Birth in the non-supine position!

Monday, 9 Nov. Yesterday marked a momentous occasion in my stay here! Not only was it my 41st day (special only for its proximity to 42), but it was the first time I convinced anyone to try an upright position for pushing!

The women in our care here are equally afflicted by back labors and presumably posterior babies as our women back home. This is somewhat gratifying, because even though this is locally explained by laziness, it's probably not, and it means that there's not something we're doing especially wrong at home. (Or maybe we're all doing it wrong.) It's also super frustrating, because these back labors are long, difficult, feel very intense from the get-go, yet the contractions are poorly coordinated and somewhat ineffective. Iit's common to have someone coming in looking like very active labor and have her be at 2-3 cm. In fact, this weekend, we had a whole series who were at 2 cm for a full day! Logically we should send them home, because they're not in active labor. For various reasons this is not always possible, usually because they live far and don't have transport, and so we don't admit them but give them a bed in the extension ward. This leads to a feeling of still being in care though, with the accompanying requests for vaginal exams, which increases infection risk and frustration when the cervix is still 2 cm. I did send a few people home yesterday though! And one person "came back" only we hadn't discharged her and had no idea she was gone.

There are a number of positions that can facilitate a posterior or malpositioned baby to adjust his head position and make for an easier exit. These are usually assymetric and forward-leaning positions, and Penny Simkin's book The Labor Progress Handbook is invaluable for its illustrated suggestions. My success rate at recommending these positions is about 50%, I'd say. I usually demonstrate them for the family, my butt way up in the air, which has led to some photos (I want a copy of that, Amy!) and a lot of giggling. Some people can't be bothered, some are too tired already, some think they're just ridiculous, and some try them once or twice or only when I'm walking by.

My success rate at suggesting pushing positions, however, is like 2%. Most the midwives were trained in the flat-on-her-back school of pushing, grabbing one's legs or buttocks, holding the breath, and pushing pushing pushing. I never push it -- no pun intended -- but I suggest that she might want to try a squat, that it might be easier on hands and knees, that some people find they have more power kneeling, etc. It doesn't help that my limited Bislama -- and the apparent lack of word for 'squatting' in Bislama -- makes it difficult to explain what I'm talking about, leading to more instances of me climbing up on the adjoining bed and demonstrating.

S had back labor and a classic peanut-shaped belly, with lots of obvious fetal movement of small parts in front, suggesting the baby's back was along her back, facing front. This isn't always the case because babies are apparently like chubby owls and their bodies can be one way while their heads are basically the other, but still. She was pushing and making tiny progress, but it seemed like she'd greatly benefit from an upright position. When I suggested she try kneeling, and climbed up on the bed, hoisting up my gown to expose my knees, she actually did it! I couldn't believe it! And there was nobody around to yell at her and tell her to "slep strait!" just me and the student nurse who seemed delighted by this bizarre change in protocol. Once she'd gotten into position, I realized I had no idea how I would catch the baby. The delivery table was angled slightly, and I flitted from front to back trying to decide where would be the best place to be. There's a great birth video called Birth in the Squatting Position where babies just slide out onto the floor, and I've seen moms catch their own babies, so I knew it was entirely possible, but then I remembered a friend's thesis on obligate midwifery (based on the premise that babies are born facing back, requiring an attendant), and got confused. I figured it would sort itself out and positioned myself behind her as I had for the first couple babies I'd caught in the States, who were all born with their moms in hands and knees. Little by little, baby's head emerged, a millimeter at a time. It seemed painfully slow by Vanuatu standards, but this huge head -- part of a 3640g kiddo -- made it out with just the tiniest skid marks on the labia, no perineal tears at all! She was a primip, even! And the midwife who came in was delighted! She said maybe it was the first squatting birth in Vanuatu. I doubted this sincerely, but I hope the student nurse carries it forward -- she'll probably end up doing deliveries by herself in a small dispenary (clinic) on another island. (More about dispensaries when I finally get around to writing about my experience on Tanna.)

The rest of the day is a blur. The student nurse was on her way out when another mom was declared "fully" and she quickly had her baby. By the time I caught up with the paperwork on those two births, there were 3 more admissions, and two Australian med student friends came by to see if they could catch some births (since they're stationed on the med ward and haven't gotten the opportunity, I texted them to let them know we might have one that night). With them in tow, we managed a long, deep decel in a premature labor (thankfully resolved after adopting the open knee chest position, and hopefully the nifedipine stops her labor), a bunch more labor checks, some more admissions, and then two births! The first was a woman who'd been at 2 cm for 2 days and suddenly jumped to 8 cm with a very strong urge to push, and the next was a woman I'd sent home who came back at 9 cm and had a little boy! She also agreed to push in a kneeling position for a little while, and I think she ultimately delivered side-lying. I had a good time with Katie and David -- with Molly and Alex and Mel gone, and the Lycee students done with their observation, I've been missing having students to pal around with, especially those who will entertain my narrative teaching -- and they seemed happy to be deployed on various tasks and were quite helpful especially considering they insisted they'd only had a week of pregnancy so far. (I tried to go to Willy's presentation at his Lycee but missed it by a few hours, but he sent me his report! In French! Oh, the hilarity of my speaking French, especially throwing in Bislama words where my French fails.) I also feel like I've eased into new territory of feeling comfortable managing on my own, which is a nice feeling considering I've now finished my graduation requirements!

There was another woman who was ready to push right when I finished suturing the last one, but it was already midnight, the midwives were on their 3rd shift of the day, I'd been there for 14 hours, and we decided to go home. Pretty good day! And the busy-ness makes me think that maybe the October dry spell is broken. They only had 159 births in October. Pathetic! Why, back in April there were 278! And yes, I made a graph!

Life and Death.

[Elias] Saturday, October 17, 2009. 0530. This entry contains some pretty explicit details, and a lot of death. Please be warned, and don't read it if these things will disturb you.

The preemie Elias is 13 days old today. Two days ago he stopped breathing for the umpteenth time and I bagged him for 30 minutes, forcing air into his lungs until he started breathing again. He's stopped breathing again countless times since then. We think he has necrotizing enterocolitis. He's on many antibiotics, antifungals, and a combination of naloxone and aminophylline. I'm not sure he'll be able to kick this infection. Every time they feed him he stops breathing again.

The preemie of S was born today. I admitted her a week ago for vaginal bleeding. She'd bled a bit each month she was pregnant and had continued to bleed while inpatient, more and more, until the blood was mixed with amniotic fluid, and we were forced to admit that her membranes had ruptured. They decided to induce her today. Maybe 28 weeks, maybe 32 weeks, hard to tell. Island dates, like island time, is hazy. In my interview she told me that she had attempted to terminate the pregnancy with kustum medicine (local plant medicine) around 9 weeks of gestation. An abusive relationship had forced her back to her parents' household, who didn't want another baby in the house. When the termination failed, she figured she would place the baby with other family members. It was a troubled pregnancy. On admission, she was having rhythmic back pain, a possible sign of preterm labor. They gave steroids to mature the baby's lungs, antibiotics in case it was infection (and then later to reduce the chance of infection with the ruptured membranes). The obstetrician counseled her extensively, that the baby would probably not survive regardless of how he was delivered, and that if he did a c-section, that would greatly increase her risks in future pregnancies. There would be no VBAC on her home island, probably no c-section either. She might have 3 or 4 more babies. It was better to deliver this baby vaginally and preserve her future.

She labored today, Friday, and I caught her baby mid-afternoon, a tiny little guy with a bilateral complete cleft lip and palate. He made no attempt to breath, but his heart rate was good. I bagged him. The pediatrician put naloxone in his umbilican vein. Then aminophylline, and more naloxone, IV. Eventually he began gasping. We argued diplomatically about what should be done. I had been bagging for an hour. Respiration 5 per minute. Gasps, really. The pediatrician wanted to intubate, but the nursery has no ventilator, so it seemed pointless. I held him.

The family wanted to see him. The men first. What happened to his face? I explained that sometimes when the face is forming, it doesn't come together completely. Then the women held him. I walked away, thinking they could hold him as he died. He began to breath more in their arms, so they attempted intubation again. The first couple times they tried, the tube just came up bloody. In retrospect, maybe he had some kind of fistula as well. When we bagged him, the air didn't seem to reach his chest, just the base of his neck. They must have gotten the tube in eventually, because when I came back, he was intubated, with oxygen running through the bag mask, making little grunting noises with every breath.

The naloxone/aminophylline combination can keep a heart/lungs going for 6--10 hours. I was angry then that he wouldn't have the chance to make an easy transition, to come and go in the same block of time, with his family there.

A mom came in today in early labor, but the difficult, back-labor kind. It was her 4th baby. Her 3rd had died at 7 months. Her CTG was flat, with occasional decels. I did a second vaginal exam and managed to wake the baby up with the stimulation, and the trace improved. She labored on, walking up and down the breezeway with her family sitting on a bench nearby. I figured even a posterior baby can make it out of a 4th time mom. Time wore on and still incredibly slow dilation, if at all. Molly delivered a quickie, and I took her to be weighed and immunized, a 2.5 kg baby with incredibly long lashes and plump lips. I took a nap on the bed in the private room. I tried to reconcile what I had felt of the baby's suture with what I palpated in her belly, with the body high and off to the left. I watched a French drama on the New Caledonian channel. I made tea. I repeated her CTG. The Chinese channel was too much static. I made another jug of tea. Back and forth she walked in the breezeway. The student nurse -- we'll call him Adam -- stayed with her, rubbing her back, encouraging her. The 3rd year student nurses 'adopt' a woman as their case study, and attach their name and phone number to her chart and are called when they have visits or go into labor. We worked together, trying to figure out why this labor was progressing so slowly. I explained what we knew about CTGs and drew pictures of the position I thought the baby's head was in. Something wasn't adding up. I was stumped.

Yesterday we found a transverse lie, with the baby lying horizontally in the uterus, neither head nor butt engaged in the pelvis. This baby definitely had a head down in the pelvis. I turned my mental model around and around. This labor is different, she told me. This is not like my other births. I demonstrated all my tricks for turning posterior babies -- somewhere there is a photo of my demonstration last week of open knee chest on a gurney in the hall, my butt up in the air -- and she tried them all, exhausted and clearly in pain. Still she didn't progress. Her cervix was still soft and thick, asymmetrically dilated, 7 cm if I was being generous. She asked if she would have an operation to cut the baby out. You've had babies before, I told her. We know your body can do it. The baby was still tolerated labor in that mildly flat way.

Finally, a little before 3 am, she had an urge to push. We took her into the delivery room and checked her. Same cervix. I tried holding back the cervix, pushing it back and having her push so that the baby's head would come down and slip past it. After a few attempts at pushing, she got the head to advance. I beckoned to Adam and had him take over. The cervix came back. THe midwife held it back. Finally it stayed. Adam gowned up. The head advanced slowly. The baby came out screaming. Adam and I rubbed her down, clamped her cord, and took her to the warmer.

Ey! The midwife cried. A twin! Not funny, I said. My first week I had been convinced that a twin remained in utero. I thought this midwife was joking. She checked for heart tones and didn't find any, but she palpated mor eand was convinced. I checked inside and found a head. I ruptured the second bag of waters. Thick meconium streamed past my hand and the midwife told the mother sternly that she must push, but she was exhausted. Our insistence became more commanding. I held back the cervix again. The head advanced. This baby was born floppy, grey. The cord was dyed green with meconium. He was white, gray, purple. I felt for a heart beat and thought that I felt one, so I did chest compressions. We moved him to the warmer, moving over his calm sister, her lying head up, him lying head down. We sunctioned lots of meconium. He made no attempt to breath, and when we listened, there was no heartbeat. All the hours of resuscitating babies had given me phantom heartbeats in my fingertips. What I thought was muscle tone in his legs was rigor.

The midwife told me that he probably died yesterday, pointing out the features of fresh- but not just now- stillbirth. The other midwife on shift came in and looked at both babies. She said she would call the obstetrician about the stillbirth. Then she told, your baby in the nursery, he is dead. Finis. Fuck, I said.

I turned to the placenta. It was still attached. I waited. It came out reluctantly. Then the bleeding began. Torrents of blood. Metric fucktons of blood. Ey! The midwife cried, reaching across the table to turn up the edges of the waterproof mat so that it wouldn't flood onto my clothes and onto the floor. I looked quickly for a tear. The blood was volleying out, practically leaping. I looked for a pulsatile motion in case she had torn a vessel, maybe in the cervix, from pushing past it. We crammed gauze inside, Adam holding it in. Still she bled. On IV, running wide open, with 40 units of pitocin in it. Another large bore IV in the other arm, in case she went into shock. Exhausted to begin with, she began to shake her. I asked her please to not pass out. I couldn't imagine what it was like, first the long, painful back labor, then being told that you have twins, then that one has died, and then losing blood, a liter already, easily. Fuck, I said. If she has a tear, I couldn't see it. I called the number by the OB's name and waited impatiently for the instructions, first in English, then in French, to finish and give me a chance to leave a message. I called the next number. He answered groggily and said he would come in.

We looked at the bleeding. It appeared to have stopped. I thought there might have been a piece missing from the placenta and searched for a long glove to attempt a manual sweep. First I had to scoop away clots. Lots of clots. Clots all the way up. 500 mL of clots? Then the bleeding began anew. Fundal massage just made it flow harder.

Finally it slowed, just in time for the OB to arrive. All the pitocin appeared to have worked (20 IU in two injections IM, then 40 in the bag). She was still conscious, thankfully, with a good pulse and a decent blood pressure. Adam volunteered to stay with her and clean her up while I took the live baby to be weighed and vaccinated. We weighed the dead one, too. The problem was that the family only brought clothes for one, not two. We used the towel to wrap him. Then the midwife washed him and dressed him with clothes from the hidden stash. Parents here bring everything for their baby. Blankets, diapers, soap, powder, oil. They bring their own toilet paper and plates. They bring their own pads. This baby was dressed completely: diaper, cover, onesie, a knitted sweater, knitted hat, their own towel, and a donated quilt. He was wrapped completely, and his identification slip was taped to the outside. I wrapped the live baby in their blanket and took her back to mom to breastfeed.

Amazingly, the mother was still with it enough to receive her baby, happily even, and put her to breast. Baby nursed eagerly. Her family had gone home in the middle of the night, and she called them to return. (I have no idea where she kept her cell phone during all that. Any illusions readers have about people in 3rd world countries should be shattered by the rapidity by which the cell phone reappears after labor and texting resumes. Everyone has a cell phone here, and it is better than yours.)

After cleaning up a bit, I went into the nursery, expecting to see baby Elias dead, as the midwife had told me. I expected to see his grieving parents. His mother sits in front of his incubator all day. Her breasts are swollen with milk. His father, with whom I ventured to the revival, quit his job on a boat to be closer to the baby and his wife. Instead, I found his bili light still on, and his belly still moving slightly. It was the other baby who had died that morning, between the births of the first and the second twin. The one who was born the prior afternoon, to the mother with the premature preterm rupture of membranes, who had been subjected to the intubation, to the taped tube pulling his mouth way off to the side. He lived just under 12 hours.

People have asked me if I'm still glad I came. All the more so. Death is an amazing thing here. It is not a novelty. It is not an opportunity for blame. It just is. After all that, after all that labor and death and life and bleeding, the mother thanked me. I told her I was sorry the baby had died, and that was it. It was the same with the 28-weeker born earlier with the cleft lip and palate. His family said they were grateful we were doing all we could, and that they loved him. I explained that we couldn't really fix what was wrong with him, that he was very small, and that he might not live. They accepted that. There's no looking for someone to blame. The attempts to evade death don't have the same desperation as they seem to have in the US. The families thank us for doing what we can and make plans for burial.

The reality is that many fewer things are possible here than in the US. A premature baby in the US has a fairly good chance of surviving to a highly functional life, even with disabilities like deafness and blindness. A premature baby here does not have that chance. There's no NICU here. There are incubators but no ventilators. There are some drugs but not the same drugs. The babies are in oxygen-rich headboxes, increasing their risk of oxygen-caused retinopathies, if they survive at all. It's the arbitrary nature of it that I hate. A soul lands on one island instead of another, and that determines so many things about her life.