Mbale Days

-From Quinn in Mbale

After the excitement of the first couple weeks in Mbale, we had some slow days last week which allowed us to catch our breaths, and get back to some of the basics we’d been missing. There were a handful of local nursing/ midwifery students on the ward, and more helping hands meant Natalie and I caught less babies, but we had plenty of opportunities to help teach the students. We also had a lot more time to spend doing labour support, something we have missed from home. Spending more time with our women last week, there were a few who really touched us both.

One first-time mother charmed us with her excellent English, as she told us about the injury she’d sustained to her leg from polio as a child. She was incredibly sweet and strong, and worked away pushing her baby down. Every once in awhile she would confirm with us “My baby is dead, or my baby is not dead?”- she had been told mistakenly that her baby was dead, when another midwife had not been able to find the baby’s heart rate. We found the Doppler ultrasound and had her listen to her baby’s heartbeat, and would remind her of the sound she’d heard whenever she asked. In the end she went for a cesarian section- because of her childhood polio, her pelvis had not formed normally, and there was not enough room for the baby to move through it. Natalie and I received the baby in the operating room, and after just a little resuscitation, he was crying and alert.

Another young mother made a real impact on me because of her strength and a refreshing sense of self confidence. She was 15, and had been in early labour since the previous day. She was sitting on a bed, waiting to be assessed. Another midwife told her to go back outside, it wasn’t time for her assessment, yet. She waited a few more minutes, while I finished another assessment, then said to me “I’m not finished!” Sure enough, she was back exactly when she had been told to return, and so I offered to assess her. “Yes!” she said, “You check!” Throughout her labour, and afterwards she remained just as assured. She requested more freezing before she was sutured, and had us tell off the neighbours who were trying to watch. Then she demanded to eat matoke, her favourite dish. It was so nice to see a mother, especially one so young, who seemed so aware of her own self-worth and was able to stand up for herself.

Friday was a busy day, as the nursing students weren’t there, and then the local midwives had a meeting to attend for 2 hours. Angela, Natalie and I womanned the ward on our own, and, of course, there were several women who seemed about to deliver. Natalie and I each caught two babies first thing in the morning, then we went to receive a baby in the OR. Luckily that baby did not require any resuscitation, so I went back to the labour ward, where I found Angela resuscitating another newly born baby on her own. I was able to lend a hand for a few minutes, until an attendant tapped me on the shoulder because her friend’s baby was coming. I barely had time to get my gloves on before her baby slipped out- with the bag of waters still intact. I had to act as both midwives for this birth, but luckily both mom and baby did very well. The day continued like that, and by the end of it, we were ready for the weekend!

Our classmates from Jinja came up to Mbale for a few days, and we all went for a hike to the nearby Sipi Falls on Sunday. It was a beautiful hike through fields and farmland, then up under and behind one of the falls, and past small houses and fields where we found friendly children playing. It was a perfect weekend, and we finished it ready for the upcoming week.

Yesterday Shannon and I went to help out at the antenatal ward. We watched the health education session, which covered lots of topics, like breastfeeding, hygiene, and especially the importance of HIV testing in pregnancy and how to reduce mother to child transmission for those who tested positive. There were probably 80 or more women in the room, who then needed to have their blood pressure and weight recorded, their bellies palpated, HIV testing and counseling, and vaccinations or medications administered. These women were there for the entire day, and we began to understand why it could be a struggle for many women to attend even the minimum 4 recommended visits.

After work yesterday, we all went for a tour of CURE, a nearby hospital specializing in pediatric neurosurgery. There they provide surgeries and other care for children who have conditions like hydrocephalus (a condition where the cerebrospinal fluid is not able to drain properly from the head, and accumulates around the brain, causing the head to be enlarged). Dr. Paddy, a friend of Angela’s from last year here in Mbale, is working there and invited us to see the hospital and then treated us all to a delicious home-cooked Ugandan meal in his home, with some of his neighbours and colleagues. We really enjoyed ourselves, and got some valuable insight into medicine, politics and hospitality in Uganda.

Hatching Babies...

-From Joanne in Masaka

I've been reminded of how few resources it can take to save lives. A year ago this nursery for premature babies did not exist. Now premature, sick, or struggling babies are brought to this nursery to be watched over, largely by one of our amazing midwife mentors here –Sister Prossy. She frequently gets called in the middle of the night to advise staff of how to care for a newborn in distress. She has now trained some of the other nurses and midwives in the art of infant IV’s to ensure babies get proper fluids and medications. Reading lamps create makeshift baby warmers. My first time into the nursery I glanced around at the stacks of blankets and assumed most babies were being carried around by their mothers, with just their blankets left behind. But as I slowly made my way around the room, peaking under corners of blankets, I found a baby under each stack! (You can always spot the babies the mazungus have brought in after resuscitation –swaddled and with their face exposed!) I can’t help imagining a flock of chicks hatching everytime I enter the warm room –the only room heated in the hospital. Being that warmth is so critical to newborns, particularly preemies, these few lamps and stacks of blankets, along with the TLC of Prossy and other staff, are literally saving babies’ lives.

 When I first met Amina she was sobbing quietly in the corner of the nursery. She spoke English quite well, and explained that her tiny daughter, born at approximately 6 months, was deteriorating. Her feeding tube had been removed, she didn’t know why. Desperate to ensure her baby was nourished, the infant’s tiny body seemed limp and weak as Amina attempted to get the miniature mouth to latch onto her breast. The babe was too small and exhausted to nurse. Fortunately there was a lull in the usual whirlwind of deliveries across the hall and I was able to sit with Amina and try to console her. I found a syringe and helped her express breastmilk and finger feed her baby slowly drop by drop. She only swallowed a few drops before she was quickly exhausted and fell asleep.

A school teacher from a rural community, Amina explained that her baby had been born two weeks earlier. When I asked her daughter’s name, her eyes welled up with tears again and she looked down to the cold cement floor. I just nodded, put my arm around her, and sat quietly. In a place where the survival of unwell babies, let alone a very premature infant, was so tentative I could sense how a mother might hesitate to believe that this little person would survive.

When I returned later in the afternoon, the baby was worse off. Her breathing was labored, she had poor colour, and her heart was beating slowly. Another nurse came in and we began resuscitating the baby with the smallest mask there was –still far too large. Even as we were doing it I was unsure that it would be helpful. It felt like a very temporary solution for this wee baby that, by Canadian standards, actually needed a ventilator, an incubator, a heart rate monitor... and even in Canada this baby would have tough odds. The baby responded, the heart rate came back up, and she was given a new feeding tube and IV fluids. I assured Amina that the midwives were doing everything they could. I left the hospital that evening considering that her baby may not be there when I returned in the morning.

Amina and her baby holding on.

A week later I walked into the post-natal room to check on a mother who had delivered the previous night. A dozen foam mattresses were spread across the floor in between the token three cots. Each makeshift bed was filled with mothers and babies, bright fabrics, visiting family members, water jugs and food dishes. “Hello Joanne!” I was shocked to hear both English and my name! Amina was smiling at me from one of the few beds. She had now been staying at the hospital for just over three weeks. Her baby had improved and continued to get breast milk through a feeding tube. She went on to ask me advice for some of the other moms in the room. One mom had had a preterm c-section and didn’t have enough milk yet to breastfeed. I suggested she eat meat and vegetables, drink chai and lots of water, and hold the baby skin to skin. Amina translated this into Luganda for the other mother. The next day she reported that the mother’s milk had come in and her baby was feeding well. One of the cherished moments where my most foundational midwifery skills had been helpful!

Based on a doctor’s estimate, Amina tells me she expects to be at the hospital for another month. She has relatives that bring each of her meals throughout the days. She will continue to float between the postnatal room and the nursery - where she expresses breast milk and holds her wee baby.

Before I leave her bedside, she grins and proudly tells me that she has named her daughter Sarah.

Lake Mburo

About an hour before leaving the safari grounds I was standing in front of Lake Mburo, being energized by everything I was taking in, while the others finished their lunch (left over roasted chicken and chapti purchased from “the Danish” the day before).   Stretched out before me, the gray/blue/green water rhythmically rolled by.  Continuous choruses of ripples traveled through the expansion of water, moving always to the right.  Streams of white bubbles sporadically rose amongst the ripples, as some unseen creature passed just beneath the surface.  A bird then entered the scene.   It swam while jutting its head forward, allowing for clear glimpses of a vibrantly orange beak.  Suddenly it picked its body out of the water, thrust its wings up and down into a regular flap, while keeping its almost neon orange feet grazing the surface of the water, so as if running on water.  Once reaching a seemingly predestined location, it lowered itself back into the water and continued on; making the prior few moments seem like an odd, but glorious mirage.  Behind the lake, layers of hills provided a frame to the north and to the east.  The hill to the east, being the closest, stood grandly cloaked in bold greens, yellows and browns.  The further hills, each positioned slightly to the left of the one before it, were each increasingly less vibrant and more translucent, as if they were painted into the space with watercolors.  The sound of various birds calling and chirping was mixed with the deep grunts and slurps of warthogs grazing through grass and garbage behind me.  A group of white butterflies flew by closely, almost grazing my arm.  I turned my head to follow them and got to witness as they curved around and surrounded me again.

I noticed that one of the park guides was watching me watching the lake.  He slowly approached and asked, “Have you heard the legend of Lake Mburo?”

Legend says there were once twins that lived in the area, one named Mburo and one Kigarama.  One day the twins were partying and got drunk together.  Kigarama revealed to his brother that he had a vision that a flood was coming to the area and he suggested that they move to higher grounds.  Both brothers soon fell into a drunken sleep.  When they woke up they remembered the vision.  Mburo did not believe his brother’s vision and so decided to continue living in the area.  Kigarama did not want to leave his brother, but felt he needed to heed the vision.  He moved to the top of a nearby hill. A flood soon came through the area.  Mburo drowned in the great flood waters and the remaining water formed a lake in the area.  The Lake was named Mburo after the lost brother.  While the nearby hill was given the name Kigarama after the brother who moved there and survived. 

~ Babil... Story from our safari at Lake Mburo

The gap between life and death is so narrow (by Tanya)

This was a particularly busy morning! We walked into a full labour room, all 5 women with complicated cases, waiting for c-sections.....

We were told that one of the women was presenting with a face presentation at 4 cms (which means the face is coming through the opening of the cervix instead of the top of the baby's head), she was third in line for the "theatre" (which is the OR) and we had to send her husband to the pharmacy to purchase a foley catheter in preparation for the OR (here in Uganda, the women must come to the hospital with their own supplies: baby hat and blanket, a bar of soap for washing, a plastic bag to birth on, cotton for delivery and a catheter in case we must drain their bladder).

Meanwhile, due to lack of beds, the mom with the face presentation was moved to our 1^st stage labour room across the hall so that another mom who was fully dilated could have her bed to birth in.  An hour later the woman's husband arrived back with the foley catheter. When Jo and I went in to insert the foley, we noticed her membranes had ruptured  with thick meconium. Just as Jo attempted to get a fetal heart rate, and I prepared to do a vaginal exam for this women, we were suddenly called to assist with a post partum hemorrhage across the hall.

Jo stepped in to assist Cathy and Lorna with the hemorrhage, and seeing as the PPH was under control, I rushed back to the women with the face presentation to check the fetal heart rate. Using the fetoscope I was able to faintly auscultate a fetal heart rate in between frequent, tetanic contractions that we assumed were so strong and long due to the herbal concoctions that many women take here to speed up labour.

Doorway into the Operating Room (aka "Theatre")

When I performed the vaginal exam, what I felt did not feel like a face, it felt like a compound presentation- with tiny fingers beside the head and a cord prolapse! I felt a faint pulse in the cord which told me the baby was still alive at this point and quickly took my hand out of her vagina for Cathy to confirm.  I quickly inserted the catheter, and then reinserted my hand to elevate the head off  the cord. Somehow, in broken Lugandan and one handed, hand motions we got the mom into a knees to chest position to help keep her baby's head light against the cord. In labour when the head is not well engaged in the pelvis, and the bag of waters breaks, the cord may fall in front of the head, which can cause compression of the cord (which is the oxygen supply to the baby). As we were not with this women when her water broke, we did not know how long the cord had been compressed. We called for an immediate c-section. 

In our emergency skills training we are taught that once you feel a cord prolapse you cannot take your hand out out of the vagina. So for  approx. 20 minutes, I had my hand inside of this poor woman, who was naked on her hands and knees, bum in the air, having incredibly strong contractions, crying out in confusion and despair, begging me to "not kill her" ....as we ran down the hallway on a rickety old rusty trolley,  my hand still in her vagina, past inquisitive Ugandans, I prayed her baby would still be alive on delivery...

Resuscitation table.

Operating tables in the OR where c-sections are preformed

                         The intern doctor passed me a limp baby, with an initial faint heart rate of 90 bpm (normal range is between 120-160 bpm).  We cleared the airway of meconium and began to resuscitate the baby with PPV (bag and mask).  Within minutes the baby’s HR was up to 120 bpm and  began making an effort to breathe on his own. Due to wet blankets and a cold baby, we left our table and ran the baby to the nursery, stopping  long enough to allow the worried father a quick glimpse of his precious little baby....

Listening to baby after resuscitation!

The gap between life and death in Uganda is very narrow. I realized that we could have lost this baby if we had not gone in to re-assess this woman at that very moment -she could have easily been left to labour in a side room, alone for too long in a small hospital that is under staffed, under equipped and constantly juggling priority cases.... 

Caring for these women and babies is a team effort and an exercise in patience, communication,  improvisation and hard work. A special thank you to the Ugandan midwives, nurses, and doctors who have allowed us to become a part of their team. 

Patience and trust in the face of the unknown

Greetings from Jinja! We are well rested after our lovely relaxing weekend at the Kingfisher with the rest of our class and we are happy to be back at work at the Jinja Hospital. The nurses and Midwives were glad to see us back to help out. This morning they greeted us with choruses of “ You are welcome” and ‘ Well done”. It feels so good to see all their smiling faces. Yesterday I had a small cut on my hand so to be safe I worked in the antenatal ward.  Wow, over 200 moms waiting to be assessed and cared for. So I spent the morning doing countless BP’s. They giggled every time I tried to call out their names, often mispronouncing them.  I also had the chance worked with the local doctor. Mother after mother came parading in with their sheet of plastic and hopped up on the table. I palpated all the mom’s bellies, listening to babies and the doctor asked them questions about their current state of health and pregnancy. In the afternoon I worked solo assessing many moms and thankfully the Sister (midwife) in the ward was there to translate to make sure everything was communicated appropriately. Liz and Grace worked on the ward and spent many hours supporting a first time mom. Her cervix took time to completely open and the doctors were convinced she would need a c section but with patience, support and lots of position changes she finally birthed on hands and knees (very rare) with an intact perineum! We had a delicious lunch at the TASO HIV support centre where we had the pleasure of enjoying a drumming and singing group performing. Their songs were all about prevention of HIV and the music gave us all energy to complete the day.

Today started off doing rounds with the doctors.  There was an 18-year-old first time mom who had been in labor all night.  She was fully dilated however the docs decided that her labor was obstructed and she would require a “ceasear” (c - section).  We sat with her for the next couple hours monitoring the baby, whose heart rate showed some signs of stress and provided what comfort we could, while continuing to assess the other moms in labor.  The grandmother was distraught and prayed over the laboring young mom. All the beds were full of women being induced for various reasons. When our mom as ready to go to the OR, we both had spidey senses that two people would be helpful, so decided to accompany her to the c-section as a team. Once we were in the OR and she was being prepped for surgery we started to see the baby’s head poking around the perineum. After an in depth consultation with the OB intern, the OB and much monitoring of the baby and progress with moms pushing efforts, the OB intern agreed to let us postpone the surgery. We wheeled our young mom into the hallway where we prepared to deliver the baby. Liz went to inform Grace what was going on and I encouraged the mom to keep pushing while coaxing the tissues to stretch around her baby’s head. Liz returned to help out and we continued to advocate for the mom to not have an episiotomy. Liz explained to the OB the benefits of letting the perineum stretch and if it had to tear then the healing process would be speedier than if we cut. We had a close eye on the heart rate and the baby was doing very well. Soon, the baby was born in the hallway outside of the OR over an intact perineum.  The beautiful baby boy required a little bit of a resuscitation, which we did before clamping and cutting the cord. The mom was grinning from ear to ear. Grace showed up to help me tuck the cervix, that was causing a bit of excessive bleeding, back up under the pubic bone and we were good to go. 

Upon return to the labor ward we found three other moms awaiting “ceasear”. Liz stepped in to assist Sister Margaret on a quick delivery of one of the moms on an oxytocin induction. Several moms were still awaiting admitting. I went to receive a baby after a surgery and provide some resuscitation. One of the interesting things about c sections here is that the OB prays before the surgery, for low loss of blood, skilled hands of the surgeon and for the mom and baby’ s health. At the ward, Liz admitted several moms in early labor, one of them only 14 years old.  Then we switched places and Liz went to the OR and I admitted moms. 

At the very end of the day, a mom came in carrying a baby that had passed following a road side delivery. I gave her a head to toe and checked that her fundus was firm, perineum intact and that she was generally ok.  Upon unraveling the baby from it’s blankets, we found that the little one had died on route after bleeding from the cord. A sad end to a good day.

Now we have returned home to scrub our scrubs, enjoy a little salad and reflect on the day. While Jinja has not being super busy with deliveries in the last week, we have enjoyed the diversity of care we can provide at all stages and the excellent opportunity to provide support and manage difficult labours.  Through patience and trust in the face of the unknown, everyday we are learning many new skills to put in our midwifery tool belts and a new humility that is a precious gift.

Reunion and relaxing

This is Natalie writing from Jinja, as everyone came from their different cities to have a little reunion in Jinja for a workshop as well as just to relax, and see each other, since this will be the only time our group will get to be all together during our time here.

On Wednesday, Quinn, Angela and I decided we would do a half day on the wards before making our way to Jinja. The morning started off slow, and quickly got extremely busy. It seemed like women were making their way in waves, everyone arriving pushing at the same time, and everyone having their baby at the same time. We would have to ask labouring moms or moms who had just given birth 20 minutes before to leave their beds to make space for others who were pushing. As I was finishing up with one mom, and Quinn was monitoring another, Angela thought it would be a good time for her to run a quick errand.

Soon after, a mom walks in and her water breaks and sounds pushy. Quinn quickly looks around for a bed, and finds one for her. We quickly get her up on the bed, and I do a vaginal exam, and my fingers have no idea what they’re feeling. At first I think its the cord, but its attached to something, so it can’t be. Then I think I feel toes, but its not that either. I ask Quinn to check, and she think shes feels toes too...but something about what we feel is telling us something about the whole picture isn’t right. Either way, we need Angela! We send our friendly Danish nursing student running to go get her, as we tell the mom not to push, but she can’t find her. Then we remember we can call Angela, and luckily she picks up and comes quickly back. She listens to our story, and as we watch the baby come lower and lower, it quickly becomes evident this is no footling breech. As Angela assesses, we see a pair of lips looking up at us, and we realize we have a face presentation! The mother pushes beautifully, and Quinn catches a lovely girl.

Then, Angela calls me over to a mother who is having her 9th baby. The baby is coming out very slowly and the mom is very tired, so Angela pulls some tricks out of her sleeve to help the baby come. The baby needs a bit of resuscitation (managed by Quinn!) but comes around quickly. It was so wonderful to attend this woman’s birth - most women here are very stoic after having their babies, and this mom was just thrilled  and so happy. She hugged everyone who attended her birth (a first!), which touched me deeply. We all shared a laugh as she looked at me and said in her limited English, “Big baby? Massive?” and it was - 4.1 kg!

In the afternoon we made our way to Jinja, a 3 hour drive between everyone hopping on and off, people sitting on top of each other, and chicken flapping their wings at my feet. It’s a beautiful road, where we get to see lots of green fields, traditional homes, and families.

Thursday and Friday we gave a workshop to nurses and midwives on obstetrical emergencies. It was great to see how much they learned and how confident they grew. Saturday and Sunday we all came to a beautiful resort  by Jinja to relax after two very hardworking weeks. It has been so wonderful to see all our friends again, share stories, laugh, hear about ups and downs, and connect again. It’s hard to believe tomorrow we will be back to the wards again...

Things we love/ things we don't

We were sitting on our balcony talking about the highs and lows of working in such a low-resource environment, and thought it might be interesting to share our thoughts with you. So, here are our top 10 things we find difficult working in Uganda, and things we just adore.

Things that are challenging:

1) When babies don't breathe with PPV alone, and accessing oxygen requires sprinting down a long hallway and pushing through two sets of doors.

2) Monday mornings when the supplies are low from the weekend, the oxytocin is missing (again), we can't get any bleach or antibiotics till noon, and sterile gauze cannot be found, anywhere.

3) When we witness things that are against current practice guidelines such as holding a struggling baby up by the feet.

4) Wearing two pairs of gloves to tie a cord with no cord clamp as fast as we can. We are still so fumbly!

5) Suturing without breaking the bed; holding needle drivers that are not really needle drivers; and using only a headlamp to guide our way.

6) Returning to deliver another baby after difficult outcomes occur (shoulder dystocia, PPH, long resuscitations, ect..). We take a few breaths, pull ourselves together, and dive right back to work.

7) Lack of timely access to the operating room.

8) The knowledge that we sometimes feel swamped, yet only two Ugandan midwives work the floor at any given time. It is so frustrating to think about how little staff resources these amazing nurses/midwives have available, and how many women suffer as a result.

9)  Not speaking Lugandan like a pro, even though we are trying to master the basics. 

10) Missing our loved ones so far across the great big sea. 

Things we adore:

1) The pregnant dog that lives outside maternity ward 8; she spends her days trying to make friends with the resident flock of baby chickens.

2) The families waiting patiently for their loved ones on the grass with their yellow water jugs, plastic basins, basket-making supplies, and oodles of children.

3) The singing and drumming we hear occasionally while women are labouring.

4) Babies that breathe and cry right away.

5) Watching our preceptor Grace suture; we are in awe every time.

6) Walking in the hospital door every morning to see our mamas so happy tucked in bed with their little ones and family all around.

7) When we get to eat lunch, or even a snack.

8) Every single Ugandan midwife we have met and their enthusiasm for their work in such hard circumstances.

9) Looking up from an intense second stage and realizing the other one of us is always there (like magic!) to track down the blankets, find the cotton, and make up a delivery set.

10) Our new bilkon hotel family and how happy we all seem to be to see each other at the end of the day. It feels like summer camp!

-Liz and Shannon (Jinja)