Tuesday, February 3, 2009

Winding Down

I'm finishing up my last few shifts, spending these last few days enjoying the amazing people, the wonderful mothers and their babies, my new midwife and doctor friends.

One of the miracles of my time here: the mother who seized for hours with cerebral malaria delivered a SGA baby on the medical ward two days later while she was comatose. His APGAR's respectable he seems healthy. He was breastfed by relatives when available, then lovingly bottlefed by visiting clucky medical students who couldn't keep him out of their arms. 8 days later, visibly neurologically altered by her malaria and probably the prolonged seizures, his mother walked slowly into the nursery to breastfeed her little man. He opened wide and latched like he'd never been fed any other way. Both of them were discharged home the next day.

The rhythm here doesn't change, the women come in waves, they push their babies out and a day or so later they pile into cars and drive home. I watched the twins speed by in their mother's arms squeezed into the front seat of one of the ubiquitous Vila buses, somehow she managed to wave to me, lovely smile on her face. Occasionally a high risk case, or an induction that goes south (still don't like misoprostol inductions) winding up in the OR, or the intensity of a big bleed. And then the lull comes again, and we sit and laugh and cut and fold gauze and roll cotton wool balls and wonder when the women will come again.

As if to remind me that not all ends well for all footling babes. That next night a woman presented in second stage with a small foot dangling between her legs. Her large (3.8+kilo) boy's body delivered to the neck, then stalled for close to 13 minutes, despite all efforts to resolve the emergency. Hypoxic/anoxic for at least a lot of that time, when his head was eventually freed he required prolonged resuscitation and predictably he began to seize within hours of birth. 4 days later he is no longer seizing, and while he will latch and breastfeed when offered, he has yet to 'wake up', or show us he's hungry, or behave as a normal healthy baby should. We continue to watch him and hope.

And this morning a phone call today from the morgue, where the body of an infant was deposited after being 'found' at the rubbish dump. Clearly born at or close to term, with a significant abdominal wall defect (gastroschesis), baby's life appeared to have been ended deliberately, before his body was discarded. We don't know who he is, or where he came from. He wasn't born at the hospital. I assume there was a death certificate issued, though he won't be counted as one of 'our' babies. Another tiny life begun and ended smartly. We all wondered out loud today about the health of his mother, who and where she was. None of which we're ever likely to know.

In happier news, the very first cervical cancer screening program here is about to be started, funded in large part by the WHO (I think). As well a vaccine manufacturer has donated 1000 doses of the HPV vaccine which offers at least 1000 little girls here hope of significantly reducing their risk of cervical cancer. I'm thrilled, as are the staff here.

It's cooler tonight, after some late afternoon rain. Sunday will see me leave here and return home. I'm keen to see my boys and husband again, after so long (5 weeks) but I'll miss it here.
NiVans are stunningly lovely people. Strong, proud, generous and cheerful. They work harder than anyone I've ever met, and have taught me valuable life lessons in gratefulness and happiness as well as my beloved midwifery.

Saturday, January 31, 2009

Twins, a kid with a headache and Henri (2.6kilos!!) for the last time.

Two seriously cute babies. Twin A, as you can see from her molding is on the right. Twin B is on the left. Both of them took one look at each other and both started sucking their thumbs.

Gazing at each other while we got mom sorted.
One lovely placenta. Tricky to photograph, no place to put it except in the sink. The midwives thought I was completely nuts photographing it. As you can see - one placenta (possibly two, fused) and two sacs of membranes. The cord insertion on the left side of this placenta is marginal, the other though, is more central. Fat, healthy, gorgeous.

The molding and caput of my career second OP baby. A 3.4kilo 'moose' born to a very worn out primip mother after a 2hour second stage (LONG by Nivan standards). Fun birth to do with a fresh med student - only her third vaginal birth - who was gobsmacked as baby rotated out into our hands: "Why didn't he do that earlier?!" was indeed a worthwhile question. I hated to point out that the AROM at 5cm likely had something to do with it.

Henri, sweet wee picaninni from week 1 (birth weight 1.8kg), returns for his last maternity ward weigh-in. He's now up to a whopping 2.6kilos. His sweet mother still giggles at my attention to her little guy.

Friday, January 30, 2009

Happy Days.

Forgive my absence this last few days, I've been struggling a bit with the delayed impact of so many hard things to see and a gastro thing which is honestly probably a sequela of too many delicious peanut butter sandwiches (My thoroughly handy pregnant in Vanuatu craving). I've also had some incredibly frustrating and enraging news from my school back home, who threaten to not allow me to graduate on schedule on an administrative technicality which I should have been informed about months ago, rather than a week ago. Needless to say I've had my plate full trying to retain my sanity and my health.

Yesterday however, my first day really trying to be a bit less manic here, take a bit more care of myself, turned into a marathon which ended with what honestly is one of the most amazing things I've ever done in my life.

I'd asked the midwives to please call me if the twin mother Dr. B had informed me about, presented in labor while I wasn't there at the hospital. In the end they didn't have to, as yesterday afternoon, my last admit of a very long shift, who should present in active labor but a gorgeous 17y.o primip with an impossibly All-American name and TWO babies in her impossibly large belly.

I checked her - presenting part of twin A was definitely cephalic, Twin B was virtually impossible to identify, but she'd had an ultrasound the day before and Twin B had been transverse breech so felt pretty safe assuming s/he still was in the interim given how little room this tiny woman appeared to have remaining. The CTG strips on both babies looked peachy and her cervix was buttery soft, effacing nicely and 4-5cm. Better yet, for the first time in ages I could feel that baby'd head was low and well applied. By this time it was 4.30pm (shift ended at 3) and I really needed to eat, shower and rest. So I made the decision to run home, do all that, and then run back to the hospital when they called me to tell me she was 9cm or so. After flirting gently with the lovely male RN (who I adore) and bribing him with timtams (chocolate covered, chocolate biscuits from Aus) he agreed to call me. As it happened this worked out nicely as they had to do 3 deliveries and manage a hemmorhage case who had been flown in from Tanna in the hour and a half it took me to do what I needed to do (including a 30 min catnap!). Quite honestly they didn't have the hands to manage another lengthy twin delivery and were happy for the help.

I raced back to the hospital, finding all 4 beds in the labor ward occupied and my twin mama pacing the hallway looking not unlike she looked when I left her - though she said with her eyebrown knitted into a frown that her belly was "much mo soa". I found her a bed, popped her onto it, ruptured the bulging first set of membranes neatly into a bedpan (knowing full well that this birth was likely to get messy), which effectively bought her cervix to complete. For the first time here I put on a plastic apron and joked with the RN that "I get dressed up for twin births!" and settled in to wait as she began to push.

This birth was a birth full of firsts, even though it's the second twin birth I've done here. This birth was different, and honestly more challenging because the mother was a primip. 40 minutes into her second stage the head compressions I was hearing became honest-to-God, freeze-your-blood decels into the 60's. The first few were very quick, and rebounded to the 130's amost instantly, but green though I may be they had my antenna all sorts of tweaked. They persisted after each time she pushed, obviously late decels which grew in duration and were slower to recover. I cranked on some O2 and, during one particularly long decel, made the decision to cut an episiotomy (my first) to try to expedite this kiddo's exit. Fortunately baby was nice and low at almost the textbook place for an epis to be cut (can't believe I'm typing that). I quickly drew up some lidocaine and told her what I was going to do. I injected her perineum and then cut an inch long mediolateral episiotomy at about 7 o'clock, baby's heartrate far slower than mine at this point. I felt rather sick as I did so, but was really worried about baby, and felt sure that it was a decent decision. Two pushes later (and yes, the epis did help that baby clear her primiparous perineum faster), at the exact time my first born was birthed she pushed out a very cute little girl. She took a little work to get her to come around, but pinked up nicely in time for respectable APGARS then lay around looking at the room with wide, wide eyes.

While Mama caught her breath I quickly injected 10u of synto into the IV fluids bag I'd already started and moved the FHR monitor to trace Baby B. who pleasingly looked happy. Her uterus was contracting actively, and it was almost impossible for me to get a decent sense of baby's lie simply with external palpation. With lovely Dr B. supervising I reached up high into her vagina to try to feel for a presenting part. High, high up, once again (shades of my first time doing this) I could feel the tiny bumps of toes. "See if you can find a heel" said the doc. I carefully crept my finger tips sideways along the tiny structure being very, very careful not to rupture her second bag. There indeed I found a small heel and enough other small parts to be convinced that, once again we had a footling breech second twin.

I told the doctor frankly that I didn't want to rupture the bag given how high the baby was, and how hard the mother had to work to push out Baby A. I thought the risk of a cord prolapse was too significant. He asked me what I wanted to do. "I want to wait" I told him. While baby looked good, and we had synto on board keeping things moving, I wanted to wait till baby came down further into the pelvis, or until a spontaneous rupture necessitated intervention. He was happy with this plan.

At about this time, another mother who had taken yet more of the "custom medecine" was being prepped for an emergency CS for fetal distress. Dr B. was about to leave to go do the surgery. He asked if I wanted the other Doc here for the second twin. I told him that I most certainly did want the doc there. He was called, and came quickly right about the time things began to unfold.
I had broken down the bed, Mother's bum was right on the edge.

Unlike the last twin birth, these twins were bigger, and their mother's pelvis 'less proven'. This breech baby did not fly out like the last. Doc followed my exam, agreed that we had two feet, and we'd see what happened when the bag was broken. "I will talk you through a breech extraction".

I should begin by saying that "Hands Off the Breech" this was not. This was the textbook, old-school obstetrical maneuver which I learned in tandem with the less interventive Varney's version. Only this time it was taught in person by an old-school obstetrics professor.

Once again I reached my fingers into her vagina and as instructed I snagged the bag of waters. It ruptured and small parts washed into my hand. "Grab the feet and pull them down." Out both feet came (toes and knees forward - ack) tangled in loops of cord. "Rotate the legs, rotate the legs". It immediately clicked that I was to help baby rotate so her back would face me. I grabbed a towel wrapped it around the slippery baby legs and rotated. Babe was out to the hips, which I grasped (Loveset) and continued to assist the trunk to rotate (all with mom's steady pushes, and an unexpected amount of downward traction, doc's hands over mine). Baby delivered to the scapulae and I could tell immediately that her arms were extended above her head. I lifted her up and to the left and swept my finger up her humerus to deliver the anterior shoulder and arm, before repeating the process on the other side to deliver the posterior shoulder.

Now out to the neck, baby 'dangling' over my arm, I reached my and up and under, reaching for the maxilla or the cheekbones. As I ran my fingers past her mouth, she apparently got some air and was stimulated to breathe, because she let out a tiny glurgling sound (disconcerting when baby'd head is still inside the vagina!). Finally I found her maxilla and with yet more steady downward, then gentle upward traction, the head slid out over the perineum and I swung her upwards onto mothers belly where, eyes wide open like her sister, she lay there a bit stunned for a second (that made at least two of us!) before screaming her cute head off.

Placenta, gorgeous, photos coming. Episiotomy repair - more challenging than I'd anticipated (the mediolateral thing threw me) but I was thankful for that extra room at the end of the day. I hated to cut her, but I do think it did some good. Babies weighed (identical 2.120kgs), poked with vaxes and vit K. Both babies put to breast and both nursed vigorously. Washed the sheets, mopped the floor. Family informs me that baby#1 will have my name.

Walked home through yet another tropical storm in the very black Vanuatu night.
All that AND two sets of twins, two breech babies.

Monday, January 26, 2009

It just never stops...

Friday's wee preemie died on Saturday afternoon He lived for a day and a handful of hours. Very early on Sunday morning, a woman delivered precipitously in the ambulance. Her breech baby was born still. Both mothers were gone from the floor this morning. I think that amounts to 8 late fetal or neonatal deaths in some 150 births, most from prematurity or unexplained stillbirth.


This morning at about 10 am we received word from the ER that a38 week woman had presented after having a seizure at home. She began seizing again in the ER and was then transferred to Maternity. She was indeed in the throws of a grand mal seizure, and despite everything we did, she continued to seize. Her differential diagnosis was clinically fascinating, but watching a heavily pregnant woman 'fitting' as they call it here is nothing short of pretty bloody terrifying. Initially thought to have eclampsia, she was normotensive, though there was slight proteinuria. She was mildly febrile, but nowhere near the 40 degrees C which is usually the threshold for febrile seizure. She had no history of seizure disorder or epilepsy. What was even freakier was that after great whopping doses of magnesium sulfate, valium, and then phenobarbitol, she continued to seize. Next stop on the ladder - test for malaria and in the meantime begin treatment with IV quinine, and cephtriaxone: if she has either malaria or meningitis we might be doing some good.

I took fetal heart tones every 15 minutes while she was there, fitting continuously. Baby vaccilated between ominously low and mildly tachycardic. Ultimately the test for malaria came back positive and the diagnosis of the very rare and catastrophic cerebral malaria was settled upon. Case fatality rates (that is the risk the mother has for dying) for cerebral malaria seem to sit around 33.1%. Rates of fetal mortality are also staggeringly high. Bottom line, 4 hours after she came to Maternity's care, she was shifted to the medical ward, still seizing constantly. There they will try to stabilize her condition, and if baby is still with us tomorrow, we'll try to help her baby. There is a very real possibility that both of them will die.


In the meantime I can report the safe, happy births of three more babies ('my' babies #101, 102, 103!). Two boys and a girl, all to mothers who said as they began pushing "I can't do this!", but then did. Boy #2 for the day became my very first OP baby, his fat face grimacing up at me, confusing me slightly as to where his shoulders were as he untwisted his neck, owl-like. Even better he was a little moose (3.9 kilos) and his mother's tissues were beautifully intact! Last baby of the day extended my 8 hour shift to 11hrs when her nulliparous second stage unfolded in a blisteringly fast 12 minutes. Her unbelievably powerful pushing efforts brought forth a petite 36 and a bit week 2.4kilo boy, along with an outrageous 3rd degree tear (also my first) despite my attempts to slow her pushing down, and support her tissues. I could feel everything 'giving' before even the perineal tissues gave. His hand up by his occiput, elbow by his ear, did her no favors at all!

The nasty laceration extended deeply down both posterior sulcus', down her perineum, through the sphincter capsule and (for want of a better term - forgive me) ' filet-ed' both labia majora from fourchette almost to clitoral hood bilaterally. It was nothing short of gnarly. I delivered her placenta, had the NA draw up a good 10cc's of lidocaine which I injected all over the place immediately before finding the OB on call, and then assisted him as he repaired her extensive tears. I'm officially a huge fan of morphine during these procedures and sims specula for retracting sufficiently to get deeper into the vaginal vault though for the record, I highly doubt I'll ever attempt a repair this extensive when I get home. I'd be far more likely to throw in a couple of interrupteds to stem any active bleeding before heading in to the lovely docs with the nice drugs for this sort of thing. :)

It was fun watching the repair though. Not quite as complicated ultimately as it looked initially, just three packets of suture (2.0 and 3.0), good pain control and lots of time and skill. Good also was the opportunity to spending time chatting with a couple of nice docs about the amazing craziness which is life in OB here in Vanuatu, and elsewhere in the Pacific. Some grumbling about the fact that the international efforts to stop Malaria in the pacific is being focused on the low incidence countries, rather than the high-incidence ones (like Vanuatu).

He also gave me a heads up on another set of twins (twin A cephalic!!) who should deliver this week or next. Fingers crossed with me that I'm on when she comes in!


Shamefully bad day on the 'self-care' front. All that and I managed to snarf down a peanut butter sandwich and 500mls of water. In 11 hrs. Boy was baby hungry this evening!

It was an intense, busy day today. But it feels good. At some point over the last couple of years I've become a midwife. I'm increasingly confident in my knowledge and with my practice. I have held on to the love I have for walking with women through the challenges and pain of birthing, and I feel more confident in the day to day tasks of catching babies, managing (or referring) issues which come up, even the big bad and scary ones. Here I've been privileged to work with outstanding midwives, who each have literally THOUSANDS (20 year careers, 35-45 births a month, you do the maths!) of births to their credit. Hundreds and hundreds of women and babies whose lives they've saved with their care. I've enjoyed the respect and tutelage of the resident and consultant physicians here. I've worked in a team, providing good, safe and effective care to a much more risk-diverse population than I'm used to (or would ever serve at home!) with minimal resources. Working here has reinforced for me that the midwifery skills and knowledge I have are substantive, real, incredibly valuable and make such a positive difference to the women and families I serve. I'm not sure why the real meaning of that eluded me so much before I came here, perhaps because midwives at home must spend so much time (and frustration and energy) campaigning simply to be able to do their jobs. Have to fight to serve the women who seek our services, and suffer still the irrational and unfair attacks from many in obstetrics who are, quite simply, ignorant. No matter, I really no longer care what they think. I no longer feel like a second-class provider (and part of me has in the past). I'll start my career with a great foundation. I'm well on my way to becoming a fine midwife. Simple as that.

How'd that happen, y'all? ;)

So it goes...

Thursday, January 22, 2009


Kinda would quite like to title this post with a stream of profanity, but it would be very tired and emotional profanity, so I won't. Another long day today.

Yesterday's little man expired at about 7.20 last night. His mother was no longer on the floor this morning. There was much shrugging and sad shaking of heads.


I rushed to the labor ward as the head midwife for the day called "Who wants to do this delivery!". The mother was bent over, clearly trying not to push. She climbed up on the table, and before I got my gloves on, before I even turned around, a splashing sound heralded the arrival of her obviously very, very preterm baby. Curled in a puddle, still cloaked in his amniotic sac, he wriggled weakly there for a couple of seconds while I finished pulling on my gloves, tore away his sac then quickly cut and clamped his cord. I took his tiny body to the resuscitaire again all the while thinking about how similar he is in size to the small boy wriggling in my belly.

I got him there, limp and floppy, not breathing, quick stethoscope to his chest: HR around 60. I grabbed the ambu-bag, and the tiniest mask I could find in the box of assorted masks piled next to the table and bagged him gently. Chest rise. A few puffs later, some small noises. I listened to his chest again, still below 80. I did 20 seconds or so of chest compressions, along with the bagging.

Had a moment of looking down at myself doing this, thinking "holy crap, you're doing chest compressions by yourself on a preterm baby who's fixing to die."

It's funny how the protocols tell you to do one thing and your gut says try something else in the moment. I listened again to his chest, his HR was now well over 100, and I picked up a towel and rubbed on him, flicking his tiny shiny feet. He opened his eyes and mewed at me and began trying in ernest to breathe. With the O2 flowing through the ambubag (I have no idea if it was functioning 'properly' but we seemed to have something which approximated a positive pressure ventilation system happening. I alternated between suctioning his mouth and nose with the machines and encouraging him to continue to breathe. As I took care of babe, midwife colleague snapped on gloves, delivered the synto which comes automatically with the birth of any baby here, and lifted the clamp to deliver the placenta. The scrawny looking cord lengthened, and then flopped limply into the waiting kidney dish with no placenta attached to the other end of it. Crap. Bloody cord had torn right off the placenta.

A passing OB was snagged, loaded her with morphine and proceded with a manual removal of the nastiest looking placenta I've ever seen. She continued to bleed though and about an hour later (things happen slowly here) she pushed out several large chunks of placenta. Officially now in hemmorage territory she was eventually taken to U/S to confirm retained products and then to the OR where a curette was needed to remove said products.

This woman had had no prenatal care, had no idea what her due date was, or even her LMP. We strongly suspect though that 'castom meresin' had been used to induce her labor. Based on her baby's size we estimate him to be 8-12 weeks early, probably around 30 weeks. He weighed in at 1.1kilos (2.4lbs).

I spent the afternoon convincing everyone, from the midwives to the pediatrician to the consultant docs to give him a crack at it. Initially the MW looked 'iffy' as I began his resucitation. I'm quite sure that he would have been left gasping on the table had I not been the one to pick him up. Honestly, had he been born dead, I could have left him be, but he wasn't dead, he was trying to breathe and his heart was beating! I'm not sure if helping him WAS the right thing to do as I write this, but I could only do what I've been trained to, which is to resucitate flat babies when they need it. As it was his breathing gradually improved, his RDS symptoms lessened and his color began to look decent. He was alert and responsive to handling, was rooting weakly by the end of the day (not that he'll be put anywhere near a breast for quite a while) and his O2 sats and HR were peachy (97-99% and 120's-130's).

Call me the eternal visiting optimist, but I would really like this little man to beat the odds. It's clear that I'm about the only person who is naive enough to think he's really got a cat's hope in hell. I scavenged a tiny knit cap (purple) and mismatched tiny preemie socks from a cuboard. I carefully changed his bedding - rolling the edges of a soft quilt up around him. I wrapped his tiny bum in gauze (no nappy small enough) and tucked him in before I left. I hope the night staff watch him closely and make sure he's warm enough.

I'm due to be off for a couple of days of much needed R and R. I suspect I may have to swing by and see how he's doing before Monday though.


As I was leaving a mama walked in. She had had her baby precipitously at home, attended by a TBA, but her baby had died (the body had been left at home). She had come in for a 'check-up', her eyes red and swollen from the crying she's begun. All I could do was rub her leg gently and say "Mi sorry tumas."

Too many dead babies for this student midwife.
So it goes somewhere south of the equator.

Wednesday, January 21, 2009

Lessons Learned

Castom meresin (custom medicine) might cause outrageously precipitous labors, but it also causes shithouse APGARS and neonates who seize at 8hrs of life.

(Almost) No pap smears in a population with epidemic HPV infection pretty much equals outrageously high rates of cervical cancer. I've spent a couple of days observing scary, scary colposcopies which will have me getting my pap smears religiously for the rest of my life.

No fewer than 4 women aged under 40 lost their uteri in the last few DAYS here. Here's hoping that is all they lose. I'm officially on board with the Gardasil vaccine. I wish we could be giving girls HERE that vaccine.

I hazard to guess also that docs in the US very rarely see cases of metastatic gestational trophoblastic disease. She's 32 and a mother of 4. Aside from also losing her uterus, there is little else to treat the metastases in her lungs, liver and spleen (and they're just the ones we can see without a PET scanner). All of which could have been prevented with a little methotrexate back when her molar pregnancy began.

And finally, sometimes after a normal pregnancy and an uncomplicated birth, you end up with a cute as a button kid who struggles, who just looks off from the word go. I cared for him during his first two hours yesterday, and then this morning was shocked to find him gasping in an isolette on 10l of 02 in the head box, cyanosis like I've never seen, O2 Sats in the teens. The peds worked on him, finally got him satting in the 60's (high 90's on room air is the goal), and set about trying to figure out if he had a fistula, or a diaphagmatic hernia, or most ominously a massive congenital heart defect (ToF was debated at length). Portable X-ray came by twice to take films of his tiny retracting chest, and even to my completely untrained eye, the large whitish shadow on the left side of his chest looked too much like a heart that is just way too big. I ran the films up to the consultant surgeon who confirmed what we all feared. That heart completely fills his left chest. We have no way of finding out exactly what congenital defect we're looking at as we don't have any of the equipment to run any of the tests. All we know is that a kid can't live with a heart that big and there isn't a pediatric cardiologist in the country. He's blue now, and working so hard. Soon, probably tonight, maybe tomorrow, or even the next his huge heart will fail.

I went back, relayed the information quietly to the staff, washed my hands, and gave him a little love stroking his cheek and his tummy before again encouraging his mother and father, who've been standing next to that isolette all day, praying on and off to love on him with their hands as well. I hope like crazy that someone will see to it that he's in his mother's arms when he finally flies away.

They have a shrug here which I've not seen before. It's the shrug that goes with horrible realities like this one. It's a shrug that says "there's nothing we can do". I saw it when that tiny baby was left on the resucitaire to expire, and again today from the surgeon. I'd really like to not see it again this trip.

Monday, January 19, 2009

The calm and then the storm.

Both metaphorically and literally...

Yesterday was very quiet, no babies, not even any laboring women, just scrubbing things (and there is much to be scrubbed!) and chatting with midwives and trying madly to not get too dehydrated.

Last night, replete with rumbly sky and lightening it rained, and rained and rained. I rustled up an umbrella this morning and strolled through the rain to the hospital this morning. By 8am we were hopping. Three women presented for inductions, two in spontaneous labor. I did the intake for one of the spontaneous mama's. I checked her first (we don't admit women unless they are at least 4 cm dilated) and found her 2-3, her cervix busily effacing. I then took her vitals which were all normal and popped her on the CTG for a quick strip. Her contractions were coming steadily every 5 minutes or so, and her baby was having variable decels like clockwork with every one. So I sat and watched the monitor and rubbed her back and watched her baby's heartrate rise and fall, waiting to see if anything more ominous would happen. Sure enough within 10 or so contractions, the bell curve shifted a little to the right, and we slid into late decel territory. I grabbed a doc, who proceeded to break her water apparrently with the intent to rule out a cord compression (by tempting a prolapse I thought!). Oddly though, the decels stopped and shortly she was taken off the CTG and was sent off to labor.

I then admitted a woman who's last baby was born still, with no cause ever determined. She was scheduled for another miso induction at 38 weeks. Her admit checks all looked good, the miso was placed, and she too was sent off to labor.

Mama number three for the morning was a woman who started her pregnancy only a few months after her 14th birthday. She too was being induced, having reached 42 weeks.

Shortly after 9, the mother of a woman grabbed me and pointed to her friend who was clearly thinking seriously about pushing a baby out. I grabbed her chart, beckoned her into the Labor ward and did a quick check, confirming that she was in fact complete and her baby was beginning to decend. I noted the scar on her belly, and realized that she too was a VBAC (my second in a week!). In hindsight the reasonably quick decent followed by a sloooooow crown, should have been a tip off, but I was so busy guarding her perineum that when the head finally delivered and then failed to restitute, it took me a 30 seconds or so to collect my thoughts and then address what turned out to my my first solo shoulder dystocia.

I thought for a second how I would ask her to flip to her hands and knees, then abandoned that in favor of instructing the nurse assisting me to pull her knees into McRoberts and do some suprapubic pressure. A couple of pushes but no movement from the shoulder. I felt deeply around baby's neck, and got a good sense of how tight it was in there (noting as I did how tight that nuchal cord was!), I attempted Rubins, still nothing. Baby's head is getting quite dark. I'm frustrated by the lack of options I have with her in lithotomy, so I insert my hand along the side of baby's head, and ran it around quickly, sliding my hand into the curve of her sacrum, feeling that carefully preserved perineum 'give' as I did so but finding baby's posterior shoulder, then reaching past it into baby's armpit then easing it and baby's arm up and out. Baby spilled out with a small torrent of thick mec, was a little flat, but came around quickly. She had pushed her a little girl into the world, her first vaginal birth. She sobbed with what I imagine was relief and no small amount of joy that she had her much wanted daughter. She reached up the way a few of these gorgeous Ni-Van women have and stroked my cheek silently, but with a big smile.

All I had to say quietly, with a big smile was "You did it!"

With impeccable timing the two med students walked in just as my still shaking hands delivered her placenta, and I asked one if he was interested in doing the repair. He did, and I helped him repair his first 2nd degree lac.

As we finished up with that birth we walked out just as the earlier woman with the variables was wheeled quickly out the door to the OR after the next CTG tracing done showed a very unhappy baby having deep, deep (to the 70's for a minute or so at a time) decels. I looked at the head MW and we agreed that decels of any description at 2-3cm probably never bode well for a normal labor course. Baby was delivered happy with a tight double nuchal cord (so much for no cord compression) but went to breast with no problems when her mom was returned to the floor.

An hour before I was due to head home, another mother was put in the labor ward with some funky irregular contraction pattern, a bag of fluids and some Synto was hung to try to even things out. Mama was desperately unhappy. Shreiking and slapping at her mother who was supporting her, and thrashing about on the bed. I sat down with her, held her hand and asked her to focus on me. I spoke soothingly with her, explaining that the contraction was waning, that she could have a rest, and that that contraction was one less. She calmed a bit, and a bit more again when I told her she could get up off the bed and walk about with her IV if she wanted. She seemed to be calmer and coping better, so I stepped out to complete some paperwork.

A short while later she was screaming and as I walked in the MW was trying to examine her. She virtually levitated off the bed, refusing abjectly to the exam, tears coursing down her cheeks. Everyone in the room was yelling at her. I squeezed in next to her, got her attention, took her hand and began speaking quietly to her, asking for her to look at me. She calmed down a bit and the midwife tried to examine her again. Once again she began screaming, begging for her mother to take her away, shreiking that she was dying. I very nearly got, but narrowly dodged a swift kick in the belly, which I think freaked out the midwife more than me. I went around the other side of her bed, sat down next to her head, held her hand and began talking quietly to her. The next exam attempt was successful - in that the exam could be performed - and the MW reduced the last cm or so of cervical lip with her first few virtually hysterical pushes.

I've rarely seen a woman so completely terrified and undone by the sensations of labor, this was more than simply pain, she was absolutely out of her mind with fear and pain and God knows what else. All I kept thinking was "What on earth has happened to you?" Though appallingly the answer to that seems pretty clear. I've never wanted pain medication for someone so badly as I did working with this woman this afternoon.

As she began pushing she gradually seemed to dissociate, her eyes glazed over and rolled back, she found a rhythmic rocking rhythm and assumed a keening breathing between contractions. Gradually, as she calmed outwardly, more and more people left the room. This relieved me. I felt acutely that I wanted as few people as possible in the room with us as she did this work. And work she did. She seemed to be somewhere else entirely but she pushed her baby down. Another sloooow crown, the largest caput I've ever seen, and as there was 6 or 7 cm of head visible, there were bony sutures palpable at 1 o'clock which had me thinking I might be shortly looking at an OP presentation. Instead, when baby's head did slide out, it did so offering me his right coronal suture and the top of one ear first. The most stunning acynclitic molding I have ever seen, and a very stunned floppy baby who took some work to get him to come around properly.

Likewise his mother took some coming around. She seemed stunned, and disinterested in her baby as he was worked on across the room. I continued to talk to her quietly and kept explaining what was happening, everything I was doing as I delivered her placenta and then inspected her (intact!) perineum. I encouraged her mother to stay with her. In a short time baby was whisked off to the nursery (some respiratory distress) and she was left there with her Mom, curled up on her side, apparently asleep but when I touched her hip, she opened her eyes, smiled faintly at me, and reached up to touch my face with another whispered "Tankyu."

Today, with her, I wished over and over that I could speak more than my presently fractured Bislama. Odd though, that her birth is the one I found hardest today, and not the heartstopping "stuck-ness' of that first shoulder dystocia.

Thursday, January 15, 2009

Your wish is my command...

I hear your requests for updates. It's been a quiet few days with only three babies for me to report, all uncomplicated deliveries and swift, easy postpartum stays. I've also had a friend in town from Aus and I took a day off to go snorkeling and lie about in the sun. I'm contemplating doing that again tomor

We have had a rash of preterm labor mamas coming in at 30-33 weeks contracting, and with cervixes making ominous changes, in all cases malaria was the preceding event, all of the women were febrile, all the babies were tachy and I learned very fast how to start women on IV mag. sulphate, monitor for toxicity and have the calcium gluconate standing by. Have also administered malaria meds, beaucoup antibiotics and the occasional indomethacin suppository to try to arrest their labors as well as the standard steroid therapy to oomph up tiny fetal lungs (all things I will never do when I get home!!). All of the women have now been discharged and we all keep our fingers crossed that they come back in active labor at 37-42 weeks or thereabouts.

We've also had a rash of babies readmitted for feeding issues and weight loss accompanied in a few cases with some pretty spectacular neonatal jaundice as well. Have spent much time teaching teen moms (16, 17ish) to hand express, cup feed and then latch babies as they improve and are less lethargic. Can now officially say I've seen some babies with "oh my God" jaundice and some TTNB. Conspired with the neonatal nurse to "Rescue" a baby from the nursery and return him to his mama for some serious skin to skin and breastfeeding action. RR fell from 110 to 80 within 30 minutes. Felt good about that.

Hemorrhage mama will go home tomorrow after recovering well. At 23 (and the mother of 4 children) she is now in abrupt menopause and her Hemoglobin this morning was a measley 5.9 after 7 units of (still-warm med student) blood. Med Students incidentally, are feeling very noble. There's little doubt that their donations saved her life. No signs of Sheehan's Syndrome which was my next concern - her breasts are full of milk and her baby is growing apace.

The twins went home on Day 2 of life, nursing and growing like little weeds. Vertex twin #1 is on the right, his footling breech brother is on the left.
Tiny baby Henri also went home with his mama a couple of days ago having made it to 2.0kilo (4.4lbs) up from his 1.9kilo birthweight (below). We think he was about 33-35wks gestation, but dates are hard to firm up here, as prenatal care is so sparse, most women don't make it in to the antenatal clinic till well after baby starts moving, and rarely if ever keep track of their periods...

Started doing some clinic today also, which was a helluva change from the leisurely 45mins-hour long visits I'm used to at home. In 1 hour I saw 8 women, and in my broken bislama managed to counsel them a bit on the importance of their diet (trying desperately to get more protein into it), drinking lots of water, and actually triaged some minor pregnancy concerns ("legs blong me soa morning"= My legs cramp in the mornings - we chatted about increasing her intake of island cabbage which is an insanely nutritious wild green and bananas and milk - hoping for a bit more Cal/mag in her diet) and some more major ones: "Man is blong yu is im killim you?" = Does your husband/partner hit you? - sadly, three of my 8 morning clients replied that yes, they did. We then talked about how often... My mission now is to devise some strategies to be able to perhaps HELP them with this situation. Not so easy when you don't have much language, but at least now it's in their chart, so more folks can hopefully address this with them. Learning curve about vertical, but that's why I came here.

So it goes somewhere south of the equator...

Sunday, January 11, 2009

Twins! And DIC/Couvelaire's Uterus.

To the midwives in my life who've been quietly praying for twins and breech babies this trip - THANK YOU! Today those requests paid off when the supervising midwife thrust a chart at me to admit. I wandered into the admitting room, greeted the mama, introduced myself and opened her very abbreviated antenatal chart. My eyes skimmed the data, and stopped dead on the ultrasound report which, like all ultrasound reports here consist of a hand drawn sketch of baby's lie, and are otherwise completely illegible. Big difference with this particular report: there were two stick figures drawn. Sure enough after some further investigation I realized I had a mama in active labor with two babies. Twin A was easily palpable as a vertex, Twin B was much more ambiguous but as supervising MW and Doc said - we'll deliver them vaginally regardless.

After a little kerfuffle about whether they were 35 weeks or later, some steriods and a little nifedipine to try to slow the labor down (didn't work) later she was shortly complete and asking to push. A short while later she pushed her first 2.8kilo baby boy into my hands. I quickly clamped and cut his cord, and we auscultated twin B who was sounding very happy. MW asked me to feel for a presenting part - I reached up and felt what felt like tiny toes inside the second bag of waters. Several minutes tick past as we waited for her contractions to pick up again, and for that presenting part (no one was overly convinced we had either a breech or a vertex presenting). To my inexperienced hands, it seemed like it could have been a head, or perhaps a compound presentation (a hand?) to engage in the pelvis. A couple of contractions later, as baby sank further down into the pelvis, the bag was broken, and in a rush of fluid and fresh meconium, a footling breech babe slid out. Another boy, about 700gms smaller than his brother. Both babies were howling at each other within minutes, as her giant placenta was born. I expect both babies will hang out here till Twin B makes 2.500kg.

Too much fun. :)

The twins were actually babies 2 and 3 of the day for me, and were followed shortly by babies 4 and 5. All NSVD's with no complications. The last one though (a G1P0) pushed out a substantial baby and tore pretty spectacularly down both posterior sulcus'. I took a good look at the tears (which actually started as baby was descending) and decided that the senior MW on the floor should do that repair. So I assisted, with both med students looking on. I used some of my BYO lidocaine and am now officially convinced that it works much better than the lidocaine we have available to us here.

The day though, started with a helluva complication, as a mother who delivered in the night bled torrentially. I immediately asked the Doc to check her first thing during rounds. Swiftly the decision was made to move her to the theater for exploration. Some small lacerations were repaired while they were there, but the blood loss was clearly originating from her uterus. Some very small fragments were removed, by this time it was estimated that she had lost some 2500cc's of blood and her uterus was still not behaving. Medications were administered, both into the myometrium directly, as well as sublingually and IM. An hour later, suspecting DIC (faucet-like, watery bleeding), an emergency hysterectomy was performed when the doc discovered a Couvelaire uterus, which was bleeding through the myometrium into her peritoneum, her uterus was simply incapable of contracting at all. TEBL at the end of the day >5000ml/cc's. She's had 7 units of blood when I left for home this afternoon and her pulse was still in the 130's. Two of the med students (one a universal donor, and the other compatible)parted with two units of their own blood before we had to send them home, dizzy. Hanging nice warm bags of 'doesn't get any fresher' whole blood is definitely something I'll remember.

She is the first woman I've worked with who literally might not survive the experience of delivering her baby who was, incidentally, born healthy and happy (no abruptio placentae which is usually responsible for a Couvelaire's uterus). Little babe has an auntie who's breastfeeding her tonight.

Thoughts tonight toward the pacific if you will, for a swift recovery for this mama.

Thursday, January 8, 2009

In which I catch 3 babies in less than an hour.

Didn't think it possible to have so many women decide to have babies within minutes of each other.

Day three, three med students in tow (assigned to me by hospital OB)and instructions to help one of them catch a baby, I arrived to find the admission board with no 8 names on it. Three of them at 8cm, the rest beyond 6, only a couple of them primips. First three hustled into the labor ward. Mama #1 (a G5P4) delivers rapidly, her petite baby (2.4kgs or so) wailed his way into the world. 3 minutes later she pushes out her placenta (I didn't even have to pick up a cord)into my waiting dish, splashes blood on the shoes of med student. Oops. ;) hand off baby to one of the other MW as grunty sounds issue from across the ward. Bolt over, changing gloves en route. Open mid-bundle grab a couple of gauzes as baby crowns. Just barely get mama to slow down a bit, she does, and another baby slides into the world to the sounds of the supervising midwives laughing at me juggling deliveries as they change sheets and threaten to break the waters of the women waiting at 6cm outside the labor ward.

More relaxed second stage to the sounds of Mama #3 fighting an urge to push with an anterior lip.

Young, clearly frightened, and in lots of pain, the three "baby doc's" and I supported her last few minutes of active labor, whispering "it's ok" in her ear, rubbing her calves and hamstrings which were cramping almost constantly. Finally (about 10 minutes later) she was pushing in earnest and we coached her into second stage, tears rolling down her face. I carefully delivered baby's head (she was a primip and respectfully there was no way I was going to let her perineum be a casualty of a 'baby doc's' first catch - aside from the fact that I'd be the one who would then have to repair it!) and then took a first year medical student's hands and helped her catch what wound up being (to me) a shockingly small baby.

For the baby's size (1.8kg's) he was a feisty little thing. Cried quickly, breathed well, and given that I immediately suspected he was either a) pre-term or b)IUGR I handed him off the the RN behind me who bundled him and stuck his tiny head under the ubiquitous plastic box with the O2 tube snaking inside it. I then handed the clamps to the other med student and he delivered her matching tiny, but healthy looking placenta. After I quickly weighed and poked the baby with his mandatory vaccinations I sped him back to his mama (who was lying there sobbing quietly), and quizzed her in my broken French about her pregnancy. "How long was your pregnancy?" "8 months" was her reply. After he went to breast - and sucked, albeit weakly - I rustled up her antenatal chart and sure enough, her babe was a good 6 weeks early. Interestingly, by dates the first mama of the morning was supposed to be less pregnant than this woman, Her baby was 8 weeks early on paper. But certainly wasn't as small or as weak as this little guy.

She called him a lovely French name, somehow appropriate for his delicate little body and he's beautiful. He's in the nursery hanging in there.

My last patient/client for the day presented early on after prodroming for three days, but was sent away with a cervix too posterior to even evaluate. When she returned at about noon, she was 8 cm, and when I broke her bag, as instructed, I found a substantial quantity of moderate, particulate meconium. She was monitored closely, baby's tracing was a bit dodgy (some variable and very occasional lates, all with quick recovery) so the OB instructed me to start some synto, and recheck in an hour in the hope that we could get her baby out sooner, rather than later. Augmentation here consists of 10u of syntocin in 1L of fluid and eyeball 10drops per minute. I started her IV, whacked in the synto and rubbed her back for an hour. At her next check her cervix was found to be the same, and baby was clearly direct OP, with a deflexed head at that. By this stage she was continuing to leak large amounts of increasingly mec stained fluid. "Up the Syntocin." was the instruction from the doc. She has 1 hr and then we get the baby out.

Long story made short: An hour later she was prepped and headed off to the OR where a fat, lovely babe was fished out of a bunch of thick meconium.

Wish I hadn't had to break that bag. But, as small consolation the Doc's parting words to mama this morning at rounds: "You'll be able to have a lovely vaginal birth next time, dear". Wish more docs would say that at home, eh?


Internet access is a bit dodgy all of a sudden... Hope to be back on more frequently soon. Haven't dropped of the face of the planet :)

Miso Mama #2

Ok, first things first. C/s baby continues to go well. His persistent cyanosis, sleepiness and generally weird behavior was attributed to asphyxia – ostensibly from his snug double nuchal cord I continue to be suspicious though that he has something else going on, and am more inclined to look askance at the Misoprostol induction. He finally woke up this morning, after an evening spent enjoying O2 and IV hydration, and wailed for his mama. He went reasonably quickly to the breast and nursed well for the remainder of the day. We’re all hopeful that he will do well. Still looks funky to me, but hopefully he’s just an FLK* who had a rough ride to planet earth to one unlucky mama.

The second miso induction, this time for postdates, from yesterday was still laboring this morning when I pottered onto the ward. We popped her back onto the CTG machine where she’d been monitored occasionally since the miso was placed. The tracing was ominously non-reactive, we put her on some oxygen and almost immediately baby perked up, as did her contraction pattern. I sat and watched for a bit, trying to get a feel for what her labor pattern was like, when the toco tracing (which monitors the uterine activity) and mama both indicated the onset of a contraction. The contraction continued, and continued, and continued. At about minute 5 after the onset of the contraction I was edgy – it should have relented by now. I turned the O2 back on and changed her position. At about minute 7 the baby’s tracing, which had been perky and reactive was again flat, and then deceled decently with slow recovery.

At about that time the OB wandered in. I grabbed him and pointed out the weirdness in the tracing. Tetanic contractions (those that don’t go away) can be an indication of an abruption and can be seen with uterine hyperstimulation which miso is somewhat notorious for. I quizzed mama about her pain, she pointed to a spot low on the front of her on her abdomen and said “It doesn’t go away and it really hurts here.” OB agreed that an abruption may be occurring and immediately asked for an amnihook. He proceeded to break her water - I’d never seen that done at 2-3cm (early!). The contraction abated immediately (about 20 minutes after it started) and the baby immediately began to improve. Within minutes we had good variability back again and shortly thereafter lots of fetal movement had me reassured that breaking her water had done whatever needed to be done in the interim. We agreed (me and the doc) that we would continue to monitor her, but to be on the safe side I drew blood to send to the lab for type and cross match and started an IV. An hour later all still looked good so I got her up and had her wandering about to try to move the labor along.

At about noon she appeared to be in active labor and I checked her – She was 8ish and the baby was so high I could barely bump it’s wee noggin. I popped the CTG on and while she was having strong contractions, the baby’s heartrate tracing was again ‘flat’. The other thing that had changed was that the fluid she was leaking was now the murky pea soup which no midwife is ever pleased to see. I called the doc and the decision was made to prep for C/S. 5 minutes later I’m preparing to insert a foley cath before transferring her across the breezeway to the operating theater and when she rolls over she informs me she wants to push. Gorgeous charge MW cackles with what can only be described with glee and tosses me a pair of gloves, while hollering for the nurse aid to bring us a “mid-bundle” as we were in the admission room rather than the Labor ward/delivery room. About 2 minutes later a pretty floppy babe was born into my hands, MW still cackling next to me. Baby came around swiftly and everyone breathed a sigh of relief a) that we had a happy babe, and b) that we avoided a C/S.

It was the messiest birth I’ve done so far which is not so much fun when you’re the one scrubbing the filthy sheets in the sink… I should note that the active management they’re doing here WORKS. These women barely bleed (~100-150ccs) at all – this birth was particularly mec-cy though which while not terribly offensive, per se, sticks like the proverbial and is hell to wash out. But I digress.

I made sure to check the placenta well (which never seems to get done here – they’re just tossed into the “bin on the right”), and sure enough I found a decent sized retroplacental clot: more evidence that she did, in fact have a, mercifully, small abruption. I asked the doc later why it was that breaking her water seemed to work so well to change the contraction and baby’s heart rate. He said that her ultrasound had shown a lowish anterior placenta and that by breaking the bag, even with the baby at -3 (or however high) and dropping the baby down further into the pelvis this way the pressure of baby’s head might place sufficient pressure on the placenta to arrest it’s theoretical bleeding. Makes some sense. Even though no-one but me will likely ever read it, I charted the crap out of it, as much for practice as anything else.

Super fun case. Which he then made me “teach” two fourth year Australian med students. Actually felt like I had some skills here! Happy days.

*FLK= Funny looking kid. No clinical reason aside from sheer luck. Fortunately the vast majority of FLK's go on to become decent looking humans. ;)

Monday, January 5, 2009

First breath to last.

When I walked into the labor ward this morning, hunting for the primary midwife for the day, I noted a tiny green bundle lying on the resuscitaire, a worn hexagonal plastic box with a tube snaking from the O2 tank beside it through a hole in the top. I figured someone had left it there from the evening shift and I wandered out. I found the midwife, asked what had gone on in the night: three women delivered babies, a fourth delivered at 23 weeks and was then transferred to the surgical wing. She gestured toward the labor ward:

"850g. Too little. He's still in there, gasping." She said simply.

I realized the tiny green bundle on the resuscitaire contained a tiny baby. One about the same size as the one in my belly. I went back in, opened the green, surgical bundle. I was expecting honestly, to find a baby who was dead. Instead, he opened his tiny eyes and began to cry. His tiny mewing sounds caught the attention of the morning midwife, who summoned one of the peds who was in for rounds and somehow the decision was made to support his impossibly slim chances for as long as he was up for the struggle. Support here for such a tiny preterm baby is minimal, but for those babies who take up the fight, they are helped as much as they can. I watched the ped start an IV line, begin him on fluids, and he was tenderly carried to an isolette in the nursery by the male midwife, easily the tallest bloke in the vicinity, where he lay, tiny arms waving occasionally. The contrast of 1lb-something baby in the hands of 6.7ft midwife was striking.

I asked when his mama would be told that her baby was still alive (she was evidently told he was dead). "The pediatrician might tell her sometime today" was the response. He clearly did, because a 1/2 hour later and then every hour after, baby boy's grandpa came up to peer at his tiny grandson through the crackled plastic of the O2 hood in the isolette.

At about 2pm I stepped in to see him. "Him give up" the male midwife reported from across the hall. I went in anyway. His tiny birdlike chest was indeed still, his hands and arms the slightly darker purplish shade which comes with death. I stood there for a while, said a little prayer for him, and his mother (who I never met) and his grandpa. His chest rose and then fell again: an agonal breath. In truth it may not have been his last breath, but in any case his short (almost 8 hours!), brave little life began, and ended today, and I spent some of it with him.

I don't think he was ever held by his mother. His whole family came to collect his body. I think they were to take him to the morgue. It may have been them I heard keening as I walked home.


Today though, about 11 am I admitted a G2P1 in active labor. Was pleased to find her a stretchy 6cm and lovely low head. I broke her bag (protocol) into a bedpan, and 15 minutes later she reported she wanted to push.

To the labor ward we went and about 10 minutes later her son felt my hands first. Wonder of wonders (doesn't happen here a lot) she welcomed him up onto her chest as soon as his cord was cut, and she cuddled him for a few precious seconds before he was whisked away. Don't fret, got him back to mama soon after, latched and nursing.

"How many babies you deliver in Vanuatu?" she asked.
"Yours is the first!" I said. She didn't seem too bothered.


Today was notable also for two misoprostol inductions (also known as cytotec, it's a very inexpensive prostaglandin medication which is placed in tablet form beside the cervix in the vagina to induce labor and treat postpartum hemorrhage). One for a woman whose chart was covered with highlighted instructions. Notes that she was high-risk. of 6 term pregnancies, she's delivered 1 living baby. Two of her babies were stillborn, and two had died within hours of birth. None of these deaths had ever been explained, no autopsies ever done. She presented for induction at 38 weeks, in the hope that we could help her have this baby be ok - her living child was born after induction at 35weeks. for this, her 7th pregnancy, 6 hours after the miso was placed, her baby - who to my eye had had really weird CTG tracings from the word go - began to decel into the 90's (should be between 110 and 160 or thereabouts. Given her history, the decision was made immediately to proceed with cesarean section.

Immediately here translates to the time it takes to call the doc, draw blood, send it to the lab for type and crossmatch, The time the lab takes to type and cross match and then send over the requested two units of blood, place urinary catheter then wheel mama over to the OR, prep for surgery. Scenic detour for me and fresh UK med student as Doc took the time to instruct us on proper hand-washing technique (I wish I was kidding). Then instruction on how to place spinal anesthesia (I KNOW I'm never gonna do that). All with no fetal monitoring going on... I have to tell you my skin was crawling just a little as he talked and 'taught' us through dissecting into the peritoneal cavity, and then the uterus, all the while saying cheerfully "with no indication of fetal distress, there is no need to hurry - I could do this much faster if necessary". I was looking around the room thinking "Dude! We're doing this CS because we had signs of fetal distress and we're not actually monitoring baby presently so we have no idea if this baby is tanking as we speak - not to mention the fact that this woman's lost 4 babies already!!"*

Anyway baby was born alive (good start) and was transitioning poorly. I wasn't actually supposed to be doing anything at this birth, aside from observing, but the baby was looking funky, very blue, low tone, not opening his eyes and I was kinda anxious that he be ok. The ped did an initial suction, but not a whole helluva lot of much else. I was itching to rub on that baby - he just looked too flat. I pulled out my stethoscope from my pocket and gestured to the ped if I could listen. He gestured to me to go ahead. I listened and his HR was 90ish. I busted into full resus mode: rubbed on him, flicked his feet. Bagged him till I got chest rise - he seemed completely disinterested in breathing and his color just sucked. He just wasn't transitioning right at all. But at least with the PPV and stim he started crying a bit and his HR got up over 100. Ultimately he went back to the nursery with blowby keeping him (almost)pink. I popped in to see him on my way home (only 2hrs after my shift was supposed to have ended) and he was still needing 4L O2 but his eyes were open. The word which keeps popping into my head is syndromic, not sure why, but something about the way he looks struck me as a bit 'off'. I hope like hell he's still with us tomorrow morning, and that he continues to do Ok. 1 dead baby is too much for any mama, 5 dead babies (term babies at that) is inconceivable to me.

BBQ for everyone tonight at the place I'm staying. Ate well, but really didn't feel at all like socializing, can hardly walk, my feet are so sore from running around all day, then standing in the OR for a couple of hours. I'm so finishing this post and going to bed.

Oh yeah. Was so tired, my entrance to the BBQ involved me walking through the screen door to my room. In a seriously elegant maneuver (I'm occasionally famous for them) I tore off the screen door completely, and the door and I landed in the bush in front of my room.

A member of my audience: smart arse South African bloke, three beers down, called out: "You're supposed to slide that one, love."

You don't say.

* I should note that I am very grateful for the cool stuff this wonderful doc is teaching me. I mean no disrespect at all to him when I relay my anxiety in this post. It was just stuff that was going through my head. It's just different is all. Cytotec inductions for a grand multip with a history of multiple term stillbirths and neonatal deaths, and lengthy decision to incision times just kinda freak out this student midwife who's used to lovely low risk, healthy gravidas!

Sunday, January 4, 2009

First Shift

6.50am Stroll up to the hospital, bags of supplies in hand.
Maternity ward found at the end of rutted dirt driveway, front door surrounded by discarded hospital beds and other miscellaneous furniture. Postpartum ward is PACKED. All 12 or so beds occupied by women, their babies in giant nappies and swaddled in LAYERS of blankets - for the love of GOD women, it's 95degrees in here! Assorted family members lying about on woven mats or up preparing food for the women - no food service here!

7.10ish meet three midwives (including tall, handsome and clearly quite shy, male midwife), 4 docs (2 OB's, one Ped, one Gyn).

7.30 Rounds. Gyn doc snaps me up and begins quizzing me enthusiastically(socratic method, anyone?) on postpartum visits - "History, examination, investigation and don't forget to wash your hands!!", then begins quizzing the other docs (felt a little weird). Discharge 10 women. Hospital has seen some 32 babies in the last 5 days including two preterm babies, a set of twins and breech baby. Round on surgical Gyn patient transferred emergently from another Island two nights ago. Poor lass had been bleeding for three weeks (!), ultimately her ruptured tubal ectopic pregnancy evulsed into her uterus (ack) and she bled three liters into her peritoneum before emergency surgery saved her life. Her Hgb this morning was 3.2. Holy shit. Needless to say, she was a) lucky to be alive, and b) feeling pretty crummy this morning.

9ish. back to the maternity ward where three women were in various stages of labor. hung out with midwives, helped a 4day pp woman learn to hand express milk, then cupfeed her pretty awesomely lethargic and dehydrated baby who hadn't nursed effectively um, EVER. NB Weightloss central. She and her baby were readmitted.

11ish. Mama #1 G1P0, complete, not having fun. Assisted MW with birth. Hope like crazy that my probably not well understood gentle words and back rubbing made up somewhat for the *slap* and sharp instructions to "yu no cry out" from my colleague during the end of her labor. 25 minute-ish 2nd stage. Vigorous baby, tiny by our American standards (~6lbs). Seriously actively managed third stage. MW proudly displays intact primiparous perineum - no sutures needed at all. I admit I'm impressed.

2ish. G2P1 stalled at 8cm for ~3hrs (I guess this counts as stalled here). Complaining of crushing back pain, I'm suspicious of malpresentation. Suggest she gets on hands and knees on the bed for a few contractions. I'm amazed, she tries it, then tries wall swaying! She pushes out large 4.6kilo babe a short while later. Baby girl met with auntie's exclamation of dismay: "Shit." When we peek between her legs. Mama starts sobbing. I spend the next 5 minutes telling baby girl and everyone else in the room how beautiful she is and how lucky we are she's here.

3.00pm. I'm supposed to go home. But the third admission, another G1P0 is "fully". I can't help myself. I poke my head in to the labor ward, and ask the MW if I may assist. We spend the next hour speaking gently and encouragingly to her (I think this particular midwife may be one of my favorites) as she slooooowly (by ni-van standards) brings her baby down to her very looooong perineum. An hour later an inch long midline episiotomy is performed, and minutes later another vigorous babe slides into the world. I take care of the babe (they are weighed and their vaccinations - HepB and BCG - and vit K given as mama delivers her placenta) and then swiftly return her to her mama. I hold her so baby and mother may look at each other as MW completes a stunning repair of the episiotomy with 1.0 vicryl.
Then baby to breast, opens wide, latches.

4.30ish. Head home. Smile on face.

Other things. Three women, three births, almost 10 hours. Heart tones were taken once on admission (a CTG strip) for each, then perhaps once more at the onset of second stage. In the case of the woman pushing for an hour, I think I was instructed to take heart tones once again. Placentas are deposited immediately into the trashcan on the right. Sheets are washed, by hand, by me. I have a new love and respect for chux pads. We have no idea just how lucky we are.

**Paul - you want to bring some stuff, and you can get your hands on disposable underpads, then bring as many of those as you want!! **

Can't figure out though, how to get gloves onto my sticky, sweaty hands.

So. Short version: day one, no drama. Lovely women, good midwives, beautiful babies.
Oh yeah. And 1970's squat hospital architecture. 95 degrees today. 1 fan in the whole place. Blessedly someone put two struggling air conditioners into the delivery rooms which helps. Anywhere except (ironically) in front of the resucitaire where we put babies immediately after they're born (the whole dry off/look over/listen/wrap up thing) it's hotter than hades.

Too much fun, peeps. Too much fun. Oh, and Emily - everyone sends you their love and best wishes for your baby!!

Friday, January 2, 2009

Sounds of a Saturday Morning

I think I mentioned that the ubiquitous crows of the neighborhood's countless free-ranging roosters kick off at about 4am. They continue at intervals of two minutes or so until about 9am. This would be less irritating if there was one or who roosters, but it amounts to a veritable dawn chorus of domestic foul in the numbers I'm talking about. Three mornings into this, and I find I'm almost used to it. The roads are largely unused by vehicles aside from buses (wee, rickety minibuses) which speed by periodically accompanied by noises which my non-mechanical ear diagnose as "sans muffler". These sounds start at about 6.30, I assume when everyone heads off to work.

One of the little kids next door begins screaming and crying. Sounds somewhat like my (almost) 4 year old pitching a whopper tantrum, but it's somehow a slightly more distressing sound to me, like perhaps he's hurt. Trips my "Mum nerve", makes me anxious. I listened to him wail, and couldn't hear anyone respond to him. He stopped eventually.

Dogs bark a lot, and fight. Small yappy sounds punctuated with larger sounding growls and scuffles. I passed a vet's office the other day, wonder if any of my neighborhood dogs are ever seen. Frankly I doubt it.

I'm writing at this moment to the sound of a piglet squealing loudly. I wonder if the kids are playing with (or pestering) it, or if they're getting ready to kill and eat him. Given the marked crecendo to his squeals, and their subsequent abrupt end I suspect the latter. Hmm. Neighborhood pig prepared for eating. Why hadn't I factored that one in? Interesting to contemplate that as I munch on my weetbix and bananas.

It's a hot one today. The sky is bright and almost an unbroken blue. I've come to rather wish for the cool promise of cloud cover which brings with it the sudden, intense 20-30 minute downpours. The rain cools the air for about as much time again before the humidity replaces the heat and I wait again for the cycle to repeat.

I promise I'll stop talking about the heat soon. Really.

I'm doing a whole lot of nothing for a few days. After a pretty manic couple of weeks traveling with Husband and boys, and then a week of extended family and the benign but nevertheless quite exhausting dances which go along with that, I'm talking three days to just sit.

I venture out to the town periodically. Walked for a couple of hours yesterday in the relative cool of the morning. It was still bloody hot though, within a half hour my fingers and wrists were swelling. I found the sunscreen I was looking for - should have bought that in NZ (1495VT - ~$15.00 for 100mls!), bought an enormous hand (I think about 25) of tiny perfectly ripe bananas at the market for the equivalent of a dollar. I also bought a couple of postcards and stood in front of the display for a while thinking that it seems fraudulent to focus so much on the pristine beaches and impossibly blue water of this place, strategically placed starfish in the shallows, when the reality of this place for most of the people who actually live here is to my inexperienced, western eye, a good deal bleaker, and certainly uglier than the beautiful images on sale for 110vt each. I suppose though, that the world isn't really all that interested in the grubby bits. In the States we buy postcards of the beautiful tall buildings of the NY skyline and central park, but there are no postcards of the housing projects, or the homeless people. Perhaps the desire to focus on the perfect, and ignore the less-than-perfect is universal?

I walked by the hospital in the morning, watched the occasional parent/child pair wander hand in hand past the piles of rotting rubbish piled by the gates and up the dirt driveway to the very modest mother child health building where I will present myself early on Monday morning.

I'm keen to get started, but I'm enjoying this little bit of time to myself, with no greater problems to sort out than what I'll make for dinner tonight (smuggled quinoa?) and totally uninterrupted knitting and reading time for at least another day or so.