Earthquake-o-namai

Elias here. There was an elective c-section this morning (they call them "cesar") for a woman who'd had 2 c-sections before. I was in the operating room watching when I felt a little wobbly. It was very hot and I hadn't had breakfast so I thought I might be passing out. I checked in with myself again -- yes, wobbly -- so I went and sat down. Then the anesthesiologist asked if I'd felt that earthquake. Oh! An earthquake! Then I'm fine!

After the surgery he checked online (who knew they had a computer with internet access in the operating section?!) and told us there was an 8.1 earthquake off the coast of Santo and now there's a tsunamai warning. In the maternity ward they turned on the radio (audible really only to the postpartum women) and we listened to warnings in Bislama, English, and French (then tropical music), advising everyone to go to higher ground, with an estimated wave arrival time of 5 to 15 minutes. They were saying the Ministry of Education had closed the schools and the kids were being sent home. I went back and forth a bit, weighing the baby, giving him shots, then helping him to breastfeed while the mother was in recovery. (We felt what we thought were aftershocks while she was in recovery. There was actually a second quake, but based on the timing, I think they were aftershocks, since this would have been after 10am and the first quake we felt was 9am.) Once she was settled in the postpartum area, we figured we'd go watch from the point at the top of the stairs down to the coast level, so we took our lunches and went our phone number in case the twin mom got close to delivery. They were saying the water in the bay in Santo had receded quite a bit, which seemed to suggest that there would be a big wave here. There were many others watching there as well, some with radios. I chatted with some Australian soybean farmers (covering a wide range of topics, from local obstetrics practices to genetically modified soybeans), but then the warning was lifted and everyone else left. There was some light rain, some wind, but not enough of either to cut the heat!

There aren't really any emergency services here (though we did see a coast guard-type vessel in the bay), but we're staying on fairly high ground (though close to the coast) so it would have been fine for us. They're accustomed to earthquakes but not tsunamais, so people were somewhat concerned. The Australian med student told us that the shelf of the reef makes it difficult for a wave to gather much momentum (as opposed to Samoa, where it's a very gradual incline up the ocean floor, which allows a wave to really collect itself). Would have been cool to see, but I guess it's fine it didn't happen.

Update: an initial news story and a later news story (post-non-tsunamai) about the quake and the warden message sent by the state department (I registered with the State Dept with my itinerary):

Dear Wardens

This warden message is being issued to alert U.S. citizens residing and traveling in Papua New Guinea, Solomon Islands and Vanuatu that a tsunami warning for ANUATU / SOLOMON IS. / NAURU / PAPUA NEW GUINEA / TUVALU / NEW CALEDONIA / FIJI / KIRIBATI / KOSRAE / WALLIS-FUTUNA / HOWLAND-BAKER

A tsunami watch is in effect for MARSHALL IS. / TOKELAU / KERMADEC IS / POHNPEI / NEW ZEALAND / SAMOA / AMERICAN SAMOA / TONGA / AUSTRALIA / NIUE / COOK ISLANDS / CHUUK / INDONESIA / WAKE IS. / JARVIS IS. / PALMYRA IS. / GUAM / N. MARIANAS / JOHNSTON IS. / YAP / MARCUS IS. / BELAU The U.S. Embassy will continue to monitor the situation, and will issue updated messages. U.S. citizens are urged to locate shelter, monitor media reports, and follow all official instructions. U.S. citizens should carry their travel documents at all time (i.e. U.S. Passport, Birth Certificate, picture ID's, etc.) or secure them in safe, waterproof locations. We also suggest that American citizens contact friends and family in the United States with updates about their whereabouts.

Earthquake-o-namai

Elias here. There was an elective c-section this morning (they call them "cesar") for a woman who'd had 2 c-sections before. I was in the operating room watching when I felt a little wobbly. It was very hot and I hadn't had breakfast so I thought I might be passing out. I checked in with myself again -- yes, wobbly -- so I went and sat down. Then the anesthesiologist asked if I'd felt that earthquake. Oh! An earthquake! Then I'm fine!

After the surgery he checked online (who knew they had a computer with internet access in the operating section?!) and told us there was an 8.1 earthquake off the coast of Santo and now there's a tsunamai warning. In the maternity ward they turned on the radio (audible really only to the postpartum women) and we listened to warnings in Bislama, English, and French (then tropical music). They were saying the Ministry of Education had closed the schools and the kids were being sent home. I went back and forth a bit, weighing the baby, giving him shots, then helping him to breastfeed while the mother was in recovery. Once she was settled in the postpartum area, we figured we'd go watch from the point at the top of the stairs down to the coast level, so we took our lunches and went our phone number in case the twin mom got close to delivery. There were many others watching there as well, some with radios. I chatted with some australian soybean farmers, but then the warning was lifted and everyone else left. There was some light rain, some wind, but not enough of either to cut the heat!

Learning the Ropes

It is late in the afternoon, the sun is hanging low in the sky, shooting rays of yellow, orange and pink over the Vila harbor. This is a harbor that I am getting to really know and love, from the inside out. Yesterday I did my usual swim in the calm, clear, early morning waters. Lovely. This past weekend I was delighted to spend two afternoons sailing on a large wooden pirate boat, Cassiopeia, with a fabulous crew of folks. I'm "learning the ropes" and taking in some fabulous sunsets. Oh, and dressing up like a pirate, too! The group of baby-docs from Australia, Elias, and myself headed out for a sunset cruise on Cassiopeia on Friday night and played to part by rummaging through an impressive collection of pirate clothes, and went to work hauling the sails on our way out of Vila. I returned on Sunday with some other folks for another sail, swim, and sunset. For such a water baby, this is a magical place!

The sun rises about 5am and sets around 6pm here, which I am loving. I am a morning person more than a night owl, which is a funny thing for a midwife since the company I keep tends to be more night-owl like- the babies, that is.

We had a busy night at the hospital last night, luckily with a full crew of midwives and students. 2 of the local midwives, 2 midwives who just arrived from New Zealand here for a working holiday, Elias and myself, and Alex, a baby-doc from Australia were all on hand. Even with the help, we were all busy. Over the course of our 9 hours there, we had 5 babes born, easily enough to share amongst us! Alex and I took the first one. I was happy to be able to coach her through catching a baby from the midwifery perspective, since all she has had exposure to thus far in her training has been through OB care. Last week after observing some births with the midwives, she confided that she's having some questions about being a doctor- she wants to be a midwife!!! Although a first time mama, this 21 year old was amazingly efficient in pushing her baby out. And Alex did a fabulous job of keeping the head from popping out to quick, ending in a lovely birth. Although her perineum and vagina were intact, she had split one of her labia, directly adjacent to her clitoris.

As you may imagine, birth folks or not, this is a very difficult and sensitive area to suture for the obvious reasons. With the coaching of one of the New Zealand midwives, I went for it. In Seattle, it is somewhat rare for students to get much suturing experience. I was lucky enough to suture 8 or 9 times before I came to Vanuatu, working with a variety of midwives, so I felt up for the challenge. This is also a big part of my purpose for coming to Vanuatu, in addition to the few births I needed for my requirements, to really get my suturing skills up to par.

All went well, and this amazingly stoic mama took it all in stride. WOW!

The other birth that I managed was a second time mama who walked in very calm and relaxed, not having had any prenatal care, but saying she was in labor. We checked her and she was nearly "fully" (aka fully dilated) so we encouraged her to walkabout. She was quickly complete, we ruptured her bag of waters and within 10 minutes she pushed out a sweet baby girl. No tears, no complications, a nice way to end the evening for me. It is in this busy maternity ward that I am reminded how often birth does JUST HAPPEN. This past year was oh so challenging in the birth practices I worked with in Seattle (which I attributed to the year of the OX- hard work and struggles), and I yearned for births where women just gave birth. Period. I am grateful to have all those challenging births under my belt, however, for experience, and I'm soaking these up and charging my birth batteries once again!

Today I slept in after our late night at the hospital, and headed out for my second scuba dive this afternoon. I'm happy to report that I had no problems with my ear this time and was able to enjoy the experience so much more. Yeah!
I was aware today of how few experiences in life are so greatly dependent on the breath. In yoga we use our breath joined with our movement. Scuba diving is similar for me. It's meditative for me, the rhytmic breathing and the ascending and descending that occurs with the breath. And the fish are so curious. I guess I do look pretty funny with my mask and fins and regulator- they must be thinking what kind of fish are YOU? I just laugh and they swim on! I noticed some underwater plants today that resemble our land-based ferns- they even seem to have fiddleheads! I also spotted a few lion fish and some tiny shrimp (i know, shrimp means small.... but there were really tiny!) A successful dive on a beautiful day. Below is a shot with the other baby docs as we suited up before our first dive last weekend! That's the Vila Harbor behind us.



Lastly I headed to the market where I decided to taste some of the local fixins. I roamed around through the booths to find one that had a menu and ordered the curry with chicken, rice, and vegetables. As I waited for the woman to fix me a plate, the woman at the stand next door started talking with me and we made a date for me to come and learn some cooking from her in her little market kitchen. As many of you know, cooking is central in my life and learning from one of these fabulous Ni-Van women will be a real treat.

I made my rounds in the market, purchasing a huge bag of fresh tomatoes for 200 vatus (about $2), wild raspberries, pawpaw (papaya), parsley, a mango, and last, but certainly not least, about 12 pounds of sweet potatoes! This is notable for several reasons: first, they are sold in these baskets-of-sorts made from banana leaves and bark (which are very strong- thank goodness), secondly, all 12 pounds cost me a whopping 500 vatus ($5), and third, my challenge was to walk back to my digs with all the above treats on one arm, and this massive basket of sweet potatoes in the other. And so I began the journey home.... I started out on my walk, down the main street of Vila, congested with buses and crossed over to the steep staircase that takes me up above the main harbor, stopping at a conveniently placed bench at the top of the stairs for a breather, then on past the roundabout, up cresting the hill, then down through our local neighborhood, around the corner, and finally home. I received some pretty funny looks from the local folks..... i probably wasn't carrying the basket as it was intended, or maybe people just take the bus when they are hauling such a load, or maybe they wondered what I, a whitie, was planning to do with all those sweet potatoes! It's a good question..... we'll be getting really creative with them! Oh and there was that one sweet potato that continued to fall out of the basket, forcing me to balance both of my loads in a way that allowed me to bend over and pick up the lone potato. I'm sure I dropped a few here and there as I walked, which will undoubtedly be eaten by some of the chickens that run about through the streets, or used as a toy by a group of pikinninnis (Bislama word for child) that play in the streets.

Home at last, I'll be making a delicious tropical fruit salad and heading into the hospital for more adventures in baby catching before the sun goes down. Mmmmmmmmmmmm..... abundant paw-paw!

3 Highs

Elias here. It's just after midnight and I just got home from the hospital. I got a ride back with the hospital truck and a bunch of other hospital folks. Even though it's only 2 blocks the other midwives didn't want me to walk, so I went along with them.

I'm hiding in the bathroom so as not to wake Molly (though I desperately need to shower which may wake her anyway, and for that I apologize -- sorry Molly!) but need to write because I'm so totally stoked.

You know it's going to be a good day when the little boys in the neighborhood actually talk to you. I was walking down the street towards the hospital and they were shooting at birds with slingshots. Aside from machetes, slingshots seem to be the weapon of choice of this neighborhood. Our security guy, for example, can occasionally be found with his own slingshot and pile of rocks. I have no doubt of their efficacy. I said hello, what's up, to the boys and one of them asked where I was from, so I told him, and then asked his name and introduced myself. (I also asked him where he was from, and he patiently explained that he was ni-Vanuatu, from Vanuatu.) Then I asked the name of the bird they were shooting at. Basically I am getting better at asking questions in Bislama, but like my ability to ask the location of the facilities in Japanese, I am completely unable to comprehend the response. Regardless! A connection! We chatted a little more (where are you going? the hospital?) and then parted ways. I was tremendously cheered by this interaction! It's a little odd having this quite nice studio apartment surrounded by corrugated tin shacks. Over the wall, of course.

I got to the hospital in time for the shift change just before 4pm. There were two preterm labors in progress, one that had been effectively stopped and who was just waiting to complete her course of steroids (to mature the baby's lungs in case the labor couldn't be stopped) and the other who was plowing ahead.

She'd had a CTG (fetal monitoring strip) done a little while before that had showed some decelerations (possibly a sign the baby wasn't handling the labor well), so we were going to repeat it at 4:30pm. I repeated it and it looked good, but she said she wanted to 'sit-sit' so I checked her cervix. The last check two hours prior she'd been 3 cm, and now it was gone! Baby right there! We all hustled across the hall to the delivery theatre. This baby was 34 weeks and 4 days and quite small. Her membranes had reportedly ruptured last Friday, but when the baby's head approached, he was still within the bag, so the other midwife picked a hole quickly with tweezers.

The baby delivered quickly -- little dude was little, after all -- but the placenta came at the same time. This has the potential to be super bad news -- the baby needs the placenta to be attached while he's being born so he can keep receiving oxygenated blood, and the placenta usually separates 5 or 10 minutes after delivery. Had she not birthed him when she did, and had the placenta still separated when it did, he could have died. He was incredibly small and not breathing. (When I was guiding him out, I was shocked to feel his shoulder blades so clearly -- he didn't have much in the way of fat layers.) We took him over to the warmer and I stimulated him, but it wasn't enough so we gave him positive pressure ventilation breaths (rescue breathing with a bag/mask). It took 4 or 5 puffs for him to start, and another couple to get him really going, but he did okay. We left the mask on him with oxygen. I asked if we could use the pulse-ox to see how well he was oxygenating, so we put it on his foot. Under the hood (a little lucite box that fits over the baby's head) with oxygen up pretty high he had great saturation, but whenever we lowered it it went down, so we left it flowing. I'm still in awe of how calm and unflustered the midwives here stay. No fuss, just doing what needs to be done. And no alarms, either. Can you imagine an American hospital without audible alarms?

Meanwhile the midwives were trying to track down the pediatrician (the one who was supposed to be on call was sick) and I checked the mom for tears (none) and tried to do a little informal check on the baby to check his maturity. He was 1.320 kg (around 2.9 lbs) and working very hard to breathe. He was transferred to an incubator in the nursery, where the pediatrician checked him and ultimately started him on glucose (and probably antibiotics? maybe more steroids?).

The next baby came quickly after that. This one ended up having a tight cord around his neck. I couldn't get it over his head and didn't think I could get his body through it, so I ended up clamping the cord and cutting it while his body was still inside. This is a high-stakes choice because if you can't get the body out, you're in a similar situation to the above -- the baby has no oxygen supply. Luckily we got the rest out of him out promptly, and he started breathing quickly and well. Compared to the preemie this guy was huge!

We had a lull then, and I sat in the tearoom with the midwives and watched first some Australian old-school revival/crusade, and then the international news (an aggravatingly Ireland- and sports-focused newscast, first in English, then in French), and then a great local show (a collaboration between AusAid, NZAid, and Wan Smol Bag Theater) called Love Patrol, a health-focused soap opera! It's fantastic! This episode was about HIV, being HIV-positive, how people should react and not be afraid. The sisters shared their dinner with me. At first I was going to decline (I'd scarfed a Clif bar a little earlier), but then I took them up on it, and was very great I did -- a rich chicken-vegetable soup with cabbage and carrots, and also the oxytocin-enabled glow of sharing food! We'd been talking a lot, and again, I felt an actual connection, the kind that comes when you can make jokes. They coached me on my Bislama and attempted to fill me in on the backstory in each of the 17 story lines on Love Patrol. I admitted knowing nothing about the Lisbon Treaty, which was the only thing besides tennis and racing covered by the news. I asked a lot of questions about what food is good to get, plant protein sources, all that good stuff. There are apparently local beans (in addition to green beans) and now I have a rough idea of what they look like at the market.

Then we had a bunch more admissions and another baby. This one also had a tight cord around his neck, but I'm wondering if maybe I could have gotten him through it (somersaulted) instead of cutting it, but at the time, I couldn't get it over his head, and the midwife couldn't get much slack out of it, so we cut it again. Luckily this one was also born fairly easily (with some insistent traction) and breathed well. She had a tear, and I decided I wanted to see how they sutured before I bungled another job, so I watched and tended the baby, then took the baby to be weighed and immunized. They have this great, massive scale with a dial reading the size of my abdomen (and I have substantial girth). The baby goes on top in a welded holder that is actually shaped like a baby, keeping them semi-upright (unlike our scales where the babies are fully supine). Then baby goes back to the changing pad on the counter while I draw up Hep B, Vitamin K, and BCG (if it's open). Last year they ran out of BCG (an immunization against TB that isn't used in the US, in part because it gives you a positive reading on the PPD skin-prick TB test that we use) so they're being extremely cautious with their supplies and only opening a vial if there are enough babies to use the whole thing. Any babies who don't get it at birth get lined up for when the vial is opened -- clearly this appeals to my logistics obsession. The vitamin K they're using is an oil, which is torture if you're used to a water-soluble preparation. The oil takes forever to draw up because it's so viscous, forever to inject for the same reason, and 1 mL of oil seems like a lot to put in a little baby thigh! (Though they actually seem to cry less with the vitamin K injection than with the Hep B injection. I wonder if the Hep B stings. Probably.)

There were some other folks still working through their labors when we wrapped up, including a woman who seemed to have some fused cervical vertebrae. She wasn't progressing as quickly as they would have liked, but I think she'll keep progressing slowly and hopefully have her baby before morning.

At shift change I finally got to meet their male midwife. There's another guy working on Tanna (the island with the volcano), but this is the guy the other students have been telling me about. He seems nice, soft-spoken. We didn't have much time to chat before we went to catch the hospital truck for a ride home. I'm going to try and figure out how to get a placement on another island's health center to see what it's like. Tanna has a hospital too, which would be great, to combine working with a trip to the volcano.

Today was the kind of the day where every time you come out of the delivery theater with a baby you see yet another laboring woman walking in: a good day.

The above photos are part of my Vanuatu photo set on Flickr.

Not my first day, but the subsequent two

2/10/2009 10:37 AM, Port Vila, Vanuatu. I am hard boiling eggs. The eggs are small, maybe 70% the size of the regular egg in the US. We got them last night at the open market, 30 eggs for 700 vatus, so probably around US$8. If you buy eggs singly they can be as many as 50 vatus apiece. The day before yesterday there were no eggs at the market. We stopped by last night on our grand survey of stores and markets last night and found them, and little bananas which had little black bugs which prompted me to put them down on the pavement and suffer the hilarity of the American guy afraid of the bugs, but if you had read the chapter in Getting Stoned with Savages about the centipede you would have been afraid too!)

I'm hard boiling eggs because the sisters at the hospital sent me home because there was nothing going on. We had already discharged the 3 post-partum patients available to be discharged. Then another sister commanded me along on her mission to do nursery rounds. The nursery babies were actually with their mothers in the "extension" ward, another room across the breezeway. All the wards are open. Each woman has a bed and a little basket on wheels for the baby, which is covered with mosquito netting. Most of the women have a relative staying with them also. This is indicated on the big board by "+ relative x 2." They cook for themselves. There is a shower and bathroom in our ward for them to use.

At some point I will get over my resistance to taking photos of relevant things and actually take photos of the ward.

So, today I discharged people, which involves writing things in 3 books, and did nursery rounds, which involves taking temps and doing pulse oximetry and asking the mom a few questions. Temps are done with a body temperature sensor (pressed against the baby's chest). The sequence for using it appears to be: press on. Press on a bunch more times until it displays "Er 3." Then it counts down and says "Ready." Then it's pressed against the baby's chest and displays the temp in Fahrenheit, which is noted on a piece of scrap paper until it can be compared against a chart of Celsius conversions. Pulse ox is done with an adult-size pulse-ox on babies who are decidedly not adult-sized. In fact, these babies being held are under 2.5 kg or premature or both. They have tiny toes. It usually gives a reading anyway though, and these are noted on the paper as well. Then we ask "titi good? piss-piss? sit-sit?" and note that they are breastfeeing well, urinating, and stooling.

When we get back to the nursery (a small room with a sign "Incubator Room") these notes are transferred to stacks of paper on clipboards, which constitute the inpatient records of the babies. None of the babies are referred to by name, just "B/O Marie" which is to say, their mother. The midwife set me to the paperwork, then gave me a little book on Ob/Gyn protocols for the country and told me to sit and read it so I can learn how they do things there. I did.

There is a small tea room with a TV, a hot water dispenser, and today's newspaper, which features a photo of Barack and Michele Obama with the PM of Vanuatu and his wife at a museum in New York. Many people have asked me about Obama, if he is good. "First black?" a sister (Annie, I think) asked me today. (I'm terrible with names.) I really want to bring home a copy of the paper. It's a mix of English and Bislama and includes a gossip column, government job postings (in English and French), and on the front page was the continuing saga of Little Sharon who has a tooth abscess and needs surgery in Australia but the Australian government won't give her a visa and so they might need to go to New Caledonia instead (continued on page 3).

Yesterday was quiet on the ward as well, so Sister Annie took me to the Antenatal Clinic. It was quiet there too, but soon a woman came for her prenatal appointment. The visits are scheduled for a general time of day, and the women wait in a waiting room with a TV playing educational DVDs. All the charts are in big binders on a table at the front of the room. There is a teenager sitting out front, checking people in, reading a novel otherwise. The sister handed me the woman's chart and indicated I should begin. I balked and asked if I could watch her do a visit first, which I did, but then she expected me to do the next visit on my own, which I did, in a halting mix of Bislama and English and confusion over what to ask, even. (I've grown reliant on the checklists we use at our clinic.) Every visit needs the basics of blood pressure, weight, how the woman is feeling, if the baby is moving well, but then I started drawing blanks. That was deemed sufficient, and the woman climbed onto the table and I did Leopold's, feeling the baby's position, and tried to estimate how far down into the pelvis the baby had descended (which they note as a score out of 5). Then I used a fascinatingly old and large Doppler to check the baby's heart rate (using KY from a tube instead of ultrasound gel). This woman was almost 35 weeks, so we decided she should come back in 2 weeks (noted as "2/52") in the morning, which I wrote on her appointment card (the back of a piece of cardboard on which all the appointments were noted and subsequently crossed off). This card is also used as a convenient ID -- it looked like she presented the card at the door, which enabled the nurse to get her chart. Then we all moved back into the midwife's office, where she was dispensed prenatal vitamins (iron and folic acid) and chloroquine (for malaria prevention) for 2 weeks (the tablets are assembled into little baggies in advance and stored in cylinders marked "1 week" "2 week" etc indicating how many weeks' worth of medications each baggie contained.

The sister (midwife) and I sat and talked for a bit, about different protocols, the services they offer in Antenatal (including family planning, cervical cancer screening, and PMTCT, which she repeatedly referred to in its acronym form until I finally asked -- Prevention of Maternal to Child Transmission of HIV). She was well-read on all the latest MTCT research, and while I read a journal on international sexual health, she flipped through a new comic book (produced by AusAid) breastfeeding, which she gave me a copy of and while I will prize as my Bislama tutorial book. (It's a very relevant story about a mother who goes back to work, so the grandmother starts feeding baby a tea from orange leaves, and the baby wastes away. At the end she learns how to hand-express her milk, how long breastmilk can stand on the counter, and how to feed baby by cup.)

There was still nothing going on in Maternity, so I headed back to our studio, and Molly and I went out to faire le shopping! I had read about a Chinatown, and we were in sore need of cheap food, so we made a big ring (including a stop at the ATM -- WestPac is in affiliation with Bank of America, which works well for me) and found all the cheap Chinese stores, most of which were still pretty expensive on the canned food front, and none of whom had dry beans. We found a little Au Bon Marche (upscale grocery store) where they had soy milk (but I didn't remember why I wanted it). We did not find a place with a sunglasses string (which I was hoping to use to keep my glasses up -- my sweat is proving an amazing lubricant to my new plastic glasses) but we did find meat (my Eat to Live sensibilities are being put on hold while legumes prove difficult to find) and cheaper cans of beans at the closest store (French-speaking Chinese-run). Bean and beef chili for dinner!

So, basically, two days without babies. But! On my first day! 3 babies! I went with Molly so I could have a little intro/transitional day before she went to a different shift, and Sister Leigtagni asked if I was ready to start, and I said "sloslo" but then we had all these babies quickquick! And oh, the paperwork! Oh, the books to write in!

The hard-boiled eggs are ready, so I'm going to pack up some lunch and head somewhere on the water. I'll try to blog more often and hope to dig up the details of those births (and my first suture job) because they're replaced by more.

(The wireless is really terrible at our place, so I haven't been able to upload photos. Maybe tonight I'll go to Nambawan Cafe to re-re-attempt.)

My First Vanuatu "Cesar" and Namesake

I've had a few very busy days at the hospital, the kind that you just work through lunch because there are so many women waiting to be checked, admitted, or are about to push their babies out. A few women and their experiences are to share......

I worked with a young, first time mom all day Monday and returned Tuesday to find her still at the hospital in labor. This was one of those primip (first time) births....... all you birth related folks out there know exactly what's to come.

Her latent labor started Friday and she came into the hospital when her contractions picked up around 8 am Monday morning. When I first checked her that morning, her baby was still floating very high in her pelvis, completely unengaged. Her cervix was dilated to about 3 cm and it was partially effaced (thinned out). Not much change happened over the course of Monday and when I retruned Tuesday she was 6 cm and her baby was engaged in her pelvis, all good signs that her labor was progressing. We suspected that her baby was also positioned posterior, which is a difficult position for any baby to come out, but especially with a first timer. As Tuesday continued, her contractions were irregular and spaced out, so the doc recommended we rupture her membranes and start an IV drip with syntocin (aka pitocin) to augment her labor. Upon rupture her water showed moderate meconium (the babe's first poop- a sign of some form of stress somewhere along the way). Her contractions did pick up more regularly with the Syntocin, but she started having the despised uncontrollable, premature urge to push while her cervix remained at 6cm. This mom was exhausted and as I have seen SOOOOO many times before with this same situation in the States, I was was hoping I could see a different outcome. Alas, the doc decided it was time to do a "Cesar"- C-section. I felt the same way I always do after these long labors, often several days, ending in a Cesar. I was able to scrub up for the surgery and receive the baby after he was born. There was a fabulous anesthesiologist from Australia running the show- a very personal, kind being, just the kind of person you want to be watching over you while you're having major abdominal surgery.
The surgical theatre was an interesting experience. Although I've never attended a Cesar in the US, I have observed them while in Costa Rica. This experience seemed overall the same, but it seemed more relaxed in lots of ways- not in safety terms, per se...... hmmmmm, not even sure how to describe the differences. I looked up at one of the surgery nurses in her scrubs, her mask, and her hair wrap, and amongst all the covering, there i saw a little white flower tucked behind her ear. Yes, in a way, that seems to sum up the experience...... if that makes any sense at all in this two dimensional story.
The surgery was a success and a sweet baby boy who had been not only posterior, but had a hand up near his head with the cord around his arm, was born..... gives some reasons as to why he couldn't come down or turn around to get out vaginally.

The Cesar rate here is around 5%, on average about 10 Cesars per month. During the 24 hour period leading up to this young mama's surgery, we had 2 others, filling nearly a third of those for the month in one day. One Cesar was for fetal distress with every contraction, and another for a pair of twins who had thick meconium and were showing some distress. As always, things seem to go in waves, and often in sets of 3.

Yesterday, Elias and I spent our first day together at the hopsital, as he just arrived on Tuesday afternoon. It was lucky that he was there because only one of the two midwives were there because the other had a family member pass away. So it was going to be just me and the other midwife, until Elias showed up. We had 4 births between 11:30am and 3pm. I caught the first 2, Elias took the next, and a student nurse who came on for the next shift took the last. I particularly wanted to write about the second mom that I worked with because she is what we call a Grand Multip. This was her 9th pregnancy. She has 7 children: 5 boys, 2 girls, and one of her pregnancies ended in a stillbirth due to a cord complication. She was planning a tubal ligation after this birth, so this was her last baby and she had recently found out that it was another girl.

She was 3cm upon arrival in the morning and when we watched the babe's heartrate on the CTG machine, we saw some decelerations with her contractions. At that point, her contractions were about 10 minutes apart, but it was undeniable that the decelerations were happening with the contractions. We moved her from side to side, started an IV to give fluids (especially as a preventive for postpartum hemorrhage since a uterus that has been stretched 9 times may have less ability to contract after the birth to stop the bleeding), and we broke her waters to see if there was meconium in her fluid, which there was a light amount. We kept her on the CTG to monitor the babe and meanwhile ran off to catch the first babe of our shift. At some point the midwife moved her into the other birth theatre, and she was just walking around, having a few more contractions here and there. I was finishing up with the postpartum events of the other babe, fondly referred to as "stickem and scalem"- giving them their injections and weighing them- when I heard lots of commotion and moaning. I ran back into the theatre literally just in time to put my hands on the babe's head as she came out, to keep her from shooting out like a cannon! She took awhile to come around and breathe, but within a minute with some good stimulation, she was breathing fine. I took her out for her pokes and to be weighed and when i returned, the mom told me that she was going to name her baby Molly. I think after 9 kids she either ran out of names, or she appreciated my care ;) I told her that there was a high probability that this little Molly would be a midwife someday, since there are so many of us "Molly the Midwife" from Bastyr. Although some women here have no interest in seeing their babes after they are born, this mom, even after 8 other births, was excited to see and asking for her baby. That's me and this little "Molly-the-Midwife-to-be" while she received her first swim-swim (Bislama for bath)!

Today I'm taking it easy and heading out for a kayaking adventure..... with a full moon in the coming days and the change in pressure we are experiencing, it's likely to make the babies drop!

The Vasovagal Reflex.... Narrowly Averted! and more...

Friday I was at the hospital for most of the day. I walked into the hospital and heard a woman in the "theatre" pushing her babe out. There are several student nurses here who are also trying to get experience, so one of them was managing that birth. So I took the opportunity to just observe and give support as needed. Well the first thing I noticed was that it was particularly hot and stuffy in the theatre that morning..... this was the third birth that had happened since midnight, so there was the smell of birth in the room.

The AC wasn't working and I was standing next to the baby warmer. I felt just yucky.... wooozy..... and could feel the vasovagal reaction building. For those of you who have had the pleasure to be around me in the perfect circumstance when such a reaction has occurred, you can see it written all over my face, right? Pale as a sheet and a glazed look in my eyes. Yes, I've been a fainter my whole life, since the time when I was touring the hospital in my kindegarden "Brownies" troop (aka pre-Girl Scouts) and the smell and the warmth of the room was too much and down I went for the first time. As a 5 or 6 year old, that was a bit terrifying, especially when I awoke in a wheelchair thinking I might be dying. Well, I wasn't that time, nor was I the several other times that the lights have gone out and the sounds faded away.

So, you might be thinking, how is it that a fainter can be a doctor, yet alone a MIDWIFE, with all that blood and stuff? Well, I'll tell you I've never once felt faint at a home or birth center birth. It is something about the smell and environment of the hospital..... since I was a child, when I was in Costa Rica, now here in Vanuatu. It's undeniable and I am reminded how grateful I am that I won't be walking into the hospital every day of my working life as a naturopathic midwife. Yes, I prefer the hardwood floors, and cozy couches, and back porches, and sunny kitchens of home births. But I am here to work in the hospital, and I know that feeling was only temporary until I adjusted to this new environment, including the tropical heat. To shake it off, a cup of hot tea (per one of the Sista's recommendations) brough the blood and color back into my head, keeping me off the undesirable floor of the birth theatre, and I felt fine the rest of the day :)

On another note......
I got to give a sweet, 4060 gram baby boy a bath (a babe this size is a novelty of sorts here!) This is something that we don't generally do at home births since we test our moms for blood-borne pathogens and we value the coating that the babe is born with as protective to their delicate skin- so we don't routinely recommend bathing newborns immediately. But as the New Zealand midwife (who's here helping for a couple weeks while on holiday) said, this is the "hepatitis bath." It is given to wash any bodily fluids off since prenatal Hep. B testing is not done here. Ideally it is done before any injections are given, to prevent transmission from mom's bodily fluids that are on babe's skin, but it is generally done after the injections are given here. I am not sure why, perhaps just based on timing and to return the baby back to the mama to breastfeed after the injections are done as quickly as possible.


After finishing at the hospital, I headed down to the Vila harbor to do the "swimming course" in the ocean (that's the harbor above). This involves swimming out around a bouy, past a floating helicoptor landing dock, then if you're really feeling it, out to a large rock. Luckily I brought my swimming goggles, sexy as they are, because it was relatively shallow for most of the swim and there are a lot of fish and coral to see. Swimming in warm salt water is soooooooooooooooooo different from Lake Washington!!!!!! I'm really enjoying the added bouyancy.

Okay BEEF lovers! Apparently Vanuatu has some of the finest organic, grass-fed beef there is because that's just how all of the cattle are raised here. Some of my Australian Baby Doc friends were headed to the Raging Bull Steak House for dinner and live music. Yes, they convinced me to go to the steak house and yes, I ate a rump steak. And yes, enjoyed it. Sorry veg friends. Can't remember the last time I ate a steak..... tropical islands get you doing all kinds of out-of-the-ordinary things.....

Like SCUBA DIVING! I started my open water scuba certificate program on Saturday. After all, there is so much to do away from the hospital. This involves some classroom theory time, some pool time getting used to the equipment, and 4 ocean dives. Of the few people I encountered in the States who had acutally heard of Vanuatu (besides Bastyr and midwifery folks), 100% of them knew about this tropical island nation because of the incredible diving here.

well, good thing I bought that all-inclusive traveler's health insurance the day before I left, 'cause I really didn't think I would be diving. But I am, and I did my first ocean dive yesterday. What better souvenir to bring back from Vanuatu? We drove out on the boat to a beautiful cove, suited up, and walked off the boat into the ocean. The experience of breathing under the water is just incredible, and a bit intense! I felt I was dreaming, being down on the ocean floor, with the rhythmic sound of breathing in and out through my regulator. I love the feeling of putting my hands behind me and just giving the slightest kick of the flippers..... then sailing through the water amongst the fish and coral, supported by the water. Magical! Our first dive was 10m for 42 minutes. Not bad for a first time! Some of you know that I am actually part mermaid, so this experience was particularly fabulous. I need to learn more about identifying the tropical sea life, as it is all new to me..... sea anenomes, lots of colorful fish (neon blue to flourescent yellow), a huge clam, huge eels..... sorry i don't know the names yet. I have at least 3 more dives to work on it.

I postponed my other dives til later this week because my right ear had trouble clearing as I descended yesterday, and then was very clogged for the past 24 hours. It's feeling much better now, and one of the Baby Docs is gonna take a look in it tomorrow at the hospital.... I infused some garlic in olive oil and had a friend funnel it into my ear to help loosen any wax and prevent any organisms from multiplying in there (garlic is wonderfully antimicrobial). These other Baby Docs sure do think we naturopathic folks do some FUNNY things. Garlic ears? Clay packs on an infected foot? B vitamins to keep the mosquitos away...... I've forgotten just how "out there" this stuff is for most people. But this is what we're working with here, the basics, and what I always start with, tropics or not. I guess that's what traveling is good for..... to give you some perspective outside the normal bubble we create for ourselves. On that note, off to bed for an early start at the hospital in the morning.

Cheers!