Saturday, April 19, 2008

Home safely, and losing our tans...

Just one smol week ago we were enjoying the warmth, cooking up a Nivan feast, stocking up on beers for our party, and decorating the area by the pool to host all of the midwives and nurses from the maternity ward. We hosted a party at our place to honor and thank all the amazing folks in the maternity ward for their teaching, humor, friendship, and love, and we had a fantastic time. We ate, drank, danced, laughed and hugged each other for hours! As if all of these incredible women were not generous enough, the sister-in-charge made us each an island dress, called Mother Hubbards. And other midwives had us line up and each garlanded us with necklaces of beads and shells, and gave us other gifts. It was almost more than we could take, the occasion was so happy and sad all at the same time! We left each other in a flurry of hugs and kisses with hopes to see each other again....

It snowed yesterday in Seattle. Perhaps I need to head back to sunny Vanuatu sooner than later.

We departed Vanuatu the morning after our party and spent three lovely days in New Zealand. It is green, hilly, full of roaming cattle and sheep, and notably not full of people or cars. The geography and weather is actually quite similar to Seattle area, and the people are incredibly friendly, hospitable, and endearing. After we landed in Auckland we headed out immediately to the Coromandel Peninsula and spent our short time out there enjoying the landscape, and the torrential rains that they have not seen the likes of in some time. Literally buckets pouring out of the sky! So we did what any good wet traveler would do and headed to the pub....

Just to illustrate the generosity of Kiwis, one evening we stayed in the beautiful town of Coromandel. One of our barmates, who also happened to be the town butcher, wanted us to try the sausages that he makes out of mussels, oysters, and other locally raised, grass-fed meats. So he went to his shop, picked out his favorites, brought them to the restaurant next door to have them cooked up and presented nicely, and then delivered to us at the bar to try them out! And they were delicious, even to the vegetarians of the crew. Thanks H!

Our entire five week trip to Vanuatu and New Zealand was charmed, to say the least. We met such incredible, loving people, worked hard, had the times of our lives, and enjoyed each other's company all the while. I feel incredibly blessed to have had the time, luxury, and support to spend five weeks of my life in this way, and I know the other ladies do as well. Thanks to all of you who supported and loved us while we were gone, and continue to do so everyday. You made a difference in our lives and in every other life we were lucky enough to touch along the way.

Monday, April 14, 2008

Safely in New Zealand

Hi all,
We made it safely to New Zealand! Will tour around here for a few days and then be home Wednesday. Tons of great pictures for the blog - including some in our awesome isalnd dresses made for us by the midwives. Our final night party we had for the maternity ward was amazing and touching. We are happy to be coming home, but also so sorry to leave.
Stay tuned for a more comprehensive blog when we get back.


Wednesday, April 9, 2008

Six sweet babies. . .

So I worked a double shift the other night and was lucky enough to catch six sweet babies in a row – my personal Vanuatu record. All were fairly straightforward except for one, which I can truly say was the scariest moment of my midwifery career (and possibly my life). My very first shoulder dystocia! Shoulder dystocia occurs when the head of the baby delivers and the shoulder get stuck on the bones of the pelvis. The tricky thing is that once the head is out, the baby only has so much time before the oxygen supply to their brain diminishes. The other tricky thing is that it is quite hard to predict (sometimes it is correlated with big babies, but more often they are normal size babies in normal sized women) and you often don’t know it is going to happen until it is happening, making it somewhat hard to prepare for.

This baby displayed the classic signs – the head came quite slowly and once the chin was out squeezed tightly back along the mother’s perineum (called the turtle sign since it resembles a turtle sticking it’s head out of the shell, only to retract back into it), then the baby failed to restitute (normally the baby is born facing the tailbone of the mother and then turns to the left or right as the shoulders come down through the pelvis). Finally, and most alarmingly, the baby began to turn deep blue. Ohhhkay. . . so I tried unsuccessfully for what seemed like hours, but was actually a minute, to get this baby out, pulling harder then I thought possible, attempting to rotate the shoulders into different position. It didn’t work. The midwife that was working with me gave it a try and I was thankful to have someone else there, surely she could get this baby out. As she tried to manuver the baby I put the woman into McRobert’s position (hyperflexed thighs) and did suprapubic pressure. Still nothing. I ached to have the space and the vocabulary to flip the woman onto hands and knees, the Gaskin Manuver, which we use quite successfully in the States. Now two minutes had passed and the midwife stopped trying to deliver the baby and told me she was going to call the doctor. The doctor who is at home, at least 10 minutes away and with a reputation of not answering the phone on the first ring. Shit, that didn’t seem like the most promising solution to our problem – meanwhile the blue baby was beginning to resemble an eggplant.

Now it’s me and this purple baby and this kid needs to come out. Right now. For real. I took a deep breath and did a quick mental review of what procedures could be done. Oh yeah, delivery of the posterior arm – let’s give it a go. And so I did and so it went, the arm slowly brought up and out across the babies chest followed by one shoulder then the other and then the whole big baby. I called out to the midwife “Hemi come, Hemi come!” Joyous relief – I looked down and knew that this baby was here. Not breathing yet, but life still in his eyes. He needed a brief resuscitation but came around fine and was crying mightily by five minutes.

Now here is where things get a little weird. I was taking a brief nap that afternoon before going into shift and was unable to sleep. I felt anxious and my stomach was in knots. Strangely nervous about my upcoming shift, wishing I wasn’t going in alone. I kept thinking about shoulder dystocias. Worried that without the language to communicate with the mother, without the space I am used to, that I wouldn’t know what to do. I kept thinking about delivering the posterior arm. All night I was waiting for it, the first four babies came and went without a hitch, despite my worry – did this baby feel big, was that a turtle sign – nope all fine. And then number five showed up and it was just like I had imagined and I panicked and then I remembered the posterior arm. Coincidence, intuition, divine intervention, manifestation - who knows, who can say for sure? I am interpreting it as a small reminder that if you listen carefully often all you need to know is right there.

Baby was 4.5 kg – about 9lb 7 oz, pretty big for a ni-van baby. Oh yeah, her first baby was 3.8 kg and had to be delivered by vacuum extraction. This baby had Erb’s palsy after the birth – a slight paralysis of the left arm due to nerve injury secondary to being pulled on (sorry tumas small boy)– usually it is self-limiting and resolves completely. This baby is getting much better by the day and everyone expects a rapid and full recovery.
Tata, Lukim Yu, Caitlin

Friday, April 4, 2008

Only one week left...

The baby catching continues at Villa Central Hospital - April is the busiest month being that it is nine months from Vanuatu’s Independence Day. Lately there have been a lot of very quick labors. Two babies have been born on the admission room table – now anyone who has had more then 4 children and looks even remotely in active labor gets put right into the labor room. In the last two days I have had three such women get up on to the bed and have their baby within in five minutes. Usually they are fully dilated with a bulging bag of waters – I arrange all of the things I need (cord clamp, gloves, towel for baby) draw up a vial of syntocin (the anti-hemorrhagic medication everyone gets immediately after the baby is born), break the bag of waters and baby come sliding out in one to two pushes. Usually this is woman who has had a few babies, however yesterday we had a first timer that was a total surprise. She was 4 cm when she came in, but laboring really hard, we started her CTG (a 20 minute strip that listens to the heart) and five minutes into it started to get decelerations of the heart rate down to 60 (normal is 110-160). All of a sudden the mom (strange to call a 14 year old a mom) started bearing down. We moved quickly to the labor ward, checked her and she was complete. So we started her on oxy gen, which improved the heart rate slightly and she pushed out her baby remarkably fast. She basically went from 4 cm to complete and pushed her baby out in less than ten minutes! Baby was fine with a strong cry, which was relieving in light of the decelerations. We figured baby was probably stressed with such a rapid decent and may have had a compressed cord.

On a solemn note, one of our babies that had been in the nursery for the past 16 days passed away. The baby had a heart defect that caused decreased oxygen saturation of the blood (for those that care about the details the O2 saturation was in the 70s since birth even when baby was being supplemented with O2), we aren’t sure of the specifics since the diagnosis was made clinically due to the limited amount of imaging technology that is available at the hospital. There are no options for doing surgery on neonates here, a large contrast to the vast opportunities we have to treat babies with heart defects in the states. This was a situation where potentially this child would have survived had there been access to medical resources.

The mothers of babies in the nursery live in the ward the entire time their babies are in the nursery – sometimes for months. Every four hours they all go together to squeeze their breastmilk into cups and syringe feed the babies who are too weak to feed and practice breastfeeding those that are getting stronger. The mother of the baby who died was a lovely woman who greeted us every morning with a bright smile and inquires about all the new moms in labor. The day her baby died I was sitting and watching her breastfeed and commenting on how well both she and the baby were looking (she had gotten a postpartum infection after her c-section and was pretty sick the first week we were here). She smiled and told me that she was feeling much better and was now just waiting for her baby to get healthy. Later that day I saw her looking quietly through the window into the nursery and wondered what she was thinking. A few hours later her baby had passed on. An elder woman from her village came to the nursery and they wrapped the baby up to take home for burial.

There is the sadness that always accompanies the death of someone young, the questioning, the wondering why – but also in this case a feeling of anger and injustice, had this baby been born in another hospital he might have lived have lived. Yet, mother and baby had two weeks together, uninterrupted by surgery or high tech interventions, time to bond and cherish the short time they would have together. We don’t know the extent of the defect or if the baby could have survived surgery. In this case he got to live a short, but peaceful life surrounded by those who loved him and return home to be buried in the village of his people. There is beauty in that.

As always, we are missing our friends and families. Amazing that we have only one week left – it is flying by!


Tuesday, April 1, 2008

April Fool's

Apparently, these past few days were meant to be a challenge for me; emotionally, mentally, physically, spiritually. And, as we all know (and for which we often hope), the pendulum will swing the other way.

After the death of Eve’s small girl, I took the day off. The morning after, Caitlin witnessed her community gathering to be present with her and her daughter. Her pastor was there, sisters, cousins, aunties, uncles..even young children came to pay their respects to the small one. Her death was not shielded from anyone in the community; her life was celebrated. They all walked into the small room where the baby was and prepared her for her funeral as a group. Their love and support for her was palpable. Give thanks.

When I went into the ward the next evening and following day I assisted Sunita and Caitlin with lovely births. Pink, screaming babies…and, quite honestly, exactly what I needed to see. I went back in on Tuesday morning, April Fool’s Day, to find a quiet ward. Two mothers on bed rest: one, a 19 year old with her first pregnancy of twin (!) girls and another on bed rest for premature labor. The mother-to-be of twins was showing early signs of pre-eclampsia, a multisystems disorder that was manifesting in her as hypertension, protein in the urine, and edema (tissue swelling). She was 38.5 weeks, quite far along for a twin pregnancy, but the OBs were worried of her progressing to the more severe eclampsia and they decided to induce her. I was asked to place misoprostol just behind her cervix, a prostaglandin E1 substance used for stimulating uterine contractions. At the time, she was having small, mild contractions and active labor seemed a long way off…

A slow morning, we spent the first few hours folding gauze, making cotton balls of varying sizes, and chatting with the ladies of the ward, as much as we can with our slowly improving Bislama. We discharged mama and baby duos, which consists of a newborn exam, a second baby weight check, paying of the hospital bill and a trip to family planning. All fairly routine. Perhaps the most entertaining part was trying to use our Bislama to get the women to follow us to administration.

Throughout the day, Sunita and I each managed a delivery. One small girl into my hands, one bigfala boy into hers. The mother of the small girl had some pretty severe vaginal tears, quite deep into the vagina and I was grateful when one OB offered to take her into the theatre to help repair her. She was given a spinal as anesthesia and after about an hour, the repair was complete (and looked quite good!…as far as post partum vaginas go, anyway).

By 6pm (12 hours into my shift at this point) the mother of the twins was fully dilated getting ready to push. We phoned the OB, wanting him to be present for the delivery, particularly of the second twin, as she was in a breech presentation at that point. She continued to breathe through her contractions for the next twenty minutes, and began to push. Now, before I continue with this birth story, I have to insist that you sit down, if you are not already, for what you are about to read will floor you.

The room felt like the inside of the furnace. I, in my sterile gown and gloves, was covered in sweat, and the mother, working harder than anyone I’ve ever seen before, was covered as well. Caitlin, Sunita and the mother’s auntie were phenomenal labor support. Sunita managed to monitor fetal heart tones and hold up the mother’s muscular leg, Caitlin held the other leg, and the Auntie was wiping her brow, whispering words of encouragement. We encircled the momma with such protective field of support and love. It was awesome. The first twin joined us in the delivery room about 1.5 hours later….completely face up! A straight occiput posterior baby (which, for those of you not in the know, means that the diameter of the baby’s head was increased by about 2 cm from the preferred, well flexed, occiput anterior position) was delivered with the help of a mediolateral episotomy. (Incidently, the first one I’ve ever seen done).

After the first baby, I felt inside for the other twin with the help of the OB. We tried to see if the baby was still breech or if she had turned head down. I felt the bag of waters and was instructed to artificially rupture it and tell the OB what I felt (he was hoping I would say suture lines). After a large, but slow, draining of fluid I made my report. “I feel labia.” He double checked my assessment, and indeed, this baby was breech. Seconds later, the second twins right leg was hanging out of the vagina. I cannot begin to tell you how bizarre that looks to a person so used to seeing heads present first. With breech presentations, footling or complete, there are two rules. Leave it alone, and make sure that the baby eventually comes out face down.

The OB talked me through the delivery….let the baby turn on its own; wait for the other hip to deliver; once you see the left knee, gently deliver the foot; leave it alone; never press on the baby’s stomach; only make contact with the bum and thighs; wait until you see the shoulder blades; press this way, now that way; now reach in and, bending the elbow, deliver the left arm; wait; now, see, here is the other shoulder blade; reach in and deliver the right arm. Good. Now we wait. See how she is moving her chest? She is getting ready to deliver. Wait until you see her neck…now, reach in with your right hand, supporting the baby on your forearm, and place your finger in her mouth. Make sure you are in her mouth! Use your left hand to press up into the back of her head and press up, do not pull. Encourage the flexion of her had with either hand. Do not pull on the shoulders…wait…come on…come on…and then, cries from the second little girl. Both babies healthy, the mother triumphant, exhausted and grateful.

The mother had quite a bit of bleeding and clot formation. All in all I think she lost over 2 liters of blood. Her placenta delivered, and it was beautiful. A two room apartment, the rooms separated merely by a transparent wall. Diamniotic twins. The babies were placed in the warmer next to each other, seemingly gazing at one another in their new world. The rejoicing, newly made bubu (grandmother) named the second twin after me…she said I was busy, busy, busy. I was honored. One small Katherine blong Vanuatu.

And, Sunita joked how it was quite appropriate that a footling breech born on April Fools day share my name, and that the grandmother somehow observed the fact that I have a hard time slowing down….does anyone else think that is funny?