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