So, let’s say you are living in an imaginary developing nation called, just for the sake of arugument, Huganda. And in the great country of Huganda, there is little access to, well, anything. And that’s usually fairly ok, as you are a midwife, and make a pretty good salarly working for this NGO called, just for the sake of argument, Manti Huganda.
Now, Manti Huganda has been trying so hard to do everything by the book in the great country of Huganda, as it is new and wants badly to be a recognizable force of positive change. So Manti has some rules, like they do not accept anyone over 20 weeks, and they transfer mamas out of care when they hit 41.5 weeks, or if they deliver before 37 weeks.
(Now we who live in the great country of (just for the sake of argument) Lamerica, or maybe Janada, especially those of us who may have some more liberal ideas about mothers and babies, and all of their inherent perfect timing in regards to birthing, may not understand these rules, and why Manti is interested in playing by them. Its ok. Just accept it. In Huganda, rules can get you into a place, and then, you can work to change them. It will be ok.)
But on a practical level, how can you abide by the rules you have set, if the mamas don’t? What if they have no idea when the first day of their last period was, and they cannot afford a dating ultrasound? What if they are measuring small because of bad nutrition? Or, conversely, measuring big because of bad nutrition? What if you, as the midwife, only had one tape measure anyway, and now its lost, and who knows if they even sell tape measures in Kasana?
(This is not as weird as it sounds. We could not even buy string. We were told four times that we would have to go to Kampala. Finally, we bought stove wicks and pulled them apart. And let’s not even get on the subject of zip locks. I may, at one point have offered to trade both Anna and Rachel for a box of gallon sized. )
Oh, and let’s also assume that Manti doesn’t have a gestational wheel, and has to rely on manual calculations. I think someone should donate a few to them. Let me know if you’d like to get in on that. I know an organization called, for the sake of argument, deesentialschmidwifery, that will probably throw a few over the ocean.
So if dates are not known, and ultrasounds are too expensive, and you’ve lost your tape measure, how do you determine gestational age? This was the question the lovely Annet posed. We were going to have to get creative. Old School.
The first thing I asked our next ambiguously pregnant woman was whether or not they had felt the baby move. Back in the day, this ws really the only reliable way you even knew you were pregnant for sure. Until delivery, that is) Most first time moms feel those first fluttery kicks around 16 weeks. But some feel them as early as 13, and some as late as 25. Second and subsequent pregnancies are usually felt earlier, but this is not a hard and fast rule. So now, we can narrow our mama’s pregnancy to between 12 and 25 weeks. Not extremely helpful.
Here’s where palpation comes in, and as its one of the things I like doing best in the world, I was eager to show these techniques to Annet and this lovely mother, who was wondering when the heck she was actually going to birth her first baby. If she were only 12 weeks along, we would barely be able to feel her uterus just beginning to poke over her pubic bone. At 16 weeks, the top of the uterus would be about halfway between her pubic bone and her belly button, and by 20 weeks, it should be at just about the umbilicus. And when the baby is done cooking, it should be about level with xyphoid process at the bottom of the sternum.
See? That just clears it right up, doesn’t it?
Of course, there is always the copyrighted Shrugging technique, where the attendant smiles ruefully (this is an important part of the protocol), and slowly raises her shoulders towards the ears, holding the pose for a second or two, before lowering them, saying, “Well, we can always Ballard or Dubowitz them when they come out.” These are assessment scales used to measure certain infant behaviors and physical properties to make an educated guess on the age of the baby.)
And that, my friends, is how we determine gestational age. And also, just maybe, how we can get around a few of those pesky rules, and renew our trust that babies come when they are meant to, even if that time is “early” or “late.” Even a baby that arrives unexpectedly, and needs some help, might be telling us that she was better out than in, that something in the interuterine environment was not as healthy as it could have been. We can still believe in that baby and that mama’s innate wisdom, while providing the best support for both of them that we can. And that, I believe, is more important than anything else.