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.