On our way Home!

Hello friends and family,

We are now in Hong Kong after returning from our holiday in Pokhara and braving the chaos of Kathmandu. When we got back to Kathmandu we could hardly believe that we were already back in the city where all our adventures began 7 weeks ago!

Our last 2 days in Pokhara were spent trying to get a glimpse of the famous Annapurna Mountain Range. Apparently this time of year is notoriously bad for fog; clear days are few and far between. One morning we got up at 4am and went on a sunrise hike but the mountains decided to remain cloaked in clouds for the entire 6hr trek. We were pretty disappointed but enjoyed the hike. It took us along a ridge of mountains and through delightful traditional villages, rice paddies, and jungle groves. The following morning we got up again at 4am and dragged ourselves to the roof top of our hotel to watch the sunrise. We finally managed to get a small glimpse of the brilliant mountains. They were stunning! Having a few lovely relaxing days in Pokhara was exactly what the midwife ordered...Even though our bus ride back from Pokhara was a grueling (and sweaty) 9hrs.

Now we're easing back into reality, having spent our last two days in Kathmandu running around buying last-minute souvenirs and gifts, packing, repacking, and saying goodbyes. We had a farewell dinner with our fabulous Nepali supervisors and dear friends, Laxmi, Kiran, and Rashmi. These women are three trail-blazing members of the Midwifery Society of Nepal who are incredibly passionate about improving maternity care in Nepal through midwifery. We feel blessed to have had these amazing women watching out for us, organizing our clinical placements, showing us around Kathmandu, and welcoming us so warmly into their lives. They have truly inspired us.

Last night before heading to the airport we had dinner with our friend and trek guide Bishnu, who invited us to his home and showed us how to make one of our favourite Nepali dishes - momos. Now we can't wait to make it for family & friends when we get back home!

Our flight from Kathmandu to Dhaka and then to Hong Kong was smooth, and we spent the afternoon touring around a very rainy Hong Kong with Yarrow's family friend. We have just a few minutes before we board our last flight which will take us back to Vancouver. We're sad to have left Nepal but are very much looking forward to hugging our family and friends, and to thanking each of you in person for the incredible love and support you gave us while reading our stories. Your messages have meant so much to us.

We should go now (it would be pretty awful to get stuck in HK now!), but are planning on sharing a few more photos and last words on our experiences when we get home.

Love to everyone,
xo
Yarrow & Lauren

Hangin' up the (dirty) scrubs

Namaste dear readers,

Our month in Bharatpur has sadly come to an end. It is amazing how quickly it passed, and now we have only memories - of beautiful births, stressful moments, sweet sleep at the end of long nights, madly itching mosquito bites, monsoons cooling the sweltering days, juicy watermelon and mango fests, elephant riding, making new friends and feeling blessed by such an incredible and unique experience.

In our final week at the hospital we put in a full week of 12hr night shifts to going out with a bang. It was exhausting and completely worth it!

In total over the four weeks, we each caught 34 babies and attended 154 births. We had 1 stillbirth, 2 retained placentas, 3 cervical tears, 4 shoulder dystocias,5 postpartum hemorrhages, 7 premature babies (who all did just fine), over 50% of births with meconium, too many episiotomies, 61 intact perineums, and 44 resuscitations. There were 92 first-time mums and 62 multiparas.

We have grown so much as practitioners and members of humanity through this experience. As we finish this phase of our journey, we would like to leave you with some of our most memorable (joyous and scary) moments from this week:

- Attending births in the dark when the power was out - thankfully, catching a baby can be done by feel but this is a bad situation when the baby needs resucitation. This happened to Lauren who needed to suction a meconium baby but the power was out, so she did PPV until someone was able to get backup power on. The baby came around well once she was able to clear the baby's airway.

- We both helped a nursing student do her first solo catch. It was a fun teaching moment and we got a taste of what our preceptors must feel. Yarrow also walked a student through her first suturing job - a small first degree tear, straight foward but difficult to instruct when you have a left handed person trying to teach a right handed person!!

- Yarrow delivered a very flat baby after it was brought by vacuum to the perineum and Lauren did resuscitation with suctiong and PPV. After the baby was stable, Lauren found a piece of the woman's cervix on the baby's head - it had ripped off during the delivery! Pretty crazy to find that.
- We each had birth "complication-trends" which seemed to follow us. Yarrow's complication was cervical tears (she had 3, while Lauren had none) and Lauren's was shoulder dystocias (she had 4, while Yarrow had none).

- We only had one birth where we were alone - just the two of us. Usually, when we were catching a baby we'd have a huge audience of nurses, students, visitors, and other curious strangers, but for this birth the woman laboured and pushed silently. No one else knew it was happening and neither of us had time to grab a supervisor. It was a fun birth to attend. Throughout our time at Bharatpur we loved working together and became very good at it - communication in times of emergency was smooth, efficient and thankfully all our outcomes were good. We felt blessed to be able to work together and teach each other our little tricks!

- Later that same night, a nursing student delivered a baby that Lauren was resuscitating when Yarrow noticed that the student didn't look well. Soon after, the student fainted and Yarrow caught her and held her up for several minutes until she came to. She was okay afterwards, but it was a weird few minutes waiting for both an adult and a newborn to come around!

- Toward the end of the shift, Lauren was watching a birth that a nursing student was attending. The student delivered the baby's head, but then the shoulders wouldn't come. She didn't know what to do so Lauren had to climb onto the bed and, with a lot of effort, free the anterior shoulder. It was Lauren's 4th and final shoulder dystocia in Bharatpur. Thankfully the baby was okay.

- We each caught babies within minutes of each other, and neither of us were able to get more than one glove on before the babies' heads were out. It was slimey, but pretty fun to have super fast births next to each other.

- We saw a lot of episiotomies. Lauren caught a baby for a first-time mother after a nurse cut four episiotomies on her. The reason for the epis was not because the fetal heart rate was abnormal, but because in first-time mothers a "tight" perineum is considered an indication for episiotomy. At birth, the baby was very flat and Yarrow had to resuscitate it with bag and mask for over 10 minutes. Meanwhile, the mother had a postpartum hemorrhage so we were both pretty busy! Luckily both the baby and mum recovered well and are healthy now.

- Baby boys are highly valued in Nepal and mothers are often very happy when they hear us tell them "Chorra paunu bayo" (You have a baby boy). One mother had literally just delivered when Lauren told her she had a son, and she sat up, grabbed Lauren's face and kissed her on both cheeks, overcome with joy. It was delightful to see her so happy. We make sure to give extra kisses to the baby girls though, since we think they deserve the love too.

- Yarrow was attending a second time mother who was pushing for a while until we saw something dark purple/maroon covering the glimpse we had of the baby's head. Once we got a better light, Yarrow realized that the woman's cervix had prolapsed while she was pushing, and it was preventing the delivery of her baby's head. It is very unusual for a cervix to come down that low - normally it dilates out of the way before we start seeing any head! Lauren pressed down on the baby's head while Yarrow slid the cervix out of the way, and very shortly after, the baby was born. We hope this woman doesn't suffer from a uterine prolapse in the future. Unfortunately, most Nepali women must do very hard manual labour (and often quite soon after giving birth), which puts them at higher than average risk for uterine prolapse. Hysterectomy for this complication is a very common surgery here.

Perhaps the best night shift of all was our last - fitting, we know! Here are some of the stories from that night alone:

- Yarrow caught a baby in the assessment room with one arm while she was holding another baby in the other arm! It happened because she was carrying a wrapped baby that Lauren had caught over to the scale to be weighed when she saw a commotion in the assessment room. Yarrow walked in and saw a woman pushing, so she lifted her skirt up and discovered the woman had already delivered her baby's body up to the umbilicus! After it was delivered, that baby needed a lot of resuscitation so the baby that Yarrow had been carrying came along for the ride and lay very quietly on the baby warmer while Yarrow worked hard to resuscitate the other baby. After several minutes he stabilized and both babies did fine.

- Later that night, we went to the hospital canteen for a break and a cold Sprite at 2am. As we were walking back to the maternity ward entrance, we passed by an ambulance and glanced in to see a pregnant woman and an older woman companion. The ambulances here are usually Tata 4X4s and are fairly basic - a gurney, oxygen, and a driver. As we walked by, the companion banged on the back door of the ambulance from inside. Lauren opened it, and to her surprise, the pregnant woman had delivered her baby's head and there was no one else around to help! Lauren tried to put her gloves on but was so full of adrenaline that she ended up doing the delivery bare-handed with the gloves in useless soggy lumps under her fingers! She had no idea how long the baby's head had been delivered before we had arrived, but thankfully the baby came out crying and vigorous. Yarrow came running with the delivery set and then we helped the woman inside. It felt like it was a dream because it was so late at night and the birth happened in such a strange setting. Lauren felt sorry that the woman seemed so scared and that they had been alone in the ambulance during such an intense time. It was lucky that the mother and baby were both fine. It was an amazing birth and Lauren felt the incredible "birth high" for a long time afterward.

- We barely had time to look at each other and say "that was crazy", before Yarrow delivered an unexpectedly premature baby to a first time mother. She had been in labour for only 1h 20 minutes when she delivered a very small 4lbs 6oz baby boy who appeared to be 34 weeks gestation (6 weeks early). We were all thankful that the baby cried vigorously and didn't need to be resuscitated. It is much harder to help a premature baby get started (and keep them healthy) in a hospital without a NICU. Lauren was sure there would be a twin because this baby was so small, but there wasn't another baby... just this little one! We had been hoping to see a twin delivery here but we had no such luck. In fact, we missed a twin birth and a breech birth in one shift while we were sleeping off a night shift!


- We each caught three babies that night - our busiest night of the trip. There were all normal, healthy primip deliveries. It was the perfect end to our placement.

Now we are enjoying a few relaxing days in the beautiful city of Pokhara. Pokhara is a major tourist destination, which is not exactly our cup of tea, but since it is the low-season it is pleasantly kui-ray (aka: slang term for "white person" in Nepali)-free. The surroundings of Pokhara are spectacular - the city is next to a pristine lake edged by the Annapurna mountain range.

Unfortunately it has been very cloudy, so we have yet to see the snowy peaks. However, tomorrow we are getting up at 4am to hike into the mountains and watch the sunrise. Today we visited Devi's falls and the Gupteshwor Mahadev cave, an eerie place where a huge 500m high waterfall cascades into the cave and disappears into the ground. Tonight we took a row boat out into the lake to an island temple at sunset. It was quite a lovely way to wind down after working like crazy for the past month...

It is hard to believe we are coming to the end of this "blogging relationship"! We feel touched that so many of you at home have been following our humble adventures, which we have so enjoyed sharing with all of you. We plan to do one or two more posts, back in Kathmandu and when we arrive home in Canada, so keep your eyes peeled over the next few weeks!!

Much love, us....

More birth tales..And why we'd like to own an elephant

Our third week in Bharatpur has come to an end. It is hard to believe we have just over one week left at the Bharatpur Hospital. It has come to feel like home and we have fallen so much in love with this country.

This week we attended our 100th birth since our arrival in Nepal! Yup, that's right, in three weeks we witnessed over 100 gorgeous little Nepalese babies enter the world and every day we have had to resist the temptation to stuff our pockets with them to bring them home. We also continue to be amazed by the strength and grace with which the Nepalese women labour and by the beauty and magic of birth itself. Below are a few stories of the births that made our week interesting...

- We started the week by observing our first cesarean section (C/S) since arriving in Nepal. The indication for the surgery was a previous C/S. Vaginal birth after cesarean (VBAC) is not common in Nepal if women come to the hospital for their birth.This woman had had a classical (vertical) skin incision for her first C/S, which is now uncommon in Canada. Surgically, the C/S was identical to a C/S at home. One big difference, however, is that it was a nurse - not an anesthesiologist - who did the spinal. Here nurse can get special training to administer spinal anaesthesia, and anesthesiologists are only called in when patients need general anesthetic. It was also an all-female team performing the cesarean (including the surgeon, 1st assist and scrub nurses). We felt very happy to see these women in leadership roles. Above you can see us in our Operating Theatre scrubs!

- The power often goes out in the hospital for 20-40 minutes at a time, which can be challenging at times when the light and equipment are sorely needed. Yarrow caught a baby in the dark during a powerout, after a third-time mother gave only a few pushes. She looped the umbilical cord from around his neck and the rest of the body came smoothly. However, he was not vigorous at birth and Lauren had to run with the baby down the dark hall to the delivery room, where the resuscitation equipment was. Miraculously, the suction was working (sometimes the backup generator kicks in, which saves the day), and the baby gave a good strong cry after some suction.

- Lauren helped deliver a premature baby (by dates, she was 35 weeks, but from her size she looked even earlier), who weighed only 3lbs 13.5oz. She was not vigorous at birth, so Lauren suctioned her and Yarrow gave her some bag & mask respirations. Strangely, when she began breathing on her own, she never once cried. We worked on her for about 15 minutes, yet she barely made a peep! In the end, we had to leave her with her mother while her heart and respiration rates were still higher than normal. We hope she's doing well and feel spoiled that in Canada it is so much easier to access Pediatricians and other specialists for consults. This baby could have used one!

- Yarrow had a very precipitous birth with a first time mother. She came in to the delivery room "squalking" (part squatting, part walking: she is so close to delivering her baby), climbed onto the delivery table, and Yarrow began setting up the delivery kit. When she turned back to the woman a few seconds later, the baby's head was already out! The delivery was smooth, but unfortunately the mother had a postpartum hemorrhage and lost 1000mL of blood. She also had a very complicated tear. Yarrow managed it very well and did an awesome suture repair (this is Lauren typing now!)


- That birth was part of a string of three baby boys who were all born within minutes of each other. Lauren could barely change her gloves fast enough to be second attendant for the births and make sure all three boys were healthy and transitioning well. It was pretty crowded on the baby warmer! It was a very fun way to end our week at the hospital. Here they are, cuddled up with each other...

















We felt very ready for a holiday, and thankfully had two days off to spend in the Chitwan National Park for a Jungle Safari. Our trip there was an adventure - the bus we had planned to take was caught behind an accident and delayed for hours, so instead we took a local bus and then an hour horse and buggy ride to the jungle lodge. It was a great way to see the countryside - we saw many goats, water buffalo, chickens, piles of maize, grains drying in the sun, rice paddies, clay houses, and women in beautiful saris & kurtas.

When we got to Sauraha (the jungle village), we took a walk through the village and down to the river where we saw our first one-horned rhino and some gorgeous Indian elephants.

After sunset, we went to a cultural centre in the village and watched a traditional stick dance performed by an enthusiastic group of boys & young men. The drumming, singing, and dancing were very entertaining.

In the morning, we got up early and set off for an elephant ride through the jungle. We were pretty excited!!

It was a bumpy and very fun ride. We saw another rhino, a crocodile, deer, and brilliant birds. Our elephant took us through the cool shade of the jungle, through a beautiful river and along waving grassy paths.

At the end of the ride, Yarrow and Matthew were pretty nauseous from the bumpiness but we were all really glad to have taken the ride.
























Now we're starting another week at the hospital, feeling well rested and hoping to see some more interesting births. If you can believe it, we missed the only breech and twin births all month while we were riding this elephant yesterday morning!

We send everyone at home our love. We're drinking fresh mango juice and eating delicious momo's (a favorite Nepali snack) for you all.

Love us...

Lychees and Labours of Love

We have just finished our second week at the Bharatpur Government Hospital, and can't believe we only have two more weeks to go! We've gotten into the rhythm of things. During the hot and muggy night shifts, we have come to love our 3am trips to the hospital canteen to get cold bottles of Sprite, and have sunk deeply into an addiction to the juicy lychees we find at the roadside stands and buy in 2kg bags.

We have attended more amazing, challenging and surprising births this week.

- The most chaotic were our "side by side" births. Yarrow was attending a multip whose second stage was very long and who seemed very afraid to push, when a multip in the next bed squatted down on the floor and started pushing. I helped this woman onto the bed as her baby was almost crowning, threw my gloves on, and suddenly got poked in the eye by a nursing student who was trying to get her gloves on fast. Barely able to see, I was trying to support the woman's perineum as she delivered her baby's head, when she let out an almighty scream and kicked me hard in the throat. It was crazy! I still managed to help her baby girl out, and three minutes later Yarrow's woman's baby was born in the bed next to us. It was definitely a disorderly few minutes.

- I resuscitated a baby with suction and bag & mask after a complicated delivery by a staff nurse. Before the delivery, she performed an episiotomy, then brought the baby's head out by vacuum delivery, cut & clamped a nuchal cord before the body was delivered, and dealt with a mild shoulder dystocia. The baby was very flat when it came out but responded well to the resuscitation.

- Yarrow had a rare situation after a delivery, when the woman kept bleeding even though her uterus was well contracted and there were no other obvious causes. After inspection, Yarrow and the nurse discovered she had a cervical tear which the nurse sutured. Weirdly, the very next delivery the same thing happened - the woman had a cervical tear that caused ongoing bleeding and needed to be sutured. Cervical tears normally happen in less than 1% of births - although the rate might be higher in Nepal.

- I caught a first-time mother's baby who was only 35 weeks gestation (5 weeks early). She was pushing for a couple minutes on her hands and knees, when I lifted her skirt and discovered her baby's head was already out. Again, I only managed to get one glove on and had to deliver her baby's shoulders with the head covered by her skirt (it was trapped under her knees and I couldn't budge it)! The birth went well except that I ended up kneeling in a lake of fluid and blood. White scrubs are a bad, bad idea.

- The next birth, Yarrow caught a baby after a very short pushing stage. The baby was born "in the caul", which means that the amniotic membranes were covering the baby's head when she was born. After she brought the baby up onto her mother's belly, we had to peel the membranes off her face so she could breathe. The baby was vigorous and cried well after that. Being born in the caul is considered good luck.

- The next baby that Yarrow caught was born in the labour room and was not vigorous, so Yarrow clamped & cut the umbilical cord and I ran down the hall to the delivery room where the baby warmer is. The baby needed a bit of suction but cried vigorously after that. I am getting better at slippery baby runs! It's like playing a greased turkey toss - only cuter.

- Yarrow and I observed a birth with a mother who was apparently 46 weeks and 3 days pregnant (that's six weeks overdue!!) and who pushed for a very long time given she was a second-time mum. We were worried about a potential shoulder dystocia but the baby eased out smoothly (eventually), along with a wave of very, very thick meconium. Sometimes meconium in the fluid means nothing - it's common with babies who are overdue - but sometimes it indicates fetal distress. In any case, the baby was very flat at birth and Yarrow and I took him to the warmer. We suctioned him and there was a lot of meconium that he had swallowed. Afterward he seemed to be doing okay, and we're hoping he doesn't develop a lung infection. Unfortunately there is not much follow-up for babies who have "potential" but not present problems. Hopefully if he does become sick, his family can access the care he needs.

- Yesterday Yarrow caught a baby on the floor of the labour room after a second-time mum came in 7cm dilated, pushed a few times, and delivered her tiny baby girl. She appeared preterm, but did very well. There was a small tear so Yarrow sutured while squatting on the floor. She was definitely feeling the burn in her legs. Squatting is not the best position for a westerner to suture in!

- I caught a baby of a first time mother after she came in fully dilated, climbed onto the delivery table, and I stood back and ruptured her bulging bag of waters. We wear long plastic aprons for a good reason! She pushed out her baby's head and there was a double nuchal cord (the umbilical cord was wrapped twice around the baby's neck) which I looped over the baby's head. Here, if there is a nuchal cord, the protocol is to cut and clamp the cord before the baby is born - however most times it is easier and takes less time to loop the cord over the baby's head. That way, the baby can still receive its blood from the placenta as its shoulders are delivered. This baby needed suction and I gave him PPV (bag and mask respirations) before he started breathing and crying on his own. He did fine following that and was tucked in with his mother soon after.

We're now eating lunch before starting another shift and are looking forward to a safari trip in Chitwan National Park next weekend. We're planning on riding elephants to go see one-horned rhinoceros' (rhinoceri?) and are excited to explore outside the hotel.

We're also very happy that six of our classmates have started their clinical placement in Uganda. You can read about their experiences on their blog http://uganda2010studentmidwives.blogspot.com/. Another classmate, Jill, has been on clinical placement in Holland since May 1st. She is writing at http://babycatchingholland.blogspot.com/.

We hope everyone is doing well, and as always, we send all our love. We're missing everyone - and both say a big thank you for your kind messages of love & support. We'll eat a few lychees on your behalf!

- Lauren