June 23, 2025

Hello! It's early Monday morning and I'm pretty sure that every single rooster in Norhtern Uganda is crowing right outside my hut! The sun is not yet out, and the Wi-Fi is terrible this morning, but I will just keep writing and we will see what happens. 😁 

Our Sonographer Mentor candidate, Max, had major delays using public transportation to get to us. The poor man arrived in Atiak at dinner time Thursday evening, found no suitable place to spend the night, returned to Gulu (1–2-hour drive), and came Friday morning instead. Dinah (a midwife from my first training group in 2024) and I had a couple of emergent patients needing ultrasounds Friday morning, which kept me busy until Max arrived.

One of our patients arrived early, with cramping and spotting in early pregnancy. Using ultrasound, we were able to see a gestational sac, without a fetal pole. There was the possibility that the pregnancy needed more time to develop, however due to the size of the gestational sac and yolk sac, it was more likely an anembryonic gestation. This is a condition that occurs when a gestational sac develops without an embryo. We decided to keep her at the center for observation, get some labs, and check her again with ultrasound over the weekend. 

Another pregnant patient arrived with more serious symptoms, specifically cramping, bleeding, and pain, as well as feeling dizzy. From an ultrasound standpoint, bleeding in pregnancy can be caused by a few different conditions, but a patient with bleeding and pain is a strong indication of either spontaneous abortion or placental abruption (a serious complication where the placenta separates from the uterus). When Dinah started scanning, it was immediately apparent that the was a serious problem with the placenta and a possible partial abruption. Dinah completed the OB ultrasound, the fetus measuring 15 weeks, 4 days, early 2nd trimester. We started her on IV fluids and also planned for a follow-up ultrasound over the weekend. Both of these patients are perfect examples of ultrasound training elevating the care offered at the birth center. 

The first patient was re-scanned and unfortunately had passed the gestational sac during the night. She still had retained products of conception (RPOC), so the midwives gave her a small dose of misoprostol to help her body clear the products and reduce her risk of sepsis. 

Unfortunately, the second patient's ultrasound also did not go as hoped. The abruption had progressed quite a bit, leading to a heavy discussion between the midwife, 2 midwifery students, and myself. All of the details would be shared with the patient, allowing her to be involved and make the final decision. The 2 factors that affect survival rate are the gestational age at birth and the severity of the abruption. A complete abruption is not compatible with pregnancy and also presents a risk of bleeding out for the mother. A partial abruption requires bed rest and monitoring, but it will never improve or reattach, and there is the question of whether or not the placenta will be able to supply the necessary nutrients for the growth of the fetus. Early delivery is not an option at such an early stage in the pregnancy, the fetus would not be viable. For the time being, everyone decided to wait it out and follow-up with ultrasound on Sunday. 

When Max was able to join us, it was in the late morning. Rachel and I spoke to him about the birth center, it's history and current training program in midwifery, and the introduction of ultrasound training. Max has an extensive background in Sonography, but more importantly in teaching ultrasound, which is something he is especially passionate about. Rachel and I both immediately felt his positive "vibe". It's so important to find people who really fit in at the birth center and there is such a strong patriarchal cultural force here, that it is easy for the midwives to lose their voice and confidence, becoming passive in the wrong environment. Max shared his teaching experience with multiple organizations and hospitals, which was extensive, and also his frustration that there were no growth opportunities in his current job. We explained our desire to start out with a part time Sonographer Mentor, who would assist the midwives that have gone through the training, visiting some of the nearby locations, and scanning at the birth center. It is our hope that if all parties are in agreement, the part time position becomes full time, and eventually the mentor would take over all of the training, allowing Rachel and I to expand the training program to other clinics in Kenya and Uganda. We decided to scan a patient with Dinah, which would allow me to see his scanning and teaching style. All went very well! He is a wonderful teacher, probably the most knowledgeable and experienced Sonographer I have met here in Uganda, with a teaching and scanning style very similar to mine. Internally, I was jumping up and down with excitement, hopeful that he was interested in the position. I had another patient to scan, so Max met with Rachel, and I joined them shortly thereafter. Dinah really liked working with him, which is high praise, because she is so shy and quiet. I am more than happy to say that he was very interested in the position and accepted the job! He will return to the birth center in the fall and take part in the next 4-week training course, which will give us the opportunity to work together and collaborate on the training. Another bonus is that he also speaks Acholi, which is so important in this area. 

On Saturday, 6 of us drove into Gulu for supplies and shopping. I was able to get some Phase 2 training manuals printed but was very disappointed with the results. So much of my training manuals are ultrasound photos, which become almost useless with the horrible printing options in Gulu. Printing at home is problematic because of the weight of bringing everything to Uganda, but we also like to take every opportunity to keep as much of our business as possible in Uganda. Allan (my IT wizard and friend from my work with ITW) has been problem solving with me and we will try to use the shop in Kampala that I have worked with before. Allan will organize the printing and then have everything sent to us by bus. We are going to try getting one manual printed and sent to us while I am still here, to see if this option will work. Going to Kampala creates some challenges with time and location, but it's a waste of my money and time to keep getting sub-par manuals printed, and Allan helping out gives him a bit of income and helps us a great deal.

We made multiple stops at the main market, grocery store, cafe for lunch, and a favorite gift shop, then headed back to Atiak. It was a faster trip than usual, but it didn't stop me from "supporting the Ugandan economy", especially at my favorite shop in the main market! 😏

I didn't want to buy these beautiful earrings, but it's so important to shop local! 😄

Saturday and Sunday were very busy, with multiple mothers arriving in labor. Because of the visiting midwife students, I have stayed out of the way for most of the deliveries, giving them plenty of space. On Sunday, I carried my knitting kits to the birth center and sat on the sidelines knitting. In the late afternoon, a group of midwives and kitchen staff arrived, excited to learn, and all of the 10 kits I had brought were immediately spoken for! Learning to knit is not for the faint of heart and can be very frustrating, but all of them persevered with great humor. After about an hour, I was called away for an ultrasound. When I returned, they were still at it, helping each other and laughing through the frustration. I am hoping with this week of encouragement, that they will keep at it and I can expand their knitting skills when I return in the fall. 

I am being called away to scan a patient, and the battery is running low on my computer, so I am going to plug in and sign off. Once charged, I will try to find consistent Wi-Fi, attach photos, and get this sent out! It's strange that I will only be here for another week, I am already missing it and looking forward to my return trip in the fall. Thanks for joining me!

Much love, MB/Jo