Monday, August 24, 2009

Lovely Weekend

I have been very fortunate to meet some amazing people while I have been staying in Port Vila. On Friday night Kelly and I were invited (by an American midwife, Olivia, who has visited Vanuatu a few times and worked in the hospital here) to a kava bar called "Felix". Kava is a medicinal herb (an anxiolytic and sedative) that is drunk here recreationally and kava bars are very common. Traditionally only men were allowed in the kava bars, and that is still the case on most of the islands (where a Ni-Vanuatu woman would need to get permission from the village's chief to drink kava) but on Efate it is common for tourists of both sexes to go (and still rather uncommon for Ni-Van women). The kava experience was pretty great, a little gross, and pretty funny since there is a whole ritual around it. You can buy a small or large "shell" of it, and the kava itself has a sort of grey-green dirty dishwater appearance. You are supposed to shoot it, swallow, then spit (which you will want to do since the taste isn't the best). Usually people, it seems, chase it with water or beer. The taste may not be the best, but the effect, I think, is pretty great. Usually your lips and your tongue go a bit numb or get a little tingly and you feel very mellow and relaxed.  I also noticed that when I stood up I had very poor balance as though I had had too much to drink (I swear that I didn't!)
Another great person that Kelly and I have met is named Seamus, and he is part of an organization called Project M.A.R.C. (Medical Aid to Remote Communities). Project M.A.R.C. participates in many medical endeavors throughout Vanuatu and when they do, they commission a ship called 'the Alvei' (a beautiful tall ship that was built in the 1920's, I believe, and then completely gutted and re-done on the 80's) to take them to whatever island they're going to. Next year they are involved in a project on the island of Santo, which deals specifically with training some of the traditional midwives there as well, I believe, in training new midwives. This project, of course, is of particular interest to me as overseas medical work has always appealed to me (and essentially brought me to Vanuatu). 'The Alvei' had recently gotten into port here and Seamus invited many of the 'Baby Docs' as well as local volunteers (Peace Corp and AusAid) to a bbq on Saturday so that we could meet each other, the crew, and learn more about M.A.R.C. It was an incredible amount of fun and Kelly and I have since been invited to join the ship in Malekula (a remote island of Vanuatu) for a week later this month where we would have the opportunity to facilitate a discussion among local women there in regards to sexually transmitted infection prevention, maternal health, the importance of antenatal medical care, and prevention of domestic abuse (to be truthful, I have no idea about how this last topic will go since the rate of domestic abuse is, as I have been told 110% as it happens in every single home). Kelly and I need to make a decision as to whether or not we will be going and meeting the ship in Malekula in the next day or two.

Saturday, August 22, 2009

Seven Babies!

I went into the hospital at 12am with Kelly (the New Zealand student midwife), hoping to attend the birth of the girl who had taken a long time to dilate from four to five centimeters. I am so fortunate to have met Kelly, not just because she is lovely and fun, but also because it is dangerous for either one of us to go alone to the hospital in the dark. I have heard (though I have trouble believing) that Vanuatu has the highest rate of assault on aid/volunteer workers than anywhere in the world. Granted, I am on only one island out of almost eighty that make up Vanuatu, and it is a very touristy island, but it is always better to be more rather than less cautious.  So Kelly and I walked the two minute walk hospital in the blackest pitch of night (I’m not even kidding…you cannot see people until they are one inch from your face), and arrived to see that the girl we were waiting on had only had her baby half an hour before we arrived (damn it!) and they had cut an episiotomy (DAMN IT!) because she had had a “long” second (pushing) stage. That being said, she was very happy and lying peacefully with her new baby boy.

 Although Kelly and I were disappointed to have missed that birth, we could not be too upset since we actually ended up being involved in seven births over our nine hours at the hospital! Kelly delivered the first baby of the evening while I assisted (albeit not for very long because I was called to deliver another baby). This woman was desperately wanting to push but we had to stop her because she was not fully dilated (although close at 8cm). The birth, itself, was a little concerning also because there was thick meconium in the amniotic fluid (babies with meconium in the fluid are usually under some stress in utero or post-dates and it can often lead to respiratory distress if the meconium is aspirated during delivery). Fortunately this baby was born and suctioned right away and had no respiratory problems whatsoever.

 The next birth that I was called into was the labor of a thirty-nine year old woman who had undergone no prenatal care for this, her fifth child. With that being the case, I had no idea what to expect (you expect that the baby will be completely fine, but there is no confirmation of this and so I needed to expect the unexpected). I performed the vaginal exam on her, assessing that the baby was, in fact, head down and that the mother was fully dilated. She began to push. And push. And push. She pushed much longer than most moms who are having their fifth baby should have to do! As I was waiting for the head to descend to the perineum, I noticed (oh, crap!) that the baby’s umbilical cord was pinned between the baby’s head and the mother’s pubic bone. This is a very dangerous situation in that the baby’s oxygen supply, until it is born, is through the umbilical cord. Because there is no continuous monitoring of fetal heart rate done here, it is difficult to say how long the cord had been pinned and if the baby was okay; the cord was not pulsing, which is not a good sign in terms of blood moving through it. One of the midwives, Sister Lydia (who is initially gruff and them so incredibly lovable!) was standing elsewhere in the labor ward and I told her the situation and asked her what I should do about this cord situation. She said, “Push it back!” (“Right,” I thought. “Duh. Push it back!”) So I did. And the mama had her baby a minute or two later. And that crazy little baby came out direct occiput posterior (with the face pointed up, or as I like to say “sunny side up”), which is not the ideal way for a baby to come out! This, combined with the umbilical cord situation, was why the pushing stage took so long. Much to my relief, the new baby boy vigorously cried right away. He was just fine. This reaffirmed to me what one of my favorite midwives back in the States always says: “Babies come out.” They do…and most of the time they are just fine.

 Baby number three of the evening was a baby that neither Kelly nor myself delivered. After our first two births of the evening, the maternity ward received a phone call. “Can you please come outside?” the caller said, “There’s a baby on the bus.” WHAT?! Kelly, myself, and Sister Lydia all went to the door to find a mother, who had just had her baby a short time ago, with some members of her family. We quickly ushered the mother into the labor ward and Kelly managed the mother and I managed the baby. The mother had not yet delivered her placenta, although she said she had given birth to the baby at least an hour ago, but she was luckily not bleeding and birthed the placenta quite easily and quickly. The baby, who I think must have been delivered outside on the ground (she had dirt and twigs on her), was wrapped in very wet and light sheets. When I unwrapped her under the warmer, her umbilical cord had been cut but not clamped. This is not a good situation since babies don’t have a significant blood volume and can bleed out through their cords if they are not clamped. Luckily this baby had bled only a little and seemed quite alert. She was actually one of the most beautiful babies I have ever seen with the plumpest little lips and the most exquisitely long lashes; she did not make a sound, just watching me as I inspected her from head to toe. I actually would have preferred her to be crying. Neither she nor her mother made much noise; I think that they were both in shock. This was confirmed when the temperature of the baby was taken and confirmed to be approximately 94 degrees F. No way. Since I was called to deliver another baby, Kelly kept taking this baby’s temperature and in the next few hours it only got as high as 96.7 or so; this was with skin to skin contact and being under a warmer. When Kelly and I left the next morning this baby was still under the warmer and her temperature and other vitals were being monitored every hour. When I go back to the hospital on Monday I hope to see that she and her mama are just fine.

 Baby number four came to a nineteen year old primip (a mother who was having her first child).  She was fully dilated and ready to push, so I gowned up and got ready. Although she was ready to push, this young girl really didn’t want to. I was telling her (and Sister Olina was REALLY telling her) that she needed to push only with contractions and when she did, they needed to be long and strong pushes. Here, it seems that most mothers just push their babies out, whether or nor they have pushed out a baby before. Because of this, I believe, the midwives here are not as patient as midwives are in some other places. It is not unheard of, and I have seen more than once, that mothers in the States can spend greater than two hours pushing when they are having their first child. Two hours for one’s first child is, in fact, average. I am saying this because this young mother was pushing (though pretty lightly and ineffectively) for about half an hour when Sister Olina, who was watching me over my shoulder, began asking me if I wanted to cut an episiotomy. Please understand that I respect and admire the midwives here as well as their expertise so very much. I am learning here so quickly that it cannot even be put in to words. That being said, was I going to cut into this nineteen-year old girl and this nineteen-year old perineum after half an hour of pushing? HELL NO! Of course, I didn’t say this. Instead I said something like, “Weeeeell…let’s just give it a little more time.” Sister Olina shrugged as though to say, “Okay, have it your way” and since the baby wasn’t in any distress (we checked on the CTG machine), we let the mama keep pushing. And pushing. And the mama was ignoring my coaching and rolling her eyes (maybe at my crappy Bislama, which IS getting better everyday. It really is!) So Sister Olina asked me, every five minutes or so, if I was ready to cut an episiotomy yet. No! I wasn’t! It hadn’t even been an hour of pushing yet! Finally, I looked at this mother and started getting angry. Not at her, but at the fact that I was trying to help her and she was only giving me these itty bitty pushes. So I started getting louder and more forceful and in ten more minutes she had her little baby girl. So she had her beautiful baby, which she had worked so hard for, and I had my small victory: that she did not tear. Not one little bit. Later I came in to check on how breastfeeding was going and the new mama’s mother handed me her new granddaughter. I cooed over her for a couple of minutes and went to hand her back when the grandmother asked my name. When I told her she said, pointing to the new baby, “This is Carrie, too.” The new mother nodded in agreement. They decided to name this new baby after me and I am beyond honored.

 Babies five and six came almost at the same time and so Kelly delivered one and I delivered one. Kelly attended a beautiful birth and luckily she was done attending to that mother and came into the other labor at the tail end. I say this because this baby had a shoulder dystocia (which occurs when the baby’s shoulders become stuck behind the mother’s pubic bone. This is very serious and though there are handful of maneuvers to try and remedy the situation, the clock is ticking so that the baby doesn’t run out of oxygen). Luckily the dystocia was fairly minor and as Kelly tried to shove the scapula of the anterior shoulder externally on the mother’s belly, I kept sweeping for it internally. Finally I was able the grasp the baby’s anterior shoulder and pull him out. There was only about two minute’s worth of sweat pooled on my back, which is not to bad for a dystocia!

 Baby number seven, though happening at the hospital that evening, was actually an event that happened at home that morning. A seventeen-year old mother who had undergone no prenatal care (I’m not sure that she knew she was pregnant) woke up and told her mother that she was feeling very ill. She said that she had cramping and generalized stomach pains. She asked her mother to take her to the hospital. Her mother, evidently, said that she did not like going to the hospital and decided instead to go to work. Shortly after the mother went to work, the daughter felt the urge to use the toilet and before being able to sit down on it, squatted and delivered a rather small baby. From what I gather, the placenta was born almost at the same time. This baby, only 1.2kg, cried for a little while (though I’m not sure for how long). She was never detached from the placenta and she died later on in the day. When the mother got home from work, they all came to the hospital. 

Life is different here and I’m not in a position to judge the people around me or comment upon the decisions that are being made. I have been fortunate to have this experience at the hospital, to be provided with a glimpse into a culture that is not my own, but I am not part of this culture and never will be. Over time I will understand it better but I will never really be a part of it. That being said, I am also not quite a tourist. Though I am fortunate to enjoy fun things and the beautiful weather while on this island, I cannot pretend that I only see the ease in living here.

Wednesday, August 19, 2009

Slow Day!

When I arrived at the hospital this morning it was fairly slow. There were three women admitted who were in labor, but the circumstances were pretty varied. One mother was contracting even though she was only twenty-six weeks along, so she was quickly put on nifedipene (to stop her labor) and steroids (so that her baby's lungs would mature more quickly in case labor could not be stopped or still occurred before thirty-six weeks). Once she stopped contacting she was sent home and she will hopefully carry her baby to term. 
Another mother had been contracting, though weakly, for a couple of days. This would not necessarily be a big deal, except her blood pressures were extremely high (180/120), she had protein in her urine, and her deep tendon reflexes were +4. She was diagnosed with pre-eclampsia (a very serious condition that can lead to seizures in the mother and thereby death of the baby through poor placental oxygen supply), which is only curable by delivery of the baby. We induced her with syntocin, which she dealt with so beautifully although her contractions were ridiculously strong. She had a very healthy and beautiful baby girl, her third child, who I was fortunate enough to deliver before noontime today. Even though that silly baby had her hand up to her face when she came out, I am happy to say that her mama didn't tear at all! 
The third mother is a very shy, sweet, and young girl who is having her first baby. She is a few days overdue at this point so we began the induction process this morning at 9am. When the other midwifery student and I left the hospital at 3pm she was having some small and rather uncoordinated contractions, but we expect that she will likely have her baby sometime late tonight/early tomorrow morning. We would very much like to be at her birth so we're going to go back to the hospital tonight  and I will hopefully be able to write about her labor and birth tomorrow!


Tuesday, August 18, 2009

I'm Here!

 I am contributing to this blog a bit later than I wanted to as I have already been here for four days, but it should be fairly easy to catch you up on what has been going on so far!

Day One

 I arrived on Sunday morning feeling a little disoriented since I had been on various planes from Seattle for approximately twenty hours and Vanuatu is 18 hours ahead of PST. Arriving in Port Vila (the main city on Efate, which is the island I am staying on in Vanuatu) at 10AM on a Sunday makes one feel as though Vanuatu is a quiet and desolate place. Not so. It is just that barely anything is open on Sunday!  Here are three things that I wish other students had told me right away, and that I think will be helpful for those following me:

  1. Don’t take a taxi from international arrivals! The cost is 2000 Vatu, which equates to about $20 USD and if you just go outside and walk to the right you will find yourself in the domestic arrival area and can take a bus. This is half the price and you can chat with a few of the locals, who are very friendly.
  2. If you are traveling alone I recommend the Coconut Palms Resort. They offer a great deal to those who are booking for a month or greater, are a two-minute walk from the hospital, and they get most of the ‘Baby Docs’. Okay, so let me tell you  about the term ‘Baby Doc’: I thought that this term meant obstetrician or midwife, but that is not true. What is means is that you are a baby doctor, i.e. not a doctor quite yet because you are a baby who is still learning. That is why you are still training at the hospital, after all—because you are a doctor who is not grown up just yet! Anyway, there are lots of ‘Baby Docs’ that I have met at this resort. Two are from Australia, one from New Zealand, and a couple from France who have just left. All of these med students are doing various rotations at the hospital. There is another New Zealand midwife who I have met as well who is finishing her training. She and I are delivering babies together. What is also great about this resort is that there is a ‘Baby Doc’ lounge/common room with a kitchen and a computer with internet access (albeit sometimes very slow).
  3. As previously stated, internet is not the best here and wireless connection can be rather expensive to buy ($5 USD per hour in my room!). That being said, there is a lovely place on the water called NAMBAWAN CAFÉ (and yes, this is pronounced ‘Number One’ Cafe) that has free and very fast wireless (you will meet many lovely tourists and they make a mean latte or anything else you might want).

So these are all the great things I learned on day one (not bad!), the day before I started at Port Vila Central Hospital (VCH).


Day Two

On Monday I showed up at the hospital at 9:15AM since I knew that was when morning rounds finished. The sisters in the maternity ward had no idea that I was coming since calling them from the states can be a bit hit or miss. This was not a problem as Sister Leitangi (the midwife in charge) welcomed me with a big smile (though she may have been welcoming my gift of chocolate) and had me shown around right away. It should be no surprise that things are very different here. The hospital is old, the equipment is ancient, and supplies are short. For those coming to work in the maternity ward, I recommend bringing these supplies if you are wanting to donate to the hospital:

  • Gloves (sterile and non-sterile)
  • Amnihooks
  • Sterile lubrication!!!!!!!
  • Chucks
  • Overnight pads (or any other maxi-pad)
  • Hand sanitizer
  • Hospital grade liquid soap
  • Short needles for IM injections on babies
  • Office supplies (pens, a hole punch, etc.)

I was told that I should bring white fabric since the maternity ward is short on sheets, but I have to tell you that I don’t think they’ll use them unless the material is extremely thin and light material. That is the quality of the sheets that they use in the delivery rooms because they are extremely easy to wash and so better quality sheets are put elsewhere.

 My first day was very good and I assisted on my first birth and then jumped right in and delivered the second baby who was born. There is a definite routine in regards to birth here. Mamas don’t generally want to see their babies right away so as soon as the baby is born he/she is dried off and taken to the warmer. The mother is given a shot of syntocin immediately upon delivery to prevent hemorrhage. The placenta is delivered and then the mother’s blood pressure is taken. As long as it is 120/80 or less she is then given a shot of ergometrine; if it is higher, you give her another shot of syntocin. I realize that to those of us in the states this may seem like some serious overkill, especially to those of us who don’t even follow an active management protocol of giving pitocin at delivery. That being said, this hospital has only had two postpartum hemorrhages in two hundred births. These women come to VCH from the 80 or so other islands that make up Vanuatu and they leave two days after they have delivered and go back to the island that they call home. There is almost no follow-up and so it is better to manage as conservatively as possible; birth is much more dangerous here than in the states.

Perineum inspection is done right after placental delivery and suturing done, if needed, at that time. The baby is weighed and given two shots almost immediately: one is Vitamin K and the other is a Hepatitis B vaccination. Although I am not used to giving this vaccination (and actually tend to advise against it in the states until a child is an adolescent at least) the Hepatitis B infection rate is very high here (I have heard 60% but need to check that out) and so it is fairly easy to understand why it is done at birth (babies are also given their BCG vaccination for prevention of Tuberculosis before they are discharged from the hospital). It is after all of this that the mama finally breastfeeds and bonds with her baby a bit.  Mothers are moved to the postpartum area about an hour after birth and her baby is given a bath. The two are then with all the other mamas and new babies and the doctors check on them the next day and discharge them by day two.


Day Three

Yesterday I finally felt like I was getting the hang of how deliveries are done here. When I arrived at 7am, one mama had just arrived after having had her baby unattended at home. She was stable and well and her baby was healthy so, thankfully, not much to report on there. Two other ladies were in labor as well, but only at four or so centimeters, so they still had a bit of time to go. They were neck and neck for much of the afternoon, even rubbing each other’s backs when their labors got very intense (I wish I had gotten a picture!), and then had their babies about a half hour apart. On the whole, the labors I have been at were fairly uncomplicated, which is definitely the way to start when you are in a new place!


Day Four

I woke up this morning to a cloudless and beautiful day. I took my shower, had some tea, and put on my scrubs, walking as far as the front door of the hotel. I stopped for a moment, turned around, and went back to my room and changed. I decided to take the day off! I realize how irresponsible this may sound after only two days at the hospital, but have decided not to feel guilty about it (and to not feel guilty is very difficult for someone with a work ethic like mine). My day, then, has consisted of a fantastic and slow breakfast with a couple lattes and lying in the sun at the pool. Not too shabby!

Will write more tomorrow....

xoxox Carrie