Five Cent Samosas

Today was a Ugandan holiday, so we thought maybe we would have a quieter day on the wards.

Not so much.

First thing when we arrived, Sarah was the 2nd attendant for a baby caught by one of the Ugandan clinician students. These students have been on the wards every day with us, and they travel in packs of four or five. Clinicians have a scope equivalent to Nurse Practitioners in Canada, and in Uganda, their third and final year of education seems to consist of spending one week rotations on every ward of the hospital, with a break in the middle for lectures. They are all very eager learners, but labour and birth are not necessarily their area of expertise, and they aren't supervised. We’ve both taught them how to do newborn exams, and we’ll be teaching a neonatal resuscitation class to a group of them on Monday.

While Sarah was busy taking care of the baby and preparing oxytocin, Lyanne started an assessment on another lady on the ward. Her chart said that she had been fully dilated for 10 hours, which is not typical for a woman who has already had three babies, and an ultrasound report in her chart (scan done the day before) had diagnosed a live breech baby with multiple anomalies. A quick exam revealed that the baby could not, in fact, be breech, because the baby’s arm was coming first.  Unfortunately, there was no fetal heartbeat, and the woman was in agony after many hours of hard labour. Two hours later, we headed into the OR to watch the cesarean section; it was clear from looking at the baby that he had been dead for some time, but that he did not have the anomalies the ultrasound had mentioned. The other day we met a lady whose ultrasound reported twins when there was only one baby present; we know ultrasound in Canada, like all tests, has a margin of error, but these examples take things to a whole new level. Once again, it made us realize how lucky we are in Canada: to have relatively accurate diagnostic tests, to have effective pain medication for labouring women who need it, and to have prompt access to surgery when there is an obstetric emergency.

We immediately went in for a second cesarean, this time for prolonged labour with an inadequate pelvis (in Uganda, many women have small pelvises, likely the result of childhood malnutrition); this time the baby came around quickly and enthusiastically with only a minimal resuscitation. For those keeping track, this is the first time we’ve had a completely successful resuscitation, so that was a bit of a relief.

Things seemed quiet, so we stepped out a quick lunch break; when we came back, a woman’s screams had Lyanne and Sarah running in to see what was happening. For the second time in three days, we walked in to find a breech delivery in progress, being attended by an inexperienced practitioner who was telling the woman to push; in both cases the body had delivered but the head was trapped behind the (not fully dilated) cervix. This is A Bad Thing, because the umbilical cord also gets trapped by the cervix, so the baby's supply of oxygen is compromised. Angela quickly came to help, and Sarah realized the woman in the next bed was about to push out her baby, so Lyanne ran back and forth between the two. Unfortunately, the breech baby died before the cervix was fully dilated. The woman’s reaction was incredibly touching and humbling; she thanked us for the care, and kept telling us that she was okay. Meanwhile, the baby that Sarah caught needed a tiny bit of help to get going, but not a full resuscitation. We certainly had our hands full.

Just as we were recovering from all of this, a woman was carried into the ward, wrapped in blankets. A different woman who had birthed 15 minutes before was told to vacate her bed to make room for the new arrival (did I mention it turned out to be a busy day?)  and it was clear that the woman who had just arrived was having a severe antepartum hemorrhage, which we suspect was from a placenta previa (a low placenta that covers the cervix). Her blood pressure had tanked, her pulse was through the roof, and Angela and one of the local midwives had quite the time starting IVs to replace her blood volume. There was no fetal heartbeat, and the woman’s relatives were sent out to buy blood for transfusion. We were asked to be in the OR for resuscitation, but the surgery was delayed; the woman’s relatives had to go out to buy suture materials, alcohol (for disinfectant), and other materials, and the anesthetist had to arrive. Bleeding this severe would be in the OR within minutes in Canada, so it was very difficult to watch and wait, yet again, for necessary treatment, as a result of lack of resources. By the time we headed home, two hours later, the woman still hadn't been moved to the OR. Can you imagine delaying an emergency cesarean to send a woman’s husband or sister off to buy suture materials and disinfectant for her surgery?

While we were waiting, Lyanne had a quick catch of a healthy baby and Sarah was 2nd attendant; everything went very smoothly, except that again we had to rush the woman up and out of bed to make room for someone else. It was good to leave on a happy note after a normal birth, and we barely had time to get dinner before dark.

On another happy note, our dinner was truly spectacular. We bought lentil samosas, rolexes, and tomatoes from street vendors just outside the hospital grounds; our dinners cost less than $2.50 each for plenty of food.

We have tomorrow and Sunday off – hopefully this will give us time to finally upload some photos from our adventures. :)