The End!

3 out of us for us are now safely back home: Sarah, Lyanne and myself. Alix has now been reunited with her husband in Casablanca is off to new adventures for a couple of weeks.

It will be interesting as the summer months go by to reflect on what has changed for us after this experience of practicing midwifery in Uganda. How have we changed within? How have the way we practice midwifery changed or will change? It is impossible to go through such an experience and stay the same, nor would I want to. Certainly all of us now feel more confident about practicing many skills, and dealing with emergencies. There is a renewed commitment to women's health, reproductive choice, and the 'art' of midwifery. I hope there is more mindfulness, more appreciation for what we have, and more compassion.

There are also aspects to going back to work in Canada that I anticipate will be challenging. Dealing with the overabundance of supplies which leads to so much waste will be difficult.  Consider that in a 24 hour period, approximately 30 birthing women will fill up 3 small garbage pails while in Canada,  one birth will fill one laundry bag and one garbage bag! I also foresee that another challenge will be to maintain sterility in the way that is expected in Canada. Finally, after seeing women be in labor for days, DAYS, without any pain medication, I believe it will take somewhat of an effort at times to continue to be present to a woman who is finding it difficult to cope while she has been waiting a 1/2 hour or an hour for an epidural. I may dislike to admit that, but it is true. So to sum up, what will be most challenging will be to keep births in Africa in their context and keep births in Canada in theirs.

Thank you to all of you who have read our blog and have written us with your kind words and encouragement. It was much appreciated.

Carolyn

And then there was one

Today is my last day in Uganda. Lyanne and Sarah flew out on Friday morning and Carolyn left early this morning. Tomorrow I fly to Casablanca to meet my hubby. What does one do with her last few hours in such a remarkable country? Well, she does laundry, on-line check-in, seeks out some waxing services (I have some serious hair growth after two months which seems fitting here in Uganda but unfit for someplace as glamorous and Casablanca) and then I will go to the Wildlife Rehabilitation Centre to see the few animals who evaded us on safari (hyenas, mongoose, and the giant shoebill bird).

There is so much to catch you all up on. Carolyn and I had a very rejuvenating last few days. On Thursday morning we took a matatu to Kampala then to Luwero town on our way to volunteer at Shanti Uganda. Getting there was an adventure as we didn't yet have an address or phone number- we guessed that it was in Luwero town (since Luwero is a district). When we arrived in Luwero town we set about asking boda  boda (motorcycle taxi) drivers if they had heard of the place while we searched for an internet connection. After 10min we found someone who new the place.  I wanted them to tell a car taxi how to get there but they didn't want to give up the fare so for the first time we gave in and got on the boda bodas with our 40lb backpacks on our backs and our daypacks on our fronts and Carolyn's drum resting on the handlebars. Off we set riding on a motorcycle down dirt roads in the village- what a thrill! The boda boda driver was true to his word and delivered us safely.  The only hitch was that Carolyn was in a skirt which she had to hike up to her thighs to ride the motorcycle which resulted in her scandalizing a quarter of the village.


Upon our arrival we were given the tour. There first structure is a waiting room, prenatal exam room and a 5 bed postpartum dorm room in a cob house painted a sunny yellow with recycled glass bottle windows.  The next building has two birth rooms with lovely double beds, shelves for birth equiptment and a shared bathroom with a sink, western toilet and a small but deep tub. There is also a small lab in this building where instruments are boiled daily, supplies are stored and bloodwork is done. They can test for pregnancy, malaria, HIV and blood group. They gave us a tour of their demonstration gardens planted with food crops (corn, watermelon, pumpkin, gooseberry) and medicinal birth plants (aloe for heartburn, hibiscus for anemia). Finally there is a large open air banda (a round building made of mud with a thatch roof) and it is here that the teen girls group meets, prenatal mothers do yoga and HIV+ women meet weekly to make beads and sew bags.

We taught the two midwives about shoulder dystocia and they taught us baby massage which we had both heard of but had never seen before. We then had the pleasure of meeting with the HIV+ womens group to colour signs to welcome the new director Sadi, who is arriving next week. After colouring the women changed into their pants and we got in a circle to do yoga. This was a RIOT! The most fun yoga class ever. A volunteer led the class and the local women are welcome to jump in and suggest a pose. Their favourite poses involve animal sounds- cat and cow was hilarious. They especially loved it when Carolyn taught them lion and they got to roar!

Yoga with the women from Shanti Uganda's income generating group

Carolyn demonstrating rebozzo techniques at Shanti Uganda

Unfortunately you will note I didn't mention accomodation on site so it was back on the boda boda with all our luggage and into town for a night of very stimulation conversation with Kristen (Shanti Uganda site director), her sister, a volunteer and a man from Free Trade Vancouver who was researching the sustainability of Shanti's products.

The next day we taught the midwives about hip squeezes, counter pressure and rebozzo techniques and they taught us a prenatal yoga sequence. We reviewed shoulder dystocia with them and made posters about shoulder dystocia management and the hip squeeze/rebozzo techniques so they could teach the other midwives. It was so lovely to see such a compassionate and holistic example of birth at the end of our trip.

Thursday night we went back into Kampala. We stayed at a great hostel, Tuhende, where we met a woman travelling from the Netherlands who joined us for dinner at an Indian restaraunt. While there two chaps from UBC also joined us (small world) and then Jennifer, Prossy's daughter came along after dinner. Again- wonderful stimulating conversations!

Friday morning we had breakfast with our friend from the Netherlands and a new friend from New Zealand and we all traveled together to Entebbe. We spent the afternoon by the pool and had a wonderful last dinner together (with creme brullee and martinis).

Posted by Alix

Home!

I got home safely, and am visiting family in Ontario. Fortunately, I got home in plenty of time to get to my cousin's wedding -- congratulations to Natalie and Kabez!

Sarah and I parted ways at Heathrow, because she flew into Vancouver, but I heard from her this morning and she arrived safely as well. Alix and Carolyn are still in Uganda for another couple of days.

Thanks, everyone, for following along with our adventures, and I look forward to reconnecting with you now that I'm back in Canada! We have updated some previous posts with new photographs, so take a quick scan through if you're interested!

Posted by Lyanne

We're leaving together...

This morning, Sarah and I managed to successfully navigate the Ugandan public transit system, and we've now arrived at the airport guest house in Entebbe.

Our last day in Mbale was very touching. We went to one birth (Sarah caught, and did a beautiful job) and we dropped off all of our leftover medical supplies; they were gratefully received. We also went by Family Planning, to say goodbye to our friend Grace. We gave her a head lamp as a gift; midwives here do cervical cancer screening by visual inspection, and her lamp hasn't worked properly for months, so she was very excited to have a new hands-free model!

We had ordered a cake for the Sisters on the ward as a thank-you gift, and prepared special gifts for each of the sisters who had supervised us these last two weeks. Little did we realize that in Uganda, a cake is A Big Deal. The student clinicians had suggested that we write "To love and serve" on the cake -- that seemed nice enough, so we agreed. It turns out these words are the last line of the Ugandan Nurses' anthem, and Sister Rose, the head of the labour suite, sang us the anthem when she saw the cake. We had a lot of fun taking group photos, and at the end of the day we gathered to cut the cake. First there were speeches, thank-yous, and prayers, and four of us held the knife together for the first cut, wedding-style. The sisters all had incredibly kind words for us, and we were both a little sniffly as we stepped out the door for the last time.

Sisters Rose and Rosemary with their cake

Later that evening, Sister Irene, a midwife we've worked with quite a bit this week, dropped by our dorms, with gifts for us and for Angela. Once again, we were incredibly touched, as we know that midwives here are not wealthy. We also had a lovely visit with her, and it was lovely to get to know her a bit better.

Our lovely farewell cake

In the evening, we had planned a farewell gathering with the student clinicians, and yet another cake. This is when we learned the four rules of cake:
1. You don't pray before cake.
2. You don't wash hands before cake.
3. You don't grab, you "pick" (dainty fingers!)
4. You don't "leave the bones" (this seems to mean that you eat everything)

Picking, not grabbing

Before getting into the cake, we all sat at a table together, and every student said a farewell speech, with the two of us speaking last. It was very sweet, and very touching. Both Sarah and I were very happy to have made friends in Mbale, but I don't think we realized how much they enjoyed our excursions, or how much they felt they'd benefitted from our teaching sessions. Once again, the cake-cutting was very elaborate; five of us made the first cut together, and then all of the clinicians took turns posing for the camera while cutting the cake. The group did an excellent job making the giant sheet cake disappear, and we couldn't have imagined a better way to spend our last night in Mbale. Not only that, our noisy dorm-mates had left Mbale earlier that day, so we were treated to silent surroundings when we headed to bed.

The whole group of us

One of the student clinicians, Denis, accompanied us on the bus as far as Kampala, and then took us to his sister's house for lunch. He had assumed we would take a boda-boda from the bus stop; we were both a little relieved when he decided we had too much luggage, and found us a safe taxi instead. His sister's house is beautiful, and lunch was delicious, but the television in the living room seems to be constantly on "E!" network. Sarah and I found that the celebrity gossip and vapid TV shows were a little much after not watching any TV for nearly two months. We were sad to have yet another goodbye today, but we're looking forward to a series of reunions when we get back home!

Our last day!

We are finally finished! Today was our last day at the hospital. When we arrived there was a mother who sounded like she was in very active labour. Her chart said she had been 6cm at 7am but when I checked her at 10:15am she was only 3cm...not even in active labour yet. Carolyn and I decided since there were many beds free we would keep her in the delivery room in case the birth was precipitous- you always wonder when a mother who has given birth before is labouring so hard at only 3cm. Her labour became so active I stood beside her and held her hand until 10:55am when I saw the head and called Carolyn. The delivery was the perfect normal birth- baby well (though only 36 weeks) and mom well, perineum intact! Carolyn spent the rest of the morning teaching the new batch of students that arrived on the ward the other day- she taught them how to use the partogram and manage a postpartum hemorrhage and I taught them how to chart a delivery note and manage a shoulder dystocia. I finally pinned down the doctor to interview for my MVA research- I have 14 interviews now. 

Traditionally UBC students have left little goodies as a thank you to the staff. This year we made each staff person a goodie bag with a black pen (There are never enough here), a few cookies, instant coffee and a few chocolates. They  were warmly received. 

We have gone into Masaka town to celebrate by picking up the clothes we have ordered at the tailor (with amazing African fabric), to use the internet, and drink a few shandies before going back to the hotel to meet Prossy for dinner.

As we reflect upon our experience, there are many things that come to mind. As per Carolyn's post near the beginning of our time here, it is so clear how much WE have learnt and received from being here.  Our confidence in dealing with obstetrical emergencies has grown exponentially, our confidence in making sound management decision has increased as well. We have seen and learnt what it is like to practice in an extremely low-resource and rural setting. After being here we can clearly identify which resources are essential (oxytocin, gloves, saline and giving sets, something to tie the cord, something to cut the cord, a needle driver) and things that are not (a billion blue pads, clamps, warm compresses, superfluous catheter supplies etc).

We wish we could give the mothers who allowed us to receive their babies more than the hats and blankets, though they were gratefully received. And perhaps we did, so many of them thanked us profusely and told us that they had had a good birth experience. 

We have reflected on our favourite births. Alix remembers the woman who she feels she was able to provide really excellent emotional support to as this woman spoke English well.  This woman reached down to touch her baby's head while pushing and asked to see the placenta (a rare occurrence here). Alix was also so happy when she caught a supremely vigorous baby who cried on the perineum before his legs were delivered. Carolyn remembers fondly a birth that happened recently. The mother at first kept calling her 'muzungu', but Prossy told her to call her Caro, and thereafter, it was "Sister Caro, Sister Caro". She told Carolyn that she had had a really good birth experience which was so touching. 

Tomorrow morning we are going to take the bus to Kampala and then Luwero to visit Shanti Uganda's birth centre. Shanti Uganda is a Vancouver based non-profit founded by a group of yoga teachers.  Many of you know I sold Shanti Uganda jewelry made by HIV+ mothers in a income generating group as a fundraiser for my Uganda trip.

Picking up clothes from the tailor

International Relations

So I am going to attempt to write a post that has as little as possible to do with birth.

I feel Lyanne and I have been very lucky in Mbale, in that we have managed to make some local friends here. Of all the things I was expecting to find in Uganda, a social life was not one of them. However, especially since our return to Mbale, we have spent some part of almost every day with our new friends. Most of these friends are student clinicians, a ‘core’ group consisting of Denis, Paul, Francis, Deogratias, Castro and Kevin, and others who join us more occasionally.

As mentioned by Lyanne in a previous post, Friday night was spent seeing how they prepare a typical dinner. It turns out, dinner is cooked in their bedrooms, on a single burner set on a small wooden frame which gets electricity via two bare wires stuck into the electrical outlet (Kevin was very careful to make sure the outlet was turned off, and to use a pen…yes, a pen… to ground the current as he placed the wires). I later found out that Denis’ mother died when he was younger from electrocuting herself using a similar apparatus.

Lyanne, Francis and Denis

Denis cooking our feast

The final product - delicious!

Friday nights the clinicians always spend out at a club (Friday night is free for students) and so Lyanne and I decided to accompany them. Dancing with Africans is entirely humbling and entirely invigorating all at once – us white folk just do not know how to dance.

Sunday we attended Catholic mass, and later brought a few of the clinicians to the pool we frequent on the weekends. While the pool fee is the equivalent of $2 for the whole day, it is still significantly out of price range for most of our friends, and so we were only too happy to treat them. We had asked them all before they arrived whether they knew how to swim, and they had all assured us that they did – a blatant lie as Lyanne and I soon found out! Thankfully the pool is only shoulder deep, and the two hours spent attempting to teach these five grown men how to do something, anything graceful in the water were entirely hilarious.

Attempting to teach Francis to float

Tonight we had the honour of being invited out to dinner by Dr. Paddy. Although I try not to pick favourites, I find Dr. Paddy’s compassion for labouring women and outright glee at every healthy baby he delivers so refreshing, especially in a country where compassion in a health care provider is not exactly encouraged (Lyanne and I get laughed at for rubbing women’s backs during labour). Dr. Paddy is currently completing his internship year at Mbale Hospital. He took us out to our favourite Indian restaurant, and we got to pick his brain about his experiences over the past year, and also about his upcoming training in neurosurgery in another nearby hospital. We’ve been so grateful for Dr. Paddy’s warm welcome of our presence on the ward. I’m sure the OB/GYN wards will be very sad to see him leave in August, but I know he will do incredible things with his future training.

Dr Paddy

Tomorrow night is our last in Mbale. Thursday we make our way to Entebbe, where we fly out from early Friday morning. Tomorrow is the day we will give what is left of our supplies to the hospital and say our goodbyes to the labour ward staff. In the evening we are having a goodbye celebration with the student clinicians. We have purchased an exorbitantly priced strawberry cake for the occasion, and expect to share it with twenty or so people.

And so our day of departure approaches, and I find myself incredibly sad to be leaving. While the experience has been intense in so many ways, it has also been very affirming for me.  If I can love being a midwife so much in these circumstances, I must really have chosen the right career. Days are long and exhausting, and sometimes devastating, but there has never been a moment when I questioned whether this is what I want to do with my life.

Posted by Sarah

PS Dear Mom, please do not be alarmed that we have no female friends here. This merely reflects the 10:1 ratio of men to women working in the hospital (in our age range anyways).

Our last few days

On Sunday Prossy took us to her village, 5 miles outside of Masaka.  Incidentally, this is the closest village to Masaka. The people of this village must walk to the hospital, but their commute is far less than many other labouring women. We first went to visit Prossy's foster family. She was warmly greeted by her 90 year old jaja (grandmother) and her uncle. They welcomed us into their home and gave us pop and showed us photos of their family- Catholics who are closely related to one of the Uganda martyrs.

Prossy and her Jaja and Uncle

We then walked to visit the Good Samaritan School for the Deaf.  This boarding school houses and educates 98 deaf children from all over central Uganda. Most of the children come from poor families and only 5 pay tuition. The government provides only $80 of funding every other year. The rest is fundraised. Children sleep in bunkbeds two per mattress and their green uniforms are splitting at the seams.Despite this they are all fluent in sign language, can read and write and do math.

Good Samaritan School for the Deaf

Yesterday we spent on the antenatal (prenatal) ward. We observed a group HIV pre-test counselling session (albeit in Lugandan) and then we proceeded to draw blood from all 55 women who attended the session. This was great practice as between us we had only done venipuncture 4 times since we learned the skill in second year. We then learned how the point of care testing for HIV and syphillis is performed. 3/55 women tested positive for HIV, none for syphillis. Somehow, being witness to these pending diagnoses was more upsetting than working with someone who already knows their HIV+ status. We reconfirmed the 3 positives using a second kind of test- they were all true positives. The ramifications of this are huge- it is likely that these women will realize upon diagnoses that their husbands have cheated and infected them. When (if) they tell their husbands they will likely blame them and may beat them. If they already have children and this was their first test they will worry about their children's status and the status of the unborn.

Point of care HIV testing

Children at HIV Cares playing with donated dolls while their parents wait for treatment

We also got to see how a malaria blood smear is done and visualized the malaria parasites under the microscope.

Today started out very slow and boring. We had no power, no running water and no IV fluid for the majority of the day so it was probably just as well that it was slow. We did each attend a birth and Carolyn resuscitated the third baby that was born. One really scary happening was that a mom brought her baby from the nursery into labour and delivery after realizing its cord tie (a glove collar) had come undone and the baby was bleeding. This is very scary because babies only have about 400ml of blood. Thankfully Carolyn quickly retied and Prossy ran to provide an IV.

Tomorrow is our last day on the wards!

Sleepless in Mbale

Sorry about the radio silence from Mbale. We had a crazy day Thursday, and it's taken a while to process it. Time for a mega-update!

Our British dorm-mates have an unfortunate habit of coming home at 11:00 pm and drinking in the hallways of the dorm until 1:00 am. After eight days of early mornings after involuntary late nights, we are both very, very tired as we head into our last few days.

Thursday

Thursday was intense. Between us, we caught six babies, including one (Sarah's catch) who took a veeerrrrry long time to crown. That's not the intense part, though.

When we arrived on the ward, Lyanne was asked to assess a woman who had just arrived. She did, and that was all fine; meanwhile in the next bed (which is immediately beside the first bed, no divider or anything between the beds) a woman was labouring hard and growing distressed. This is not an uncommon sight on the labour ward. As Lyanne was heading out to chart her assessment on the first lady, the second lady's attendant mentioned that the woman was "having trouble seeing." Vision changes, in the maternity world, are closely associated with high blood pressure and a disease called "pre-eclampsia," which, if left untreated, can lead to seizures and is the second most common cause of pregnancy-related maternal deaths worldwide.

Anyway, at this point Lyanne got the woman to lie on her side, and quickly took her blood pressure. 166/120, aka really very high. The shocking thing was that this woman had been in the ward for 12 hours already at this point, and no one had taken her blood pressure in all that time. There was also a nurse from Mississippi on the ward that day, and she quickly set up an IV, while Lyanne tracked down her Ugandan-midwife-supervisor to ensure that the woman was treated with the appropriate medications. Unfortunately, at this point we couldn't hear the fetal heart; the baby had died. Once the woman was resting, Lyanne stepped out to do two quick catches, and Sarah took care of a woman having her first baby (the verrrrry slow one mentioned earlier); when we got back on the scene, the woman had birthed her stillbirth, and was just birthing the placenta (a Ugandan midwife, one of our supervisors, was caring for her). After the placenta came out, there was a rush of blood clots -- the woman had clearly had a concealed placental abruption (when the placenta separates before the baby is out, causing bleeding). The high blood pressure might have caused the abruption, and likely the abruption was the reason the baby didn't survive. It quickly became clear that the woman was hemorrhaging. The midwife set up a second IV, the American midwife put pressure on the uterus, Sarah gave medications and put in a catheter, and Lyanne took vital signs and kept the IV bags running. The midwife ordered blood for transfusion, but the blood bank didn't have any of the right blood type. The woman's blood pressure was plummeting, the bleeding wasn't stopping, and she started having seizures. The doctors arrived a few moments later; unfortunately everyone's best efforts just weren't enough. The woman passed away shortly afterward.

It was probably a good thing that we were kept busy for the rest of the day, catching babies on the ward, and going into the operating room to receive and resuscitate babies after two cesareans.

One of the cesareans was a bit crazy as well. The anesthetist decided to do spinal anesthetic; typically women here have cesareans under general anesthetic (in this case, Ketamine). A spinal is the same idea as an epidural; freezing around the spinal nerves. In theory, this is much more localized. If the woman lies flat on her back, however, there's a danger that the anesthetic will rise too high along the spinal cord, and rather than just affecting the nerves of the abdomen, it can affect the nerves that control breathing. This is exactly what happened. The anesthetist put in the anesthetic (after the oh-so-reassuring comment, "This must be the right place"), the woman laid down on her back, there was no way to angle her body at all, and after a few minutes, the woman stopped breathing and lost consciousness. Fortunately (?) the anesthetist seemed almost to expect that this would happen, and he moved quickly to ventilate the woman's lungs, so she was fine, and regained consciousness shortly after the surgery.

Unfortunately, the baby did not do so well. The baby would respond very well to receiving air from the bag-and-mask, and would start breathing on her own, but then would rapidly deteriorate whenever we stopped ventilating her lungs. She was also very blue in colour, and had an asymmetric chest; all of this suggested a heart problem. In Canada, this baby would have been put on a respirator, had some diagnostic tests, and then had surgery; baby would probably have been fine. Here, however, there was nothing that could be done. After consulting with the doctor, when we had been breathing for the baby for about an hour, we had to make the difficult decision to stop the resuscitation and to let the baby die.

Friday

There's a strange phenomenon here in Mbale. It seems whenever there's a really intense, busy day, the next day is very quiet. Friday was no exception. After the intensity of Thursday, we were shocked to come to work to find only one woman labouring. Sarah caught her baby. Another woman transferred in, and Lyanne assisted the doctor with the delivery; Lyanne's grandmother will no doubt be pleased to know that there's now another baby "Lillian" in Uganda. When that woman left, we experienced something we've not seen before -- the delivery ward was completely empty. Eight empty beds, and no one waiting on the bench in the lobby. Over the next few hours, a few women trickled in for assessments, but most of them were in early labour, so they went back outside. After two hours on an empty ward, we headed home.

Friday night, our student clinician friends cooked us dinner -- rice and beans. We met them at their dorm, and one of them brought a one-burner hotplate into the room. Fortunately, the power stayed on until five minutes after the rice was ready. It meant eating by candlelight,  but the food was delicious, and several of the students from nearby rooms joined us for the meal. We photo-documented the experience, but unfortunately we can't get the photos from Sarah's camera onto Lyanne's computer.

The Weekend

The weekend was lovely and relaxing. Perhaps the most newsworthy event -- Sunday morning, our friends took us to mass at the local Catholic church. Neither of us has much experience with Catholic services, but I think we managed to not do anything too embarrassing. The music was amazing -- no printed hymns, so all of the songs were repetitive with simple lyrics, but everyone in the packed church was singing, clapping, and moving to the music.

Monday

The most exciting thing today -- Lyanne caught a baby that came out face-first! This is not something that happens often; face presentation is relatively rare, and often these births end in cesarean, because the diameter of the face is much wider than the diameter of the top of the head, so these babies often have trouble fitting through the pelvis. The mom was incredibly strong, and it was really amazing to see.

The midwives here were all very sweet when they were reminded that this is our last week on the ward. One joked that she would have to tie a rope to our feet so that we couldn't go back to Canada. Clearly there are often international visitors in the hospital (we've seen several during our brief time here) but the midwives have been very welcoming, and they were happy that we came with some competance and a willingness to work hard. We might not miss the intensity of working here, but we will certainly miss the people.

Posted by Lyanne and Sarah

The ATM has captured my card

We have decided to post with some of our favourite Ugandan uses of words and turns of phrase, as well as some of our language errors.

"The ATM has captured my card."

"The matoke refuses to leave the spoon."

Matoke is mashed plantain- a staple here.

"Alix, why have you soiled yourself?"

This is what they say when you accidentally get blood on yourself.

"I have failed to deliver this mother."

When the mother's labour is not progressing. 

"They made us go to bible study in college, Imagine!"

"You are most welcome."
A common greeting when arriving somewhere new.

"Do you like peanut butter?" response "Uh ugh"
(really nasally, said the way my 4 year old niece does)

"The woman who went for c-section had a ruptured uterus." response, "eiiiiiiii"

"Those people will have some IV cannulas."

"Could you get us some toilet paper rolls please?" response from hotel receptionist, "Yes please."

Here, someone says please not when making a request, but when granting one. 

"Is this where we catch the the costa to Kampala?" response eyebrow raise

Here, an eyebrow raise means yes- they are not making a suggestative gesture....unless they have long dreadlocks and seem to be familiar with western culture, in which case...

"That evening the wind blew up, the sky grew dark and it what? It rained."

Ugandans love to pose a question and then answer it themselves.

"In Canada, elementary and secondary school are free." response, "Sure?"

"How are youuuuuuuuu?" response "Fine" 

Carolyn and Alix had a Lugandan lesson in Vancouver. At that time they were taught that endaggala means medicine. After 6 weeks here Prossy finally informed us that endaggala actually means banana leaves...daggala is medicine. 

During our Lugandan lesson we also learnt that ebizza means contraction. However, in Lubisu (which is spoken in Mbale) ebizza means pubic hair. Imagine! We say, "To ebizza, to sindica. Ebizza-sindica." (no pubic hair, no pushing, pubic hair-push).

Woot, woot!

Yesterday Alix and I had a really good day working on the ward. We were supposed to work on antenatal, but when we arrived in the morning Prossy told us that there were 4 women who were 8 to 9cm and would deliver soon, so we quickly grabbed our supplies and headed to the delivery room.
It was a day of feeling really competent. I managed to get two IVs in successfully without any assistance at all (I often need someone to at least connect the IV because the cannulas are heavy and I am always afraid of losing it if I let go). These two IVs have also been after several successful IVs and this has been a tremendous feeling as I had decided that IVs were the bane of my existence :)
I also made a good management decision regarding one of the births, properly assessing what was wrong, and what was needed, which was reaffirmed by the OB when I spoke with him.
Alix did an amazing job suturing a 2nd degree tear without assistance. It was a work of art and looked perfect, and all in an acceptable about of time.
She also perfectly handled a shoulder dystocia and was gentle enough that the woman had no tears.
It was great to have such a positive day as it rejuvenated us and has made us be able to look at our final 3 days of work with some equanimity.

Tomorrow we are going with Prossy to visit her family in one of the villages, so it should be a good day.

Where is the key?

Yesterday Carolyn and I caught 1 baby each at the end of the day and then went for beans and rice for dinner at the Banana Chick Hunger Care Centre (sounds simple but it is such a pleasure the odd time we get beans). The lady from the grocery store we shop at treated us each to a banana for dessert. Carolyn has patiently taught Alix how to play whist and crib and we enjoy playing cards and drinking a beer on the patio of the Zebra in the evenings.

This morning all the moms were for CS but one, mom #1. The obstetric Operating Room was in use for general surgery all morning- an Ear/Nose/Throat doctor had been in surgery for several hours removing a foreign object lodged in a young boy's throat. One of the women waiting for c-section was in labour with her second baby. She had quite a bit of bleeding for 6cm and a bandal's ring was starting to form (separation of the upper and lower segments of the uterus- a warning sign of uterine rupture). Wisely Prossy advocated for her to be the first c-section noting pending rupture. She was right- by the time the c-section was done the uterus had ruptured along the scar from a previous c-section. The baby thankfully survived but the woman needed complicated surgery because her uterus had also adhered to her bladder with scar tissue. 

Another woman today had a blood pressure of 240/160- more than twice the healthy blood pressure. For some reason she hadn't received any blood pressure medication yesterday and was only being induced today. To make matters worse they are out of Magnesium Sulphate, a medication used to prevent seizures in women with pre-eclampsia. For a woman to buy her own costs 90,000 UShl ($35) -more than anyone delivering in a public hospital could afford. I hope she will be ok.

Carolyn caught baby #1- a very cute and healthy little girl and mom's perineum was intact- yay! Next a woman came in from home- she had been pushing for 4 hours and her baby's head was swollen with a blister and her vulva was swollen with a blister. The fetal heart was very fast. I didn't expect her to deliver but when I was assessing mom #3 she did. Baby #2 was born with a heart rate of 40, not breathing. Carolyn quickly began bagging the baby and then moved to chest compressions. She was about to give up when it moved its leg so she continued. Prossy told us to move to the nursery (where she could start an IV on the baby) so Carolyn and I walked carrying the baby down the hall while I listened to the heart and Carolyn bagged it- but the key to the nursery was missing so we had to stand in the hall holding the baby in a bloody blanket in between us while waiting for the key to be found. The baby never did breathe on its own and after 20 minutes we ceased our efforts and gave the news to the mom.

While we were resuscitating baby #2- mom #3 delivered in the first stage room. She had given birth to 5 previous babiess and had only been 5cm with mild contractions half an hour before. 10 min earlier when I had checked her blood pressure she still appeared to be in early labour...the is why we have a saying, "never turn your back on a multip!"

Tonight the administration has invited Carolyn and I and the group of Danish nursing students who are here to dinner to give them feedback on how they could improve. We are flattered that our humble student opinion is valued and look forward to the social time. Tomorrow we will do our mandatory shift in the antenatal ward.  We are braced to see up to 100 patients in only 8 hours!!!

Strength and Resiliency

On Monday, Lyanne and I arrived on the ward in Mbale for the first time in almost three weeks. At rounds we had heard that there were many women awaiting cesarean (seven, as it turned out - in a ward with eight beds, that's pretty significant). Five of these were emergency cesareans (as previously stated, ‘emergency’ means a woman will wait at least two hours, often much more, before going into theatre). Throughout the morning, EVERY SINGLE ONE of the women waiting for emergency cesarean section delivered vaginally, three in very quick succession (there was 15 minutes at most between each birth). Three of these babies did not require any amount of resuscitation whatsoever. Unfortunately, the remaining two babies had died in-utero (one mother had a prolapsed cord, the other a placental abruption).


Yesterday, Lyanne and I assessed a primagravida first thing when we arrived on the ward. She was 9 cm dilated, and had been very slow to progress throughout her labour. The doctor on call came in and assessed this woman an hour or two later, and determined that when her membranes ruptured, she would deliver - he did not suggest an oxytocin augment. (Perhaps I should mention that it is rare for health care providers to artificially rupture membranes here - there are no amni-hooks. When they want a woman's membranes to rupture, they get them up and walking around). Things got a bit busy on the ward, and it was several hours later before I returned to reassess this woman yet again. Her cervical dilatation was the same, and her membranes remained intact. I managed to rupture them myself, which revealed thick meconium stained fluid (for those not in the know, this can often indicate fetal distress). Throughout the day, the baby's heartrate had remained in the normal range, though we were listening only every few hours. At this point I needed to consult again, and so waited an hour for the doctor to arrive. Minutes after his arrival, Lyanne and I noticed this woman was pushing and that we could see the head coming. Lyanne did a beautiful job catching the baby, and this lovely little boy came into the world as healthy as you could wish, no resuscitation required.


So all of this makes me think - in Canada, our lady yesterday would likely have had an oxytocin augmentation, an epidural, possibly a cesarean section. Every one of the ladies for cesarean on Monday would have made it to theatre. Perhaps the babies that did not survive on Monday would have survived in Canada; it's impossible to know. I think most people would agree that doing six cesareans to save two babies is reasonable. However, I can’t help but feel we are giving women’s strength and babies’ resiliency too little credit. Birth works, so well, so much of the time, even if it doesn’t go according to our expected timeline.




Posted by Sarah

I like boots. They make my feet feel safe.

Hello from Masaka!

As with Lyanne and Sarah, we returned 'home' on Saturday, though unfortunately we wouldn't call it a pleasant trip. We got onto the bus to go to Kampala without mishap but getting in and out of Kampala is always a disaster and so it took us an hour once we arrived in Kampala to get to bus station, and another hour once we actually left the bus station, to get out of Kampala, to Masaka. Buses schedules around here are non existent, basically buses leave when they are full so we also had to spend an hour on the bus refusing water, pop, bracelets, cellphone holders, loaves of bread and meat on a stick. In any case we finally made it to Masaka in one piece 7 hours after leaving Jinja. The joys of 3rd world travelling! We should mention that we did get quite the kick from the person sitting in front of Carolyn who kept nodding off. Finally Carolyn had to put her hand in front of her own head to prevent getting headbutted which provided a nice cushion on which this man to put his head.

The wheels on the bus go round and round...

Our two days of work in Masaka have been uneventful. Carolyn's shoes got baptized by a load of meconium stained amniotic fluid at the one delivery of the day. Thankfully she was able to borrow Prossy's boots, which lead her to remark that she liked boots because they made her feet feel safe. Unfortunately this delivery was another macerated stillbirth. Today was slightly busier with two deliveries and several assessments; however overall we hope that it will pick up a bit.

6 days left of work and then it will be time to head back home.

Things we have accomplished so far this week

- We have figured out two more uses for a sterile glove package (What is that now? 25 possible uses? More?)

- Lyanne did bimanual compression of a uterus without getting blood on her clothing or her arms

- We have caught another four babies (two each)

- We have resuscitated two babies after cesarean section

- Sarah started an IV under pressure with no trouble at all

- We found our way to the Indian restaurant all by ourselves (okay, Sarah found the way, Lyanne followed)

The internet has been fairly unreliable in Mbale since we got back, so our updates will likely be less frequent. Alix and Carolyn no longer have access to a laptop, so their updates will likely be even less frequent.

"It's almost like coming home..."

After wishing our fearless instructors a fond farewell, our intrepid foursome spent one final night in Kampala, and then left for Jinja, bright and early, for one final day of adventures before returning to our respective placement sites.

We enjoyed a beautiful day by the pool, a delicious dinner, and a fabulous night of DIY karaoke (singing along to music from our computer) and a rousing game of zilch. Our plan for a late-night swim was foiled, alas, by a disembodied voice that came out of the shadows to warn us that the pool had just been treated with some heavy-duty chemicals, so we had to settle for a final morning swim instead. Our fellow guests at the resort this time was a group of about 25 female missionaries from the Southern U.S., so the stay was a little less quiet than before. Still, it made for good people-watching.

The four of us went together to the matatoo park. Matatoos are kind of a cross between a bus and a taxi -- large vans that follow set routes and pick up/drop off people at set points along the route, but the fare depends on the distance travelled and there is no set schedule. Lyanne and Sarah managed to find their way onto the matatoo headed to Mbale, and we have arrived safely after a fairly pleasant drive.

Seasoned travellers that we are, we've been pilfering saving the little bars of soap and extra rolls of toilet paper from the hotels where we've been staying these last few weeks, so we arrived at our dormitory well-armed. We're staying in the same building, but different rooms, just to maximise our potential for trying to open someone else's door. Mbale feels lovely and familiar after all our travelling, and when we headed to the supermarket to pick up some food for tomorrow's breakfast, we ran into the Ugandan midwife who is our main supervisor for our last two weeks, which made us feel a little more like we've returned to our Ugandan home-base. It's certainly strange to be navigating the city without Angela, and speedbumps have been added to the road near where we're staying, which has thrown off our whole system for crossing the road. Fortunately our favourite Rolex vendor was working tonight (no samosas for sale today, unfortunately) so we picked up a tasty, if greasy, dinner and we're settling in for a quiet night. Our plan is to spend Sunday by the pool once again to shake off any remaining Lower Mulago stress -- neither of us is particularly the "lounge by the pool" type normally, but we're both finding that spending a day swimming and reading is the perfect way to unwind from the craziness of the work here.

Monday we head back on the wards!

Posted by Lyanne and Sarah