Mbale continued...

Phew!

We have spent three days in Mbale now, and I’ve seen more in three shifts here than I likely would in three months in Canada. For example, today began with a review of the past 24 hours in LDR and postpartum. A representative from each ward was present, and negative outcomes were reviewed. We learned that a woman had come into labour and delivery an hour and a half before with a prolapsed cord, but as the operating theatre, and in fact, the entire hospital, had no suture material in stock, she had not been prepped and sent in for cesarean and was still labouring. Angela dashed back to our dorm, two minutes away, and brought back all the suture material that we had brought from Canada. Lyanne, Angela and I then prepared to go into the OR and resuscitate the baby. Protocol is slightly different in the ORs here – they have no booties to cover our ward shoes, so we were first directed to change into open-toed sandals (pink for me, brown for Lyanne) to wear into the OR. In the end we found enough mismatched white gumboots to go around, and entered the OR in those.
     When the baby was delivered, it had no heartbeat. We went through NRP protocol and attempted to resuscitate the baby with positive pressure ventilation and chest compressions for twenty minutes, but unfortunately we were unsuccessful in bringing this baby around. As we left the OR and weighed baby and began to debrief the experience, we noticed another woman pushing. It was her third baby, so I donned my double pair of gloves and Lyanne rushed around as second attendant, finding oxytocin, blankets and instruments. Just as the baby was about to be born, however, Lyanne was called to another delivery. Angela took over as second for me, and had just enough time to do the same for Lyanne when her client delivered ten minutes later. Thankfully both women birthed easily and both babies were healthy.
     Not very much longer, a woman who was having her fourth baby began to sound pushy. Although she was not fully dilated, she could not control her urge to push. Knowing the risk of cervical swelling and cervical tearing if a woman pushes on an undilated cervix, we tried all our midwife tricks to dilate the rest of the cervix and decrease her urge to push. In the end, she pushed out her baby on a cervix which was dilated only to 8cm. Baby was born followed by a big gush of blood which had us all alarmed about a potential cervical tear and PPH. Thankfully, we were able to staunch the bleeding, and on examination the cervix, while certainly not fully dilated, was not torn. Baby and mom were absolutely fine. I believe it was at this point that Angela and I looked at each other and burst into laughter – half from relief, half from incredulity. One of the student clinicians came up to me afterward and said, “Sarah, I think you are very bizarre. Also, I think you should teach us clinicians your skills.” And I thought to myself – bizarre and skilled, maybe I really am on my way to becoming a midwife!
     We were to have three more deliveries that shift. Two vacuum deliveries followed, the first straightforward, the second devastating. The second mother had a placental abruption, and baby was born still. Lyanne and I attempted to resuscitate baby, but as with the baby earlier that morning this baby never had a heartbeat. Meanwhile, the mother went on to have a very serious postpartum hemorrhage, and ended up with a hysterectomy. I have no idea whether this woman had previous children, but my heart breaks for her – to lose a baby and then lose your uterus is tragic indeed. The final birth of the day occurred amid all the craziness from the second vacuum delivery. We heard someone call “masow!” (doctor) and turned to see a woman who had just birthed a crying baby girl on the bed. Once again, we saw the contrast between an incredibly straightforward, normal birth (no midwife required!) and a devastating, dangerous birth for both mom and babe. A wise woman told me before I left Canada that my trip to Africa would teach me more about death than it would about life, and I am trying to take these lessons to heart. Right now, my mantra seems to be “trust birth, but don’t take it for granted.”
     Despite the craziness, the heartbreak, the tragedy, I find myself loving my work here more and more every day. I get laughed at for my ‘post-birth highs’ – the adrenaline rush is only magnified when you are at six births a day. Even better, I know that my skills are improving with every birth, and I’ve been able to pass on some small pieces of knowledge to the others who are working here – in particular the student clinicians, who seem to get little if any one-on-one instruction. I’ll be the first to admit I began this Ugandan adventure with no small amount of trepidation, but I feel more comfortable, confident and competent every day (Angela refers to me on the ward as being ‘in there like a dirty shirt’ – I’m not quite sure what that means but I’m taking it as a complement). In conclusion, life is beautiful, life is tragic, life is complicated, and here in Mbale life is anything but monotonous.