Well, my time here on Efate is ending. I am sitting at the airport on a Sunday morning awaiting the departure of my flight to Nadi, Fiji. It is a very lovely day here in Port Vila. The sky is blue with patches of big cumulus clouds. As I look out the airport windows I see a big mountain range in the background and in the foreground I see palm trees and other lush green trees. There is a group of Fijian young woman who are travelling today. They are cricket players who had played 6 games in Efate and won 5 of the 6 games. They are rejoicing by singing and clapping. The NiVans are friendly and have been good to me as a visitor to their country. I will miss walking down the street and exchanging many greetings…”Halo”, “Gud night”. I will miss the bus rides and seeing all the people walking around. I will miss the 24/7, 6 days a week out door “farmer’s” market. I will miss the sun and warmth. I will miss my daily swims. I will miss the women and babies at the hospital. I have had an unbelievable experience and feel very fortunate that I was able to make the trip to Vanuatu.
Tuesday, April 19, 2011
Friday, April 15, 2011
Tanna Adventure
It had been quiet at the hospital this week so I decided to go with the women from New Zealand to the volcanic island of Tanna for an overnight trip. I bought my plane ticket at the local Vanuatu Air ticket office and packed my hip pack and was ready to go. We left early Thursday morning in search of a bus to take us to the airport. We had walked to the end of the street and I realized I had forgotten my passport. So, I ran back and grabbed it. I return and the ladies have still not found a bus. I see one and flag it down.
We get checked in at the airport and to our amusement there is a low budget film crew from Madrid, Spain who are frantically running around assessing their filming site, the airport. Annoyingly, they are holding up our flight for ½ hour’s time. We had discussed why hadn’t this film crew arrive early to get their film shots. Finally, the film crew had completed its business and we board onto a small plane. Tanna Island here we come!
We step down the stairs of the airplane onto the tarmac and walk over to a tiny airport, through the doors and look for our driver. Our driver is not here. In fact, he never arrives. We have forgotten the name of the place we are staying and did not bring the brochure. A woman sees our distress and approaches us to help. I had a cell phone with me and we find the number of the place we are staying in the phone history as I had called them the day before to reserve a room. The woman talks to Dream Island Bungalows (our accommodations) to find out that the river had been high and the driver was not able to get over to the airport in time to pick us up and that he had just passed over the river. So, the woman finds a driver for us and we are off to the East side of the island.
We have about a 3 hours drive to our bungalow on a road that is quite bumpy. We cross the river and drive over miles of wide expansive volcanic ash at the base of Mt. Yasur (the active volcano on Tanna Island). We continue on the bumpy ever-changing volcanic ash road and arrive to our bungalow. It is a beautiful setting overlooking a lake and the ocean. We get settled in and decide to hike to the local beach, which is about a ½ hour’s walk to the white sand beach. We arrive and go for a quick dip, as the sea was un-inviting (the current was strong). As we walk back we get caught in a heavy downpour. This was the beginning of the heavy rains that pretty much ruined our Tanna trip.
We had heard that when it rains here that it is difficult to drive up to the volcano. Despite the warnings our driver attempts to get us to the volcano. We try one road and it is no longer accessible. When you see small waterfalls in the road, it is not a good road to be traversing! The roads on Tanna Island are made of volcanic ash and when it rains here the ash easily washes out and the road changes in a matter of minutes. There can be holes in the roads, big drop-offs, un-even terrain, etc. So, back to the adventure of getting to the volcano… Our driver turns around and decides to take us on the beach to try another route. We “slide” a short distance down the beach and suggest going back to the bungalows. The driver happily agrees and we start our drive back. As we are pulling into the bungalows the left front wheel of the truck falls off. Luckily we are very close to our accommodations and this did not happen miles away in the downpour. The driver and his assistant scramble to look for the 6 bolts to the wheel as the sky is beginning to turn to night. We head to the dining bungalow to wait for our dinner and count our blessings.
After dinner we are exhausted and head off to bed. Our accommodations are simple, 3 beds and a table. I sleep on the bed underneath the window, which ends up being a mistake as it pours all night long with heavy gusts of wind, which blow rain on me over the course of the night. Elizabeth and I hear something crinkling in the room. She turns the flashlight on to see that there is a rat in the room munching on the bread that was left out. This rat was big! The body was about 8 inches long. She puts the bread in her luggage. I now have some trouble falling asleep; rain falling on me, rats crawling around, fleas jumping, etc. It is going to be a long night, as I think to myself. Shortly after the rat returns and I see it crawling up Elizabeth’s bed near her luggage which she has up on her bed. I call out her name but she is deeply sleeping. I shoo off the rat, which was the last I heard of it that night.
We awake in the morning to more rain and it is suggested to us that we get an early start back to the airport in order to make our 3pm flight back to Efate. So after our breakfast we begin at 9am our drive back to the airport. To begin the drive to the airport, we have a truck in front of us with 8 men with shovels who are creating the road for us to drive over as the rains had destroyed the road. This was a slow process as you can imagine. I get out of the truck to assess the situation and watch what the men are doing and think to myself, what am I doing here. As I walk back to the truck I take a look at the wheel that had fallen off last night to see that they had only found 4 of the 6 bolts that were once on the wheel. Hmmm, hopefully the wheel will stay on this time! We inquire with the driver regarding the wheel and he tells us he will drive us to the river and then we will get in another truck. Oh good! We arrive to the river and it is too high to pass. So we all squat at the river for a couple of hours. The river is at the base of the volcano and as we sat there waiting for the river to go down the volcano would “grumble” from time to time. To pass the time, I immersed myself in the Mistress of Rome, which is a great book if you haven’t read it already. Meanwhile, the men are assessing the river.
We get the okay to get in another truck to cross the river. In this truck to cross the river, I am standing in the back on the bed of the truck holding tight onto these bars. Oh, so this is going to be like a roller coaster ride. Nice! We are all ready and the driver starts the car and then just as we think we are going he turns the engine off. Okay, false alarm. We wait another ½ hour and then we decide to cross. And it was a breeze crossing the river. We drive for about a ½ hour and something is wrong with this truck and they pull over to stop another driver of a truck who had crossed the river too. Our driver asks the other driver if he could take us to the airport. He agrees and we are now in truck three of the day to the airport!
Now, driver number three is quite in a hurry to get us to the airport. We are slipping and sliding down the road. We end up in the ditch twice. The first time in the ditch we went I was not sure that we would make it out. There were many times on this drive to the airport I was uncertain if we were going to get there in time to board our plane. Although we got to the airport in time with a ½ hour to collect ourselves and reflect on what happened in the last 24 hours. Stepping onto the plane and off onto Efate terrain was a very happy moment for us 3 women! Lesson learned, check the weather forecast before going to Tanna and go when it is not raining.
Highlights of the quiet week at the hospital included lots of gauze cutting and folding, cotton rolling, scissor sharpening, cleaning, stocking and organizing. As well, one of the baby’s I delivered was from a 19-year-old woman who had inverted nipples. The mom and baby are the perfect match because the 3.42 kg boy had a great strong suck reflex.
The end of my activities here on Efate is closely approaching.
Monday, April 11, 2011
Busy Week at Vila Central Hospital!
Week 3
Miliaria is gone! Once I started using the air conditioning at night it cleared up.
This was a very busy week for the Maternity Ward at Vila Central Hospital. To follow is a few of the highlights of the week. I hope you are enjoying this and let me know if you have any questions or are curious about anything that I have not mentioned.
There were 2 vacuum extractions performed by the Doctor that I observed. One was to assist a mom during 2nd stage of labor (pushing) because she had severe heart disease. Before the vacuum assist she had an episiotomy. This woman had a severe heart murmur you could easily see by looking at her chest wall. It was very unforgettable to hear and palpate. Her baby was thought to be somewhere between 36 and 39 weeks gestation and she delivered a 2.26 kg girl. The second vacuum extraction was performed on a woman who needed a little extra help and she had a big (3.92 kg) baby boy who had a cleft lip and hard palate. By the way, he did great with breastfeeding despite this anatomical deformity!
I continue to practice my suturing and observing the midwives suture. This week I have had lots of opportunities to strengthen this skill and I am feeling much more confidant suturing.
There were a couple resuscitations this week. One was on a 3kg boy who had AROM (artificial rupture of membranes). AROM is where the bag of waters are broken with a device called an amnihook. There was thick meconium in the bag of waters. His 1-minute, 5-minute and 10-minute Apgar’s were 5/5/9. He received suctioning and blow-by oxygen. Another was a 3.9 kg girl with 1-minute, 5-minute, and 10-minute Apgar’s of 3/6/10 and who was SROM (spontaneous rupture of membranes – bag of waters broke on their own naturally) with thick meconium. She received suctioning and blow-by oxygen. The mommy of this big girl had placental membranes that were slow to deliver and cervical prolapse.
A 24 year old G3P2 (3 pregnancies, 2 viable births) VBAC (vaginal birth after C-section) gave birth to a 3.14 kg girl with Apgar’s 9/10!
I observed another footling breech with a nuchal cord who had an emergency C-section. She had a 2.62 kg boy with Apgar’s 9/10. It was interesting to feel the little toes of this boy during the vaginal exam. I am very familiar feeling the heads of these little babies not little toes!
We had a baby girl who was BBA (baby born on arrival), which means that she had her baby at home. This woman had had her baby at home and her mother brought her in with the placenta still inside the mom and cord attached to baby. We clamped and cut the cord on the truck and wheeled the mom into the delivery suite where we tried to deliver the placenta. Unfortunately after a couple hours the placenta was not coming out. So we arranged for Dr. Robert to manually remove the placenta in the surgical ward. This is a very painful and invasive procedure that I witnessed and that I hope does not happen all that too often. She had been given the strongest analgesics and sedatives the anesthesiologist had. The placenta was completely manually removed and mom and baby are doing great!
Lastly, I had to help a mother a little with the delivery of her 3.4 kg baby girl who had been a little stuck and required me pulling her. It was not a true shoulder dystocia by the way.
For fun, I have been continuing my daily swims. The New Zealand midwife, Elizabeth, and her midwifery student, Angela, arrived. Angela and I went to go swim the swim course and dove into a group of jelly fish. I could not see any jelly fish but they were there. We both had this strange nerve tingling feeling all over our bodies. The sensation went away for both of us after a few hours. I have been scuba diving in the waters around Efate and the ocean environment is beautiful. I have been eating out a couple times to get a sense for the restaurants in the area. I had a wonderful fish dinner with mango chutney at a restaurant called Chill, which is located on the waterfront. It was during sunset and I saw a most magnificent sky. The cruise ship was leaving the port and oh my, this ship is huge! It had a big television screen, which I could clearly see the screen as it sailed away. I continue to enjoy my walks to the hospital whereby all the little children so happily greet me as I walk by.
Tuesday, April 5, 2011
Week 2
Well, I seemed to have gotten miliaria. No, not malaria! And for those who don’t know what miliaria is, it is a heat rash. For me, it developed on the backs of my hands and has spread to my lower arms, legs and feet. At first, I thought it might be an allergy to the latex gloves, latex is what is exclusively used in the hospital here. No latex free option for those who have developed an allergy to latex, which is a common allergy in those working in the health profession. It has been suggested to me to give it some time and my body will adjust to the heat. And to give myself a break from the heat, I have succumbed to using the air conditioner at night when I sleep. I have slept better since doing this.
Recently, I have been thinking a lot about life and death. A fellow peer at Bastyr was on a Nicaraguan study abroad trip this Spring break and drowned while swimming in a lake. Her name is Michelle Eustache and I knew her as a very enthusiastic and curious person and it is sad that she is no longer part of this physical realm. Please keep her parents and those closest to her in your thoughts and prayers.
There have been several deaths at Vila Central Hospital in the Maternity Ward…
Sadly, the 960-gram, 25 week old baby boy I told you about in the last post died.
And the baby in the nursery with the omphalocele that I also shared in my last post has passed away as well. It is very sad. The baby was healing well and the omphalocele was receding and seemed to be improving.
When someone dies in the hospital many people gather around and wail. It can go on for an hour or so. The echoes of this last loss still permeate in the memories of my ears. It is hauntingly eerie sounds that some women make. From my observation, it seems very healthy for the family and friends to be together and to discharge this energy.
So some birth highlights of week two here in Vanuatu…
Getting lots of practice in the artificial rupture of membranes. The midwives like to use this technique to speed labor progression.
So far, the youngest birthing mom is 18 years of age and the oldest is 37 years of age.
I manually replaced a prolapsed cervix of a 37-year-old G4/P4 woman. After that, I had educated her about Kegel exercises, which don’t seem to be something well shared here. These exercises bring tone the pelvic floor muscles, which get super stretchy and lax after childbirth. They are exercises we all can benefit from doing.
I observed an elective C-section of a footling breech presenting baby who had a nuchal cord times two (the umbilical cord was wrapped twice around the neck)!
And the largest weighted baby was a 3.92-kilogram girl (that’s 8.64 pounds) which is big for NiVans!
And for a little rest and relaxation, I have managed to go for a swim everyday since I have been here. The ocean is nice and warm and the pool where I am staying is a nice cool off from a hot day.
I went to church with one of the nursing students on Sunday. We took the “bus”. Which is a man who drives a van and will take you wherever you need to go for 150 vatus. We were taken to a rural area, which was well taken care of by the inhabitants. The gardens were lovely and well tended. As we walked up to the church, I quickly discovered that the NiVans have very strong and beautiful singing voices and I love the lyrics to some of their songs. They sing about the value of life and being thankful. It is interesting to hear them sing so loudly and strong because most NiVans are soft spoken, men and women alike. I have heard on a couple occasions a NiVan shout but mostly they talk softly. On this particularly Sunday there was a group of men soccer players from Mele village (a village that has the famous waterfalls on Efate island) who sang a song for us. It was interesting to me to see these men become quite shy and humble before us. They sang wonderfully!
More to come wait patiently…
Friday, March 18, 2011
First week in Vanuatu!
Thursday, March 17, 2011
I am Very Thankful, and Will Miss....
Wednesday, March 9, 2011
The Downs and Ups
It has been a while since my last post in part because I have found it challenging to put words to the experiences that I had over the past week/weekend. I will try to recount the events as I experienced them, with the disclaimer that the following stories are sad, hard to read, and at times hard to re-live. I also want to make sure to note that I believe that those involved have done the best they can with what they have and know, although I would have handled the situation in a different manner. With that said this part of the post involves death and I advise skipping to "The Up's" at the bottom if you don't want to read about it. I am going to try to keep it brief.
I came to the hospital last week to find that a planned c-section had occurred for the purposes of ending a pregnancy. The mom was 30 weeks gestation (same age as the little one I delivered the first week I was here...who is still doing well). She had an ultrasound earlier in the week and the findings were that her baby had severe hydrocephalus (a condition where there is water on the brain and swelling of the head occurs). Sadly, they do not have the resources or ability to put a shunt in, as would be done in many other parts of the world. Knowing that the newborn would not survive and that the size of the head would continue to grow larger if the baby was allowed to continue in utereo, the family and doctors decided to do the C-section as a termination. The issue, was that most knew the baby was going to be born alive. I was not in the room for the section but one of the students (who I have become close with) was and she re-counted the events for me that left her quite sad. When the baby was born one doctor wanted to suction him to help him out, and another doctor said "no, just leave him." He was alive!
I was in the labor ward when one of the midwives brought the little bundle in, all covered in blankets. This little boy was very much alive, still breathing, and giving small whimpers. She said the doctors said we are to leave him here and she set him on the cold receiver (which had not been turned on). I walked out of the ward to get the story on this little one who looked just fine to me, although there was liquid on the brain that you could palpate. Once I realized that he was being left there to die, I couldn't help but return to the room to put my hands on him, uncover his sweet face and gently talk to him. Mom was still in post-op. After discussing the case with a few others who felt deeply touched by the situation I turned on the warmer and another midwife gave the little one oxygen. He gave little crys. I walked out of the room momentarily and then returned to find that the doctor had turned off the warmer, taken away the oxygen and exposed his little body to the air. I was in the room when the father walked in and I heard as the doctor described, "baby no good". The family knew that the boy wouldn't survive but I am unsure how much they understood of just how alive he would be, when he was born.
After the dad left, the midwife asked me to weigh the little boy. With tears mounting behind my eyes I picked him up, wrapped him again and gently carried him to the scale. He was 3 1/2 pounds. I cried as I brought him back into the ward, and I refused to leave him uncovered. He opened his eyes as I walked back with him and I saw that him mom was being wheeled back from surgery. I set him on the warmer.
The student who was so disturbed by the on goings at the c-section had left the surgery and saw me in the labor ward crying, she said, "Kate that is exactly how I felt". However, within minutes I had to very quickly collect myself as another woman was brought into the room, pushing! We needed the warmer (which doubles as the resuscitation area- if need be) to get ready for this next baby so we put the 30 weeker in a bassinet in the same room where he continued to give small crys. The head was right there for this mom of one, yet I could tell that part of her bag was still intact so to make it easier for the baby to come out, I broke her bag. A thick black substance like I have never seen before came out (an extremely bad sign), very old meconium. Next thing I knew the little boy was born but had clearly passed away at least 1-2 days earlier. I checked for a heart beat anyway and another midwife called a doctor in to confirm that he was in fact deceased. He also had some serious malformations. I was unaware that prior to coming into the labor ward, no one had listened for heart tones on this babe (there may not have been time).
One other time I have been involved in the birth of a still born, however the family was aware of the situation. I have never had to give a mom the news before. I was told that she was 35 weeks but after looking at her chart saw that by her dates she was only 27 weeks along (although the baby did look closer to 35 weeks). We later found out that she had a fall one week prior where "water came out", she did go to the antenatal clinic when this happened. She also reported that she hadn't felt baby move since the day before. I wiped the little boy down and wrapped him as best I could and handed him to his mom, telling her that I was so so sorry for her loss. It was terrible! And the other little boy was still in a bassinet in the room, alive but quietly and slowly leaving his body. It is an indescribable feeling to be surrounded by that.
After the delivery this woman's mom left to get clothes to dress the deceased boy in (as they do here) so she was alone and in visible shock. I asked her if there was anything that I could do for her. She couldn't answer me verbally but I know she understood me. I gently rubbed her back. After a while I was instructed to also weigh this boy- this was one of the hardest things I have ever done, I gently took him out of her arms and spoke to him as I walked to the scale, again in tears!
I returned and gave her the boy to cuddle with again. Her husband was a teacher so he was at work. I took the other baby (from the c-section) out of the room and brought him to his parents and extended family to spend his final moments with them. I let them know that he was still alive but I was unsure how long he would survive. He died about an hour and a half later with his family. The other boy stayed in a private room with his family for most of the day.
There were two more births that I helped with that day (that went very well) however the day had still taken a toll on me and I felt I needed to take some time away. I cried a lot that day. Many of the staff felt greatly effected by how the case with the boy with hydrocephalus was handled and there has been much discussion, reflection, and prayer. For the most part I am very impressed by everyone out here yet that day was a hard one, a day that has really made me thankful for the resources that I am privileged to have, should I need them. I have 2 step siblings who have a half brother that has hydrocephalus, when he was born he was "the size of a coke can", he is now 16 years old and a track star. I took the following two days off to reflect.
Another "down" to share, before we get to the good. Early this week a woman (almost 40 years old) came in, in labor with her 7th child. That is what she told us....although, her belly was flat, she said she was due the following month but had been having contractions. I palpated her abdomen but didn't feel anything, and we couldn't get a heart beat. With the help of another midwife I asked a few questions, "had she felt the baby move?" Yes, a lot. "Had she taken a pregnancy test?" No. "Had she sought pre-natal care?" She had been to the clinic once at the beginning. We thought it best to call in the doctor on-call to address the case. The midwife told me that this was the third case she had experienced like this. The doctor arrived and brought in his portable ultrasound machine to show the woman and her husband (who had brought all of the clothes and supplies along for her and the baby) that there was in fact nothing in her abdomen. It was very very sad, they thought she was in labor and in fact she was not pregnant! I am not quite sure what this woman's mental situation/stability was.
I returned home after a very long day (12 + hours) to find that a pair of my flip flops that I had left outside my door for the past 3 weeks, had been taken. Without energy to get that upset I was a bit annoyed and went to bed.
THE UP'S:
I woke to find that my flip flops had been returned. They were in the same place I had left them before heading to work early the morning before. I guess someone just wanted to borrow them for the night! This made me laugh out loud.
As I mentioned briefly before, I am happy to report that baby Sonya, the sweet little one who was born into my hands at 30 weeks pre-mature is doing well and needs less supplemental oxygen on a daily basis. She is still in the nursery and mom still stays at the maternity ward to give her hand expressed milk to the little girl every few hours. I have seen the young mom helping others out with their babies as well.
I got asked if I wanted to attend a portion of a 3 day conference that was occurring in town. It was about the state of maternity and neonatal care in Vanuatu and more specifically Efate (the island I am on). There were members from the WHO, UNICEF, UNFPA, doctors, pediatricians, midwives, and nurses in attendance. I came to the session on the Role of Midwifery Care. The statistics were interesting and the presentation really got the director of the WHO generating ideas for how to improve the numbers of midwives in the area and the conditions under which they work (long hours, understaffed times, etc.). I was glad to attend.
Last week the ambulance went to pick up a mom and her newborn who was 'BBA'- Born Before Arrival; this was her third baby and the previous one was a c-section. Baby was unintentionally born at home with the assistance of a traditional birth attendant (a community midwife, who has learned via experience). All is well with the new addition and mom.
Later in the week I attended a very lovely and loving labor. I have only been to one other birth where the partner has been in the labor room, and it was their 4th baby. This time, it was the mom's first pregnancy. She was a young 20 year old and her boyfriend was at her side, holding her head up, encouraging her, giving her sweet kisses the whole time! It was so nice to see. His mom was also there helping her along. When the baby came out she needed a little extra assistance to come around. I was so happy when she finally gave a cry and really came into her body. The uncle entered the room not too long after and I don't know if I have ever seen someone so overjoyed and excited for the family, her was laughing and crying at the same time! I helped this mom breastfeed for about an hour. Dad made sure to get my name and took photos of me on his cell phone. They had been discharged by the time I got to work the next day, (another sign that all was well) so I am unsure if there is a little Kate around or not but none the less, it was a beautiful birth with great support.
I have been able to help support the student nurses along their training and be by their sides assisting as they help deliver more babies and practice their skills. It has been rewarding to see how far some of them have come in just a few weeks!
One of the midwives met her 20 year old niece for the first time when she came to the hospital for antenatal care this week. She lives on another island, the family had moved there right after her birth so this midwife never got to know her. It wasn't until she checked the unusual name with the name of the father of the young girl that the midwife realized this was the daughter of her brother! I am not sure if she has had her baby yet but I hope the aunt got to be there if she has.
Also, I walked into the labor ward to see a woman pushing and the midwife asked if I wanted to do the delivery. Of course, yes! As I was coaching and supporting the 23 year old through the delivery the midwife informed me that she had delivered this young woman (23 years ago!!). That was really special!
And finally for now... there have been 70 births in the first 11 days of March here at Vila Central Hospital. This is actually down from last year (if you can believe it!) which means that the sex education that they have started to provide at some major events here (i.e. Independence Day- which is 9 months prior) may be working! However, I have also been told that some use the condoms that have been handed out, for fishing bait "because the spin so well in the water" =) Hopefully they are also being used for the intended purpose.
Can't believe I have only just over 1 week to go! This has been a truly amazing experience, one which I will forever be blessed to be a part of. I have told the midwives that if they ever make it to Seattle they will have somewhere to stay...in fact MANY places to stay as all of us that have experienced their kindness and tutelage would probably all be wanting to house them!
Thanks for reading!
