Catching babies the Canadian way

Like the mountain that we could not see and then appears as if my magic, we feel like things have drastically shifted since our arrival at the hospital. With the language and cultural barrier in our first 2 days we felt a bit imposing and awkward and were unsure what the nurses and nursing students had been told (or not told) about our partnership. It was hard for us to even think about how to share our experiences here, because we weren't even sure about them ourselves.

Since the first few challenging days however, we have managed to work more effectively as a team with our Nepali colleagues. We discuss everything from culture, to marriage, to children, to fashion and of course clinical management with them and by doing this we all have learned so much.

We have now attended quite a few women in labour, and I have had the privilege of catching 2 babies (both multips) and Kristi caught a preeclamptic primip! Krista was about to have her first catch tonight when a weird case presented itself. All of the nurses who checked the woman had said she was fully dilated. When Krista finally checked her she thought there was a thick cervical lip but they were seeing head during contractions. Finally Cathy checked and determined her to only be 6cm even though the head was visible! Cathy said in all her career she had never seen this before and this woman likely has and will have a uterine prolapse. There's always something new in our work, even for the very experienced!

There are some differences in management here that we are learning about and working with. One is oxytocin augmentation and induction. Like in Canada, the doctor and nurses are concerned about postdates. Most of the nurses here say the protocol for induction is 41 weeks but we have seen variation in cases. One woman was augmented at 40+1 and another at 41+5. As far as I can gather when the women present and how far they travel from is impacting this decision. This is the case in Canada too. The difference here is that management decisions are generally decided for women rather than them being able to chose or reject an induction. The interesting thing about all the oxytocin/IVs in general is that we have been able to observed some skilled IV insertions and also had to monitor our own flow rates carefully, as there are no pumps to do that for us. Another reason for the daytime augments/inductions is a resource one. The doctor capable of C/S is around during the day so they would like more women to deliver (or not) during the day so if they need a C/S he is readily available. There are also less staff on at night. Yesterday there were two C/S. One had a previous C/S with a vertical scar. The other was a footling breech. It ended up being a bit exciting as they did the C/S for footling later in the day and by that point she was 8cm dilated! For those of you who are not clinicians, footling breech is a dangerous presentation because the feet are small parts and the cord could easily slip by if the mother's membranes ruptured leading to a cord prolapse and possible baby death.

The delivery tables also present their own challenges. They are narrow and high and short. Designed for semi-recumbent/lithotomy position they are difficult for the women and also for us to encourage more woman friendly positions. Today however, we managed to show how left lateral position could be done. It is Cathy's favorite position for preventing/reducing tearing and it worked! The multip I delivered had an intact perineum afterwards and Kristi's primip only had a small first degree tear. We were both super happy and on a birth high this afternoon/evening! It was also exciting because our Nepali colleagues were excited about it too and were quick to share with us and each other that this position was better than lithotomy because it reduced tears. Left lateral has now been dubbed the Canadian way. :)

We also noticed at the first two births we observed/attended that there was a desire to suction breathing babies. This is not a good idea and is not a part of Helping Babies Breathe, the neonatal program that is taught here. So we have decided this is one thing worth discussing and working to change here. It will make a big difference for all the babies who do not need to be suctioned after birth as it can cause harm to their little mouths and problems with feeding as well.

The other things we have modeled are waiting for restitution, two somersaults for nuchal cord (around the neck) instead of trying to loop or cut a tight cord, delayed cord clamping, immediate skin to skin with mom and no episiotomies, which are still common here for primips.

Today is International Nursing Day so Happy Day to all the amazing nurses here and far who do so much to improve the lives of people in maternity and beyond!

Unfortunately, you will have to wait for more photos as the internet here is slow and patchy.