Cambodia: A Lot Happens On Our Days Off
Theresa is in Cambodia, where she's working at the Doctors without Borders / MSF hepatitis C clinic. She blogs about the tiniest patient of her posting so far, and why doctors are rarely entirely off duty...  
I was having lunch with the MSF epidemiologist, Momoko, on Saturday afternoon in a nice restaurant in Phnom Penh. My roommate, Helen, MSF’s nursing activity manager, was visiting friends in Kampong Cham, a province about two hours away. Some of her friends live in a village which is flooded annually by the Mekong River during rainy season. Helen was taking rice and other provisions to them on a river boat.
After I ordered dim sum, Helen sent me an urgent text: I’m in a wooden boat over the flooded delta with a primip woman who’s in pain help me.
“Hold on,” I told Momoko as the waiter arrived with siu mai. I called Helen back. “What’s going on?”
“This is her first baby and she’s writhing in pain.”
“You’re on the river? How far from town?”
A man crouches at the prow of a wooden boat, propelling it forward with a wooden pole.
View from the delivery room.  Photo: Helen Tindall / MSF
“Maybe 45 minutes.”
“Okay, feel her belly when she’s having pain. If it is rock hard and the skin looks shiny and stretched out, then those are contractions.”
Helen confirmed they were. I thought about it. There isn’t much you can do to make labor more comfortable on a wooden boat in the Mekong. “You can probably get her to the hospital before she has the baby,” I said. “Just help her change positions to get more comfortable.”
“I can’t hear you,” said Helen.
“I THINK YOU HAVE TIME,” I yelled. “JUST MAKE HER COMFORTABLE IF YOU CAN.” Fellow diners looked at me uneasily.
We ended the call. Momoko and I ate siu mai and shrimp dumplings and talked about work, then Helen called again: “I think her water just broke.”
“Okay, well things will probably progress faster now. How far are you away from town?”
“Maybe 15 minutes.”
“I think you still have time. Call me back if you need me.”
“I THINK YOU STILL HAVE TIME,” I yelled. The waitress scurried over in alarm.
I ate a spring roll and another siu mai. Momoko and I talked about data management. My phone rang again.
“We’re at the boat dock. The head is crowning,” said Helen.
“Okay, don’t worry. Wrap a cloth or something around your hand and put some pressure on her perineum.”
Mumbling from the other side of the phone. “Oh, now the head is out,” said Helen.
“The head is going to rotate--“
“It just did!”
“--so the rest of the baby will start to come out--“
“--the shoulders are out now!”
“--just ease the baby onto your forearm,” I said, then I heard lusty crying. “Oh, I hear it! Did you have a boy or a girl?”
“Let me look.” (Professional tip: when you’re delivering a baby, the genitals are the last thing you’re worried about.) “It’s a boy.”
“IT’S A BOY!” I told Momoko, who was wide-eyed and eating pork and chive cakes. More glances from neighboring tables. “Now, just lay the baby on mom’s chest.”
“On her chest?” asked Helen.
“Yes, if the umbilical cord is long enough. Don’t put a lot of traction on the cord.”
“Oh my god, I just delivered a baby!”
“Good job! Now, get a clean cloth--any relatively clean cloth will do--and dry the baby off.”
“He stopped crying.”
“That’s okay, they don’t cry continuously. He’s breathing and looking around, right? Like he can’t believe what the hell just happened?”
“So he’s fine for the moment. Try to get him skin to skin with mom.”
“What should I do about the cord?”
“You need two clean clamps or some clean string or dental floss to tie off the cord,” I said, “I’m guessing you don’t have any of that right now.”
“Damn, I wish I had my toiletry bag with me,” said Helen.
“Never mind. There’s no hurry to cut the cord. Whatever you do, don’t let anyone cut it with the knife they use to cut fish with, or anything that has been used in the dirt. That’s how babies get neonatal tetanus. How far are you from the hospital?”
Mumbling. “Maybe ten minutes.”
“So she might deliver the placenta before you get there. Get a plastic bag, like a shopping bag, to catch it in if it happens, because it'll be a bloody mess if it lands on the ground.”
“So what happens when the placenta delivers?”
“Don’t be surprised if a big gush of blood comes out behind the placenta,” I said. “It will look like a lot, but it’s normal. Then reach up and massage her stomach at the belly button. The uterus should feel firm, like a melon.”
“OK, I’m going to get off the phone--”
“--good, because this is the weirdest conversation I’ve ever had--”
“--and I’ll call you again if I need help. Thanks!” 
Postscript: the mother and infant made it to the district hospital, and I finished my chive cakes with a pot of tea. I’ve been involved with a thousand labor and deliveries, but this is the first one I attended over the phone. From now on, I’m sending Helen out with a clean pair of scissors, gloves and dental floss.