Ward 14 – Learning to deliver

I finally found my way back to Mulago Hospital for my much anticipated rotation on Obstetrics and Gynecology. As instructed by the many international students who have rotated there before me, I requested to start out my rotation on Ward 14, the labour suite in Old Mulago for low-risk obstetrics patients, entirely run by a team of uber-experienced midwives, and a perfect learning ground for newbies like me.

I met with a cold welcome when I first presented myself to the sister-in-charge on Ward 14. The midwives there are really busy and overworked, and in their experience, most of the students who pass by stay for only a short while, disrupting the overall pace of work in order to gain experience and knowledge, and disappear before they are actually skilled enough to help lighten the workload. Thus, that you really have to prove yourself to be eager to learn and help out before they will pay you any attention. When I first told them that I was only planning on staying for 2 days, they scoffed. “But what can you possibly learn in 2 days? You must stay for at least a week.” Sister Florence, the in-charge, informed me. And by the end of my first day, I had already learned so much from them that I decided to stay for the whole week. They showed me the ropes in terms of how to deliver women in these low-resource settings, and how different it is from what I’ve been used to in the US.

The first delivery that I observed totally shocked me. These women have to bring their own delivery set, which includes, at the minimum, the following items: a large plastic basin, a small bottle of Jik bleach, at least 2 large plastic sheets, a huge roll of cotton, a few pairs of sterile gloves, a razor blade, 2 sheets for the soon-to-arrive baby, and a change of clothing for themselves. Why these items, you wonder. Well, allow me to explain.

The laboring mother who is found to be in the active stage of labour gets a bed in the labour suite, and she proceeds with her suitcase (presumably filled with the items of her delivery set) to the bed. She spreads the large plastic sheet on the bed, both to protect her against the nastiness of the bed and to protect the bed against the nastiness of her labour-induced fluids soon to be spread all over the plastic sheet. She also provides the sterile gloves for the midwives to use while doing vaginal exams and during the delivery. Then, if she is lucky, she may get checked once or twice before her actual delivery. If she is super unlucky, she may end up pushing out her baby on her own while the midwives are busy with other deliveries. Let’s say she’s lucky. She screams her classic second-stage scream (if you work in a labour suite for long enough, you learn to recognize the unique scream that soon-to-be mothers emit when their babies are crowning – it is a terrific combination of pain, anxiety, and anticipation, brushed with a hint of desperation and a tinge of hope – that directs you to the woman who needs your attention most immediately in a room full of laboring women screaming in agony, forming a strange cacophony of sweet but unbearable pain) and you rush to her side (after hopefully having had time to don a plastic apron to protect yourself against splashes, and if you’re me, you also wear goggles for eye protection, though I don’t always have time to put these goggles or the apron on before the baby starts popping out). You prepare your delivery “tray”, in case you don’t have an assistant by your side when the actual delivery happens. Note that this preparation precedes the checking of the mother to see if she indeed is in the second stage of labour, because we cannot afford to waste a precious pair of sterile gloves on the vaginal exam, which results in the not-uncommon tragedy of the mother pushing her baby out while the deliverer, in this case, me, is busy preparing the “tray” and does not even have gloves on to try and catch the baby before it pops out traumatically, ripping a nasty tear into the mother’s vaginal wall and perineum. Anyways, back to the “tray”. You first track down the plastic basin that all laboring women bring with them. You place it beneath the mother’s bed. Then, you find the huge roll of cotton, a necessary part of any delivery. You break off a big chunk and set it close to the mother’s perineum, ready to wipe off and push away poop that may get squeezed out as the baby’s head descends, to catch the amniotic fluid that may fly out as the membranes rupture, and to support the mother’s perineum as the baby’s head exits the vagina to prevent tearing. You open one set of sterile gloves, tearing off the rubber rings located on the wrist end of the gloves that are meant to provide some elastic traction to keep the gloves from sliding off your hands – these rings are used as ligatures to tie off the umbilical cord. You place the rings on top of the sterile-ish package holding your now not-so-sterile elastic ring-less gloves, and this serves as your delivery “tray”. You break open a glass bottle of Pitocin for use after the delivery of the baby to help the uterus contract and prevent post-partum hemorrhage, and fill a syringe with the drug (it is to be delivered as an injection intramuscularly), making sure to save the broken glass bottle in case you need to use it to rupture the membranes (if the membranes are not already ruptured). All these items are placed on your delivery “tray”. Lastly, you open the razor blade and add it to your “tray”. Finally, you search around the suitcase until you find the baby sheets, and place one of these sheets on the mother’s abdomen. You now open another set of sterile gloves, so that you can double-glove. You first don the not-so-sterile pair of gloves on the inside, and add the actually sterile pair of gloves to the outside. You do a vaginal exam and more often than not, the mother is in the second stage of labour just as you had expected, and is ready to start pushing. Good thing you already prepared your “tray” so you’re ready for the delivery.

If the mother is still dressed, you ask her to strip. Yes, these women give birth absolutely naked. Not a whole lot of dignity gets retained during this birthing process. The mother starts pushing, with shouts of encouragement from you. “Sindika! Sindika! Yongera! Sindika!” “Push, push,” you yell. You tell her to raise her head off the bed, and hold onto her legs with her arms. This goes on until the baby’s head is crowning. Usually, this process proceeds smoothly. However, once in a while, the mother demonstrates “poor maternal effort”. This basically means that the mother is not pushing effectively, either because she is tired, or because she doesn’t know how to push. Now, for outsiders like me, there is only so much we can do to encourage these women. But there comes a time when encouragement alone does not suffice, and some intimidation is necessary to get the baby out. Now, I have not yet fully adapted to the delivery process here, and so intimidation is not currently in the arsenal of tools I have at my disposal. So I call in an experienced midwife, usually Sister Sarah, the most experienced and intimidating of them all. She comes, screams at the mother, pushes her roughly into the optimal position for pushing (head tucked, legs pulled way open) and sometimes slaps her a few times on her thighs. Now, this may seem barbaric to some of you back home, and when I first witnessed this, I thought it was so unbelievably mean and unethical to treat women who are already suffering so much with so much cruelty. But it turns out that it is not cruelty, but the lesser of two evils, and I swear that it works like a charm. What I couldn’t get the mother to do with some 30 to 45 minutes of eager encouragement, Sister Sarah gets done in a matter of minutes, and when I say minutes, I mean usually less than 5. Suddenly, the mother is able and willing to push, and push effectively, and the baby pops out effortlessly. I have carefully considered this matter, and discussed it at length with both my American and Ugandan friends working at Mulago. As a result, I have drawn a tentative conclusion. I believe that Ugandan patients do not respond as well to encouragement as American patients do, and they certainly respond much better to threat and intimidation. I have seen and experienced this many times myself. For example, when I politely asked a patient’s attendants to leave the labour suite, they dragged their feet, and basically didn’t move. When a midwife came and ordered them sternly to leave, yelling at them, and shooing them away, they left immediately. So perhaps, when polite encouragement fails, threat and intimidation is the way to go. In fact, all of the mothers I’ve seen who were yelled at, and even slapped, were super grateful to the midwife who yelled at and slapped them, despite their apparent “meanness”. These midwives got the job done, and got the babies out before they became distressed, or worse. All of the mothers seemed to prefer a few slaps and rough words to a sick or dead baby. I know I would. Interesting food for thought, isn’t it? Where would you draw the line between ethical and humane conduct, versus doing everything you can to avoid a possibly terrible and tragic outcome?

Anyways, back to the hypothetically smooth delivery. The baby’s head is crowning, and you use cotton to support the perineum as the baby’s head pops out, and if you do your job well, the mothers generally do not tear. Once the head is out, you wait for restitution, and the shoulders to descend. Then, you deliver the anterior shoulder, followed by the posterior shoulder, and the rest of the body follows. You deposit the baby on the sheet on top of mom’s abdomen, and quickly dry the baby off. If all is going well, the baby is pink and feisty, and crying at the top of his/her lungs. You give mom the Pitocin injection, often without cleaning the skin with any kind of antiseptic, and hope the mother’s immune system will prevent her from getting an infection. You tie off the umbilical cord with the elastic ring ligatures, and grab the part of the cord between the ligatures with a piece of cotton to absorb the blood splashes before cutting it with your razor blade. You clean the baby off and show the sex to mom – “Muana ki, mommy?” Then you wrap the baby snugly in the second, clean sheet, and find a relatively clean area of the bed to place the baby. By this time, the placenta should have separated, and you use another piece of cotton to firmly grip the umbilical cord. You use firm traction to deliver the placenta, while applying pressure just above the pubic symphysis to prevent uterine inversion. As the placenta reaches the vaginal introitus, you let go of the cord and grab it with both hands, twisting as you gently pull to gather the trailing membranes into a stronger cord, so that hopefully no membranes will be left behind. You examine the placenta for completeness, and then drop it in the large plastic basin beneath the bed.

Now you get to the really nasty part – the cleaning. I’m telling you, I’ve never properly appreciated nurses and patient care technicians until I had to do the cleaning part myself. I will never again take any nurse or PCT for granted, I swear. The first few times I witnessed this process, I almost ran away. But I had to start cleaning as soon as I started delivering. You have to take charge of every part of the delivery, including the gross aftermath. So here’s what you do. The mother is now lying in a pool of nasty fluids such as amniotic fluid, blood, urine, feces, etc, atop the plastic sheet. You roll up this plastic sheet, trying to catch all the fluids in it, without letting any leak onto the bed underneath (not always a possible feat). You ask the mother to lift herself off the plastic sheet, which you then pull out from under her. You then drop the rolled-up plastic sheet into the basin. You take the basin with you to the instrument room, separating the placenta out from the rest of the waste, depositing it into the placenta bin, and then toss the rest of the contents of your basin into the biohazardous waste bin. You rinse the basin off, and fill a small tin bowl with Jik diluted with water by a factor of 6. You bring the now relatively clean basin back to mom, and drop her soiled clothing, sheets, etc into it. You ask the mom to get off the bed, and clean her with some cotton soaked with diluted Jik. She starts getting dressed as you wipe off the bed with more cotton soaked with diluted Jik solution. You dry off the bed with cotton (see the importance of cotton in all of this?) and then spread a new plastic sheet over it. If the mother has a bed sheet, you place it on top of the plastic sheet, and the mom gets back into her bed to recover. You then weigh the baby, and write your delivery notes. A job well done!

P.S. I am never giving birth at Mulago.

Menstrual Health Project in Kalisizo

I traveled to Kalisizo to work with Brick-by-Brick on a menstrual health project. The theory is that many girls in low-resource, low-income settings hit puberty, start menstruating, and start missing school, because they do not have access to sanitary products that ensures adequate protection against embarrassing leaks. These girls’ grades drop, and some of them probably end up dropping out of school. Thus, if we provide them with access to sanitary products, then they can stay in school, get an education, and get further ahead in life then they would have otherwise. This sounds reasonable and logical, but the theory is supported by little more than anecdotal accounts. In fact, the largest, and possibly only, randomized controlled trial conducted to study the subject found that girls missed very little school in general, and girls who were provided with free sanitary products had no difference in school attendance from girls who were not provided with the products. Thus, Marc Sklar, the founder of Brick-by-Brick, wanted to find out if there is an interest in and need for access to reusable sanitary products amongst primary school girls in Kalisizo, and I had been tasked with conducting the survey. I shall not delve into the details of the survey. Suffice it to say that there is a great interest in access to affordable and reusable sanitary products amongst the girls.

In order to derive enough energy to conduct this study, I had to find nourishment around town. And that was how the chapatti guys came into my life. I first met Frank and Hassan while hunting around for rollexes in Kalisizo. They sold chapattis and rollexes in the mornings and evenings, and I purchased at least one rollex from them every single day. Their rollexes were delicious, and I may or may not have developed a mild addiction to them. However, one fine morning, I woke up a little bit late, and arrived at the chapatti guys’ stand to find everything sold out. I was absolutely distraught. I was craving a rollex. I wanted it. I needed it. Frank calmly told me that there were no rollexes left, as he was preparing two rollexes right in front of me. “What about those rollexes?” I asked him. He shook his head. Those were for him and Hassan. The rollex he was preparing was the biggest I had ever seen – he had stuffed it full of eggs and tomatoes. He must have been hungry, but I was hungrier. I sat down and refused to leave. I want to buy that rollex, I told him. You told me you’d be here until noon, and it’s barely 11.30am! How can you already be sold out? That is unacceptable. A businessman must keep his word to his customers, especially one as loyal as I. Please. I really want a rollex. Please? Pretty please? Frank shook his head in defeat and sold me his lunch. “Webale nnyo nnyo nnyo sebo!!!” I screeched in delight. I sighed with complete happiness as I bit into my rollex, brushing aside the tiny tinge of guilt lingering around my cloud of bliss. I would make it up to him. And I did. On my last day in Kalisizo.

On my last day in Kalisizo, I woke up at the crack of dawn and headed to town. I arrived at the chapatti stand before either Frank or Hassan. I was their apprentice for the morning. I wanted to learn to make chapattis and they didn’t mind the help (or hindrance – these are really really nice guys). They taught me the correct proportions of flour and water to use, how to mix everything (that was really hard work – Frank did most of it, since I apparently do not possess the requisite upper-body strength to make a master chapatti chef). We added some oil, and started to break off pieces of dough to turn them into these little dough balls ready to be rolled into chapattis. This is a lot harder than it sounds. You have to first break off a piece of dough that is just a little bit bigger than the right size for making one chapatti. Then, you place the dough in your hands and start to tuck the outside edges of the dough piece into its center with your two thumbs, while slowly nudging it towards your left palm. Eventually, the dough ends up completely in your left hand, while your right thumb is still tucking the bottom edges into the center of the now almost completely round ball of dough. You close your left hand into a fist, squeezing the dough very gently so that it pops up as a completely round ball right on top of the ring formed by your thumb and index finger – it kinda looks like you’re holding an invisible ice-cream cone with the dough ball as the scoop of vanilla ice cream sitting triumphantly on top, basking in the glory of its perfect spherical geometry. This whole process takes about 3 seconds (if you’re Hassan or Frank), but I started out at 30 seconds with a semi-spherical glob, and worked my way to about 10 seconds with an almost perfect sphere. Progress!

We then flattened the dough balls and rolled them into flat pancakes. Hassan then showed me the next stage of chapatti making. He put a flat dough piece on the round chapatti grill, and then turned the dough with his left hand while stretching out the circumference of the dough with the curved medial edge of his right hand (the meaty part of his hand right underneath his pinky finger), so that the chapatti became further flattened out into a perfect circle of deliciousness. This was really hard for me to learn, as I kept worrying that I was going to burn the skin right off of my right hand. But I got it, eventually, kind of.

At this point, we had attracted a crowd of spectators. Apparently, they had never seen a Chinese person make chapattis before. Business was great! We sold all of our chapattis and rollexes by 11am. And my greatest triumph – I made my whole Rollex from start to finish and ate it with great relish!

Queen Elizabeth National Park

The film crew decided to go into Queen Elizabeth National Park and film the wildlife as a creative adjunct to their episode on Matrix involvement in Uganda. Chug was the only documentary character invited to go, as a focal point for the wildlife interlude. Max and I decided to tag along as well, since neither of us had ever been to Queen Elizabeth National Park. I had been on a few game drives before, in Kenya and South Africa, and had seen the whole gamut of animals – elephants, giraffes, crocodiles, rhinoceros, etc. However, I had never seen lions in their natural habitat, and that was my one goal for this drive. Queen Elizabeth National Park had lions, and I wanted to see them. I asked the religious people to pray for me, just to cover my bases. And what do you know? Hardly 30 minutes after entering the park, we saw a whole pride lions! I was extremely excited, and took about a hundred photos (just of the lions). My trip was complete, and the day had just begun! We had brunch at the hotel inside the park, sitting on the veranda overlooking the lake. The view was absolutely breathtaking. We just ate, chatted, relaxed, and had a wonderfully enjoyable time at the hotel, until it was time for our river cruise. We sighted many other animals during the cruise, and the crew took a lot of footage of the animals along the river shores. For the first time since returning to Uganda, I felt like a tourist again, which was not a bad feeling at all.

Going West

When I got back from Nairobi to Kampala, I contacted Marc Sklar of Brick-by-Brick to see when he would arrive in Uganda. I had been communicating with him for some time now regarding a menstrual health project that we wanted to collaborate on. As it turned out, he was arriving very soon in Uganda with a large film crew. They were making a documentary called Planet Doctors, about the good work that Matrix, an environmentally friendly and socially conscious engineering company, was doing all around the world. One of their projects involved a collaboration with Brick-by-Brick, which is an NGO that Marc had started a few years ago. They were manufacturing interlocking bricks, which were of higher quality than the burnt bricks the locals favored. Their main work involved building rainwater harvesting tanks for different groups in Uganda, structures which required bricks of better quality and structural integrity than burnt bricks could offer. Marc had kindly offered for me to join him and the crew for a few days. They were heading out west to the site of their latest project, a small town close to Kasese. They were building two rainwater harvesting tanks in that community – one for the local school, and one for the households.

This was extremely exciting for me, as I had never been out west before, nor had I ever been on site while a documentary was being filmed. I woke up super early on a Friday morning, and made my way over to Fang Fang hotel. As it turned out, the flight had gotten in late, so the crew had postponed their 6am call-time to 8am instead. So I waited in the hotel lobby. Soon, hotel guests started coming into the lobby and sitting on the couches next to me, everyone on their laptops, presumably using the internet. I guessed that I was in an area with good wireless reception. I saw a guy who I recognized as American by his accent as he greeted us. He worked as an engineer for Matrix, and was one of the main characters in the documentary. We moved to the breakfast area, and the rest of the crew soon joined us. They were a fun bunch of people. One of the crew members, Kerwin, had apparently worked extensively with Spike Lee. Unfortunately, my knowledge of pop culture is appallingly limited, and I proceeded to embarrass myself by asking if Spike Lee was a director (he is), and then wondered out loud if he was Asian (he is not). I defended my general knowledge ineptitude by proclaiming that Lee is one of the most common last names in both China and Korea (fact).

On our drive out to Kasese, we stopped at the equator. Chug paid for a demonstration of the different rotational directions of water swirling around a sink on different sides of the equatorial line. Something to do with some physics principle which I’ve never heard of and no longer remember. But it was cool all the same. Chug even got a certificate proudly proclaiming “I’ve been to the equator!” That was the only fun interlude in the long, hot, tedious, day-long journey west.

Near dusk, we reached our lodge, and met up with Griffin, Max, and John, the core group working for Brick-by-Brick. Griffin and John are Peace Corps volunteers and Max is their Ugandan counterpart. We all were assigned rooms, and I was sharing a room with Griffin. We showered, changed, and had dinner and (lots of) drinks. Afterwards, I went to bed early in preparation for our 6.30am call-time the next morning.

A long-lost relationship: Part III – Reunion

I took a matatu from the coach station to Valley Arcade shopping centre, and called Isha’s husband’s aunt’s cellphone from there. The family was just getting ready to head to Diamond Plaza, a stronghold of Indian culture and gallery of Indian products in Nairobi. They swung by Valley Arcade to pick me up. When Isha stepped out of the car, we exchanged a quick hug, and then she ran off to change Zuzu’s diaper. Zuzu is her younger son, one and a half year’s old. I met her husband, Zain, who was carrying their older son, Raphi, age 3. Her aunt, Aunt Nastaran, was the driver.

This time around, there was no room for awkward silences. Isha’s sons filled the air with their voice boxes, crying, laughing, everything toddlers do on a day-to-day basis. Amidst all the chaos, I didn’t really get a chance to catch up with Isha. We went to Diamond Plaza, where Aunt Nastaran got her spa treatment, and Isha and I went to check out the gold store, looking for a pendant for her friend. When we finally got back to Aunt Nastaran’s house, I was utterly exhausted. Aunt Nastaran’s two kids, Arman and Ariana soon came home from their daily tennis lessons. They were such adorable children, at an age when I really start to actually like them – Arman is 11, and Ariana 10.

Back home, power was off (even in Kenya, power outages are a common occurrence), and Zain needed internet for his work. So as soon as the children had showered, off we went to Valley Arcade again, this time stopping at Java’s café where we all got drinks and snacks, and Arman and Ariana played with Raphi and Zuzu in the playground nearby. Zain worked on his laptop the whole time, only stopping to argue with Arman about random nonsense. They interacted like siblings, which was no surprise. Aunt Nastaran had stayed with her older sister, Zain’s mother, up until she got married. She had looked after Zain and his brothers until they were well into their teenage years and almost onto adulthood. She was like a second mother to them, so naturally her children would be like siblings to Zain.

When we got home, Aunt Nastaran had prepared a sumptuous meal for us. I loved her cooking, and would’ve stayed in her household forever if I could. Even more than that, I loved her kids. They were so much fun to be around, and for the first time in a long time, I felt that familiar ache in my soul, the ache to be part of a large family, so interconnected, so loud and boisterous and happy and annoyed, all at the same time. I would marry into a large family like this and have lots of children, I promised myself. Then I laughed at myself, at this ridiculous notion that I could actually plan for something like that. With my luck, I’ll end up marrying another only-child, and we would have an only child, and the three of us would sit at the dining room table, eating silently, only the sound of utensils clinking against plates breaking the enormous silence. I shuddered at the thought, and drew myself back into the present, to the loud arguments, jokes, and just random chatter flying around the dinner table. I couldn’t have been happier.