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.

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 OB or might not. We go through the same steps of initial assessment about every four hours until the mom tells us that she wants to push.

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 Vanuatu woman pushes her baby out in 5 to 15 minutes even if it is their first baby! 10 IU of Pitocin is injected into the mom’s thigh with the birth of the baby’s head. You wait for the baby to restitute and then the mom pushes out her baby. The cord is clamped and cut. The baby might be lifted up to be viewed by the mom and then is taken to the warmer. Babies are routinely suctioned with an electric suction unit with a tube in their noses and mouths. To our dismay it seems like the goal is to suction all the way to the intestines. How far does that tube need to go in? The placenta is born quickly often with no pushing just controlled cord traction. The mom’s BP is checked and if it is not high she is given an injection of Ergo/Methergine in her thigh immediately after the birth of the placenta. If her BP is high she is given a second dose of pitocin. Any tear is repaired. (There is lidocaine thankfully although sometimes the midwives will try to talk us out of using it).

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.

The movie was well made, very interesting and had so many themes: adultery, domestic violence, murder, working for foreigners, magic, family ties, community ties, chiefs, gossip and many, many, more! There were songs as well. The performers spoke in Bislama and there were English subtitles. Some things were lost in translation because the crowd would sometimes burst into laughter at things we did not find funny. I was a little surprised to see that there were so many children of all ages at a film with such serious content. No rating system here…

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 25^th 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 37^th 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 Solomon Islands and they are reveling in the vast luxuries of available supplies and equipment her at VCH. So I guess everything is a matter of perspective.

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 Efate birth at VCH. I had thought that the 15 births I attended in the last 5 weeks prior to departing for Vanuatu might help prepare me for the hospital volume – so naïve. The Vila hospital handles about 200-250 births per month or 6-8 babies a day on average. Some come to the hospital in early labor and others when they are pushing. Some give birth at home or “in the bush” and just bring their baby in after the birth. If a baby is BBA (born before arrival) they are given a five day course of IM antibiotics in case they got an infection. We are just surprised that there is such a low rate of infection in the hospital.

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 Australia or other foreign countries – very little stays in Vanuatu.

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. Eton Beach is beautiful and was nearly deserted when we arrived. Blue Lagoon is truly gorgeous and a mix of fresh and salt water complete with rope swings and an outrigger canoe!

Horse race

On Saturday July 12^th 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.

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.