Observations from the Special Care Nursery at Mulago

Posted on behalf of Sarah McIntire, MedPeds 4th year resident

Eighty. That’s probably a good estimate of the average census in the Special Care Nursery at Mulago Hospital in Kampala, Uganda. On busy days, the number of infants can rise over 100. Clearly, there’s no such thing as a cap on the number of admissions we can take in one day, let alone a couple of hours. Here, the babies are divided into two rooms: preterm and term. Preterm infants can be anywhere from roughly 26-28 weeks (here, viability is typically considered 28 weeks), and often come in multiples – twins, triplets, even one set of quadruplets! Term infants can present with problems ranging from low Apgars at birth or respiratory distress, to asphyxia, seizures, or severe sepsis. As Mulago is a major referral center and a government run hospital, many infants are transferred in for complex management or simply because their parents cannot afford step-down nursery care at a private hospital.

The Special Care Nursery, where I work is quite different from the NICU I have become accustomed. There are no ventilators, only CPAP. There are very few continuous infusion pumps. Phototherapy is limited, and labs take about a day to turn around, so if an infant appears jaundiced, they are often just brought to a separate isolette and squeezed together under the lights. 

On my first day in the SCN, I felt overwhelmed by the sheer number of patients, and the limitation of resources. I could only think of what I wouldn’t give for a ventilator, or even just a quick CBC. At first, it was so hard to see past the differences between NICUs in the United States and here in Uganda. But, just like any new rotation back home, I waded right in, and started to realize that just because the care of newborns here is different, that doesn’t make it bad. It’s more about realizing how to make use of the tools you have available. 

Sarah and Kendahl with the Special Care Nursery Nurses

I learned to rely on mothers, who act as bedside nurses, and who don’t need a nursing degree to tell you that their child is too warm, or is breathing funny, or has a distended abdomen. I diagnosed a trachoesophageal fistula on my third day, after learning to place nasogastric tubes and having one that just wouldn’t go into the belly. Chest X-ray confirmed the TE fistula, and surgery was there the next day and ultimately took the child to the OR for repair. Just like back home (although perhaps without a CT scan or prenatal ultrasound).

But the most amazing thing to me about the Special Care Nursery goes beyond the medicine. My contribution of prescribing antibiotics or advancing feeds paled in comparison to the absolute love and devotion of the parents and families caring for these infants. I saw a mother, after breastfeeding her own child, pick up an abandoned infant awaiting placement, and, gently holding him, feed him formula from a syringe. She could have (and should have) been resting, but to her it was more important to care for this child who had been left behind. Another infant, whose mother died in child birth, was cared for lovingly not by his parents, or grandparents, but by his paternal aunt who gladly purchased formula to feed him, and stayed for days in the hospital until he was ready to discharge.

Special Care Nursery Nurses with Kendahl and Sarah

In a place where there can be so much tragedy (on reading the death log, it appears that about two or three infants die daily in SCN), it’s easy to feel disheartened. But on the eve of leaving, I can only say that I’m overwhelmed be the love and gratitude of the families and nursing staff here. It’s been an experience I’ve been lucky to have, and I look forward to more to come in the years ahead.