Sunday, April 29, 2012

The First Three Weeks - Ob/Gyn at Mulago Hospital

Olyotya! (Lugandan greeting). It's hard to believe I have already been in Uganda for three weeks. I just finished my last day of my Ob/Gyn rotation on Friday and will move on to the Casualty Ward (Emergency Medicine) next week. It has been an incredible experience so far and I am absolutely enjoying every day.

I spent the three weeks of my Ob rotation on the high risk labor and delivery ward. At the end of my time, I delivered 9 babies - most of them I did solo and learned how to repair second degree tears. The labor ward at Mulago Hospital has the most deliveries per capita in all of Africa. With the Ugandan fertility rate being 6.7, the hospital delivers on average 80-85 babies per day. The main labor ward of the high risk unit contains around 25 beds. On most days, all of these beds are filled and often there are mats laid out on the floor with another 3-10 laboring women lying on those as well. Most of the women end up delivering when they are on a bed, but on the busiest days, there are a few that end up delivering their babies on the floor. There is no privacy within this ward. Not even curtains or dividers to separate the beds. No one is allowed to come into the ward with the woman - not the father of the baby or family members or friends. It is overcrowded as it is and so no one is allowed inside except for the laboring mothers, a few midwives, a few nurses, the international students posted to the ward, and the doctors, interns, and residents during the rounds. The day typically starts at 8:30am with the morning report. It is really interesting as they report daily the events from the previous 24 hours. For the labor ward, they report how many deliveries, both vaginal and cesareans, complications from the deliveries (stillbirths, maternal deaths, multiple births, breech deliveries, etc.), and go over the pending cesarean cases. There is a lot of discussion that takes place after the report and it is really encouraging because the Ugandan Ob/Gyn doctors, midwives, and nurses are very proactive to try to identify major problems and discuss ways to resolve these problems. The maternal mortality rate is unfortunately high in Uganda and despite the lack of resources and inadequate staff, there is a strong motivation to find whatever way they can to try and reduce this using the resources and the staffing that they have.

Following the morning report, we head off to our respective ward rooms for rounds. On rounds in the main labor suite, there is a senior house officer (a resident), 1-3 junior house officers (interns), the international medical students, occasionally a consultant and occasionally Ugandan medical students. We go through every patient in the main labor suite - review their case, do an exam, and discuss the complications. The primary purpose of the ward rounds seems to be to make the prioritization of cases for cesarean section for the day. There are always more patients that need cesareans that will get them before they deliver vaginally so it is really important to prioritize the cases from the most urgent to the least urgent. This is difficult in and of itself, but unfortunately on a regular basis, there are patients that seem equally needy for cesarean. One day in particular, there were three women who had all had two previous cesarean sections (meaning that there chance of rupturing their uterus is unacceptably high). One was dilated to 7cm, one to 6cm but with a multiple pregnancy, and one only at 4cm but with signs of possible rupture occurring at that moment. When rounds are finished - often after a few hours and often interrupted by anywhere from 1-6 deliveries - the doctors all leave. Some go to admissions, some to the operating room to start on the list of cesareans, some to the pre-eclampsia/eclampsia ward, and some to the high dependency unit. After this, the only people left in the main labor suite to take care of the 25+ near-delivery mothers are 1-3 midwives and the international students. At times things are quite quiet but it seems that as soon as one delivers and that baby lets out its first cry, then several start to deliver. Some of the women yell (typically you hear cries of "Musawo!" which means doctor in Luganda) as they realize they are about to deliver while others are pretty quiet and I have often found myself turning around only to see a woman on her back with her legs flexed and the head of her baby starting to crown. I throw on my gloves, if I have time (as in the head is just at the introitus and retreats when the mother is not pushing), I will gather the supplies needed for the delivery - a syringe of 10 IU oxytocin, two elastic cuffs from gloves to use to tie off the umbilical cord, and a blade to cut the cord. If I really have time, then I will try to find the blanket that the woman brought to have her baby wiped down with and get the cotton ready. The women have to bring their own supplies for the deliveries - they are supposed to bring cotton to clean themselves with, two plastic sheets to lie on to try and keep the bed clean, bleach to wipe the bed down with after delivery, as well as sterile gloves for the person doing the delivery and for their vaginal exams prior to delivery.

I was a little terrified with the first baby I delivered in Uganda. The head was crowning and because another international medical student and I were standing at the bedside, the midwives assumed that we were fine and did not need them. Besides, there was a lot more work to be done elsewhere so if we were not in need of help, then they had a lot of other things to be doing. As the mother was pushing, I realized that head seemed to be too big to fit through the vaginal opening. We don't routinely cut episiotomies in the US, but it seemed in this case that one was needed. I had never cut an episiotomy before in my life and did not feel comfortable experimenting without supervision on a Ugandan woman and had to ask the midwife twice to come over and cut it for me before she finally came over and did it. As I delivered the head, I felt for a nuchal cord which there was one wrapped twice around the baby's neck. I couldn't get it reduced and so stuck my fingers between the cord and the neck to try to protect the baby from suffocating and finished the delivery. Everything turned out fine - the baby was healthy and had a good cry. The mother was so grateful for my help in delivering her baby and kept telling me "thank you, thank you" over and over again. It was a great feeling. After that first delivery turned out well, I no longer felt terrified of the imminently delivering mother. In addition to delivering several babies on my own, I also helped some of the other international students deliver babies as well. Several of them had never delivered a baby before and a few had not even had Ob/Gyn at home yet. It was fun to do some teaching and get some incredible practical experience as well.

Unfortunately not all the deliveries turned out as well as my first one. Everyday I saw at least one stillbirth and participated in three of those deliveries myself - one that I did solo. Sometimes the mothers seem to know when they are going to delivery a stillborn and other times, it comes as a surprise. There are also times when the baby comes out not breathing and due to a lack of a well equipped NICU, many of these babies don't make it despite our best resuscitative efforts with the resources we have. The worst stillbirth experience for me was with a mother who knew she was giving birth to a stillborn. The baby was in a breech position and when I walked onto the ward that morning, I saw the woman lying on the bed with the baby half out. She had stopped having contractions and had been stuck like that for I'm not sure how long. I alerted the doctors doing rounds to her predicament and was told to start an IV with 10 IU of oxytocin to try and get her to contract. I did this and as I was standing there, she asked me if she was going to die. I told her no, that she was going to be fine. She asked me if I would stay by her and not leave and I of course said yes, that I would stay with her until she delivered. After about 30 minutes of the IVF running and still no contractions, I again alerted the doctors who told me to add another 10 IU to her IV. They said that when she had her next contraction, I should deliver her baby. I have never done a breech delivery in my life and even though the baby wasn't alive, I certainly did not feel comfortable tackling this one on my own. Again, no one would come to help. The midwives told me to leave her be and she would deliver on her own, but I had promised her that I would not leave her so that was not an option. When the mother seemed to have a contraction, I instructed her to try to push. The baby was completely stuck. At this point it had been about an hour since I had started that IV and beyond this one weak contraction, the mother was not having any. I again asked the midwives to help. They told me to just wait. I asked the doctors to help and they said that they would come back to her when they finished their rounds. I kept pleading and finally a visiting resident from Canada came over and assessed the situation. She agreed with me that this baby was not going to deliver on its own and was able to recruit the Ugandan consultant and intern to come and help with the delivery. Turns out I was right. In order to deliver this baby, the consultant had to dislocate both shoulders, broke one arm and finally got the arms delivered (which had been up above the baby's head). After delivering the arms, the consultant realized that the baby seemed to have hydrocephalus and so the head was way to big to deliver. So, they had to manually drain CSF from the baby's skull in order to shrink the head to get the baby out. Nearly 2.5 hours after I first saw this woman, she had finally delivered her stillborn. Thankfully she seemed stable after this traumatic labor and delivery experience. In the US, breech is an indication for cesarean but here, there is not enough OR space to section all the breech babies so many of them end up delivering vaginally. Of the 4 breech deliveries that I saw and helped with, only one lived through the delivery.

The other really traumatic delivery I helped with was for a woman with severe eclampsia who had major mental status changes because of her eclampsia. She was agitated, anxious, and almost seemed to be in a psychotic state. Her baby was stuck and because there was no space for her in the OR, the decision was made to try a vacuum delivery. A third year resident from the UK that I had been working with for two of the weeks I was on the ward took charge of this delivery. This resident was the best part of my Ob rotation - she was an incredible teacher and provided the perfect amount of supervision and autonomy. She really cared about each and every one of the patients and we teamed up on many deliveries which I think made the whole process go much more efficiently and better overall for the mothers we delivered. Anyway, this particular mother due to her eclampsia and her mental state was aggressively uncooperative. We sedated her with diazepam and it still took four of us holding her down to be able to deliver her baby by vacuum. Thankfully, the baby came out alive but needed immediate resuscitation and so the resident and two of the other international students left to work on that. The Ugandan midwife and doctor who had also been helping disappeared and so I stayed with the mother who was lying in a pool of blood from the episiotomy that had to be cut to deliver her by vacuum. She was continuing to bleed and I was concerned about her stability since she was bleeding and had been given sedation. I watched her respiratory rate and kept checking her pulse and watching her bleeding. One of the midwives stopped by and looked at the patient, shook her head saying "that was not the right way to cut an episiotomy - what a mess" and walked away. The UK resident returned and between her and the three of us international students, we tried to hold her down to repair her episiotomy. The mother was still fighting us despite her sedation and we asked the midwife to come and help hold her down. It seemed like all she really had to contribute was criticism - for the episiotomy and the "slowness" of the repair and for the fact that I was leaning over the patient, trying to hold her down and subsequently was getting blood on my clothes. I said that I could wash the blood out of my clothes later and the resident told her that she should show her how to do a fast repair. The whole scene just felt wrong - four people holding down this poor woman while someone tried to suture her and stop the bleeding. It was a sloppy job, but it seemed to work to stop the bleeding. At the morning meeting the next day, I found out that the patient and the baby were both stable and the mother was in a better mental state than the previous day.

Every day was a complete adventure on the labor ward and if I wrote all the stories I had to tell about my experiences, it would be a short novel. It was incredibly hard and difficult but also equally rewarding. I felt like I was learning so much and at the same time was able to give back and help others. Even though at times it seemed like people didn't care or moved too slowly when you needed something NOW, they really do an amazing job with the resources that they have and for every person that seems to not care when something terrible happens, there are at least two that really do care. I was also so inspired by the motivation of the staff to identify problems and try to brainstorm ways to fix them to decrease their maternal and neonatal morbidity and mortality rates. I am sad that my time on Ob is over, but I am excited to start something new - Emergency Medicine!

Location:Kampala, Uganda

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