Lira report Rosie Riley 2022

Name: Rosie Riley

Role: Band 6 midwife at Poole maternity based in maternity triage and Haven Birth Suite

I first heard about the Poole Africa link in 2019, at the time I was a newly qualified midwife and was developing my confidence and skills, however I made a mental note that if the opportunity arose in the future, I would put myself forward. When it was advertised again this year following the pandemic, I was extremely keen to get involved. Although I had limited experience in teaching larger groups, I am a passionate mentor and a desire to share my knowledge and expertise with future midwives in order to improve maternal and neonatal outcomes. My recent travels to Ethiopia and Kenya had ignited a desire to use my midwifery skills in areas which had limited resources and high maternal and neonatal mortalities.

When we first arrived at Lira, we were welcomed at Lira referral hospital and taken on a tour of the grounds. The crowded and chaotic conditions of many of the wards were shocking and so far from what we have come to expect within the NHS. However, I was pleasantly surprised that the maternity unit had recently been refurbished with Japanese funding and included 6 delivery rooms, with comparatively modern facilities. Although privacy and dignity were not high on the agenda as the back of each delivery room opened out into a shared corridor filled with around 40 student midwives, a sister in charge and one or two qualified midwives. Woman who required caesarean section were transferred along the outdoor paths, past the gathering of family members who cooked food for their loved ones and waited patiently for news. The antenatal, postnatal and HDU areas were much more basic with heavily pregnant women bunking under one another’s beds. The triage area consisted of a wooden bench beside a board of statistics of the maternal and neonatal deaths that occurred that year. This was a busy maternity unit with 6000 births a year, where women were referred from both rural and urban settings with the understanding that although care was funded by the government, all medical equipment that may be required for their birth and any interventions they may require must be bought by themselves within a bucket that they carry in with them. In contrast when we visited the Lira University hospital which is located on the outskirts of Lira and charges a fee for care which is unaffordable to many and is therefore remarkably quieter and underutilised.

During our first week myself and colleague Emily Seddon (perinatal mental health specialist midwife) focused our attentions on providing education to the large numbers of 3rd year student midwives who came from 3 separate institutions. We were welcomed by the Sister Christine in charge who gathered up the students and gave us permission to make use of the empty NICU room that was now relocated to the paediatric building. We had to be resourceful in our teaching approach and used the tiles as our whiteboard, alongside a doll, pelvis, placenta and our acting skills for the many scenarios we ran. The students were so keen to learn and quickly found their voices to demonstrate their knowledge and determination to provide safe care within low resource setting. Over the week we responded to their learning goals and taught topics including labour assessments, portograms, positions for labour, the biomechanics of normal birth and adjustments that can be made to maternal positions to optimise fetal position (focused upon OP positions). As requested by the students we discussed obstructed labour and its management and the role of the hormones of labour. We ran realistic obstetric emergency scenarios including breach, shoulder dystocia and postpartum haemorrhage. We encouraged story sharing and challenging the practicalities of our UK based practices to ensure that our teaching was appropriate to their reality in Uganda. During this first week their were 2 breech births, including a footling breech which was successfully delivered and beautifully demonstrated by the students in attendance using the doll and pelvis.

At the end of the week I had the opportunity to teach basic life support, newborn examination and recognising an unwell baby with the 1st year students at Lira University alongside GP Luke Turley. We were then joined by consultant microbiologist who gave an engaging and informative talk on HIV and opportunistic infections, which encouraged some insightful conversations in the group around tackling stigma and overcoming barriers in diagnosis, treatment and prevention.

The following week we ran a full PROMPT course at the Lira University alongside the team including Frankie the Anaesthetist consultant, Ben the Paediatrician and anaesthetist, Luke the GP and Emily the midwife. This included lectures and multi-disciplinary team scenarios on PPH, Pre-eclampsia, recognising the deteriorating patient, sepsis, maternal collapse, shoulder dystocia and neonatal resuscitation. The 3rd year students thoroughly enjoyed the scenarios and demonstrated excellent underpinning knowledge, enthusiasm to practice these skills and openness to constructive group feedback.

Emily and I had the pleasure of teaching these students the following day. I decided to incorporate topics including team working, managing difficult conversations, informed consent, creating a compassionate work culture, recognising burnout, the importance of self-care, and the impact of vicarious trauma. I felt strongly that these areas of midwifery may often be overlooked, however raising awareness is essential particularly in a country where midwives experience so much tragedy and trauma within their career. Emily provided a wonderful talk on the importance of maternal mental health which created some thought-provoking discussion and deeply moving stories shared by the group. Many have since been in touch to highlight how raising this awareness of mental health both for the women in their care and themselves as midwives has been so beneficial. As requested, we ended the day with breech birth (both lying and on all fours management), water birth and care of the perineum.

We also had the opportunity to attend a free breast clinic with the project lead and Breast Surgeon Judy in a rural level 4 hospital located in Eboke. This clinic was well attended by over 60 women with various breast complaints and identified 3 breast cancers which Judy was able to take biopsies and make ongoing plans of care for these women who would otherwise have remained untreated. Halfway through the day however we were called to an emergency in maternity where a woman who had travelled by Boda Boda with an arm presentation required an urgent caesarean section. They were unable to cannulate and desperately understaffed therefore we assisted in her preparation for theatre and fortunately were able to resuscitate her baby girl who was born in very poor condition following a difficult and traumatic delivery. This unexpected emergency was incredibly eye opening experience as it became clear that neonatal resuscitative efforts were minimal, medical equipment and medications in extremely short supply and conditions were dirty, crowded and challenging.

One of our observations from practice and working with the students was that there was no means of accurately assessing blood loss in cases of haemorrhage and this often resulted in delayed recognition and treatment of APH/PPH. Therefore, we decided that a simple implementation of weighing scales and red buckets (similar to those already used to collect bodily fluids in labour) would enable accurate measurement of blood loss and therefore improve the management of these women. We provided a brief presentation about the benefits of this practice and demonstration of its use including posters to remind staff about the importance of measuring blood loss to help save lives. We also took the opportunity to demonstrate use of the cannula dressings that we donated as we identified that the use of tape was an infection risk for mothers.