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