Case records and commentaries submitted in partial fulfilment for the award of masters of medicine degree (obstetrics and gynaecology) of makerere university.

Abstract

GENERAL INTRODUCTION Mulago hospital complex is the national, referral and one of the teaching hospitals in Uganda. It is situated about two kilometers from the city center and has abed capacity of 1200 beds. It provides training for doctors, nurses and allied medical workers. It also carries out community based outreach programmes and research in all disciplines of medicine. It is a complex comprising of New Mulago and Mulago Hill Assessment center where patients are screened at arrival and sent to the appropriate departments. The hospital has specialized departments in Medicine, Surgery, Paediatrics, Obsterics and Gynaecology, Radiology, Anaesthesian and Public Health. Department of Obstetrics and Gynecology. This is located on the 5th floor in New Mulago but has other units in New Mulago and Mulago Hill assessment center. In New Mulago, there are departmental offices, the lying-in wards, labour ward, theater, outpatients’ clinics and antenatal clinic. Other services include human reproductive research unit with laboratories and data units. Professors, Consultants, Lecturers, Registers, Senior and juniors house officers and the nursing/mid wife staff run the department. Others include theatre attendants, record clerks, social workers, counselors and nursing aides. These are allocated to different firms. The wards in this department include antenatal, postnatal, gynaecological emergency and patients clinics include antenatal, gynaecological and infertility. The workload done by the department includes about 20,000-23,000 deliveries/year and about 5,000-6,000 gynecological patients/year. WARDS Gynaecological emergency ward (5A Annex): This ward caters for the emergencies that present to the hospital. It has an admission room, lying-in ward with a bed capacity of 16 beds and a minor theater. Some of the emergencies dealt with include abortions, ectopic pregnancies, acute pelivic inflammatory infections, complications of pregnancy before 28 weeks of gestation and complications of pueperium. Minor operative procedures such as evacuation of the uterus for incomplete abortions are carried out in the side room minor theater. The majority of patients seen in this ward come with abortion related problems and about 3,000 abortions are seen per year. Labour ward: This is an emergency ward which is covered 24 hours by a team on duty consisting of consultant/ registrar, senior and junor house officers and midwifes who rotate in shifts. The patients come form several places which include in-patients, transfers from OMMC, those booked in New Mulago hospital, referrals from near by maternity centers/private clinics and those who did not receive any form of antenatal care and from the surrounding districts. In Mulago about 22,000 deliveries are conducted per year with a caesarean section rate varying between 13-18%. Activities in the labour ward Admission: Registration Relocation of files to booked patients Administration of files to referral and the unbooked patients Checking of blood pressure, temperature and taking social-demographic details Examination room The admitting doctor takes the relevant history and examines the patients then decides the mode of management. OMMC: This maternity center is run by midwives daily and caters for mothers who are assessed as low risk. They transfer any mothers with complications of pregnancy and labour to New Mulago. There’s a postnatal ward where parturient mothers are observed for at least 24 hours. Family planning clinic and VSC centre This provides general family planning services and also offers other reproductive health services such as counseling, immunization and treatment of sexually transmitted diseases. The VSC centre performs bilateral tubal ligation, vasectomy, implantation of Norplant and other contraceptive methods. Outpatient clinics: In New Mulago the outpatients are seen in different clinics according to their disease conditions and the clinics are run on firm basis on different days. These include antenatal, gynecological and infertility clinics that are run by the specialists, senior house officers, intern doctors and midwives. Laboratories: The department runs side room laboratories for simple investigations while the major ones are sent to the hospital major laboratories located on the third floor. There are also laboratories in the reproductive research unit. Imaging Imaging procedures required in the management of patients such as ultra sound sonography and X-rays are found on the second floor in the radiology department. The patients with gyaecological cancers who require radiotherapy are referred to the radiotherapy unit. Patients with mild medical conditions in pregnancy but not in labour and those in latent labour are treated and sent to the antenatal lying-in ward for further management. Those in labour are sent to the first stage room where they are monitored using a partogram until they reach the second stage of labour. Deliveries are carried out in the second stage room which has facilities for normal, assisted instrumental, breech and twin deliveries and a resuscitation area for the new born babies. Labour ward also consists of an intensive care room reserved for patients who are high risk or have complications of pregnancy. These include conditions such as pre-eclampsia, eclampsia, ante partum haemorrhage, chronic medical illness such as cardiac, sickle cell disease and diabetes in labour and those requiring induction of labour. The mothers and babies are observed for at least six hours in the labour ward and are then transferred to the postnatal lying-in wards. Mothers with babies born before arrival with in 24hours are also admitted to the labour ward to manage complications and for observation. Operating Theatre: This has three operating rooms; one for elective surgery and the other two for emergency operations. Anaesthetists come from the department of anaesthesia. The private patients are operated in the private theatre on the 6th floor. On the average about 5614 operations are performed annually with the majority being emergency operations. Special care unit: This is an intensive unit for the management of the newly born babies. It is located on the same floor and is managed by the department of paediatrics. It is within easy reach of the labour ward and is open 24 hours. This unit caters for babies who are prematures, have low Apgar scores, birth asphyxia and any abnormalities from labour ward, other centers or from home. The mothers with babies in SCU are admitted in the general ward (mothers’ club), from where they go to see and breast-feed their babies. In case of illness they are managed by the doctors/nurses on the ward.