Saturday, September 21, 2013


Several long days in the hospital this week prevented me from doing much blogging. Today's hours, for example, 16. I needed to wind down, though, so I thought I'd reflect a bit.
Two new students from New Zealand started this week. They are quite lovely and excited to be here. We've had some very busy days and a lot of great experience - a couple babies with sticky shoulders and a couple babies with thick meconium. A breech that actually wasn't a breech, but the woman had that baby just before she was about to have a cesarean due to the breech positioning....which turned out to be a head-down position. Hmmm.  One of the mornings (I honestly don't remember which) I walked straight into a resuscitation while three other women were pushing out their babies.
But back to today. The morning was low key. Just one baby. It's just after that point that I went home for a short nap because I was feeling a little under the weather. When I returned, the hallways were filling up with laboring women, but they were all hanging around 5 to 7 cm dilation. I had a feeling we were about to be full up in the delivery room. And that is exactly what happened. First, a second time mom with a short pushing stage delivered a beautiful little baby boy. A little suturing needed. No problem. Across the way, a young first time mom was ready to push. After another hour and 19 minutes and some really big decels, she pushed out a beautiful little girl. As I was suturing her, one of the students was working with a multip (5th baby) just across the curtain who was starting to push. And behind me, across the room, a 28 week breech was being delivered by another student. I finished suturing, and helped the student with multip. During pushing, the waters broke with fury all over everyone within a few feet of distance. Not the tidiest birth I've been a part of, but a beautiful baby girl was the result. We've learned to try to be as tidy as possible, because after the birth, we have to scrub the sheets as clean as possible before they go to the laundry. Anyway, that little 28 week breech basically jumped out and was being tended to by the student, who was very frustrated by the lack of medical support. The baby was breathing fine, but he was just 2.3 lbs - such a little angel he was! He definitely needed to be in the NICU though and nobody was initiating that move (coming back to this, he is doing quite well in the NICU several days later).
So we charted, sutured, cleaned, more charting, did newborn exams, gave immunizations, and transferred the babies and moms to bed. Then we cleaned some more. The halls were still full, but by this time it was about 11:30pm and we were ready to get home. Two of the students had left already around 9:00. Just as the other student and I were about to leave, we headed over to the delivery room to look for a notebook we had left, and on one of the beds, alone, was a woman obviously about to have a baby. She grabbed the student and said "will you help me"? A quick check and a couple pushes later, she pushed out her second baby girl. So we charted and cleaned and did all that....and THEN we ran out the door as fast as we could, just after midnight. A wonderful and exhausting day. The best part, I had the following day off! Leni, a friend of hers (her neighbor, really), and myself rented a car and drove around the island of Efate. Best idea ever! For a grand total of about $50, we spent all day visiting waterfalls, beaches, villages, caves, resorts, and then we stopped to watch the sunset just before arriving back in Port Vila. The weather was perfect and the scenery was incredible - it was a much needed day off! I'm so glad I had the opportunity to see more of the island and learn about some of the villages in the area. Everyone was so welcoming. They allowed us to see things after they had closed if in return we'd give them a ride to the nearest village to get a tank of gas. No problem! One man even gave us our money back.
My last day, Friday, was a normal 7am-3pm day with just three births facilitated by Leni and myself. All three had prolonged ruptured membranes, interestingly enough, but all three had beautiful deliveries without complications. After those births, when I went back to my hotel, I took some time to reflect on the last two weeks. I realized how much I learned in that short period of time. I learned new skills and techniques, improved on others, and gained confidence in areas I felt weren't my strong points. I am so thankful to all the women and midwives here in Vanuatu that have allowed me this incredible opportunity. When I was saying my goodbyes on Friday, I couldn't have said thank you enough to everyone for being so kind and helpful and for letting me experience midwifery in Port Vila.
And now it's Saturday and I feel exhausted. Maybe I've got a little bit of a bug, or maybe the last two weeks have just caught up to me. I flew from Vanuatu to Fiji at 9:40 this morning and slept the whole way there. Then, I had (well, have, I'm still here) a 10 hour layover in Fiji. So, I walked across the street from the airport to a resort and laid by the pool for a few hours. That was followed by a nap. I can't seem to sleep enough. In fact, I wish I were sleeping now. In just a few hours I will head to LAX and finally back to Seattle. While I have enjoyed every single second of my trip here, I miss everyone at home and will be happy to return.
Last but certainly not least, thank you to all you lovely midwives back home who helped me get here. This trip wouldn't have happened without your help!

Friday, September 13, 2013

Women Inspire

It's Friday the 13th. But don't worry - no freaky stories to be told. I woke up at 4:30 this morning to dogs barking and roosters crowing. Since I went to bed at about 9:30 the night before, I guess I'd gotten enough sleep. The sunrise was incredible, though. I can see it right from my hotel window. I can't wait to take a day off to explore all this island has to offer.
I woke up with enough time for blow-dry my white scrub pants again. It's so humid that nothing really dries here. So I spend about 30 minutes with my hair dryer blasting my clothes for the day dry each morning. I'm sure my neighbors love me. I have to wash them. It wouldn't be okay to wear them otherwise. Birth can be messy.
I look forward to breakfast each morning - since it will likely be my lunch as well. It is included with the cost of my room. And it's actually quite good - eggs, a rice pilaf-type dish, some sort of sausage, fruit, toast, muffins, etc. I eat a little and take the rest with me to the hospital to have for lunch. Even better - after several days of not knowing - I found out I get a free coffee with that breakfast. Espresso even. I feel spoiled.
Everyone at the hospital wears sandals. Even the foreign students, midwives, and doctors. I don't understand this. We go through the charts and see all the infections some have...and even worse, don't see much of what some others have. I've been blasted a few times with a popping bag of waters all over my feet or on my clothes. Needles have been dropped, medication vials crushed on the floor, AND there are a few resident mice and rats crawling around the hallways...Why even take the risk? I don't think "when in Rome" applies in this situation.
Friday was a great day in the maternity ward. These women of Vanuatu are just incredible. They are so strong. Some are so quiet that you barely know they are in labor.  Just a little sound here and there, and then they're all of a sudden pushing - quietly of course. Yeah, there are others that will squirm around on the bed. I've actually seen a few women putting their legs nearly back to their ears - straight, not bent like you'd think). I've almost been booted across the room a couple times. But hey - whatever it takes to get that baby out! Most women's pushing stages are quite short here - we were talking about how it might be due to the fact that they spend a lot of time in the squatting position. This might help form the hips in such a way that the head can get through a bit easier.
Three babies today during my shift. All three were boys. Two of the women required suturing. The first one had her cervix come down to where you could see it, so we used gauze again to put it back in place. This seems to be happening too often, they start pushing before they are completely dilated and just can't stop pushing. The second mom's waters had been broken for nearly 40 hours. The baby's heart rate was hanging around the 180s. She was contracting about every 3 minutes with good strong contractions, was 8 cm dilated, and they put her on Syntocin to augment her labor. I don't really understand why. She would have done just as well without it. We were concerned for this baby, thinking that this mom might have a bit of a longer pushing stage because it was her first baby - would this babe be able to handle it? Well very shortly after they started to augment her, she said she felt like pushing so we went over into the labor ward. She pushed like a champion, and as that head came out, so did the thickest meconium I have ever seen. Meconium streaming out of the nose, the mouth. Covering the face, the ears. When that baby, a large baby at that, came out, we had to do a bit of suction and a little free oxygen - but he started screaming just fine. He pinked up really well. His heart rate stayed up at about 180 for quite a while, with a respiratory rate of 70 (high) and a bit of a temp. Mom also had a temperature, her respirations were 30, and her pulse was staying around 120. It was apparent that the mom had an infection and we were concerned about the baby too. The baby doc came in, though, and said that the baby was fine. Antibiotics were given to the mom. We were really hoping they'd give the baby antibiotics too, but none were given before I left.

Yep. I'm working the weekends. But it's so worth it. A shorter shift today. Two lovely, very strong women had their babies. The first one was a first time mom. She had had several CTGs throughout two days that showed regular early (and occasionally late) decels. They continued to monitor her every 3-4 hours and gave her IV fluids. When I arrived this morning, she was about 6 cm dilated. Not too long after, she was feeling pushy. Babies heart rate continued to go down...into the 60, 50s, 40s. Thank goodness these women have short pushing stages. Just a minute later she pushed out a beautiful baby boy with great APGARs. That's the 7th baby boy in a row. She had a few bad 2 degree tears that took an hour to repair. Partly because I go slowly, but partly because it wasn't straight forward. Unfortunately is was about 100 degrees in that room, with a bright light shining down on me, and 95% humidity. I sweat easily, so you can only imagine what I looked like when I finished. Then finally a girl! A sweet young woman arrived at the hospital having had no prenatal care and unsure of her dates. She was measuring 34 cm. Baby didn't feel too small though. That baby was also having several decels. We brought her into delivery. She was nearly complete and ready to push. After a very short pushing stage, she delivered a sweet little baby girl - probably about 37 weeks gestation. They named it after the student midwife from New Zealand who's birthday it was today as well. I also have a little baby girl named after me. They like to do that here - name their babies after you. One of the midwives from New Zealand that's been here for 3.5 years has dozens of babies named after her. She started requesting that they start using her kids names instead.
We got done early, got showered up, and are relaxing by the pool and listening to live reggae music. Tonight we'll go down to a local pub and watch rugby and celebrate the student midwife's birthday with a bunch of other locals.
I am so appreciative for the experiences I'm having here. It has been so wonderful and the women have been inspiring. I look forward to starting my second week. I can't believe how fast the first week has gone by!

Thursday, September 12, 2013

A few rainy days later...

I've had a few days at the hospital now and I'm feeling much more settled. I understand the routine better, which midwives are in charge, which meds are used and where they are, and when it's okay to take a coffee break. I have really enjoyed each day and have already learned so much. The time flies. A couple of the days I have walked into the maternity ward and was directed right into delivery, where I would stay for hours.
On Tuesday, the delivery room was full, the beds were full in the postnatal area, with mattresses on the floor, and the hallways were full of pacing mothers. Women were coming in with strong contractions, we'd put them on the CTG, and they'd have their babies a couple of minutes later in the admission room. That same day, I was with a second time mom pushing at only 7 cm. I was having her try to breathe through contractions. I told the head midwife my findings when she popped in, but the mom was feeling pushy so she encouraged her to push. She thought she must have been complete. A minute later, we see her pushing her cervix into the vaginal vault. That woman had a mild hemorrhage, but did end up pushing her baby through that 7 cm cervix within 10 minutes. On the bed next to her, a woman's cervix presented at the vaginal opening postpartum. I remembered seeing that once before, that shiny, smooth, purplely colored flesh. We used gauze to push it back in and hold it in place. Also on this day, a woman transferred from the island of Tanna via plane. She was with a Canadian doctor that works in the only hospital on that island. The doctor said that the woman had been bleeding, and contractions had started afterward. The baby sounded okay the whole time, but started to get tachycardic near the end of the trip (Nifedipine was administered on the way). She was immediately hooked to a CTG and an ultrasound was done. A large placental abruption was noted and she was taken in for an emergency cesarean. The baby struggled to come around. She had a strong heartbeat, but has not wanted to breathe on her own. They say she needs advanced care that they cannot provide here in Vanuatu. She has been in the NICU, dad by her side, for three days now, still not breathing on her own. Her last oxygen stats I saw were sitting around 75%. The mom had a large hemorrhage, but she survived. And still on the same day, after 11 hours of being at the hospital, a mom at 31-32 weeks gestation came in feeling like "sit sit". We brought her right into the delivery room, checked her cervix, and she was complete and at +1 station. Just a few minutes later she gave birth to a beautiful baby girl. This little girl wasn't ready to breathe yet, however. Her heartbeat was strong the whole time, but no respiratory effort. We had to breathe for her for about 6 minutes (it felt like a loooong 6 minutes), but she started to breathe on her own and is now thriving. During that resuscitation, we asked for a peds doctor or a head midwife or anyone to assist - nobody came. About 30 minutes after the resuscitation, the doctor on call showed up. By that time, the baby was nursing well and everything was fine. She didn't even need to go to the NICU in the end, though she was quite small. EGA was 31 weeks.
After that long, busy day, I headed back to my hotel, had some food from the restaurant (a salad with a side of veggies, because I felt like I needed some good nutrients, but didn't want to pay a fortune), headed back to my room and did some laundry in my sink. I didn't bring enough scrubs, I've found. And I brought the wrong color. Don't wear white. I was told that the midwives wear white here, and a couple of them do, but dark colors are much more appropriate. So I do a lot of clothes washing with shampoo and hand soap in the sink. It works surprisingly well though!
The next day, Wednesday, was evenly spaced with births and a little more low-key. Chris, the New Zealand midwife, took myself and Leni to get some good Tanna coffee at a local resort. It was such a great change from the instant coffee I have been drinking. I do love my coffee. This day was a great suturing practice day. Both first and 2nd degree tears. I'm learning some great new techniques. We got done early today (7am to 5pm rather than 9pm) and Leni and I headed straight down to the market to buy some fresh fruit and veggies. I was so happy to have some delicious grapefruit, tomatoes, raspberries, and other colorful foods.
Thursday was a low-key day. Just one birth. The placenta came out duncan with incomplete membranes. We did our best, with a speculum, to get the membranes trailing out of the external os. We got all we could see, but knew there was some left inside. The head midwife suggested 20 IU syntocin in a bag for her. So that's what we did. They are running out of syntocin here. There isn't any left in the pharmacy and there isn't much in the delivery rooms. There are also very few IV catheters, and the only ones available are the 18 gaugers. Not always the best to use on some of these veins. We got done early today and are having a relaxing evening at The Coconut Palms - the first real evening of relaxation. As I look up, I see a clear sky and I know the stars will look incredible tonight. I'm so excited. Behind me, a man in traditional Melanesian tribal attire is giving a talk on Kava Kava, a common drink here in Vanuatu. I look forward to a busy and educational rest of the week.

Saturday, September 7, 2013

Just getting started - Day 1

I fell asleep to reggae last night, which was being played live downstairs at our hotel. It felt like they were playing at the end of my bed, but I was too tired to care. That's just a side note really. I had my first day at the hospital today. I arrived at 6:45 am because I was told to arrive at 7 to do rounds with the midwives and doctors. I should have known that that meant rounds would be at about 9. I enjoyed meeting everyone while we waited though, because they are just so incredibly kind. They all say hello to everyone at home and appreciate the flavored coffee that was recommended as a gift. They also say I should speak Bislama with those of you back home who now speak it. You know who you are. I was given another tour this morning and then there was a lot of waiting. We waited for the doctors. We waited for women that were slow to dilate. We waited for things I didn't even know we were waiting for. The nurses were watching a downloaded movie on the television, while women paced the hallways, families cooked in the kitchen, and the shifts continued to change over. Finally, two doctors came to do rounds and I was told about all the things, surgeries, deliveries, and strange and peculiars that had occurred during the past week. A couple of huge fibroids that surprised them during a cesarean that caused them to do a strange-looking T-shaped incision and will likely lead to a hysterectomy; a couple sets of twins, one term, one preterm, but all healthy; and several tubal ligations, which seems to be encouraged and quite common. I was surprised by this - 21 year old girls getting tubal ligations. The access to and/or education about contraceptives is very limited, but tubal ligations are just so permanent. I won't harp on this. I'll move on.
Today was simple and easy. This really means uncomplicated, because we all know no sane laboring woman will say "that was easy" afterward. And that's not to say being there wasn't tiring, because I always find myself pretty worn out after any birth. The adrenaline just gets you. Three babies were born during my 9 hour shift, all within a couple hours of one another. The first I was helping with, when the midwife said she was going to step out for a moment. I continued to be with this young woman as she was finding her "push." She appreciated some manual pressure to guide her, and soon enough the head was crowning.  Eventually, two midwives came into the room and said "your assistants are here." They were going to let ME be primary. I was surprised, even though I'd heard stories of this. I was happy to do it, though. I felt ready, because birth is birth, no matter which country you're in. One of the midwives got into the young woman's face and strapped her feet down on the foot pads. A few minutes later, that midwife left the room, and her feet were unstrapped so as to pull her legs back and open up her hips. Seconds later, the head delivered - LOA it appeared, however strangely enough, that head that was facing mom's left thigh turned ALL the way around to face the right thigh while letting his shoulder free. Very owl-like. Happy, healthy little baby boy. Next, in the room across the hall, a woman was pushing so I popped my head in to see what was going on. The midwife in that room asked if I wanted to do the delivery. Of course, I said yes! Less than 10 minutes later, a tiny little baby girl was born. The mom was supposedly 35 weeks, but this baby was just over 3.5 lbs. She had a decent suck, nevertheless, and was "labeled" SGA rather than pre-term. Again, across the room, another woman was pushing.  Then, all of a sudden you could hear a huge gush and a good-sized baby girl was born with a lake-sized amount of water behind her. She was vigorous and healthy. The midwives were more than happy to allow me to suture, but today I wanted to learn their styles before I jumped right in. I've always found suturing to the be the thing I'm a little hesitant about. I've always found, all the same, that after I start, I actually enjoy the art of doing it. I'm sure I will get plenty of suturing experience here.
        After leaving the hospital, I took a little walk into town, which was mostly closed down. I grabbed some snacks from the only open mini-market, some peanut butter and crackers, and headed back to the hotel to read and relax.
Things I took away from today: 1) Despite being located in the middle of the South Pacific, the midwives in Vanuatu practice much like the midwives in Argentina, but with more patience. I found that to be very interesting.  2) While I think active management plays an important role in some births, I wonder about the role it plays in those placentas that are really hard to get out (something I experienced today). 3) The people of Vanuatu are so lovely and I look forward to the rest of my days here.