Ward Round

We arrive on the ward and there is anxiety in the air. The nurse calls me over, she looks quite flustered. There is a young woman, second trimester, gasping. She still has a pulse but clearly about to go into cardiac arrest. She needs to be ventilated so I ask for the usual bag-mask-valve combo we use to ventilate in the first instance. The nurse is frantically looking through a cardboard box and not winning so I go and help; a tangle of old tubes and oxygen masks, covered in dust, but not the one we need, and it’s not a great surprise. Back at the bedside, things have deteriorated and I ask the woman’s sister to step aside. I ask for a bag of fluids to get things going, but there is no stock. We have a look through the notes, not much is known yet, maybe meningitis, maybe malaria, maybe a blood clot to the lungs. No investigations back yet, the lab is not working and blood gets sent across town for analysis. Her breathing is worse, I consider mouth to mouth, but that’s for the movies, and this woman’s fate is sealed. The pulse weakens and stops. Another doctor has come and tries some chest compressions, and I ask him to stop. A moment for collection and the ward team start preparing the body. A bandage used to strap the mouth closed, the body covered in a sheet, and a cardboard tag with her details tied around her left big toe. Another maternal death, unknown cause. I offer my condolences to the sister who seems remarkably calm. She must be shocked. The death of her sibling won’t sink in until later. The patient in the adjacent bed looks terrified; they’re only a metre apart and there are no curtains. On with the ward round.

A few moments to settle the nerves of said terrified adjacent patient. She cries whilst I hold her hand, worried she’s in the same boat. Fortunately, she’s on a different journey. She suffered with severe pre-eclampsia, the high blood pressure disorder in pregnancy. Her baby was born early and died the previous day. She has three, but wants two more. Fluid has built up in all the wrong parts of her body from the inflammation of pre-eclampsia, but most importantly for her in the lungs. I can hear the two puddles of water in the base of her chest. The SHO (obstetrics and gynaecology trainee) has arrived now and says they have asked the cardiothoracic surgeons for an opinion. It’s a blessing that they won’t come anyway, the last thing she needs is a knife. Her body should pass the water naturally over the next few days. I counsel her that she may need blood pressure medication when she goes home, and her next pregnancy will be very high risk. She will need careful antenatal surveillance in case this happens again, a service she unfortunately will not get. She’s going to get stepped down to the general post-natal ward now, a room with 40 mothers and crying newborn babies, and she will feel her loss.

I notice the catheter bag of a lady in the corner is a brownish red and suggest we see her next. She’s not looking well. She presented yesterday from another health centre after a prolonged obstructed labour at term, her first pregnancy. The baby had already died, and the operation notes suggest a very difficult Caesarean section. She is now semi-conscious and breathing very quickly, heart rate too fast, oxygen sats low, blood pressure holding. She’s either bleeding, or there is infection. No investigations, the family can’t afford the blood tests. She’s on some nasal prongs with a futile amount of oxygen trickling through. We get her on a more appropriate mask, and get another cannula in her arm. She needs some fluids, then I realise we have none. The woman’s mother is buzzing around, so the nurse writes ‘normal saline’ on a scrappy piece of paper and sends her to the strip of private pharmacies that line the hospital fence. ‘Free healthcare for all women and children!’ the government announced some years ago… I ask if we can check her blood sugar, but there is no glucometer available. I have my own machine, and one last testing strip. It’s low at 2.1, we give her a push of IV glucose. I’m half hoping it really picks her up; she stirs a little, but not much more.

We need to see what’s happening down below, why there is blood in the urine. The specialist gynaecology consultant has arrived now, thank goodness, he knows exactly what to do. But it’s bad news for the woman; the wall between the vagina and the bladder has been completely destroyed, a large fistula. The end of the catheter has prolapsed into vagina, and is draining a mixture of urine and blood and infection. We clean the area and there is clearly rotting flesh. The woman is in septic shock. With some basic plumbing we manage to get the catheter to stay up in the bladder. Back to treating the whole patient. The woman’s mother has returned with the fluids and we are into the second bag. We get some stronger antibiotics into her. More cleaning down below. Then the gurgling that I recognise, some fluid in the chest, we need to slow down the fluids. Everyone is working well as a team, despite the difficulty of the case and the conditions. The oxygen levels have come up, the pulse reduced a little. It’s the basics of medical resuscitation, it’s exhilarating and shocking all at the same time. Then things change, the pulse suddenly races to 210 beats per minute, far too high, a sprint that the heart muscle will struggle to keep up with. The adrenaline from the pain of the internal examination has probably shocked the heart into a short circuit. We continue the resuscitation, I’m hoping the rate will revert spontaneously, but it’s not budging and the oxygen level is dipping a bit. It would really help to know what rhythm she is in, but there is no ECG machine in the hospital. I start weighing up the options – difficult without knowing the rhythm. Some beta blocker? Some amiodarone? Would it be safe without monitoring? First do no harm. No chance of a defibrillating shock if she crashes, no defibrillator! Her salts could be abnormal causing the rhythm, but no way of knowing as the lab is not working. Probably wise to give some potassium and magnesium in case, low potassium will kill quicker than high potassium. We manage to get an anaesthetist from downstairs. She agrees, chance of harm if we start giving other cardiac drugs blindly, let’s give her some time. On with the ward round. Another woman has had a stroke from the high pressure of pre-eclampsia, another is swollen with fluid as her kidneys have completely stopped working. She needs dialysis which the family can’t afford, and she too will die.

I drive out of the hospital with that familiar feeling, a bit disconnected, a little overwhelmed, but knowing it will pass soon. Everyone getting on with life as usual out here. Those women are out of sight and out of mind. Maybe it would be different if we were at the heart of a humanitarian crisis, but this is a capital city in 2018. 2018! Do you remember how futuristic 2018 sounded? Hover boards? A meal in a pill? In 2018 a pregnant woman teetering on that fine line between life and death can’t get a bag of fluids and a basic blood test, whilst all the world carries on. One assumes that the health system they are working in is on an upward trajectory but a longitudinal view over some years makes me wonder otherwise. The funding and systems in place are deficient, creating a demoralising environment for the doctors and nurses that work tirelessly to make things better, indeed they are the strongest cog in the wheel. Families are not shocked, because this stagnation is an accepted part of life. The problems are systematic, and they come from the top. Whilst I stand by the philosophy of singing the good news stories, sometimes one feels the need to lay out the truth of what is really happening on the ground. It can’t be right. What on earth are you meant to do about it? Who does one shout at when we all know that method doesn’t work? Surely it’s wrong that we let pregnant women die of preventable causes well into the 21st century. Frustration and anger, probably not constructive, but important emotions, to write down and perhaps to share.

The woman in the photo is a generic image pulled from the internet.

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The tightrope of pregnancy in Uganda

Pregnancy is an uncomplicated business (in the medical sense at least..) for most women, most of the time. But when things go wrong, the situation can rapidly deteriorate putting both the mother and baby’s lives at risk; babies get stuck, mothers bleed both prior and after delivery, and many suffer a serious disorder of blood pressure called pre-eclampsia which can lead to fits and strokes. The avoidance of such grave consequences requires a tight system of antenatal surveillance and rapid sequence of action when complications arise. Whilst the health system in Uganda has the potential to supply each of the component parts of this system, they are weakly tied together, and elements of the chain may break due to basic inadequacies in infrastructure such as electricity and surgical supplies.

Each year we teach a two week of module of maternal, neonatal and child health which forms part of the East African Diploma in tropical medicine and hygiene (DTM&H). Seventy-two post-graduate doctors from both East Africa and around the world pass through and will expect an introduction to the practicalities of clinical medicine and research in sub-Saharan Africa. Each afternoon we take groups to meet women and hear stories which exemplify both the public health and obstetric challenges a woman may meet along the tortuous journey of pregnancy in Uganda. We make an effort to celebrate good maternal and neonatal care, as well as pick up on shortfalls. The cross-cutting themes include the impact of gender inequalities, educational background, and socio-economic components of care-seeking behaviour. Here are some of their stories. Names have been changed.

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A group of students on the 2017 course

Respectful care

Robhina is a 26-year-old lady, with a good educational background. Her first baby was born by Caesarean section due to obstructed labour; the baby’s head was simply too big for the mother’s pelvis, a common problem worldwide but even more prevalent where woman’s growth is stunted due to malnutrition in childhood. A vaginal birth is possible after Caesarean section, but must be done in a very supportive environment, and probably avoided in the context of pelvic insufficiency. Robhina laboured at home for a considerable time before going to a health centre IV, which should be able to provide blood products and a Caesarean section if needed. She continued to labour there overnight in considerable pain before it was clear she would need an operation. Unfortunately no doctor was there to do the operation and was transferred an hour across town to our facility which was overflowing. She was received in a very poor state and in agony. After another hour she was in theatre; her uterus had ruptured along the previous Caesarean scar and the baby was found floating free in the abdomen and already dead. She got the blood transfusion she needed and the surgeons managed to repair the uterus and avoid a hysterectomy (removal of the uterus). The team did a great job saving the woman’s life, but it was too little too late for the baby. We see around 4 of these ‘fresh’ stillbirths every day. Rhobina told her story totally matter of fact; she clearly had no idea that this was an avoidable outcome. So common are such stories amongst women that they are normalised. I asked her why she hadn’t come to the hospital sooner to deliver. It came down to the way she had been treated previously; talked down to, no privacy, scorned for complaining. Why not have a go at home with loved ones around? Explanations like these remind us that the respectful care of women is an integral part of future health system reform.

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Hearing personal stories provides context and a deeper level of learning (East African DTM&H 2016)

A new wave of medical disorders in pregnancy

Urban Africa is not only about empty plates. There is a rapidly expanding middle class with a taste for refined sugar, and a culture which associates large abdominal girth with higher social class. As a result we are beginning to see a rise in cases of diabetes in pregnancy. Doreen is 31 and has just had her third child. The first was delivered normally and weighed a decent 4.2kg. The second was even bigger at 4.8kg and needed to be delivered by Caesarean due to obstructed labour. Big babies are the hallmark of untreated diabetes in pregnancy; the high sugar level means the baby lays down more fat around the shoulders and abdomen raising the likelihood of complications at delivery. They also get so used to the high sugar and produce so much insulin that when they are born into the world their sugar level plummets which can kill. There is no screening for diabetes in pregnancy in Uganda. We do not yet even know which screening test would be best, or even what we would do if it was picked up as management is not straightforward and beyond the present antenatal system. As I spoke to Doreen the story of diabetes in her case was clear. This recent baby needed a Caesarean as there was not enough fluid around the baby (diabetes causes both too much or too little fluid). Her baby was wrapped up in sheets beside her and I see a tiny area of the sheet flickering over and over again in a repetitive way. I ask to see her 2-day old baby and sure enough the tiny girl was having a seizure, repetitively jerking her left arm up in the air. Doreen has no idea, and no doctor has been around that day. One junior doctor usually has to cast an eye over around 80 women and their new babies in the course of a morning. Few get a thorough check, and besides Doreen has no diagnosis. We take her baby to the special care unit for anti-convulsants; perhaps a low sugar level soon after birth could explain the fits, or infection, or low oxygen levels, we don’t know. Fortunately both are discharged a few days later, but the impact of the seizures and damage to the brain may not be realised until months later.

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The Maternal HDU (High Dependency Unit) during clinical rounds with Dr Anita Makins

Living with fistula

Ruth is 43 and has travelled from a very rural farming community. She has a coy smile and has the air of a once confident person who has suffered too much hardship in her life. She came to the hospital after hearing a radio advertisement. She had been leaking urine for twenty years having developed a vesico-vaginal fistula (abnormal connection between the bladder and vagina) after the birth of her third child. She laboured at home for three days before giving birth to a baby who had already died; she had been unable to afford the transport to get to the nearest hospital 7 miles away, a mere £3. The pressure of the baby’s head, stuck in the pelvis, caused damage to the tissues leading to abnormal tract formation. It’s a condition very rarely seen in the West, but still common in areas without accessible and affordable health services. Since that time she withdrew from village life, and farmed alone, hiding her shame from the community. Fortunately a supportive husband stayed with her, though many are not so lucky. Ruth has had decades to contemplate her fate, has come to terms with her condition, and is now happy that something may finally be done about it – surgical repair. Opposite Ruth sits another girl, with the same condition, but at the start of her story. She is very small, and looks incredibly shy. She is only 16 years old, but as I gain her confidence she tells me her story. Her first statement says so much; her family was not able to pay for her to go to school, so she stayed at home and became pregnant, totally matter of fact about the inevitability of such a chain of events. Again she laboured at home and got to the hospital too late. A dead baby was delivered using a suction cup in what sounded like an extremely traumatic series of events. She started leaking urine 6 weeks later, again due to injuries from a prolonged obstructed labour. She looked very vulnerable and alone, in a room full of women with totally avoidable internal injuries, victims of a world that still fails to recognise the equitable status of women in society.

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With Dr Ed MacLaren, my tutoring partner for the module, and one of the HDU nurses

The antenatal visit

Annett is a 24-year-old lady, a bubbly character with a broad smile across her face. She had given birth to a baby boy the week before and is overjoyed. Her first pregnancy had not been so successful; she had suffered high blood pressure which hadn’t been picked up in her antenatal visits. They didn’t have the basic testing strips for analysis of the urine, and blood pressure had not always been measured. She lost her first baby at 34 weeks of pregnancy. The staff encouraged her to get to antenatal visits early in subsequent pregnancies. Annett had the confidence and educational ability to speak up at her antenatal visits and demand the basics were done. She also had some money to get an antenatal scan – less than £10 which is far more than many can afford. As often happens she suffered with high blood pressure again. She came into the hospital at 26 weeks and was managed with medication for another 5 weeks to give her baby the chance to mature. At 31 weeks her condition was so severe that her baby had to be delivered, since the placenta is the cause of the blood pressure disorder. Her baby boy was taken to special care unit. On the first day Annett showed me pictures on her phone, but the next day took me to see him in the neonatal unit. Seventy similar babies were lined up, many with NG tubes in their noses, their mothers expressing milk and pushing it down the tube with a syringe. One doctor has the job of looking after all these delicate beings. Annett tells me all about what she does several times per day for her baby, and in immense detail. This is a mother’s love and casts out the common attitude of ‘just another stillbirth, or just another neonatal death.’ Annett and her baby had received great care, using basic principles of medicine. But she only got there because she had the educational and financial means to transcend the gaps in the chain, a privilege of few. Four young women, one just 19 years old, died of this high blood pressure disorder in our two weeks on the unit this year.

They are morbid stories in themselves, but more frightening is the sheer number of similar stories that are told every day, even in this one hospital. An old friend presented me with an audit of the women’s health service in the same hospital from 50 years ago, 1967-1968. Each maternal death is detailed and the stories are hauntingly similar. However much we try to champion good progress in sub-Saharan Africa, with health statistics improving year on year, it’s hard not to feel like the two worlds in which I spend my time are moving further apart. Whilst total average worldwide wealth improves, the inequities both within and between nations are worsening. It’s easy to be paralysed by the enormity of the problem, but inertia is far from an effective solution. Sharing stories like this will not change the world, but the least one can do is advocate for those without a voice. It may at least help in appreciating the excellent standards that our National Health Service affords our women and mothers.

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The 2017 contingent graduating in the gardens of Mulago Hospital

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Tutor group on the 2017 course

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A group on the 2016 course