Fighting for survival

Midwives magazine: Issue 5 :: 2011

I arrived at Kamuli Mission Hospital, 100 miles from Kampala in Eastern Uganda, to find that the government had not funded the hospital for three months, meaning there were no intravenous fluids, limited drugs and no dressings for a hospital that covered a population of 750,000 (www.friendsof kamulimissionhospital.org, 2011). Furthermore it was the rainy season, and bare wires on metal nails without insulation resulted in power shortages.

Within the first week of my visit, two babies died of hypothermia. Frustratingly, four incubators, ordered prior to my arrival, were delivered shortly after. The incubators, manufactured in Africa, were made of wood and Perspex, heated by three 75 watt lightbulbs and humidified by a tray of water. The medical superintendant asked me to train staff on how to use the incubators. I made diagrams on how to clean, maintain and use an incubator as the hospital has no computers.

The power supply was usually unavailable at night, as the back-up generator was not running to provide electricity for operations. When babies were born, they were not dried and were left in damp cloths, as no nappies were available. The ward had broken windows and it was cool at night. I demonstrated on a blackboard how to keep a newborn baby warm and prevent heat loss via convection, conduction, radiation and evaporation. I emphasised the importance of getting and keeping babies dry and that babies could get warm in the incubator because there were no drafts.

I did not demonstrate skin-to-skin contact, as neither the Ugandan women nor the students or midwives were keen on doing this; it was not part of their culture. I discussed the importance of breastfeeding three hourly. This is when I discovered that babies of women who had caesarean sections were not fed until the mother was conscious 12 hours later. I demonstrated to students and midwives that it was possible to feed a baby whose mother was not alert as per the UNICEF breastfeeding guidelines (UNICEF/WHO, 1998).

Some babies did not survive birth. One of the reasons was the resuscitation technique. There was just one ambu-bag and mask that had not been chewed by a rat, however they were not used. The midwives and students cleared every baby’s airway using a size CH 14 suction catheter, then squeezing the chest, believing this provided lung stimulation. This was a problem following caesareans as the drug used as an anaesthetic is ketamine and it heavily sedates a baby to the point that they don’t breathe for themselves. I demonstrated the techniques of intermittent positive pressure ventilations and maintenance breaths using an ambu-bag, and a stethoscope to monitor the heart rate, encouraging students to do likewise. However, there is no neonatal resuscitation doll for the students and staff to practise on.

High maternal death rates
The main causes of death in Uganda are influenced by the socio-economic condition, diet and that women are regarded as chattel, which means the men decide whether a woman can use contraception. The women therefore risk criminal abortions.

I did see a woman die from an unsafe abortion; dying from gas gangrene as a result of perforating the bowel via the pouch of Douglas, probably caused by clostridium perfringens. The other indirect cause of death was a volvulus of the transverse colon following the normal vaginal delivery of her fifth child, possibly because the colon fell into the space left by the contracted uterus. Volvulus is a more common bowel disorder in Uganda due to a high fibre diet. I saw an obstructed labour, which resulted in a ruptured uterus. The abdomen was like an hourglass, hard at the fundus and lower segment but soft in the middle. The woman came in hard labour that lasted over 48 hours and the rupture was noted when there were no contractions but signs of shock were visible. She  subsequently had a hysterectomy and survived. Another cause of maternal/neonatal death was the effects of malaria, which led to premature deliveries and anaemia causing haemorrhage.

The staffing levels for the maternity unit were one midwife and eight students for 45 women. There is no bleep system and it takes time to find the doctor. On one occasion, the students were on a break and the midwife was at the pharmacy, leaving me alone. I realised that the labouring woman was delivering, but there was no delivery equipment, as it had not been sterilised. Fortunately, I had a pair of gloves in my pocket. So I used half a razor blade (resources have to be used sparingly) and three cord ligatures, and successfully delivered the baby and secured the cord.

On another occasion, one of the midwives was delivering a breech and the head was stuck because the arm was alongside it. I did a McRobert’s manoeuvre by hyper-flexing the legs and flattening the sacro-lumbar promontory to enlarge the space within the pelvis, resulting in a successful delivery.

This visit taught me how to adapt my skills to the environment and resources available. I am now fundraising for a neonatal resuscitation doll and textbooks to enable Ugandan students to have access to vital practice tools and information. 

Causes of maternal death in uganda:
 25% Severe bleeding
 19% Indirect causes
 15% Infection
 13% Unsafe abortion
 12% Eclampsia
   8% Obstructed labour
   8% Other causes


Gillian is a rotarian for Rotary Doctor Bank.