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 2nd 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.