I am back home, readjusting to a first-world life and the SF time zone. I thought i would give everyone a final Vanuatu update.
I attended a total of 26 births in Vanuatu. I was the primary midwife for 19 of the 26.
Of the 19 mommas i was primary for there was 1 vacuum extraction by an OB, 1 cesarean section (obviously by the OB) and one set of vaginally born breech twins (the OB caught one and let me do the other) with a grand total of 17 vaginal births. One momma had a VBAC (a vaginal birth after a cesarean birth). One mom had a serious postpartum hemorrhage and several had minor postpartum bleeds. One mom had a two minute shoulder dystocia.
Ultimately, two babies were named Michelle. One baby was named Kent for my brother and one named Francisco for San Francisco. Thankfully, and luckily in at least one case, there were no fetal or maternal mortalities in my 19. There was one neonatal death of a baby whose birth I witnessed. His mother rolled on top of him in her sleep. The vacuum extracted baby had an erbs palsy (nerve injury from the vacuum extraction). I resuscitated one baby and wished that I had resuscitated another...
There were 249 total babies born during my 7 weeks. 12 of these were born by cesarean section making the percentage of cesarean births 4.8%. Considering that there were 2 planned cesareans so that grand multips could have a tubal ligation at the same time, one placenta previa and two breech cesareans this brings the number of other cesareans to a very low number. The cesarean rate in the US is at an all time high of 31.3% (in 2006 the most recent data) and rising.
Of the 249 births there were no maternal deaths but sadly 8 babies died. There were 3 stillbirths, 3 premature babies, one whose mother rolled on him and I don't remember the reason for the last. None of the deaths were in labor or related to their births.
One baby was born with a significant spina bifida. The week before I arrived two babies were born with anencephaly.
There were no cases of preeclampsia or gestational diabetes. I think this is at least partly because it there is not much screening. There was a lot of preterm labor. They do not screen for GBS and no babies died of infection (somewhat surprising given the state of cleanliness in the hospital and the opportunities for cross contamination).
Overall, it was an amazing experience. I am so happy that I had the chance to do this. Despite the occasional difficulties and sadness it was wonderful. I hope I get to return again in the future.
Thank you to everyone who donated supplies or money for supplies. You made a significant difference in midwives', mommas, and babies lives. Thank you so much!
Friday, August 15, 2008
market food...
everything is organic, free-range, freshly picked/caught and/or grass fed... Buzz words we pay lots of mone for in California. Grass fed organic beef is $1.50 to $2.00 per pound!
The open-air market is run by women and is open 24 hours a day 6 days a week (closed Sunday for church). You can buy delicious fresh produce (and occassionaly a live chicken) or sit down for a homecooked meal (typically a curry, stew, steak or fish with rice or during the day you can sometimes get laplap). the meals cost 350 vatu or about $3.50 US.
Saturday, August 9, 2008
Sleep in Vila
so it is impossible to sleep through the night here. I am lucky that i fall asleep easily and do not have insomnia. last night i was awakened 8 times between midnight and 9am.
roosters begin crowing hours before the sun rises and there is an army of them! In the daylight the dogs are sleepy loners shy of humans. By the dark of night they must form large roving packs that get into huge gang fights. These fights break out several times a night and sound totally vicious. Geckos loudly bark at random intervals. Once the sun is up the roosters get quieter and the raucous mynas take over.
Aside from the animal life there are periodic torrential downpours that wake you and make you think that every faucet and the shower must have suddenly turned on. Then at 6am the hotel turns on the fountain that happens to be right outside my window.
When i lived in the main hotel building for the first month. there were three kava bars right outside. so from 4pm until 2-4am you would hear muffled voices and lots of spitting and hawking.
then i moved to the studio and can no longer hear the kava drinkers and the roosters are further away but there is the wafer thin door between my studio apartment and the one next door. our units are designed to make a suite. I assume that the door is the problem because i never hear the neighbor on the other side. i can hear literally EVERYTHING that goes on in there. There must be some sort of bizarre acoustical trick happening because everything sounds like it is happening in my room with no sound distortion. you might expect to hear muffled conversations and TVs and the like in a hotel room. However, i can hear every word of every conversation. it reminds me of the movie "office Space" when apartment neighbors yell through the wall to get their neighbor to turn to a different TV channel except i would not have to yell! It was kind of fun practicing my French with the francophones from New Caledonia. Coughing sneezing and snoring regularly awaken me. I can even hear and see due to the large gap at the floor every flick of a light switch. I can hear cooking of course but one morning at 7am i awakened to the sound of someone eating cereal! I'm not kidding. i could hear the clink of the spoon in the bowl and the crunching of the cereal in the mouth. although i do not know any of the neighbors i have had i feel like some kind of voyeur since i know many things about them. it has made me a very silent neighbor.
my biggest issue with the repeated wakings is my mosquito bites. every wakeful period reminds me that i am very itchy and i compulsively scratch and scratch and scratch...
Finally, 9 am the housekeeping staff makes their first rounds. there are no do not disturb signs to place.
So no rest for the weary.
roosters begin crowing hours before the sun rises and there is an army of them! In the daylight the dogs are sleepy loners shy of humans. By the dark of night they must form large roving packs that get into huge gang fights. These fights break out several times a night and sound totally vicious. Geckos loudly bark at random intervals. Once the sun is up the roosters get quieter and the raucous mynas take over.
Aside from the animal life there are periodic torrential downpours that wake you and make you think that every faucet and the shower must have suddenly turned on. Then at 6am the hotel turns on the fountain that happens to be right outside my window.
When i lived in the main hotel building for the first month. there were three kava bars right outside. so from 4pm until 2-4am you would hear muffled voices and lots of spitting and hawking.
then i moved to the studio and can no longer hear the kava drinkers and the roosters are further away but there is the wafer thin door between my studio apartment and the one next door. our units are designed to make a suite. I assume that the door is the problem because i never hear the neighbor on the other side. i can hear literally EVERYTHING that goes on in there. There must be some sort of bizarre acoustical trick happening because everything sounds like it is happening in my room with no sound distortion. you might expect to hear muffled conversations and TVs and the like in a hotel room. However, i can hear every word of every conversation. it reminds me of the movie "office Space" when apartment neighbors yell through the wall to get their neighbor to turn to a different TV channel except i would not have to yell! It was kind of fun practicing my French with the francophones from New Caledonia. Coughing sneezing and snoring regularly awaken me. I can even hear and see due to the large gap at the floor every flick of a light switch. I can hear cooking of course but one morning at 7am i awakened to the sound of someone eating cereal! I'm not kidding. i could hear the clink of the spoon in the bowl and the crunching of the cereal in the mouth. although i do not know any of the neighbors i have had i feel like some kind of voyeur since i know many things about them. it has made me a very silent neighbor.
my biggest issue with the repeated wakings is my mosquito bites. every wakeful period reminds me that i am very itchy and i compulsively scratch and scratch and scratch...
Finally, 9 am the housekeeping staff makes their first rounds. there are no do not disturb signs to place.
So no rest for the weary.
Starry Starry Night
the night skies here are amazing when there are no clouds (often) since there is so little light pollution. There is not a street light to be had. Combine the lack of light with the sidewalk situation and night walking is a real challenge without a flashlight. yet the locals do it just fine! It is interesting to see skies that are at once reminiscent and yet totally unfamiliar. i have decided that the "Southern Cross" should be renamed the much more appropriate "Southern Kite".
Yep the sinks and toilets drain backwards too!
Yep the sinks and toilets drain backwards too!
my first cesarean in Vanuatu
Last week we had a mom transfer from Pentecost (an outer island - hours away by plane) after 48 hours of slow labor and 12 hours of SROM. Can you imagine getting on a plane in labor with none of your family to go to another island? she did travel with her nurse (which means that Pentecost was without any medical assistance - they do still have a nurse's aide and a dispensary- for several days until there was a flight back) and the govt pays for her flight to efate but she and her family must pay for the return ticket - about $140. I was assured by the midwives that this would not be a problem for someone from Pentecost. It is apparently a rich island because they are a main supplier of kava.
She arrived during shift change so it was just me evaluating her. her baby's baseline was 180+ with repetitive late decels to the 150s and virtually no variability. her BP was 140/120 then 140/100, plus 1 protein and she had a severe headache. she felt blazing hot and when i took her temp for 30 seconds on a mercury thermo (had to take it out as she had a contraction and started gnashing her teeth) her temp was already 102! geez! her cervix was 4 cm open, 100% effaced and the baby was at a plus 2 station - so low for that dilation. My hand was covered in what really looked like pus after the exam. obviously we called the OB and she had a cesarean. they had a really hard time getting her ROP ascynclytic 4kg baby out. i was shocked that once they decided to go to cesarean we just turned off the CTG. the baby was unmonitored for well over an hour before he was born (he reeked of a nasty chorio infection at birth). even more amazing was that his apgars were great 8,10,10. These details may not mean much to the non medical folks but for those of us who know... HOW could that baby been OK?
She arrived during shift change so it was just me evaluating her. her baby's baseline was 180+ with repetitive late decels to the 150s and virtually no variability. her BP was 140/120 then 140/100, plus 1 protein and she had a severe headache. she felt blazing hot and when i took her temp for 30 seconds on a mercury thermo (had to take it out as she had a contraction and started gnashing her teeth) her temp was already 102! geez! her cervix was 4 cm open, 100% effaced and the baby was at a plus 2 station - so low for that dilation. My hand was covered in what really looked like pus after the exam. obviously we called the OB and she had a cesarean. they had a really hard time getting her ROP ascynclytic 4kg baby out. i was shocked that once they decided to go to cesarean we just turned off the CTG. the baby was unmonitored for well over an hour before he was born (he reeked of a nasty chorio infection at birth). even more amazing was that his apgars were great 8,10,10. These details may not mean much to the non medical folks but for those of us who know... HOW could that baby been OK?
this mom had a single dose of IV antibiotics and i was really concerned about her. 4 hours after the surgery they removed the catheter and she was up walking around (fully upright not hunched) laughing and nursing her baby. they don't have toradol or duramorph just a regular spinal but these women just bounce back as if nothing has happened. it is truly mind boggling.
This was the first cesarean i have seen in Vanuatu. There were only 11 in the whole month of July. considering that there were several breech babies, and a placenta previa this is an astoundingly low cesarean rate for over 200 births.
This was the first cesarean i have seen in Vanuatu. There were only 11 in the whole month of July. considering that there were several breech babies, and a placenta previa this is an astoundingly low cesarean rate for over 200 births.
Friday, August 8, 2008
I got invited to a wedding!
Friday the 8th i went down town for lunch and ran into one of the midwives - Olina. Olina was with her husband Jimmy an anesthesiologist whom i had met a few weeks ago but did not know the connection. This is just one of many examples of the 2 or 3 degrees of separation every single person on this island shares. You mention a person and invariably the person you are talking to will tell you "oh he's my cousin" or you mention a place and they say "my sister's husband works at that shop/restaurant/hotel". Everyone has a connection to every other person, place and thing on the island. It becomes downright disconcerting! At first i thought the midwives were kidding when they would say that they were at someone's first birth 6 years ago and they remembered them. everyone's memory is incredible here. they remember the spiderwebs of connections in full detail no matter how much time has past. i imagine it as some kind of mental game of twister to work out all the layers of connections.
So, they remember everyone... that is unless you are not a local. i guess we all look alike (they have told me so) because they just don't remember anything about us the second we are out of their sight. the midwives had trouble remembering the students that Olivia worked with 7 months ago. in fact days after Olivia left some of the midwives would ask me my friend's name. She'd been here for a month for goodness sake. Then yesterday one of the midwives came up to me and called me Olivia! good grief - i have been here for more than 6 weeks! Oh well.
Anyway, Olina asked if i would like to join her and her family at a wedding at 3pm (it was 2:30). once i ascertained that i was dressed appropriately enough and that it was acceptable for me to come not knowing the bride or groom i leapt at the opportunity.
First we bought the wedding gifts. 10 yards of island dress fabric for Olina to present and a sarong for me to present. then we went to Olina's house so she could change and headed out to the Anglican Church of the Resurrection, Tagabe, Port Vila. The first thing i noticed when i arrived was a momma who had birthed her baby on the first night Olivia and I worked at the hospital. When her baby was 5 days old he died. Renata, (the mom) had left before Olivia and i came back to work and we had mourned for her and her baby and wondered what became of her ever since. Renata deserves her own post so suffice it to say that she seemed to be doing very well and it was incredibly joyful and healing for me to see her in good spirits.
I was hoping it would be the Kastom ceremony but apparently that had taken place the day before. The service was fairly similar to services in the US but here are some highlights... the guests sang beautiful hymns in the Pentecost language to keep themselves entertained while waiting for the wedding to start. So I was happy that the service was 90 minutes late. The church was decorated in palm leaves, and tropical flowers. It's doors and windows were wide open so local stay dogs came in and out during the ceremony and birds sang on the windowsills. Olina's 78 year-old brother a retired preacher gave a 45 minute ad lib sermon on genesis with some creative license if i remember the story correctly. he had a great sense of humor and thoroughly engaged the crowd at least for the first 30 min. There was lots of wonderful singing and fairly traditional vows. afterwards the bridal party all got into decorated cabs and buses and toured the city for about 45 minutes with loud music and honking before returning to the church grounds for the reception.
The reception was set up with all the chairs and benches in row facing the bride and groom - no tables. i wanted to sit with Olina and her family but everyone insisted that i sit in the front row facing the couple. we all faced off for some time before the band/DJ played some really loud music and then we all got into a line and presented our gifts personally by laying them unmarked on the pandanas mats at the couples' feet. all the gifts are shared by the full families of the bride and groom including sending some items back to the islands where they are from. no need for thank you cards since you don't know who will get your gift and they wont know who it is from. we then shook hands and kissed cheeks and it was time for food. the buffet was an amazing spread of local fare... laplap, tuluk, roasted meats, vegetable dishes etc. one funny moment came when i asked what a particular dish was that looked like pink cauliflower - it was "lettuce" i then asked about a dish that was mostly carrots and other indistinguishable vegetables and it was also "lettuce". Apparently all veggie dishes are "lettuce" how have i been here this long and not known this? the first dish turned out to be potato salad with beets. There were at least 40 different dishes to choose from and all delicious. the cake was finally cut at about 10:00pm and slices were put on to trays and passed around. you took your cake in your hand and ate with your hand. if you were lucky, you had not thrown away your napkin from the dinner. We left well before the end of the reception as olina had to work at 11pm.
So, they remember everyone... that is unless you are not a local. i guess we all look alike (they have told me so) because they just don't remember anything about us the second we are out of their sight. the midwives had trouble remembering the students that Olivia worked with 7 months ago. in fact days after Olivia left some of the midwives would ask me my friend's name. She'd been here for a month for goodness sake. Then yesterday one of the midwives came up to me and called me Olivia! good grief - i have been here for more than 6 weeks! Oh well.
Anyway, Olina asked if i would like to join her and her family at a wedding at 3pm (it was 2:30). once i ascertained that i was dressed appropriately enough and that it was acceptable for me to come not knowing the bride or groom i leapt at the opportunity.
First we bought the wedding gifts. 10 yards of island dress fabric for Olina to present and a sarong for me to present. then we went to Olina's house so she could change and headed out to the Anglican Church of the Resurrection, Tagabe, Port Vila. The first thing i noticed when i arrived was a momma who had birthed her baby on the first night Olivia and I worked at the hospital. When her baby was 5 days old he died. Renata, (the mom) had left before Olivia and i came back to work and we had mourned for her and her baby and wondered what became of her ever since. Renata deserves her own post so suffice it to say that she seemed to be doing very well and it was incredibly joyful and healing for me to see her in good spirits.
I was hoping it would be the Kastom ceremony but apparently that had taken place the day before. The service was fairly similar to services in the US but here are some highlights... the guests sang beautiful hymns in the Pentecost language to keep themselves entertained while waiting for the wedding to start. So I was happy that the service was 90 minutes late. The church was decorated in palm leaves, and tropical flowers. It's doors and windows were wide open so local stay dogs came in and out during the ceremony and birds sang on the windowsills. Olina's 78 year-old brother a retired preacher gave a 45 minute ad lib sermon on genesis with some creative license if i remember the story correctly. he had a great sense of humor and thoroughly engaged the crowd at least for the first 30 min. There was lots of wonderful singing and fairly traditional vows. afterwards the bridal party all got into decorated cabs and buses and toured the city for about 45 minutes with loud music and honking before returning to the church grounds for the reception.
The reception was set up with all the chairs and benches in row facing the bride and groom - no tables. i wanted to sit with Olina and her family but everyone insisted that i sit in the front row facing the couple. we all faced off for some time before the band/DJ played some really loud music and then we all got into a line and presented our gifts personally by laying them unmarked on the pandanas mats at the couples' feet. all the gifts are shared by the full families of the bride and groom including sending some items back to the islands where they are from. no need for thank you cards since you don't know who will get your gift and they wont know who it is from. we then shook hands and kissed cheeks and it was time for food. the buffet was an amazing spread of local fare... laplap, tuluk, roasted meats, vegetable dishes etc. one funny moment came when i asked what a particular dish was that looked like pink cauliflower - it was "lettuce" i then asked about a dish that was mostly carrots and other indistinguishable vegetables and it was also "lettuce". Apparently all veggie dishes are "lettuce" how have i been here this long and not known this? the first dish turned out to be potato salad with beets. There were at least 40 different dishes to choose from and all delicious. the cake was finally cut at about 10:00pm and slices were put on to trays and passed around. you took your cake in your hand and ate with your hand. if you were lucky, you had not thrown away your napkin from the dinner. We left well before the end of the reception as olina had to work at 11pm.
Thursday, August 7, 2008
crazy night - don't read this post if you are pregnant!
Really, don't read this if you are pregnant...
SO last night when i walked in there were three moms pushing (with visible baby heads) and only two midwives working. i had to beg the third mom to slow down her pushing both to protect her perineum and get my gloves on. I caught her baby exactly 2 minutes after i walked in the door and found out her name afterwards. This was her 6th pregnancy and she had a minor postpartum hemorrhage after her placenta was born.
Then there was a mom with suspected malaria (remember that is supposedly does not exist in vila) who had been in prodromal labor for 3 days. She was really having a hard time and suffering with her labor. She kept begging me to help her. It is awful that there is absolutely no pain meds to offer those moms who do need it. She finally gave birth at 10:20. her baby was born with the most mec and the most unusual meconium (baby poop) i have ever seen. He had well dissolved mec, thick mec, terminal mec and some mec that looked like bright yellow breastfeeding poop all mixed together, (i asked the pediatrician about this later and he thought that maybe the baby had a problem with its liver and was passing billirubin already). I gave her pitocin, and methergine (as is the norm here) and she had an IV of pitocin going as well as we all thought she was a post partum hemorrhage risk due to her long labor and spaced out contractions.
As the malaria mom (evelyn) was birthing a woman (may) came in pregnant with breech twins. and yet another mom (lilly) was pushing by herself in the delivery room across the hall. There are still only two midwives on shift with me. we are the entire staff and are also trying to care for two sick babies in the NICU, the other 3 laboring mommas and the 10 postpartum mommas and babies. round about this time another mom came in saying she needed to push.
so i went to catch lilly's baby, one midwife was calling the on call OB to do a cesarean on the twin mom and prepping her for surgery and the second midwife was checking the mom who came in pushing in the admission room. evelyn was breastfeeding her baby.
after catching lilly's baby i ran to the other delivery to check on evelyn. i was concerned that she might have a postpartum bleed because of her prolonged labor. i checked her fundus and it was high indicating bleeding. sure enough i was able to expell some big clots and this brought her total blood loss to almost a liter. one of the midwives continued fundal massage while i ran to grab the OB who thankfully had just arrived to do the cesarean on the twins.
he took the mom into the OR and figured that despite the the pitocin and methergine she was still bleeding too much to survive a hysterectomy. She was fully in shock and not conscious at this time. they did general anesthesia and discovered that her uterus just would not fully clamp down to stop the bleeping. he inflated a balloon in her uterus to put pressure on the bleeding vessels and gave her more drugs to tighten the uterus muscle. he estimated that she lost another 2 liters. of blood in the OR. Her hemoglobin was 4. there was no blood to give her so a nurse with O- blood was called from home to donate blood on the spot to give evelyn a transfusion. That is some amazing dedication. She ultimately had two more transfusions. This was the closest i have ever come to seeing a woman die.
Meanwhile the twin mom was laboring away. May's first twin was well in her birth canal. I went into the OR with her and it was determined that we should try for a vaginal birth since the first baby was so low in the birth canal. We could not get any heart tones so the OB cut an episiotomy and delivered the first double footling breech baby girl. he let me deliver the second double footling breech baby girl! i also delivered their fused placentas. Each baby was depressed at birth and needed resuscitation. In this case the word deliver is more appropriate than catch or receive my personally preferred terms for what i do at a birth. there was definite manipulation on my part and the OB's.
It was now 3am and i was now roped into helping the pediatrician (who came in a big hurry - just 1 hour after the call) start IVs on evelyn's baby (who was now in obvious respiratory distress probably due to meconium aspiration) and May's twins since they had needed resuscitation after birth and were clearly preemie despite being 38weeks by dates. The two night shift midwives were both catching babies and there were still more laboring women in the hall.
I finally stumbled home at 4am after working more than 12 hours on my feet. I could not sleep due to the adrenalin still coursing through my veins. I had caught 4 babies, seen a mom nearly die and seen and caught/delivered my first breech baby. i truly hope i never see a night like that again.
SO last night when i walked in there were three moms pushing (with visible baby heads) and only two midwives working. i had to beg the third mom to slow down her pushing both to protect her perineum and get my gloves on. I caught her baby exactly 2 minutes after i walked in the door and found out her name afterwards. This was her 6th pregnancy and she had a minor postpartum hemorrhage after her placenta was born.
Then there was a mom with suspected malaria (remember that is supposedly does not exist in vila) who had been in prodromal labor for 3 days. She was really having a hard time and suffering with her labor. She kept begging me to help her. It is awful that there is absolutely no pain meds to offer those moms who do need it. She finally gave birth at 10:20. her baby was born with the most mec and the most unusual meconium (baby poop) i have ever seen. He had well dissolved mec, thick mec, terminal mec and some mec that looked like bright yellow breastfeeding poop all mixed together, (i asked the pediatrician about this later and he thought that maybe the baby had a problem with its liver and was passing billirubin already). I gave her pitocin, and methergine (as is the norm here) and she had an IV of pitocin going as well as we all thought she was a post partum hemorrhage risk due to her long labor and spaced out contractions.
As the malaria mom (evelyn) was birthing a woman (may) came in pregnant with breech twins. and yet another mom (lilly) was pushing by herself in the delivery room across the hall. There are still only two midwives on shift with me. we are the entire staff and are also trying to care for two sick babies in the NICU, the other 3 laboring mommas and the 10 postpartum mommas and babies. round about this time another mom came in saying she needed to push.
so i went to catch lilly's baby, one midwife was calling the on call OB to do a cesarean on the twin mom and prepping her for surgery and the second midwife was checking the mom who came in pushing in the admission room. evelyn was breastfeeding her baby.
after catching lilly's baby i ran to the other delivery to check on evelyn. i was concerned that she might have a postpartum bleed because of her prolonged labor. i checked her fundus and it was high indicating bleeding. sure enough i was able to expell some big clots and this brought her total blood loss to almost a liter. one of the midwives continued fundal massage while i ran to grab the OB who thankfully had just arrived to do the cesarean on the twins.
he took the mom into the OR and figured that despite the the pitocin and methergine she was still bleeding too much to survive a hysterectomy. She was fully in shock and not conscious at this time. they did general anesthesia and discovered that her uterus just would not fully clamp down to stop the bleeping. he inflated a balloon in her uterus to put pressure on the bleeding vessels and gave her more drugs to tighten the uterus muscle. he estimated that she lost another 2 liters. of blood in the OR. Her hemoglobin was 4. there was no blood to give her so a nurse with O- blood was called from home to donate blood on the spot to give evelyn a transfusion. That is some amazing dedication. She ultimately had two more transfusions. This was the closest i have ever come to seeing a woman die.
Meanwhile the twin mom was laboring away. May's first twin was well in her birth canal. I went into the OR with her and it was determined that we should try for a vaginal birth since the first baby was so low in the birth canal. We could not get any heart tones so the OB cut an episiotomy and delivered the first double footling breech baby girl. he let me deliver the second double footling breech baby girl! i also delivered their fused placentas. Each baby was depressed at birth and needed resuscitation. In this case the word deliver is more appropriate than catch or receive my personally preferred terms for what i do at a birth. there was definite manipulation on my part and the OB's.
It was now 3am and i was now roped into helping the pediatrician (who came in a big hurry - just 1 hour after the call) start IVs on evelyn's baby (who was now in obvious respiratory distress probably due to meconium aspiration) and May's twins since they had needed resuscitation after birth and were clearly preemie despite being 38weeks by dates. The two night shift midwives were both catching babies and there were still more laboring women in the hall.
I finally stumbled home at 4am after working more than 12 hours on my feet. I could not sleep due to the adrenalin still coursing through my veins. I had caught 4 babies, seen a mom nearly die and seen and caught/delivered my first breech baby. i truly hope i never see a night like that again.
Sunday, August 3, 2008
baby names
so there is finally a baby named Michelle in Vanuatu! I had heard that often the mommas here will name their babies after the midwife who catches their baby and i was beginning to get a complex...
So far Olivia and i were given the opportunity to name a baby boy who died a few days later (a long and sad tale for another time) and one of the baby boys i caught was named Francisco after San Francisco but alas no Michelle... Finally last week a lovely momma from Nguna named her baby girl after me. Of course Michelle will only be one of her names as folks here have many names.
So far Olivia and i were given the opportunity to name a baby boy who died a few days later (a long and sad tale for another time) and one of the baby boys i caught was named Francisco after San Francisco but alas no Michelle... Finally last week a lovely momma from Nguna named her baby girl after me. Of course Michelle will only be one of her names as folks here have many names.
"sidewalks" AKA anklebuster 2008
So Port Vila "sidewalks" are really only sidewalks because they are adjacent to roads and it is possible though perhaps not recommended to walk on them. it appears as though each property owner is responsible for their stretch of land next to roads and some pave them as sidewalks. however there is no regulation width height. (the same lack of regulation is apparent in stairs as well.) Even the "sidewalk" in front of the parliment building is in a poor state.
as a result expats and volunteers are regularly seen sporting ankle braces or knee braces or ace bandages. you never see a ni-van wearing any such item. here are my theories as to why...
as a result expats and volunteers are regularly seen sporting ankle braces or knee braces or ace bandages. you never see a ni-van wearing any such item. here are my theories as to why...
- ni-Vanuatu have as many injuries but are just much tougher and more stoic than the expats. This is my top theory because only one in 50 women in labor here so much as whimper.
- the Ni-Van are trained from birth to walk on even more uneven terrain - this is obviously true...
- why waste money on such ridiculous luxuries?
I spend nearly all of my walking time staring at my feet or just in front of my feet to avoid an embarrassing face plant. i had a neck and headache for much of the first week here before i got used to it. I thought that perhaps the uneven surfaces would act as a kind of physical therapy for my ankles but that was foolish. i have of course sprained my ankles and twisted my knees many times despite usually doing a good job of looking where i am going.
Thursday, July 24, 2008
National Holiday and Priate Sail...
Yesterday was Children's Day - a national holiday. The holiday is to promote children's rights and awareness of children's issues. There was a parade through town led by uniformed armed men that looked like soldiers but i think they were the police force and then a marching band, school children and the public carrying various banners. The parade started at the water went through town to a large park (Independence Park).
We were standing next to a woman who worked for save the children who was very disappointed that the announcer was not talking about children's issues at all and was rambling on. The highlight for Olivia and I was the interpretive dance by dancers of the Baha'i faith set to "Total Eclipse of the Heart" by Bonnie Tyler where a woman was abused and then tempted by four dancer each with a word written on their back (alcohol, kava, cocaine and weed). she danced with each and then they killed her...
After the parade Olivia and i went sailing on a pirate ship, the Cassiopeia. Well she flies a pirate flag and the captain takes her out for tourists dressed as a pirate (with swords and all). He was not in pirate gear for us since the trip was arranged by some Australian expats. Captain Harry has lived on his schooner for years sailing in the Caribbean and South Pacific and apparently winning many races. I was amazed at how relaxed and skilled he was. He had one guy on ship who seemed to have some idea how to sail but still needed some direction and about 25 folks with no idea and he was able to patiently teach us how to hoist sails, drop sails, pull up anchor, drop anchor, steer the ship, get in/out of harbor without sinking us or another ship etc. His entire safety lecture was "If it looks like something is going to kill you - run out of the way!" Somewhat to my surprise no one was knocked overboard, left at sea, or injured and no boats (ours or the many others in the harbor) were harmed! My only disappointment was the cat that lives on board stayed ashore for the trip.
Sunday, July 20, 2008
sore tumas posts (sorry for posting too many posts at once)
i must apologize to anyone reading this post for too few posts and then too many posts... We are sharing one computer with about 17-20 other volunteers and the room is locked up at night and the internet is down for hours at a time. I have been writing posts in a word doc and saving them for a chance at the computer when the internet is working.
Mozzies
A few nights ago in the delivery room while a mom was pushing I was frantically smashing mosquitoes and the midwife said to me completely seriously “Oh don’t worry, that’s just a dengue fever mosquito.” I told her that I did not want dengue fever OR malaria and she proceeded to describe the malaria mosquito bites as really itchy, red angry, welt-like bites and I pointed to the 10 plus such bites on my legs and said “like these?” and she said “Yes!” She wanted to know if I had been to some certain river where the malaria mosquitoes hang out - I haven’t – and told me that there is no malaria in Port Vila. So who knows I may be brewing a wicked case of dengue or malaria or maybe not but regardless I am smashing every mosquito I see!
On Call
So there are Obstetricians and Pediatricians on call for every shift. Unfortunately they do not all seem to take this as seriously as I had expected. Sometimes the midwives do not bother to even call the OB ’s for things like fetal distress because they don’t think they will come. Apparently there have been many incidents like not answering their phones at all or answering and then saying they won’t come because they are too drunk on kava. Last week a 28 week baby was born prematurely and the pediatrician took 3 hours to come…
Birth in Port Vila Central hospital
OK here is how a typical birth here goes…
A woman comes in and we do an initial assessment.
- Length of labor
- Status of membranes (amniotic sac ruptured or not)
- 20 minutes of fetal monitoring as long as everything is normal
- Blood pressure and pulse
- Belly palpation
- Cervical exam
If she is 6 cm or more and her bag is intact her amniotic sac is ruptured. If she is less than 6cm she is encouraged to walk around. If the baby’s heart rate is anything other than reassuring we may keep her on the monitor longer or recheck in an hour. We might call the on-call
Once the mom wants to push we take her into one of two delivery rooms. Here cervix is checked to ensure she is ready to push and her amniotic sac is ruptured artificially if it has not already happened. The moms lie on their backs and push their babies out. I tell the truth – the average
The baby is taken to another room where he/she is weighed and given a Hep B vaccine and a Vitamin K injection. Although we have been told by the British medical students working in the antenatal clinic that nearly every woman has some kind of STD there is no erythromycin ointment for the babies’ eyes and we have not seen any eye infections. We have not heard of any STD caused blindness either – fascinating! The baby is brought back to the delivery room and put in the warmer to be dressed. The baby is then given to the mom for its first feeding. Sometimes the moms will say that they need to rest and are not yet ready to hold their baby. Amazingly despite all the interruption the babies almost all nurse very well.
One hour after birth the mother is wheeled to her postpartum bed. She is basically left to the care of her extended family at this point. If it is daytime her baby is then taken away for a bath but if it is after 5pm it is considered to be too cold for baths (Of course I am still sweating) and the bath waits till the following morning. The mom will most likely be discharged the following morning after her baby gets a TB vaccination, a second weighing and a quick newborn exam.
So that is how we are supposed to do it. We have managed to eek out delayed cord clamping most of the time. In one case until after the placenta was born! We avoid the suction unit pretty well if there is no meconium and the baby breathes right away. We have tried to get moms in other birthing positions but mostly they look at us like we are crazy. Occasionally the mom will sportingly get into a different position and then as soon as her contraction begins she will invariably flop back onto her back and push. We have encouraged moms to touch their baby’s heads and a few moms have reached for their babies. This delights us and we eagerly pass them their babies. It is clear that the midwives think this is foolish but so far they have put up with it.
Wan Smolbag Theater
Olivia and I went to a showing of the latest film by Wan Smolbag tonight. http://www.wan-smolbag-theatre.org/ Wan Smolbag is a theater group dedicated to social change. The produce plays and films with a message. The film was shown at a local school – Ecole Anabrou and the 100v (a little over a dollar) entry fee was donated to the school. There were about 300 people there to view the film. During intermission food, drinks and kava were sold.
Charts & Due Dates
So we had a momma pregnant with her first baby come to the hospital in labor last Wednesday. In one of her earliest prenatal visits she had been estimated to be 37 weeks pregnant (this was in March!). At one of the next visits there was a notation “wrong dates” and then the dates of her prenatal visits seemed to make sense. However, on June 25th she was 37 weeks and 5 days pregnant and 10 days later she was 37 weeks and 0 days pregnant! This miracle momma had managed to be in her 37th week of pregnancy on three different weeks during her pregnancy! Inaccurate dating is the norm here as it is rare to keep track of menstrual cycles, get early prenatal care and/or have access to ultrasound for dating. This can be problematic when women present in preterm labor. Or more accurately when we do not know what “term” is for a particular woman. In VCH we do have access to tocolytics to stop preterm labor and to steroids to help a premature fetus mature their lungs. (at least they have some stock of these drugs at the moment).
So far I have only seen one chart with a prenatal hemoglobin written down. Then again it is a good thing when a woman has had prenatal care at all.
A hard reality is the hand written question on most of the charts that reads “Domestic violence? Yes/No Then, Current partner? Yes/No” some shifts 75 % of women’s charts read Yes/Yes. I am not sure if the charts without this question mean that the woman has no history of abuse or more likely no one asked the question. DV is obviously a huge problem here. There are posters around town and at one local restaurant all employees wear black on Thursdays to support violence free families. So much for the happiest place on earth status…
Luxuries
Well here are just a few of the things that VCH does not have…
- No hot water from any tap. You can boil water if you like…
- Water in the mop bucket at night. (Yes, one night we just spread bodily fluids all over the floor with a damp and already dirty mop for lack of a better idea.
- Paper towels… we have nothing to dry our hands on except our scrubs in the delivery rooms. We brought a towel on the first day and it never made it to the delivery room. If we get a chance to come back we really want to get an electric hand dryer for the maternity ward.
- Garbage cans that you can step on a lever to open. This means you have to use your hands every time to remove the lids to garbage cans and laundry bins alike.
- Disposable items… We use disposable/single use items more than once. The end result of all this is Olivia and I spend every free moment scouring the place in an attempt to not feel like we are spreading germs from one mom/babe to the next.
Despite the things VCH lacks I think they do an amazing job with what resources they do have. We are actually able to get through most births with half of a single chux pad (disposable underpad) and pair of sterile gloves. Of course it helps that the mommas do not tell us they need to push unless the baby is really eminent. For a point of reference most homebirth kits include 10-20 disposable underpads and hospital births probably use more than that.
There are some British medical students here that just came from the
Our first night July 7th
Olivia and I had a “trial by fire” our first night at Vila Central Hospital Maternity ward. There were seven babies in seven hours and even more admissions. We stayed late to clean up and ended up on our feet for about 11 hours.
That first night there were only 4 of us altogether. Two midwives, Olivia and me. We did all the work in the maternity ward for our whole shift. There is no one else. No janitorial staff, no nurses, no other staff at all. This means that we admitted new patients, managed labors, caught babies, cleaned up, charted etc. it is a good thing that there were no babies in the nursery (also our responsibility) and none of the postpartum moms/babies (also our responsibility) needed us that night. I honestly don’t know what the midwives would have done without us that first night.
In this kind of environment you can forget about “continuity of care”. I was happy if I had seen the woman’s chart and knew her name before she birthed. Many times I found myself alone with a woman and with very little way to communicate. I would catch glimpses of Olivia in the other delivery room and wonder how she was doing and if I would make it through this night…
We left that night 2 hours after our shift was supposed to end, exhausted and thoroughly filthy. (Covered in “life broth” as Ching –Wei would later joke.) Thankfully we have not had a night as busy as that one since.
Port Vila Central Hospital
I have put off this post because I haven’t known where to begin…
There is only one shared labor room with 4 beds. Women labor either on the beds or roaming the hall. Most women are very quiet. If all of those beds are full then the laboring women and their families roam the main hall. Most women come in with several female members of their families and occasionally their partners. This means that on a busy shift the halls are lined with adults and sometimes children and lots of bags. The laboring mommas walk up and down the halls until the urge to push is overwhelming and then we bring them into one of two delivery rooms for the birth of their baby. Some women will have one female relative join them for the birth but many chose to be alone. There are different customs from every island. On some islands the mother of the laboring mother is allowed to labor with her daughter but when the laboring momma is ready to push only the mother in law may join her. On some islands men can be with laboring women and on others they cannot.
Each delivery room has two beds/tables and one warmer. The delivery rooms actually have AC unlike the rest of the maternity ward. This is a strange decision since it means that newborns are born in the only air conditioned room in the hospital but it feels really nice to us midwives when we are running around like crazy.
Most women from
It costs 675v (about $7) per day of postpartum recovery to give birth at the hospital. Labor does not count and the amount of care you receive does not change the fee. Whether you walk in and push your baby out in 10 minutes or have a “cesar” (as cesarean sections are called) after 3 days of labor the cost is the same. I am told that minimum wage is about $20 per month so this is no small fee for most folks. At our hotel the staff makes about $2 per hour so it is obvious that tourism provides good jobs but knowing what the staff earns makes us feel bad about ordering a sparkling water that costs more than they make in one hour. Also, of course the hotels all charge western prices for everything to the tourists and none of the hotels are owned by locals. All that tax free income goes back to
Because there is no charge for laboring at the hospital many women come in as soon as their water breaks or at the first contractions. The vast majority of women spend one night in the hospital after their baby is born and are discharged. So it is typical that we catch a baby in the night and they are sent home at 10 am the following morning. I feel like the moms and babies evaporate. I am so used to the luxury of continuity of care that it is hard to come to terms with the fact that a single interaction is all I get.
There are 24 beds in the big open postpartum area. Each woman has a twin sized bed (non electric – non adjustable) a bedside table/cabinet and a curtain they can pull closed for some privacy. There are a few chairs around but not enough for each bed. So women and their extended families lie and sit on woven mats on the floor. The babies appear to be as stoic as their mothers and it is rare to hear a crying baby. Each baby has a rolling bassinet similar to the ones in US hospitals but these come with mosquito nets.
There is one bathroom/shower to be shared by every laboring woman, postpartum woman and all of their extended families. There is also one private labor room with a private bathroom and a small refrigerator that costs about $145 US for a night. We have seen it used twice. Once by a teacher whose husband works in the hospital and once by the Prime Minister’s daughter. Special meals are provided for the private room, the other mamas are supplied with a small portion of white rice and some sort of vegetable meat stew for breakfast, lunch and dinner. Laboring women, however, rarely eat or even drink water. We have to encourage them to do so repeatedly.
Eton Beach and Blue lagoon
Olivia, Ching-Wei and I hired a taxi for a half day and got out of Villa to some surrounding beaches.
Horse race
On Saturday July 12th we went to the annual Kiwanis horse race. Apparently the race track is only used once a year! There were seven races. Apparently the first horse across the finish line wins even if they lose their rider along the way.
Friday, July 4, 2008
getting to know Vila
Our friends Olivia and Ching-Wei arrived from Oakland yesterday. Olivia and I start working at the hospital on Monday. So my stint as a tourist is about to end. Rob leaves tomorrow and we are deciding what our final tourist activities will be...
SO far we have been having a great time. Eating good food and walking hours every day. We also have been taking buses especially at night. Buses here are just a privately owned mini van with a driver who picks up anyone who flags him down anywhere - very convenient. It does go against conditioning to flag down a stranger's car and jump in and ask to be taken somewhere... The buses provide for some interesting views into neighborhoods we have not yet explored and some circuitous trips around the city - quite fun and all for 100 vatu per person just a little over a dollar. What a deal for door to door service!
The other great thing about buses is that there are so many of them you rarely have to wait more that a minute or two for one to drive by. the bad thing about that is they run on deisel so by the end of the day you can actually wipe the deisel soot off your body... Bleh
So i thought i was getting used to the heat and them i had a rude awakening. It had actually been cooler for two days and then we had a hot humid day again...
i have had requests for pictures. i will send some photos when i get a chance. it takes a REALLY long time to upload them so you will have to wait until i get home for the majority.
SO far we have been having a great time. Eating good food and walking hours every day. We also have been taking buses especially at night. Buses here are just a privately owned mini van with a driver who picks up anyone who flags him down anywhere - very convenient. It does go against conditioning to flag down a stranger's car and jump in and ask to be taken somewhere... The buses provide for some interesting views into neighborhoods we have not yet explored and some circuitous trips around the city - quite fun and all for 100 vatu per person just a little over a dollar. What a deal for door to door service!
The other great thing about buses is that there are so many of them you rarely have to wait more that a minute or two for one to drive by. the bad thing about that is they run on deisel so by the end of the day you can actually wipe the deisel soot off your body... Bleh
So i thought i was getting used to the heat and them i had a rude awakening. It had actually been cooler for two days and then we had a hot humid day again...
i have had requests for pictures. i will send some photos when i get a chance. it takes a REALLY long time to upload them so you will have to wait until i get home for the majority.
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