I feel both a bit nervous and excited about going to Vanuatu. We met right outside the terminal. Liz, in particular, had a ton of bags filled to the brim with sheets, medical supplies, baby paraphernalia and other stuff donated by many to help Port Villa hospital maternity services. We were about 44 kg above the weight allotment (and thats on top of extra 10 kg each that Air Vanuatu already agreed us to take. We ended up finding someone (two lovely Pacifica gentlemen) to take one of the heavier suitcases. Unfortunately they then ended up over the limit. The total, $13 per each extra kg, came to $132, which the men paid and refused to accept our money. WOW! We ended up buying them a nice bottle of Sapphire Gin and a bottle of Absolut. Really wonderful to see such a generosity.
On the plane, which was only about half full, I took up a whole 3-seat row to myself, feeling a bit antisocial as I often do when flying. Meanwhile, Liz and Chris got all sorts of juicy details from the woman sharing their row about where to change money, eat, drink, etc. I'm typing this as we are flying through the air at 32 thousand feet.
By the time we arrived and checked in, it was after 3PM. We ended up going to the local fruit market and to the supermarket to get some food. Both Liz and Chris were quite tired, so we had dinner at their room and retired to bed early.
Thursday, April 10th, 2008
Got up early today and headed to the Vila Hospital. Its about a 5 minute walk, even in this heat. The small, two lane road leading there is fighting a loosing fight with the encroaching jungle. Through the dense green one can glimpse the mud floor huts cobbled together from bits of wood and corrugated iron. Chickens venture wearily to the edge of the pavement, and skinny, brindled dogs prick their ears questioningly as we walk by. The hospital itself is a series of low buildings set in a field of Bermuda grass and mud. Here and there attempts have been made to brighten them by painting the window frames and door bright tropical colors, but the effect is largely spoiled by piles of old medical equipment rusting in the sun. Patients, visitors and employees are indistinguishable, and you don't see anybody walking about purposefully as you do in any first world country. Life here, even for the sick and dying, has a leisurely pace. The heat is thick and palpable. It is like moving through a piss- warm, chest-deep lake. One is given to take frequent rest stops, even when crossing the street, which can explain extraordinary high rate of accidents involving human injury.
The maternity ward is roughly divided into the antenatal area at one end, a postnatal at the opposite and two delivery rooms in the middle. All rooms are arranged along a long corridor and have about them an air of decay. Acoustic tile ceilings sag under the weight of collected rain water that drips through the roof. Linoleum floors have thin patches and dark lines, where the adjoining pieces spread apart of the years. All the instrument trolleys have a thick dark crust of old blood and unidentified substances around the wheel wells.
The staff, by contrast, is resplendid in their uniforms. They are also extraordinary warm and welcoming. Our gifts of linen, medical disposables and baby packs are received with deep gratitude. We are shown around the ward and get to meet and chat with some of the patients there. In the postnatal room, everyone is breastfeeding without any seeming difficulty, which is SO refreshing. After a few hours we head back to our rooms to get some lunch and a refreshing soak in the pool.
Rosie meets an woman in labor and is eager to get back so that she can attend her in birth. We all head back and I trail Janet, the Sister in charge (god, I love that name Sister... has a real warm, fuzzy feeling to it). Janet is taking care of Wendy. Wendy is a 19 yo primup, 36/40, who had a SROM 4 days ago. She has come to the hospital shortly afterwards, got given some oral antibiotics, injection of steroids and sent home. Wendy has been back daily for a CTG (reassuring) and more antibiotics. Finally, this morning at 10AM she started having regular and strong contractions. I get to do a speculum exam (my first) and you can actually see the top of the baby's head deep down.... probably station 0 or so. Janet estimates that Wendy is around 7cm. We walk around for a bit. Wendy is quite vocal when someone is with her, but left on her own she bears the contractions with surprising stoicism. After about an hour, another 15 minute strip of CTG, placement of a leur, a shot of IV antibiotic and a quick obs, we usher Wendy into the delivery room.
Because of prolonged ROM, we do no VEs and just wait and watch. Wendy is clearly is going through the transition, her toes curl under with each contractions and her eyes roll briefly up in her head. She starts making involuntary pushing noises and Janet and I begin coaching her through pushing. Unfortunately, Janet talks to her in the local dialect, which is a form of Pidgin English, which I can make out about one out of every 10 words or so. I get to be the cheerleader, chanting “push, push, push”. After about 20 minutes, I get on the right side of the bed, slap on a pair of gloves and, under Janet's watchful eye and generous suggestions, place my right hand on the perineum with some force (Janet keeps telling me to apply more pressure). After about 3 pushes the head emerges, I feel for the cord around the baby's neck and deliver the rest of the body. WHOOOHOOOOO.... The hospital protocol is 10 units of Synto followed by 0.5 mg of ergot (kind of make-it-yourself Syntometrine), which Janet delivers. I wait... and sure enough there is the elongation of the cord and the trickle of blood... with my hand of Wendy's fundus I can feel the uterus rising slightly and I do a CCT. The placenta is beautiful and plump. Wendy's perineum is intact. The baby girl was born at 2:40 PM and weight 2.76 kg, not bad for 36 weeks gestation. I get to place her briefly at her mothers side for a quick BF, before she gets to be taken to the nursery for her own IV antibiotics, necessitated by the prolonged ROM.
I feel INCREDIBLE. I was SO focused on what was going on, that I didn't even realize the both Liz and Rosie came in to the room during the delivery and Rosie took some pictures. Cannot wait to see them!!! I felt calm and in control. Even when the arterial clamp slipped off the cord during the CCT, I just repositioned it. I love this feeling of being so engrossed in the moment that nothing else in the world exists! Cannot wait till tomorrow!!! On a more sobering note, the ward had two stillbirths last week and one significant maternal trauma. So onward with my fingers crossed.
Friday, April 11th, 2008
Had a big dinner last night at the Waterfront restaurant. Food was mediocre, but the band surprisingly good. Had a really late start this morning and went to the cultural center. Got to see some sandroings (stylized drawings of totem animals and pictorials of transitional moment- birth, death, marriage) as well as a guided tour of the collection. Rosie was fascinated, I bored. However, the guide volunteered to take us kava drinking later tonight. Should be fun.
Made it to the hospital around 11:30. Just missed 2 birth just minutes apart. Got to watch a manual removal and clean up afterwards. Yack! Actually Rosie had a real problem just watching. She felt that the doctor (a skinny black man) was treating the woman like a piece of meat. I just thought it was very gory. Chris and I went and bathed both babies. By the time I came out, Rosie and Liz were doing another delivery. Helped out as much as I could but mostly watched. A young woman of 20 has labored all on her own for almost 18 hours and came to the hospital already 8cm dilated. She delivered a healthy tiny (2.5kg) boy less than an hour after arrival. Did get to do a baby check and give vitamin K and Hep B shots.
Women here in Vanuatu are so strong and stoic in their labors. I'm so impressed. One thing I noticed from observing/participating in these births over the last two days, is that they all call for their mommies while in transition. I'm wondering if this is some sort of cultural thing, since I never seen it either in New Zealand or the US.
We met Eddie, the man from the cultural center, at 5:30 PM and went to the place where he lives to drink kava. I had 4 shells, the rest of the girls just had a little taste. Kava is pale greenish-brown in color and tastes like grass with some mud thrown in. You lips and tongue go numb almost instantly, but it doesn't really make you feel intoxicated. Not sure what the islanders get out of drinking the stuff. I get a lot higher by just drinking half a beer. And... the stuff makes you really gassy. Oh, well, at least I can now tell people I drank kava with a small, dark man from Vanuatu. Afterwards, he escorted us back to the Tradewinds and we sat around a while at the pool, drinking beer and talking.
Saturday, April 12th, 2008
Spent over 3 hours in the hospital, but nothing was going on. We ended up taking a boat to a small island and having a wonderful lunch there. The girls went grocery shopping afterwards, and I went back to the hotel and took a loooong nap. It is incredibly hot here, the humidity is through the roof and I feel practically narcoleptic every afternoon.
Sunday, April 13th, 2008
Went to the hospital around 9AM. They already had three deliveries earlier in the morning and nobody else was in labor. We went to the Church of Christ for services. Those lasted for hours and hours. The girls sat in the church and I lounged on the mat outside with local women. Had great conversations, held lots of babies. Went back to the hospital around 1PM and I got to deliver a little boy at 1:40PM. Liz had her hands in and she has a completely different technique from what I'm used to. The baby was tiny (2.45kg) and yet the woman ended up with a second degree tear. I'm pretty sure it was because the head got forcefully extended by us too early, but Liz believes we did everything right. We didn't palpate the mom adequately, but both Liz and I felt after a few brief feels around that the baby's back was on the R side of mom. Imagine my surprise, then, when the baby rotated in the opposite direction from what I expected. However, I just went along and all was well. Had my first “cord-around-the-neck”. Started slipping it off, but Liz took over. I asked her to let me do it on my own next time.
Came back to the hotel after the birth (cleanup took about an hour). Liz and Chris went back for Chris to catch another baby. We were asked not to come along. Bummer.... Maybe we (actually I) are too pushy. Screw it. I'm here to get as much experience as I can. If Chris doesn't like it... well... it is every midwife for herself. At this point, at least, both Rosie and I got to do two deliveries each. Maybe if the ward is busy we can go back later tonight.
Chris and Liz just got back and Chris is absolutely glowing. She delivered a little baby girl and describes the experience as “absolutely lovely”. Nice to see her animated and involved.
Monday, April 14th, 2008
Attended morning rounds at the hospital today. Really interesting. The volunteer doctors, primarily from Australia, all try to speak local dialect so I picked up a few phrases, like “ You harem good?” - “you feel good”, and “You pullem wind” - “take a breath”. The postnatal reviews seem to be quite superficial, but I think the docs are just looking for big problems, since midwives largely run the postnatal ward. Afterwards, I got to do antenatal clinic: lots of palpations, urine sticks and obs. Interestingly enough, each initial antenatal visit includes a full breast exam and an internal speculum examination. Apparently the rates of cervical and breast cancers are some of the highest in the world here, and they also have exceedingly high rates of various venereal diseases. For a country that is so deeply religious its kind of interesting.
Got to do my first ever speculum exam by myself. I did get to take a peek before, but never actually inserted one myself. Still having difficulty knowing what it is exactly I'm looking at. Everything down there in pregnant women seems to look like everything else. Because the tissue gets much more vascular and some oedema is always present, the anatomy gets distorted somewhat. On the other hand, I'm getting quite good at palpations, and when the doc and I disagreed about the baby's lie twice, I turned out to be right. Feeling rather full of myself at the moment. Will be going back for the high risk clinic this afternoon.
Went back around 1:30PM and practically walked into a delivery. The baby was born at 2:15PM. Got to do it all by myself. 2.8 kg little boy. Mom, Allena was an 18 year old primup and all her family waited anxiously in the corridor. They whooped and danced around when I came out to tell them it was a little boy. EBL of less than 200 ml AND intact perineum. I got to do a VE and everything. Actually, other than giving the Synto shot immediately afterwards, I did EVERYTHIG. Finally I feel like a real midwife.
Rosie had another young (17yo) mom, Esther, in labor. So I just hang around for a bit. Another woman came in. Elizabeth was 34 P3/G2. Sister Olina assessed her and took her to the delivery room and had me do the birth. I did my first ARM. Felt really nervous for the first time in Vanuatu. II kept thinking that I would damage baby's head somehow with the hook. Elizabeth was horrible at pushing. All the other women here seem to push as though their lives depend on it. Elizabeth, by contrast, was a reluctant pusher who gave little half-hearted pushed that had little to do with her actual contractions. It took us about 20 minutes to get things going and I got to deliver a lovely 3.2 kg girls at 4:30PM. Sister Olina has COMPLETELY different technique of perineum support from Sister Janet. I really had to apply incredible pressure. We had no fan in the room and by the time the little girl was out I was absolutely drenched! After I delivered the head I felt for the cord but felt nothing. I was really surprised that as I was delivering the body, the cord was draped around the neck, back down below one arm AND around the waist. I did unwrap it quickly, but felt a bit surprised. Two deliveries in one day... how cool is that! Rosie's mom, Esther, had her baby, a massive 4.1kg boy a short time later. It was a difficult delivery, the baby was OP for most of the labor and the posterior shoulder got a bit stuck and required suprapubic pressure to pop out. I took a couple of really lovely pictures.
Tuesday, April 15th, 2008
Went to the hospital this morning, but did almost nothing. One woman had a SROM two days ago and they were inducing her by applying the gel. Hang out for a few hours and then went to town to do some shopping. I was bored to tears. As we went to the supermarket, felt a migraine coming on and headed back to the hotel to take meds. Passed out for a few hours and feeling better now. BBQ later today at the hotel.
Wednesday, April 16th, 2008
What a FABULOUS day. Went to the hospital around 8AM and did two deliveries today!!! The first woman had a prolonged SROM and a posterior baby. By the time I got to the hospital she had a synto drip going and having very strong a very painful contractions. No surprisingly, no analgesia of any kind. I stayed with her rubbing her back and wiping her brow. She was complete by about 9:15AM and began pushing. This was her third baby, but baby's descent was slowed down by the fact that she was rotating a lot more than usual due to the OP position. At one point during the second stage we simply couldn't find the fetal heartbeat. I grabbed the mother's hand, found her pulse and was slapping the delivery bed in time, so that Janet would know if it was maternal beat she was picking up. Liz told me that she would have cut an episiotomy at this point. Janet and I just encouraged more pushing and eventually the baby came out. Janet suctioned her as soon as the head was out. It took a lot of force to get the rest her her out. I had my fingers hooked under her armpits and was pulling for all I was worth. She was completely flat and the eyes were rolled up in her head on delivery. I rubbed her down and cut the cord while Janet gave mom a shot of synto. Janet then rushed the baby to the resus table and suctioned her some more, then put her under an oxygen mask (a plastic pot turned upside down with the hole drilled on top to let the tubing from the oxygen tank enter). I did third stage. There was more than usual amount of blood but it slowed down quickly. Mom had intact perineum and was really surprised at the size of the baby – 3.4 kg, much bigger than her two previous babies who where around 2.5 kg each. Five minutes later the baby was doing really well, had a lovely color and went on the breast like a dream. I got to do the Vitamin K and Hep B vaccine as usual.
My second delivery of the day happened at 1PM. Mom was only at 36 weeks gestation and was an extremely tiny 17 year old who gave out pathetic little meows with each contraction. She pushed well but didn't stretch very effectively and ended up with a first degree tear despite the fact that the baby was only 2.1 kg. I though it was interesting, that very little is done for these tiny babies who are well at birth. They don't do BG or keep the babies under observations. Despite her size, the baby was very alert and active and sucked urgently on her own fist while I was rubbing her down. When put to the breast, she sucked vigorously, stopped for a bit, had a little spill and latched right back on. This is the first time I did 3rd stage completely on my own without even being told what to do. I also did all the documentation for both deliveries, including filling out their birth certificate. Funny, how the smallest countries, Vanuatu for instance, have the most impressive state seals : ))
Interesting aside... When mothers milk dries up too early, coconut milk from unripe coconuts is used as a substitute. Sometimes the soft unripe flesh is mushed up and fed to the babies as well. Another observation: when two women meet, they don't hug each other, but instead always shake hands, just like men do. Also, I took really great pictures of Rosie doing a delivery. Lovely picture of three generations of women: grandma, mom and daughter at the breast.
All in all I'm feeling so much more confident about my midwifery abilities now. When I go out with my LMC later next month, I know I'll be able to do so much more.
Thursday, April 17th, 2008
We originally went to the hospital to spend the day at the antenatal clinic, but it was very quiet there and we only saw one woman. We ended up going to the labor ward. Liz, Rosie and Chris went to the market and I stayed on the ward and took care of a few women in labor. When Rosie got back we went to get something to eat and by the time we got back, one of the women I took care of already had a baby and another was ready to push. Rosie took that delivery and I went to help out with the first woman's baby who had some respiratory distress. As I was giving the little girl some oxygen another mother walked in ready to push. I barely had time to glove up. It was a beautiful easy birth. I did an ARM. The 2.95kg baby girl was absolutely covered in vernix head to toe. I never seen so much of the yellowish-white gunk in my life! I actually had to wash her face with some water so she was able to open her eyes. The family were SO excited to great the baby. Alice, the mother, asked me not to tell her husband what she had and so I brought him in and she told him. He whooped and jumped around. It was so wonderful to see such excitement in a father. Tomorrow is our last day here and I hope to do one or two more deliveries to add to my 7 to date.
Friday, April 18th, 2008
Another eventful day. I'm so sorry we have to leave tomorrow. The ward is busy, busy, busy. Lots of moms in the hallways and just outside leaning against the walls, their mothers/sisters/aunties rubbing their backs. I wanted Rosie to do the first delivery so I spent most of the morning running all the unit's labor assessments. I hooked women up to the aging CTG unit and ran 20 minute strips, palpated ad nauseam and did lots of VEs. Had a young girl come in at 20 weeks. She couldn't feel her baby move for over 24 hours and I couldn't find the FH. Had Janet check her out and she couldn't find it either. We sent her over to the antenatal side to have the doctor tell her the sad news. Also had a couple of pregnant women who just had car accidents and wanted reassurances that their babies were OK. The woman I ended up spending a lot of time with and assisting at her labor was Lucy.
Lucy was a 34 year old G3P2, with entirely unremarkable history of pregnancy and birth in her two previous pregnancies. This time, however, she developed gestational diabetes and associated hypertension. Both were poorly controlled, and Lucy's BP in labor hovered around 140/100. I first met Lucy while doing labor assessment. Lucy was a large woman and a difficult one to palpate. Anterior shoulder, which normally presents an easily identifiable lovely curved bump, was not felt. I could feel the head down in the pelvis but was not able to feel the occiput and synciput at all. I was able to feel some distinct body parts on the left side of the abdomen and so was able to find fetal heart easily on the lower right quadrant of the abdomen. Baby's FH rate was fine. VE showed Lucy to be 3-4cm dilated and about 90% effaced. Because baby's head had a large caput, I couldn't really ascertain his station, since I couldn't feel around to find the actual top of the head. This was my fourth labor assessment of the day and I remember thinking that this baby might be OP, since all the other women had FH on the left side of the abdomen. Lucy had terrible back pains with her labor which just confirmed my suspicions. I relayed my thoughts to the midwife, who told me that I was probably right, but there was no way to know for sure. In retrospect, damn, should have pushed the issue a bit more.
Lucy ended up having a prolonged second stage with Synto augmentation and very scary late decelerations of FH. She has been pushing for 1hr 25min (20+ minutes w/ Synto drip) and made only marginal progress. Baby came out face-to-pubes via vantouse with a massive episiotomy. I remember seeing his head being born and feeling everything click. In retrospect, I should have pushed the idea of POP (persistent occipital posterior) presentation with more rigour. This way Lucy could have avoided the pain and anxiety that she had to go through with the second stage, and baby would not have suffered fetal distress for as long as he had. I know that I will be much more attuned to the signs of POP in subsequent births.
Baby, a 3.5kg boy, came out completely flat. I ran him to the resus table, gave oxygen, rubbed his feet and whole body.... nothing. Ended up screaming for someone to give me the time since it seems to take forever and I couldn't see the clock from where I was. Started giving him cardiac massage. Janet finally came up just after he started breathing. Had Rosie ran to the neonatal nursery to get the unit's only pulse oxytometer so that I can check the O2 levels. Still quite low at 82, but came up quickly. He started crying to. Oh, what a relief. After about 20 minutes he was warm, pink and had great tone. When put to Lucy's breast, he sucked lustily. Such a pleasure to see! Lucy was stitched up. She was crying and kissing my hands and asking me to name the baby. What an end to my trip.
Later in the evening, Chris Likeman has arrived and we ended up going to dinner. Chris is going to check on Lucy and the boy tomorrow when she goes to the unit. Fingers crossed....
Saturday, April 19th, 2008
Went to bed last night and couldn't sleep. Kept seeing this upturned dark purple face of Lucy's boy. When I finally fell asleep, his eyes opened in my dream and he breathed out a tiny meow, like a kitten. Sorry to leave this place could have easily stayed another couple of weeks. So much to learn, such amazing women, such incredible midwives! Hope Lucy's boy is OK.
We moved to another rented house about 2km from the old one. Its a real neighborhood this time and Sabrina is quickly making friends with other little kids around us.
We were planning a trip to Thailand in June, but now it looks like we might go to Europe instead because a company in Munich is interested in Stuart's latest invention. If we do go, we'll start there and then do a week each in Prague and Budapesht.
I got a consulting gig advising BSA (Breast Screening Alliance of New Zealand) on what kind of PACS solution they need to implement. Don't know how I'm going to do this with a full school load, but it is very prestigious and it pays well.
2. Avoid cutting yourself slicing vegetables by getting someone else to hold while you chop.
3. Avoid arguments with the Mrs. about lifting the toilet seat by using the sink.
4. To treat high blood pressure: simply cut yourself and bleed for a few minutes, thus reducing the pressure in your veins.
Remember to use a timer.
5. A mouse trap, placed on top of your alarm clock, will prevent you from rolling over and going back to sleep after you hit the snooze button.
6. If you have a bad cough, take a large dose of laxatives, then you will be afraid to cough.
7. You only need two tools in life - WD-40 and Duct Tape. If it doesn't move and should, use the WD-40. If it shouldn't move and does, use the duct tape.
8. When confused remember, everyone seems normal until you get to know them.
Tomorrow is September 1st, the day that all the good little future communists in the FSU put on their still crisp uniforms and started their school year by singing the national item. It is also an anniversary of our move to New Zealand. I'm unhappy but afraid to admit failure and also terrified of making a decision while depressed. I'm cheered by the fact that I'm FINALLY making really good friends. My wonderful hubby is doing another one of those 10 days home, 10 days abroad month and I'm flying solo on this anniversary. Now that I have friends and one of the volunteered to take our pets if we decide to leave, I feel unexpectedly more cheerful.
Just found out that Kimio is dead. He died on April 28th. He was standing in line to pick up a concert ticket at “will call” window when he collapsed. He was taken to the hospital and was DOA. I only found out now because a mutual friend left a message on our US phone and Stuart (who is in the US right now attending a conference) checked the VM.
I have known Kimio for over 25 years. He never lived for the future. He lived in a dump, drove an old car, traveled widely and made everyone around him smile. He never married, but was dating Wendy for almost 8 years. I know she loved him and hoped to build a life with him. My heart goes out to her.
He had a wonderfully wry sense of humor and a deep-throated chuckle of a laugh. He was a great gardener and contributed many superb sensamia strains to the Oakland Cannabis Club collection of which he was a member. He was a great friend and one of the most generous and genuine people I knew. I am very, very, very sad.
This is a practical invention, meant to help those of us in medical professions to quickly and accurately measure temperature of our patients in the absence of necessary tools, such as a thermometer or a temperature strip. The co-author of this invention, my husband, and I would like to call it Testicle Ascension Index, or TAI. All it requires is a presence of a male, which as we know is an abundant and easily accessible recourse in practically every situation. The measurement requires patient placing his/her hands underneath the testicles, letting his/her fingers wrap softly around them. The grasp should be sufficiently firm to allow the patient to determine degree of ascension of the testicles. Typically, if the patient has temperature in the normal range, the testicles will remain in the original position, lower than normal temperature will result in testicles ascending rapidly in the sack, sometimes retreating all the way into the body cavity, fever, by contrast, will cause the balls to sag into the palm of the patient's hand. To calibrate any male, simply place your hands underneath cold water for approximately 15 seconds. Place your hands on his balls and observe the results!!! TAI can also be used in conjunction with exercises to improve grasp strength. Just squeeze rhythmically while measuring the temperature!