We’ve had two days of work at the Masaka Hospital. Cathy told us she would ease us in with a couple of “easy days” before we start working normal shifts… but she lied to us! They were full, full days – the second we even categorized as “a very hard day.” So far I have had 5 births as the primary attendant including: twins, breech, two pph’s (post partum hemorrhages), a retained placenta, a shoulder dystocia, and sadly a neonatal death. I’ve also assisted with some of the births that Lesley attended (which I’m sure she will write about at some point too!!), and heard a few happening behind the curtains separating beds – I think two births happened on either side of me as I was attending the twins!

The neonatal death was hard. The baby died about 20 minutes after she was born. When the mother’s water had broken there had been meconium present, but she did not come to hospital until 4 days later when she was in 2^nd stage (the pushing phase). We rushed her into the delivery room. The head birthed very slowly and I recognized “the turtle sign” right away – the baby’s head shrunk back in turning purple as it did so. The baby had a double nuchal cord around her neck as well as a shoulder dystocia. The lead nurse Prossy helped me deliver her (after I did McRoberts and Woodscrew she stepped in and I’m not quite sure what she did but the baby came!) The baby was born limp and did not respond to positive pressure ventilation (resuscitation), which we performed for ~20 minutes. Additionally, the suction equipment here is broken, and they actually do not have the capacity to intubate for deep suctioning in the delivery room. We suspect the baby succumbed to meconium aspiration deep in her lungs. Meanwhile the mom started to hemorrhage and had a partially retained placenta. We administered 10 IU oxytocin IM as part of active management of the third stage, and another 10 IU oxytocin IV in 500 mls of normal saline to help the uterus contract and stop the bleeding. We also catheterized and emptied her bladder and then Cathy took over and manually removed the placenta, which is a painful procedure (and the situation here is such that there is no option for pain medication.) This whole birth was difficult for me, and I had to take a few moments in the corner to shed a few tears. But then I had to buck up and carry on because there wasn’t a single moment between our 10am to 6pm shift when there wasn’t a woman about to birth and several more in the hallway. In fact, Lesley caught a baby in the assessment room, and a few of the other Ugandan student nurse-midwives were catching other babies in the assessment room as well because the delivery room and it’s three beds were constantly full! (((But with so many students & midwives helping women in the assessment room there were several times the delivery room lacked any staff at all, leaving women unattended during the very time when they needed attention most.)))

One of the biggest questions I have come to Uganda with is the question of ethics: is it ethical for me to be here? This question is important as I make decisions about future goals, and I didn’t feel like I could answer it without coming and seeing first hand. Tonight as I consider what I have seen so far, this is where I’m at: One of the ethical concerns I think about is whether a woman actually has a choice in whether to have me, a foreigner, as part of her labour or not. For some my white skin represents a colonial past they want to forget. For others my lack of the local dialect inhibits the full scope of care I can offer. And for others, the fact that I am a student in need of a preceptor to check everything I do may involve more meddling than they want. But. From what I’ve seen so far (and yes, it has only been two days…) – this is the wrong question. Choice is important, but maternity care in Uganda is *so far behind* what we have in Canada and birth is literally a life and death situation for many of the women who come to the hospital. And, the resources here (including staffing, equipment, and medication) are in such short supply that if we (Canadian midwives and students) weren’t here several of the women we attended these past few days would not have been attended at all.

The non-glamourous truth is that women arrive at hospital with a plastic sheet to put on one of the three plastic covered “beds”. By the end of their delivery they are often soaked from their own blood, urine, and amniotic fluid – and there are no cloths to offer them to clean up. We are not able to get them a clean sheet or even a pad to go in underwear if they have underwear. The last woman I attended yesterday had a few cotton balls worth of cotton baton left from her “mother kit” after her birth so I used it to wipe off a small corner of her wet back – but it was a pretty useless move on my part.  She had to head over to the open shower in the corner to wash off (and there is often no soap), and while she was away we poured bleach on the cement floor under her bed and squeegeed all the blood to the drain at the side of the room, and wiped down her bed in preparation for the next woman to come in.

Many women come from villages, and they are coming to hospital because they are experiencing problems. As I learned from the video about “Mrs. X” (see here if you are interested) one of the biggest concerns for maternal and neonatal mortality are the “3 Delays” – the delay to recognize a problem in pregnancy/labour, the delay to get to a hospital, and the delay for the hospital to act (usually due to lack of staffing/supplies). In fact yesterday morning a woman died in the labour ward having suffered from an antenatal bleed that started at home 4 days earlier. She was a Gravida 12 (had been pregnant 12 times prior) but by the time she got to the hospital there was nothing that could be done for her. She was somewhere between 26-32weeks, and her baby was stillborn. Prior to her death I attempted to get her blood pressure, but I was unsuccessful because it was so low. She was given a unit of blood but it was too late.

Today I don’t think it’s unethical that I’m here. I’m a student, but I have come with Canadian preceptors who hold me to Canadian standards. The women don’t get to choose me, but together we bring skill and care that many women would not receive were we not here. Every birth I have been a part of so far has ended with the mother thanking me for helping her. I don’t know. I might not be seeing all the issues yet. But I do know that when we left tonight the head midwife said to Cathy, “You saved that woman tonight” (referring to a case I wasn’t a part of, where a woman had a severe pph and retained placenta but Cathy got it out during the long wait for the OR.) Many of the women coming to hospital are coming because there are problems, and skilled help makes a world of difference for them and their families.

I’m going to need more time to flesh all this out, and to form solid opinions, so bear with me in the posts to come! There is going to be a lot to process as the weeks move on. We’ll do our best to keep you updated, but the days are long, our internet is sporadic, and we are already tired! But the pineapples and avocados are still amazing, and they are going to help me process everything too 😉

***I’m posting this now after our third day at hospital. I had another baby born who wasn’t breathing at birth, but today our resuscitation efforts were rewarded with a baby who came to, is breathing, and we have every reason to believe is going to be a-ok. That feels good.

On arrival I could tell Uganda was going to be interesting.

The streets of Kampala are fascinating. There is always something or someone super interesting to look at: a woman with scores of bras hanging around each arm squeezes past a man balancing several packages of toilet paper on his head and then is passed herself by a man whose bike is loaded with dead chickens hanging from the handlebars. Women wrapped in bright fabrics balance huge loads of mangoes or jugs of water on their heads. Little boys rush up to car windows eager to sell bananas as they strive to earn money for school fees. Bodas (motorcycle taxis) flood the streets driving according to their own rules, sometimes (often!) crashing into other bodas. Some guy with a couple of 12 foot poles manages to get himself positioned on a boda and they take off, and some other guy cycles by on his bike with a dresser strapped to his back. Taxi-vans cut you off every few minutes. The speed bumps are massive (our car bottoms out on the speed bumps erected on main roads!), and traffic cops seem always to urge cars forward through red lights or make you stop at green lights.

The streets are made of packed red dirt and contrast beautifully with the many green leafed trees and huge expanse of blue sky filled with white cumulus clouds perfect for staring at.

I have been in Uganda for over 2 weeks already, awaiting the start of our Ugandan placement (which begins next week). And though I hadn’t planned to have these extra weeks in Uganda, they’ve been a real gift. While here I have spent time in rural markets and urban shopping malls. I spent a weekend at a maize farm an hour out of Gulu. I visited a goat farm just outside of Kampala, and a women’s cooperative where women who survived the days of the Lords Resistance Army as well as women currently surviving HIV/AIDS create goods to sell for income (including dolls, bags, jewellery, peanut butter and honey). I got frisked going through security just to buy some KFC (which is wildly popular here, and expensive!) I helped hold, feed, and change triplets and quadruplets! I went to THE NILE! I had a visit with my friend’s friend inside her mud hut. I went swimming in a pool-with-a-view. I’ve eaten a year’s supply of pineapple and mango. I also ate part of the rooster who woke me up every day at 5:30am for the first week of my stay here…

Over these first few weeks my thoughts have regularly returned to Nepal, to the needs of the people in the aftermath of the earthquake, and to my instructor Cathy who is still there offering midwifery care in the hardest hit villages and preparing workshops through MIDSON and UNICEF to train and send nurses to deal with maternity needs in villages that are even further out. I have also been processing the maternity care we witnessed, and considering the midwife I hope to one day be. And now, as I begin to prepare for the next stage of this trip, I am beginning to consider the issues that face the women of Uganda. I wonder what issues will be the same as those we discovered in Nepal and what will be different? Will what I have read in books and articles come to life in the people I meet and the care I observe?

As I near the halfway mark of this experience I know I’m still at the beginning of what I have to learn about global maternal-infant health, and I’m grateful to be here. I miss Jacquie & Emma like crazy, but I am looking forward to reuniting with my classmates Lesley, Zahra and Nancy who arrive Monday.

We will have so much more to write in the weeks ahead, and we may even have more to process about Nepal too. Hope that’s ok. And, if any of you have any questions – feel free to ask!

After a lovely breakfast with our Nepal buddies, Dr. Mickey and Cathy, we headed to the airport. Before we headed off, Bishnu adorned us with these scarves for safe travel and Mickey pulled out his fancy camera to take our picture.

I’ve spent the last week or so starting to digest the experience we had in Nepal. I probably won’t do an earthquake reflection, as Rachelle already so eloquently captured much of what we were all feeling. That said, I can’t say that experience hasn’t changed me, or framed my experience in Nepal – because it would be impossible for it not to. However, today I’d like to focus on the parts of this experience that really delighted me and made me recognize the value of our education here in Canada, and the good work we can do elsewhere in the world.

Our first experience of birth in Nepal was attendance at the birth centre in Kathmandu – in a teaching hospital. We were told at the time of how wonderful that experience was, though our presence felt a bit intrusive to us, in our jet-lagged state. We learned later that this experience really was absolutely wonderful, especially when compared with our later observations in Pokhara. Fortunate for us, we moved on to Baglung, arriving 15 minutes before the earthquake struck, taking us farther away from the epicentre and to a hospital that welcomed us with open arms. Though we all felt a bit dopey after the earthquake, as the aftershocks carried on, we were invited at every opportunity to provide care for women at the Baglung hospital, and had a wonderful time working with the Nepali nurses and doctor in providing care.

We began attending births on the Monday following the earthquake, which happened around noon on Saturday. The Baglung hospital was about a 5 minute walk from our hotel, a walk which occurred along a dirt road, with vibrant shops of all kinds lining the street as the bottom floor of low-rise buildings. At the hospital, the staff had moved all maternity patients down to the first floor, and deliveries were taking place in the minor procedure room located down the hall from where the women were labouring or recovering postpartum. Women would come into the hospital, some from quite far away by Jeep, or by foot, and would be assessed and laboured in or around their bed in the open ward. Then, as their moaning grew stronger and they started to act pushy, they would be brought into the minor procedure room, assessed for dilation and usually proceeded to push their babies out. Our first catch went to Emma, who headed in with Cathy on that Monday afternoon. The next day we went in together and Emma got her second catch in the minor procedure room, while I was able to help with the somersault maneuver for a baby born with the cord around its neck. That turned out to be good timing, as we were able to teach the somersault maneuver two days later at one of our continuing education workshops. I was lucky because this baby came out fast and furious, in the hallway between the labour/postpartum beds and the minor procedure room. Attending births helped to take our minds off the aftershocks and allowed us to experience and participate in birth in Nepal.

The following day, Rachelle got her first catch and we taught our first continuing education workshop. As it turns out, teaching the workshops was a real blessing. We were able to watch all of the nurses and the head doctor light up as they watched various global health videos in Nepali on the eight danger signs of the newborn baby, immediate care after birth and care of the mother during labour. We then got to work demonstrating various skills like three different ways to deliver a baby with a cord around its neck (which included the somersault maneuver), neonatal resuscitation (according to the Helping Babies Breathe protocol) and delayed cord clamping. We learned how to simplify our language and speak more slowly so we could be understood. We also learned how to connect with the nurses and doctor attending, by smiling, encouraging, giving the thumbs up and laughing together.

These are the parts of Baglung that in the last week I have imprinted into my mind. Though our time there was short, we so enjoyed working to take our minds off of the reality of what happened on arrival. To reframe things in my mind, I’ve spent time thinking about the wonderful connections we made there and the real potential for students to be welcomed back there next year. All of Cathy’s hard work paid off in getting us to this wonderful place where we could start to feel confident in our own skills, and work in teaching others by example and through more formal channels. I feel so fortunate to have been able to participate in the daily operations of the Baglung hospital and to have gained the trust of the nurses, doctor and most importantly the Nepali women, who were so strong and so much more supported here than what we witnessed elsewhere.

One of our anticipated highlights of this Nepal placement was a teaching workshop that was supposed to happen May 5-7 in Jomsom (in Mustang.) Our anticipation for this workshop grew after we had the chance to run a few teaching sessions to a very eager and responsive group of nurses in Baglung. Due to our early departure from Nepal we were not able to complete this particular workshop… but I thought some of you might be still interested in what the workshops schedule was supposed to be! And so, here it is:

I want to take a moment to write at least a little about our experience of the Nepal Earthquake of 2015/2072. Thousands of people have died and many more have been injured. People have lost homes. Whole villages are flattened. And even now almost two weeks later, aftershocks continue causing for many a rise in pulse and fear, as well as being a constant reminder of what has happened. Many people are still unable to live in their homes; instead, they sleep outside, under tarps if they have them, and weather the monsoon rains which have started a month early this year.

Our experience does not compare with those communities that bore the brunt of the earthquake’s magnitude, but before I can move on to share stories of birth and midwifery and learning, I feel a need and desire to tell our story (from my perspective; Jac and Emma – you can write from yours too!)

We had just arrived in Baglung and were in the midst of bartering for a better price in our hotel room with the manager when it happened. The walls started shaking and the floor started rolling under my feet which I have never experienced before. We ran out of the hotel as the manager yelled “Earthquake!” – and he fell really hard on the stone stairs as we came down from the 2^nd floor. Everyone was running to the street and we followed suit. The streets in Baglung in our neighbourhood were only one lane wide (ie. very narrow!) and most of the buildings lining the streets were one, two or three storied old brick or concrete buildings, some topped with tin roofs held down with large rocks. There was also one huge glass building that no one wanted to be close to! Small groups of people huddled together, some standing in the middle of the dirt street, others crowding under tin overhangs. Cathy, Jacquie and I remained in the street and Emma ran for cover under the frame of a concrete building that was under construction. I know what she was thinking. As a child I was taught that the safest place – other than a wide, open space – is to stand in a door frame: everything will fall around it, but it is likely to remain upright and you safe under it. But – there was a huge piece of concrete overhang that seemed precarious from our vantage point, so we called her back over to us after a few moments.

It was actually pretty quiet in the streets. Some people were calling out to one another, but the stillness in the midst of such force was startling to me: this massive earthshaking power occurred, but in it’s pause people crowded together in silence, and then as you wait together, you wonder if it’s done. But then it’s not done, and the earth shakes again with a power that is impossible to articulate.

The first big aftershock (or was it simply a continuation of the original earthquake?) occurred within a minute or two and that was really the only moment I felt afraid – but I did feel afraid. The four of us huddled together as the ground shook and rolled and buildings swayed and (some) rocks fell. And oh how I prayed. It lasted for about 30 seconds if not longer (at least that is what is in my memory; who knows, maybe it was only 10 seconds, maybe it was a full minute.) After it stopped an old Nepali woman came over to us exclaiming something in Nepali with a look of gratefulness on her face and she patted our faces and grabbed Cathy for a hug. My best guess is she was glad that we – and everyone around us – were safe, that nothing had crumbled in our midst.

We spent the rest of the day in the courtyard of the hotel. Most of the town went to an open field a few blocks away and our hotel manager (clearly a leader in Baglung!) brought tea to the 2000 or so people who gathered there. We felt best remaining with other Nepali hotel guests who also stayed at the hotel. The sun was hot and the “open field” would have been crowded. Our courtyard felt open enough and offered some shade and access to bathroom facilities. Jacquie, Emma and Cathy immediately called their families (& UBC) to let them know an earthquake had occurred and we were safe. It was ~1230am back home, so I decided to wait to call mine. I wasn’t convinced the quake would make international news (little did I know…) and wanted my folks to get a full night sleep before waking them up!! Thankfully Jacquie’s husband saw news images appearing online by 1am, and he called my parents right away to let them know we were safe. I was also able to talk to them later in the day. That decision to call right away was such a good call by Cathy, and we felt grateful to know that our families knew we were safe. And it was happening all around us. Locals at the hotel and in the streets were all on cel phones, trying hard to get in touch with their loved ones around the country. All around people asked, “Is your family safe? How is your home?”

The earthquake did disturb some normal routines which ended up being a little unfortunate (for me and Jac in particular!). An older woman scooped out some of the rice from our dinner pot to feed her granddaughters. This is not a bad thing in and of itself, but we noticed that she did so with her hand… her *left* hand. We remembered this little detail later that night as I suffered from the worst diarrhea and vomiting I’ve had to date! Oh man. Jacquie suffered along with me and poor Emma had to listen to us all night long! Oh we had some good laughs about it, which provided some major comic relief in the midst of the many aftershocks! Suffice it to say, none of us slept a wink and Jac and I were pretty weak so we decided to hold off going in for our first day at the hospital. This was a good thing as there was another major aftershock (~6.7) that next day in addition to the ongoing smaller ones. I fell running from the hotel with the big shock and sent Cathy and my computers flying (which I had grabbed in haste) out of my hands and onto the pavement (thankfully they didn’t get smashed!). I also scraped my hip, knee and gauged a little chunk from my hand, but we cleaned and bandaged right away and it’s been healing nicely ever since. Our hotel manager who fell with the original earthquake pulled out a back brace, but apart from these two minor injuries we didn’t hear of anyone sustaining anything major.

The earthquake changed our trip. Over the next week we started our official clinical placement in the hospital (which was awesome, and I will write more in another post), but the ongoing aftershocks and the daily communication with UBC, DFATD, and our families made it difficult to forget. The news images that began to appear in the days to come showed us the extent of the quake which we had been blind to over that first 24 hours. The devastation and horror so many Nepali’s faced and continue to face is impossible to explain. In Kathmandu bodies were being pulled from buildings and rubble everyday over that first week. In fact bodies were being pulled from a building that crumbled right beside our guesthouse the day we returned to Kathmandu a week after the quake. All week, 24 hours a day, bodies were burned in a park in central Kathmandu. I can’t imagine this on top of all the fear and uncertainty of that first week. On our drive back to Kathmandu we saw many houses standing… but we also say many houses that had either crumbled or tipped “in tact” to the side.

UBC made the decision to call us home, and while we understand the reasons I found it difficult to leave. Selfishly, I am so disappointed to have this placement cut off short. I was loving it, and the next portion of our journey was to take us into the rural areas. We were so looking forward to both the trekking in the mountains and also (especially!) teaching in the tiny health posts. Cathy has connections in small villages from all the work she has done here over the years, and they had asked her to come and teach specifically about STIs and to address their primary concern: neonatal mortality. We were so excited to be a part of that. But even as I worked to let go of my disappointment, I found myself wishing I had the skill to be a true help, to stay and be a part of relief effort. But the truth is I know I would have been another body to feed and outsider to watch over had I remained. What makes me feel better about leaving is that because we left, our instructor “Foreign Nurse #74” Cathy and Dr. Mickey have partnered with our trekking guide Bishnu (a true leader in his community) and his “team” to provide medical aid, shelter and food/water to villages that have been drastically destroyed.

Because our trip was cancelled, they have been free to offer true help and I can’t wait to hear more of the fruit of their efforts.

Anyways, I think that’s it. I’m sure I’ll have more to share in time, but for now… this is it.

Pictured here: Our last night in Kathmandu before heading out. We have many more thoughts to blog, and will do our best to share them in the weeks to come. In the meantime let it be known that we “the girls” would like to send a huge shout out of gratitude to our awesome instructor “The Cathy” and our amazing guide, helper, and new friend “The Bish” (ie. Bishnu). You are both the best.