essentialmidwifery

Birthy Thoughts by Jane E. Drichta and Jodilyn Owen

Viola October 22, 2012

Filed under: Jane,Uganda — EssentialMidwifery @ 8:49 am
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There has been a woman in labor here at Shanti for the past two days.  Viola looks about my daughter Anna’s age, but she is actually 25, and this will be her third living child.  She is petite, commited to this labor, and really really working hard.  She is laboring out of site of the training, although we catch glimpes of her walking around the beautiful grounds, working with through her contractions with the help of an older woman.  I assume this is her mother-in-law, as they seem to be the most common labor attendants here.  She has captured all of our hearts; her labor is difficult, and she is so so tired.

We always say that third babies are the wild card.  While they are housed in an experienced uterus, it is one who has been stretched out.  Third babies can get into all sorts of wonky positions, causing a longer  (and depending on the position of the baby) more intense. labor.  Early this afternoon, one of the midwives asks if I would check her, as they would like to know if I can ascertain the position of the baby, and maybe give some suggestions to help.

When I enter the birth room, Viola is lying on a plastic sheet, moaning slightly, even when she is not actively contracting.  She is having a very difficult time relaxing between contractions, and she is holding her lower back.  I note where she is lying (her left side), and that she taps out a quick staccato rhythm with her right hand when she contracts.  She is sweating, shaking, and she is deep deep into that place we call Labor Land.  She does not glance up at me as I sit silently on the bed next to her, just letting her get used to my presence. Her belly is flat in front, from just above the umbilicus to a few inches below.  Her contractions are irregular, between 3 and 6 minutes apart, although when they do come, they are very strong. I ask her softly if I can feel her belly, and she nods quickly, just once.

Now, so far, my “examination” of her has been pure  observation, and observation is the heart of doula work.  If she’s clutching her back, there’s a good chance it probably hurts even in between contractions.  Lying instinctively on her left side is not only good for getting the maximum amount of oxygen to the baby, but can also help a baby rotate and come down into the birth canal.  And a flat front belly can indicate a baby who is hanging out in the occiput posterior position, also known as “sunnyside up.”  The baby’s spine is resting against the mother’s and this bone on bone action can cause the dreaded “back labor.”  And, from the shape of her belly, I can tell that the baby has not yet dropped down into the pelvis.  This is not uncommon in women who have had prior babies, so it doesn’t really concern me.   From the length of her labor, I can theorize that this baby is probably not only sunnyside up, most likely acynclitic as well, a situation where the baby’s head gets cocked off to one side or the other. This makes it harder for the baby to descend, as the surface area of the head is increased.

All of these things can be helped along (sometimes) by positioning exercises, which, coincidently, is exactly what we are teaching today!  So convenient.  The midwives have already used some of the exercises we showed them, but here is a great chance to illustrate how to read a labor, how to put all these little clues together and make a plan to get this baby shifted.  I knew that as soon at the baby worked out how to drop into the pelvis, Viola would not have to push long.  I could tell from the size of her belly and some gentle palpation that this was not a giant baby, and if she had birthed two full term babies previously, there should be plenty of room.

At this point, I pretty much knew all there was to know, and an internal exam was just going to be a formality.  She was most likely almost through dilating, but the baby was still high in the pelvis, trying to turn its head this way and that, searching for the way that fit him or her best.  The trick was going to be to give her enough time, and keep her energy up enough to let her body and her baby do their work.  She was very very tired, although she was eating pineapple and peeing frequently.  (This last is important, as a full bladder can impede a baby’s descent.  Think about how close the bladder is to the uterus, and you can see why.  For those readers without a uterus, I’m sure you can imagine.

I grab a glove from the box, and ask her permission to examine her.  She nods once and rolls over.  Sure enough, she is 9 cm dilated, but the baby is still floating.  As hard as she has been working, she’s going to have to do a bit more.  I explain how to position her on her left side, with her leg raised high on pillows, almost lying on her baby.  In the western obstetrical world, we call this position Modified Sims.  In Viola’s world, we call it resting comfortably.  I give the midwives a few more suggestions for when Viola is able to participate more actively, including the Captain Morgan (one leg on a chair, the other on the ground, swaying gently through contractions) and hands and knees, leaning over one of the new donated birth balls.  (Thank you, Simkin Center in Seattle!!).  I smile at her, check the heart tones of the baby to ensure that he or she is liking this position, (heart tones are perfect!) and leave her with the Ugandan midwives.

This goes on all afternoon.  Periodically I would be asked to check on her, and periodically I would go in and hang out with her, offering suggestions as we went.  Eventually the midwives start an IV, just to keep her hydrated in the Ugandan heat.  We also used the rebozo with her, and put her through a million different other positions.  She was a trooper though all of it.  Eventually it was time to leave, though, and Viola was still laboring.  I was certain she would either deliver that night, or be transported for an obstructed labor.

The next morning, I was delighted to find that she had birthed during the night.  Hooray!!  Photo: Baby Patrick and his gorgeous mother, Viola. Sometimes even 4th babies have two day labors.And sure enough, it had only taken two pushes .  Baby just had to find the way.  As Melinda and I sat admiring the baby, and telling Viola how wonderful she was, I asked his name.  “Jane, I want you to name him,” she replied, smiling.  I was shocked and honored.  Together we decided on Patrick, after my beloved husband.  It is a gift to get close enough to someone that they want you to name their baby.  A true gift  to connect on the most basic womanly level, though birth.  I hope Patrick lives a long and happy life.  I know he has a wonderful family, and I hope I can see him next time I return to Shanti.

 

Drums, Lunch, and Doula Musings-Jane October 20, 2012

Filed under: Jane,Uganda — EssentialMidwifery @ 6:39 pm
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Our visit to the hospital over, it was time for a visit to the drum shop and then lunch.  Sadie wanted to get the large drum used at Shanti bonfires re-covered, and I think we were all interested in perhaps purchasing a percussive souvenir. Drums are such a part of Africa. It is a stereotype to say that the entire country of Uganda has rhythm, but I’m going to risk it.  I’ve seen folks drum on jerry cans when nothing else was available, and it ends up sounding just perfect.

I don’t know what the drum shop lady thought when a herd of mzungus descended on her; its entirely possible that she had never sold so many of her wares at one time, and it is equally possible that she was just sitting down to lunch, and we were a huge interruption.  The drums, however, were beautiful, and we all picked out our favorites.  Several of our gang’s had insects inside, so they set them outside their door back at the guest house, where they remained the rest of the trip. Some people have old room service trays.  We have buggy drums.

Here’s the drum lady.  She looks considerably happier than when we first arrived.

Drums bought, we were off to lunch.  It was a buffet style on the Anglican diocese grounds.  We ate here last year, and it was remarkable in that it was basically our only bites of animal protein the whole trip.  I’m such a carnivore.  I was completely looking forward to it again for that reason.  No mattooke today for this girl!  And, in fact, there it was, sitting in the covered dishes in all its glory”  A piece of stewed chicken.  I think it was a thigh.  I’m not sure.  I didn’t care.  I was just so so happy to be eating it.  i also knocked back a bottle fo the local ginger beer (non-alcoholic).  It was delicious!

The afternoon’s training was four hours on how to educate your clients, and politics and power dynamics in the birth room.  I could talk all day on these subjects.  The education piece is always tricksy for me.  A doula’s job, on the deepest level, is to help draw out what a mama already knows.  We always say we want a mother to trust herself and trust her body.  The easiest way to facilitate this is to help her understand that she already knows the answers to the deepest questions, which in turn builds her confidence that she can participate fully in this experience without fear.  With help, a mother is often able to access that internal knowledge about the larger philosophical questions of birth and life and death, and can be taught how to express them coherently, This is awesome and magnificent, and these moments keep me going as a doula.

However, when it comes to the shallow questions, the nitty gritty details about birthing, like “WIll I poop on the table?”  or “Will Hospital X let me have my baby on my chest right away?”  I am totally fine with just telling them the answers. Many doulas (and this is not a slam.  Really.  It is a stylistic difference.) feel that it is our job to provide resources, rather than provide specific information, so they tell their clients where they can find the information, rather than just sharing the information itself.  People remember things best when they have to work for them a little bit, of course, so there is a great argument for educating that way.

Me?  I think that one of the reasons they hired us is to make their lives just a bit easier on their Birthing Day.  And if I can do that by just saying,”You might poop.  Its a great thing.  It shows you’re pushing in exactly the right place, and chances are you won’t even know you did.”  then I probably will.  It seems like an oral tradition to me, sharing the sacred knowledge (Yeah, I think poop can be sacred.  its an odd life I lead.)  with the uninitiated, helping lead and prepare them for that time when they too will undo go the trials, the rite of passage, if you will, into motherhood.  American women today often don’t have time to completely research every little question they might have, evaluating sources, and wading through a swamp of google hits.  They wanted an expert in birth, and that is why they hired a doula.  And, to bring it back around to Uganda, most of these women don’t have Internet access, so asking question of their mothers, their sisters (read “their doulas”) is how they get information in the first place.

So that means, doulas, know your stuff.  Study up, keep abreast of current information, and don’t be afraid to say that you don’t know, that you will get back to them.  The only thing worse than no information is bad information.  And keep in mind, that at the basest, most primal level, mothers know how they need to give birth.  You’re just there to fill in the blanks

 

A Visit to Kasana Hospital Part 2-Jane October 18, 2012

Filed under: Jane,Uganda,Uncategorized — EssentialMidwifery @ 7:03 pm
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We left the boy with tetanus, and make our way through the regular women’s ward, and then to the maternity section.  We file though in single file, like nuns in a procession, our hands folded, careful not to touch anything.  Our guide, Dr. Agaba, runs this place.  A shortish, roundish man in his early 50′s, Dr. Agaba has the patient resignation of one who has worked in healthcare for a long time, doing his best to do what he can, and knowing with all his being that it will never ever be enough.We actually met him yesterday, when he came out to visit Shanti, and was very interested on our doula training.  He smiles easily, and jokes with Sadie, Shanti’s project manager.  They seem to have a lovely relationship, built on respect and common purpose.

However, he is not smiling now, as we enter the maternity ward.  Softly, he points out the postpartum women sitting on the naked beds, explaining that sometimes they are two and three to a bed, sometimes they are sleeping on the floor.  Agaba explains the culture of rape, the lack of access to safe and legal abortion.  Abortion is illegal in Uganda, although, of course, it still occurs.  Forget the coat hangers and back alleys of North American history; here we are talking about dirty sticks and poisonous herbs, sometimes self administered, sometimes not.  But Agaba does not judge or flinch from reality.  “If a woman comes to me, it is my duty to treat her, not judge her.  I am only here to help.And that does not help.”  Wise words.  What if we only did what helped, forgetting judgement and bias and acting only with love and acceptance?

There is a woman in labor and the hospital midwife takes us into the delivery room to see her. She is sitting on the vinyl table, naked from the waist up.  She is crying and moaning, and we are just staring at her.  This is clearly silly.  We are birth professionals, for goodness sake.  I move to her side, smile, and murmur some words of encouragement.  I don’t expect her to speak English, so I just use the Birth Voice, telling her that she is so strong, that she is doing a great job.  Surprisingly, she answers me.  “I don’t feel like I am doing a good job.  I feel like I’m going to die.”

“It this your first baby?”

“Yes, my first.”  A contraction hits hard and fast.  She slumps over, moaning, her breath hitting me in the face.  The world over, a laboring woman’s breath is slightly sweet, but sharp.  She probably hasn’t eaten today.  I wish that a Cliff Bar would suddenly appear in front of me, or lacking that, at least some drinkable water.

I help her off the bed, and show her how to lean forward onto it, feet wide apart.  We work together for a few more contractions, easing her breath out, rather than holding it, or screaming it out.  She is a strong woman, and has a lot of reserves left.  And she is close.  Her body is beginning to tremble, and she is burping a lot.  The contractions are right on top of each other, pulling apart her resolve.

“First babies are hard.  But you can do this.”  I keep my words simple, but try to infuse them with all my belief, not only in her, but in all women.  I glance behind, and my team has moved on.  Everything in me wants to stay, to support, to help.  I know I probably could.  Shanti volunteers have doula-ed here before, but I don’t want to miss our afternoon training session, so I give her one last smile and a hug, and catch up with my people.

Throughout the day, my thoughts keep returning to that woman.  I feel guilty.  I should have stayed, should have helped. It killed me to walk away from her.  She was scared and in pain, and I left her.  I hope she had a beautiful baby, and that she can forget the pain and the fear, and concentrate on her little one.  I hope she has a man who loves her, and a family that will welcome this baby, and respect her hard work in bring him or her into this world.I hope she does not bleed too much after, or come down with an infection.  I hope her baby lives. It is the most I can hope for in a place like this.  Dr. Agaba said that “if you come to this place, you have come to Hell.”  I hope she finds some bit of Heaven here instead.

 

A Visit to the Kasana Hospital Part 1-Jane October 17, 2012

Filed under: Uganda,Uncategorized — EssentialMidwifery @ 12:27 am
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I can’t look away, and on some level, I don’t want to.  The young boy, maybe 7 years old, arches his back again, his entire body spasming, his face stuck in a grotesque and totally involuntary leer.  Sweat pours off his body, running down his neck, pooling on the black vinyl mattress. His mother, standing by his side, moves to support his head, but is stopped by a nurse, who explains softly that she could hurt his neck muscles, and to let the seizure take its course.  Not that it matters.  This boy has tetanus, and this boy is going to die.Tetanus is treated with metronidazole, diazepam, and tetanus immune globulin, none of which are available in this Level 4 Health Center that serves Kasana and the surrounding countryside.  The staff has only comfort measures to offer, and in this “hospital” nothing is comfortable.

It is hot inside the small run down building, sunlight and its attendant heat streaming in though the massive holes in the roof.  Add to that the humidity that naturally occurs when you have lots of people, especially lots of sick people, gasping in one room, rebreathing the same air over and over.  There is no ventilation, save the afore mentioned holes, and the stench is incredible.  And for now, it has all narrowed to this boy, this child and his mother, who can do nothing but watch, her tears adding just that much more moisture into a room already overburdened with misery.

Americans are mostly vaccinated against this disease, and even in those who do manage to acquire it, there is a 90% recovery rate. Not here. Here there is nothing to be done.  This hospital does not have the necessary drugs, nor does the bigger one a few towns away.  They will transport the boy anyway, to the larger hospital, but it is still hopeless.  Even with the needed drugs, by the time the spams, called opisthotonos, have reached this level of intensity, it is almost always too late.  They are strong enough to tear muscles, to cause fractures.  And they often affect the muscles surrounding the airway, causing brreathing difficulties. This family, at the very least, does have the money to transport their child.  Hundreds of others do not.  If you do not have the money for drugs or fuel, you or your child dies.  That is the harshest of realities.  Ostensibly medical care in Uganda is free, but if the hospital does not have the drugs you need, then it is up to your family to procure it from an outside pharmacy. But, what happens when the pharmacy does not have the drugs?  You die.  Just like this child, probably infected while playing outside in the dirt, just as children do the world over.  One child and one mother.

Everyone on our trip is a mother.  We have birthed our children into the world, transforming ourselves at the same time.  To look at this Ugandan woman, to share in her knowledge that her child is dying, and to be able to hold that seems impossible. How do we even do that?  Why don’t our hearts just crack wide open and we all just die right there?

On some level, I think they do.  I have held this vigil before, holding babies and children in my arms as they pass from one world to the next.  I’ve sat with parents, held mothers as they screamed their grief and anger and disbelief to the universe, when it seems there is no good or rightness in the cosmos.  To watch a child die is the unfairest of the unfair, and it is no different here than anywhere.

So I can’t look away.  It it an intrusion, to observe someone’s pain when you are in no position to help?  I don’t know.  Probably in America it would be.  Death is seen as private, and grief inconvenient.  We are so uncomfortable with death that we try to wish it away, pretending it doesn’t exist and those whom it touches are somehow weak, and perhaps even to blame.  But here, death, like life, is communal, part of a rich tapestry of family and community.  And so I offer myself as a witness, joining her world for a few moments, a silent chronicler of one mother’s worst nightmare.

 

Back to Uganda! (Jane) August 11, 2012

Filed under: Birthy Thoughts,Jane,Not-so-birthy Thoughts,Uganda — EssentialMidwifery @ 7:07 pm
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Its official!  I’m headed back, and this time I’m bringing friends, some of whom I know, and some of whom I am looking forward to meeting.  In a few short weeks,  I’m leading a team of awesome doula trainers, and we will be sharing our knowledge and skills with the Ugandan midwives, several aspiring Canadian doulas, and each other.  Many of these women have never travelled internationally at all, let alone to a developing country.  I wish I could see the trip through their eyes, because I’m curious like that.  I want to know everything…why they want to come, what they hope to accomplish, how I can  support them.  We’ll discuss all of that, of course, and I will do the best I can, but in the end, it’s just like birthing.  (Hey, I’m a midwife.  I can make a birth metaphor out of two pieces of gum, a string, and a small poodle.  I’m McGyver with a doppler.)

Everyone who is going on this trip has different experience with birth, with travel, with education, with life.  As a leader, I feel it is my obligation to meet each participant where they are, to facilitate growth and provide a safe little cocoon in which to process and relax.  But I can’t force my idea of what they should be experiencing onto them.  It has been so interesting just to watch different folks’ reactions to the preparations, trying not to butt into their processes and tell them what I think they should do. Everyone has different ideas about vaccines, ebola danger, political instability, the lack of infrastructure, what technology to bring, etc etc etc.  I’ve tried so hard to offer choices, to tell them my experiences, and then just shut up and get out-of-the-way.  It’s not my birth, it’s not my birth, it’s not my birth.  I have no expectations around this trip, except to offer who I am, and then to sit back and let the labor take its course.

The constant, of course, is Uganda, with everything that that implies.  After all, Africa always wins.  Those of you who came along with me on the blog last year may remember that I couldn’t find string in Kasana, and had to disassemble a mop to make a project work.  (see, I wasn’t kidding with the McGyver bit.)  That experience has become my symbol of flexibility, of creative thinking, of letting go.  It will be so interesting to see what symbols the other team members gather, which little image or event worms its way into their brains, and stays with them back home.

All I can do is my very best, and trust the process.  After all, its always worked before.

 

Out of Africa or I’ve Been Waiting the Whole Blog to Say That–Jane July 25, 2011

Filed under: Jane,Uganda — EssentialMidwifery @ 11:08 pm

So here we are, coming to the end of the midwifery portion of our trip.  We do go on and have several other adventures, such as waking up beside the Nile and seeing monkeys eating old room service, or staying in the absolutely creepiest hotel in the world and surviving, but those are stories of life and its times, not specifically midwifery, so they will stay untold here, unless I get thousands of private messages, filled with Really Good Bribes.

Our last day in Kasana was just so typically Kasana-ish, that it fills me with a certain masochistic joy.  Anna and her new friend Rachel the sophomore UNC volunteer, were planning on making friendship bracelets and doing relay races with the Teen Girls group.  As it turned out, Anna and I ended up leaving a little before the group was scheduled to start, so we didn’t wind up actually doing that.  But we didn’t know that then.  We girded up our loins and walked up to the main road where all the shops live, to gather needed supplies.  We knew this was going to be an exercise in frustration, but we were up for the challenge.  Africa was not going to win today, my friends.

First, we needed string.  We went to five different “stores,” which are really little shack type things, sometimes with a living area behind them, but always full of things you absolutely do not need.  Certainly, no string.  In each store, we were told that we would probably have to go to Kampala.  Really?  Nobody has ever bought string here before?  Finally we ended up getting embroidery thread from a tailor, and that was only after Rachel shared her street bought popcorn with the proprietor.  Then, of course, we needed beads.  Luckily, there has been a donation full of them fairly recently, if we could find anyone at the center who knew where they had been stored, so we felt pretty confident about that.  It was on to the relay race supplies.

Rachel wanted to do three legged races, so we needed some rope.  Of course rope, the elder sister of string, was also not available, even at hardware “stores,” so we ended up buying a mop and disassembling it, and then tying the pieces of mop together to make a rope.  It was a riot, and I think McGyver would have been proud.  We also needed some eggs for the egg and spoon race, so we headed to Hespa’s little roadside stall, next to our house.

Now, I know where eggs come from.  And I know that the place they come from is pretty close to a chicken’s butt.  However, even with all that poultry knowledge, I am still surprised whenever I buy an egg here, and it has chicken s#$& all over it.  I guess maybe all eggs do, but that our American ones are washed before they are sold?  Or maybe Ugandan chickens are really messy?  Or that maybe I should move on, and not spend quite so much time thinking about chickens, their eggs, and their butts?  Ok.  Moving on.

We headed down to Shanti with our booty, and I was actually quite sad, thinking this was the last time I was going to travel this road.  I had come to know the people along my route, the old women sweeping, the children screaming “Mzungu!”, and the eternally formal old men, who stopped their hoeing to wave, and ask me how I was.  We laughed, thinking of how out-of-place any or all of those things would be in Seattle, the land of the aggressive passivity.  If someone called a greeting to stranger from their porch in Seattle either their mental health or their safety would quickly be called into question.  It is the exact opposite here.

It was hot that afternoon, and soon into the walk we began to sweat, the ever-present red dust sticking to our legs and feet.  I resolved to sweat more at home, to actually get outside and interact with my environment, and not hide in my office or behind a keyboard.  I felt alive, dare I say, at peace, with myself and my place in the world.  And I realized, that this leaving had come at exactly the right time.  I love Uganda.  I will come back.  But for now, I was ready to go home.

We got to Shanti, dropped the supplies off in the prenatal clinic, and said our goodbyes.  We took tons of photographs of the grounds, and of the staff, which I promise I will get up on facebook soon.  (If you are not my friend, and are interested in seeing them, just drop me a friend request.  My internet privacy polices are so low as to be non-existent.)  We shed a few tears, exchanged a few email addresses, and then our ride was there, and our time at Shanti was over.  All that anticipation, all the build-up, all the angst, and it was over.  I felt like the bride after a wedding, sort of empty and confused.  Now what would I think about?  What would I spend my time doing, if I couldn’t chase after string or solve waterbirth logistics?   I’m sure I will think of something.

So now I am home.  Our book needs writing, my clients need midwifing, and my husband needs loving.  My days are indeed full again.  But I left a little piece of myself in Kasana, somewhere on that red dirt road.  And I can’t wait to go back and see what it will have done in my absence.

 

Where are the birth stories?–Jane July 19, 2011

Filed under: Jane,Uganda — EssentialMidwifery @ 10:36 pm
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Ha!  You noticed!  There aren’t any.  Yes, there was not a single baby born during our stay in Uganda.  However, I learned so much anyway.  It really put the focus on prenatal care, and teaching, which is something I really love, so please believe me when I say that the trip was not in any way disappointing.  Good prenatal care is really the foundation of all midwifery work.  It is not only about meeting mothers where they are, but really peeling back the layers of who she is as a person, and showing her how she is absolutely the best mother for her baby.  It is about showing mothers what they already know, and how they are the experts both on their pregnancy and on their particular baby.  And it’s about convincing other people that no matter who this mother is, whether she is a 15 year old singlemama, or a 35 year attorney , they deserve respect and honor.  And in this case, it was doing all of this in a language I do not speak.

Many many women come to these rural centers never intending to deliver there; in many cases they live too far from the center to reliably make it in time.  In others, the pressure to birth in their village is just too strong.  But they come to Shanti anyway, to learn, to share their pregnancy experience, and to be with other women. Remember, these women cannot just look up a symptom on the internet.  They do not have electricity or running water.  And they may not have their mothers or grandmothers around to ask all those questions that a new mother has.  There are 3,000,ooo orphans in Uganda, victims of a brutal civil war in the 80s and 90s, AIDS, or other diseases.  These women are having children now, and are starved for information and love.

Shanti also functions of a de facto medical clinic, dispensing malaria treatments, parasite eradication protocols, and other basic supportive health care needs to pregnant women.  That’s something I would never see in Seattle, and I’m grateful for the chance to deepen my knowledge.  There is also a huge emphasis on post baby family planning.  It is vital that Uganda get its over population problem under control, or the many strides it has made will be for naught.  Safe, reliable birth control has to have a huge place in Uganda’s future, and I was very pleased to see it taken so seriously at Shanti.  The average Ugandan family has 8 children.  The death rate, thank goodness, is dropping, but the birth rate remains the same.  Clearly this is not sustainable, and is a huge obstacle to the empowerment of Ugandan women.  Choosing to have many children, as some of my most delightful clients at home do, is very different from it being forced upon you by circumstance.  Again, choice, choice, choice.

Immersing oneself in another culture is always challenging.  I am asking a lot of the midwives at Shanti, to reevaluate what they have been taught to do, and what they have been doing effectively in their previous jobs. In turn, I am reevaluating my own methods and work, making sure that they still match up with who I am, and what I believe is my purpose in this world.  And really, that is one of the most important things we can do, as midwives, or just as  human beings.  We keep examining, keep searching for clues as to how to find our true place, and if we are really lucky, we meet others who can help us, like I have both here in Uganda and at home.

 

Waterbirth, Waterbirth, Waterbirth–Jane

Filed under: Uganda — EssentialMidwifery @ 8:21 pm
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At one point, almost 90% of the births I attended took place in the water.  It has dropped off a little, due to some speedy babies that wouldn’t wait for the tub to be filled, but there is just no denying that this is a very popular way to birth.  I was excited to hear Shanti’s take on it, and share what we have learned over the years.

They have a built in tub there, but it is really much too small and much too deep.  Its lovely, of course, as is everything there, but I’m afraid it just wouldn’t really work.  Luckily, Kristin, the coordinator, already knew that, so I wasn’t breaking anybody’s heart with that observation.  They assured me that they could just pull out all the tile and build another one, quite quickly.  (Now, I don’t want to judge, but “quite quickly?”  Well, we will see.)

I was asked to give a workshop on the down and dirty details of waterbirth, and I was delighted to.  It was so off the wall, so unheard of, that I actually think it could work out fine.  See, Shanti is fighting a battle with their midwives.  They have all been trained in the classic 1950′s Western model of birth.  Even getting them to acknowledge that there are better positions than McRoberts has been a bit of a challenge.  They begged me to ask Kristin to get rid of the large queen sized beds with the homemade quilts in the birthing room, and get them some real hospital beds.  They said the beds were too low, and were hurting their back.  (I can completely sympathize with that, of course)  However, when I gently asked if they could just climb up on the beds with their mamas, well, let’s just say my suggestion wasn’t met with overwhelming enthusiasm.  I did, after much roleplaying and coaxing get several of them to promise to at least try it.  So again,we will see.

And don’t even get me started on the episiotomy issue.  I’ve been reading Jodilyn’s struggle with this, and I can only nod vigorously.  They ladies love to cut.  (When they found out I had never ever done one, I think I actually lost some of their respect.  I had to make it up later by bringing chocolate to share.)

I think the main issue here is that out of hospital birth is not seen as a beautiful, candle lit experience, where the mother is surrounded by people of her choosing, and comes gracefully into her power as a woman.  No, here it is a dark and dirty affair, usually with no trained attendant,  the threat of hemorrhage, or other disasters lurking just over there in the corner.  The hospital is a place of (relative) safety, even though that little bit of increased safety comes at a huge moral price.  Shanti is trying to change that.  But its slow going, especially when you have to start with your staff.

But waterbirth?  They had hardly even heard of it, so they had no preconceived ideas.  And that, I have found, is one of the best places to start from a teaching standpoint.  We talked for hours, first dispelling the normal waterbirth questions that everybody from my mother to the guy in the supermarket have asked me.  No, the baby won’t drown.  No, you shouldn’t leave the baby underwater for a long time.  Yes, we tend to see less tears.  Yes, it IS hard to cut an episiotomy in the water.  How great of you to notice!) Etc etc.

Then, one of my favorite midwives asked the question:  “How do you run a resuscitation?”  And just like that, we were off, off in a completely juicy conversation regarding the physiology of delayed cord clamping, the unseen yet oh so powerful bond between a mother and her child, how the midwife’s own attitude and demeanor can influence outcomes, when to actively help and when to encourage from the sidelines…oh, it was wonderful!  We had almost no common ground to start with; they have not been trained in NRP in the same way that I have, so we really had to start from square one, because we really weren’t even talking about the same thing.  But once we defined our terms a bit, we were deeply engaged in one of those meaty philosophical discussions that all midwives love.  (It was a bit more difficult because of the language barrier, but we kept at it.)

By the end, they were excited about waterbirth, and I think, even a little bit eager to try it out.  Annet even wanted to skype me in on their first one, to help guide them.  I wonder how the mother will feel about that!  And I hope its not a long birth, because there is no electricity at the center.  But those are just details.  I’m sure we will work it out.  The point is that we are starting to give these mothers options, options that they have never even heard of before.  And with options comes choice, and with choice comes dignity.  And that is what all mothers deserve.

 

Mean Girl-Jane July 13, 2011

Filed under: Jane,Uganda — EssentialMidwifery @ 9:41 pm
Tags: ,

For the first time today, I felt threatened. It was not from the men who regularly ask me if I want an African lover. I mean, they are shouting from trucks, so even if I decided that, yes, I absolutely did want an African lover,right now, they would be long gone. They may need to work on their technique.

And it was not from the slightly sketchy guys at the Indian supermarket, who glare at me whenever I ask for something they do not carry, as if it is my fault. And it’s not even from the market men who happily cheat me, and charge me twice as much as a Ugandan, cause they smile when they do it, and we both sort of consider it a game.

No, my nemesis is a teenage girl. She approached Rachel, Anna, and I last evening, as we were walking back from the market, munching on some roasted corn. She stepped in front of Rachel quite aggressively, throwing her shoulders back and narrowing her eyes. She demanded to know where we were from, and when told spat out, “Give me your corn. I want it.”

Now, there was no way Rachel was going to give her the corn. It was good, and it was Rachel’s. The girl glared, told us she had no money (although she was carrying school papers, thus was getting an education, and was obviously not starving) and got a little up in Rachel’s face. It was classic bullying behavior, and it was not going to work. Eventually she gave up, said what I can only assume to be a few rude words, tossed her fake hair, and flounced off down the road with her friends.

Now, if that were the end of it, I would have forgotten it already. But this morning, she was outside her house, with her friends, on the road to Shanti. As I passed her, she looked me in the eye. I greeted her and kept walking. I heard her say, “That’s my friend,” loudly, in a way that was definitely not friendly. The hairs on the back of my neck did a little dance, and I was acutely aware that I was alone, carrying a bag with comparatively, quite a bit of money in .

Strange that of all the people I have encountered and all the places I have been, that I would feel intimidated by a run of the mill, common Mean Girl. I will watch out for her.

 

War Stories-Jane July 12, 2011

Filed under: Jane,Uganda — EssentialMidwifery @ 7:08 pm
Tags: , , , , , , ,

 

It is just inevitable that when a group of like minded individuals get together, the war stories come out. (I know of what I speak, for I am the former wife of a F-15 pilot, and the now-wife of an SCA fighter.) This is especially true if there is a stoop involved, and some heavy warm air, maybe not quite enough work to fill the time, and some food to be shared. And so it was today at Shanti.

 

Annet began. “Jane, have you ever had the woman with the pre-eclampsia? She who had a fit? It happened to me, when I was alone here with Martha. It was night time, and the woman had not come to the clinic for two months. She only came when it was time for delivery. And she had great big pitting edema, and her blood pressure was so high. And I was so scared, and I told the mother of the mother that this was very dangerous, and that we had to go to hospital right away.”

 

“So I called Ben (the driver) but I could not get him on the phone, and she was starting to get worse. As I was thinking about what to do, her eyes rolled into her head, and she had a fit. She was shaking and not breathing well, and we were all alone at Shanti in the middle of the night. So I ran down the hill to the end of the road where there lives a boda man (Boda-bodas are motorcycle taxis and the drivers are known for insane traffic moves), and I banged on his door over and over again. Finally, he came to the door and I was screaming, ‘ I am a midwife, and this mother is going to die!’

 

So he came to Shanti and Martha and I were trying to balance this woman who was so out of it and without strength on the back of the boda. There is not really room for three people on the back of the boda, so Martha was standing up to make more room, and I was hanging on to the woman, and all I could think of was what if she had another fit on the way to hospital. And then it started to rain.

 

It rained all the way to hospital, when we finally got there. And she was already pushing on the boda, but she was actually only 6cm, so she had to wait. After a time, she did push out her baby, and she was ok. But I was so scared, and I did not know if I wanted to be a midwife anymore. I had to think about it a lot, but I decided that nobody else could have done better than me in that situation, so I might as well stay.”

 

So here’s a secret, and it is what I told Annet: Every midwife in the world has felt that fear. Everyone from the senior-est PhD Certified Nurse Midwife at Yale down to the youngest traditional birth attendant in a mud hut in Sudan. If they haven’t they are either lying, or a bad midwife. The fear is good. It keeps you and your clients grounded in the moment, and its in single moments when lives are lost or saved.

 

Midwifery is a lifestyle full of contradictions. You must do the schooling and learn the facts, but also be open to your intuition. You speak of honoring families, while neglecting your own.

 

But most importantly, like Annete, you have to humble yourself to the mother’s inner knowledge and respect her experience , yet be arrogant enough to act fast and hard when you have to. Its knowing that when a person’s life depends on you, nobody else can do it better. So you might as well stay.

 

 
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