One January day, Jill’s daughter-in-law presents to Leonie, who is on her own midwifery-wise; Ivan and Adele are both away in the north seeing patients. Jill has noted the young woman’s headache and puffy feet and hands and has correctly decided these are worrying enough symptoms this early in the pregnancy to encourage her to check things out with Leonie. The mum-to-be is not overly worried herself; she is only just over 26 weeks, but would prefer to have some reassurance. She chattily tells Leonie that she dropped into the cafe on the way and picked up a slice of their amazing sticky date cake to enjoy later as she reads a few magazines.
Leonie is only half listening, because she is looking at the blood pressure reading and becoming alarmed. It is high, and throughout the visit, each time she measures it again, it is rising—dangerously so. Nor is the swelling limited to a bit of puffiness about her hands and feet: the skin of her calves and wrists is stretched taut. The conclusive test is the urine. There is protein present, and these three signs, together with the history of headache are indicative of an escalating emergency—a fulminating (rapidly deteriorating) pre-eclampsia.
Leonie explains her suspicions to the young woman.
‘I was only reading about that the other day,’ she says, horrified. ‘I won’t start fitting, will I? Will this harm our baby?’
Leonie offers what reassurance she can and suggests arranging an emergency evacuation to the mainland and specialist care at National Women’s Hospital. The patient, shocked at this rapidly escalating scenario, offers no resistance, and Leonie phones an obstetrician to devise a care plan. The helicopter is summoned.
While they are waiting, the young woman is preoccupied with trying to alert her husband. Leonie has already asked Jill to find him, but Jill tells her that, confident all was well with his wife, he has left on a diving trip with her own partner. Leonie sits with her patient, breathing slowly and calmly and encouraging her to do the same, but leaves the room every now and then to try Jill again. It is all she can do to keep herself from yelling down the phone, ‘What? You still haven’t found him?’
‘There’s no marine radio on the boat,’ Jill says. ‘I’m doing everything I can.’
Leonie pauses before returning to the room where the patient is lying, and takes a deep breath to restore her aura of serenity. This takes some doing, as the moment is fast approaching where she will have to despatch this concerned young woman alone on the Auckland Rescue Helicopter. If her husband is not on that flight, it will be a long time before he catches up with her.
To make matters worse, Leonie has other patients. It is high summer—peak season at the health centre—and she has to balance her nursing duties with this emergency.
The phone rings with the news that the helicopter has been delayed. Jill’s daughter-in-law is keeping it together, but the anxiety is not helping her hypertension. Just before the aircraft’s revised time of arrival, a young man strides into the health centre dressed in a wetsuit, a swipe of sunblock across his nose, ghostly pale and still clutching his catch bag (with live crayfish scratching about inside it).
‘You made it,’ Leonie says.
Jill’s son nods, even as the windows begin vibrating with the beat of the rotors. A short time later, the helicopter paramedic arrives, accompanied by a cameraman who is shooting a reality-TV show. There is no time to waste, and the patient, her husband and his crays are all loaded aboard and the helicopter lifts off without delay.
Leonie later learns the details of how Jill alerted her son to his wife’s plight. Jill, at her wits’ end, decided to telephone the local marine radio channel. They obligingly put a call out over channel sixteen, the emergency frequency, detailing the boat, the men aboard and the need for their urgent return. The locals knew Jill’s partner’s boat well, but there was still no response. George, the radio operator, decided to call in favours. He knew the RNZAF Orion was involved in an exercise nearby, so he alerted them to join the search.
The men had just surfaced after a successful cray dive. As they were waiting on the surface, the Orion scribed a circle low above them, then another, each time dipping its wing.
‘Jill wants you to hurry home!’ one of the men joked, and they both laughed. But the Orion came back and performed another double circuit, dipping its wing, and their smiles disappeared. Something serious was afoot.
Once aboard, the boat sped to the wharf at Whangaparapara, just around from Okupu, where someone shouted to them that both Jill and her daughter-in-law had been involved in a car accident. They were seriously injured and were about to be air-lifted to Auckland Hospital.
We often find that stories are muddled in times of emergency as they are passed between people.
Jill’s partner gave his engines all they had on the trip around to Okupu. He was relieved to see Jill standing at the head of the bay waving them in. Their relief was short-lived. When the correct details were relayed, her son jumped back in the boat, was ferried at speed to the wharf from where a car whisked him to the health centre, just in time to be evacuated with his wife.
The pre-eclampsia was managed by the specialists at National Women’s, and in the fullness of time Jill’s daughter-in-law delivered Jill her first granddaughter. In celebration of the birth, Jill gave Leonie a handcrafted wooden trug, which takes pride of place on top of her fridge and which she loads with flowers and vegetables in season. It is a reminder—as if she is ever likely to forget.
Chapter 10
NO MAN (OR WOMAN) IS AN ISLAND
There are two obvious consequences of living in a place as remote as Great Barrier Island. The first is that it throws people back on the resources available to them—both their own and the community’s. The islanders have always been resilient individuals, first as a matter of necessity, and also as a matter of pride. Whereas you may find hospital emergency department waiting rooms filled with people with coughs and colds and non-specific aches and pains, it is unusual to have an islander present with anything trivial. Sometimes, we wish they had a slightly lower threshold.
The other consequence of isolation is that it makes our clinical judgement absolutely critical. We must tread a fine line between being precautionary—if we make the wrong call and fail to send someone off-island for further assessment, it could have profound consequences—or likewise put the islanders to the considerable expense and inconvenience if evacuation to the mainland proves unnecessary.
Of course, things have improved vastly over the thirty years we have practised on the island. In the days when there were no health facilities on the island, people were on their own and so became resourceful. The pioneering and Māori families all have stories of instances of having to deal with emergencies with no available health professionals close by at all. One day, an elderly woman proudly stuck out her arm as Adele was examining her.
‘Well, what do you think of that?’ she asked.
‘Looks like a pretty normal arm to me,’ Adele replied.
‘Ha!’ the woman said. ‘I fell out of a tree when I was five years old and it went snap and it was all crooked. My mother pulled it back into alignment and tied a piece of mānuka to it and we all sat back and waited for it to get better.’
The woman pointed at her elderly brother.
‘Look at his nose. See anything?’
Adele shook her head.
‘Well, he was cut right here,’ she indicated the bridge of her nose. ‘Talk about bleed! Our mother glued it up with some gum from a tree and it’s good as gold. No scar, at all!’
Even today, there is use of rongoā (traditional medicine)—such things as koromiko (a hebe) for digestive health, kawakawa infusions with multiple therapeutic uses. There is also widespread use of mānuka oil and balm that is produced locally on the island.
One of the areas of our practice in which clinical judgement is absolutely critical is in the birthing of babies. As we have mentioned, there is an unstated expectation these days that mothers will have their babies on the island unless there is a goo
d reason why they should not. There are, of course, precedents for this, too. A midwife from the settler families, Ida Gray (née Hight), had birthed three of the seven children she had on her own. Like her twin sister, Muriel, (who went on to marry a Medland), Ida had undergone some nursing training, and she was registered as a midwife in 1926 after training at St Helen’s Maternity Hospital. Her first child was stillborn. Her second, third and sixth were managed by others, but she delivered the fourth by herself on the mainland because the doctor who was expected to attend could not make it. Similarly, she managed the fifth and seventh on Aotea herself because Annie Medland, who was the midwife, didn’t make it in time. That last child was born at the height of the typhoid outbreak in 1937. According to Ida’s daughter, Ida suspected her seventh baby, who died at eight months, was also a victim of the disease—although this was never able to be confirmed.
With her training and all that experience, Ida was granted a midwifery contract by the Auckland Hospital Board in 1938, on a salary of £2 for midwifery work and 15 shillings for travelling expenses.
Adele can only marvel at the strength and courage of Ida and other women like her. She finds inspiration in their stories, even as her own stories unfold.
Adele examines Jenny. She is getting near term in her third pregnancy. She has expressed a determination to have the baby on the island, but Adele is anxious. All the signs are that the baby is going to be very large, which could lead to complications. Adele—and Ivan concurs when she consults him—that Jenny go to the mainland for an ultrasound scan.
When she arrives back on the island, Adele is reassured.
‘So we got it wrong?’ she asks. ‘The baby’s not so big after all?’
‘No, you were dead right. It’s a whopper. They estimate it will be ten pounds.’ Jenny smiles. ‘They wanted me to stay and have an early induction.’
‘So what on earth are you doing back here?’ Adele asks, alarmed.
‘Relax, Adele. It’ll be all right. I just have big babies.’
Over the next couple of weeks, each time Adele and Ivan see each other, they worry about how much more Jenny’s baby will have grown. By now, Adele is practising stuck-shoulder manoeuvres in her sleep. But when finally the day of the birth arrives, Jenny gives a few pushes and delivers a ten-and-a-half-pound baby with minimal fuss.
‘Well, Jenny!’ Adele says. ‘You made that look easy! It could have been even bigger and we still would have been OK.’
Jenny smiles. ‘Told you so,’ she says. ‘I wasn’t worried. I just have big babies.’
This is Adele’s fifth home birth, and it is one where she starts to learn to trust in and listen to the women. Unless there are clear signs to say otherwise, the mother generally knows what will be best for her baby’s birth.
Still, there have been many occasions when Adele has been acutely aware of that line between safety and precaution. Early one summer evening, she gets a call from Sarah, three days before her due date.
‘Hi, Adele,’ Sarah says. ‘I hope you don’t have anything on today. I have strong contractions and a small show.’
‘Have your waters broken and is the baby active?’ Adele enquires.
‘No and yes,’ answers Sarah. ‘And, by the way, I’ve also rung Emily* to tell her to keep her legs together as I’m going to be needing the midwives!’
Adele laughs. Emily, Sarah’s friend, is ten days past her due date.
Sarah and Adele talk frequently over the course of the afternoon as the labour strengthens. Sarah is the second generation to live in her house. Like many of the island women, she has a strong spiritual connection with the land and, more specifically, with the valley that is her home. She is naturally keen for the baby, the first of the third generation, to be born there.
‘I woke this morning with the feeling that something special was going to happen,’ she tells Adele after she arrives in the evening. ‘I slipped into the vege garden early to enjoy the magic of the dawning day. I took Nyal a coffee at seven-thirty and told him he would be having the day off. I knew I was going into labour.’
He grins. ‘I told her I’d better get the final coat of paint on the nursery!’
‘So we spent the day pottering around the house, finishing off all our chores. I stopped every now and then to let a contraction pass. When there was no doubt about it, I phoned you at midday.’
Adele is listening to the baby’s heartbeat, and finds it is very rapid.
‘I don’t think it’s safe to proceed with the birth at home,’ she tells Sarah. ‘I think we will have to send you over to hospital by helicopter.’
Sarah looks devastated.
‘I’ll get a second opinion,’ Adele says. ‘But I want you to be prepared.’
Sarah nods. She later told Adele that she had made an internal commitment to trust her judgement and not to protest if the call was made to go to leave the island.
Adele phones Aotea Health’s other GP, who in turn phones an obstetrician who is experienced in and supportive of home births. He offers a ray of hope.
‘Have you been in the bath at all?’ Adele asks.
‘Yes,’ Sarah replies. ‘I was in and out of it all afternoon after the contractions started.’
‘How hot did you have it?’
‘I don’t know. Pretty hot. The heat seemed to help.’
Adele reproaches herself for not instructing her to keep the water temperature at or below 38 degrees celsius.
‘The doctor says that sometimes the baby’s heart rate is high if the mother has been in hot water and that it usually settles,’ Adele explains. ‘My feeling is that it has been too fast for too long.’
Adele performs another examination. Sarah’s temperature is normal, her pulse is normal and her waters have not yet broken. At five centimetres, she is around halfway dilated. But still the foetal heart rate is high. Adele thinks it best to proceed on the assumption that Sarah will be evacuated. Nyal begins packing a bag for them both.
‘Who do you think we should get to look after the chooks and feed the cats?’ he asks.
As Sarah is pondering this question, Adele is listening to the baby’s heartbeat.
‘Great! We’re back in the normal range,’ she says. ‘It could be it has settled down.’
There is an anxious wait, but the baby’s heart rate stays in the normal range, and they all relax. After two hours of powerful contractions, Sarah’s cervix is still at five centimetres, and Adele decides to break the waters to try to bring on the birth.
A backup midwife, has arrived by now. She and Adele examine the amniotic fluid and note meconium in it—this is a foetal bowel motion, and a reliable indicator that the baby has been under stress in the womb.
‘It’s thin and brown,’ Adele observes. ‘Pretty recent, I’d say. Probably only means the baby was in heat distress. Do you agree?’
The midwife nods.
‘OK, well we can probably go ahead with the birth here. But we had best get the GP here at the end.’
They phone the GP and ask her to be on hand in case the baby has inhaled any of the amniotic fluid, which can cause a dangerous lung problem, and just in case there is some reason other than heat for the signs of foetal distress and a resuscitation should become necessary.
By now, it has been a long labour. Sarah has endured twelve hours of strong contractions without pain relief. While the breaking of the waters has sped things up, it is still another hour and a half before Adele decides the birth is imminent and summons the GP.
Soon enough, with Nyal encouraging and holding her, Sarah begins a marathon of pushing and finally the baby crowns. As soon as the head is born, the GP suctions the mouth and nose and Adele checks that the cord is not around the baby’s neck. Everything seems normal. With the very next contraction, Arwyn Alice, a wet, wrinkled little bundle, slips into the world. Colour and muscle tone are not brilliant—she is a little pale and floppy—but shortly she screws up her face and cries. Adele dries her quickly and gives her to Sara
h to hold.
‘Such a big head!’ Nyal is saying through his tears. ‘I thought the head would just keep on coming and coming!’
Arwyn’s heartbeat is over 100 beats per minute—quite normal—and once the cord has stopped pulsing, a proud father cuts it. Adele remarks that it is quite a short cord, and observes that research has shown that it starts out the same length in all pregnancies, but gets stretched by the movements of the baby in utero. Girls move less and tend to have shorter cords.
The baby’s father has a swift look, and his face is a picture of delight. ‘It’s a girl,’ he tells Sarah. ‘Just like we wanted. It’s a girl.’
Sarah is nodding.
‘A little girl. That figures. Her movements were really gentle in my tummy.’
All proceeds normally after that, and after a few stitches to Sarah’s perineum and a vitamin K injection for baby Arwyn to assist with blood clotting, the health team leave the family to bask in the glow of a happy outcome.
‘I was that close to sending her over to Auckland,’ Adele says as they leave. ‘That close.’
One of Adele’s earliest supports when she moved to the island was the family who owned the shop. There were three generations living on the island: a grandmother, her daughter and her granddaughter. And now a great granddaughter is on the way.
Trouble is, it is to be Serena’s first birth. This is at a time when Adele is not keen on first births on the island, because there is no track record on which to judge how the mother will bear up. Furthermore, it is more common in first pregnancies for the baby to present in a difficult position, which can prolong the labour and wear out both the mother and her supporters—which makes the pain more intense—and also poses the risk of major complications arising. At least if a woman has given birth previously, you know that, all things being equal, she can fit a baby through the birth canal.
Island Nurses Page 16