Family Planning Success!

Over the past few months I have been working closely with the nurses and midwives at Kabubbu Health Centre. A lot of my work has concentrated on providing health education to the local women, particularly about family planning. This has been a great success. So far we have held 4 sessions in the community, with 30-40 women attending each session. Our hard work paid off and on February 16 2012 we held a one day 'camp' for women to come and get the contraceptive method of their choice, free of charge. We inserted 38 implanons, which provide contraception for 3 years. (This photo shows myself and one of the midwives inserting implanons). Providing long term contraception allows women to space their children and have the opportunity to work thus reducing their levels of poverty. I provided training on the insertion of implanons for the nurses and midwives so they can continue to offer this service. As well as continuing to expand the family planning services at Kabubbu our next goal is to provide cervical cancer screening. The incidence of cervical cancer in Uganda is high and often presents with advanced disease when it is sadly too late for surgery.

A greater proportion of my work is currently focused on improving the functionality of health centres that provide maternity care. Essentially this means getting operating theatres up and running so caesarean sections can be performed without having to refer women to Mulago Hospital. If we can achieve our aim we hope to reduce congestion at Mulago and also prevent women from making long uncomfortable journeys when they are in labour. One such health centre, Kasangati (pictured) has a operating theatre which is not currently in use, however with a small amount of investment and a bit of rebuilding we are aiming to have the health centre functional in next couple of months (building is due to start next week). A Ugandan doctor has just been appointed to work at Kasangati during the week, which improves the long term sustainability of this project.

My current work at Mulago has concentrated on patient monitoring. During my time at Mulago I have noticed that many women simply do not get their observations taken (blood pressure, heart rate, temperature and respiratory rate) and all too often I hear the words "woman found gasping" and then she dies before the doctor has had a chance to do anything. I believe that if these women are properly cared for and have their observations done regularly we can identify those women who are deteriorating and get help to them earlier. To try to assess the scale of this problem I have started an observational study that looks at the frequency of patient observations and any barriers to getting them done i.e lack of equipment and over crowding. Hopefully with the results in hand we can really try to improve patient monitoring, which is a step in the right direction to reduce maternal mortality.

The first caesarean in 18 months!

After all of the hard work getting the operating theatre up and running at Kawempe health centre we finally did the first caesarean section in 18 months! This is a massive step forward. The theatre was tested to the max, firstly the theatre light broke so we had to turn the operating table towards the window so we could see what we were doing, then the power went! The midwife on duty didn't know how to turn the generator on, but she finally worked it out 30 minutes later, if this had been at night we really would have been in trouble. The mother and baby did really well and were discharged 2 days later!

Last week I went to join a team of British doctors, nurses and midwives who were volunteering at Hoima hospital (about 200km from Kampala). They set up project similar to the Liverpool-Mulago partnership 3 years ago and visit Hoima hospital several times a year. The hospital is much smaller than Mulago and therefore much more manageable. I visited the hospital for 2 days with one of the midwives from Mulago. The aim of our visit was to implement and train the midwives about patient observations and monitoring using a scoring system (MEWS). The visit was successful and we returned a week later to give the midwives their own 'kit' which has all of the equipment needed to perform basic observations.

I had a welcomed visit from Prof Louise Ackers last week. We had a busy week of meetings at the Ministry of Health and Kampala city council. We are really pushing the authorities to help to appoint medical officers (doctors) at the health centres that we are working at. It is impossible to recruit medical officers because of poor working conditions and low pay, it is much more attractive to them to work in the private sector or for NGO's who pay big bucks. The meetings were successful but I imagine it will take a while before we see any medical officers in these health centres.

Much of the work I have been doing over the past few weeks has been concentrating on getting the operating theatre in Kawempe health centre up and running. This has been a slow and slightly frustrating process. The main problem has been with the generator. It hadn't been wired up to the theatre so in the case of a power cut (a daily occurrence) there was no alternative power source. It has taken about 8 weeks but the generator is finally wired up and the theatre is ready to go! As of yet there hasn't been any caesareans, mainly because of the lack of doctors at the clinic. I am currently spending one day a week there but this isn't enough, there really needs to be a doctor present 24 hours a day for the theatre to have the intended impact on Mulago. This has been the biggest challenge and is a problem reflected throughout all health centres in Uganda. The government is aware that there should be a doctor at Kawemepe and despite asking the health authority to help they still haven't appointed a medical officer.


I've been continuing with the community health education at Kabubbu health centre, concentrating on contraception and antenatal issues. We are currently planning a 'one stop shop' for women to have any gynaecological issues dealt with and to get the contraception of their choice. We have just appointed two new members of staff, a very experienced midwife and a nurse who will help push Kabubbu in the right direction. The number of women attending for antenatal care and the number of deliveries has started to increase, which means less women are delivering at home (either alone or with traditional birth attendants).


Work at Mulago goes on and I'm really enjoying it at the moment, partly because I am getting small breaks when I go to the other clinics. I've been splitting my time between the main labour ward, the admissions area and the high dependency unit. Post partum haemorrhage kills many women at Mulago. Partly because it isn't managed well. Slow decision making and the chronic shortage of blood means that these women often die. For example a woman had an emergency caesarean section because of a placenta praevia (low lying placenta), she started to bleed and was taken back to theatre. However the bleeding continued. She arrived in the high dependency unit but I couldn't control the bleeding and her condition was deteriorating. She needed to go back to theatre. Getting blood was a nightmare.The intern had to find the blood and cross match it herself because the lab technician was nowhere to be found!  The woman was taken to theatre for a second time and had a hysterectomy, fortunately for her she had completed her family.

Sorry it's been a while!

I hope everyone had a great Christmas. It’s been a while since I wrote my last blog, so it’s going to be a long one!

The 2 weeks leading up to Christmas were perhaps the most intense two weeks that I’ve had at Mulago. Over these two weeks all of the SHOs were on exam leave and to make matters worse the interns were on strike because they hadn’t been paid. During this period I was the only junior doctor on the rota to cover labour ward, theatre and admissions (there would normally be 3-4 SHO’s and 4 interns)! Two seniors were supposed to be covering labour ward during the exam period, however often only one would turn up and would go to theatre leaving me alone. On one day no specialists turned up at all, so I wasn’t able to open theatre when there were 8 women waiting for caesareans. A woman presented with cord prolapse so I had to take her to theatre but she was the only caesarean that got done. We had 2 days with no IV fluids in the whole department, this meant no caesareans, and keeping fingers crossed that no women had a PPH. To say I felt vulnerable would be an understatement, and in true Mulago style everything you could imagine happened: Eclampsia, twins, breech deliveries, abruptions, ruptured uteri. One particular incident happened when I was alone in admissions. A woman arrived in a semi-conscious state following an eclamptic seizure, and was now having an abruption (premature separation of the placenta leading to heavy vaginal bleeding). It was very hard to auscultate a fetal heart beat and I feared the baby was dead, after delivering the baby with a vacuum it needed urgent resuscitation. I attempted to resuscitate the baby but it was futile, I didn’t have a towel to dry the baby and the resuscitation equipment was broken. A very frustrating and upsetting day.

Another incident that I believe could have been prevented represents some of the struggles we have at Mulago. A woman with obstructed labour had a caesarean section during the night and was found to be bleeding in recovery. She was not taken back to theatre, but instead admitted to the high dependency unit (HDU) where she continued to bleed. In the morning meeting she was reported as a maternal death until one of the nurses informed us that she was still alive! I went to HDU to find her in a peri-arrest condition. Two units of blood were rapidly transfused while I tried to locate the specialist who could take her back to theatre. She was eventually taken back to theatre for a hysterectomy but desperately needed more blood. After madly running around the hospital I was able to get another 2 units of blood but unfortunately she died a few hours later. If there had been more staff and no shortage of blood this woman’s life could have been saved.

In my last entry I mentioned a health centre called Kawempe and I’m pleased to report that the operating theatre will be up and running at the end of the week, ready to start doing caesareans! And hopefully start to reduce the burden on Mulago.

The other health centre I have been working at is Kabubbu. I have been really trying to promote health education and improve access to family planning, and this week I had a session with 30 local women about contraception. It is unbelievable how many myths there are about contraception such as causing cancer, birth defects and infertility. It was brilliant to be able to dispel these myths and give the women more options. Hopefully we’ll be expanding the contraception provided at Kabubbu to include the IUD and implanon, which the women seemed really keen on. Just a small step in the right direction!

Finally I would like to say a BIG thank you to everybody who sponsored me to run the Kampala half marathon. I have raised over £600 for the Liverpool Mulago partnership. We are still deciding how to best spend the money but I will keep you all informed.

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.