Unlike internal conflicts, which are personal fears and struggles, external conflicts are between a character and other outside forces. These are the main types of external conflicts.
Character vs. character is the most common external conflict. This occurs when a character has a problem with another character. In this book, Louse has an external conflict with her sister, Sara and her parents, because they pay more attention to Sara.
Character vs. society is a conflict because Louise feels stunted by the small-town life on the island. She also has problems with society’s expectations of her as being feminine and beautiful.
Character vs. nature involves the problem of Caroline being born sickly, so that Louise gets less attention. There are also the elements involved in living on an island.
Character vs. technology is a lesser conflict in the novel, but Caroline is born sickly and medical technology also plays a role because Louise becomes a doctor, and at the end struggles to keep the baby she delivers alive.