Cord prolapse

I figured I would probably have to deal with some crazy stuff while here, it seems everyone else that has ever told me stories about Vanuatu talk about the one ever lasting memory of the crazy scary emergency that happened. Mine got to be cord prolapse, well at least I hope that is the scariest it gets while here… I might like and easy breech or twin though… but no more emergencies please!

 

I caught 3 babies today, the 3rd right before Elias and I were going to leave. I wanted to leave early because yesterday we were at the hospital for 14hours, running around doing a million things. It was this momma’s 4th baby and I figured it would be quick and easy then we’d go home.

 

Let me give you a little background, yesterday there was a mom who had a cord prolapse and the baby died, same thing like a week or twon prior (as told to me by someone working at the hospital, we weren’t here yet). I think most people reading this know that cord prolapse is a very rare emergency (it seems to happen here a lot more often) where the baby's cord falls out through the vagina (or just past the head) gets compressed between the baby's head and moms bones and most often baby dies because they don’t do a c-section quick enough.

 

Well, she started feeling an urge to push, I checked her and she was fully dilated, the head was low but not coming lower because of what felt like a huge bag of water over the baby’s head. I figured she’d give one good push and that bag would break and flood everywhere, or be really thick and inhibit descent. So I routinely checked for the cord over the baby’s head, as we are taught to do. Elias put the Doppler on baby, all very routine... during a contraction I barely touched the bag with the amniohook and it broke it, I controlled the descent of the head a little (didn’t have far to go at all, but with a G4 I figured she’d have so little resistance to baby coming quick). Baby's heart rate started tanking, I checked and felt a cord along the top/side of the head (with all of that fluid it flushed it down further toward the opening), we flipped mom to knee chest position and called the dr for emergency c-section, but supposedly an ER CS takes like 30-40 minutes here (supposedly that is what happened last week) and the baby would already be dead (or we would have to hold the baby’s head up until the surgery was ready and would be quick), so I shoved my entire hand up momma (as she quite audibly complained  because it f***ing hurts to have somebody's hand inside you next to your already huge baby head), pushed the cord back inside as far as possible, kept trying because it kept slipping and baby's heart was low, I was really persistently trying to get it to go around baby's neck and stay, and eventually it did! Heart rate went up and we had momma push like a crazy woman... the cord was still tangled and had some dips and since baby had been deprived of oxygen for so long we didn’t know how baby would handle everything, .... I was so, so scared that the baby would die... but ~30 minutes after the cord had first prolapsed the baby was born and cried pretty quickly (30 minutes is way too long to not know if this little baby is going to live), after the birth everyone was still and quiet. I am so thankful he lived. He complained a little while and then started smiling... No kidding, he started smiling, and babies don't commonly smile when they are awake and newborn… they smile in their sleep or when they are older... but he seriously was smiling, several times. He laid there on mom and the cord pulsed for so long, I really think it was quite beautiful that it pulsed so long to give him all the oxygen he needed that he was deprived of :)

What a day! I am tearful now just thinking about the poor momma that had lost her baby yesterday and how this sweet smiling little boy might not be alive right now...

 

 

 

Done with day 2

Wow. What a day. We spent 12 hours at Vila Central Hospital today, all day on our feet going between laboring, prenatal, and postpartum moms and babies. It was the equivalent to any sauna I have ever been in, hot as hell and humid. It was pretty challenging working that long in the heat and not taking the time to eat at the hospital or sit... so now being fed, clean, and laying down feels quite heavenly.

When I pictured the hospital and Vanuatu as told to me by the many midwives that have come here before me, never in my thoughts had I imagined it being so poor, and so dirty...and all the bugs everywhere, even crawling all over the hospital. It is so different from anything I have ever seen or experienced, and I am very grateful to have this amazing eye opening experience.

Something else I didn't expect is how friendly and kind everyone is. Almost every stranger we pass on the street say some greeting or start up a conversation. People are also being very understanding of my funny sounding Bislama, its getting better with every encounter I have though (hehe, only when people talk slow).

One of the births I attended today was a first time mom that had been in the hospital since the day before with SROM, she was contracting all night but mildly. I went to check in with her and she had had some bright red bleeding that had soaked a menstrual pad, I took her over to the monitor and listened to baby for a bit, she had more bleeding, quick slight drizzles. Then baby's heart rate was lost off the monitor and when I found it it was 50, I called in one of the head midwives to see about er c/s, baby's heart was still so low, about 80. After about 5 minutes without the monitor tracing baby, and my frequent checks finding 50-80, baby came back up to normal. I put an iv in, the dr came in, and said keep her on the monitor and if it happens again let me know, check her dilation in a couple hours. I stayed with her closely, mostly monitoring babe and giving support, she'd say to me "oh mummy it sore, so sore" and grab my arms, sometimes pulling me in to hold onto me during a contraction. About 2 hours after that scary as hell decel she started to push! We moved to the delivery room and had a lovely birth of a very healthy and strong baby (after an hour and 20 minutes pushing)! I loved that it all turned out ok, for many reasons (I felt quite bonded to her after our morning together), but her birth happened right after a mom who had decels to 70, a c-section, and a baby with meconium aspiration and apgars of 2 and 5. A good reminder how birth is always different.

Well, I need to get some rest before another long and amazing day tomorrow.

Final Week

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

Tanna Adventure

Week 4: Tanna Adventure

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

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

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

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

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

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

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

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

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

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

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

Busy Week at Vila Central Hospital!

Week 3

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

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

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

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

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

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

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

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

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

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

Week 2

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

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

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

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

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

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

So some birth highlights of week two here in Vanuatu…

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

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

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

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

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

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

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

More to come wait patiently…

First week in Vanuatu!

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