3. Choiseul Province, Western Solomons. Obstruction due to inadequate uterine contractions and malposition

4. Personal and Antenatal History Biography Mrs. X, 18yrs, married, Housewife, Melanesian, United church, Sirovanga Village, Choiseul Province Level of education: Grade 6 referred from Sirovanga RHC to Taro Hospital for safe delivery. Antenatal History: Present Pregnancy. Gravida 2,Parity 1 LMP: 28/06/12. EDD: 04/04/13 Term Pregnancy (41/40gestation) ANC at least six visits. Past History. - Teenage Pregnancy(15yrs) &Normal Vaginal delivery at a Nurse aid post in 2011.

6. Admission Date: 25/04/13 Time: 10.30pm Term Pregnancy - 41/40 gestation Contractions: Mild to Moderate (2 : 10) : durations (20 – 40seconds) Time: 11:15pm VE : cx- 100% effaced Os – 3cm dilated membranes intact PP – Ceph Station – 0 Mothers observations BP 120/70, Pulse 80/m, Resp 28/m, Temp 37c, FHR 140/m In latent phase- continue to monitor progress of the labor. Herbal medicine

7. Progress Report Date: 26/04/13 Time:12:30am (repeat VE) Labor continued to moderate to strong contractions Contractions 2 : 10, duration 40 sec to 60secs Observations stable (BP120/70,Pulse 80/m Resp 28, Temp 37c FHR 140/m) VE: cx Midline Position, 100% effaced, Os- 10cm dilated, PP – ceph,Station – 0 Membrane ARM with clear liquor. Mother was encouraged to push with contractions several times but failed. The mother was encouraged to mobilize and do rocking movements within the labour ward.

8. Progress Report Date: 26/04/13 Time: 5:30am Repeat VE – cx- fully dilated, PP- cephalic with occiput posterior and caput ++, station O -+1 Contractions 2:10, duration 20 secs to 40secs (mild to moderate) Mothers observation is stable  Delayed 2 nd stage due poor uterine contractions and OP position.  Management IV fluid Normal saline/D/saline for hydration Commenced on Ampicillin 1gm IVI commenced 6hrly IDC inserted. Plans for emergency referral made Bad weather (cyclone warning) unable to refer to next level of care – Gizo Hospital Sea ambulance (6hrs to 8 hrs) monitor contractions and observations Reassure mother and relatives on condition and evacuation plans.

9. Limitations No Doctors No Vacuum Extraction equipments Augmentation

10. Evacuation Plans 27/04/13 Time:7am Contacted Obstetrics Dr. Honiara thru phone. Ordered antibiotics – Flagyl 400mg iv 8hrly _ Gentamycin 240mg iv stat Arranged for evacuation. Plan A-Diversion of solair flight from Gizo to Taro (unsuccessful) Plan B- RAMSI Chopper (successful)

12. R AMSI - E vacuate

14. Total distance = 664 miles Leave Honiara = 11:30am Arrive Munda = 1pm Refill Arrive CHB = 2:45pm Return Leave CHB =3pm Arrive Honiara at 7pm CHB Airport Munda Airport Henderson Airport Key Air port Transport Evacuation trip Escorting trip Refill

15. N eferraospital N ational R eferra l H ospital NRH ambulance. Seen by Registrar Dr. on call in Labour ward Augmentation Vacuum Extraction done Apgar score - Bwt: 3’740gms Both mother and baby well Discharge from NRH (home by boat)

16. Return Home by boat One Week Travelling