I arrived at the hospital today and was handed a chart. "8cm, you want to do this one?" OK, I shrugged. A couple of hours later she was fully dilated, and then she refused to push. She didn't say "no" or stomp her feet, she just...didn't do it. We cajoled and talked and changed positions and threatened and finally she settled in to heavily guided pushing. At the 2 hour mark, with contractions 7 minutes apart, we began pitocin augmentation. No progress. At 3 hours, we informed on-call obstetrician, the same woman that paid us little attention yesterday. We fared slightly better today, although she still did a shitty job of informing the woman of her plans. Baby was high, not managing to make his way past the pubic bone, despite the now-effective pushing efforts. We suspected acynclitism and so did the OB. She made the odd decision to try a vacuum (too high! ack!) and then, after three failed attempts, the forceps...I'm not sure what she thought she was doing, but any idiot could see she was doing it wrong. The blades were positioned incorrectly, the handles wouldn't lock, and she kept asking the male midwife on staff to help her pull in an uncoordinated fashion. To do all of this, she cut a truly nasty episiotomy.
As this was going on, across the room, a woman delivered her stillborn baby. Her baby had been alive during the night shift; late decels were recorded, no response was made, and her baby was dead when the morning shift came on and checked in with her. It isn't certain that this baby's death was preventable, particularly with the long response time for the OR staff, but it is a definite possibility.
Back to the woman I'd been with most of the day. After all this traumatizing predictably-ineffective intervention, the decision for c-section was made. The episiotomy was repaired, which the OB accomplished skillfully (finally). The far-flung team was called and drivers were sent.
This poor woman also had a very strong urge to push, which she could not stop. She bore down despite the heavy swelling and the stitches. We monitored her baby intermittently, and he didn't seem to mind the pushing, so we encouraged her not to push but didn't go to any great lengths to stop her. We prepped her for her c-section, and waited. For over an hour. Her baby moved no lower during this time.
Her c-section, once begun, was fine. Her baby had a massively molded head and I truly don't think he was going to come out her vagina - there was no more molding to be done, his head now sweeping back from his face in dramatic form.
Despite the large number of women walking around the ward in various states of labor, we left after the c-section. We'd run right on through shift change and were feeling like we'd had quite enough for one day, thanks.
Saturday, March 28, 2009
Friday, March 27, 2009
Another work day
Arrived at the hospital around 9:30am, and found a woman having recently been started on pitocin for augmentation (after spending all night at 4cm, and inexplicably having her water broken around midnight). We discovered that her second child had been a stillbirth after a cord prolapse, something that hung somewhat over this birth.
A female OB came in, did a very ungentle exam, and T may have talked her into giving this woman another few hours to let the pitocin work; we don't know whether that is true, because she didn't ever really talk to us despite us talking to her.
Meanwhile, T had managed to bring up the reused suctioning tubes at precisely the right time, which led to a review of appropriate indications for suctioning AND *hallelujah* the ordering of many disposable tubes so that the reuse would end.
Anyway, by a bit after 11am she was pushy, and by 11:42 she was "complete"...ok, actually, she was 9cm, but she had a strong urge to push, I thought the cervix would go away, and I lied to the other midwives there so that they wouldn't stop her pushing. Her cervix did indeed go away, she took a bit longer than expected to push out her baby, but eventually out came a very GDM-looking baby. Not just big - this baby was big by Ni-Van standards at 3.98kg, but was not technically macrosomic - it was about the proportions. Pull as I would, I could not get this darned kid's chest out. Poor kid was starting to cry less than halfway out, his mom had lost her pushing steam, and I pulled, then another midwife pulled (same results as when I pulled, so she stopped) and then T finally piped up with a "you HAVE to push your baby out now," and out he came.
Her postpartum went smoothly.
Boredom and cleaning.
In the waning half-hour of shift, a woman who had a c-section for twins 10 days before came in reporting bleeding and fainting. This woman's English is excellent, and we had a much easier than normal triage conversation, which revealed that she was indeed bleeding too much. The OB was called - a different one, but again, a very ungentle exam. He admitted her for observation overnight.
As I attempted to leave (seriously, I was picking up my backpack), a dad flagged me down for help with breastfeeding.
Still, we left only a little late.
To the market and back, ate in our room, watching and hating-but-not-enough-to-turn-it-off Australian TV.
A female OB came in, did a very ungentle exam, and T may have talked her into giving this woman another few hours to let the pitocin work; we don't know whether that is true, because she didn't ever really talk to us despite us talking to her.
Meanwhile, T had managed to bring up the reused suctioning tubes at precisely the right time, which led to a review of appropriate indications for suctioning AND *hallelujah* the ordering of many disposable tubes so that the reuse would end.
Anyway, by a bit after 11am she was pushy, and by 11:42 she was "complete"...ok, actually, she was 9cm, but she had a strong urge to push, I thought the cervix would go away, and I lied to the other midwives there so that they wouldn't stop her pushing. Her cervix did indeed go away, she took a bit longer than expected to push out her baby, but eventually out came a very GDM-looking baby. Not just big - this baby was big by Ni-Van standards at 3.98kg, but was not technically macrosomic - it was about the proportions. Pull as I would, I could not get this darned kid's chest out. Poor kid was starting to cry less than halfway out, his mom had lost her pushing steam, and I pulled, then another midwife pulled (same results as when I pulled, so she stopped) and then T finally piped up with a "you HAVE to push your baby out now," and out he came.
Her postpartum went smoothly.
Boredom and cleaning.
In the waning half-hour of shift, a woman who had a c-section for twins 10 days before came in reporting bleeding and fainting. This woman's English is excellent, and we had a much easier than normal triage conversation, which revealed that she was indeed bleeding too much. The OB was called - a different one, but again, a very ungentle exam. He admitted her for observation overnight.
As I attempted to leave (seriously, I was picking up my backpack), a dad flagged me down for help with breastfeeding.
Still, we left only a little late.
To the market and back, ate in our room, watching and hating-but-not-enough-to-turn-it-off Australian TV.
A day off, and that #*&@(*&#$ partograph
On Wednesday we took the day off. We walked into town to get sandwiches to take to the beach, and went to the market. Someone who had been doing labor-support of some sort at the hospital for a relative was at the market. Shamefully, we had no idea what her name was, but she remembered us, shook our hands, and gave us a largish bunch of the itty-bitty bananas they have here. We also ran into one of the midwives there, and paused to take photos of us being not-at-work. It was fun to be recognized. Kicked the day off right.
We proceeded to spend the rest of the day reading in the shade on the beach, the prettiest day here so far. We went snorkeling a couple of times along the effortlessly-easy-to-access reef. And I had entirely too much fun swimming out to the floating thing and diving off. We didn't leave until 5pm, and nobody else was on the beach for a good portion of the afternoon - why, we didn't quite know. We didn't find a bus right away, so we walked to the main road. There, we caught a ride in a very-full bus with much happier than average drivers, listened to "Johnny Be Good" and other classics on the radio, bouncing along the road with the windows down, all packed into the bus. I was unnaturally happy with it all.
We did not go to the hospital on Wednesday.
On Thursday I arrived at 11am and found the hospital in relative disorganization (always somewhat disorganized, but usually in a "but I know where everything IS" fashion). Women were crammed in all manner of odd places. At 11, when the discharge routine is usually finishing up, they were just getting started. A student nurse was walking around in a fog, completely incapable of answering (yes we communicate fine, I've worked with him before) my questions about who was where and why the heck there was a postpartum mom in the store-room, and where on earth was I supposed to take this new admit and where was her chart?
It all got sorted out in the end, most of it by the time T showed up at 1. Women were in actual beds on the actual ward, babies were looked over and given their little blue cards and birth certificates, and things were calming down dramatically.
In this mess, the woman I'd thought I was admitting but in fact had been looked after previously and just not documented, was not dilating very well.
At 3, at shift change, a nurse named Viri who typically works evening shift in the NICU came on. I was roundly admonished for walking home on Tuesday. The hospital has truck drivers that will take you home, something that is not worth it for me because I am staying a whole 5 minute walk from the hospital and the truck often takes half an hour or more to catch. Apparently, Viri and the midwife were worried about me, and made the driver circle the block several times to see that I was home OK. "It was so dark! Didn't you hear the dogs? It's too late to be out!" I feel like the little family groupings sitting up and chatting in the areas I walk through make the lack of danger pretty clear. That, and the friendliness of the people I talk to there. The midwife and nurse, I think, are either living with a little bit of extra caution sunk in from the not-too-far distant past (about 20 years ago).
My admit - the one we were talking about, anyway, continued to dilate slowly through the day. At a little past 4pm, she was 7cm and well past that #*&$@(#*&$ "action" line on the partograph (there are two lines on the WHO partograph: the first, the "alert" line, is the 1cm per hour line, and passing over that just means you should pay some attention; the second, the "action" line, presumably means that should someone pass it, you should do something about it). She was not distressed, her baby was not distressed, we figured breaking her water would set things in motion. The very-senior-midwife on duty, however, took issue (vocally) with our plan, because apparently over here AROM is not "doing something," and chose to also initiate pitocin augmentation without waiting to see if the membrane rupture did the trick on its own.
She had her baby a little after 5pm without issues. Her first three babies had been boys, and she was extraordinarily happy to have a girl. She called for her partner enthusiastic about telling him they had a girl at last, but we couldn't find him. "He went out to walk," said another father who had been pacing the hall with his wife all afternoon. After unintentionally setting several other men in the area on the task of finding the new-again dad, we did a flurry of hospital chores, settled everyone in, and left at a respectable hour. Viri clapped my shoulder on the way out, and let me know that it was getting dark, I should hurry home, but I didn't need to wait for the truck at this hour. Good luck, good night...
We proceeded to spend the rest of the day reading in the shade on the beach, the prettiest day here so far. We went snorkeling a couple of times along the effortlessly-easy-to-access reef. And I had entirely too much fun swimming out to the floating thing and diving off. We didn't leave until 5pm, and nobody else was on the beach for a good portion of the afternoon - why, we didn't quite know. We didn't find a bus right away, so we walked to the main road. There, we caught a ride in a very-full bus with much happier than average drivers, listened to "Johnny Be Good" and other classics on the radio, bouncing along the road with the windows down, all packed into the bus. I was unnaturally happy with it all.
We did not go to the hospital on Wednesday.
On Thursday I arrived at 11am and found the hospital in relative disorganization (always somewhat disorganized, but usually in a "but I know where everything IS" fashion). Women were crammed in all manner of odd places. At 11, when the discharge routine is usually finishing up, they were just getting started. A student nurse was walking around in a fog, completely incapable of answering (yes we communicate fine, I've worked with him before) my questions about who was where and why the heck there was a postpartum mom in the store-room, and where on earth was I supposed to take this new admit and where was her chart?
It all got sorted out in the end, most of it by the time T showed up at 1. Women were in actual beds on the actual ward, babies were looked over and given their little blue cards and birth certificates, and things were calming down dramatically.
In this mess, the woman I'd thought I was admitting but in fact had been looked after previously and just not documented, was not dilating very well.
At 3, at shift change, a nurse named Viri who typically works evening shift in the NICU came on. I was roundly admonished for walking home on Tuesday. The hospital has truck drivers that will take you home, something that is not worth it for me because I am staying a whole 5 minute walk from the hospital and the truck often takes half an hour or more to catch. Apparently, Viri and the midwife were worried about me, and made the driver circle the block several times to see that I was home OK. "It was so dark! Didn't you hear the dogs? It's too late to be out!" I feel like the little family groupings sitting up and chatting in the areas I walk through make the lack of danger pretty clear. That, and the friendliness of the people I talk to there. The midwife and nurse, I think, are either living with a little bit of extra caution sunk in from the not-too-far distant past (about 20 years ago).
My admit - the one we were talking about, anyway, continued to dilate slowly through the day. At a little past 4pm, she was 7cm and well past that #*&$@(#*&$ "action" line on the partograph (there are two lines on the WHO partograph: the first, the "alert" line, is the 1cm per hour line, and passing over that just means you should pay some attention; the second, the "action" line, presumably means that should someone pass it, you should do something about it). She was not distressed, her baby was not distressed, we figured breaking her water would set things in motion. The very-senior-midwife on duty, however, took issue (vocally) with our plan, because apparently over here AROM is not "doing something," and chose to also initiate pitocin augmentation without waiting to see if the membrane rupture did the trick on its own.
She had her baby a little after 5pm without issues. Her first three babies had been boys, and she was extraordinarily happy to have a girl. She called for her partner enthusiastic about telling him they had a girl at last, but we couldn't find him. "He went out to walk," said another father who had been pacing the hall with his wife all afternoon. After unintentionally setting several other men in the area on the task of finding the new-again dad, we did a flurry of hospital chores, settled everyone in, and left at a respectable hour. Viri clapped my shoulder on the way out, and let me know that it was getting dark, I should hurry home, but I didn't need to wait for the truck at this hour. Good luck, good night...
Wednesday, March 25, 2009
Boyness2
Yesterday T and I went in to the ward to find it overflowing with pregnant ladies. We grabbed a multip that looked like she was rocking along and brought her to the labor ward for the admissions check, since admissions was full. She turned out to be 7, so we stayed there. Her labor had begun days previous, with up-all-night contractions slowing during the day, until this morning they accelerated.
And stayed there. We chatted between contractions. This was her second baby, her first had been born 9 years ago, a girl. She told me I was lucky to have my three children, since she had been trying to have another baby since her girl was 2 years old.
And T caught two babies and observed two more, while I stayed there. Unexpectedly, the hours rolled by. Contractions came and went, and progress - the measurable sort, anyhow - was not achieved, although I now suspect that there was dramatic baby-head molding going on beyond the reach of my fingers.
She told me she was exhausted, that she "got no moa powah." She told me she wanted to go "to the theater" (OR for a c-section), although she stopped telling me that after I told her that this hurt, but a c-section would hurt more, since this would be over when she had her baby but a c-section would keep hurting. She told me she needed to be cut last time, T told her that was on the outside and wouldn't help now, it was the inside that needed to open. Her contractions spaced to every 10 minutes, though still strong, and her cervix stubbornly held on to its last centimeter with a big 'ole swollen anterior lip, and after 3 hours of this we began some IV pitocin on a veeeery slow drip (this was a mildly agonizing decision for me to make, but her contractions were really not doing the trick and she really wanted to be done), which brought her contractions back up to once every 4 minutes or so. After laboring for a while on her back and side, the way women here usually do, she actually took my suggestion and got on hands and knees. Once freed, she followed her body to her feet, to a squat, to the floor, where she eventually began pushing spontaneously (finally) and delivered a very molded-headed baby over an intact perineum (right on past that episiotomy scar) while rocking between side-lying and flat on her back. She dropped promptly off to sleep once the placenta was delivered (in my paranoia I checked her blood pressure a tad more often than is common here, but she was actually just sleeping), still on the floor.
She named her baby boy after Boyness, because "your Boyness' mom was with my Boyness' mom when he was born."
And stayed there. We chatted between contractions. This was her second baby, her first had been born 9 years ago, a girl. She told me I was lucky to have my three children, since she had been trying to have another baby since her girl was 2 years old.
And T caught two babies and observed two more, while I stayed there. Unexpectedly, the hours rolled by. Contractions came and went, and progress - the measurable sort, anyhow - was not achieved, although I now suspect that there was dramatic baby-head molding going on beyond the reach of my fingers.
She told me she was exhausted, that she "got no moa powah." She told me she wanted to go "to the theater" (OR for a c-section), although she stopped telling me that after I told her that this hurt, but a c-section would hurt more, since this would be over when she had her baby but a c-section would keep hurting. She told me she needed to be cut last time, T told her that was on the outside and wouldn't help now, it was the inside that needed to open. Her contractions spaced to every 10 minutes, though still strong, and her cervix stubbornly held on to its last centimeter with a big 'ole swollen anterior lip, and after 3 hours of this we began some IV pitocin on a veeeery slow drip (this was a mildly agonizing decision for me to make, but her contractions were really not doing the trick and she really wanted to be done), which brought her contractions back up to once every 4 minutes or so. After laboring for a while on her back and side, the way women here usually do, she actually took my suggestion and got on hands and knees. Once freed, she followed her body to her feet, to a squat, to the floor, where she eventually began pushing spontaneously (finally) and delivered a very molded-headed baby over an intact perineum (right on past that episiotomy scar) while rocking between side-lying and flat on her back. She dropped promptly off to sleep once the placenta was delivered (in my paranoia I checked her blood pressure a tad more often than is common here, but she was actually just sleeping), still on the floor.
She named her baby boy after Boyness, because "your Boyness' mom was with my Boyness' mom when he was born."
Monday, March 23, 2009
Crappy Day (sensitive readers skip this post please)
Mid-week last week, a 16-almost-17 year old primip had gone for an ultrasound to evaluate size greater than expected for dates at 21 weeks, and was found to be carrying conjoined twins. Because the twins shared a heart, termination was recommended. After a not-very-informed discussion (this based not on being there, but on what the doctor told me about the plan), the family agreed that the pregnancy be terminated as soon as possible, which translated into misoprostol induction on Monday.
The misoprostol caught up to her finally this morning, and T and I were present when her babies delivered vaginally without issue, completely unresponsive and unmoving although with a heart beat. The babies made no attempt to survive. Their mother was relieved it was over. The family is taking the babies home to bury.
Not too much later in the day, we began the admissions process for a woman in labor at term with her third baby, and were unable to find heart tones. She reported last feeling movement early this morning. The ultrasonographer was on lunch and unreachable, so every person on the ward tried again, and again, for almost an hour, unsuccessfully. The mom reacted very little to this. By the time the ultrasound happened, the expected conclusion was fetal demise. The ultrasound confirmed a non-beating heart. The mom was still not reacting much to this news at all when we left, even laughing with the hospital billing person. This baby will be almost a pound larger than her other two, and as she was already in labor (although just 2cm), she will likely deliver her dead baby some time tonight.
Perhaps the only good part of our day was greeting the postpartum women whose babies we had caught yesterday and the day before.
I was amazed yet again at how much the women on the ward seem to enjoy having each other around. When the labor ward was full the other day, two of the immediate-postpartum moms wanted us to remove the separating curtains so that they could chat, which I found amusing. In the overheated, overcrowded "extension" room, where moms and babies stay if they need a bit longer for whatever reason - usually low birth weight - I've walked past to see groupings of moms talking, playing cards, nursing babies in a circle. I won't say it is ideal, just that the sharing of space doesn't feel as bad as I imagined it would.
We've seen a fair amount of the hospital and are concluding that the maternity ward is the highest volume spot but is in a state of furthest disrepair. It is also the hottest spot in the hospital, and this is not our imagining. It is shameful. The doctor that is the most motivated to make changes seems oddly focussed on crazy little things like the boards that are used for bandages maybe carrying staph bacteria (not a problem that has been encountered...) instead of things that are actually making people sick, like the inappropriate reuse of suctioning equipment. We are not here to fix anything, we are here to participate and to provide good care the way we know how. But it is hard to see things proceed in such a mal-coordinated fashion.
T and I both left early; T because she felt unwell, myself because it was just an hour until the end of shift and I was very hot and very done, and there were more people there than things to do already. I had taken to sanitizing all the surfaces in the delivery rooms (um, is this ever done? oh the disgusting things I found), but once all the handles, knobs, and cabinetry were done, I was about finished with scrubbing things with gauze.
We are back, in air conditioning (oh lovely air conditioning), being overheated and exhausted in our room.
The misoprostol caught up to her finally this morning, and T and I were present when her babies delivered vaginally without issue, completely unresponsive and unmoving although with a heart beat. The babies made no attempt to survive. Their mother was relieved it was over. The family is taking the babies home to bury.
Not too much later in the day, we began the admissions process for a woman in labor at term with her third baby, and were unable to find heart tones. She reported last feeling movement early this morning. The ultrasonographer was on lunch and unreachable, so every person on the ward tried again, and again, for almost an hour, unsuccessfully. The mom reacted very little to this. By the time the ultrasound happened, the expected conclusion was fetal demise. The ultrasound confirmed a non-beating heart. The mom was still not reacting much to this news at all when we left, even laughing with the hospital billing person. This baby will be almost a pound larger than her other two, and as she was already in labor (although just 2cm), she will likely deliver her dead baby some time tonight.
Perhaps the only good part of our day was greeting the postpartum women whose babies we had caught yesterday and the day before.
I was amazed yet again at how much the women on the ward seem to enjoy having each other around. When the labor ward was full the other day, two of the immediate-postpartum moms wanted us to remove the separating curtains so that they could chat, which I found amusing. In the overheated, overcrowded "extension" room, where moms and babies stay if they need a bit longer for whatever reason - usually low birth weight - I've walked past to see groupings of moms talking, playing cards, nursing babies in a circle. I won't say it is ideal, just that the sharing of space doesn't feel as bad as I imagined it would.
We've seen a fair amount of the hospital and are concluding that the maternity ward is the highest volume spot but is in a state of furthest disrepair. It is also the hottest spot in the hospital, and this is not our imagining. It is shameful. The doctor that is the most motivated to make changes seems oddly focussed on crazy little things like the boards that are used for bandages maybe carrying staph bacteria (not a problem that has been encountered...) instead of things that are actually making people sick, like the inappropriate reuse of suctioning equipment. We are not here to fix anything, we are here to participate and to provide good care the way we know how. But it is hard to see things proceed in such a mal-coordinated fashion.
T and I both left early; T because she felt unwell, myself because it was just an hour until the end of shift and I was very hot and very done, and there were more people there than things to do already. I had taken to sanitizing all the surfaces in the delivery rooms (um, is this ever done? oh the disgusting things I found), but once all the handles, knobs, and cabinetry were done, I was about finished with scrubbing things with gauze.
We are back, in air conditioning (oh lovely air conditioning), being overheated and exhausted in our room.
Bored-and-not
Yesterday (Monday), T went in to the hospital a couple hours before I did, while I stayed behind and did some business-plan writing and blog-catching-upping. She admitted three women, and when I arrived, one had delivered, she was coaching the second - a primip who had been pushing for an hour already - to push in a variety of positions, and another woman was writhing in looks-like-ready-to-push condition across the way with nobody in attendance. I went out, found her chart, and did an exam; she was complete, and relieved to be "allowed" to push. She pushed for about 15 minutes, and then we had a 5 minute shoulder dystocia that I was completely alone for, with T across the hall just having caught the other baby, which began to cry as I began to move through maneuvers. What ran through my mind? A passage from Gabbe - "you must not pull desperately on the head." I find that somewhat random and not entirely helpful, but the maneuvers are so entrenched in my mind at this point that they were pretty automatic. Hip flexion, Rubins, posterior shoulder, sweeping for an arm...Woods Screw maneuver - pushing both shoulders simultaneously, in this case counter-clockwise, to find the spot where they would come through - worked, and out came a floppy baby with a blessedly acceptable heart rate. T came across the hall just as the baby was beginning to respond to my stimulation, to let me know she was available - I told her the baby was coming around, thanks, I'd call if I needed another pair of hands, since she was all of 15 feet away. Baby cried vigorously at 2 minutes after suctioning and further stim - at which point I lunged back at the bed to catch a placenta - and by 5 minutes was happily snuggling with her mom, who had uncharacteristically requested her baby be handed to her.
This episode was then followed by 6 hours of utter boredom. Two primips arrived, one at 3cm who was still at 3cm when I left, and another at 4cm who was at 5cm when I left, both of them laboring quietly and with the help of relatives. I sat and read, watched the midwife and nurse play computer games, chatted, and was in many similar ways completely sleepy and bored out of my mind.
10 minutes before the shift completed, we got an interesting phone call...they were sending someone down in labor. The catch here is that this woman hadn't known she was pregnant.
Apparently, after having her fourth child, she had begun depo provera and had been getting regular shots for 10 years, including during this pregnancy, uninterrupted. She continued to have monthly "cycling" with light spotting, which happened even during this pregnancy. At some point a few weeks previous, she had become suspicious of pregnancy because she had felt strong movement, but then her monthly bleeding occurred on time, and she concluded that something else must be wrong. She came in to the hospital in labor, still not totally sure what was going on and entirely unprepared to give birth or have a baby. We felt her belly and concluded that she was somewhere around 38 weeks, we couldn't know really but it seemed reasonable that she was at term.
She apologized to me throughout. For what, I'm not sure; maybe for not having prior care, maybe for not having her things with her, maybe for having another baby at all, maybe she was apologizing to herself and her baby by apologizing to me.
Her baby came quickly. Fifth baby, after all. Vigorous boy in a sludge of mec, looking 40-ish weeks old. Mom had through the swift (half an hour from admission and being told that yes, she was pregnant to having a baby) labor apparently managed to come to terms with the fact that she was having a baby. "Wun smol boy!" she repeated after us. After she'd delivered her placenta, she sat up in her bed, nursing and staring at her baby. "Gonna have a STORY to tell when I get home," she said.
I wandered home through the ever-so-dangerous (insert eye-rolling here) alley, through the usual chorus of "good night"s from the people living there, a bit past midnight, and sleep was not far behind.
This episode was then followed by 6 hours of utter boredom. Two primips arrived, one at 3cm who was still at 3cm when I left, and another at 4cm who was at 5cm when I left, both of them laboring quietly and with the help of relatives. I sat and read, watched the midwife and nurse play computer games, chatted, and was in many similar ways completely sleepy and bored out of my mind.
10 minutes before the shift completed, we got an interesting phone call...they were sending someone down in labor. The catch here is that this woman hadn't known she was pregnant.
Apparently, after having her fourth child, she had begun depo provera and had been getting regular shots for 10 years, including during this pregnancy, uninterrupted. She continued to have monthly "cycling" with light spotting, which happened even during this pregnancy. At some point a few weeks previous, she had become suspicious of pregnancy because she had felt strong movement, but then her monthly bleeding occurred on time, and she concluded that something else must be wrong. She came in to the hospital in labor, still not totally sure what was going on and entirely unprepared to give birth or have a baby. We felt her belly and concluded that she was somewhere around 38 weeks, we couldn't know really but it seemed reasonable that she was at term.
She apologized to me throughout. For what, I'm not sure; maybe for not having prior care, maybe for not having her things with her, maybe for having another baby at all, maybe she was apologizing to herself and her baby by apologizing to me.
Her baby came quickly. Fifth baby, after all. Vigorous boy in a sludge of mec, looking 40-ish weeks old. Mom had through the swift (half an hour from admission and being told that yes, she was pregnant to having a baby) labor apparently managed to come to terms with the fact that she was having a baby. "Wun smol boy!" she repeated after us. After she'd delivered her placenta, she sat up in her bed, nursing and staring at her baby. "Gonna have a STORY to tell when I get home," she said.
I wandered home through the ever-so-dangerous (insert eye-rolling here) alley, through the usual chorus of "good night"s from the people living there, a bit past midnight, and sleep was not far behind.
Sunday, March 22, 2009
Busy, Busy, Busy
Yesterday (Sunday), T left for an overnight to see the volcano at Tanna, and I left for what was supposed to be a swing-shift at the hospital from 10-6 but wound up being a bit longer.
I arrived to find the ward pretty quiet, a situation which changed dramatically over the next hour as we admitted 4 women, all of them primips and all but one of them hovering around 5cm. They labored into the afternoon; shift change happened at 3, leaving myself, one midwife, and one nurse on staff. At 4 a multip showed up at 5cm. Two of the primips were creeping their way slowly (for here) towards the finish line, and it looked like we were in for a bit of a rush. Another primip showed up fully dilated. Fortuitously, an advanced nursing student showed up at this time as well, and although he required the midwife's continual supervision (something she doesn't think I need...hahahahaha), he was another set of hands. We split up one per bed, with three women in the four-bed labor ward (which they typically like to have only two women in at a time).
The multip's contractions had spaced out to almost 10 minutes, and although she was eager to push, her cervix was a firm 8cm which didn't yield well during a push, so I discouraged it. Someone opened the door and pleaded tearfully for me to come check her relative who was "so much soa now, please you check?" Which I ran out and did between multip-mama's contractions, to find her at 6-7cm, which was only slight progress from her last check 3 hours previous.
The fully-dilated-on-arrival primip delivered first, which I observed while the student nurse and MW Tamanu did a four-handed catch.
The multip delivered next, as I held back a decent sized anterior lip of cervix; this birth I managed completely with the student nurse swooping in to give a shot of pitocin on my request, and MW Tamanu showing up to suction the baby for some random unexplained reason (breathing fine) about two minutes after the birth (ok not so random, since there was moderate mec, but this was a pretty nonsensical time to suction) - both of whom disappeared rapidly because they were still cleaning up from the first birth, while I was occupied with the mom's somewhat-larger-than-average blood loss and they were entirely uninterested in the matter. Her placenta came out fine, her blood loss ceased, her baby looked fine hanging out in the warmer, and another primip began to push.
MW Tamanu proposed that she monitor multip-mom and baby while I managed the next primip's birth. I had feared for this primip's perineum since I had checked her on admission, because of the difficulty admitting my fingers for the VE despite her good attempts to release tension and her apparent calmness about the exam. She had perhaps the best pushing control I have ever seen, and she breathed and slowly pushed her baby past an intact perineum with absolutely no issues whatsoever. Her placenta arrived just 3 minutes later. The entirety of her blood loss, I could have cupped in one hand.
All this she did less than 25 minutes after the first mom had delivered.
We got the babies their shots, registered the births, got the moms and babies sorted out and into their beds, and I left the MW and the student nurse to handle the remaining women, one of whom had been admitted with SROM and no labor and continued to have a non-labor, and the other who I had recently checked at 7cm looking no closer to delivering. I walked back to the room through the usual chorus of "goodnight"s from the village-in-a-city occupying the block adjacent to the hospital, and fell into bed at 10:30.
I arrived to find the ward pretty quiet, a situation which changed dramatically over the next hour as we admitted 4 women, all of them primips and all but one of them hovering around 5cm. They labored into the afternoon; shift change happened at 3, leaving myself, one midwife, and one nurse on staff. At 4 a multip showed up at 5cm. Two of the primips were creeping their way slowly (for here) towards the finish line, and it looked like we were in for a bit of a rush. Another primip showed up fully dilated. Fortuitously, an advanced nursing student showed up at this time as well, and although he required the midwife's continual supervision (something she doesn't think I need...hahahahaha), he was another set of hands. We split up one per bed, with three women in the four-bed labor ward (which they typically like to have only two women in at a time).
The multip's contractions had spaced out to almost 10 minutes, and although she was eager to push, her cervix was a firm 8cm which didn't yield well during a push, so I discouraged it. Someone opened the door and pleaded tearfully for me to come check her relative who was "so much soa now, please you check?" Which I ran out and did between multip-mama's contractions, to find her at 6-7cm, which was only slight progress from her last check 3 hours previous.
The fully-dilated-on-arrival primip delivered first, which I observed while the student nurse and MW Tamanu did a four-handed catch.
The multip delivered next, as I held back a decent sized anterior lip of cervix; this birth I managed completely with the student nurse swooping in to give a shot of pitocin on my request, and MW Tamanu showing up to suction the baby for some random unexplained reason (breathing fine) about two minutes after the birth (ok not so random, since there was moderate mec, but this was a pretty nonsensical time to suction) - both of whom disappeared rapidly because they were still cleaning up from the first birth, while I was occupied with the mom's somewhat-larger-than-average blood loss and they were entirely uninterested in the matter. Her placenta came out fine, her blood loss ceased, her baby looked fine hanging out in the warmer, and another primip began to push.
MW Tamanu proposed that she monitor multip-mom and baby while I managed the next primip's birth. I had feared for this primip's perineum since I had checked her on admission, because of the difficulty admitting my fingers for the VE despite her good attempts to release tension and her apparent calmness about the exam. She had perhaps the best pushing control I have ever seen, and she breathed and slowly pushed her baby past an intact perineum with absolutely no issues whatsoever. Her placenta arrived just 3 minutes later. The entirety of her blood loss, I could have cupped in one hand.
All this she did less than 25 minutes after the first mom had delivered.
We got the babies their shots, registered the births, got the moms and babies sorted out and into their beds, and I left the MW and the student nurse to handle the remaining women, one of whom had been admitted with SROM and no labor and continued to have a non-labor, and the other who I had recently checked at 7cm looking no closer to delivering. I walked back to the room through the usual chorus of "goodnight"s from the village-in-a-city occupying the block adjacent to the hospital, and fell into bed at 10:30.
Sunburnt on Saturday
On Saturday, off to the beach at Hideaway. The day looked dreary and we settled ourselves out in the open, where the light was enough to read by and just slightly warmer than the wet/shade. The sun began to shine brightly, I did some snorkelling (although the water was somewhat murky, the fish were abundant and the corals very much alive - Hideaway is definitely the place for easy snorkelling), and then headed into dappled shade under a tree.
Somehow, my forehead, one thigh, and a particular portion of my back became dramatically sunburnt whilst the rest of me remained pretty much fine. And yes, I did apply sunscreen to the entirety of the exposed all-too-white surface of my skin.
The effect of the sunburn on the flushed appearance I managed to work up last night on shift was incredible. Anyway, we left the beach at around 1:30 and were at the hospital at around 3pm, which is when the afternoon shift starts.
*following portion concerns stillbirth and is not for the faint of heart, please stop reading here if easily disturbed and skip past the indented portion of the post, or to the next post entirely if you'll be tempted*
Meanwhile, the laboring woman appeared to have been deserted by whatever much-older man had brought her to the hospital, and was having difficulty dealing with her labor. I walked with her for a while, rubbing her lower back during contractions (it seems that this is most often what labor support consists of here) and essentially just being present. She decided to lie down in the admissions room as another mom came in with some sort of early labor going on, and started sounding transition-y, which for a multip is cause for some sort of action. Off to the labor room we went, but when I checked her she was 7 and not yet ready to push.
She seemed most comforted at that time, unfortunately enough, to drape her arm over my shoulder and flex her hand right against the spot on my back that was sunburnt. Attempts to rearrange the situation failed. I feared for my ability to break loose and catch her baby when the time came; fortunately, she got more used to T and began to switch up her routine a little bit.
About an hour later she was actually ready to push, and out came her 3.5k (7 and a halfish pounds, large for here) baby, with linebacker shoulders and looking huge for this small mama, over an intact perineum with a push for the shoulders, a push for the chest, and a push for the hips. Baby came out floppy and blue, and her APGARs were 2/5/7, which is misleading in that because her heart rate was over 100 the entire time, and she was attempting to breathe by 2 minutes, the situation was not particularly panicked. MW Tamanu had been in and out of the room in this time, while she was giving report to the midwives during shift change. Baby improved, mama delivered the placenta without major incident, we got baby set up and nursing, and we left to stagger to our room just after midnight.
Somehow, my forehead, one thigh, and a particular portion of my back became dramatically sunburnt whilst the rest of me remained pretty much fine. And yes, I did apply sunscreen to the entirety of the exposed all-too-white surface of my skin.
The effect of the sunburn on the flushed appearance I managed to work up last night on shift was incredible. Anyway, we left the beach at around 1:30 and were at the hospital at around 3pm, which is when the afternoon shift starts.
*following portion concerns stillbirth and is not for the faint of heart, please stop reading here if easily disturbed and skip past the indented portion of the post, or to the next post entirely if you'll be tempted*
A woman whose baby had died in utero (this had already been established the previous day) appeared at the hospital in what looked like early labor, and then left again, only to reappear a couple of hours later in roaring labor. T volunteered to catch after a bit of encouragement from midwife Tamanu. The woman, an 18 year old primip, disassociated heavily while she pushed. Her macerated baby girl came out weighing 1k, with the cord wrapped very tightly around its neck three times. T had to exit the room while Dr Robin and MW Tamanu examined the baby; in the meantime, I attended to third stage, which Dr Robin encouraged me to hurry along with cord traction but I was reluctant to do because I wasn't sure about the heartiness of the cord. All was well there. The baby was carefully wrapped and arranged and brought to the family outside; there was much crying, and at one point T and I walked by to see the dad with his whole body draped over the bassinet, just sobbing.
Meanwhile, another woman was laboring up and down the hallway, and although she paused to stroke the back of the grandmother for a moment, appeared not to be upset by the mourning family, nor them by her.
After the hour was up, we moved the mom out onto the floor. Mercifully, the patient load was light, and she got a room with four beds (normally fully occupied) to herself, but her family was nowhere to be found. She continued to essentially stare off into space and interact with us minimally. Almost an hour later, her family reappeared. I'm not sure I've ever been so glad to see such a crowd of people show up postpartum. She sat up, reached out, and sobbed into her mother's shoulder...and sobbed, and sobbed, and clung to her aunties and to her boyfriend, and each time we passed for hours there she was, clinging to a relative and crying.
Meanwhile, the laboring woman appeared to have been deserted by whatever much-older man had brought her to the hospital, and was having difficulty dealing with her labor. I walked with her for a while, rubbing her lower back during contractions (it seems that this is most often what labor support consists of here) and essentially just being present. She decided to lie down in the admissions room as another mom came in with some sort of early labor going on, and started sounding transition-y, which for a multip is cause for some sort of action. Off to the labor room we went, but when I checked her she was 7 and not yet ready to push.
She seemed most comforted at that time, unfortunately enough, to drape her arm over my shoulder and flex her hand right against the spot on my back that was sunburnt. Attempts to rearrange the situation failed. I feared for my ability to break loose and catch her baby when the time came; fortunately, she got more used to T and began to switch up her routine a little bit.
About an hour later she was actually ready to push, and out came her 3.5k (7 and a halfish pounds, large for here) baby, with linebacker shoulders and looking huge for this small mama, over an intact perineum with a push for the shoulders, a push for the chest, and a push for the hips. Baby came out floppy and blue, and her APGARs were 2/5/7, which is misleading in that because her heart rate was over 100 the entire time, and she was attempting to breathe by 2 minutes, the situation was not particularly panicked. MW Tamanu had been in and out of the room in this time, while she was giving report to the midwives during shift change. Baby improved, mama delivered the placenta without major incident, we got baby set up and nursing, and we left to stagger to our room just after midnight.
A Day Off
On Friday, we spent our morning huddled over our computers yet again, at work on our Senior Papers. Mine is very close to being finished, thank goodness.
Around noon, we wandered downtown, mailed off some postcards to the kids, ate lunch where many of the local people do, at the large produce market:
We wandered through a large school assembly that was taking place near the shore; some kids on stage, others playing in the grass or jumping off the concrete wall into the bay (it looked like they were having insane amounts of fun). The playground set there includes the typical swings and slides and such, and then a slide off the edge of the wall and into the water. Not that the kids looked confined to the slides; play was happening everywhere. Preteens and teens walked around, wearing a set of street clothes under their school uniforms (T and I both wondered, how on earth could they handle that much clothing in the heat and humidity? I guess people can get used to just about anything).
Through a tourist-trap open-air market, where we got some goodies for the kids; as we were looking, the air got thicker and heavier, and women began pulling their merchandise under cover, so we hastened to a nearby cafe, where we waited out the rainstorm with lattes (each of which cost the same as both of our lunches at the market, yay tourist-centric pricing...) under an adequate awning that kept out the rain but was powerless against the humidity.
A slow...easy...way-too-hot-still walk back to our room, where I jumped into the pool as soon as I possibly could and then talked to my family on Skype, which was a lovely experience - the kids were very much into showing off their new musical learning on the piano and ukulele and drum, which was very not the torture it could have been, mainly because they've managed a fair amount of rhythm and it lasted only about 10 minutes and absence makes the heart grow fonder.
I said goodbye somewhat reluctantly, but happily, after our short conversation, and we threw on clothes and headed off for the "Melanesian Feast," which turned out to be a really great experience. Vanuatu is a very diverse country, with many cultures evolving in relative isolation (the reason Bislama is so prevalent here is that a large number of the native languages aren't similar enough to allow good communication), so we saw just one culture's dancing, singing, and food. Perhaps my favorite thing was the kids that were completely allowed to steal the show, and the adults that indulgently encouraged the little ones to sing, dance, and drum along.
We avoided getting rained on, major incidents with insects, cultural inappropriateness from the 4 elderly gentlemen on holiday from Holland (whose major sin so far appears to be stating "basket blong titi" loudly during the bus rides, but oh boy do those men have some embarrassment potential), and got back in time to sleep at a reasonable hour.
Around noon, we wandered downtown, mailed off some postcards to the kids, ate lunch where many of the local people do, at the large produce market:
We wandered through a large school assembly that was taking place near the shore; some kids on stage, others playing in the grass or jumping off the concrete wall into the bay (it looked like they were having insane amounts of fun). The playground set there includes the typical swings and slides and such, and then a slide off the edge of the wall and into the water. Not that the kids looked confined to the slides; play was happening everywhere. Preteens and teens walked around, wearing a set of street clothes under their school uniforms (T and I both wondered, how on earth could they handle that much clothing in the heat and humidity? I guess people can get used to just about anything).
Through a tourist-trap open-air market, where we got some goodies for the kids; as we were looking, the air got thicker and heavier, and women began pulling their merchandise under cover, so we hastened to a nearby cafe, where we waited out the rainstorm with lattes (each of which cost the same as both of our lunches at the market, yay tourist-centric pricing...) under an adequate awning that kept out the rain but was powerless against the humidity.
A slow...easy...way-too-hot-still walk back to our room, where I jumped into the pool as soon as I possibly could and then talked to my family on Skype, which was a lovely experience - the kids were very much into showing off their new musical learning on the piano and ukulele and drum, which was very not the torture it could have been, mainly because they've managed a fair amount of rhythm and it lasted only about 10 minutes and absence makes the heart grow fonder.
I said goodbye somewhat reluctantly, but happily, after our short conversation, and we threw on clothes and headed off for the "Melanesian Feast," which turned out to be a really great experience. Vanuatu is a very diverse country, with many cultures evolving in relative isolation (the reason Bislama is so prevalent here is that a large number of the native languages aren't similar enough to allow good communication), so we saw just one culture's dancing, singing, and food. Perhaps my favorite thing was the kids that were completely allowed to steal the show, and the adults that indulgently encouraged the little ones to sing, dance, and drum along.
We avoided getting rained on, major incidents with insects, cultural inappropriateness from the 4 elderly gentlemen on holiday from Holland (whose major sin so far appears to be stating "basket blong titi" loudly during the bus rides, but oh boy do those men have some embarrassment potential), and got back in time to sleep at a reasonable hour.
Around the Isle and Back Again
On Thursday, T and I did an almost-all-day around the island tour (9am to 5pm). It was absolutely wonderful. Our tour guide was *this post interrupted to let you know I've just squashed a spider the size of my fucking HAND, "no poisonous spiders in Vanuatu" is the best thing I've read in a while, seriously* entertaining and knowledgeable. We got to see several beaches, our tour guide pointed out many villages, farming areas, etc. All of which, due to the dreary rainy non-photogenic nature of the day, I didn't get much photographic evidence of. Nevertheless, the tour was more useful than I had anticipated.
Efate, the island we're on, contains several paved roads in the main area (Port Vila and immediate surroundings); after that, the road is unpaved. The government is working on a sealed road to circle the island, but is nowhere near completion yet. Our driver did a masterful job of remembering that his passengers were pretty much used to flat, even, not-water-covered roads.
We got out at a beach mid-morning where we swam in crazy variable-temperature water, stared at a few fish, and drank/ate coconuts. We stopped to look and play at a banyan tree:
At lunch, we had local food at a "restaurant" that was owned by a man from an island you could see from the beach, and ate some great local food:
T made a friend (I even held a hermit crab...not kidding). There is some insane number of hermit crabs on this island, just look at a piece of beach and it will start moving:
And we saw the "American swimming pool," so named because the Americans made it in other endeavors not intended for recreation:
To top the day off, we visited Mele Falls and Cascades, which has to be the most photogenic river/stream ever:
A little past that point, we had to cross the river multiple times to get to the top, and that combined with the waterfall spray from the larger falls was too dangerous for the camera. It was awesome, though.
We decided to go that evening to the hospital, and spent about 5 hours there attending to women in various stages of labor, none of whom delivered by the time we left just before midnight.
I still didn't work on my business plan. Tomorrow is another day (as is the next day...and the day after that...)
Efate, the island we're on, contains several paved roads in the main area (Port Vila and immediate surroundings); after that, the road is unpaved. The government is working on a sealed road to circle the island, but is nowhere near completion yet. Our driver did a masterful job of remembering that his passengers were pretty much used to flat, even, not-water-covered roads.
We got out at a beach mid-morning where we swam in crazy variable-temperature water, stared at a few fish, and drank/ate coconuts. We stopped to look and play at a banyan tree:
At lunch, we had local food at a "restaurant" that was owned by a man from an island you could see from the beach, and ate some great local food:
T made a friend (I even held a hermit crab...not kidding). There is some insane number of hermit crabs on this island, just look at a piece of beach and it will start moving:
And we saw the "American swimming pool," so named because the Americans made it in other endeavors not intended for recreation:
To top the day off, we visited Mele Falls and Cascades, which has to be the most photogenic river/stream ever:
A little past that point, we had to cross the river multiple times to get to the top, and that combined with the waterfall spray from the larger falls was too dangerous for the camera. It was awesome, though.
We decided to go that evening to the hospital, and spent about 5 hours there attending to women in various stages of labor, none of whom delivered by the time we left just before midnight.
I still didn't work on my business plan. Tomorrow is another day (as is the next day...and the day after that...)
Subscribe to:
Posts (Atom)
