Sunday, February 21, 2010

The Lighter Side

By the sounds of my posts you would think its all serious and intense here. I think that is just what inspires me to write. The first week here, the peace corp had brought all the volunteers from the outer islands to give them some flu shots and do some training. I met tons of lovely people from all over the US doing really interesting projects in villages across Vanuatu. Living in the villages they had many wonderful insights into the culture that have helped in my work in the hospital. They happened to be here during the superbowl. There is a bar / microbrewery here called the Wild Horse Saloon owned by a couple from Colorado. They have a big projection screen and we had a Monday morning (I am living in the future) USA style super bowl party. Followed by guitar hero sillyness. My mom was wonderful company cooking and doing laundry here, she eased me into the culture shock and helped get through the intense few weeks. We went on tour called the Caloonga cruise. Where we took this 80 foot old sailboat out to a deserted beach accompanied by dolphins. At the beach we did some amazing snorkeling with insanely bright coral and marine fish in a marine sanctuary and then had a barbeque. And yes I ate the beef. After 10 years of being a vegetarian. Adventures in traveling I guess. I also met this lovely Australian fellow who invited me along to a tour in Tanna, the island with the Volcano. We flew over in a Cessna one afternoon and then took this amazing four wheel drive road across the island passing villages of grass huts with kids screaming and waving and women in brightly colored dresses and huge old Banyan trees. We got up there in the late afternoon, it was a bit rainy and foggy, which made it more dangerous cause it is harder to see if the lava rocks are coming at you if it goes big, so we stayed back from the rim at first. As night fell we went over to the rim a bit closer and you could here it go off the smoke coming up would glow red and then lava would shoot out. We sat and watched for a good while and as we were all saying we were over it and ready to go this one dude said one more, lets stay for one more. Well the next one was huge lava came shooting right out of the volcano in our direction. The guide yells for everyone to stand still and only move away if it comes close. Once all the lava hit the ground, the guide tells us its TIME TO GO! As we walked past where we were sitting before there were these two huge glowing hunks of lava rocks. Then as we were driving back home, just 15 minutes later as we came around the back side of the volcano there were two HUGE eruptions that shot lava rocks half way down the backside of the volcano. The back side had a higher rim so they had to be pretty huge eruptions to send lava that far. The guide said we were lucky we weren't still up there. Kinda sketchy. Definitely got the heart racing, but it was amazing to see. You could hear the Volcano rumble all night from the spot where we stayed which was pretty incredible because we were on the opposite side of the island with big mountain range in between.

The Mundane: I get up every morning and have a breakfast of tropical fruit, check my email, then I either head for the hospital to do the day shift or go out for a day adventure to swim and snorkel at some white sand beach and come back to do the evening shift. Somewhere in there I cook some food, stop by the hotel bar to chat with the fun people I meet and have a Richard special. Richard is the bartender here and he makes this amazing cocktail with rum, mint, lime and lychee. When I get back from the hospital I always go for a dip in the pool whether it is 3 in the afternoon or 2 in the morning. Life is not so bad.

2/19/10 Stillbirth

I see why everyone told me to stay for 6 weeks. I have been here for nearly 3 weeks and I am just getting fully competent in the procedures of the hospital. Now I can really be useful. If I had stayed a month then they would only get a week of that. Yesterday I was the admissions girl. Doing the initial evaluation of the multitude of women coming in to the hospital. A young 18 year old woman with gorgeous skin and an infectious smile came to me and handed me a card, I got her chart and brought her into the admission room. I felt her belly determined which side I thought the back was on and asked her then normal run of questions. Had her water broke, has she seen any blood, has baby been moving, when did her contractions start? I put the the Doppler on her belly to check the fetal heart rate, nothing. I tried the other side of her belly nothing. I slathered her with gel and glid the Doppler across her lower abdomen, occasionally a rate of 50 something would flash but no beat. I went to get the midwife and inform I couldn’t find a heartbeat. She came and repeated my steps, still nothing. And in fact she hadn’t felt the baby move since yesterday. She went and got a doctor so that we could send her for a scan or ultrasound. He found nothing, she was four cm, plenty of time for a scan. About twenty minutes later I saw her walk past the admission room, tears streaming down her face. They hadn’t found a heart beat. For the rest of the morning I saw her walking gracefully, moaning through her contractions all with sad eyes brimming with tears. She delivered that afternoon, a small quite blue baby. We wrapped it blankets and the family passed it around rocking it and wailing. I sat behind the curtain just listening to it the melodic wailing. Some peace corp workers told me this time is important. It is essentially the only time they are allowed to express their grief. When someone dies they wail initially and until the funeral and after that it becomes inappropriate. I will always remember the father. He came into the delivery room with his sunglasses on and tears streamed out from underneath, covering his cheeks. I was surprised at the amount of emotion displayed. He did not wail, he just cryed. He watched as I weighed and bathed the baby. The room was silent except for his sniffling. Its true, they are still born. Several babies were born after that, and I often caught him standing at the door, watching me as I weighed and bathed the other babies. These little ones screamed in discontent and being uncovered and I would try and soothe them with my silly little cooing noises. I wonder what was going through his mind.

2/16/10 The Night Shift

Everyone once in awhile there is this mark on the board: BBA. It stands for born before arrival. Baby is born at home and then they come in or it is born on the bus on their way to the hospital. For whatever reason baby doesn’t wait until the delivery room. Even though most of the time I am clueless that it is coming I know when its happening because a wheelchair heads into the delivery room instead of out of it (most women walk into the delivery room when they are in labor). Last night there was such a wheelchair so I followed it into the room to see if I could help with something. This woman could not even get up out of the chair. The boyfriend, the student nurse and the midwife lifted her out of the wheelchair and set her on the delivery bed. As she settled on the bed I noticed that her arms and legs were covered in bruises. I gasped. I thought DIC a disorder where the body clots and bleeds and nearly always causes death. Then I noticed her hands were huge and swollen. Lissie pointed out the bruises to me, as if I hadn’t already noticed. She had the umbilical cord hanging out of her, so we grabbed a clamp delivered the placenta. I heard them inquiring about the whereabouts of the baby. I gathered that the baby had not lived and had been left with the grandparents at home. The boyfriend was sent out of the room as we delivered the placenta and after it was determined she had no tears, the energy of the room settled and Lissie asked what had happened. He eyes were white and glazed over and she had barely spoken a word since she arrived. Just whispering her name and address as I filled out her intake. There was a woman with her from her villiage, she stroked her head and told her to tell the doctors the truth to tell us what happened. First it came in small bits and slowly she got comfortable and the story unfolded from the beginning. On Sunday, her boyfriend had become suspicious that she was having relations with another man, so he began to beat her (7 months pregnant) with a stick to try and get her to admit it. This went on all day and all night, she was not allowed to sleep. He told her if she would just tell him the truth he would stop, so she told him that it was true so that he would stop. He continued to hit her wanting her to divulge details, which she was unable to provide since nothing had happened. This went on through Monday and into Tuesday morning. He pushed her and she landed with her belly on a table. Her water broke. She tried to tell him she was going to deliver and to get help but he thought she was lying so instead he kept hitting her with the stick. The word for hit or strike in Bislama is killim. I sat there listening to the story thinking of the irony of that. She was describing it, “he was killim mi, killim me.” Which sounds like he was killing me, killing me. And in fact he had, only he killed his daughter. She was born dead in his home and only then did he go and get someone to get his girlfriend to the hospital. Lissie suggested that she file a police report and press charges but I think she was too scared. She made me promise noone would see the history I had taken. Then he stayed there in the hospital most of the night, caring for her in this very sweet way. For her protection I had to force myself to look down each time I saw him so that he wouldn’t see my rage, that I knew the truth.

Sunday, February 14, 2010


Interesting how life doles out experiences to you. The first delivery that I did after my last post was a woman who was having her second baby after her first one was a stillbirth. It was so moving to be helping her after what I had just been through. It is interesting because in my experience in the US after the baby is born and in their arms women are usually crying tears of joy and are very emotional. Here after the baby is born women sort of seem to check out, barely interested in holding their baby savouring the relief of being done with labor. This women looked up as the baby came out and with the first cry, tears began rolling down her cheeks, it was amazing. There were also twins born yesterday. Very exciting to see my first twin vaginal delivery. There was an intern in the hospital yesterday so she got to do the delivery and I just assisted. The first baby was coming down asynclitic, which means the head is tilted a little sideways. She wasnt making much progress after about 4 pushes so the doctor pulled out the vacuum and helped her get the first one out. It took several long pushes, with lots of pulling on the doctors end and an episiotomy and the first one a boy at 3.6 kg. Both babies were head down and after the first one was born there was about a 8 minute pause and then her contractions started again and two pushes later the second one, a girl at 2.7 kg was born. Two perfect beatuiful, healthy babies. It was awesome!

Tuesday, February 9, 2010

Warning: Graphic

My second day here, I got the low down on how to do all of the paperwork. In their chart you fill out the newborn information. There are two boxes on that page: live birth and stillborn, the stillborn box is then toggled in to two more boxes: fresh and macerated. The first time I read through this, I thought, “gnarly, I hope I never have to deliver a macerated baby”....

When I arrived at the delivery ward this afternoon it was slammed again. Most of the beds were full, a mom was about to come out of c-section, several moms were written in red meaning that they were antenatal and waiting to deliver. One of the student nurses came up to me and asked me, "how do you call it when the baby dies inside?" Fetal demise I told her, and helped her spell it out in her little notebook. That's how I found out there was a woman in the ward waiting to deliver a dead fetus. Part of me really wanted to participate in this experience and part of me was terrified of it. I went about my business running from here to there trying to make sure everything was getting done, when at around 8:45 one of the student nurses grabbed me and asked me to check a mom that he thought was getting close to delivery. It was the mamma with the dead baby. My heart sped up but I went in and checked her and she was 9 cm just a small lip on the right side. I had her lay on that side and checked with midwives about how to proceed. They recommended I go and break her water and then check her again in a few minutes. I grabbed a bedpan and amnihook and knowing that meconium was coming held my breath as I snagged her bag of water. Thick dark brown water came pouring out. I had never seen anything like it. After a little while I checked her again, the midwife asked if the baby was head down or breech. She was fully dilated and as I began to determine the position my fingers ran across the cord, at least I think that is what it was, it had no pulse so I couldn't confirm it. The presenting part was bumpy and not smooth like all the heads I have felt so I guessed that the baby was breech. I had one of the midwives come by and double check and she said she thought it was breech and felt a cord also. It would make sense a cord prolapse would be a definite reason this baby didn’t survive. It was about 9 pm when we determined that she was fully dilated. This was getting intense I was about to do my first breech delivery, and my first and hopefully only stillbirth. The midwives instructed me to just let her continue to have contractions until she could not resist the urge to push and not encourage any pushing until that point. So I sat in the delivery room with this mom and coached her through contractions and supported her the best I could, constantly wondering if she understood what was going to happen. As I sat there the two beds in the second delivery room filled up with two moms almost ready to push and then a fourth mom came in and started pushing in the bed next to us. It felt so chaotic. Not what I wanted for this mamma that was about to do something so difficult. Finally, a little after 11pm, pushing was irresistible and there were clear signs the baby was getting close. One of the midwives was standing with me coaching me on what to do when a student ran over to say that the mom in room two was about to deliver so she left to go catch the baby. Mind your room 1 and 2 are connected by a sink room where they was the sheets and instruments. As I gowned and gloved up, a round circle with hair appeared on the perineum. I was slightly confused because I was sure that baby was breech but I just let the events unfold. My heart was pounding and my throat was totally dry, I was very scared of what I was about to witness. The top of a tiny round head began to emerge, I went to support it and was shocked by the soft consistency of it. The head kept coming sort of oozing out of her body I wasn't sure if I just let come or support it or support her perineum. I was freaked and at a total loss for what to do. Finally the face appeared and with another little push the body slipped out after. As all of this was happening you could hear the mom in the next room pushing and newborn baby crying. A stark contrast to the deafening silence coming from the baby I had just delivered. I never imagined the joyful sound of a new baby’s cry would be so tormenting. I couldn’t believe these two things were happening at once it seemed so cruel to the mamma I was helping. After the baby, came placenta about the size of the palm of my hand. I kept looking up at this mamma that was staring at me blanking. I was wishing I could know what she was thinking and feeling, wanting to take whatever it was away. The midwife came back over to check on how things were going. She told me that I had to go and weigh the baby. I was mortified and then I was mortified that I was mortified. I didn’t want to touch it. Its head felt mushy with a few disconnected cranial bones and its skin was splitting and peeling. It turned my stomach when I lifted it up to carry it to the scale, I swallowed hard to hold it together. It broke my heart that I was reacting like this to this poor sweet baby. 1.5 kg and then I put him in a crib wrapped in a blanket and cleaned up the mamma. The shift was changing and sweet, sweet Lissie who had just come for the night shift came in and took the chart, put her hand on my shoulder and sent me off telling me to go home. I walked to the nurses tea room and just burst into tears. Everything felt so intense, I couldn’t imagine being the mom. Once I pulled it together I went back to the delivery room and held the mammas hand as she cried watching Lissie diaper and dress the baby and then wrap in blankets. The family gathered and the weeping began and I slipped out to head home. When I got back to the hotel around 1 I slipped into the pool, it is the first clear night since I arrived here usually there are a fair amount of clouds in the sky. And the stars were fierce. Glinting and glowing in slight shades of white, yellow and red. I have heard some legend somewhere that the stars are the souls of all the unborn babies.

Thursday, February 4, 2010

I arrived to the ward this morning to sounds of many women wailing. Someone was sobbing and crying out. At first I thought someone was having a difficult labor and was in a lot of pain but as I walked up to the desk the midwives informed me that the baby that was born a few days ago with meconium aspiration and just died a few minutes before I arrived. They lost two babies in the ward last night, another one had died a few minutes after birth due to meconium aspiration also. In my grief and loss class my teacher Beth Coyote had told us about the wailing in St. Lucia when there was a death there and I kept thinking of that as I walked the halls. Eventually the grandmother carried the baby out of the nursery with family and the midwife following to bring the baby to the morgue. They had to hold the mother up as she walked sobbing. A few tears dripped down my face and the midwives giggled at me. I am definitely not used to accepting that kind of loss like they are. It is a good learning experience. In happier news there were triplets born there yesterday. The women came in expecting twins while I was there on the evening shift. I waited well into the next day and finally exhausted they convinced me to go home and rest, when I woke from my nap I was trying to decide between getting some dinner and going to the hospital and I decided to eat and missed it. So bummed, I will probably see another set of twins but not likely triplets. There are all healthy and doing well and weigh about 2kg. Everyday since I have been here the ward has been "full up." Every bed full with mothers in labor wandering the hall waiting to deliver. They have had 41 babies as of 3 o'clock this afternoon already in feb. Thats almost 10 per day. I have done 5 deliveries in 3 days. One of them today hemorrhaged. They actively manage here, which means they give meds to stop bleeding before the placenta comes to prevent women from bleeding. Most women dont lose much blood at all and I had already gotten used to it. When this mom kept bleeding and bleeding, filling up one bowl after another, my heart was pounding I gave her all the meds I had available to me while one of the nurses put in an IV. I kept massaging her uterus trying to express clots and get it to clamp down and this mom was screaming at me and pushing my hand away. We sent for the doctor and just as he arrived they put some syntocin (anti-hemorrhage meds) in the IV and the bleeding slowed. I stayed with her for about an hour keeping an eye on her blood pressure and then when the nurses decided she was stable enough to move to postpartum I was helping her to the wheelchair and she collapsed in my arms, I set her on stool and she came to, she kept trying to shake her head to "get clear" The midwife brought her some warm water with sugar and after a few sips we got her into the wheelchair and back into bed. I went out to the store by the hospital and bought her a box of juice and some crackers hoping some food would help her energy and improve her blood pressure. They were so grateful, it made me want to buy crates of juice so that we could give them to every mom postpartum.

Tuesday, February 2, 2010

First Day, Four Babies

Spent my first day working at the hospital. I was super nervous.... here all by myself, don't speak the language, not sure what I am diving into. There was nothing else to do but jump in, so i threw on my scrubs and headed over there. I hung back and observed today so I could get the flow of things here, they do things a little different from the meds they use to the way they chart. I kind of expected someone to walk me through it, and explain what I was expected to do but no one did, so I just watched everyone do it and took careful notes so that I can do it right in the future. There were four babies born on the day shift today. Apparently it has been super busy here lately, over 250 babies born in the hospital in Jan. Nearly a record. The first two babies today were born 15 minutes apart and the midwife was running back and forth between them, directing nursing students through the deliveries and I jumped to help everywhere I could. Then things calmed down for a bit and it was about time for a shift change when someone came in saying that there was a mom that was about to deliver in a bus outside. We grabbed a delivery kit and a wheelchair and headed out there. We easily got this mom from the bus to the delivery room but when the midwife broke her water there was thick meconium. We coached her to push hard and fast to get the baby out as quickly as possible. The baby came pale and floppy and it was well after a minute before there was an attempted breath. They suctioned her over and over again and tons of green gunk came out of her nose and mouth but she had aspirated some of the meconium and was in respiratory distress. One of the Chinese doctors came over to check her out and gave her an several medications but her oxygen saturation wouldn't climb above 65%. The doctor said he didn't think she would survive the night. First day,welcome to Vanuatu. I kept standing by her and talking to her as she struggled to breath and everyone scurried about trying to get the delivery room ready for the next mamma that was complete and ready to push her baby out. We moved the sick baby into the nursery just as mamma number four got ready to push. By this point I was more familiar with the routing and took the baby to be weighed and vaccinated and brought her back to her mamma to feed. At this point I was well past shift change and totally spent. It was an exciting first day and I am ready to have a more active role tomorrow.