Wednesday, October 7, 2009

First Bus Birth, Breech, and Stillbirth

To second Elias' posting below, all is well here on the island of Efate after some shifting of the tetonic plates earlier this morning. Light rain is falling outside from heavy, low clouds, taking the humidity down with it. We're taking a siesta before heading back to the hospital for the evening shift.

Yesterday we arrived and before we could even put our bags in the staff room there was a phone call announcing the arrival of a bus with a woman and her baby, and could we please HURRY! We ran up to the bus, whose door was already open, and saw a mom semi-reclined with an older woman sitting between her legs. As she lifted the pregnant mom's dress ever so slightly I saw the little feet, then round thighs and bum, and thought, oh, the babe was already born and is just laying here in her dress..... until the body stopped at the nipples and I realized this little boy had been breech and his head was still inside.

So to catch non-birth folks up to speed, breech births in general are avoided in most parts of the States by elective Cesareans, and although there is some debate about how risky breeches really are with experienced maternity care providers, this situation is the worst case scenario and illustrates the most common reason given for avoiding vaginal breeches.

We gathered the timeline and story from the family as best we could during the course of the 25 minutes between when the bus arrived and when the baby was born. It sounds like this mom started her labor around 2pm and tried to get transportation to the hospital but for some reason was unable. The labor progressed quickly and soon there were feet hanging out of here vagina so she started pushing and figured she would just give birth at home. Breeches come in several varieties, depending on what part of the lower half is presenting, footling being the most tricky because the little feet and legs can fall through the cervix before it is completely dilated, while the much bigger shoulders and head can get stuck. And that's exactly what happened with this little one.

By the time the family realized that the head was stuck while the legs and belly were born, somehow got a bus, and arrived at the hospital, it was at least 30 minutes, likely more close to 50 minutes. When I placed my hands on the babe, he wasn't moving and was already cool, and the small amount of cord that was visible was not pulsing anymore. We tried to deliver him quickly while still in the bus and after no success, we moved the mom to the birth theatre on a stretcher.

At that point, we were all pretty sure that this little one was already gone. Once in the theatre I tried to turn him slightly and sweep one of his arms, that were both still inside, down in front of his body with no success. It was a tight squeeze and all I could feel was his shoulder blades. One of the other New Zealand midwives stepped in to help, also with no success. Finally one of the Vanutau midwives was able to get one arm, then another, and finally, finally..... his little head.

The pediatrician had arrived and although he heard no heartbeat, he attempted a short round of chest compressions with no success.

We cleaned up the babe, wrapped him in a blanket, handed him to the family, shed a few tears and said some blessings for this mom, babe, and their extended family, many of whom were standing in the hall outside the theatre.

Birth is a continual reminder of the dance between life and death, and I knew coming here that it was not a matter of if, but when I would experience the latter part of this dance.

On a more joyful note, I have acquired a small group of personal escorts on my 3 minute walk from home to hospital. They range in age from 5-12 years old. They are the pikinninnis of our local neighborhood and I first met them the other night after my last blog entry. The darkness has snuck up on me and it was past sunset by the time I walked over to the hospital. I had my headlight out as I walked out to the main road to the hospital, a pack of 10 kids greeted me and circled me, some more bold with questions while others shyly smiled. They had so many questions: what is your name? are you a doctor? where are you going? do you really see the babies come?

All of these children were born right there at Vila Central Hospital, just like the many babies we've seen born there too. They were FASCINATED with my head lamp (thanks Casey and Mike for that gift!), especially since I can change it from white to red light. They all tried it on their little heads, turned it on and off, and asked with amazement and wide eyes, "What do you call this?"

They proceeded to walk me down the road to the entrance to the hospital, with more children turning back the further we got from home. So every day since then, as I walk over to the hospital in the late afternoon, they are there to greet me and accompany me to the hospital entrance, shouting, "Molly! Molly!," and scrambling to their little feet when they see me walking by. They are sweet kids and I would like to buy them a communal soccer ball, for a sport that they love to play but for which they have no ball. Will check out what's available in Port Vila this weekend.

On that note, packing up some dinner for our shift and will be heading off soon. We have a woman being induced today who is pregnant with twins, so with any luck Elias and I will each get to catch one tonight! Also, I'm going to try to add some photos to the posts below and will add more to my next posting now that Elias has shown me the magic button for doing so :)

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