Rachelle has borne the brunt of the blog posting so I thought it was time to step up to the plate with more than a few photos. Which are hard to add due to the slow nature of most internet connections I have come across so far.
Uganda is a beautiful country with red roads and lush greenery. There are flowers everywhere and the people favour brightly coloured clothing.
The hospital in Masaka is large, covering the grounds of a compound with various buildings for ART therapy (HIV/AIDS), antenatal, labour and delivery, a women’s ward and men’s ward, a canteen, and much more. I love the fact that the storks hang around outside labour and delivery.
Inside the labour and delivery ward is very crowded. The hallways are narrow and the building is in a t shape. You enter on the short arm of the t and straight ahead lies the family planning, a rustic toilet and ward 11 known as the Happiness ward, to the left is assessment, 1st stage room, delivery, and finally ward 9 which is high risk antenatal and to the right is post Cesar (as it is called here) and anyone else who may need some nursing care post birth. On the right arm of the T also lies the neonatal unit.
The floors are cement, the lights are minimal and often turn off, the staffing is low, there are never enough staff to accommodate all the people and the smells are very strong. You learn to mouth breathe quickly but then sometimes you can still taste the smells.
We spend our days in delivery and 1st stage, we are not very usefull in assessment due to the language barriers but are sometimes called in to do a VE to help with the assessment.
Quite often women deliver in the assessment room or in 1st stage either because the beds are full in delivery or because they didn’t get moved on to delivery in time.
The delivery room has three beds and sometimes we have a stretcher in there too to accommodate one more, this gets awkward as it ends up in front of the sink and you spend the entire delivery trying not to fall in the bucket of Jik (this is the bleach water we use to wash the beds and floors).
Clean up is the least favourite job as it involves squeegeeing blood and other muck across the floor to the drains.
The nurses/midwives work very hard here as there never seem to be enough on at a time. There have been days where there are only one or two in labour delivery and babies can come in three’s. Not enough hands.
We are learning a huge amount. I came to Uganda still feeling a little unsure about myself and the skills I had acquired to date. However after just over two weeks I feel like my skills have solidified, that my new learning is coming in leaps and bounds and I feel ready to move forward with my midwifery in Canada.
The women here are so amazing. They come in, and labour, often alone or with little support. They don’t complain, they don’t have access to pain medication, and they just have their babies, get up, shower and wander off to Happiness.
Sadly however, they sometimes come expecting help and there are too few resources, not enough doctors, or some other problem that means they don’t receive the care and attention they need until it is too late. There is a very high maternal and neonatal morbidity rate in Uganda.
The other day a family came to get their baby off the shelf; this is where our little ones who did not make it are placed until the family comes. All of a sudden there was a commotion and I was being summoned. The family thought the baby was still breathing and they wanted me to check and make sure it was really dead. I did as they asked of course, listening carefully with my stethoscope and let them listen too. It was very hard to watch their loss and not be able to offer words of comfort or at least compassion.
There are very funny moments too, the women have good senses of humour and seem to enjoy having us around even though we have to act out parts of our conversations or have very basic ones. I can tell someone to push, and to not push, to roll to their side, and to pant. My favourite is “cabina” for bottom. We get lots of laughs asking them to move their cabina, or telling them, “no hanky panky” after we stitch them up.
Some days are hard but most are amazing and I am very grateful for the opportunity to be here.

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.