Rebecca and Emily Oct ’24 Report

This year Rebecca Savage, Consultant midwife and Emily Seddon, Perinatal Mental
Health Specialist midwife both travelled to Lira, Uganda for two weeks with the
Poole Africa Link charity.
This was Becca’s first trip to Lira and Emily’s third visit. The aim of the visit was to
spend time teaching students to at Lira University and to observe the care offered
at the Lira Regional Referral Hospital (LRRH), in particular sharing our knowledge
and expertise, connect with senior leaders and look for opportunities for quality
improvement. Emily has continued relationships with staff and pupils from previous
visits, so it was beneficial to continue working together and developing the projects
explored before. Emily also wanted to continue her mental health work that was
started with the mental health unit in Lira in 2023.
Becca’s expertise is focused on considering the strategic levels of maternity care,
quality improvement, education and clinical practice. Her many years of experience
means that she can think about opportunities with those that are able to consider
change. Becca wanted to discuss higher levels of safety, evidence and how that
translates into clinical practice.
Lecturing at Lira University:
Poole Africa Link and Lira University have a longstanding relationship, and each year
provides teaching to the students as part of our visit. We contacted the university
prior to our visit to understand what might be beneficial during our stay but this did
not lead to clarity on topics or time commitments. After an initial meeting on the
first day, we were asked to teach on topics such as normal midwifery, abnormal
midwifery, and perinatal mental health. We therefore taught students about
obstetric emergencies including shoulder dystocia and breech birth. We spoke
about important issues such as consent, dignity, human rights in childbirth and
mental health conditions, which were well received.
We used alternative methods such as pictorial aids; to discuss a birth they
commonly see in Uganda and what care they would like to see. We did this for both
the BSc and master’s students, and both were engaged and open to considering
various aspects of their midwifery care.
Last year when visiting Lira University, Emily spoke to the lead who writes the
curriculum. At this time mental health was not an included topic, so we discussed
the importance for themselves and those that care is offered to. We made some
new contacts this year and have been provided with the Midwifery curriculum
which will support future trips with planning and preparing relevant lectures.
During our visit we taught for 12 hours. The students appreciated the different
topics that were either not on the curriculum or presented in a different to the way
they have lectures.
Lira Regional Referral Hospital (LHHR)
The LRRH is a busy referral hospital in Lira with approximately 7200 births per year
which is double that of UHD. Emily has visited hospital during her two previous trips
to Lira and so it was a familiar place to come to. On our first day we orientated
around the hospital so that team were aware of where to go and how to get there.
We saw some of the student’s taught at the Lira University, but also students from
different school doing college or diploma level study. We offered group teaching in
shoulder dystocia, consent, dignity, partogram use, fetal auscultation, educating
about care planning, risk assessment and documentation.
The obstetric clinical director was kind enough to invite us to join their weekly Local
Maternity and Neonatal System (LMNS) meeting in the second week. This was an
incredibly helpful opportunity to understand the wider landscape in Lira and
Uganda. This was taken from the British system with the support of a team from
Birmingham who worked with the ministry. It has enabled regular communication
between various levels of health care provision and to learn and share data. On this
occasion, we were able to explore the data on maternal and neonatal mortality for
the LMNS region for the year. This highlighted some key areas for future projects to
continue to support maternal and perinatal safety such as the use of partograms. It
was highlighted that at LRRH, only 22% of the babies that died in utero had had a
partogram documenting the labour process. This is an essential risk assessment and
decision-making tool designed specifically for use in countries where determining
obstructed labour and slow progress is important to support timely transfer and
delivery.
Mother with a baby in a breech position
Although we do not work clinically (unless in an emergency), we needed to support
the care for a woman having her first baby in a breech presentation. She was on the
bed, flat on her back and trying to push as hard as she could. We went to hold her
hand and support her. We were even able to move her into a hands and knees
position, which is not a position that is often adopted in Uganda. She had been
pushing for an unknown amount of time as there was limited documentation, but it
was clear that this baby was not going to been born vaginally.
The baby could only be born by caesarean, but the woman had not bought sutures.
For the caesarean to happen, Becca and Emily went to the private pharmacy to pay
for the sutures, but there was no stock, so we had to go to another private pharmacy
to purchase the sutures. The sutures cost 15’000 USH, £2.50.
We followed the lady to theatre on a stretcher that needs to be pushed up a hill, where
we had to wait in the reception area, next to other people to go into theatre. We were
able to auscultate the fetal heart, which we were concerned would not be there, but
knew that without urgency, there was a possibility that both mother and/or baby would
have significant morbidity or mortality.
It was a relief to hear the baby had been born, a little boy. The woman experienced a
reasonable post-partum haemorrhage, and the doctor said after that the uterus had
been close to rupturing which is a side effect of obstructed labour. Without the sutures
a caesarean could not be performed, and it would have been a poor outcome for
mother and baby.
Woman with 32-week twins in labour
We then returned to the maternity unit to collect our belongings, a mother had just
birthed her 1st twin, a little girl weighing 1.3kg at 32 weeks. Shortly after her 2nd twin
was born, it was obvious he was in extremely poor condition. He was very small and
needed resuscitation. There was no bag or mask in the maternity unit, so we had to go
to the neonatal unit (NICU) holding him in our arms. To get the essential needed for him
to survive we took him from maternity to NICU, to paediatrics, to NICU, to maternity
and back to NICU. Every second felt like it was taking an hour to get the help he needed,
just a simple bag and mask to inflate his lungs took a considerable time to be found.
When we were able to get a bag and mask, we started resuscitation, but it was not
possible to inflate his lungs. After trying several different methods, we did not see any
improvement and at one point we were taking the baby back to his mother to have
those last moments with her son before he passed away. The 3rd time we went to NICU
we were able find a doctor who was able to see that the little boy needed help. He had
a good heart rate and saturations improved with nasal specs, but his lungs were not
inflating. It was thought that he had respiratory distress and when we left NICU the
expectation was that he was not going to survive.
The next day we went back to the NICU and the little boy was on CPAP, his skin was a
better colour, and we met the father of the babies. The mother was in the postnatal
tent with her daughter, it was such a happy moment and relief to see that everyone is
well.
Mental Health Project
Emily has a passion for mental health and last year made a connection with Doctor
Charles, Consultant Psychiatrist, and his team. Emily had wanted to look at
maternal mental health and how to support antenatal and postnatal in the
community. During last year’s visit it was clear that to support service users’ mental
health, staff were experiencing burn out, trauma and struggling.
This year Emily returned with the plan for Dorset Healthcare Perinatal Services to
partner with LRRH to firstly find ways to support mental wellbeing of staff. The
second phase will be how to integrate maternal and perinatal mental health support
into the community and rural settings.
A Padlet was created with resources that can be used to signpost for mental
wellbeing and self-care. In addition, there is a link to research, maternal mental
health resources and self-help courses that can be carried out online.
This will be a continuing partnership to ensure that both sides of the partnership
are able to learn and develop a long-lasting relationship that both areas will benefit
from.
The Future
We have identified and curated helpful new connections with key professionals that
we will continue to stay connected with regarding future teams and working on the
projects identified from this trip
We will aim to work online with a midwife and the sister as the leads for quality
improvement and PAL
We would like to continue to attend the LMNS meeting once a quarter to keep up to
date with progress and wider issues
We have created a padlet of midwifery information that will be available to the
students. This is interactive and can be added to with future trips or new useful
information
Teams visit approx. 3 x a year and it is helpful to have midwifery representation on
at least two of them as this is a key area for improvement as well as teaching at the
university. I would like to return with the team to continue with the progress we
have made.