Midwifery Students Travel to Vanuatu

These journal entries come from one of the two naturopathic midwifery students who traveled to Vanuatu, an independent island nation off the coast of Australia, to perform births in a hospital for a month. This student preceptorship helped them fulfill the requirements needed to complete the Certificate in Naturopathic Midwifery.

Delivering Twins
Late Nights in the Hospital
Life in the Maternity Ward
Babies Lost and Babies Saved
Attending Rounds
Cultural Sensitivity Training
A Premature Birth
Vanuatu: An Experience Like No Other
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Delivering Twins
It is another beautiful day in Vanuatu and we have begun working at the hospital. It has been an amazing experience so far. The midwives are all very friendly and happy to have us there to help. Jennifer and I have been managing all of the births that happen while we are on shift and have stayed into the night shift a few times for a few deliveries that were imminent.

Shortly after arriving to our first shift, a woman was ready to deliver. I delivered the first baby. It was slightly awkward because I wasn't sure how the midwives in Vanuatu "caught" babies and didn't know if they wanted us to do it their way. It was great to learn quickly that we were in the most welcoming and comforting environment. Everything about delivering babies in Vanuatu is relaxed and friendly - how wonderful for the women giving birth to be so supported. Shortly after this delivery another woman was ready and Jennifer stepped into the other room to deliver her first baby in Vanuatu - another girl.

The grandmother of the baby I delivered told me they decided to name her Loren, after me. I was so honored I wanted to cry. They asked us for our permission to take our names. We are so blessed to be able to have this experience, to be so warmly welcomed into a culture and share in such a sacred experience with these women.

One of the midwives came to our apartment the other night to wake us up to come for the delivery of twins. The mother was very large, which made us all wonder how big these babies were going to be. Just looking at her uterus made you feel her pain. I was going to manage the delivery. They were both head down, so we didn't expect anything unusual. By the time the mom got to the pushing stage she was so tired, so we let her rest. By then it was morning and the obstetrician decided to find out why she wasn't making any progress. As he was examining her, she gave the biggest push ever and the first twin flew out. He only had one glove on and didn't want to touch the baby. I jumped in and caught the baby so that it landed nicely on the table. I moved in to deliver the second twin. I broke the bag of water and discovered quickly that not only did the baby's head descend, but a loop of umbilical cord decided to arrive in front of the baby. This is dangerous because the cord can become compressed between the baby's head and the pubic bone cutting off oxygen to the baby. I placed my hand inside onto the baby's head to take pressure off of the cord and told the midwife that we had a prolapsed cord. She called the obstetrician in immediately. I slid my hand out as he slid forceps in to bring the baby out immediately. The baby was perfect and vigorous. I have heard so many horror stories about the use of forceps. It was great to see them used so effectively with no damage to the baby or the mother.

Late Nights in the Hospital
We have been staying at the hospital until around two in the morning each day. The other night we stayed over night at the hospital. Jen and I slept for about 4 - 5 hours before being woke around 4 am to attend another delivery. We ended up working straight through the next day, taking three hours to go home, shower and eat before returning for the evening shift. Again we stayed last night until 2:30 am before returning home. The midwives are really appreciating our help, especially when they get busy.

We have two girls from the UK living with us now. They are medical students doing rounds in surgery. Their days are very short. They go in around 7 and are home by 11:30. Then they are "on call" if anything comes up, however, they haven't been called. They have more free time than we do, so they are exploring options for traveling other parts of the country for us all.

Jude and Prush are the names of the girls living with us. Jude told me that they had sent someone over from surgery to maternity to see when the next births were pending. The surgical ward was hoping to collect some amnion (the bag that the baby lives in inside of the uterus) to apply to the skin of burn victims to protect it while they were working on getting skin grafts. The victims suffered burns when cooking oil in a pan caught on fire. It is great having connections with other medical students at the hospital to get a perspective on what else is going on there.

There have been a few deaths at the hospital this week. It is not hard to know when this happens because the windows are open everywhere in the hospital and when someone dies the walkways between the wards erupt in loud crying. The other night someone died and the cries erupted just as I was bringing a baby out of the womb. It gave me the chills.

I had many chances to suture today. All first time moms who needed a good amount of work. The fourth chance for me to suture came around 1:30 am. I couldn't get the woman to stop bleeding. Her uterus was firm and the placenta was complete, but I couldn't figure out where the bleeding was coming from. We had already given her a shot of syntocin (a medicine given to cause the uterine muscle to clamp down on the blood vessels to stop bleeding). I was sure that there were labial tears as well because I felt them under my hand as the baby delivered. The external tear (or "broke" as they would say in Bislama) was anterior into the clitoral hood. Everything in me said that I didn't want to suture into that because it is an extremely sensitive area. Another midwife came in and I asked her what the local midwives do in this situation. She seemed to think that the labial tears were the source of the bleeding and began to suture them. During the suturing, as the woman is crying out, she mentioned that she forgot to give lidocaine (numbing medication). I sutured with it on one occasion where the woman screamed out the entire time – an experience I hated. I couldn't imagine doing this procedure without medication. After the midwife sutured, she said "see that stopped the bleeding", but it hadn't - she was still bleeding from higher up. I mentioned that she was still bleeding and the midwife just said to give another dose of syntocin and put a kotex on her. The women stay in the hospital for at least 24 hours and can be monitored as problems arise. If the bleeding persists they will hopefully be able to catch it and manage it appropriately.

Life in the Maternity Ward
Jennifer had the idea of buying a deck of cards to occupy the time, something we could all do together. Spending time on the maternity ward when it is slow is like a slumber party. You are up all night hanging out telling stories and laughing. The midwives and really all the women in Vanuatu are shy, happy and giggly. They have not lost the happiness or beauty of youth. It is so refreshing to be around.

The maternity ward is a small building that has a long hallway off of which are several rooms. To the left, upon entering is the sister's room. This is the break room where you will often hear contagious laughter. In here we take a break, eat our meals, and in the evening on a slow night we watch television.

Vanuatu only has two channels on TV one is a Christian channel that comes from the US and the other has music videos (from the surrounding islands) and the news. The news is run twice, once in French then repeated in English. After the news is the nightly movie. The nights alternate between a movie in French or English. The reception of the television at the hospital is one that generates a lot of laughter. The antenna needs to be positioned perfectly in order to receive the image and decent sound quality. Then, if you are feeling particularly challenged, you can try to position it for color as well. Unlike in the US where people might easily become frustrated and yell, we all just laugh because we are together, enjoying our time together, whether it is watching television or trying to make it work.

When women come to the maternity ward they are often accompanied by their mother. It is a wonderful thing to see the women so well supported with their mothers by their side. The mothers often bring a fan woven out of coconut, panadus, or palm leaves. They fan the women while they are in labor and during delivery. If you are the one delivering and are standing just right, you'll benefit from the fanning as well. Just don't stand too close because the mother's focus is on her daughter and you might get whacked by the fan if too close. After we assess the progress of labor in the admission room we either go into the delivery theatre or have the woman walk around. They do a lot of walking in labor which really helps it progress. Jennifer and I are impressed at how willing they are to just walk for hours. In the US we have to struggle and bargain with women to get them to walk.

Across from the admissions room are the delivery theatres. There are two of them. They are connected, so at times if I am in one and Jennifer in the other, we can hear the progress of each other's labors. Women typically don't enter the theatre until the delivery is imminent. The women deliver on the table, on their backs. While in the US, as midwives, we give the options for other positions for pushing, the positioning here is logical in that it minimizes the area that needs to cleaned and protects the mother and baby by providing them a clean area to deliver. These women know how to push their baby's out, often within 30 minutes, but more typically in less than 10 - including first time moms. The midwives often begin to get concerned if the pushing takes much longer than that. Jennifer and I have been attending births together. It is much more fun this way. When a baby is being born, one person delivers the baby and the other receives the baby. After the baby is born, cord cut, and dried off, it is taken to another room to ‘scalem’ baby (weigh the baby) and ‘stickem’ baby (vaccinate- vitamin K and Hepatitis B). During the time the baby is away the placenta is delivered, mom is sutured if needed, and the mom cleaned up and turned onto her side to begin nursing the baby (‘givem titi’) once the baby returns.

Babies Lost and Babies Saved
We had a spell recently where the numbers of births had gone down. We began to spend all of our time at the hospital, including sleeping there. The weather began to grow hotter and hotter and HUMID! Then one evening, the rain began and didn't stop. It grew heavier and heavier being followed by strong winds, thunder and lightening. At first we were relieved that the rain had come to lessen the heat, but we were told it was typical of the beginning of a cyclone. We decided that this would be a good night to stay at the hospital because we would find out what was happening here. Besides, what better place to be than with people who are used to this weather. The storm continued to grow. It lasted through the night. The winds would catch and open door and slam it shut which was startling. The next morning as quick as it had began, the storm ended. It was as if someone flipped the switch to off.

The next morning our slow wave of births had changed. The maternity ward was buzzing with activity and lots of laboring moms. We have heard the wives tale about large shifts in barometric pressure bringing on labor and I'm convinced it is true. We delivered eight babies that day and a few more the next morning. It was 6 am and the maternity ward was about to come to life again. Jennifer and I were at the end of our fuse. We had been up for nearly three days straight and knew that if we stayed, we wouldn't sleep again until that night. We told Ennith that we were going to go home to sleep. She agreed that we should because losing too much sleep was against the laws of health.

We have seen many baby's born and are nearing the end of our birth requirements for graduation. Jennifer needs to deliver three more and I need to deliver two more. At that time we will surely rejoice. Unfortunately not all birth stories are happy ones. We had a mother come in who had not felt her baby move in three days. When attempting to listen to the baby's heartbeat, there wasn't one to be heard. The baby had died after 25 weeks of gestation. This is not uncommon in Vanuatu and the family accepts the death without question. The baby was born quickly without much effort from the mother. Jennifer brought the baby out and placed it onto the cloth at the end of the bed for me to receive. It was a little girl, fully formed, just very small. I carried the small girl into the other room to weigh her and then brought her back into the room where Jocelyn told me that the mother would like to see her. She reached out and said, "I'm sorry" to the baby girl and began to cry. The father of the baby came into the room at which time Jocelyn learned that this was the baby of her husband's nephew. He brought in a special blanket to lay the baby in and told me how he wanted her positioned. Under 500 grams the family can take home and bury in their yard. Over 500 grams the family was going to bury her in a cemetery. Becoming a midwife, I know that I needed to have that experience, but I'll be happy if that was the last.

We have been having lots of tight cords wrapped around the baby's neck that we are unable to lift over as the head delivers and so we need to cut the cord early before the shoulders deliver. Jennifer and I attended a birth where the baby's heart rate was going down at the end of the contraction and recovering slowly. We decided that continual monitoring was best to be sure that the baby was recovering from the contractions. Jennifer called me in to look at the recording of the fetal heart rate in relation to the contractions and I instantly recognized the pattern. We placed a call to the obstetrician on call (Dr Sala). The doctor didn't want to do a cesarean and decided it would be fine to watch and wait. We learned quickly that the syntocin was hyperstimulating the uterus so we stopped it, however the baby continued to have decelerations.

The midwives were deferring entirely to us because we understood the heart tracing patterns much better. We had to proceed with the labor. She was a first time mom and so her pushing stage was longer than they are used to in Vanuatu. They asked if we wanted to cut an episiotomy or have forceps, but the baby wasn't low enough for those yet and the obstetricians still were not concerned. They said that they'd allow her to push for an hour at most then they would do a c-section. She did push the baby out and just as we had expected, there was a tight cord around the baby's neck, so tight that you could see it was strangulating the baby. Jennifer cut the cord. The baby was completely floppy and unresponsive. We began vigorously stimulating the baby to no avail. I began resuscitation on the baby. Still no response. Jen and I continued resuscitation and eventually got a weak respiration response.

Nellie delivered the placenta for us although somewhat reluctantly. The baby started to pink up and develop more tone. We learned from this woman's sister that she had lost a baby that had been resuscitated and then died two hours later. We continued to check on the baby. The woman's two sisters came over to us, looked at the baby and smiled. We had just saved their nephew. They told us that they had chosen to name the baby Anthony. Jennifer and I made the executive decision that this baby was going to be admitted to the nursery. A few days later the baby is starting to breastfeed and is doing well.

Attending Rounds
Today, I attended rounds with the head OB and the medical students – a very challenging thing to do. He can just look at you and fire a question. If you're wrong, well you better have some good self-esteem. I just let it roll off my back and kept my mouth shut about most things and didn't question him because that's what the midwives there do.

He then induced two women with Cytotec, one who had ruptured membranes for 24 hours with no contractions and one who was 11 days post-due. The one with ruptured membranes delivered at 12:30 pm, three hours after being induced. Three more admissions then came in on the evening shift but were still in early labor. At 6:30 pm, the second one who was induced delivered into my hands. There were two more still walking the hallway and one looked like she was about ready. We pulled her into the other delivery room but she had stalled at 8 cm with the baby very high in the pelvis. We decided to augment her labor a little so I put in an IV with Syntocin and within two minutes her contractions picked back up and were long and strong. When she was at 9 cm I hooked up the heart tone monitor and noticed that the heart rate of baby was low. She pushed her baby out at 7:25. Whew, what a night!

Cultural Sensitivity Training
A 19-year-old deaf/mute girl was brought in by her mother. Here they call them deaf and dumb. I have taught most of midwives that it is mute, not dumb. This girl is obviously not treated well by her family or by much of her society.

She will barely even open her legs for me to check her dilation. When she does not cooperate her mother raises her hand as if she is going to slap her. I see all of this and know that I must be gentle. I really have no idea under what sort of circumstance she ended up pregnant, whether it was consensual or not. I made sure to have a gentle touch and not force her to do anything. By the time she is in active labor and ready to push, the poor girl is so scared. She has no idea what is happening or what is going to happen. She would not lie straight on the delivery table and the midwife kept slapping at her legs so she would open them. She also kept wagging her finger at the girl. It is very hard for me to watch this. I kept saying to the midwife that it was alright and I just kept being as gentle as possible.

Once the baby was born, he was lying at the end of the table while I was drying him off. The girl was just looking at the baby and did not seem very happy. The baby was crying and the girl pulled her leg and foot back as if to kick the baby. I looked at her and she sort of smirked. It made me sad that this baby was going into this family.

When we brought the baby back after weighing him and giving him his shots, I helped the mom start breastfeeding and explained to her mother that she was going to have to help her daughter since she couldn't hear when the baby would cry out. There was not one smile on the girl's face but at least her mother was smiling. I saw them the next day and they were full of smiles. That made me hopeful that this baby would go into a home of love.

It has slowed down again at the hospital. There was only one delivery on the evening shift last night. I went into the delivery room and got my gown and gloves barely on when she rolled onto her back pushing. I removed the pad she had between her legs and there was baby head almost all the way out. She pushed him the rest of the way out very easily but the baby didn't go very far as I discovered the cord was cinched tightly around his waist twice! I unwound it, dried him off and held the baby up for the mom to see.

The women here aren't like most of our homebirth American women. I have tried to place the baby on the mom's belly a couple of times and they just stare at it like it's an alien. They also don't smile and rejoice as we do after they give birth. They are very stoic about it all. I usually don't see a smile until we bundle up the baby and give it to her to breastfeed. It is assumed that all women here will breastfeed. There are many women here from China and when they come in to have their babies, they bring a canister of formula. They will not breastfeed their babies. I am not sure why.

Many times, the women do not come in with their husbands. Their mothers, grandmothers, aunties or family friends will bring them in. Occasionally the father of the baby will come to the hospital with the mom but they never come into the delivery room. Once we walk in, they leave. I have seen a few fathers coo over the babies, but usually not.

A Premature Birth
I had a new experience last evening in delivering a baby. A woman walked in to the maternity ward looking like she was starting to push. We got her into the delivery room and asked her a few questions in between contractions. We didn't have her prenatal records or anything yet so we had no information on her. I looked at her belly and noticed it was kind of small. I did a quick estimate of fundal height and suspected that she was not at term. I asked her when her due date was but she didn't understand me. I then asked when her last moon cycle was and she said November. A quick calculation in my head told me that this baby was not ready. We determined that she was around 34 weeks with the fetal size around 2 kg (4.4 lbs). There was no stopping labor because she was fully dilated and pushing at that point. We also noticed a scar on her belly from a previous c-section. It went quickly. I caught the smallest baby I had ever caught...1.940 kg. A very interesting experience. The baby is breastfeeding well and doing well.

I am getting lots of good practice at resuscitation, suturing, cervical exams and speaking Bislama. I feel very fortunate to have had the opportunity to come here. I am learning from the doctors and doing reading in between to supplement my knowledge. It seems that my learning curve went steep again when I came here because there are quite a few complications. Like this morning I was checking a woman and could not feel what the presenting part was - whether it was head or not. Turns out, the baby was at an oblique angle. My suturing has vastly improved. When I came here it took me 45 minutes to do a repair and now I can do it in about 15 minutes.

Vanuatu – An Experience Like No Other
On our last night in Vanuatu, the midwives had a goodbye party for us. Earlier on our last day, we went to the hospital to get a few last pictures and found out that quite a few people were coming. At 4:15 I looked towards the hospital and a group of 8 women were making their way up the hospital driveway towards our house, all dressed for a party. Soon Enneth came with all the food as well as her youngest daughter.

Nellie, the midwife in charge for the month, said we should begin. I thought she was referring to dinner. Instead, she began talking. She was speaking on behalf of everyone and was telling us how much each of them had enjoyed their time with us. They thanked us for how hard we worked and how much time we spent with them. She told us that we were the first students who had taken the time to become friends with them. She said that from the very first day we were different than the rest and immediately became a part of their world and one of them. She told us that we were now a part of their family and we were going to be missed dearly. The rest of the group proceeded to speak about how much they cherished their time with us and how much they would miss us. All of them spoke through many tears.

Next, each of us had to say something. I told them that I had never questioned the cost of energy, time, or money it took to come to Vanuatu because I knew the experience would be like no other. But I had never expected or could have ever dreamed that the experience would have been even a fraction as valuable as it had been. There is no price that could ever be put on finding a whole new family and that family is the only word that could describe this group of women. ‘Friend’ does not describe the way each of them had welcomed me and taken care of me in their home.

I know this barely describes the whole night but I wanted to share it the best I could. It was an experience like no other and I could never expect to have another like it in my lifetime.

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