Yesterday was Sunday. It has been raining and although I got myself all caked in mud on Friday in the name of going to market and getting out a bit, I stayed inside Saturday and had cabin fever by 5:30am Sunday morning. The computer seemed like a trap I had no desire to lose my toes in so I decided to go to work. I brought my umbrella to walk there. It doesn’t rain for 10 or 15 feet and then the showers come on and frankly, they come on so fast and so hard that by the time my umbrella is up I am already drenched. So I was mostly wet by the time I arrived but I passed one of my favorite midwives on her way home as I walked down the hill to the hospital. She told me it was super busy and they will be happy to have my hands.
After that there is a giant blur but I will try to break it apart. I walked in and put my backpack down in the lounge. As I made my way to the board to see what was happening someone handed me a baby with directions to bathe and give it shots. Oh Happy Work!! I love love love floating these babies in warm water, watching as they unfold and look around and kick and relax. Not to mention the baby cuddles which come in spades as I hold them in a towel to dry them off instead of rubbing their skin which I think must feel so sensitive in the first days after birth. I brought baby to her mother and got them skin to skin, laying down in bed and then walked back to check the board which I had not managed to do.
“Jordilyrn!” (every midwife here has their own version of my name, this I recognized as one of the senior midwives who walks with a limp but manages to lift mothers out of bed and scrub blood and muck out of sheets and do all of the hard labor involved in working here.) I followed her voice to the delivery room and she told me she thought this mama was going fast. She was opening the delivery kit and I looked at the mom, walked over to the counter and put on some gloves and turned around and caught the baby. “Oh, you are going to do this delivery?” She asked. “Ummmm….you are welcome to but here is baby.” A delighted laugh issued forth as she turned around again and saw baby already skin-to-skin with mom. I offered to clean up and suture which she gratefully accepted. I tidied up, sutured, and then got to scrubbing while the mother enjoyed her baby and her extended family came in to admire the new arrival. I got mom to her bed, baby bathed and in bed with mom and then went to try again to look at the board and the charts.
The hallway was swarming with pregnant women. They rub their own backs through contractions, reaching around and pushing up and down on their tailbones. Sometimes their mothers or aunties or sister-in-laws will be there doing it for them and sometimes they will be sitting nearby chatting with the other mothers and aunties and sister-in laws. Who is who? I wonder about them. I like to have my hands on a woman’s body before she births so I have an idea of her. I want to know her name and what number child this is and if she tested positively or negatively for STDs. I want to feel her belly and say hello to the baby. I want to have a sense of her hygiene and some idea if her hemoglobin is beyond the low we think of as low. I read through as many charts as I could but another page through the hallway, “Jordilyrn!”
I follow the call back to the delivery room where a young mother (and by young, I mean she is the exact age of my own daughter) is pacing back and forth, moaning. I assume she is a first time mother because she is so young. The midwife tells, me, “you stay with her.” So I do. I pick up her chart off the counter and see this is her second child. The first was by cesarean section birth because the baby had been lying sideways in the belly. OK, hooray! A VBAC! I am really good at these. I am smiling to myself and happy to be there. I read the whole chart. The doctor wants regular updates as to her progress and he wants her waters broken when the baby gets low enough. OK, out of the range of things we would do to a VBAC but I am here on their turf. I pause and watch her and start to think this through. My rebellious VBAC self is screaming just to let her go and to have her baby before we call. I rub her back and she wraps her lanky arm around my neck and strokes my shoulder. She nuzzles her face into my neck and moans. She is a child. I feel her body, rubbing her hips and shoulders. I look at her mother who is watching us and her daughter cries out to her, “Auwe Mommy!” I miss my girl. Her mom is crying, watching her daughter like this. She wipes her tears and shakes her head and comes to her daughter who launches herself from me to her mother. She leans on her mother as I rub her back and talk in soothing soft words. Telling her not to be afraid of what she is feeling. Telling her she is safe and this is ok.
As her labor progresses I ask her if she wants me to check her. She says she does. I go and get my favorite nurse who acts as my translator. She speaks softly to the moms and treats them gently. I ask her to tell the mom that if the baby is low enough we can break her water, which will make her labor more intense. I want to know if she wants me to do this or if she prefers not. She wants me to if I can so I prepare ahead of the exam and confirm the plan with the head midwife. I feel the baby, so low into the pelvis, and a bulging bag of waters ahead of it. I snag the bag gently and it opens. But the give of the bag was too easy and I felt it pull apart and rip down. I listen to the baby as I think about what I felt. Baby is doing great. When I think about things not being as robust as I would expect them to feel or be here, I wonder right away about nutrition. I ask the mom if she eats fish, chicken, beef, or ham. No. She eats island cabbage and white rice for dinner. I park that in the back of my mind. I tell the head midwife that she is nearly complete but since it is the first time she is pushing a baby out it could be a while. I don’t want the doctor cranky with me for calling too soon.
I walk back into the room and she is pushing. I trot back out and say, “Nevermind. She is pushing. Calling Dr. B.” The midwife comes into the room as the first of the head is showing with strict directions from the doctor to call if she has not delivered within an hour. I ask her to stay. I don’t feel good about friable tissue. I see the telltale sign of bleeding from behind the baby. I know what this is now, after having seen it so many times and know that she will be shredded on the inside and I want a witness to see that I did not do it to her by not cutting an episiotomy and that I have followed the doctor’s orders. The midwife even remarked that she must be tearing on the inside. Baby is born with three pushes, it is a beautiful wonderful birth. And then the bleeding starts. It is not pulsing, just gushing. I feel for the uterus and can’t find it. I make a map of her belly and start my search in quadrants. I finally locate it but it is too low down. Something is really really not right. I rub and rub and it finally hardens beneath my hands.
I ask the midwife to start an IV and give her fluids and synto. She gets it up fast. We can’t run IVs as fast as mom is bleeding. I take gauze and go in hard, looking for the source of the bleeding, thinking that if I can compress the tear it will stop. It hurts mom. I tell her I’m sorry and to take deep breaths. I see one big tear, and what looks like the uterus, or the front of the uterus, or some other organ. There is blood everywhere and it is hard to see but I know my landmarks and that is not one. I start packing gauze into every tear I can find. I am screaming in my head, “Protein!” I know this is not the time to be thinking about nutrition and that I should be screaming other things in my head. But I am frustrated with these women falling apart. The doctor comes in and he is friendly and kind. Blood is pouring over the gauze I have packed in her. I am trying to convince her uterus to stay firm and I say outloud, “I would really like this uterus to stay firm. Mama: talk to your uterus, tell it to get hard. Talk to your body. Tell it to stop bleeding.” It sounds bananas but this really does help when we do it at home.
I am dumping a bowl-full of blood out and putting the bowl back again. And again. I give the doctor the summary. What has happened. What I’ve felt. What I’ve seen. He takes my position and asks for a speculum. I do not waste time removing my gloves and my bloody hands open the door and get out the kit he needs. He confirms that the lower segment of the uterus has come down, he can see the rectum. Everything is in the wrong place. The one thing I know about this is that we can get it back up where it goes. Sure enough he pushes the uterus back up and I can see it rolling up her belly. I lock my hand in place on her belly to hold it there from the outside. I massage it with my other hand. It won’t stay hard despite the massive quantities of syntocin going into her through IV. We place a second IV and draw blood to cross and match it, then hook her up to more fluids. The doctor meanwhile is busy trying to find an apex to one of the tears so he can start suturing. He eventually does it by feel.
He worked for 45 minutes with myself and another doctor assisting him. She was bleeding the whole time.
He cleans up the best he can—the room is a flood of blood and looks like a hurricane has hit it as we tore open supplies and cracked bottles of medicine and fluids. I am eager to clean up, I know it will feel soothing. I ask for instructions from him—how often to do vitals (I did them twice as often), how much fluid to give, when to call him back. I made a chart to record everything and put in consults to him once every 45 minutes for the first three hours. He leaves and she has the shakes. I chase him down and ask him how he feels about that. He tells me to put some blankets on her and watch her vitals. I do. Her blood pressure tanks. I get the senior midwife back again and she tells me to load on a plasma replacement gel and she will call the doctor and tell him that he wants us to do that. I love that woman. He tells us to load her with two doses of gel and keep running fluids until her pressure normalizes. She has no urine output despite the now 4000 units of fluid we have put in.
I spent four hours with her, scrubbing the room to a shine while taking her pulse and temperature and blood pressure. The grand-mother had taken the baby out to be with family. I realized she needed a family member with her so I went to find her mom. I saw her boyfriend there and I changed tactics. I asked if he would come see her. He too is just a teenager and he was scared witless. I told him just to come talk with her. She was in a sleep when we got to the room so I woke her and told her to say hello…I would later tell the doctor that this young man was the best medicine we gave her all day long. I watched him step over his fear to be with her and encourage her. She was shaking and pale and he spoke gently to her. He looked up at me and said, “I think she is hungry.” Teenagers are magnificent, capable, wonderful creatures. I know they are busy finding out who they are but the sensitivity and depth of empathy they display when the chips are down are palpable.
I sent him to go get her some food and he returned with the source of her friable tissue….orange soda and white bread. Frankly, I thought the sugar would do her good so did not object but made my way to the mom to ask her to go and get some milk. She slowly ate and the combination of his company, the fluids, the food, and time seemed to be bringing her some strength. At the end of the fourth hour her blood pressure looked pretty darn good and there was urine output again.
For my birthy people, don’t think I haven’t wondered if I had ignored orders and not broken her water if she would have shredded. All I can offer up is past experiences here which tell me it did not make a difference whether the water was neatly emptied on a midwife’s schedule or came flying out all over me—this is so far beyond what we know of in America. Poor nutrition here is not fast food and snickers bars. It is a lifetime of orange soda, white bread, fried leafy greens and white rice. No protein. An entire lifetime of it.
It was already two hours past the end of the shift but the senior midwife had stayed with me to see this mom through. I learned from this mother. At home I always tell laboring moms who are having a long labor that they and the baby each have a story to tell and a journey to make, and we will understand it very clearly when it is all over, but cannot know it before then. So too for the midwife. The labor will tell its own story. If I assume that each moment is the story I will be mired in parts instead of learning from the whole. She was dying. Then she was not. And she did not. And I worked hard and sweated and used everything I had available to me, including a consult to a very good physician to make it so. We moved her to a postpartum room close to the midwives’ desk and got her settled with her baby, who forgave her the hours she had been away and eagerly looked at her and nursed well.
As I was dragging myself toward my backpack and home, I heard it again. “Jordilyrn!”
I took a breath. Really? “Can you just check one mom before you go?” Of course I can. I brought mom into the admissions room. A fourth time mom. A posterior cervix. No bleeding, no broken waters. Hardly a contraction to speak of. I saw Dr. B in the hall and asked him to come translate as she had no English. “Can you ask her if she has any concerns? I am wondering why she is here so early in labor if it is her 4th—she must feel something is happening.” He skips my version and asks her all of the questions I already know how to ask and he tells me she should just go home. She lives nearby and can come back later in more active labor. Now a fourth time mother usually has a reason for calling a provider or showing up to a maternity ward. I put her on the CTG to get a read on baby and contractions, just making sure everyone looked good before sending her home. They looked stellar. After 10 minutes I unpluged the machine from her and told her she could go home, or walk-about around here, or go into town with her sister for a girls night out…the choice was hers. I helped her sit up. She stood and there was a puddle of water. I looked at her. Her face had changed. She was sweating and looking at me like I might have the missing piece to a puzzle she has been working on for years. “OK” I say, “let’s go—right there” I was pointing to the delivery room. She is nodding slightly and making small deep questioning Scooby-doo-like noises. “huhhhhh?”
I would like to pause to thank the two women I have been with as a doula who had posterior cervixes hardly dilated, followed by two contractions, followed by a baby. Thank you. I recognized in her what I was privileged enough to see in you. I remember the nurses yammering on and on about how you couldn’t possibly be in labor, about how it will be several hours…I resolved not to be that person.
Mom took two steps up the stool to the bed and lay down. I put on some gloves and turned around. I placed my hand gently on moms belly. “Ok baby, today is your day. Now is your moment. Come to us gently and kiss your mama who has taken such good care of you.” Mom smiled and pushed her baby out slowly. A lovely pink healthy girl. She did not cry. She just lifted her head from mom’s chest and looked around. “Welcome, welcome” I hum. Mom was smiling dreamily from the baby to me and back again. Auntywas laughing and crying. I was waiting for the hemorrhage but it did not come. I know how to do this birth. I relax and smile and am thankful. So thankful. I feel the cord pulsing. It pulsed for 19 minutes. Aunty cut the cord. Placenta came easily. Hardly any bleeding. “Surprise!” I say, laughing. “Happy, Happy Birthday Baby…I’m so happy you are here ” I talk to the baby as I check to see if the cord has three vessels, if she is really as healthy and strong as I think she is. Mom names her Jodilyn on the spot. I can’t refuse. I’m too happy.