Wedding planning

I have acquired the free services of a local wedding advisor. Naomi is my neighbour, and we became friends when she came over to meet Luthien. Now she visits almost every day to entertain Luthien, and we usually end up going for a walk or chatting about school, and moving around the world and cultural differences and life. She was very excited about my engagement and has helped me surf the web for possible wedding venues, critiquing them primarily for their ‘family friendly’ qualities. On Thursday she brought me some beautiful roses as an ‘engagement present’. Oh, did I mention that she is in 5th grade?


Hasn't Luthien grown?

Mental Health Day

During the last two weeks the Christian Medical and Dental Association has held a medical education conference just outside of Nairobi. In addition to some very helpful lectures and workshops I enjoyed the opportunity to network with clinicians working all over Africa. And I did take the opportunity to have some fun too – one day Sara (OB/Gyn Kijabe, Kenya), Stephany (Paeds, Kijabe, Kenya), Christina (OB/Gyn Kapsowar, Kenya) and I went into Nairobi for lunch and had our nails painted.

Christina, Sara and Stephany enjoying a curry.

Pretty toes.

More pictures

Here I am with David and Luthien when he came to visit in Kenya. We looked for a ring together in Nairobi. We found a tanzanite (a stone mined only in Kenya and Tanzania) - which is exactly what I had hoped for.

Here's our attempt at a sentimental engagement photo - we couldn't stop laughing at each other.

And another thing...

I promised in my last post to let you know why I was in such a hurry to leave Kijabe on 29th January. Well, that's because I was on my way to Nairobi to stay with my parents before flying out to Kampala on Saturday. That afternoon I met my friend David Pitches who drove me down to Mburo Game Reserve about 200km south of the city. We stayed at Mihingo Lodge (http://www.mihingolodge.com/ for those who are interested), a hotel on a hilltop overlooking a lake on one side and a watering hole on the other. Each room had it's own terrace with a view of the watering hole. Coffee was brought in the mornings to wake up as you watched the animals come for a drink. We watched game from a nearby hide, went for walks in the moonlight overlooking the lake, and a horseback safari. Then on the final day we were together, David asked me if I would marry him - and I said yes. :-)

This is the hotel restaurant and bar on the top of the hill.

There were only 10 rooms, each one tucked away among the trees on the hillside. The entire hotel was run on solar power and water collected from rain water. Trails were made from local rock slabs and at night they were lighted by lanterns. Birds, monkeys, rock hyrax and bush babies could be seen daily, and they had a great variety of vividly coloured butterflies living in the shrubbery.

Each room had an individual terrace overlooking the watering hole - a lovely place to watch animals as you drank coffee in the mornings or had afternoon tea.

Here are some of the impala that we could see from my terrace.

We went for a horseback safari and were able to get very close to the game - I guess the smell of 'horse' overpowers the smell of 'human' and reassures the animals. (This particular photo was taken by our guide - who clearly lacked some understanding of photo composition - in addition he was riding a rather excitable Ethiopian pony who kept prancing about during our photo session.)

This pool is just underneath the restaurant at the top of the hill (and the water comes from rainwater as well). They have built a ledge at the end overhanging the hill, so you can stand with your elbows on the edge of the pool and watch the animals when you wanted a rest from swimming. Just below the pool they have another terrace - and it was there that David proposed.

Another memorable patient

On Fridays we have our gynaecology outpatient clinics. They are usually very busy, with 60-90 patients most days. And on the 29th I was just finishing up (an hour late), very eager to get off for some important weekend plans (about which more in the next blog). But on my way out the door I was stopped, 'Doktari, we have this very short woman who has come in in labour and the baby is transverse.' Well, 'short' was definately correct. I don't know exactly what was wrong, she didn't look achondroplastic, but she clearly had severe bony deformities - less than 4 feet tall, contractures of knees, hips, pelvis, elbows and wrist, severe kyphosis, scoliosis and lordosis (i.e. a very twisted and fused spine).


The anaesetists tried to site a spinal with no success and eventually did a general anaesthetic and secured an airway with a fibre-optic ET tube (all this is very fancy stuff that I'm fairly amazed we even had). Then my challenge was getting into the abdomen with her hips flexed at 90 degrees, and trying to figure out where important structures like the ureters were running (they were pushed way out of their normal position). But praise God we had a healthy mum and a healthy baby.

Mother and baby in the nursery.

Caesarean Hysterectomy

Sometimes when a woman is bleeding excessively after delivery the only way to control the bleeding is to remove the whole uterus. This is pretty much a last-resort option when other techniques to stop the bleeding have proved inadequate. In England caesarean hysterectomy is pretty unusual – in six years of training I had personally only ever been involved with one – but here they are much more common. I get a lot more referrals from other units, and certain management options (e.g. interventional radiology) are not available here. Also significantly, a lot of our women are anaemic, and it’s much more difficult to get blood for transfusion.

From November to January we had 8, and those weren’t particularly unusual months.

· 5 placenta praevias with associated accreta (where the placenta is at the bottom of the uterus and cannot be separated from the uterine muscle) - (4 following previous caesarean sections)
· 1 uterus with massive fibroids
· 1 uterus that refused to contract
· 1 ruptured uterus

Many of these babies are premature at delivery, and 2 of the 8 died not long after birth. I am always very grateful for our excellent neonatal unit as without our it at least 4 others would have died as well.

This little one started off on 'bubble CPAP' to support her breathing.

A few days later she was breathing well on her own, and has since gone home with her mother.

Frankly, these are not operations that I enjoy (at least, not until they are over). They occur in dangerous situations where a woman’s life is at risk, frequently in the middle of the night with theatre staff who are not used to gynaecological procedures. They require great speed and usually you are operating in a bloodbath. Knowing when to proceed to hysterectomy is not always easy – you don’t want to rush to a procedure that will prevent a woman from ever having more children in the future, but you know that if you delay too long, she will have used up all her clotting factors and be much more likely to die.

Last Friday was one of my more interesting caesarean hysterectomies. This woman had been actually come to casualty because her husband was ill, and then she started to bleed. When I scanned her and saw the praevia I knew that with her history of 2 previous caesareans she was highly likely to have an accreta. What I didn't expect, as I was opening the abdomen was to find that the placenta had eroded all the way through the uterus and was stuck to the anterior abdominal wall and the bladder.

The mother is doing very well post-operatively, but her baby is struggling a bit, still requiring CPAP.

Twins...

When we first arrived the labour ward team was very anxious about twin deliveries. They know all too well the kind of things that can go wrong - epitomised by a young woman who died in our unit recently. She had delivered in another facility - twin 1 survived but twin 2 died. Then she had a post-partum haemorrhage, a late decision to procede to hysterectomy, and she eventually sustained severe brain injury do to lack of oxygen. She never regained consciousness after surgery and was transferred to us essentially to die. We looked after her during her final week of life and our paediatric team helped the family to prepare for how they could look after the surviving twin.

But although twins are certainly a challenge, delivering them safely is one of the most rewarding parts of my work. For the last six months Sara and I have been working with our midwives and interns, encouraging them to develop their skills and experience, and we have seen them grow in competence and confidence.

This is Pauline, one of our new interns, with a set of twins that she delivered. We supervise our interns very closely to ensure that they are well supported and learn safe management from the beginning.

I also have the midwives manage these deliveries whenever possible, though again, I am always present for supervision and support. After this woman delivered her managing midwife was very pleased with how things had gone. 'I am so happy to be working in this hospital,' he announced to me. 'In most other hospitals in Kenya this would have been an automatic caesarean section. But here we know how to safely deliver twins.'

P.S. The little girl was named after me. :-)

January - the drama never ends...

Since returning from my holidays we've been pretty busy in Kijabe. Here are a few medical memories from the last few weeks...

Just after getting back we had a woman with an 18 week abdominal pregnancy. This baby was growing outside the uterus with the placenta stuck to part of the bowel. She came to us complaining of pain, and she had started to bleed internally. We had to operate, and though the baby could not survive, the mother lived.

Almost all of our operations are carried out under spinal anaesthetic, so the patient is awake during the surgery. One of the more interesting features of theatre ritual here is showing the patient the specimen after we have removed something from their body. My nurses were perplexed when I explained that it was not typical practice in the UK to show patients their uterus after doing a hysterectomy. 'How do they know that you removed it if you don't show it to them?' the nurses wanted to know.

My favourite operation of all is still repairing obestetric fistulas. This young woman is one of our typical patients - Like many of our fistula patients she is from Somalia, a teenager with an early marriage, obstructed labour at home for many days, finally delivering a stillborn infant and left with the hole between the bladder and vagina. Less than an hour of surgical time and two weeks of care in hospital and this young woman went home dry for the first time in years - smiling with hope for the future.

Sometimes patients forget to read the textbooks before presenting to us with problems. 'Everyone' knows that patients are only supposed to get eclampsia after they have first had pre-eclampsia. It's only courteous of them to warn us that they intend to have a convulsion by getting high blood pressure or protein in the urine first. However, two of our patients this month decided to have their convulsions before the other signs and symptoms. Fortunately we were able to stop the fits, stabilize them and deliver them safely of healthy babies. How grateful I am to have magnesium sulphate!