Monday 18 June 2018

The Masaka Experience

The Masaka Experience – By Kati McGeorge

In mid May, I and 6 other UBC midwifery students arrived in Uganda with 5 UBC instructors. Our purpose is to work with pregnant and birthing women in Ugandan hospitals alongside of the Ugandan midwives, doctors and other care providers, as well as with other students, both from Uganda and other countries.
The Masaka Market

 We are here to learn the ways of midwifery in a low resource setting and to consolidate our clinical skills. We also teach some updated information and techniques used in Canada , by one on one teaching moments on the wards,  through modeling of good practices and compassionate care,  and in workshops. In addition, we brought donations of medical equipment and supplies that had been previously identified as needed and useful.

My destination was the Masaka Regional Referral Hospital. It is a large hospital covering the city of Masaka as well as the surrounding villages. It also takes in women referred from smaller hospitals and clinics in the area, especially on the weekends when these facilities are often closed.
When first arriving at the hospital, before even entering the building, I noticed the women and their families sitting on the grass, picnic style, waiting for their labour to be active enough to be admitted, or waiting for their woman to give birth. Each woman has an attendant with them, whose job it is to manage their birthing supplies and to help them to shower and move to the postpartum ward after the birth.
Arriving at the hospital

My second impression was of the smells and sounds in the dimly lit hallways, crowded with women and men, waiting to be admitted, waiting for their loved one to give birth. The smell was strong, musty, organic and not particularly pleasant, and there was a babble of voices speaking in Lugandan, the main dialect spoken in that part of Uganda .  I thought of how this scene differed from what I knew as the norm in hospitals at home in BC where the smells would be more chemical and medicinal and the hallways bright, clean, quiet and predominantly empty.

On a typical day we arrive on the labour and delivery ward by 9:30 after having changed into scrubs and a heavy plastic full length apron. We are ready for action and all geared up, having stuffed our pockets and fanny packs with supplies, such as gloves, IV cannulas, urinary catheters, packets of gel, alcohol swabs, and many other necessary items. The hospital supplies are limited and often doled out a little at a time so they will last throughout the day. We brought our own supplies from Canada and purchase more from local pharmacies to augment those supplies lacking in the hospital. There is nothing more frustrating than urgently needing to site an IV and having to search through empty drawers or go ask a Sister midwife to find us the missing pieces.

When working on the ward, our UBC preceptor is always by our side or within calling distance to give a hand when needed. Often we also search out the Ugandan Sister midwife who is working that day to ask for advice or assistance. We also consult with the Ugandan doctors and obstetrician, who come to assess the situation and write orders in the chart. There are many 3rd year medical students, nursing students and interns on the ward as well.  Some of these students are knowledgeable and can give us a hand, while others still have large gaps in their experience and knowledge and we can often give them pointers and help them with an assessment. This is one of the ways in which we give back for all the learning opportunities we have experienced.

Very early on we learned that the Ugandan culture requires a different approach than what we are used to in Canada. In Uganda it is important to be socially warm, greeting a person and asking how they are doing, then commenting on your own wellbeing, before getting down to the business of why you need to talk to them. This is especially challenging when seeking information (such as what a woman’s name is or when looking for a chart) or when needing assistance (with a woman with an obstructed labour for instance). In the maternity ward rapid paced atmosphere this back and forth play of cordiality can be frustrating and feel like a slow motion dance, but we soon got used to it and even learned to appreciate these moments of social exchanges as pearls of calm amongst the chaos of the ward.

Once on the ward we do a quick scan of the work area, removing stray needles, razor blades and other sharp items and cleaning the surfaces. Then we restock the cupboards and check that the resuscitation equipment is clean and available. With that accomplished, the first task of the day is to meet the labouring women, learn their names and find their charts. When asked their name, women give their names in a near whisper, last name then first, and if we are lucky we recognize the first name and enough of the last name to identify their chart. Charts may be in the Admissions room if they were recently admitted, or on Ward 9 at the end of the hall if they arrived in early labour the day before or if they have some further complication. More often than we like we can’t find the chart and must make notes on a scrap of paper until the chart is located or a new one started.

We assess women to see how far along they are and what their specific needs are, making plans for their care. We monitor vital signs and fetal heart rate, start IVs, give antibiotics, insert urinary catheters, and give care as the need arises. We birth the baby, using a slow controlled technique when possible, check for the presence of a twin, give oxytocin prophylactically to prevent post partum hemorrhage, deliver the placenta, assess the vagina and perineum for tears and suture when needed. 
We assess the newborn, weigh it, and treat it with eye antibiotics and a vitamin K injection.

Catching a baby

When needed, and with the assistance of our preceptor as well as a Sister midwife, we  manage emergent cases such as labour obstruction, shoulder dystocia, post partum hemorrhage, newborn resuscitation and other more complex issues, like twin and breech birth, cord prolapse, or uterine rupture.
Twin brothers

Ugandan women are strong and stoic, often labouring silently with no pain medication options. Births can occur suddenly and unexpectedly, especially with women who have given birth many times before. This year it seems there are more first time mothers than in previous years and we try to give them a slow birth of the baby’s head to diminish tears and trauma to their tissue.
A happy new mother whom I helped birth her baby

The number of births managed by students in one day can vary from zero to 4 or more. One memorable day, 3 students and 1 instructor assisted with 9 births, a nice even 3 each per student, and on at least one occasion I caught 4 babies in one day!

My time here is flying by, and I am so thankful for this amazing opportunity and all the learning that comes with it. I have learned so much! My clinical skills, assessment skills and ability to look at the bigger picture have solidified, my confidence has increased, and I have gained a valuable understanding of how to manage labour and birth with minimal resources in conditions well below what we experience at births in Canada. This will help me to be more capable and effective when working in remote and rural settings or when other problems arise. This truly is a once in a lifetime trip.
We often walk home in the twilight. Notice the crescent moon laying on it's back. Seeing the stars and moon behave differently really exentuated that we were far from Canada!

Friday 1 June 2018

Hoima 2018

Gillian and I are wrapping up our two week placement in Hoima Regional Referral Hospital. This hospital receives people from many small public hospitals, making it a bustling hub, with a diverse range of labour and birth stories. We have had a drastic learning curve, adjusting to a completely different environment, with each day presenting itself with unique challenges, emotional rollercoasters and learning opportunities. Every feeling imaginable we have gone through, twice, and we have learned so much from our supervisors, our colleagues and most of all, our mamas.
It is difficult to put this experience into words.

On our second last day on the ward,  Gillian anf I were working side by side in one of our delivery rooms. We had two mothers bring their babies into this world almost simultaneously. We felt so blessed to be present for these women, and to be along side them as they met their two beautiful, healthy babies for the first time!

During these two weeks, we have worked closely with the hospital care providers, as well as the many nursing and medical students. We have exchanged knowledge regarding normal birth, as well as the management of obstetric emergencies. A portion of our time here was dedicated to education, so, with Cathy and Mickey, we held sessions on normal delivery, third stage management, postpartum hemorrhage, and sepsis. In addition to these workshops at the hospital, one afternoon we were fortunate enough to visit a local girls school and provide information about sexual health. This was definitely a highlight for us!

We head to Masaka next week, where our amazing classmates have already been hard at work! We are sad to leave this hospital as we are finally feeling settled, and will miss the people we have met, but are excited and optimistic about what's to come!

Friday 18 May 2018

Reproductive Health Camp Bhaktapur

Today we attended a reproductive health camp with an emphasis on cervical cancer screening using VIA in a village in Bhaktapur. It was organized together with MIDSON, UBC Global Midwifery, the community health worker for the village, and the Family Planning Association of Nepal.

Sudal outside of Bhaktapur

Health Post in Sudal 

Some posters in the Health Post

VIA (Visual Inspection with Acetic Acid) is a method of screening for cervical cancer that has been proven to be very effective in low resource settings.

The procedure consists of a vaginal speculum exam, a cervical swab with normal saline, and then the application of 3-5% acetic acid solution to the cervix. This is followed by a visual inspection of the cervix using an adequate light source.In the presence of cervical cell abnormalities the acetic acid will cause the affected area to turn white with well define margins, attached to the squamocolumnar junction.

We arrived mid-morning and spent about an hour setting up the different spaces we needed. We had two exam rooms, a room for history taking, a room for dispensing the various medications MIDSON brought and a room for Mickey to hold an education session with the community health workers. Additionally we set up a registration area where the women registered, and had their weight and blood pressure taken.

After registration the women waited to have their history taken before being sent to the exam rooms.

As we were setting up the women started trickling in. They had expected 150 but we ended up seeing 83 women. Of the 83, 2 had a positive VIA test and one screened positive for cervical abnormalities, most likely HPV.

Many of the other women reported vaginal itching, discomfort and discharge. These women were given antibiotics and some of them were counselled to have their husbands tested and treated as well. In many lower income families the husband works outside of the country, and there is a rise in STI/HPV/HIV in Nepal do to this, as the men are visiting sex workers while working away.

We took turns observing the history taking and the exam rooms and had the opportunity to see a positive VIA test. The women who screened positive were referred to the local hospital for further testing.

It was very interesting to participate and learn more about the work that goes into organizing a health camp. 

After participating in our first reproductive health camp, from our observations these are the areas of women’s health care that still need improvement:

Getting informed consent
Making sure the women understand why certain procedures are being performed
Using sterile water or lubricant for speculum exams and pelvic exams
Adopting gentle but effective insertion techniques for speculum exams
Maintaining women’s privacy 
Maintaining confidentiality 
Following the VIA protocol accurately
Use of adequate lighting

We are grateful to MDSON for organizing this opportunity for us.

Refresher Workshops in Phaplu

On May 12th we held a two-hour workshop for the ANM students at Phaplu hospital. We taught through role-playing clinical and counselling skills. First we demonstrated slow delivery of the head, active management of third stage of labour, skin-to-skin, and delayed cord clamping. The second role-play was to show how to educate mothers in the antenatal period about breastfeeding and proper latch in the postpartum. This was considered important to teach as it is common for first time mothers to experience breast abscess’s here in Nepal. Jenny brought out her brilliant tips and tricks for teaching breastfeeding.

The second day we provided a similar two hour workshop to the staff nurses at Phaplu hospital. When we asked the head nurse what topic we should focus on, she requested PPH and uterine inversion. The hospital recently had a case of uterine inversion resulting in maternal death. The nurses were keen to learn how to prevent and manage a similar situation in the future.

Our time in Phaplu has been short because of us being sick in Kathmandu and the time in which it takes to travel here. We wish we could spend more time getting to know the students, nurses and doctors. We have so many ideas and hope we can make plans for future work in the Solokhumbu region!

Wednesday 16 May 2018

Back to Phaplu: Going with the transportation flow

May 11, 2018 

Our drive from Sotang to Phaplu was eventful. We had booked a jeep for 7:30 am but for a number of reasons we did not leave Sotang until 9:30. We said our goodbyes to Chaita, Shreedhowj and Babita, and off we went. 

We asked our drive to stop at the Dudh Kosi so that we could take pictures. 

We had a gorgeous view of the mountains as we drove up the mountain to our tea place.

The ride was smooth and we were making good time when we were stopped by a tractor that was blocking the road. It had run out of gas and the driver had just left it sitting there. After an attempt to make room for our jeep to drive around it (which did  not work) we suggested that the driver put the tractor into neutral and back it up and off to the side of the road. A number of young men, our driver included, pushed the tractor off the road and off we went.

Shortly afterward we stopped again as there was a line of jeeps parked on the side of the road.
We quickly learned that there was a large landslide the day before and they were still working to clear the road. The jeeps in front of us had been waiting in their jeeps all night for the road to reopened. 

We got out and walked around. We met a local woman, who recognized Pema as the nurse who had taken care of her sick relatives at the hospital. She made us coffee and gifted Pema with a bag of her home grown millet. Our driver told us it would be cleared in 1 hour, almost 4 hours later we were on the road again. It was just about dark and our driver was clearly impatient to get to Phaplu. We had to remind him to drive slowly after he drove too fast around a corner and almost hit another jeep.

There was lots of traffic and the road was very dusty. We finally made it to Phaplu by 7:45 pm. Just in time for a delicious dinner of chicken momos prepared for us by Rashmita. We were so happy to be able to shower and sleep in extremely comfortable beds after being in the jeep all day.

Distance travelled 80 km. Duration of travel: 10 hours

Sotang Womens Group

We really enjoyed our time in the remote, yet very lively village of Sotang. We spent time meeting with different people and groups including the local health council discussing future plans for a maternity waiting home, and the possibility of having cesarean section at the health centre in the future. By chance we also had the opportunity to interview the new ANM from another very remote village called Gudel. She started working at the Gudel Health Post 8 months ago and has assisted in 18 deliveries. She shared with us her challenges, her successes, and reasons she refers women to higher centres like Sotang, Phaplu or Kathmandu. The main complication she has dealt with is women arriving with retained placentas after giving birth at home. Using her oxytocin, experience, and clinical skills she is usually able to save these women's lives.

Jenny, Cathy, Pema, Hari (ANM from Gudel), and Emma 

One evening we hosted the local women's group for snacks, conversation and to watch global health initiative videos. We learned that the women's group began when a local woman needed to be helicoptered out for an emergency cesarean section and had no money to pay for the up front cost. The government will reimburse people for these expenses, but it is more money than most people have available ,and the government delays, sometimes never paying the money back. This group of women came together and started a community based lending program for women in their community in similar situations. The group meets each month and is also fundraising to build their own women's centre.

The 15 women who joined us were shopkeepers, teachers, university students, farmers, and hair stylists. We asked them what their community of women need, and they all agreed that they want a female doctor and for women to own land. Among the different groups in their community, it is most common for land to be only owned by men and inherited by men. Their own land and centre would allow for them to create a safe place to continue supporting the women in their community.

Sotang Primary Health Centre

May 7-11th 2018
From Phaplu, we hired a private jeep to take us to Sotang. Pema, a retired Nurse and Midwife, joined us to help translate and support us. We also had a wonderful cook, Chiyta join us. All of us crowded into a jeep for a 6 hour drive through a long steep, dirt mountain roads.

We stayed with the very hospitable community health worker Shreedhowj Rai and his family. Shreedowj was originally chosen and trained to be one of the first community health workers in his village by Sir Edmund Hillary's foundation.

Mickey, Cathy, Jenny, Emma, Pima and Chiyta in Sotang

The Primary health Centre was just a 15 minute walk from where we were staying. They had 75 births at the birth centre last year and that number is lower this year, which is likely due to the fact that women in the nearby village of Gudel can now give birth at the health post there with the support of SBAs and an ANM. We met the ANMs at Sotang Primary Health Centre and were invited to observe the doctors as they conducted clinic. It was very interesting to see the different complaints. There appeared to be an outbreak of chicken pox in the community as we saw three children who were affected. According to the doctor this is common for this time of year.

Sotang Primary Health Centre as seen from the Helicopter pad. 

We also participated in antenatal visits. The women were first seen by the doctors and then went to see the ANMs for a more thorough antenatal check up. There is ultrasound at Sotang Primary Health Centre and they use it for a variety of reasons: dating of pregnancy, fetal position, to check for fluid levels, and more. They can also order full bloodwork, urine and Liver Function Tests, which makes screening women for things like pre-eclampsia much easier.

Women in Sotang can access Family Planning and CAC/PAC (comprehensive abortion care/post abortion care) although we did see in their referral book that some women are sent to a higher centre for incomplete abortions, despite having trained staff on site. One woman did come for CAC while we were observing. She had 3 children already and did not want more. She requested a medical abortion and insertion of a IUCD (intrauterine contraceptive device) (IUD in Canada). She was counselled, had a dating ultrasound, was provided with the medication, and was counselled on what to expect in the next 48 hours, when to come in, and when she could have the IUCD inserted.

On our last day in Sotang, the plan was to teach an afternoon workshop. When we arrived at the health centre, a woman was in labour. Mickey continued to teach the workshop, while Jenny and Emma provided labour support. She was in labour with her 8th baby. Together with Pema translating for us we discovered that she had a urinary tract infection that had likely triggered her labour. We continued supporting her throughout the day and evening.

At one point we stepped out for some dal bhat, and missed the dhami (shaman) arriving and providing some rituals to encourage the baby to come. After many hours of irregular contractions with little cervical change we decided that the mother should try to sleep and maybe more active labour would pick up in the morning. We also needed some sleep since we were waking up early the next morning to drive back to Phaplu. The next morning we learned that the mother delivered a couple of hours after we left! We were disappointed to have missed her delivery, but very happy to hear that she had her baby and that it was a girl, as she had 6 boys at home!

Sotang Primary Health Centre

The labour and postpartum room before we bought new mattress and sheets. 
Us with Pema and the ANM's next to the sheets and pillows we purchased for the health centre. 

Delivery room at Sotang Primary Health Centre 
Scale and frame built by the community to weigh babies as part of the super cereal program. 

A rose bush, Shreedhowz planted outside of the Sotang Primary Health Centre