Wednesday, July 17, 2013

Overview of the trip

We left Vanuatu Saturday and I have been reflecting on the experience since then so I wanted to write a last post about it.

Being a hospital that serves ~300 birthing women each month, serving a large number of women living in poverty, with hepatitis B, STIs, and HIV being rampant, it amazed me how well the outcomes were!
Most of these women, despite the odds, would just birth their babies, and their babies would nurse without issue! There was a lot of preterm SROM (spontaneous rupture of membranes) and preterm labor (likely from all of the stis)…
The don't have pain releif in labor, except when cesarean is required, so the women just deal with it. And they know they have to deal with it, so most of them did just fine. A lot of them have a friend or mother there to help support them through labor... and I spent a lot of time rubbing backs, holding hands, and talking mommas through the pain...  Their c-section rate is around 7%

I witnessed 20 births while there for 2 weeks. I worked the day shift (night shift is when most babies are born) and we took a few days off (after really exhausting 14 hour shifts, or stressful births).

This is a brief overview of what I witnessed (mainly for those people thinking of going to Vanuatu J)

1-cord prolapse (well, 2 if you count the mother that I spent time giving her labor support while she was at the hospital for induction after she had a prolapsed at home and lost her baby, I did not witness her birth though, only helped her with labor, then postpartum was amazed by her kindness when I saw her rubbing a laboring mom’s back (a stranger) in the hall just the day after she birthed her still baby)

1-set of twins

1-footling breech (twin A)

1-postpartum hemorrhage

1-intersex baby (baby had a uterus and ovaries but external genitalia appeared male)

~15 times suturing

A handful of resuscitations (on newly born babies and on a preterm baby in the nicu)

A handful of IVs (and two 16 gauge ones!)

Some teaching, and alot of listening and learning J

Several lovely births, several women I supported during labor but did not attend their birth, several prenatal, and postpartum visits, several times changing bedding or scrubbing birth goo out of sheets, or charting…

I am so grateful for the experience of going there. Although I most certainly would have adrenal collapse if I were to deal with the amount of stress they experience on a regular basis, I am glad I could experience it in a small dose.

When my family picked me up from the airport, my baby Owen (16 months) was mad at me.

By the time we got home he started warming up to me, but he got mad at me any time I would offer to nurse him, and he wanted David only that first night…

That was completely heartbreaking.

Fortunately the next day we had a lot of close time together and the next night he went back to breastfeeding! He now is as loving as ever, and I am enjoying many snuggles from him and my sweet, sweet Jude (who is 5 years old, and has been very understanding and loving the whole time).

It was the hardest thing I have ever done, leave my husband and 2 young sons for 16 days (2 days travel and 14 days there), and I will never do that again. But, it was worth it, just this once, to have this amazing experience.
The picture below is some of the staff and us when we went in to say goodbye

Tuesday, July 9, 2013

I never imagined I would see all I have seen and experience all I have experienced here in a short week and a half. I got what I came for, and so, so much more. As hard as it has been being away from my husband and 2 boys, this trip was worth it, the experiences have made me feel really truly ready to practice on my own, and I have new skills to go along with it!
This place is amazing, and really dramatic and stressful, and joyful. Someone could seriously make a reality series based on Vila Central Hospital, and every single day they would have an excess of captivating footage of all the crazy, and all of the amazing-ness that goes on here.
An intersex baby was born yesterday, he/she has an older sibling with the same thing. What are the chances?! Congenital Adrenal Hyperplasia, never thought I'd see it....
Yesterday I also spent some time in the NICU with a 30 ish weeker, he is 10 days old and had been going downhill... he had 2 episodes where he stopped breathing altogether, and both times I was alone (just checking in on him, this tiny little person) and called someone else in to help me resuscitate him. We did, and after got him on skin to skin and he started rooting and breastfed! Today he nursed again too, and I think the skin to skin and small amounts of breast milk are helping him some. They also gave him a blood transfusion which is helping.
I've been a bit frustrated by the lack of the nurses being willing to push for something with the Drs. For example, the chart said with that baby, nothing by mouth because of the apnea. But, baby was rooting and self latching when put on skin to skin! The nurse said no, don't feed him. So I marched down to the peds department of the hospital and spoke to the Dr who gave the orders, told her baby was rooting and self latching, and she said "great, we thought we were going to lose him yesterday!" so went back and told the momma that yes, you can feed your baby, because thank goodness he is now strong enough to try to get it!

Today, Elias and I attended 3 births, then in the afternoon after getting to the point of complete exhaustion, we decided to stay and attend a very premature twin birth, we very actively participated in the positive outcomes for all 3 ladies involved (and I am sure daddy was happy too :) and I am so grateful for the experience. Elias led the resuscitation, in the most amazing way! And initially he was surrounded by people that he had to teach how to help him resuscitate, but of course he handled it well and eventually got that baby breathing (and also got a umbilical catheter in!). And I managed the vaginal delivery of twin #2 after the OBs attending said they couldn't get the nuchal arms to budge and would need to do a cesarean section, I just asked them if I could try too, and they said yes and they went to go prep for surgery.

On top of the crazy births, I have gotten a lot of amazing easy normal births, crying healthy babies, and a ton of suturing experience!
Also good is I have had to do a few IVs, and got two 16 gauge needle IVs in first try! Only tried because they were out of 18s, and 20s... they run out of supplies pretty quickly here...
And today we got to attend the birth of a baby born in the caul (in an unbroken bag of waters)!!

Today is Tuesday at home, we arrive home Saturday, I can't wait to kiss my boys!

The first picture is me giving twin B oral vitamin K, the 2nd is Elias giving some to twin A

Friday, July 5, 2013

Busy baby hour! Scope of the hospital...

Yesterday was a mellow morning and afternoon, I spent most of my time cleaning, stocking, helping the staff  and hearing about their lives, admitting a couple preterm SROM mommas, spending some time in the prenatal clinic, and labor sitting with a 43 week momma that had been having late decels for hours. Around evening time she started feeling like she needed to push, so we moved to the delivery room, baby was OP and she had a cervical lip that kept coming down, it took her awhile to get him to move (eventually he turned). We had her cycle through running start position and mcroberts, and kept a close eye on baby, who at some point had sustained very low heart rate...  well, eventually baby was born completely limp, no respiratory effort, and pale, skinny as heck with a large head (very obviously IUGR for 43 weeks). His cord was pulsing strong so he stayed attached to mommy for 10minutes, we ended up giving him some breaths on mom, and some oxygen breaths when cord stopped pulsing.  We gave him apgars of 1m- 3, 5m- 5, 10m- 6, 20m- 8. Eventually he came around and about an hour and half after birth he started nursing! Hooray!

Because they are a hospital, their scope of practice is much further than what I will practice back home, the experiences are educational, but still with some of these I would have transferred awhile prior.. Such as when she had an ultrasound and was found to be severely IUGR, or when she hit 43 weeks... long before birth, but even if it was during birth, the late decels would have clued me off to transfer.... We consulted with the Dr on staff so many times with her, and each time we were told to keep going. On the positive side of it, he got to stay on mom and get all his blood, and oxygen from mom while we did breaths on her chest, and only for a few minutes did he go to the warmer for oxygen and breaths and vitals assessment... that is the benefit of having midwives in hospital (and also some rare special OBs do this...but so few), baby is going to have a much better chance because neccesary resuscitation was done with cord attached.

Since they do ultrasounds so minimally here, and their ultrasounds are very, very basic, I'm not even sure they would have done anything different for baby, such as inducing when they realized he stopped growing... Ultimately it turned out ok this time, but that won't always happen....

Then, a little bit of time went by and bam! 4 babies in an hour!! We ran from one room to the other! Very, very fun! And each were quick, easy, normal deliveries, the babies cried right away, and the perineums were intact! I think Elias and I needed a run of healthy, easy births to restore our faith after the 2 prior (the cord prolapse and the 43 wk limp baby).

So off we go to another full and crazy day!!

Wednesday, July 3, 2013

Cord prolapse

I figured I would probably have to deal with some crazy stuff while here, it seems everyone else that has ever told me stories about Vanuatu talk about the one ever lasting memory of the crazy scary emergency that happened. Mine got to be cord prolapse, well at least I hope that is the scariest it gets while here… I might like and easy breech or twin though… but no more emergencies please!


I caught 3 babies today, the 3rd right before Elias and I were going to leave. I wanted to leave early because yesterday we were at the hospital for 14hours, running around doing a million things. It was this momma’s 4th baby and I figured it would be quick and easy then we’d go home.


Let me give you a little background, yesterday there was a mom who had a cord prolapse and the baby died, same thing like a week or twon prior (as told to me by someone working at the hospital, we weren’t here yet). I think most people reading this know that cord prolapse is a very rare emergency (it seems to happen here a lot more often) where the baby's cord falls out through the vagina (or just past the head) gets compressed between the baby's head and moms bones and most often baby dies because they don’t do a c-section quick enough.


Well, she started feeling an urge to push, I checked her and she was fully dilated, the head was low but not coming lower because of what felt like a huge bag of water over the baby’s head. I figured she’d give one good push and that bag would break and flood everywhere, or be really thick and inhibit descent. So I routinely checked for the cord over the baby’s head, as we are taught to do. Elias put the Doppler on baby, all very routine... during a contraction I barely touched the bag with the amniohook and it broke it, I controlled the descent of the head a little (didn’t have far to go at all, but with a G4 I figured she’d have so little resistance to baby coming quick). Baby's heart rate started tanking, I checked and felt a cord along the top/side of the head (with all of that fluid it flushed it down further toward the opening), we flipped mom to knee chest position and called the dr for emergency c-section, but supposedly an ER CS takes like 30-40 minutes here (supposedly that is what happened last week) and the baby would already be dead (or we would have to hold the baby’s head up until the surgery was ready and would be quick), so I shoved my entire hand up momma (as she quite audibly complained  because it f***ing hurts to have somebody's hand inside you next to your already huge baby head), pushed the cord back inside as far as possible, kept trying because it kept slipping and baby's heart was low, I was really persistently trying to get it to go around baby's neck and stay, and eventually it did! Heart rate went up and we had momma push like a crazy woman... the cord was still tangled and had some dips and since baby had been deprived of oxygen for so long we didn’t know how baby would handle everything, .... I was so, so scared that the baby would die... but ~30 minutes after the cord had first prolapsed the baby was born and cried pretty quickly (30 minutes is way too long to not know if this little baby is going to live), after the birth everyone was still and quiet. I am so thankful he lived. He complained a little while and then started smiling... No kidding, he started smiling, and babies don't commonly smile when they are awake and newborn… they smile in their sleep or when they are older... but he seriously was smiling, several times. He laid there on mom and the cord pulsed for so long, I really think it was quite beautiful that it pulsed so long to give him all the oxygen he needed that he was deprived of :)

What a day! I am tearful now just thinking about the poor momma that had lost her baby yesterday and how this sweet smiling little boy might not be alive right now...


Monday, July 1, 2013

Done with day 2

Wow. What a day. We spent 12 hours at Vila Central Hospital today, all day on our feet going between laboring, prenatal, and postpartum moms and babies. It was the equivalent to any sauna I have ever been in, hot as hell and humid. It was pretty challenging working that long in the heat and not taking the time to eat at the hospital or sit... so now being fed, clean, and laying down feels quite heavenly.

When I pictured the hospital and Vanuatu as told to me by the many midwives that have come here before me, never in my thoughts had I imagined it being so poor, and so dirty...and all the bugs everywhere, even crawling all over the hospital. It is so different from anything I have ever seen or experienced, and I am very grateful to have this amazing eye opening experience.

Something else I didn't expect is how friendly and kind everyone is. Almost every stranger we pass on the street say some greeting or start up a conversation. People are also being very understanding of my funny sounding Bislama, its getting better with every encounter I have though (hehe, only when people talk slow).

One of the births I attended today was a first time mom that had been in the hospital since the day before with SROM, she was contracting all night but mildly. I went to check in with her and she had had some bright red bleeding that had soaked a menstrual pad, I took her over to the monitor and listened to baby for a bit, she had more bleeding, quick slight drizzles. Then baby's heart rate was lost off the monitor and when I found it it was 50, I called in one of the head midwives to see about er c/s, baby's heart was still so low, about 80. After about 5 minutes without the monitor tracing baby, and my frequent checks finding 50-80, baby came back up to normal. I put an iv in, the dr came in, and said keep her on the monitor and if it happens again let me know, check her dilation in a couple hours. I stayed with her closely, mostly monitoring babe and giving support, she'd say to me "oh mummy it sore, so sore" and grab my arms, sometimes pulling me in to hold onto me during a contraction. About 2 hours after that scary as hell decel she started to push! We moved to the delivery room and had a lovely birth of a very healthy and strong baby (after an hour and 20 minutes pushing)! I loved that it all turned out ok, for many reasons (I felt quite bonded to her after our morning together), but her birth happened right after a mom who had decels to 70, a c-section, and a baby with meconium aspiration and apgars of 2 and 5. A good reminder how birth is always different.

Well, I need to get some rest before another long and amazing day tomorrow.