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University lecturer report Lira October 2016

Poole-Africa Link (PAL) Lira Oct 2016

Lesley Milne, Senior Lecturer, midwifery, Bournemouth University.

Objectives for the trip included;

  1. Create links and support PAL
  2. Orientate to both Lira hospital and university
  3. Network with staff and students of both placements and create ongoing links
  4. Experience the reality of working in both placements
  5. Teach in both placements
  6. Identify teaching opportunities during trip for the future
  7. Reflect on lessons learnt with team
  8. Plan for future ongoing links and future trips
  9. Conduct scoping exercise for Bournemouth University to determine possibility for Bu students and staff undertaking visits in the future
  10. Discuss the possibility of Lira University linking with Bournemouth University
  11. Feedback report to PAL and Bournemouth University

Lira Regional Referral Hospital.

On my first day I went to Lira Regional Referral Hospital (LRRH) and befriended Jane, a qualified nurse, midwife, in charge of maternity, who then orientated me to the maternity unit. The maternity unit is a one storey building which comprises a 4 bedded first stage room, a 4 bedded second stage room, a 20 bedded nightingale ward for women who have had a caesarean section and an office. The postnatal ward is another nightingale ward which is a separate building linked to maternity via a concrete path accessed through the caesarean section ward.

The maternity unit looked like it had not been refurbished since being built in 1929.
It is small in size, but there are approximately 20 births a day/6,000 per year. Consequently a number of women quietly labour in 30 plus degrees heat outside the font entrance of the maternity unit until they are almost ready to birth as there is no room inside.

There are 3 shifts, morning, afternoon and night shift. At any one time there appeared to be 3 nurse/midwives on shift. There are a variety of uniforms, colours and styles worn which appears not to be an indication of someone’s grade or seniority so it is difficult to tell who is in charge. In addition, there were 57 students from at least 4 institutes allocated to the labour and postnatal wards covering a 24 hour, 7 day service. Qualified staff didn’t seem to know who was on shift or who was new to the unit. There did not appear to be any orientation of students to the unit and the ratio of staff to students on shift was approximately 1:8. Some students used their initiative and tried to get involved in caring for women, many stood around just observing and appeared clueless. It was not unusual to see 8 plus students standing watching 4 women at once, naked lying in close proximity to one another with no curtains dividing them, being catheterised (there is no toilet on the ward for either women or staff) having vaginal examinations, giving birth and some going on to haemorrhage.
There appears to be no formal allocation of staff to women. On a number of shifts the head midwife spent most of the shift in mufti so it was difficult to identify her as a member of staff or that she was in charge. Her main duties included manning the autoclave and being ‘gate-keeper’ to the store cupboard and drug cupboard as she held the keys. Some members of the PAL team reflected on this and surmised that perhaps the head midwife was, not surprisingly, ‘burnt out’.

I witnessed a number of vaginal births and in most cases the nurse/midwife had not prepared the delivery equipment in advance. Despite having sterile gloves and cord clamps and cord scissors, there were no delivery packs made up in preparation for a birth. This was discussed with the VSO midwife, Gudrun, who discussed with head midwife and packs are now apparently being put together and autoclaved in readiness for deliveries. We supplied cord scissors so that they can also be used as part of the delivery pack instead of using scalpel blades that people try to re-sheaf in their wrapper before shortening the cord. I witnessed scalpels being misplaced under women lying on the birthing couches. I also witnessed women being shouted at and having their thighs slapped. Couches and the resuscitaire were rarely cleaned between women and babies unless a student was directed to do so. There did not appear to be any cloths to clean or dry surfaces with. Women bring in their Mama pack but there are no sanitary pads, there is nothing to clean or dry the women with e.g cloth, flannel, soap, towel. There was no soap for people to wash their hands with and nothing to dry them on. I provided soap that was later tied with giving set tubing to the one and only tap on labour ward.

Teaching undertaken on the maternity unit was ad hoc and included;

  • How to facilitate a vaginal birth
  • How to check a placenta and membranes for completeness
  • How to ‘rub up a contraction’ and manage PPH
  • How to receive a newborn baby
  • Partogram recordings
  • Fetal heart recordings
  • Frequency of blood pressure and fatal heart recording on a woman with Pre-Eclampsia

In addition, Hilary and I prepared a PPH box and Gudrun and I put together an Eclampsia box for future emergencies.

Lira University

I facilitated teaching for all four year of the BSc Midwifery course. I was initially timetabled to deliver ‘normal midwifery’ to year 1 and 2 students and ‘abnormal midwifery’ to year 3 and 4 students. However whilst speaking to various staff members it became apparent that students do not start studying Midwifery until their 3rd year.
I was asked to deliver a teaching session on the ‘role of the midwife’ but felt Lira midwifery teaching staff are more appropriately placed to talk about this in relation to Uganda so I decided it would be more pertinent to discuss the major causes of maternal mortality in low resource settings with particular reference to Uganda to year 1 student’s. The session was called ‘Why did Mrs X die?’ and student’s discussed the barriers to women accessing maternity services in low resource settings and locally. Particular reference was made to the barriers that student’s identified from their own experiences of working in the local maternity unit and they discussed possible ways to address these both now and in their future roles as nurse/midwives. Teaching resources used included the ‘Why did Mrs X die?’ video and game. The game was highly valued according to the written feedback. The session was drawn to a close by raising awareness of respectful maternity care, the universal rights of childbearing women and the ongoing global work of The White Ribbon Alliance for Safe Motherhood www.whiteribbonalliance.org/respectfulcare an initiative that many countries including Uganda and universities including Bournemouth have signed up to. Similar sessions were also presented to year 2, 3 and 4.
Other sessions taught in university included;

  • Team teaching year 4 PPH with Joy, Midwifery teacher
  • Suturing with Judy, year 2
  • Introduction to communication with Judy, year 1
  • Emergency scenarios, shoulder dystocia, breech, cord prolapse year 3 and 4
  • Assessing progress of labour and vaginal examinations year 4

A copy of all my teaching sessions were uploaded onto memory sticks for each student year and several copies left with Lira staff.

Networking at Lira University included several productive meetings with Professor Jasper, VC Lira University and I briefed him on the teaching I had been involved with around maternal mortality and respectful maternity care, barriers to women accessing services and team teaching. We also discussed his vision for the university and the new hospital build which includes a maternity wing. There may be scope for a future link with Bournemouth University in addition to the PAL, I have left my contact details with him. It was also suggested that Lira University might seek to make a video around respectful maternity care in Uganda with PAL and BU. LM will enquire at the media school at BU.

Conclusion

I was tasked with determining whether Lira Hospital could become a possible elective placement for Bournemouth university students but conclude that, at present, it would be unethical to send more students there. I believe this was a very successful trip and the work we did was very much appreciated and I have met my objectives. I look forward to supporting PAL in the future.

Suggestions for next trip to Lira University

  • Continue to champion for, and facilitate teaching sessions on, respectful midwifery care.
  • Re-visit “Why did Mrs X die?” using WHO you tube video and board game.
  • Continue to teach maternity emergencies such as PPH, cord prolapse, shoulder dystocia and breech birth using skills and drills scenarios and Mama Natalie.
  • PAL to consider signing up to The White Ribbon Alliance, perhaps Lira University could too. LM to find out how to do this.
  • Continue to liaise with Lira University and NGO staff

Suggestions for next trip to Lira Regional Referral Hospital

  • Continue to champion for respectful midwifery care
  • Continue to liaise with Labour ward staff Joy and Gudran from VSO
  • Supply more soap
  • Supply plastic box for emergency PPH and Eclampsia items



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