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.