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.