Friday, October 30, 2009

Misoprostol Will Save the World

I went back to Labor Ward today to check on the woman I had started inducing with liquid misoprostol, and was thilled to find that she had delivered vaginally.

She told me that she had kept taking the liquid miso as directed all night until she felt contractions. She started the miso at 2:30pm, labor started around 2am, and she delivered around 9am. Perfect!

The baby was small - 2kg - but it's hard to say whether it was preterm or growth restriction. With the oligohydramnios and intact membranes, it really could have been growth restricted, in which case it's good that she delivered. The baby boy seems fine - tiny and adorable. She asked me to name him, but I felt weird about it, so she asked me for my brother's name. So Daniel and mother are doing well and will likely go home tomorrow.

I'm very excited that the miso worked in this way. This could make a huge difference, especially in avoiding cesareans.

Thursday, October 29, 2009

Postnatal Ward

After 3 months of hard work, we finally finished most of the preparation for our clinical trial, and we finished the training yesterday. Today I was finally able to go over to Labor Ward and Postnatal Ward to round and help out.

On Labor Ward, two mothers were progressing well and expected to deliver soon, so I was not needed there. The midwife there told me that there were some post-cesar patients with bad incisions that I should see.

It was really nice to see patients again. Then again, it was bewildering to do so in this setting. I know what I would do in the US, but is the same thing appropriate here? What can they afford? What is asking for too much?

I soon noticed that it was asking too much to expect all four vital signs (blood pressure, pulse, respiratory rate and temperature) to be taken . If I need vitals, I need to pick the most vital.
For a woman with oligohydramnios (low amniotic fluid) and a severe headache for one day, I picked blood pressure (which I took myself). It was 90/60.
For a woman complaining of fever and dizziness, I picked temperature. It was 38 degrees Celsius.
I take heart rate myself, which I did on the woman with fever (it was 96) and a woman who had a blood transfusion after hemorrhage for a hemoglobin of 5, and was still quite pale (it was 100 sitting and 120 standing).

For the woman with fever, I think she had endometritis. She was already on Ampicillin, which her family had bought. So what do I do? Do I add Gentamicin? Clindamycin does not seem to be an option here. Is Amp & Gent enough? Or should I switch to Ceftriaxone, which everyone seems to get here for endometritis. But then she wastes the Ampicillin her family just bought for her.
As it turns out, the decision will be made based on what is available in the pharmacy. Tomorrow. When the In-Charge Nurse is there. Nothing can happen tonight, so I told her to continue the Amp anyway.

For the pale woman with orthostatic tachycardia - blood count isn't repeated after transfusion. I could request it, but she might have to pay for it, and do I really need it? She is asymptomatic, aside from fatigue. She is ambulating well, no shortness of breath, no chest pain. Would a blood count really make a difference? She's asymptomatic, so I wouldn't transfuse her anyway (especially given the paucity of available blood and the abundance of HIV). I sent her home.

Another woman had delivered triplets 4 days ago. They were clearly preterm - between 2.1 and 2.3 kg. She had six boys before, now she has 9 boys. To my surprise, when I went to see her, she and her mother were spoon-feeding water with glucose to the infants. I didn't know that you could spoon-feed a newborn, much less a preterm newborn. But these tiny little infants were sipping successfully from a spoon. Of course, I encouraged her to breastfeed in order to bring more milk down.

I saw several women who had had cesareans and whose wounds were infected or separated. It is truly remarkable how many of the women here have had infants die. The first woman had 3 babies, and 1 had died. The second had 6 babies, and all were alive. The third had 12 babies, but 3 had died. The fourth had just delivered her first child, but she is HIV-positive, and since mothers have no choice but to breastfeed here (and don't get HAART after delivery), it is highly likely that this child will die or develop HIV or both. The last woman had delivered 2 infants, and both were alive, but the third, which she had just delivered, had been stillborn. The woman with anemia who had a transfusion had delivered twins, but the second twin had been stillborn.

The last woman I saw was brought to my attention by her family member, who took my hand as I was leaving and asked me to see her. It was the woman with oligohydramnios and a headache. By her menstrual period, she was 37 weeks, but on ultrasound, the femur had measured 32 weeks. The fluid was low, but not specifically measured. The nurse had found her to be dilated only 1cm, and the doctor by phone had suggested either induction or cesarean. She had 2 prior normal vaginal deliveries. On my exam, I found her to be 2cm. Clearly, induction was preferable.
But how to induce? It seems that people often get Cesars here because of a lack of good options for induction. Oxytocin IV is not possible - there is no monitor for the IV drip. Misoprostol is used occasionally, but I discovered a few weeks ago that when they use it for induction, they give the woman 200 micrograms orally (or buccally, not sure). 200! This is almost 10 times the dose we use in the US, and has been clearly associated with uterine rupture and birth asphyxia. But how to correct midwives who have been doing their jobs for 10 or 20 years?
Luckily, this time I didn't have to. I decided to use the technique told to me by a highly respected Obstetrician in Kampala - dissolving a 200 microgram tablet in 500cc of water, and having the woman drink 60cc every four hours. The nurse sent the family member to buy the water and the misoprostol from the pharmacy in town, and she was back in less than 20 minutes. We dissolved the tablet, measured out 60cc, and she drank. We also had her eat some food to improve her headache.
When I went back 3 hours later, her headache was improved, she was feeling some cramping, had seen her mucus plug, and soon was ready for her next dose. The evening nurse was all prepared to give it to her, without my having to ask. I was surprised at the lack of resistance.
I told the woman I hope to come in tomorrow morning to find her holding her baby. I am keeping my fingers crossed, hoping it works, and hoping this method will be adopted by the midwives.

Sunday, October 25, 2009


This weekend I went to visit the Abayudaya - a village of Ugandan Jews. It was a nice experience. Some reflections:

1. If/when you go, bring directions. And a phone number.

2. Driving around the Mbale area at dusk is a good way to get very lost.

3. When a strange man with a huge gun on a dark road in a small village gets in your car, sometimes he will actually help you get to the place you are looking for.

4. I’m not very Jewish (this one is not new, just a reaffirmation).

5. I’m not sure what being Jewish is – is it wearing a yarmulke, reading the Torah and turning out the lights on Friday night? Or saying “oy,” eating bagels and lox and exhibiting a self-deprecating sense of humor? Or a factor of maternal lineage?

6. Ugandan Jews are more Jewish than I am.

7. The Ugandans said “Shabbat shalom” as they greeted us. This is as foreign to me as the Swahili “Habari” - I can pronounce it and know what it means, but it’s not my language. I felt very silly saying it in response and did my best not to giggle.

8. There are a lot of Jewish songs besides Dayenu, and they can all be approximated by singing “watermelon watermelon.” (Thanks, Deb).

9. People sometimes define community in superficialities, but I’m not sure I agree.

10. Things are as profound as you want them to be.

11. Religion in Uganda is private and respected, but not worn on one’s sleeve.

12. There are many religions coexisting in Uganda. Within 5 minutes’ drive of the Abayudaya, we saw a mosque, a catholic church, and a Jehovah’s Witness hall.

13. Hospitality is a human trait, but is especially a Ugandan trait, and this was evident during our visit.

14. Ugandan Jews are Ugandans, full stop.

Friday, October 16, 2009

8 Days in Cape Town

I spent 8 days in Cape Town for the FIGO 2009 conference. The conference was great and Cape Town is seriously amazing.

First, the conference.

I reconnected with old friends

and saw some great presentations. The conference was so good I was reluctant to miss any of it to go sightseeing.

One of the most memorable was one of the smaller sessions in which these 2 women from Montevideo, Uruguay presented a program for reducing unsafe abortions there, called Iniciativas Sanitarias.
Abortion is illegal, but doctor-patient confidentiality is sacrosanct. So they designed a pre-abortion and post-abortion counseling program.
Women considering abortion came to their clinic, received counseling, evaluation, and information on unsafe abortion, and on misoprostol (which is still illegal as an abortion method, but widely available, and much safer than surgical abortion with non-sterile instruments). The women were then sent home.
Around 12% decided not to have an abortion, and around 85% had a safe, successful ("illegal") abortion with misoprostol.
It's a phenomenal idea. As one of the FIGO speakers said "While countries waste time in a sterile discussion of whether or not to do abortions, women continue to die of unsafe abortions."

After the conference, I had time for sightseeing, and there is a LOT to see in Cape Town.


Bo Kap, a colorful Malay neighborhood :

The District Six Museum

Beautiful mountains behind beautiful buildings

Live music at Mama Africa

A very tiny cannon

Table Mountain, first attempt - cable car closed due to wind

Table Mountain, second attempt - successful

Robben Island - where Nelson Mandela was imprisoned for 18 years

Questionable clothing labels

Good coffee and muffins

And great company.

All in all, a wonderful trip.
Who's joining me in Rome for FIGO 2012?

Wednesday, October 14, 2009

Scott's Drawings

Scott has an extraordinary talent for drawing, among other things. While he was here, he started drawing again, and it became a wonderful way to interact with people. As soon as he would start drawing, people would collect around him, discussing his drawing with each other in local languages, and occasionally exclaiming, "Fine artist!" They had good reason to be impressed. His drawings were vivid and inspiring, bringing out the color and spirit of the subject. I would be sitting there watching him draw a scene and think "Wow, I want to be there" - even though I already was there.

This was the view from the window of a beautiful house we stayed in in San Francisco.

This is a street scene in Tororo.

Sipi Falls

A shop owner and her three children. She was very amused to pose for Scott, and when he showed her the completed drawing, she burst into raucous laughter and showed everyone in the shop. One of her young daughters really took to Scott, calling him "my mzungu" and frequently asking him to "write the baby" (read draw a picture of her infant sibling).

The market

A tailor

The Bo Kap neighborhood of Cape Town

A woman in Tororo

There are so many and they are all so beautiful.

Monday, October 5, 2009


Before Cape Town, I went on Safari outside of Johannesburg at Madiwke Game Reserve.

We stayed at the Mosetlha Game Reserve - a cute little place that had no power or running water. It was very quaint for three days - I imagine any longer than that would be a pain in the ass.
In order to take a shower, you had to take a bucket of water, drag it to the water heater, pour it into the water heater and then back into your bucket, drag it to the shower, lower a bucket on a pulley, pour the hot water in, list the bucket back above your head, and shower. There was enough water only if you shut off the water while soaping up. But the shower wasn't quite enclosed, so there were chilly breezes that would make you somewhat cold if the water was off.
Still, it was very cute. We stayed in comfortable little cabins

We drove around in an elongated jeep, which was remarkably comfortable given the circumstances. Each game drive was four hours long, from 6am-10am, and 4pm-8pm.

The car

Some days, we saw lots of game. Other days, we saw very little. But over the 3 days we were there, we managed to see a lot:

(incidentally, I had some Kuru carpaccio in Cape Town - it was delicious!)







Sunday, October 4, 2009

South Africa

I just arrived in Cape Town. We were outside Johannesburg on Safari - I'll post about that later.

At the moment, I am remembering the comforts of industrialized life, including the following things:

1. Sushi
2. Insanely fast internet
3. Smooth roads
4. Lanes in the smooth roads
5. Brie
6. Architecture, esp. Art Deco
7. Pervasive hipness
8. Attentive restaurant service
9. Salad
10. Mustard
11. Sidewalks

It's also refreshing and slightly confusing that everyone understands me when I speak. I am so used to having to enunciate and convert my accent that it's hard to stop doing.

I've been in Cape Town for 2 hours, and I'm already in love with it. It seems so beautiful and fascinating. I think there are too many things to do - I'll definitely have to come back.