essentialmidwifery

Working nights has its distinct advantages and disadvantages…it is quite rough as the senior midwives on at night deliver babies using a method called “chinning” which is quite rough on both mother and baby.  This is the method taught in 1940’s and 50’s Obstetrics.  It is brutal to watch and I have taken to actually looking away just to preserve my sanity.

I did have one of them ask me why we leave the placenta instead of clamping and cutting it right away and she was really amazed to learn about the transfer of blood from placenta to baby that takes place.  I saw the light turn on as I explained the physiology of it to her.  She has now taken to waiting until the cord stops pulsing before cutting.  I am always impressed when someone in the middle or end of their career wants to learn and grow in their knowledge and skills and she surprised me with her eager discussion.

A senior midwife has just returned from 3 months at the hospital on another island so I met her for the first time last night.  We were sitting with a mom who had been induced using Cytotec.  This off-label use of the drug causes terrible labors.  I have seen many back in the day at home (it is not used as often in the US anymore due to piles of research and controversy about its safety) and recall with perfect clarity the vomiting, the intense pain, the constant contraction as the uterus clamps down and will not release for extended periods of time.  This mother was having a classic cytotec birth.  I explained this to the students who were kind of baffled by her behavior.  She was literally out of her mind and laying on the bed groaning and rolling from side to side.  I stood next to her and placed a hand on her chest, below her neck.  She stilled and reached up and looped her arm through mine.  I rubbed her forehead with my thumb and she rolled towards the other midwife who was on the other side of the bed and puked.  The look of surprise on the other midwife’s face was something else.  Women don’t typically throw up here.  This is only the second one I’ve seen who has.  Somehow the shower of vomit narrowly missed the midwife and she barked at a student to go get a bowl and the mop and clean it up.  Sometimes it just sucks to be the lowest one on the totem pole.  I mean, you have no responsibility which is awesome, but you also get the grunt work.  After all was tidy the midwife I normally work with at night came in.   These two proceeded to tell me their life story—they have been friends since they were small and slip into stories and laughter at each other and themselves.  All of the sudden one of them starts singing, “Darling I’ll miss you…Remember I’ll always be true…And then while I’m away I’ll write home everyday…” they trail off, forgetting the words to this classic Beatles tune.  I pick up where they left off and it prompts them to continue with their concert, which becomes a medley.  I have my hand on the mother and feel her still.  I look at her and her mouth is agape in clear wonderment at this turn of events.  There is a popular Fijian musician who apparently came and sang at the conference in the Solomon Islands last week.  The midwife who was there proceeds to reenact both his singing and the response of the Fijian midwives, nurses, and doctors.  This included fanning and screaming “Oh Sossi, you’re so sexy!  You’re so sexy!”  I have to say that I was so completely entertained by this woman—I could not peel my eyes away.  I was having fantasies of bringing in a Kareoke machine and setting her loose.  The mother also seemed to be taken with the show but felt too lousy to enjoy it.

Mother was stuck with an anterior lip—something I am convinced most mothers have but we don’t worry about because we don’t know about them because we are keeping our hands out of their most intimate private places and leaving the baby to do the work of birth as much as possible.  With the help of the nursing student who has become accustomed to my ways, the mother got on her hands and knees for four contractions, on her left side for two, and then rolled onto her back and pushed her baby out.

The next birth was also a primip but everything was slow going.  I have come to expect the friable tissue when things go that slowly here…a lack of coordination of the uterus was clear as her contractions were quite short despite the fact that baby was so low.  The baby’s heart rate was very low due to the never-ending head compression and it felt like time to birth.  We gave her what we call a “whiff” of synto—a super small dose just to inspire the uterus a bit and it clicked her contractions right into the strength she needed to push the baby out.  I put my stethoscope on the baby’s back and listened to its heart and lungs as they kicked into gear.  I caught a glimpse of the cord and noticed it looked strange, with big bubbles of Wharton’s jelly staggered up the length of the cord.  I was helping the student with the placenta which looked odd when it came out and sure enough the membranes dissolved before they were totally out.  Thus I went on my first true fishing expedition.  I have had to coax them out before when they trail or break but there is still a visible bit there.  This was about looking for bits and pieces.  I gave myself a pep talk—I knew that it would hurt her but the other choice was to let her bleed endlessly.  I proceeded to fish bits and pieces from near and far until I could find no more.  I watched her bleeding and wondered if there were some left.  I tried again but got none.  I asked the other midwife to check as well—they do this all the time so have experienced hands.  She found no more but I paid attention to how she held her hand and her methodology.  Learning, learning, always learning…

After getting both mothers and babies settled in they asked me to do a CTG on a mother with twins.  I went to fetch her—she has asymptomatic pre-eclampsia and was sleeping in the private room of the hospital.  I brought her to the room and she sat down and cried.  She looked like a Samoan princess—tall and with a regal face and posture and gigantic belly full of babies.  I sat down next to her and put my arm around her and she started talking in English (!)  She was afraid.  She did not understand this hospital and just wanted  her babies to be healthy and did not want a cesarean birth.  She did not want to take medicine to make her numb so they could operate on her.  She did not want to feel so out of control.  Oh mama.  Oh mama.  How hard it is to come into a strange place and feel that people will do things to you without your permission.  How frightening not to understand why or have things explained to you.  Of course you are stressed out.  You have been housing and loving these babies for 36 weeks.  You are not a woman anymore.  You are a fierce lion-mama and you feel protective.  You have the power to take down anyone who comes near you and you feel that power in surges over and over and over again throughout the day as a parade of doctors and midwives and students come in to “feel the babies”, ignoring the person that you are.  She nods in vigorous agreement.  “Yes, like a lion!  I want to claw them!”  I nod and listen to her tell me her story.

She was married in 2009 to a man she met at a church conference in Samoa.  They had exchanged letters and one day he appeared at her house with his family and spoke with her parents and the two families happily became one as they married.  They moved to his home here in Vanuatu where he runs day tours to a small island and is quite successful.  They hoped for babies but none came.  A woman she knows in Samoa had her 8^th child and could not provide for him.  She asked this young couple to adopt him.  They have loved him hard.  He is the child of their heart and he cries when his daddy goes to work each day.  About 30 weeks ago she started feeling ill and vomiting.  She came to the hospital where they told her she was pregnant.  She could not believe it.  They rejoiced and he comes home every day for lunch—not to eat but to take care of the baby so that she can rest for a half hour.  She has a good man.  She went home to visit her family in Samoa for Christmas and visited the hospital there where she was told she has twins.  She called home and told her husband and he was so stunned he just kept repeating, “it can’t be, it can’t be.”  But it is, and they are so excited.  And now she has learned that both babies are head down but she doesn’t know anything about birth because her girlfriends at home started to tell her how much it hurt and she felt that was bad preparation so stopped listening to them.

We had a little childbirth education class.  I talked with her about the physiology of the sensations.  She asked questions, and we talked and talked.  After an hour and a half she was ready for the CTG.  The machine here does not handle twins very well but I tricked it into giving a reading on one baby, and a reading on the contractions.  I used a handheld Doppler intermittently throughout the 20 minutes to listen to the second baby and wrote its heart rate on the strip of paper issuing forth from the little machine.  Babies sound wonderful.  She held my hand and we walked back to her room and she asked if she could eat some dinner.  I encouraged her to prepare as if she was going to run a marathon, plenty to eat and drink.  Because the worst that will happen is she will go into labor tonight and feel like she has to throw-up and so-what if she does!  She should take care of herself.  She was smiling and happy and beautiful.  It was nearing the end of my shift and I went to review the CTG results with the head midwife.  She asked me to go and get a full set of vitals from her before I left.  I went back in and her mother, who had been sitting in the corner on a chair looking at me suspiciously before stood up and hugged me and smiled and said thank you.  I checked her blood pressure, her temperature, her pulse and told her to get a good dinner and sleep, and left them alone for the night.  All I want to do is go in and see how she is doing today but my shift doesn’t start for another hour.

I am back where I started six weeks ago—that humanity always matters.  Kindness and communication transcend culture, skin color, and the “way things have always been done”.  Fear will always rule where knowledge is lacking—in one woman or in a society of people.  And while midwives can’t solve all of the problems of a society, we can always ease the fear of the woman in front of us by sharing the truths in the most complete ways we can find to do so (even when they are unhappy truths).  Did I miss a birth?  Actually, I missed two.  And I feel I was the beneficiary of this woman’s sharing of her-self and the story of her family.  Today I don’t want to go see and what that busy ward will bring me in terms of experience and skill development.  I just want to see her and sit with her and hopefully welcome those babies and tell them what a great mama they have.