Monday, October 19, 2009

More twins (alive this time) and Q&A with the neighborhood boys

Alice[Elias, Tuesday Oct 20, 8am] Sunday was fantastic. I went to the hospital to check in on the mom from the other day, and she was already discharged, just waiting to be picked up. (BTW, for those who care, her hemoglobin was 8.5 after the hemorrhage, and up to 9-something by discharge.) She said she felt well, and that she wanted to put my name on the surviving baby, so her name would be Alice.

Me, Mom and Alice

Neighborhood CrewOn the way home from the hospital, I ran into a bunch of kids hanging out around a parked truck. This is a different group of boys than who had adopted Molly, but they still asked me where "woman blong [me]" was. She's not my woman, I told them, she's my friend. We started talking, and oh man, the questions they had. How do the babies come out? Men and women have different parts-- private parts? Yes, private parts, and the baby comes out from the woman's private parts. I thought they came out of the belly? No, out of the private parts. I thought they came out of the ass? No, out of the private parts. There is a hole? Yes, a hole (the whole time pantomiming the sequence of events). Do you know Rey Mysterioso? No. Do you know Mexico? Yes. Rey Mysterioso is from Mexico [showing me the Mexican wrestler pictured on one boy's t-shirt]. Do you know 50 Cent? Yes. Tupac? He is dead. Yes, he is dead. 50 Cent was shot with a musket [gun] but he was wearing a bullet proof vest. You know Celine Dione? Yes. Michael Jackson? Yes. Michael Jordan? Yes. In the US, do people smoke marijuana? Some people. Drugs? Like what? Like white powder in nose. Cocaine- some people, makes bad heart and brain. If you drink too much kava your legs will turn white and the skin will be broken. Can you operate on a dog? No, only people. No dogs? No dogs. The babies come out of where, again?

Neighborhood CrewThere were two boys whose English was better (and their confidence higher), and the boys would dictate something extensive and then tell them to tell me. I told them if they spoke slowly, I could understand their Bislama, and the reality is that with the accent, it was often difficult to understand the English. I'd ask them to write it down (which they usually declined) or use another word to help me understand. They were very concerned about me standing out in the sun and asked me a few times to stand in the shade of the truck. Then they decided we should move across the street, to the carport, so we could all sit in the shade.

Their questions continued: what do you eat in the US? Do you have oranges and lemons? Mango? Rice? In the US, how much does a truck cost? Are the trucks made by people, or robots? More questions about marijuana and other drugs. Do you want to see marijuana? Sure. Wait here. A smaller boy went and crept under some bushes and retrieved a small pot with a tiny, tiny marijuana plant which ostensibly belonged to an older boy. (I have a photo, but I'm not going to post it, in the interest of protecting this little 9-year-old.)

No matter where the conversation went, it always returned to how, exactly, the babies come out. When I told this story to one of the midwives later, she told me that the kids are told that babies come from the belly button -- this is perhaps linguistically entangled with the fact that belly button and umbilical cord are the same word, 'nambeton' -- and that the belly button is cut to have the baby come out. I asked if they learn about sex in school, and then they tried to get me to understand something which turned out to be, "you know porno?" I tried to explain that there are different kinds of videos that have sex, some are for learning, and some are porno. I can only imagine how all this was reported to their parents. Hopefully they don't hunt down the random foreigner telling their kids about condoms and HIV and how, exactly, the babies come out.

The next day, I got up early and went into the hospital for the day shift. There was a first-timer delivering, so I caught that baby and stitched up the mama. That baby had no rooting reflex and no urge to suck. I worked with him for a little bit, assessing his palate, which was fine, and got him to latch and suck once, but he wouldn't do it again, so I called in Daryl, a New Zealand midwife who's excellent with breastfeeding. She expressed some colostrum and fed him by syringe and eventually he developed more of an interest. Most of the babies here nurse very easily right off the bat. They usually lie very quietly on the warmer while we finish up with the placenta and suturing, showing their rooting signs (smacking their lips, licking their lips, opening their mouths and looking around), and are usually very ready to eat by the time they're brought by back from weighing and vaccinating ("scalem and stickem"). Moms stay in the delivery room for an hour after delivery, and just turn to their side to nurse the baby. Grandmas and aunties are usually pretty helpful at getting the baby to latch, but when the baby's not doing their part, that calls for more intervention.

We also had a twim mama coming in for induction. As soon as I introduced myself, I knew her English was way better than my Bislama. She was a woman of size, and her babies were good size, and it was difficult to get both babies on the monitor at the same time. Hell, it was difficult to get either of the babies to stay on the monitor, since it required the ultrasound puck to be at exactly the right angle. Eventually I rigged something up with a 5 mL syringe under the strap. She was induced over the course of the day, and since they wanted so much monitoring, she spent the majority of her labor on the bed. She had great support though, including her husband and other folks who live with them on a shared compound sort of deal. By the time she was ready to deliver, both OBs had arrived. I wasn't sure if I'd get to catch them, given the level of interest displayed by the OBs, but I talked to the senior doc and he said we would do it together. The regional OBs are terrific -- they're patient and practical, counsel well, and are very realistic. (There are also foreign national OBs and pediatricians whose skills are not a good match with the resources available here. I am attempting diplomacy.)

Scans had shown both babies were head down (which we say 'vertex' and they say 'cephalic' with a k-sound, kefalik), but some of the midwives were thinking twin 2 was breech because of the way we were getting heart tones. When she started pushing, she wasn't making a ton of progress. The OB felt there was a little more cervix and said she could push past it. She ended up liking my guided pushing, with my finger inside, and I ended up holding back that little cervix (since I was in there) and the head came down nicely. Because we thought the second baby was breech, we'd taken off the end of the bed and had her scoot down as far as possible so that baby would be able to dangle. We also had her in stirrups in case forceps or vaccuum was needed (she had a history of forceps delivery). This meant there was nowhere to lay the baby after he was delivered, which is typically how it's done here, so I finally got enact my dream of putting baby up on mom's abdomen! Or her leg, in this case. With lots of encouragement and intense eye contact, she pushed him all the way down and out -- I was really glad her English was so good, because it enabled me to use a lot more of the languages and images I'd use at home, although it was, as always, paired with pantomime. He was born screaming and quickly clamped and moved over to the warmer.

The OB went in to rupture the second baby's bag, and meconium came out. He told me the baby was cephalic though, so I moved back in to catch this one too (though I was really hoping to be able to catch a breech!). When I went in to check, I felt a cord. It was confusing though, because there was obviously a cord from the first baby, but I felt that baby's cord, and a second loop of cord pulsing. I told the OBs and one of them confirmed the prolapse. There was a huge crowd in the room -- 3 OBs, 2 advanced nursing students (the junior ones, and the random biology student observing for the day, had gotten booted an account of crowding), 2 med students, 3 midwives, a pediatrician, and me. Cord prolapse -- when the cord comes ahead of the head -- is a scary thing because the cord gets squeezed off between the head and the cervix/uterus/pelvis, stopping the flow of blood and oxygen to the baby during delivery. This cord had a pulse of around 80. They told her she must deliver this baby quickly, and moved to get the vaccuum set up. While they were setting up, I resumed my place encouraging her pushing, and she was able to push so effectively that she got him out before they could get the vaccum set up! The OB showed me how to push the cord back over the head, and I caught the baby and laid him back on my arm to untangle him (cord bandolier around his shoulders and chest), and they suctioned him right there on my arm. I took him over to the warmer and the NZ midwife gently guided me back to the woman, saying they take responsibility for the baby, and I stay with the mother. We all heard him cry, finally.

With multiple gestation, the uterus gets really stretched out, and this increases the risk of postpartum hemorrhage. (See: the other night.) We'd gotten tons of syntocin ready beforehand: 10 IU for intramuscular, and 30 IU for her IV (she already had 10 IU in the bag from induction, making 40 total). Her IV was leaking though, and we weren't sure how much was actually getting into her. Her prior IV hadn't been flowing, so this was already her second IV. It turns out it was leaking from the cap, and a midwife stuck a syringe on there and everything was good. Anyway, the placenta! This one was two placentas fused together. Pretty rad! She had a laceration that was difficult to see and repair because of the way her tissues were situated, so the NZ midwife put on steriles and helped me get situated. My suturing is definitely getting more fluid!

I stayed on to make sure she was stable and not bleeding (including lengthy negotiations about using the toilet vs being catheterized) and back in her room with the babies (private room! what! that is my nap room!) and then I headed home!

Outside preparations were underway for the grand opening of the Vanuatu College of Nursing Education Tuesday morning. One of the twin mama's support people is faculty at the nursing school, and she was out there with her husband and kids (the parents are Australian but the kids were all born here, at our hospital), and she thanked me for being so supportive and positive, saying this mama had had negative experiences in the past, since they didn't think she was pushing effectively, etc. They were by far the most US-like duo I'd encountered so far, with this woman having a very clear doula role, and them having practiced different aspects of the delivery. Anyway, I'm off to attend those festivities!

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