April Fool's

Apparently, these past few days were meant to be a challenge for me; emotionally, mentally, physically, spiritually. And, as we all know (and for which we often hope), the pendulum will swing the other way.

After the death of Eve’s small girl, I took the day off. The morning after, Caitlin witnessed her community gathering to be present with her and her daughter. Her pastor was there, sisters, cousins, aunties, uncles..even young children came to pay their respects to the small one. Her death was not shielded from anyone in the community; her life was celebrated. They all walked into the small room where the baby was and prepared her for her funeral as a group. Their love and support for her was palpable. Give thanks.

When I went into the ward the next evening and following day I assisted Sunita and Caitlin with lovely births. Pink, screaming babies…and, quite honestly, exactly what I needed to see. I went back in on Tuesday morning, April Fool’s Day, to find a quiet ward. Two mothers on bed rest: one, a 19 year old with her first pregnancy of twin (!) girls and another on bed rest for premature labor. The mother-to-be of twins was showing early signs of pre-eclampsia, a multisystems disorder that was manifesting in her as hypertension, protein in the urine, and edema (tissue swelling). She was 38.5 weeks, quite far along for a twin pregnancy, but the OBs were worried of her progressing to the more severe eclampsia and they decided to induce her. I was asked to place misoprostol just behind her cervix, a prostaglandin E1 substance used for stimulating uterine contractions. At the time, she was having small, mild contractions and active labor seemed a long way off…

A slow morning, we spent the first few hours folding gauze, making cotton balls of varying sizes, and chatting with the ladies of the ward, as much as we can with our slowly improving Bislama. We discharged mama and baby duos, which consists of a newborn exam, a second baby weight check, paying of the hospital bill and a trip to family planning. All fairly routine. Perhaps the most entertaining part was trying to use our Bislama to get the women to follow us to administration.

Throughout the day, Sunita and I each managed a delivery. One small girl into my hands, one bigfala boy into hers. The mother of the small girl had some pretty severe vaginal tears, quite deep into the vagina and I was grateful when one OB offered to take her into the theatre to help repair her. She was given a spinal as anesthesia and after about an hour, the repair was complete (and looked quite good!…as far as post partum vaginas go, anyway).

By 6pm (12 hours into my shift at this point) the mother of the twins was fully dilated getting ready to push. We phoned the OB, wanting him to be present for the delivery, particularly of the second twin, as she was in a breech presentation at that point. She continued to breathe through her contractions for the next twenty minutes, and began to push. Now, before I continue with this birth story, I have to insist that you sit down, if you are not already, for what you are about to read will floor you.

The room felt like the inside of the furnace. I, in my sterile gown and gloves, was covered in sweat, and the mother, working harder than anyone I’ve ever seen before, was covered as well. Caitlin, Sunita and the mother’s auntie were phenomenal labor support. Sunita managed to monitor fetal heart tones and hold up the mother’s muscular leg, Caitlin held the other leg, and the Auntie was wiping her brow, whispering words of encouragement. We encircled the momma with such protective field of support and love. It was awesome. The first twin joined us in the delivery room about 1.5 hours later….completely face up! A straight occiput posterior baby (which, for those of you not in the know, means that the diameter of the baby’s head was increased by about 2 cm from the preferred, well flexed, occiput anterior position) was delivered with the help of a mediolateral episotomy. (Incidently, the first one I’ve ever seen done).

After the first baby, I felt inside for the other twin with the help of the OB. We tried to see if the baby was still breech or if she had turned head down. I felt the bag of waters and was instructed to artificially rupture it and tell the OB what I felt (he was hoping I would say suture lines). After a large, but slow, draining of fluid I made my report. “I feel labia.” He double checked my assessment, and indeed, this baby was breech. Seconds later, the second twins right leg was hanging out of the vagina. I cannot begin to tell you how bizarre that looks to a person so used to seeing heads present first. With breech presentations, footling or complete, there are two rules. Leave it alone, and make sure that the baby eventually comes out face down.

The OB talked me through the delivery….let the baby turn on its own; wait for the other hip to deliver; once you see the left knee, gently deliver the foot; leave it alone; never press on the baby’s stomach; only make contact with the bum and thighs; wait until you see the shoulder blades; press this way, now that way; now reach in and, bending the elbow, deliver the left arm; wait; now, see, here is the other shoulder blade; reach in and deliver the right arm. Good. Now we wait. See how she is moving her chest? She is getting ready to deliver. Wait until you see her neck…now, reach in with your right hand, supporting the baby on your forearm, and place your finger in her mouth. Make sure you are in her mouth! Use your left hand to press up into the back of her head and press up, do not pull. Encourage the flexion of her had with either hand. Do not pull on the shoulders…wait…come on…come on…and then, cries from the second little girl. Both babies healthy, the mother triumphant, exhausted and grateful.

The mother had quite a bit of bleeding and clot formation. All in all I think she lost over 2 liters of blood. Her placenta delivered, and it was beautiful. A two room apartment, the rooms separated merely by a transparent wall. Diamniotic twins. The babies were placed in the warmer next to each other, seemingly gazing at one another in their new world. The rejoicing, newly made bubu (grandmother) named the second twin after me…she said I was busy, busy, busy. I was honored. One small Katherine blong Vanuatu.

And, Sunita joked how it was quite appropriate that a footling breech born on April Fools day share my name, and that the grandmother somehow observed the fact that I have a hard time slowing down….does anyone else think that is funny?