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)

Babies having babies

We have finished our first week of work here in Mbale, and it is hard to believe so much has happened in 5 days!

Thursday was a very busy day- between us we caught 7 babies! The day started out slowly, and began getting busy around lunchtime, when most of the local midwives needed to leave the ward for a hospital-wide meeting. I got back onto the ward after a 5 minute lunch break just in time to be sent to deliver a woman who had arrived already pushing. I got her up on the bed, and was about to examine her to make sure she was ready to push, when I saw 5 adorable toes at the opening of her vagina. Another footling breech! I called over Natalie and Angela for help, and within a few minutes had caught a little baby boy. As I put the baby up onto his mother's stomach, we realized that it was not yet empty- twins! When I examined her I felt another little foot, with a little bum right behind it. Another footling! Natalie caught this baby, and he needed a little help to breathe, so I took him away to resuscitate for a few minutes. It was pretty amazing for us to realize that this woman would not have delivered vaginally in Canada. It really made us question some of our own ways of thinking about things at home. It seems like some of the things we think of as abnormal at home could actually be just another version of normal.

Other cases made us really miss some of the bells and whistles from home. A woman came in who wasn't able to walk. Her vital signs were poor, and she had very bad abdominal pain. It seemed that she was suffering from a ruptured uterus (this is rare, but more common among women who have had cesareans with previous babies, particularly when the uterus is stitched back together in a single layer- which seems to be the norm here- instead of a double layer). We put in an IV, and gave her fluids, but she needed to have another surgery as soon as possible. Unfortunately, there is only one operating room at the hospital, and there were two other women who also needed emergency cesareans ahead of her. When she finally got into the operating room, they discovered that not only had her uterus ruptured, but she had a placenta percreta (the placenta had implanted too deeply into the uterus- also more common when women have had a caesarean before), and she had to have a hysterectomy. Unfortunately, the power went out at that point, and although the doctor borrowed one of our headlamps, he wasn't sure that he had properly closed the blood vessels. (The following day this woman was returned to the operating room due to internal bleeding, and has since stabilized.) It was difficult to just wait, providing support and monitoring for this woman between other deliveries, not knowing how much she had been told, or understood, and knowing that at home she would never have had to wait for an emergency surgery. Another woman we attended had a baby with a cleft lip, and some other abnormalities. At home, we would have been able to access a pediatrician, and other sources of support to help this woman care for her baby. Here no one could tell us when they would be able to get a pediatrician to see the baby, and it was clear that there was no support available for her mother.

Before we arrived, we had all thought about the fact that there may be some experiences here that would challenge and upset us. I have been surprised, however, to find that it is often something unexpected that will catch me off guard. The thing that has upset me most is how many very young mothers we see, often abandoned by their partners, and with no real options. Thursday night the last mother I attended was 15 years old, and terrified. From her behaviour I suspected that she may have a history of abuse. Unfortunately, she had a tear that needed to be sutured. In an attempt to be helpful and stay out of our way, I'm sure, her mother stepped away with the baby, and left us to work. The poor girl seemed even more terrified, and then the electricity went out again (luckily I had a headlamp on), and she was crying for her mother and afraid. Natalie provided some great support to her, but it was hard to know how much she was able to understand. I left that evening feeling very sad and wondering what had happened to this girl. Things here seem to happen in waves, and the first girl I attended yesterday was also 15, and also afraid.  In a bed nearby, there was a 14 year old who would curl up and lean into us or hug us and cry with her contractions. In the waiting room yesterday there was a girl who looked to me to be no older than 12, although she told me she was older. I thought she was there as an attendant for one of the other women until a midwife asked me to take her blood pressure and I looked down to see her bulging belly. (The doctor who assessed her thought that her pelvis was not developed enough to deliver vaginally, and it was decided to send her for caesarian section.)

This week has been full of learning experiences and the great privilege of helping many brave mothers and their beautiful babies. We are taking the weekend off to integrate our learning, recuperate, and get ready for the next week!

-Quinn and Natalie in Mbale

Jinja

Its Saturday morning here in Jinja. The air is humid and filled with  a haze of diesel and charcoal smoke from the cooking fires. After a slow breakfast of Spanish omelet, milky tea, and the best pineapple any of us have ever had, Shannon and I are trying to collect our thoughts from this challenging, difficult, yet amazing week. Uganda is a much louder country than Canada. The girls boarding school next to our guest house is blasting Ugandan dance music, and a training soccer team just ran by singing while keeping what looked like very fast race pace. We wake up every morning at 4:00 am to roosters, and the hospital has a resident flock of chickens that quack incessantly.

It has only been a week, but so much has happened it feels as if we have been here a month. We arrived Monday to the Jinja hospital a little nervous and hesitant-we are the first students from UBC to work here, and we had no idea what to expect. To our total delight, the midwives, residents, and nursing students have welcomed us with open arms; they are so happy to have the extra hands in such a busy hospital. The labour and delivery, post-partum, antenatal, and special care wards are all connected-we already love that we can visit our mamas the day after they give birth to check in and say hello. Sister Margaret, a regal head nurse/midwife, is an incredible teacher and compassionate care provider. On Thursday, when two of the women Shannon was monitoring began to fade, Margaret helped them up, said a quick prayer, and began dancing along with them to help them find energy and strength. It was beautiful.

We felt totally out of place on our first day, but within an hour of arriving Grace had a gorgeous catch of a primip; we have been rolling along ever since. The hospital is quite busy, but many women arrive in early labour so we spend a fair amount of time doing initial assessments and providing labour support and monitoring.  This provides much variety to our days. During a slow moment Friday, we finally solved the mystery of where to find sterile gauze and how to clean the birth supplies, and earlier in the week I walked in the room to find Shannon surrounded by nursing students devouring her every word as she explained how to find the fetal heart and do the newborn exam. Success! Its nice to confirm that a labouring woman anywhere appreciates the same things: a sip of tea, a hand to hold, pressure on the back. We are learning the particular Ugandan signs of impending birth- slapping the leg, waving the hands in the air with such gorgeous rythym, calling for their mother or God. When there is time we eat lunch of beans, matoke, rice, greens and peanut (ground-nut) sauce in the hospital canteen and bring the nurses orange fanta in glass bottles. The staff are so helpful teaching us Lugandan, and everyone loves our pictures from home. We are grateful for these moments of cross-cultural connection when faced with such a fast pace and the difficulty of working in a very under-resourced hospital.

However, when things get busy, they get busy! This week we saw so many things-placenta previa, very young mothers, twins, obstructed labour, lightening fast second stages, bleeding, cord prolapse, and tear repair with minimal light and broken needle drivers. We experienced the heartbreak of babies that didn’t make it, even with chest compressions for what felt like hours. Every morning the little morgue has had babies that didn’t make it through the night. Its been so frustrating to have bad outcomes that would not have happened if the hospital had supplies like oxygen or drugs like epinephrine available. With this said, Shannon and I are really enjoying learning to back each-other up, and often find ourselves running between delivery rooms trying to make sure everyone has enough oxytocin and an apron for delivery. We are overwhelmed at times with the intensity of learning to work in this new hospital and culture but feel deeply happy we are here.

-Elizabeth and Shannon (Jinja)

Here we are!

Masaka in a Snapshot...

A warm hello from us in Masaka!! (by Tanya)

First Morning at the hospital! Lorna, Joanne, Tanya, Claire, Babil

Cathy, Lorna, Babil, Jo and I, and a medical anthropologist named Claire, have been here one day shy of a week and it feels as if we have learned a semester full of new information. Although Claire is here working on a research project which is looking at birth planning in rural areas we have deemed her “honorary doula” as she seems to show up to the hospital at just the right time to hold someone’s hand during labour, retrieve an extra pair of gloves, put on our headlamps or protective eyewear while we try to remain sterile, or pop a piece of chocolate in our mouths to keep us from crashing.

Under the patient, gentle guidance of our incredibly wise and experienced instructors, both Cathy and Lorna have enabled us to embrace this experience, and have supported and guided us along this intense learning curve this week.

Between the 3 of us we have had enough births within 4 days to keep us running on adrenaline all day long. Collectively we have performed resuscitations on premature babies and term babies (some of which went well and some of which we sadly  lost) we have had severely anemic women, and septic woman, obstructed labours and contracted pelvis’, we have managed post partum hemorrhages with a bi manual compression, a shoulder dystocia, helped suture a 4th degree tear with no retractor, witnessed  an episiotomy with a razor blade, sutured the episiotomy from the razor blade, caught an undiagnosed breech, and a couple somersaults through tight nuchal cords. We have had to console distraught woman having abortions at all stages, of all ages, with no medication, we have double gloved when attending women with HIV and hold back tears when a young 18 year old mother tells you she will name her baby “promise”. We have given our lunch snacks to women who come in so poor they do not have shoes on their feet and use their thumb print to sign their name as they cannot read or write. We have learned to check the shelf above the washing up sink for small bundles of baby’s who have not survived the night when we come to begin our day. We have sat in on a couple workshops and helped teach rural midwives how to resuscitate newborn babies......

We have experienced the highs and lows of emotions we only knew existed , and have learned more in a week then we could have ever dreamed of, while  trying to manage all of this with very minimal supplies,  a language and culture barriers.

But most of all, we have learned that women are strong here, babies are incredibly resilient, a gentle touch during labour is universal, and smiles of all kinds can warm your heart for a day…..

Uganda is one of the most beautiful countries I have ever been to. Every morning as the sun comes up, I walk out on our deck that looks over green hills speckled in red roofed houses, brightly colored tropical flowers and colorful birds that sing the prettiest songs....across the rust colored dirt road is an elementary school.  As I have breakfast and drink African tea I can hear the little kids dressed in their uniforms line up for school and chant in synchrony, morning greetings to their teachers….. And then we begin our walk to work, so thankful for the privilege to be here.

Sunrise over Masaka

Big hugs-Tanya xoxo

Don't forget to breathe!

Hi everyone, this is Natalie writing with Quinn from Mbale! Yesterday was a crazy, crazy day, so take a deep breath and...

Quinn, Angela and I arrive on the maternity ward around 9:00 and are told we have someone in second stage. Quinn quickly throws on her gloves and receives her second baby! This baby is born limp and not breathing, so Angela helps me with my first neonatal resuscitation....for 60 minutes. The baby has a great heart rate the whole way, and does start breathing on its own. We quickly do some charting and are told another mom is at 8 cm. This mom is someone we had seen before: she had come in the night before with severe bleeding at 28 weeks. She was diagnosed with placenta previa, and while the mom was stabilized, unfortunately, her baby had died. She seems to be progressing, so we leave nature to take its course for a while since she is stable. Then...another mom in second stage! Quinn gets on her gloves and receives another baby! As I spend some time with the other mom, Quinn diagnoses twins! Then, Angela is called. A first time mom with a footling breech (when the feet come first. In Canada, this would be a c-section) in second stage! But as Angela assesses, she discovers not only is it a footling breech, but also a cord prolapse (a cord prolapse can be very dangerous as the cord falls through the cervix, it gets compressed and the baby doesn’t get all or any of the oxygen it should). We get the woman to push as hard as she can and the baby is born in less than 2-3 minutes. I take the baby for another resuscitation, and it comes around really well. We quickly eat our lunch, and Angela calls me to assess another woman who was sent to the hospital for a footling breech (ok now, really? 2 footling breeches in one day?), but as her birth unfolds and I examine her, I don’t find a foot, but...a very cute hand that grasps my finger. The baby comes out easily like superman, with one hand and arm in front of its head. It’s already 7 pm, but we want to stay to see our ladies through- Quinn, the twins; and myself, the woman with the previa from the night before. The woman with twins is so stoic and quiet that its only when Quinn decides to check up on her because she was scrunching her face that she saw she was pushing. The mom pushes beautifully, and the twins come out without a hitch. Angela and I have to hold Quinn down so she doesn’t take the twins home, they are so cute. And did I mention all intact perineums (no tears)?

The mom I had been following was developing a fever despite antibiotics, and because her uterus was getting bigger, we suspected she was having an abruption. She was quickly taken for a cesarean section. At first it seemed like she had lost too much blood and her condition did not look so good, so I was thrilled and relieved when I came in today to find out she made it through the night and is now doing well.

I’m very sad to write, though, that when we arrived this morning a mother had passed. She had been very sick. Her husband is a school teacher, and she left several children at home. It made us all sad to think that had a few things been different in her care, perhaps she could have lived.

Adjusting to Ugandan life both warms my heart and makes me take pause. I love the  warm culture, the traditional hand shake ( a combination normal handshake, followed by  closing your hand in each others, and another handshake), the dancing hugs (hug side to side three times while simultaneously patting each other’s back), the bustling market, the red soil that’s everywhere and stains the ankles of all your pants, the bright coloured dresses, the babies wrapped around their mother’s back, and the at least 5 year old I saw nonchantly standing up and breastfeeding. I especially love the care taker, who has the most wonderful ear to ear, eye squinting smile, who every morning tries to teach us Lugandan and laughs as we try to imitate. I love that I can see that babies are so resilient; and that births many people would be fearful of back home, despite little technology, can be normal. But Quinn and I have struggled with other aspects, such as some of the treatment of women, differences in practice management, and how to communicate our knowledge of evidence based practice in a way that builds relationships, and lack of technology when it really can make a significant difference to the mother and baby’s outcome.

For me, its only my third day and I have learned so much. And the more I learn, the more I realize the less I know. I am so appreciative to have a great friend, and an unbelievable mentor to guide me.

Hello Muzungu! First impressions in Mbale, Uganda

Natalie and I arrived in Mbale with our teacher, Angela, two days ago, and spent our first day settling in and getting organized and oriented here. We are staying on the hospital grounds, not far from the labour and delivery and post-partum wards. The grounds are lovely and green, and are kept that way by many hard workers- we saw them cutting the grass this morning by hand with machetes! Many of the hospital staff live here, and have created a community. On our way to the wards or into town, we walk past stalks of corn and friendly children playing with a soccer ball they’ve made of old plastic bags.

The local midwives, doctors and nurses have been warm and friendly, and we feel welcome. Natalie’s name has turned out to be too difficult to pronounce, so she goes by Lea (her middle name) here. On the other hand, my name gets a different reaction, and I have to explain to everyone I meet that no, I am not trying to convince them that I am royalty. Angela has begun spelling my name whenever the eyebrows of my new acquaintance go up- “It’s Q- U- I- N-N, not Queen.”

The local children are also very interested in us, and will call out “Hello Muzungu!” as we pass, or run over and shake all of our hands or give us a squeeze. (A muzungu is a foreign person, but if you look it up on Wikipedia, you learn that it translates literally as “someone who roams around aimlessly” or “aimless wanderer”... How appropriate!)

I was nervous this morning arriving at the ward in my white uniform (already red-brown to the ankle with earth from the short walk over). I wasn’t really sure what to expect. We sat in on the rounds first thing, where we heard about the 25 or so women who had delivered in the last day, and the obstetrician’s recent trip to a fistula clinic. (For those who don’t know, a fistula is when there is damage to the bladder or bowel resulting in medical consequences such as incontinence, and social stigmatization for many women. It is most often caused by a labour that doesn’t progress normally, but can also be caused by cesarian section or sexual assault.) Then we reported to the labour and delivery ward, where things were rather quiet. But, there were many women with their families just outside, waiting for their labours to be active enough for admission.

It was a bit of an adjustment catching a baby under these new circumstances, and I was caught off guard more than once when I realized I didn’t have some piece of equipment I was used to from home. Despite all the differences, we had incredibly satisfying experiences today, and realized that more was the same than was different. The woman I helped today was lovely, labouring with the help of her doting mother. I managed my first sticky shoulder (the baby’s top shoulder became wedged behind the pubic bone), and was surprised how much force was required to dislodge it, but happy that my efforts worked, and the baby came out just fine. Natalie also caught her first Ugandan baby today, an adorable little girl. It was straight forward, and she managed it like a pro!

The midwives and clients looked at us funny more than once when we suggested things from home that were out of the ordinary here, like labouring or delivering in different positions or slowly delivering the head. We were instructed on some of the local practices, for example holding up the baby to show the mother its sex. We are trying to bridge our previous knowledge to the birthing culture here, and we are sure we will learn a lot in the process!


-Quinn