More twins (alive this time) and Q&A with the neighborhood boys

[Elias, Tuesday Oct 20, 8am] Sunday was fantastic. I went to the hospital to check in on the mom from the other day, and she was already discharged, just waiting to be picked up. (BTW, for those who care, her hemoglobin was 8.5 after the hemorrhage, and up to 9-something by discharge.) She said she felt well, and that she wanted to put my name on the surviving baby, so her name would be Alice.

On the way home from the hospital, I ran into a bunch of kids hanging out around a parked truck. This is a different group of boys than who had adopted Molly, but they still asked me where "woman blong [me]" was. She's not my woman, I told them, she's my friend. We started talking, and oh man, the questions they had. How do the babies come out? Men and women have different parts-- private parts? Yes, private parts, and the baby comes out from the woman's private parts. I thought they came out of the belly? No, out of the private parts. I thought they came out of the ass? No, out of the private parts. There is a hole? Yes, a hole (the whole time pantomiming the sequence of events). Do you know Rey Mysterioso? No. Do you know Mexico? Yes. Rey Mysterioso is from Mexico [showing me the Mexican wrestler pictured on one boy's t-shirt]. Do you know 50 Cent? Yes. Tupac? He is dead. Yes, he is dead. 50 Cent was shot with a musket [gun] but he was wearing a bullet proof vest. You know Celine Dione? Yes. Michael Jackson? Yes. Michael Jordan? Yes. In the US, do people smoke marijuana? Some people. Drugs? Like what? Like white powder in nose. Cocaine- some people, makes bad heart and brain. If you drink too much kava your legs will turn white and the skin will be broken. Can you operate on a dog? No, only people. No dogs? No dogs. The babies come out of where, again?

There were two boys whose English was better (and their confidence higher), and the boys would dictate something extensive and then tell them to tell me. I told them if they spoke slowly, I could understand their Bislama, and the reality is that with the accent, it was often difficult to understand the English. I'd ask them to write it down (which they usually declined) or use another word to help me understand. They were very concerned about me standing out in the sun and asked me a few times to stand in the shade of the truck. Then they decided we should move across the street, to the carport, so we could all sit in the shade.

Their questions continued: what do you eat in the US? Do you have oranges and lemons? Mango? Rice? In the US, how much does a truck cost? Are the trucks made by people, or robots? More questions about marijuana and other drugs. Do you want to see marijuana? Sure. Wait here. A smaller boy went and crept under some bushes and retrieved a small pot with a tiny, tiny marijuana plant which ostensibly belonged to an older boy. (I have a photo, but I'm not going to post it, in the interest of protecting this little 9-year-old.)

No matter where the conversation went, it always returned to how, exactly, the babies come out. When I told this story to one of the midwives later, she told me that the kids are told that babies come from the belly button -- this is perhaps linguistically entangled with the fact that belly button and umbilical cord are the same word, 'nambeton' -- and that the belly button is cut to have the baby come out. I asked if they learn about sex in school, and then they tried to get me to understand something which turned out to be, "you know porno?" I tried to explain that there are different kinds of videos that have sex, some are for learning, and some are porno. I can only imagine how all this was reported to their parents. Hopefully they don't hunt down the random foreigner telling their kids about condoms and HIV and how, exactly, the babies come out.

The next day, I got up early and went into the hospital for the day shift. There was a first-timer delivering, so I caught that baby and stitched up the mama. That baby had no rooting reflex and no urge to suck. I worked with him for a little bit, assessing his palate, which was fine, and got him to latch and suck once, but he wouldn't do it again, so I called in Daryl, a New Zealand midwife who's excellent with breastfeeding. She expressed some colostrum and fed him by syringe and eventually he developed more of an interest. Most of the babies here nurse very easily right off the bat. They usually lie very quietly on the warmer while we finish up with the placenta and suturing, showing their rooting signs (smacking their lips, licking their lips, opening their mouths and looking around), and are usually very ready to eat by the time they're brought by back from weighing and vaccinating ("scalem and stickem"). Moms stay in the delivery room for an hour after delivery, and just turn to their side to nurse the baby. Grandmas and aunties are usually pretty helpful at getting the baby to latch, but when the baby's not doing their part, that calls for more intervention.

We also had a twim mama coming in for induction. As soon as I introduced myself, I knew her English was way better than my Bislama. She was a woman of size, and her babies were good size, and it was difficult to get both babies on the monitor at the same time. Hell, it was difficult to get either of the babies to stay on the monitor, since it required the ultrasound puck to be at exactly the right angle. Eventually I rigged something up with a 5 mL syringe under the strap. She was induced over the course of the day, and since they wanted so much monitoring, she spent the majority of her labor on the bed. She had great support though, including her husband and other folks who live with them on a shared compound sort of deal. By the time she was ready to deliver, both OBs had arrived. I wasn't sure if I'd get to catch them, given the level of interest displayed by the OBs, but I talked to the senior doc and he said we would do it together. The regional OBs are terrific -- they're patient and practical, counsel well, and are very realistic. (There are also foreign national OBs and pediatricians whose skills are not a good match with the resources available here. I am attempting diplomacy.)

Scans had shown both babies were head down (which we say 'vertex' and they say 'cephalic' with a k-sound, kefalik), but some of the midwives were thinking twin 2 was breech because of the way we were getting heart tones. When she started pushing, she wasn't making a ton of progress. The OB felt there was a little more cervix and said she could push past it. She ended up liking my guided pushing, with my finger inside, and I ended up holding back that little cervix (since I was in there) and the head came down nicely. Because we thought the second baby was breech, we'd taken off the end of the bed and had her scoot down as far as possible so that baby would be able to dangle. We also had her in stirrups in case forceps or vaccuum was needed (she had a history of forceps delivery). This meant there was nowhere to lay the baby after he was delivered, which is typically how it's done here, so I finally got enact my dream of putting baby up on mom's abdomen! Or her leg, in this case. With lots of encouragement and intense eye contact, she pushed him all the way down and out -- I was really glad her English was so good, because it enabled me to use a lot more of the languages and images I'd use at home, although it was, as always, paired with pantomime. He was born screaming and quickly clamped and moved over to the warmer.

The OB went in to rupture the second baby's bag, and meconium came out. He told me the baby was cephalic though, so I moved back in to catch this one too (though I was really hoping to be able to catch a breech!). When I went in to check, I felt a cord. It was confusing though, because there was obviously a cord from the first baby, but I felt that baby's cord, and a second loop of cord pulsing. I told the OBs and one of them confirmed the prolapse. There was a huge crowd in the room -- 3 OBs, 2 advanced nursing students (the junior ones, and the random biology student observing for the day, had gotten booted an account of crowding), 2 med students, 3 midwives, a pediatrician, and me. Cord prolapse -- when the cord comes ahead of the head -- is a scary thing because the cord gets squeezed off between the head and the cervix/uterus/pelvis, stopping the flow of blood and oxygen to the baby during delivery. This cord had a pulse of around 80. They told her she must deliver this baby quickly, and moved to get the vaccuum set up. While they were setting up, I resumed my place encouraging her pushing, and she was able to push so effectively that she got him out before they could get the vaccum set up! The OB showed me how to push the cord back over the head, and I caught the baby and laid him back on my arm to untangle him (cord bandolier around his shoulders and chest), and they suctioned him right there on my arm. I took him over to the warmer and the NZ midwife gently guided me back to the woman, saying they take responsibility for the baby, and I stay with the mother. We all heard him cry, finally.

With multiple gestation, the uterus gets really stretched out, and this increases the risk of postpartum hemorrhage. (See: the other night.) We'd gotten tons of syntocin ready beforehand: 10 IU for intramuscular, and 30 IU for her IV (she already had 10 IU in the bag from induction, making 40 total). Her IV was leaking though, and we weren't sure how much was actually getting into her. Her prior IV hadn't been flowing, so this was already her second IV. It turns out it was leaking from the cap, and a midwife stuck a syringe on there and everything was good. Anyway, the placenta! This one was two placentas fused together. Pretty rad! She had a laceration that was difficult to see and repair because of the way her tissues were situated, so the NZ midwife put on steriles and helped me get situated. My suturing is definitely getting more fluid!

I stayed on to make sure she was stable and not bleeding (including lengthy negotiations about using the toilet vs being catheterized) and back in her room with the babies (private room! what! that is my nap room!) and then I headed home!

Outside preparations were underway for the grand opening of the Vanuatu College of Nursing Education Tuesday morning. One of the twin mama's support people is faculty at the nursing school, and she was out there with her husband and kids (the parents are Australian but the kids were all born here, at our hospital), and she thanked me for being so supportive and positive, saying this mama had had negative experiences in the past, since they didn't think she was pushing effectively, etc. They were by far the most US-like duo I'd encountered so far, with this woman having a very clear doula role, and them having practiced different aspects of the delivery. Anyway, I'm off to attend those festivities!

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.

A Week in Review.....

Bush crabs (still alive and squirming) sold at roadside market.
Bus driver stops abruptly, reverses and purchases feast for dinner
while transporting riders, then continues on with live crabs on-board.
Never a dull bus ride in Vanuatu.

well halo out there.... have been getting some hints that it's been awhile since i've posted.
there are a few good reasons for that...... and today is my day of doing all things computer, including some writing about the adventures here in Vanuatu. where to begin.....

For one, the Vila Central Maternity Ward has been quite slow. We've crossed the half-way point of the month, which generally would mean that an average of 100 babies had been born in any given month. This month, we're still in the low 70's, so although we've been spending time in the hospital, it hasn't involved many births. Instead we've been filling our time with chatting with the New Zealand midwives, continually amazing each other with what our standard of care is, or isn't, and laughing about the differences in pronunciation of words, both common and medical. Although we all speak English, lets be real..... sometimes we are not speaking the same language! Some is a matter of accent, some is just a complete difference in choice of words for describing something. For example.... Elias and I say vaginal like this.... vag-in-al, like most of you probably do, too. Everyone else here in the southern hemi says vagina-l. so everytime we refer to a vaginal exam or a vaginal birth or a vaginal suppository..... it's just a little different and there is a brief moment of each of us looking at each other in awe before moving on in the conversation. wish i could insert some sort of tool that would allow me to play some blips for you..... i bet elias would know how to do that! Another word that made me roar in laughter came up during a conversation about chocolate. Apparently Cadbury is one of the bigger chocolate companies in New Zealand. I asked what about dark chocolate and I heard, oh, yes, "Nizzle" makes that. I'm thinking, hmmmmm, I'm going to NZ in a few weeks, I'll look for Nizzle chocolate, that sounds good. But upon asking for the spelling I quickly realized the reference was to NESTLE chocolate! Endless laughs about that one.....

Secondly, the weather this past week was far closer to that of Seattle than the tropics. we had 5 days of gray skies and rain..... some pouring rain. so the day of snorkeling and the day of sailing that we had planned were both canceled, replaced by days ofdrinking coffee and watching movies and reading books. Am i in Seattle, i wondered a few times? But one quick assessment of the coconut trees and smell of burning brush reminded me that, no, this is nothing like Seattle.

we did have a family BBQ here at our place before a couple of the baby docs headed north to the island of Santo for some diving and adventures away from Vila. Luckily we had a few experienced Aussie BBQers since that is really not my specialty, I'm the first to admit it. I excelled nearby, however, as I maintained my reign as table tennis champion! Who knew that those endless weeks of table tennis during my freshman high school PE class (and i do mean endless weeks....) would be of any benefit in my life. Yes, we all have our strengths that we bring to the table..... or the grill.... We feasted on steaks and grilled sweet potatoes and salad, and Elias and I experienced our first taste of Tam Tams, an apparent Australian delicacy- essentially tasty chocolate covered wafers, for dessert. It's a curious thing the grills down here..... 2/3 of the grill is regular grill. The other 1/3 is a grill pan of sorts that you can grill veggies, onions, mushrooms, etc. on so they don't fall through into the flames. That's my kind of grillin, whereas in the States you have to purchase a separate "veggie basket" and it's this whole separate ordeal, at least at all the BBQs I've been to. Emma, you'll have to encourage Sean to import his next grill from the South Pacific, preferably before next summer.

Other news.... I finished my scuba course, culminating with 2 dives last Saturday morning. The first was near the same place I'd done the prior 2, although once down under I wouldn't have been able to tell- there's always new things to see. The last one, however, was the Cathedral, a rock cavern under the sea. WOW. First of all, this was a surprise because I was still finishing my course so I didn't think I would be doing it until until after I finished, but there were several other experienced divers doing it and apparently the tide was just right. My instructor and I descended to the bottom and we did our safety tests, where he filled my mask with water and I cleared it, and then he made me take my mask off and put if back on, take out my regulator under water..... all those sorts of things to be sure I could deal with any of those situations if they arose. Then he pointed towards the entrance to the Cathedral and shrugged his shoulders as if to ask, wanna do it? I think even through my mask and with the reg in my mouth, my face shouted yes! yes! So in we swam.... essentially into a cave of sorts. High above us I saw some light shining in and as we swam we slowly ascended towards the light and eventually popped up into a shallow pool that was actually inland. We surfaced and looked out to the ocean, breathing the sea air once again. Then we dove back down through the cavern, all the while swimming backwards to watch the light rays get smaller and smaller as we descended down and out of the cavern and beyond into the deep blue abyss. That was my deepest dive, to a full 28 metres. It was pretty exhilarating and as to be expected, my oxygen depleted much quicker. A fabulous way to complete my course. Wish I could have taken some photos down there.

Snorkeling off Hideaway Island

Yesterday we headed out to Hideaway Island, well known for great snorkeling. It was beautiful and a great way to spend a hot, sunny day here in Vanuatu. Snorkeling galore, for hours and hours...... which unfortunately left me with a snorkeler's sunburn, that is, backside only. A quick reminder that water-resistant sunscreen is not even close to waterproof sunscreen. Badger sunscreen, #1 rated on the Environmental Working Group's site for safety and efficacy, really stinks for water sports. Just FYI for those heading to their next tropical destination, I wouldn't rely on it. Anyway, I'll be purchasing myself a rashie (fancy name for swimming shirt) so I won't have to slather my bod in sunscreen and can snorkel to my heart's content. Emma, I think that's what you were telling me about with your Australian friend..... many people wear these rashies while diving and snorkeling and swimming. It just makes sense to do so here as the sun can be brutal :)

on the road back to Vila from Hideaway

now i'm heading into the hospital for a late afternoon, evening shift..... fingers crossed for some babies! i know that we are inducing a women who is only 29 weeks or so today because her water broke close to a week ago. i'm nervous for the outcome of that since we don't have a NICU (neonatal intensive care unit) here and the preemie that Elias caught a couple weeks ago has not being doing so well, and he was several weeks older than this unborn babe. we'll see what happens. we've had a string of Cesars this week, as well. 2 inductions ended in Cesars after fetal tachycardia (heart beating too fast) for one, and decelerations (really low heart beat) for the other. the Cesar that i observed involved the use of forceps to get the babe out from the incision.....that coupled with many many pokes to place the epidural, plus a lot of pushing and pulling on the belly and baby to get her out made it pretty trying for me..... oh the hot, stagnant operating theatre and my vasovagal friend that sometimes lurks beneath the surface to remind me that she is there. some days are easier to be in the theatre than others. on that note, here's to some nice vag-i-nal (or vagina-l to be fair) births!

Lukum yu! (See you later)

Revival

[Elias] A small magical adventure tonight. I went into the hospital, thinking I'd bridge the evening and night shift, but there wasn't a lot going on. There was one antepartum patient I was already acquainted with, and another woman who was in very early labor but had a fever. The midwives were in the tea room sortof watching a French music show, but mostly not. Everywhere in the hospital, and indeed the whole neighborhood, you could hear music, yelling, more music, and counting. I asked someone where it was coming from, and they said the museum grounds. We'd seen revival-type stuff going up on the stage there, so it made sense, but the museum grounds (Chief's Nakamal, or the chief's kava bar) were more than a few blocks away, and for the music to get to the hospital with such clarity... that's a hell of a sound system.

The preemie I caught is soldiering away in his incubator. His mom hand-expresses milk, and he feeds both at the breast and through a nasogastric tube. Since I worked a few evenings in a row, and his dad comes by after work, I got in the habit of sitting with his dad and talking about his condition (as much as I knew), or about his work and study plans, or about where I'm from in the US, or sometimes politics (he supported Hillary Clinton and was surprised I was an Obama supporter, for whatever that's worth now). Tonight I talked briefly with his mom, and then later saw his dad in the nursery and went into chat. The baby has graduated from oxygen, so he no longer has his lucite oxygen hat-box (which I lined with gauze so he wouldn't hurt his arms or shoulders) or any supplemental oxygen in the incubator at all! The phototherapy, which had been off, is back on again, but he looks a little more hearty since he's wearing a diaper cloth which supports his upper leg a bit.

Tonight his dad, K, told me that he'd talked to his dad, and told him that the baby would be named Elias. Sometimes I'm afraid to ask too often about the baby's name lest the parents exasperatedly name the baby after me just to get me off their back, so I haven't been asking much, but I do like to call the babies by names other than "little dude." I'm very honored and look forward to a series of photos documenting his graduation through the nursery process. Hopefully I'll see him get to the extension ward at least before I leave! (Only the incubator babies stay in the nursery proper. The other nursery babies, being held until they gain enough weight, stay in "cots" with their mothers in the extension ward across the breezeway. Non-nursery babies stay in cots next to their mothers in the postpartum area.)

We were hearing the loud music in the nursery, and I mentioned that I wanted to go check it out. He seemed wistful and said he did too. I suggested we go check it out real quick. Right now? Sure, why not? He lit up and I grinned. I grabbed my jacket and told the midwives we were going. The New Zealand midwives (two here on their vacation) wanted to come with, but when they saw it was raining, they turned back. We headed towards the museum grounds, but the sound got more faint. Every so often, K would ask someone walking, or someone driving a bus, where the music was coming from. He eventually paid for a bus for us and told him to take us to the museum grounds.

When we got there, there was a large, sedate revival happening. A man was preaching in front of a full choir. Fifty or so people stood out in the rain directly in front of the stage, with clumps of people under umbrellas scattered around the edge of the grounds.

Problematically, we could still hear the music. And it wasn't there.

We headed towards the music again, and K stopped to ask someone again where the music was coming from. He pointed dead ahead. We thanked the man and headed forward, but it looked like the road banked around to the right, and the music was definitely straight ahead. Does the road continue? I asked. Yes, he said. We turned right, then turned left sharply. You have your torch? he asked. I turned on my headlamp and we headed straight into the bush.

Let me take a moment to explain that I am wearing sky blue scrub pants loaded with gloves (both sterile and non), a turquoise green scrub shirt, a rain jacket acquired from the bargain rack at Old Navy, and Nothinz-brand closed cell polyethylene foam clogs, known generically as Crocs. This particular pair of clogs was acquired extremely recently before my departure, and was acquired online, through onlyslippers.com, and thus was purchased without the benefit of, say, a size check. Despite being the same listed size as the pair I have comfortably worn for 3 years prior as a well-insulated house shoe, these shoes are extremely large, and leave quite a bit of room for, say, sliding.

And we headed straight down. Through the forest. Through the bush.

With the help of a hanging onto a fence with one hand while I shined the light with my other (not bothering to affix the light to my head), we both made it to the bottom, him with slightly more aplomb than myself. We stumbled out of the forest, around a tin shack, and found a fire burning brightly. YO! a man cried from behind the fire. Yo, pronounced e-o, is the all purpose greeting, the Shalom of Vanuatu. Yo! we said! And then we were there! A large clearing with a small stage, a small band, and dozens of people merrily dancing in a large circle. This was not, however, the hora-type circle you might be imagining, if you are familiar with the hora. Instead, it was more like a windmill, with short rows of people 3-4 abreast pushing forward around an invisible axis. The music was catchy, sung in Bislama, and primarily regarding Jesus.

You want to dance? K asked. Of course! We joined the mass and danced around in the circle. It was mostly teens and kids with a few adults, all having a great, raucous time. Between songs, the preacher would count 1-2-3 and they would respond JESUS! This is exactly we had been hearing all night at the hospital, only we'd only been able to hear the 1-2-3 through the speakers.

In searching for a Jewish community in Vanuatu with whom to celebrate the season's holidays (but not finding any), I came upon a newspaper article written by a guy who visited in 2001, wherein he mentioned describing himself in Bislama as a man of Israel, which I reasoned would be "man blong Israel." I hoped that nobody would ask me to testify to my faith in 1-2-3-Jesus, practicing what I would say instead, but quite enjoyed myself dancing anyway, even as my clogs filled up with dirt and my cuffs with mud. K mentioned his friend was one of the singers onstage. It's a small world here -- he's not even from this town.

We only caught the last 3 songs, and then he started saying good night, naming the nearby villages and neighborhoods in turn, thanking the components of the trinity (my Bislama is therefor expanded towards the theological realm), the chiefs, and encouraging people to come back for church service tomorrow.

We headed back towards the hospital (which turned out to only be a few long blocks away). K said he'd been wanting to go see the music and was truthfully getting a little bored of sitting in the nursery looking at the baby. I'm glad to have given him a break. It can be pretty onerous to have a baby in the nursery and not have much to do other than stare at him and worry. I might encourage him to bring his books and read to the baby, even his technical books, just to share with him. It was a nice outing for me too, and very cool to enjoy a neighborhood event with an insider.

Gud night!

Newest baby Elias! Twins!

The twins were born! Sister A called this morning to tell us to come in to see the twin delivery. I took this to mean, run! Molly and I both threw on scrubs and ran out the door. Of course Molly's entourage spotted us on the way out, and they called out, Molly! Molly! But we were running! Well, I was running, Molly was saying we don't have to run. We didn't, but it was fun.

When we got there, her most recent exam put her at 3 cm, but they had decided to augment her, and she progressed quickly. There was other business on the ward, including two other multips who were each at 7 cm, so we floated around, getting things ready, catching up on notes and progress made since we left at after midnight last night. I was on my way to check on someone when I heard my name-- twin 1 was already emerging! Molly was right there to catch him. When the mom and grandmother saw it was a boy, the grandmother declared he would be called Elias. I was honored! Molly took him to the warmer and I stepped in for twin 2. It took a few minutes for her contractions to come back, so we checked heart tones to make sure the remaining baby was okay. Then she started pushing again. Twin 2 emerged face up! Another boy! The grandmother quickly reassessed the situation, and decided that twin 1 would be called Moli and twin 2 would be called Elias, each after the midwife who caught him.

There were a crowd of nursing students in the room, midwives, and the consulting OB in the room, all thrilled to see another vaginal twin delivery. I have no awareness of who took the babies to be weighed and immunized ("scalem and stickem") -- I stayed to manage the placenta. The supervising Sister told me it was one placenta and I would manage it just like any other, and sure enough, one larger placenta with two cords and a chorionic divider.

The twins are adorable, clearly, and good weights (2.4 and 2.7 kg apiece). I caught up with them in the scale room and drew up the Vitamin K and Hep B vaccinations for K, one of the Australian med students, to administer to little E. Taking after the naturopathic midwife I work with in the States, I refused to jab him, lest he have negative associations with his namesake!

Quickly thereafter, two more women delivered. Molly guided Alex (another Australian med student) through that delivery and repair (and the family naming that baby after her), and I worked with K. The mom turned out to have a bit of cervix left, so I ended up holding it back to she could push past it, and that little girl was born quickly. This ended up being the first baby I bathed ("swim baby") and while I got her hair somewhat clean, that was all I'd seen done, so we'll see how well managed with the rest of the bathing and dressing. The only diapering accessory they have in common with cloth diapering folks in the US is the Snappi! (and the diaper cover, but here, from the day they're born, the babies wear giant covers that will last them at least a year).



Then we went swimming in the ocean at Eratap. Holy fantastic swimming. Go see the pictures.

Mother fruit!

We bought a stalk of coconuts yesterday with 8 coconuts attached for 200 vatus (around $2).

I was tasked with carrying it home (Molly having lugged the giant bag of sweet potatoes home the day before while shopping alone).

Lacking a bush knife, here Molly demonstrates her architectural approach to cracking a coconut.

First Bus Birth, Breech, and Stillbirth

To second Elias' posting below, all is well here on the island of Efate after some shifting of the tetonic plates earlier this morning. Light rain is falling outside from heavy, low clouds, taking the humidity down with it. We're taking a siesta before heading back to the hospital for the evening shift.

Yesterday we arrived and before we could even put our bags in the staff room there was a phone call announcing the arrival of a bus with a woman and her baby, and could we please HURRY! We ran up to the bus, whose door was already open, and saw a mom semi-reclined with an older woman sitting between her legs. As she lifted the pregnant mom's dress ever so slightly I saw the little feet, then round thighs and bum, and thought, oh, the babe was already born and is just laying here in her dress..... until the body stopped at the nipples and I realized this little boy had been breech and his head was still inside.

So to catch non-birth folks up to speed, breech births in general are avoided in most parts of the States by elective Cesareans, and although there is some debate about how risky breeches really are with experienced maternity care providers, this situation is the worst case scenario and illustrates the most common reason given for avoiding vaginal breeches.

We gathered the timeline and story from the family as best we could during the course of the 25 minutes between when the bus arrived and when the baby was born. It sounds like this mom started her labor around 2pm and tried to get transportation to the hospital but for some reason was unable. The labor progressed quickly and soon there were feet hanging out of here vagina so she started pushing and figured she would just give birth at home. Breeches come in several varieties, depending on what part of the lower half is presenting, footling being the most tricky because the little feet and legs can fall through the cervix before it is completely dilated, while the much bigger shoulders and head can get stuck. And that's exactly what happened with this little one.

By the time the family realized that the head was stuck while the legs and belly were born, somehow got a bus, and arrived at the hospital, it was at least 30 minutes, likely more close to 50 minutes. When I placed my hands on the babe, he wasn't moving and was already cool, and the small amount of cord that was visible was not pulsing anymore. We tried to deliver him quickly while still in the bus and after no success, we moved the mom to the birth theatre on a stretcher.

At that point, we were all pretty sure that this little one was already gone. Once in the theatre I tried to turn him slightly and sweep one of his arms, that were both still inside, down in front of his body with no success. It was a tight squeeze and all I could feel was his shoulder blades. One of the other New Zealand midwives stepped in to help, also with no success. Finally one of the Vanutau midwives was able to get one arm, then another, and finally, finally..... his little head.

The pediatrician had arrived and although he heard no heartbeat, he attempted a short round of chest compressions with no success.

We cleaned up the babe, wrapped him in a blanket, handed him to the family, shed a few tears and said some blessings for this mom, babe, and their extended family, many of whom were standing in the hall outside the theatre.

Birth is a continual reminder of the dance between life and death, and I knew coming here that it was not a matter of if, but when I would experience the latter part of this dance.

On a more joyful note, I have acquired a small group of personal escorts on my 3 minute walk from home to hospital. They range in age from 5-12 years old. They are the pikinninnis of our local neighborhood and I first met them the other night after my last blog entry. The darkness has snuck up on me and it was past sunset by the time I walked over to the hospital. I had my headlight out as I walked out to the main road to the hospital, a pack of 10 kids greeted me and circled me, some more bold with questions while others shyly smiled. They had so many questions: what is your name? are you a doctor? where are you going? do you really see the babies come?

All of these children were born right there at Vila Central Hospital, just like the many babies we've seen born there too. They were FASCINATED with my head lamp (thanks Casey and Mike for that gift!), especially since I can change it from white to red light. They all tried it on their little heads, turned it on and off, and asked with amazement and wide eyes, "What do you call this?"

They proceeded to walk me down the road to the entrance to the hospital, with more children turning back the further we got from home. So every day since then, as I walk over to the hospital in the late afternoon, they are there to greet me and accompany me to the hospital entrance, shouting, "Molly! Molly!," and scrambling to their little feet when they see me walking by. They are sweet kids and I would like to buy them a communal soccer ball, for a sport that they love to play but for which they have no ball. Will check out what's available in Port Vila this weekend.

On that note, packing up some dinner for our shift and will be heading off soon. We have a woman being induced today who is pregnant with twins, so with any luck Elias and I will each get to catch one tonight! Also, I'm going to try to add some photos to the posts below and will add more to my next posting now that Elias has shown me the magic button for doing so :)