Stupendous

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!

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.

Saturday
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!

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.

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.

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

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

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!!

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...

 

 

 

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.

Final Week

Well, my time here on Efate is ending. I am sitting at the airport on a Sunday morning awaiting the departure of my flight to Nadi, Fiji. It is a very lovely day here in Port Vila. The sky is blue with patches of big cumulus clouds. As I look out the airport windows I see a big mountain range in the background and in the foreground I see palm trees and other lush green trees. There is a group of Fijian young woman who are travelling today. They are cricket players who had played 6 games in Efate and won 5 of the 6 games. They are rejoicing by singing and clapping. The NiVans are friendly and have been good to me as a visitor to their country. I will miss walking down the street and exchanging many greetings…”Halo”, “Gud night”. I will miss the bus rides and seeing all the people walking around. I will miss the 24/7, 6 days a week out door “farmer’s” market. I will miss the sun and warmth. I will miss my daily swims. I will miss the women and babies at the hospital. I have had an unbelievable experience and feel very fortunate that I was able to make the trip to Vanuatu.

Tanna Adventure

Week 4: Tanna Adventure

It had been quiet at the hospital this week so I decided to go with the women from New Zealand to the volcanic island of Tanna for an overnight trip. I bought my plane ticket at the local Vanuatu Air ticket office and packed my hip pack and was ready to go. We left early Thursday morning in search of a bus to take us to the airport. We had walked to the end of the street and I realized I had forgotten my passport. So, I ran back and grabbed it. I return and the ladies have still not found a bus. I see one and flag it down.

We get checked in at the airport and to our amusement there is a low budget film crew from Madrid, Spain who are frantically running around assessing their filming site, the airport. Annoyingly, they are holding up our flight for ½ hour’s time. We had discussed why hadn’t this film crew arrive early to get their film shots. Finally, the film crew had completed its business and we board onto a small plane. Tanna Island here we come!

We step down the stairs of the airplane onto the tarmac and walk over to a tiny airport, through the doors and look for our driver. Our driver is not here. In fact, he never arrives. We have forgotten the name of the place we are staying and did not bring the brochure. A woman sees our distress and approaches us to help. I had a cell phone with me and we find the number of the place we are staying in the phone history as I had called them the day before to reserve a room. The woman talks to Dream Island Bungalows (our accommodations) to find out that the river had been high and the driver was not able to get over to the airport in time to pick us up and that he had just passed over the river. So, the woman finds a driver for us and we are off to the East side of the island.

We have about a 3 hours drive to our bungalow on a road that is quite bumpy. We cross the river and drive over miles of wide expansive volcanic ash at the base of Mt. Yasur (the active volcano on Tanna Island). We continue on the bumpy ever-changing volcanic ash road and arrive to our bungalow. It is a beautiful setting overlooking a lake and the ocean. We get settled in and decide to hike to the local beach, which is about a ½ hour’s walk to the white sand beach. We arrive and go for a quick dip, as the sea was un-inviting (the current was strong). As we walk back we get caught in a heavy downpour. This was the beginning of the heavy rains that pretty much ruined our Tanna trip.

We had heard that when it rains here that it is difficult to drive up to the volcano. Despite the warnings our driver attempts to get us to the volcano. We try one road and it is no longer accessible. When you see small waterfalls in the road, it is not a good road to be traversing! The roads on Tanna Island are made of volcanic ash and when it rains here the ash easily washes out and the road changes in a matter of minutes. There can be holes in the roads, big drop-offs, un-even terrain, etc. So, back to the adventure of getting to the volcano… Our driver turns around and decides to take us on the beach to try another route. We “slide” a short distance down the beach and suggest going back to the bungalows. The driver happily agrees and we start our drive back. As we are pulling into the bungalows the left front wheel of the truck falls off. Luckily we are very close to our accommodations and this did not happen miles away in the downpour. The driver and his assistant scramble to look for the 6 bolts to the wheel as the sky is beginning to turn to night. We head to the dining bungalow to wait for our dinner and count our blessings.

After dinner we are exhausted and head off to bed. Our accommodations are simple, 3 beds and a table. I sleep on the bed underneath the window, which ends up being a mistake as it pours all night long with heavy gusts of wind, which blow rain on me over the course of the night. Elizabeth and I hear something crinkling in the room. She turns the flashlight on to see that there is a rat in the room munching on the bread that was left out. This rat was big! The body was about 8 inches long. She puts the bread in her luggage. I now have some trouble falling asleep; rain falling on me, rats crawling around, fleas jumping, etc. It is going to be a long night, as I think to myself. Shortly after the rat returns and I see it crawling up Elizabeth’s bed near her luggage which she has up on her bed. I call out her name but she is deeply sleeping. I shoo off the rat, which was the last I heard of it that night.

We awake in the morning to more rain and it is suggested to us that we get an early start back to the airport in order to make our 3pm flight back to Efate. So after our breakfast we begin at 9am our drive back to the airport. To begin the drive to the airport, we have a truck in front of us with 8 men with shovels who are creating the road for us to drive over as the rains had destroyed the road. This was a slow process as you can imagine. I get out of the truck to assess the situation and watch what the men are doing and think to myself, what am I doing here. As I walk back to the truck I take a look at the wheel that had fallen off last night to see that they had only found 4 of the 6 bolts that were once on the wheel. Hmmm, hopefully the wheel will stay on this time! We inquire with the driver regarding the wheel and he tells us he will drive us to the river and then we will get in another truck. Oh good! We arrive to the river and it is too high to pass. So we all squat at the river for a couple of hours. The river is at the base of the volcano and as we sat there waiting for the river to go down the volcano would “grumble” from time to time. To pass the time, I immersed myself in the Mistress of Rome, which is a great book if you haven’t read it already. Meanwhile, the men are assessing the river.

We get the okay to get in another truck to cross the river. In this truck to cross the river, I am standing in the back on the bed of the truck holding tight onto these bars. Oh, so this is going to be like a roller coaster ride. Nice! We are all ready and the driver starts the car and then just as we think we are going he turns the engine off. Okay, false alarm. We wait another ½ hour and then we decide to cross. And it was a breeze crossing the river. We drive for about a ½ hour and something is wrong with this truck and they pull over to stop another driver of a truck who had crossed the river too. Our driver asks the other driver if he could take us to the airport. He agrees and we are now in truck three of the day to the airport!

Now, driver number three is quite in a hurry to get us to the airport. We are slipping and sliding down the road. We end up in the ditch twice. The first time in the ditch we went I was not sure that we would make it out. There were many times on this drive to the airport I was uncertain if we were going to get there in time to board our plane. Although we got to the airport in time with a ½ hour to collect ourselves and reflect on what happened in the last 24 hours. Stepping onto the plane and off onto Efate terrain was a very happy moment for us 3 women! Lesson learned, check the weather forecast before going to Tanna and go when it is not raining.

Highlights of the quiet week at the hospital included lots of gauze cutting and folding, cotton rolling, scissor sharpening, cleaning, stocking and organizing. As well, one of the baby’s I delivered was from a 19-year-old woman who had inverted nipples. The mom and baby are the perfect match because the 3.42 kg boy had a great strong suck reflex.

The end of my activities here on Efate is closely approaching.

Busy Week at Vila Central Hospital!

Week 3

Miliaria is gone! Once I started using the air conditioning at night it cleared up.

This was a very busy week for the Maternity Ward at Vila Central Hospital. To follow is a few of the highlights of the week. I hope you are enjoying this and let me know if you have any questions or are curious about anything that I have not mentioned.

There were 2 vacuum extractions performed by the Doctor that I observed. One was to assist a mom during 2^nd stage of labor (pushing) because she had severe heart disease. Before the vacuum assist she had an episiotomy. This woman had a severe heart murmur you could easily see by looking at her chest wall. It was very unforgettable to hear and palpate. Her baby was thought to be somewhere between 36 and 39 weeks gestation and she delivered a 2.26 kg girl. The second vacuum extraction was performed on a woman who needed a little extra help and she had a big (3.92 kg) baby boy who had a cleft lip and hard palate. By the way, he did great with breastfeeding despite this anatomical deformity!

I continue to practice my suturing and observing the midwives suture. This week I have had lots of opportunities to strengthen this skill and I am feeling much more confidant suturing.

There were a couple resuscitations this week. One was on a 3kg boy who had AROM (artificial rupture of membranes). AROM is where the bag of waters are broken with a device called an amnihook. There was thick meconium in the bag of waters. His 1-minute, 5-minute and 10-minute Apgar’s were 5/5/9. He received suctioning and blow-by oxygen. Another was a 3.9 kg girl with 1-minute, 5-minute, and 10-minute Apgar’s of 3/6/10 and who was SROM (spontaneous rupture of membranes – bag of waters broke on their own naturally) with thick meconium. She received suctioning and blow-by oxygen. The mommy of this big girl had placental membranes that were slow to deliver and cervical prolapse.

A 24 year old G3P2 (3 pregnancies, 2 viable births) VBAC (vaginal birth after C-section) gave birth to a 3.14 kg girl with Apgar’s 9/10!

I observed another footling breech with a nuchal cord who had an emergency C-section. She had a 2.62 kg boy with Apgar’s 9/10. It was interesting to feel the little toes of this boy during the vaginal exam. I am very familiar feeling the heads of these little babies not little toes!

We had a baby girl who was BBA (baby born on arrival), which means that she had her baby at home. This woman had had her baby at home and her mother brought her in with the placenta still inside the mom and cord attached to baby. We clamped and cut the cord on the truck and wheeled the mom into the delivery suite where we tried to deliver the placenta. Unfortunately after a couple hours the placenta was not coming out. So we arranged for Dr. Robert to manually remove the placenta in the surgical ward. This is a very painful and invasive procedure that I witnessed and that I hope does not happen all that too often. She had been given the strongest analgesics and sedatives the anesthesiologist had. The placenta was completely manually removed and mom and baby are doing great!

Lastly, I had to help a mother a little with the delivery of her 3.4 kg baby girl who had been a little stuck and required me pulling her. It was not a true shoulder dystocia by the way.

For fun, I have been continuing my daily swims. The New Zealand midwife, Elizabeth, and her midwifery student, Angela, arrived. Angela and I went to go swim the swim course and dove into a group of jelly fish. I could not see any jelly fish but they were there. We both had this strange nerve tingling feeling all over our bodies. The sensation went away for both of us after a few hours. I have been scuba diving in the waters around Efate and the ocean environment is beautiful. I have been eating out a couple times to get a sense for the restaurants in the area. I had a wonderful fish dinner with mango chutney at a restaurant called Chill, which is located on the waterfront. It was during sunset and I saw a most magnificent sky. The cruise ship was leaving the port and oh my, this ship is huge! It had a big television screen, which I could clearly see the screen as it sailed away. I continue to enjoy my walks to the hospital whereby all the little children so happily greet me as I walk by.

Week 2

Well, I seemed to have gotten miliaria. No, not malaria! And for those who don’t know what miliaria is, it is a heat rash. For me, it developed on the backs of my hands and has spread to my lower arms, legs and feet. At first, I thought it might be an allergy to the latex gloves, latex is what is exclusively used in the hospital here. No latex free option for those who have developed an allergy to latex, which is a common allergy in those working in the health profession. It has been suggested to me to give it some time and my body will adjust to the heat. And to give myself a break from the heat, I have succumbed to using the air conditioner at night when I sleep. I have slept better since doing this.

Recently, I have been thinking a lot about life and death. A fellow peer at Bastyr was on a Nicaraguan study abroad trip this Spring break and drowned while swimming in a lake. Her name is Michelle Eustache and I knew her as a very enthusiastic and curious person and it is sad that she is no longer part of this physical realm. Please keep her parents and those closest to her in your thoughts and prayers.

There have been several deaths at Vila Central Hospital in the Maternity Ward…

Sadly, the 960-gram, 25 week old baby boy I told you about in the last post died.

And the baby in the nursery with the omphalocele that I also shared in my last post has passed away as well. It is very sad. The baby was healing well and the omphalocele was receding and seemed to be improving.

When someone dies in the hospital many people gather around and wail. It can go on for an hour or so. The echoes of this last loss still permeate in the memories of my ears. It is hauntingly eerie sounds that some women make. From my observation, it seems very healthy for the family and friends to be together and to discharge this energy.

So some birth highlights of week two here in Vanuatu…

Getting lots of practice in the artificial rupture of membranes. The midwives like to use this technique to speed labor progression.

So far, the youngest birthing mom is 18 years of age and the oldest is 37 years of age.

I manually replaced a prolapsed cervix of a 37-year-old G4/P4 woman. After that, I had educated her about Kegel exercises, which don’t seem to be something well shared here. These exercises bring tone the pelvic floor muscles, which get super stretchy and lax after childbirth. They are exercises we all can benefit from doing.

I observed an elective C-section of a footling breech presenting baby who had a nuchal cord times two (the umbilical cord was wrapped twice around the neck)!

And the largest weighted baby was a 3.92-kilogram girl (that’s 8.64 pounds) which is big for NiVans!

And for a little rest and relaxation, I have managed to go for a swim everyday since I have been here. The ocean is nice and warm and the pool where I am staying is a nice cool off from a hot day.

I went to church with one of the nursing students on Sunday. We took the “bus”. Which is a man who drives a van and will take you wherever you need to go for 150 vatus. We were taken to a rural area, which was well taken care of by the inhabitants. The gardens were lovely and well tended. As we walked up to the church, I quickly discovered that the NiVans have very strong and beautiful singing voices and I love the lyrics to some of their songs. They sing about the value of life and being thankful. It is interesting to hear them sing so loudly and strong because most NiVans are soft spoken, men and women alike. I have heard on a couple occasions a NiVan shout but mostly they talk softly. On this particularly Sunday there was a group of men soccer players from Mele village (a village that has the famous waterfalls on Efate island) who sang a song for us. It was interesting to me to see these men become quite shy and humble before us. They sang wonderfully!

More to come wait patiently…

First week in Vanuatu!

Hello! So this is the story of my adventure to a small "developing" city, Port Vila, in the Republic of Vanuatu on the island of Efate. I arrived last week safely and got started the following day of my arrival at the local hospital, Vila Central Hospital, in the Maternity Ward. My first day I arrived at 7am and was warmly greeted by one of the sistas (midwives). She casually showed me around as we waited for everyone to gather for the report from the night shift. So much has gone on this last week and I will briefly summarize. There have been 3 "sheksheks", otherwise known as earthquakes. One was 6.5 and 26K's beneath the Earth's surface, this one I was sitting at the Midwives station doing paperwork when the building shaked. It got eerily quiet for a few seconds and then after it was over everyone went back to their business. Last week I have been getting familiarized with procedures, language (Bislama), who people are and where things are at. Everyone has been super helpful and friendly. There were a lot of normal births early in the week, not much unusual last week. And with the full moon Saturday, the maternity ward became quite busy. Later in the week, we had a premature delivery of 25 weeks, one smol pikini, 960 grams, from one petit mother! The baby is doing well in the nursery. Unfortunately we had a delivery of a baby with hydrocephalus (excess fluid build up in the skull which leads to brain swelling) and an omphalocele (whereby the intestines stick out the belly button) and sadly this baby did not make it. Currently there is a baby in the nursery with an omphalocele and is scheduled for surgery this week for repair. One mom had a nuchal cord (a super long cord wrapped 3 times around the neck)! I was able to reduce it. Whereas another mom had a super tight nuchal cord wrapped around once and I was unable to reduce it and ended up clamping and cutting the cord on the perineum. This little one we ended up suctioning and giving some oxygen and within 5 minutes was no longer blue and was pinking up. In the short amount of time that I have been here I have become aware of how much I really do know through teaching the nursing students. I enjoy sharing the knowledge and they seem to be very curious. Until next time...

I am Very Thankful, and Will Miss....

As my time here comes to an end, I am reflective and thankful for the people and all that I have learned. I will miss the constant smiles, even from mom's amidst their most challenging parts of labor. I will miss holding the hands of these women as they gently say, 'ohhh Mrs., ohhh Mrs.". It has been such a pleasure to help these lovely people and have them thank me after the birth when really it is them who deserve the thanks and praise. I will miss the kindness of strangers; the other night I was coming home from dinner alone and trying to catch a bus, it wasn't late but it was quite dark. I quickly realized that there weren't many of us on the street. A couple of men asked if I was alright, at first, due to apprehension I didn't answer. They asked again and I said yes, they didn't come closer but instead made sure to find 2 security guards who were close by and said, "make sure you help this lady get a bus and not a taxi, okay" (Taxi's are at least twice as expensive here). I thanked them and the security guard who helped me, and a bus was along in no time. I felt looked after. I will miss the students asking me questions and observing their learning. I will miss the beautiful babies who cry when they get their injections and then peacefully relax as they sink into my hands when I wash their hair and give them their first swim (bath). I will miss the family and community support that is so evident here. I am thankful that I have not only met and exceeded my "required birth numbers" during my time here (I have over 100 births total!) but that I have been able to help with many other tasks as well; whether it is making gauze, cotton balls, sticky strips to be used as band aids, cleaning the labor ward, assisting with breast feeding, etc. I am thankful that I have truly gotten to be a part of life at Vila Central Hospital. It has gone so quick! Over the past few days I have helped with more lovely, uncomplicated births and been able to see a few mom's who have returned to have their babe's weighed and I love being able to catch up on how they are doing. I plan to visit with a family in the next few days whose baby I helped delivery (my first week here). I am thankful that the little girl who I delivery at 30 weeks is still doing well. I am thankful that the cyclones that occurred while I was here didn't do any major damage, that the Tsunami warning that came in the middle of the night, went without impact and that the 2 earthquakes that I felt yesterday also have not harmed any of these amazing and open people. I am thankful for the babies that I knew, even for a small time. Their little souls have touched me, even the souls who left their bodies before I knew them have had an impact on me. I will miss the midwives generosity and laughter. Even though at times I wasn't sure what they were talking about, their laughter was contagious. I will miss a lot and am thankful for countless experiences and the beautiful, resilient people here.

The Downs and Ups

THE DOWN'S:

It has been a while since my last post in part because I have found it challenging to put words to the experiences that I had over the past week/weekend. I will try to recount the events as I experienced them, with the disclaimer that the following stories are sad, hard to read, and at times hard to re-live. I also want to make sure to note that I believe that those involved have done the best they can with what they have and know, although I would have handled the situation in a different manner. With that said this part of the post involves death and I advise skipping to "The Up's" at the bottom if you don't want to read about it. I am going to try to keep it brief.

I came to the hospital last week to find that a planned c-section had occurred for the purposes of ending a pregnancy. The mom was 30 weeks gestation (same age as the little one I delivered the first week I was here...who is still doing well). She had an ultrasound earlier in the week and the findings were that her baby had severe hydrocephalus (a condition where there is water on the brain and swelling of the head occurs). Sadly, they do not have the resources or ability to put a shunt in, as would be done in many other parts of the world. Knowing that the newborn would not survive and that the size of the head would continue to grow larger if the baby was allowed to continue in utereo, the family and doctors decided to do the C-section as a termination. The issue, was that most knew the baby was going to be born alive. I was not in the room for the section but one of the students (who I have become close with) was and she re-counted the events for me that left her quite sad. When the baby was born one doctor wanted to suction him to help him out, and another doctor said "no, just leave him." He was alive!

I was in the labor ward when one of the midwives brought the little bundle in, all covered in blankets. This little boy was very much alive, still breathing, and giving small whimpers. She said the doctors said we are to leave him here and she set him on the cold receiver (which had not been turned on). I walked out of the ward to get the story on this little one who looked just fine to me, although there was liquid on the brain that you could palpate. Once I realized that he was being left there to die, I couldn't help but return to the room to put my hands on him, uncover his sweet face and gently talk to him. Mom was still in post-op. After discussing the case with a few others who felt deeply touched by the situation I turned on the warmer and another midwife gave the little one oxygen. He gave little crys. I walked out of the room momentarily and then returned to find that the doctor had turned off the warmer, taken away the oxygen and exposed his little body to the air. I was in the room when the father walked in and I heard as the doctor described, "baby no good". The family knew that the boy wouldn't survive but I am unsure how much they understood of just how alive he would be, when he was born.

After the dad left, the midwife asked me to weigh the little boy. With tears mounting behind my eyes I picked him up, wrapped him again and gently carried him to the scale. He was 3 1/2 pounds. I cried as I brought him back into the ward, and I refused to leave him uncovered. He opened his eyes as I walked back with him and I saw that him mom was being wheeled back from surgery. I set him on the warmer.

The student who was so disturbed by the on goings at the c-section had left the surgery and saw me in the labor ward crying, she said, "Kate that is exactly how I felt". However, within minutes I had to very quickly collect myself as another woman was brought into the room, pushing! We needed the warmer (which doubles as the resuscitation area- if need be) to get ready for this next baby so we put the 30 weeker in a bassinet in the same room where he continued to give small crys. The head was right there for this mom of one, yet I could tell that part of her bag was still intact so to make it easier for the baby to come out, I broke her bag. A thick black substance like I have never seen before came out (an extremely bad sign), very old meconium. Next thing I knew the little boy was born but had clearly passed away at least 1-2 days earlier. I checked for a heart beat anyway and another midwife called a doctor in to confirm that he was in fact deceased. He also had some serious malformations. I was unaware that prior to coming into the labor ward, no one had listened for heart tones on this babe (there may not have been time).

One other time I have been involved in the birth of a still born, however the family was aware of the situation. I have never had to give a mom the news before. I was told that she was 35 weeks but after looking at her chart saw that by her dates she was only 27 weeks along (although the baby did look closer to 35 weeks). We later found out that she had a fall one week prior where "water came out", she did go to the antenatal clinic when this happened. She also reported that she hadn't felt baby move since the day before. I wiped the little boy down and wrapped him as best I could and handed him to his mom, telling her that I was so so sorry for her loss. It was terrible! And the other little boy was still in a bassinet in the room, alive but quietly and slowly leaving his body. It is an indescribable feeling to be surrounded by that.

After the delivery this woman's mom left to get clothes to dress the deceased boy in (as they do here) so she was alone and in visible shock. I asked her if there was anything that I could do for her. She couldn't answer me verbally but I know she understood me. I gently rubbed her back. After a while I was instructed to also weigh this boy- this was one of the hardest things I have ever done, I gently took him out of her arms and spoke to him as I walked to the scale, again in tears!

I returned and gave her the boy to cuddle with again. Her husband was a teacher so he was at work. I took the other baby (from the c-section) out of the room and brought him to his parents and extended family to spend his final moments with them. I let them know that he was still alive but I was unsure how long he would survive. He died about an hour and a half later with his family. The other boy stayed in a private room with his family for most of the day.

There were two more births that I helped with that day (that went very well) however the day had still taken a toll on me and I felt I needed to take some time away. I cried a lot that day. Many of the staff felt greatly effected by how the case with the boy with hydrocephalus was handled and there has been much discussion, reflection, and prayer. For the most part I am very impressed by everyone out here yet that day was a hard one, a day that has really made me thankful for the resources that I am privileged to have, should I need them. I have 2 step siblings who have a half brother that has hydrocephalus, when he was born he was "the size of a coke can", he is now 16 years old and a track star. I took the following two days off to reflect.

Another "down" to share, before we get to the good. Early this week a woman (almost 40 years old) came in, in labor with her 7th child. That is what she told us....although, her belly was flat, she said she was due the following month but had been having contractions. I palpated her abdomen but didn't feel anything, and we couldn't get a heart beat. With the help of another midwife I asked a few questions, "had she felt the baby move?" Yes, a lot. "Had she taken a pregnancy test?" No. "Had she sought pre-natal care?" She had been to the clinic once at the beginning. We thought it best to call in the doctor on-call to address the case. The midwife told me that this was the third case she had experienced like this. The doctor arrived and brought in his portable ultrasound machine to show the woman and her husband (who had brought all of the clothes and supplies along for her and the baby) that there was in fact nothing in her abdomen. It was very very sad, they thought she was in labor and in fact she was not pregnant! I am not quite sure what this woman's mental situation/stability was.

I returned home after a very long day (12 + hours) to find that a pair of my flip flops that I had left outside my door for the past 3 weeks, had been taken. Without energy to get that upset I was a bit annoyed and went to bed.

THE UP'S:

I woke to find that my flip flops had been returned. They were in the same place I had left them before heading to work early the morning before. I guess someone just wanted to borrow them for the night! This made me laugh out loud.

As I mentioned briefly before, I am happy to report that baby Sonya, the sweet little one who was born into my hands at 30 weeks pre-mature is doing well and needs less supplemental oxygen on a daily basis. She is still in the nursery and mom still stays at the maternity ward to give her hand expressed milk to the little girl every few hours. I have seen the young mom helping others out with their babies as well.

I got asked if I wanted to attend a portion of a 3 day conference that was occurring in town. It was about the state of maternity and neonatal care in Vanuatu and more specifically Efate (the island I am on). There were members from the WHO, UNICEF, UNFPA, doctors, pediatricians, midwives, and nurses in attendance. I came to the session on the Role of Midwifery Care. The statistics were interesting and the presentation really got the director of the WHO generating ideas for how to improve the numbers of midwives in the area and the conditions under which they work (long hours, understaffed times, etc.). I was glad to attend.

Last week the ambulance went to pick up a mom and her newborn who was 'BBA'- Born Before Arrival; this was her third baby and the previous one was a c-section. Baby was unintentionally born at home with the assistance of a traditional birth attendant (a community midwife, who has learned via experience). All is well with the new addition and mom.

Later in the week I attended a very lovely and loving labor. I have only been to one other birth where the partner has been in the labor room, and it was their 4th baby. This time, it was the mom's first pregnancy. She was a young 20 year old and her boyfriend was at her side, holding her head up, encouraging her, giving her sweet kisses the whole time! It was so nice to see. His mom was also there helping her along. When the baby came out she needed a little extra assistance to come around. I was so happy when she finally gave a cry and really came into her body. The uncle entered the room not too long after and I don't know if I have ever seen someone so overjoyed and excited for the family, her was laughing and crying at the same time! I helped this mom breastfeed for about an hour. Dad made sure to get my name and took photos of me on his cell phone. They had been discharged by the time I got to work the next day, (another sign that all was well) so I am unsure if there is a little Kate around or not but none the less, it was a beautiful birth with great support.

I have been able to help support the student nurses along their training and be by their sides assisting as they help deliver more babies and practice their skills. It has been rewarding to see how far some of them have come in just a few weeks!

One of the midwives met her 20 year old niece for the first time when she came to the hospital for antenatal care this week. She lives on another island, the family had moved there right after her birth so this midwife never got to know her. It wasn't until she checked the unusual name with the name of the father of the young girl that the midwife realized this was the daughter of her brother! I am not sure if she has had her baby yet but I hope the aunt got to be there if she has.

Also, I walked into the labor ward to see a woman pushing and the midwife asked if I wanted to do the delivery. Of course, yes! As I was coaching and supporting the 23 year old through the delivery the midwife informed me that she had delivered this young woman (23 years ago!!). That was really special!

And finally for now... there have been 70 births in the first 11 days of March here at Vila Central Hospital. This is actually down from last year (if you can believe it!) which means that the sex education that they have started to provide at some major events here (i.e. Independence Day- which is 9 months prior) may be working! However, I have also been told that some use the condoms that have been handed out, for fishing bait "because the spin so well in the water" =) Hopefully they are also being used for the intended purpose.

Can't believe I have only just over 1 week to go! This has been a truly amazing experience, one which I will forever be blessed to be a part of. I have told the midwives that if they ever make it to Seattle they will have somewhere to stay...in fact MANY places to stay as all of us that have experienced their kindness and tutelage would probably all be wanting to house them!

Thanks for reading!

2 Sets of Twins!

I awoke at 6am at the hospital to get a report that the mom of twins was 5-6cm. I went to check on her as she was being monitored on the CTG (Electronic fetal monitor- for heart rate and contractions). I rubbed her back and gave her smiles, during a contraction she would quietly say, "ohh Mrs." At about 10am we moved her into the labor ward to get checked by the doctors who had also been over seeing her case. They decided to break the bag of twin I (the one who was head down) and advised to begin induction at 12pm if she was not in more progressive labor. I stepped out of the room for a minute to find we had a new admit. A woman who was having a planned c-section in 2 days, she had 2 previous sections, and also twins!

The NZ midwife asked if I wanted to help and we brought her into the other side of the labor ward to be assessed. We could tell by her breathing that she was having a urge to push. The midwife did a quick vaginal exam and found that not only was the woman fully dilated but there were 2 feet there!! She asked the woman to try not to push, said, "Kate can you put an IV in?" and with that, quickly left the room to get the doctors who were meant to perform the section. Soon after about 4 people came into the room and one doctor said, "On the ultrasound they were head down" - Not anymore. Moving swiftly we got another bed in the room and had her transferred to the operating theatre. I didn't think there would be time to get the epidural in before this set of twins arrived; however they managed to get her numbed up in time to get both babies, who were BOTH breech, out safely. We sent one of the students in to observe and she was over the moon when she came out of the operating room. Everything went great! The twin girls were brought back into the labor ward and placed on the warmer to await their injections, swim (bath), and scale (weight). As they laid arm in arm, our mom in the next room was surprised that they were out already and she told me she was feeling as though it was time to have hers. It seemed as though something might be holding her back though.

It is not uncommon here to have a Vanuatu Midwife say to the women with a stern but effective voice, "You no cry!" I went in to support the mom and she told me that she wanted to cry but the midwife said she couldn't. She had also shared this with one of the student nurses that was around. When the midwife was not in the room, I did a vaginal exam finding she was at 7cm at about 11:30 and I told her that it was okay to cry. Again, I rubbed her back and she repeated, "Ohh Mrs." Enter the midwife (who, don't get me wrong, I very much like). She started the induction and within 10 minutes the mom of twins was fully dilated. I got into place to catch twin I. She came out head down, screaming away, big and beautiful. Then the doctors and another midwife were in the room to assist with the breech twin if necessary. I smiled up at the mom in between births and reinforced what a good job she had done. Again I got ready to catch, I did a quick VE (Vaginal Exam) to confirm the position- it was a leg! We waited a few minutes for twin II to present. Next thing I knew, not only did a little foot come out, but so did a hand! Seriously! Imagine that, and straight away came his bum and the rest of him, except his head. Both myself and another midwife were hands on, within seconds and with a bit of assistance the smaller sweet little boy was born. I again gave mom (who had been silent through out pushing) a big smile. Many hands were around to help as I delivered the 2 separate placentas at the same time.

Right away another midwife brought both the girl and boy over to the mom for some skin-to-skin time. I have never seen a bigger smile in my life- it was so so beautiful to see this mom with her two little ones in her arms and her ability to express her feelings, that this time I couldn't hold back my tears. Slowly multiple family members entered the room to meet the two new additions. All three are doing well and I have checked up on them everyday since. It made my week!

Delivered a baby with very "sticky shoulders" yesterday, to a young 23 year old who was post dates. This would be her second pikinini, she was just shy of 8 pounds (large for here). And today, everything began very slow and quiet. I had time to make a whole box full of cotton balls, yes, by hand! They have a large roll of cotton wool that you pull apart and roll in your palm to make the balls. They also make their own gauze squares here (of which I have also made a load). Anyhow, in the afternoon a woman came in pregnant with her first baby. I stayed outside of the assessment room as the nursing students practiced their skills of blood pressure, pulse, palpation, and attempting to listen to the little one. The woman sounded as though she was in very active labour- close to pushing I would have guessed by listening from 5 feet away. After about 15 minutes I went in to check how things were going. The woman's water had broke in the car on the way to the hospital and I asked how far dilated she was, they told me 5cm (half way there). She didn't want to sit still and was trying to take the monitors off of her belly. I asked her if she wanted to get up and she said yes. I told the students that she was welcome to get off her back and stand up as long as they could continue to monitor the baby. I watched as the woman began to silently push - I felt as though she may just be trying to push prematurely and feeling baby's head (as can sometimes happen)- the vaginal exam of 5cm from 5 minutes earlier had also been confirmed by the doctor.

Next thing I knew the woman who had started to get off the bed, quickly got back up and I saw a head and shoulders emerging! No time for gloves, I grabbed the sheet that was at the foot of the bed and caught the little man as the rest of his body was very quickly born! I rubbed his back and blew a little in his face to get him to come around and within about 30 seconds he was singing away with his cries. Poor mom had gone into labor just under 2 hours earlier! When she said she needed to push, she meant it! I was so thankful that she managed to get back onto the bed in time. I helped to get baby onto the breast after the midwife repaired the 2nd degree tear and made sure he had a new warm blanket on. I have heard that babies "fly out" here and this birth was truly one of those cases! After going over a few things with the student who had helped out, and cleaning the assessment (turned labor) room I headed back to my bungalow for a shower and dinner. I am sure tomorrow will bring more excitement, but hopefully we will be able to get all the mom's into the labor ward this time, before they push their babies out! All is well =)

Another Lovely and Busy Week

Since last week, the weather has affected the phones (which are still not working) and the internet where I am staying so it has been challenging to add to the blog- but every so often I find an internet connection so here we go! This week has proved to be just as eventful as the last 2! I am continually amazed by the strength of these women and the community that surrounds them. Often I ask the support person if they are the mum (of the laboring woman) or a friend and sometimes this is the case but also I observe cousins, aunts, and neighbors stepping in to help. It is really quite beautiful how everyone looks out for each other and how extended families live together under the same roof. During the week one of the mom's who I helped last week returned to the ward to have her baby weighed. Her older sister has taken the family in as the new dad is not able to be around (due to school commitments) for the first 6 months. This is the mom (that I wrote about previously) who left the hospital after I had done an initial assessment on her and didn't return until the next day when I found her vomiting in the hallway. She and her sister are both lovely, I was able to visit with them for about an hour as we had an unusually slow period and they waited for the pediatrician. At their request we exchanged e-mails and they told me that they would really like to see me before I leave and wanted me to be able to see baby Uriah again. It made me feel wonderful; I actually ran into the sister in the supermarket a few days later and almost felt like a local as we both greeted each other with large surprised smiles and the traditional kiss on either cheek. I look forward to meeting up with them in the weeks to come.

I have been blessed to help out with many more births over this past week, in addition to assisting the Vanuatu nursing students with their required births and skills training. It has been a great combination to be perfecting and learning new skills myself, as well as teaching and reinforcing knowledge with these great young students. I have formed relationships with a few of them and I love it when they come and ask me questions about IV's, injections, bleeding, newborn breathing patterns, or anything in between. I have watched as some of them catch a baby for the first time. And sometimes it is a group effort. In fact, a few days ago one of the students did his first catch and after inspecting the perineum we noticed that the mom had a first degree tear, the midwife there at the time turned to me and said, "okay and now Kate will sew this up". I was glad to work on my skills again and this time it didn't take an hour.
More beautiful babies are in this world!

Saturday was quite eventful... I got to catch 3 babies and in between help out with a few other mom's. I was sitting at the front desk writing up the birth report and entering names and statistics into the one of many books they keep records in, when a Vanuatu woman quickly walked to the desk speaking in Bislama, the words that I understood were "blood and come now!" I followed her to the showers where I found a mom who had given birth about 2 hours earlier (with the help of one of the students), she was standing in the shower and there were a few very large blood clots at her feet. I had her sit down immediately and quickly went to get another midwife to help out. We got her into a wheel chair and took her back to the labor ward, where she passed out in the chair just before getting to the room. See quickly came around and we got her up onto the bed to assess her bleeding. As we re-inspected the perineum I pointed to something that looked "different", the midwife replied "oh that's the cervix" however I just wasn't convinced so I continued to inquire....turns out what we were looking at were retained membranes (hence the bleeding-even a very small piece can make a woman continue to bleed, or get an infection), once the piece was removed and a bag of fluids had been put into the woman she was doing very well. I stepped out of the labor ward to find a very concerned looking man and I asked him if he was with "Celine", he was very pleased to have me tell him that his wife was going to be just fine and thanked me (more than once) and I could see and feel that relief sweep over him.

Not too long after this, one of the nurses asked if I could help pick up one of the postpartum mom's who had "fallen out of bed and wee'd all over the floor". Poor woman, she has been at the maternity ward for almost 2 weeks now as her newborn needed extra help and was in the nursery. Women stay as long as their babies do (we have someone who has been there 52 days!). This mom had been waking every 2 hours to hand express milk and then feed her newborn. When we got to the unusually obese woman she was on the floor next to the bed and very confused. I thought she may have had a seizure, but after asking more questions to those around this was ruled out. We moved her to a room closer to the front desk where she could be monitored closer and called the doctors in for a consult. She has very high blood pressure, very low hemoglobin, and was extremely fatigued (among other medical concerns). After getting a unit of packed cells she seems to be doing much better- I give her a big smile anytime I see her walking about.

Just after this happened I brought a laboring mom into the delivery room, to assist I broke her water and soon after she was ready to push out her son. I had just finished sewing up a first degree tear and making sure baby was feeding well, when I turned around to see another woman in the labor ward getting ready to push her little boy out. I was there in time to catch him and make sure all was well (according to her dates she was only 35 weeks). No suturing this time =). 8 hours at the hospital and I was ready to head home for dinner.....yet there was a mom of twins who had been admitted earlier that day and I really wanted to be around for the birth so after dinner I returned to the hospital for another 6.5 hours. No twins tonight but I got to help a postdates (43 weeks) mom have her 3rd boy. She arrived at the hospital and had her baby in her arms 2 hours later.

I was able to assist another 17 year old with the birth of her sweet son. Her water broke the night before she came in and I took her case. She was not contracting and by her dates (which are often off here, even by a month) this young mom was only 33 weeks gestation. She received steroids to assist in the development of her unborn babe's lungs. After 36 hours of ruptured membranes she also was started on antibiotics to prevent infection (not common practice for us). Finally after being at the hospital for days the doctors decided to begin induction. Everything happened very quickly for her and as I was supporting her while she was having a CTG (Cardio Toco Graph- records the heart beat of the baby and contractions), she literally was getting contraction on top of contraction and was climbing the walls and crying. The trace of the heart rate didn't look great and intuitively something felt off so I called in the midwife for a consult. We did a check for dilation upon my request and found that babies head was right there!! I didn't even think we had time to move her into the delivery room but we wrapped her in the gown that we had handy and quickly took her across the hall. In about 5 minutes this young mom had her screaming (very term looking, which means at least 37 weeks old) baby in her arms.

I was still waiting for the twins to arrive. Earlier in the day when I was looking after the mom of twins- who would be pikinini's number 7 and 8 for her she started speaking to me in Bislama....after a little while I smiled a big smile and said, "sorry, my Bislama is small small" to that she replied, "I said, that I like you very much". It was heart warming, I told her that I would love to be around for the birth of her babies. So when I left the hospital to have dinner with my 2 midwife friends from New Zealand on a nearby island, I made sure to put a pair of scrubs in my purse so that I could have the bus take me directly back to the hospital that night. When I got back, still no twins but there was an emergency ectopic pregnancy removal about to occur. I went into the operating theater for observation. After the removal of the one fallopian tube this woman had remaining I left the operating room with a heavy heart- that was not was I was expecting to see, although I was happy that this woman was alive because a ruptured fallopian tube can easily lead to death. It was about midnight, I had shared the banana's and passion fruit that I had bought at the market earlier with the Midwives on duty, the pregnant mom of twins, and her support people (one who happened to be her first born 18 year old daughter). Then I decided to take the Midwives up on their offer to lay down in one of the two private rooms that they have (for mom's), making sure that they knew to wake me if the twins decided to become more active. I felt like I was back on call again! Kind-of exciting, waking every so often to the sounds of newborn cries from the babies near by.

More on the twins in the next entry....stay tuned.