With a recent visit from a surgeon and nurse from Liverpool, we evaluated the gynaecology services at Mulago. Surprisingly over half of the maternal deaths are happening on the Gynae wards. With over 40% of these deaths occurring as a result of sepsis. Mainly septic abortions (complications from illegal abortion including perforated uteri from instrumentation of the uterus with sticks) and puerperal sepsis (postpartum infections). I assisted in a case of a 16 year old girl, who presented 10 days after a caesarean section for obstructed labour in which her baby died. She had severe peritonitis and at laparotomy we discovered her whole uterus to be extremely necrotic and full of pus. Simple measures such as providing safe abortions to mothers would significantly reduce maternal mortality, and would save many children the pain and hardship of loosing their mothers.

I spent a week at a fistula 'camp' in Mulago. Fistula's as a result of obstructed labour do not occur in the UK, so this was a fantastic opportunity for me to see how they are repaired.  Women were initially screened to stage their fistulas, and sadly the women would often be standing in a pool of their own urine. The majority of women had fistulas between their bladder and vagina. Some of the fistula's were massive and a finger could easily pass straight into the bladder. Some women had no urethra at all and a small amount  had recto-vaginal fistula. These poor women suffer in silence, and are often ostracised from society.  I was amazed at how easily the fistula's could be repaired and at the skill of some of the surgeons. They were able to refashion urethra's and use the rectus sheath as a sling to correct stress incontinence.

I had a visit from the Liverpool Mulago team, which was great. We concentrated on some of the 'smaller' health centres (which in fact deliver 8,000+ babies a year). Many of these health centres have theatres for caesarean sections, however they are not functioning. Mainly because the doctors don't turn up and a lack of funding means that the theatres run out of supplies. Approximately 60% of maternal deaths at Mulago occur in women who have been referred from these health centres. It is vital to get these theatres up and running in order to reduce the congestion and number of maternal deaths at Mulago. I am quite excited at the prospect of working in some of these smaller health centres.  The photo below shows a fully equipped theatre at Kewempi health centre, but it has not been used in 18 months!

I've also spent some much needed time out exploring Fort Portal in western Uganda. It's a beautiful spot, in the foot hills of the Rwenzori Mountains. The area is dotted with amazing crater lakes, formed centuries ago by volcanic activity, leaving stunning lakes surrounded by rain forest.

The past few weeks have been really busy. I had a break from Mulago for a few days (I really needed it) and went to a village health centre just north of Kampala, in a place called Kabubbu. It's funded by a UK charity, which has built a primary and secondary school that provides free education to children who have been sponsored by families in the UK. It also has as a health centre that focuses on HIV and maternal health. My main reason for going was to evaluate reasons why mothers weren't having their babies at the health centre. This was a fantastic opportunity to visit women in their homes. The conditions people live in are truly shocking, the majority don't have electricity and you can forget about running water. The women were so welcoming and their children amazing, even if I did scare the hell out the smaller ones (I've never seen kids run so fast in true fear! I guess I must have been the first white person a lot of these children have seen). We managed to get some really good information on how to improve the services at Kabubbu. I've devised a training programme for the midwives, hoping to improve their clinical skills, address issues such as patient confidentiality and implement a community health education scheme. Especially trying to dispel some of the myths surrounding birth control, such as it causing cancer and birth defects.

Back in Mulago things continue as they always do-slowly! I've spent a lot of time on the labour ward and I've actually managed to do some operating, mainly second stage caesareans. I'm also surprised at the number of vacuum deliveries I've been able to do, I was under the impression that vacuum deliveries weren't something that were practiced at Mulago. Most recently I had to do a vacuum delivery on a second twin with cord prolapse, luckily the baby was born in good condition (phew!)

One of the main issues at Mulago is the lack of senior support. I think this is two fold. Firstly the seniors aren't easy to get hold of and secondly the junior doctors don't seem to ask for help and tend to just get on with things, which clearly isn't safe practice. For instance I was left to deliver a 14 year old girl, her first pregnancy and it was breech (she should of had a caesarean). The head became entrapped and there were no forceps available. I asked for help but no seniors came, luckily a midwife helped me and we eventually managed to deliver the baby. Thankfully the baby survived but the mother sustained a 4th degree tear (a tear through her vagina and rectum).

Many women suffer from eclampsia (seizures due to high blood pressure). This is a complication of pre- eclampsia that we rarely see in the UK. My first experience of eclampsia was with a women in obstructed labour. After rushing round frantically trying to find magnesium sulphate and hydralazine, I managed to stabilise her (thank god for all of my emergency skills training in the UK!) I wheeled her round to theatre and  the baby was delivered by caesarean. The mother did well after a short stay on the high dependency unit.

Over the next few weeks, I'll be mainly working with a Consultant and a nurse from the Liverpool Women's Hospital looking at the gynae oncology service at Mulago. This should be really interesting as there is a lot of scope for making some much needed improvements.

Sorry it's been a while since I last wrote, I've been really busy working on guidelines and teaching, so I haven't really had much to write about. I just completed a new guideline on the management of obstructed labour that I presented to the department on Friday. I received really good feedback so fingers crossed it will actually make a difference to the way women are managed.

I spent a couple of days at a conference for the Association of Obstetricians and Gynaecologist of Uganda, which was an eye opener. The theme of the conference was improving family planning as the average Ugandan woman has 6.7 children and 52% of the Ugandan population are under the age of 15. Access to contraception is a big problem here and abortion is illegal which means it still significantly contributes to maternal mortality.

I had a tough couple of days last week. I spent some time on the gynaecology admissions ward, and managed a pregnant woman with severe malaria, something I haven't done before, thankfully she improved with some basic treatment. What I found most frustrating about this case was that this women had actually been seen on the ward round but nobody had made sure she was given any treatment and consequently she deteriorated!  Lots of women present with complications of miscarriages and illegal abortions. These women  often have surgery to evacuate their uterus while they are awake and if they are lucky they get a small dose of pethidine. When I questioned why the women weren't given more analgesia or an anaesthetic the response was 'Ugandan women are used to pain'. Unbelievable.

Unfortunately babies are still dying. I found a baby a few minutes old whose umbilical cord clamp had come off and had lost a lot of blood. I managed to resuscitate the baby by giving chest compressions but it was still not breathing on it's own. I knew the baby needed a blood transfusion and respiratory support, so I picked the baby up and ran to the special care baby unit were we manged to give the baby some blood and it started to breath spontaneously, it was really hard to hold back the tears, and such a relief that I could tell the mum that her baby was still alive.

So my second week at Mulago wasn't as harrowing as my first. I'm starting to settle in and the staff are starting to get to know me. I have still been dividing my time up between the different Obs and Gynae wards (there are many). One thing I have really been impressed with is the determination and hard work of the doctors and midwives. I have learnt that the SHOs (doctors of my grade) do not get paid for the work they do because technically they are 'students' studying for their postgrad qualification in Obs and Gynae. These doctors work so hard, I am truly shocked that they don't get a penny! I have no idea how they have the motivation to carry on.

I spent some time on the gynae oncology ward. This was depressing. Cervical cancer accounts for about 80% of all of the gynae cancers in Uganda. The woman are often young and present with advanced disease as there is no cervical cancer screening programme and HPV is very prevalent in HIV positive women. If the women are operable they often have to wait several weeks for surgery as only one oncology patient is operated on a week! The majority of the women are waiting for radiotherapy and palliative care.

Unfortunately there were two maternal deaths last week. One of which has upset me and really driven me to try to improve the care of women in obstructed labour. Again this girl was young, only 19, she was fully dilated for over 16 hours, she had an emergency caesarean and developed septicaemia (sorry for the jargon!). The patient needed to be transferred to intensive care but the family could not afford it, so she died. However I truly doubt that she would have survived had she gone to ITU. Obstructed labour is a massive problem here. Many woman are young and malnourished or have diseases that distort the shape of their pelvis, making vaginal delivery impossible. So women often wait many hours in labour developing fistulas, infections or rupturing their uterus and often end up with a dead baby.

On a lighter note I had a great weekend! I sampled one of Uganda's finest night clubs which was an experience I wont forget for a while! On Saturday we had a house warming party and slaughtered a goat for the occasion! We butchered it outside our house and roasted it on the BBQ, it was tough as old boots but it went down well!

What an interesting first week I've had..

So my first week in Kampala has been really good. I've settled into my house and I'm living with 4 other people, 3 of them from the USA and a girl from South Korea. There's plenty going on in and around Kampala, there's always a house party to go to, some really good markets, nice restaurants. I've spent the day in a lovely resort with a 50m outdoor pool chilling and relaxing in the sun after my first few days at Mulago!

I started at Mulago hospital on Wednesday and to say it is different would be an understatement. The hospital is massive and so is the O&G department, with over 30,000 deliveries a year! My first day was tough. The day stared with a morning meeting, we were informed about two maternal deaths that occurred over night, both women were very young, the first a 19 year old girl died from a massive haemorrhage and the second, a 23 year old woman died from sepsis. This was shocking to me as I have not encountered a direct maternal death in the UK in my fours years working as a doctor. Their bodies were left in full view the corridor by theatres, god knows what the women going for their caesareans thought as they walked by. My second day was a little better, but could have been a nightmare. I decided to attend the labour ward ward round, which proved to be very frustrating. I watched while approximately 40-50 women in one massive room (all naked, in labour and with no privacy) were examined by young male doctors with awful bedside manner. I was so shocked at the conditions these women had to give birth in with absolutely no respect for their dignity and autonomy. Midwives are few in number and very busy, running between women giving birth. One particularly shocking moment was when a woman was delivering breech, and the SHO didn't know what to do. So I was left to do the delivery by myself, and luckily it was an easy delivery. The baby almost died, it needed urgent resuscitation, only to find there wasn't any resuscitation equipment that worked. A medical student finally found some equipment that worked and I managed to resuscitate the baby. I fear though that if I was not there that baby would have died. The midwives and junior doctors have very limited newborn resuscitation skills. On my 3rd day I decided to attend the general gynae ward round. This was a new experience for me, I felt like a medical student again. Every other patient either had malaria, HIV or TB, something that we very rarely see in the UK. There were many really ill patients waiting for urgent surgery but the hospital had run out of sutures. This meant none of them could go to theatre. I am beginning to imagine that this will not be an infrequent occurrence at Mulago. The powers who be would prefer the additional cost of keeping sick patients in hospital waiting for surgery, rather than find money to buy sutures.

Arriving in Uganda

Hello everyone,

Hopefully this blog will be interesting and not boring! So i'm going to keep things short and sweet. I'm living in a large house with 4 other people, all working for NGOs. The area seems really nice with a slum down the road! Everyone is friendly and you don't get hassled!

I'm going to head down to the hospital tomorrow and get started! So I guess I'll let you know how things go...