course for him and some of his colleagues after their classes today. We were expecting maybe 4 or 5 people to show up -- there were over 30! We had students standing in the back of the room, and peering in through the windows to get a better view! Among other things, we emphasized not holding the baby upside-down by the ankles -- hopefully if nothing else, a few of the clinicians will take that message away from the session.

We have discovered that Mbale seems to specialize in (East) Indian food -- we tried out a new restaurant today and it was fantastic! We certainly didn't expect to be enjoying excellent palak paneer and chicken tikka masala in small-town Uganda!

And at last -- we managed to upload photos! (Sorry it took us this long, Mom!)

The ant hill in the garden on the hospital grounds in Kampala:

 Lyanne and Sarah outside lower Mulago hospital, in Kampala.

 The labour and delivery ward in Mbale:

 Bicycle parking at the hospital in Mbale:

 The toilets at the Trade Show. Let us never again complain about the port-o-lets at the PNE!

 View from above Sipi falls. Note the ubiquitous cows.

 Intrepid trekkers, with one of the Sipi Falls waterfalls in the background (and another cow. If you've ever donated to a charity that bought a cow for a family in Africa, I think we've met her. The cow, I mean.)

 Eat local!

Fire ants, drums and dusty roads

This weekend we had an adventure and went to Mpenga eco-forest, two hours from Masaka. This forest is the home of quite the variety of animals, birds and insects. There are the red and black tailed monkeys which we got a glimpse of, the hornbill birds which are black and white and hard to find. We believe they must know this as their call sounds like they are cackling at us. There are also beautiful butterflies of all sorts, including an elusive green one that we were unable to take a picture of, and thousands of spiders. Our least favorites were the safari ants that come in the thousands. Unfortunately for Carolyn, she got to feel first hand what it feels like to get bit by one of them. This made us both somewhat skittish the rest of the time, jumping every time something got into our sandals. Perhaps runners would have been a good idea!

In the afternoon, we tried to follow the butterfly trails, but missed the landmark and ended up in a little village. This was an interesting experience as we hadn't had the chance to see what a litle village was like. The local children were fascinated and called out to us frequently. A few followed us for a while and we took a picture of them. We finally found the main road and walked a way to Mpingi where many people make and sell drums. Carolyn bought a drum for Seth and is hoping that he won't be too horrifed by the fact that the next day she sat on it while waiting for a ride :)

So the next day found us back on the main road waiting for a taxi bus called a matatu. It was horribly hot and dusty. We waited over two hours before we finally found a ride back to Masaka. We think we were very fortunate as we really could have waited for hours!

The biggest tree in the forest- a fig tree

Papyrus in the swamp

Fire ants!

Praying mantis

Termite/ant hill

Our accomodations=the banda.  A bamboo house on stilts in the forest.

A millipede 5'' long

Waiting to flag down a matatu

Lucien and Alex gave us a ride home.