essentialmidwifery

It’s been a few days…the long shifts caught up with me and I essentially stumbled home day after day, hit the shower, walked down to the market for some food, then home for dinner and then I literally crash straight into a deep sleep.  I slept through Saturday and spent Sunday reading on a chair poolside and taking cat naps.  This is a good life though, to wake up in the morning with the sun and work hard and try to learn something or do something good for someone (or both!), laugh with friends, preparing fresh food for dinner and then a good good sleep.  I don’t miss my phone or the TV (well, a little bit the TV!) or trying to do twenty things at once and being mostly successful at all of them or hardly successful at any of them, depending on the day.  I don’t miss driving.  I don’t miss the chill or the clouds or the lack of sunshine.  I do miss my family and my friends.  I miss chux pads and ziplocks.

I have been swimming early in the morning, walking down streets on an island just waking up.  Mothers wrapped in their lava-lavas (sarongs) rinsing their bodies off and warming up food on the fire for their families.  It is quiet time.  Where the evening hours are all about the men and the Kava, and the afternoon hours are for the children, home from school, to play loudly and fiercely in the streets or the open areas, the early morning is about the women and their entry into the day.  It is a lovely time, where “hallo” is a whisper or a raise of the eyebrows and “good morning” is mouthed silently as I walk by.  It is the only time I see women moving slowly here.  Of course when people walk here, they walk flip-flop time, but the women are always busy-busy.  Slinging enormous bundles of veggies or children or bags or getting themselves to and from work.  So it has been a treat to see these moments and to walk with only the noise of the birds and tropical creatures.  The roosters don’t even disturb this hour—although they send their proclamations shooting through the night air from the hours of 11pm-2am with no sense of humility whatsoever.

After I swim I walk back to my room and pack up for the day—some leftovers from dinner for lunch, loading up with bottles of water, changing into my scrubs which I have just come to accept will be covered in all sorts of bodily fluids from mothers and babies by the end of the day.  I really am the tidy one in our practice at home.  Here, it seems like woman after woman has been coming in with her waters intact with a baby well on the way (as in, ‘let’s see where you are at….oh! there’s a head!’).  With the membranes so tight against the baby’s head I am reluctant to try to rupture them for three reasons:

1)      I do not want to hurt the baby’s head with the hook designed to break the membranes which hold all of the amniotic fluid inside along with the baby

2)      It is kind of useless at that point anyway as the head is blocking the water so even if I create a hole on top of the head, the membranes are going to rupture again down by the shoulders and create a large splash regardless of my fiddling

3)      Sometimes the bag is intact for reasons we can’t understand.

So Jodilyn, normally known as Tidy, has found herself on the receiving end of some phenomenal tidal waves bursting forth from mothers as their babies emerge.  At home I could manage it all with a handy chux pad but here, there is nothing to catch the flood with but the floor and whoever happens to be nearby.  The rubber mats they place under mothers are useless except in that they keep the sheet below the rubber mat dry and the bed below the rubber mat clean.  But it tends to act as a propellant for any liquid, shooting it further faster than it would have done with no rubber mat.  Now here is the thing.  I have a possie of medical students following me all day long and I have been working them into the births, trying to get their hands on everything while I can be the first voice in their heads.  I explain to them that the maneuvers they see here came out of the time when twilight sleep was the rule for birthing.  The pushing and pulling of babies from women who were under drugs which caused them great duress or total passivity.  Physicians began to reach in and pull babies from the womb, trying to work the baby under the pelvic join and then down and up and out of the birth canal.  These maneuvers were written down and studied and taught and somehow survive here still.  But a mother under her own power will bring her baby to you.  A baby under its own power and with the force of the contraction behind it, will find its way through.  A baby’s head will stretch and massage a mother’s internal tissue better than we can with our weak fingers.  More efficiently, more robustly, and in just the way it needs.  So I have spent my time with these students letting the mothers and the babies teach us all about the natural design and function of the elements of birthing.  And with regards to the waters bursting forth…I can’t say it bothers me.  I like it.  It shows the power of the uterus and birth in a very visual way.  It is a marvelous reminder of who is in charge in the room.  It is a great teaching aide.

And all of that has been enhanced by some very challenging moments where I am desperately trying to understand what is happening and how to make it right.  I believe there is a low consumption rate of protein here amongst many of the mothers.  It affects tissue integrity, iron levels, and vitality.  There are many mothers who have only one or two prenatal visits or none at all.  We are flying blind and must be on the lookout for premature babies, low hemoglobin levels, STDs, dehydration, and substance use—probably Kava—but it seems to affect placental health.  All of these elements affect birth and especially the immediate postpartum time.  Babies who are slow to start, mothers who seem to want to bleed forever or who are weak from dehydration or who have tissue that is so so difficult to suture because it is friable.

There are moments when my trust in birth fades, when my knowledge feels useless, when I feel like an inept bumbling idiot…and I have been so grateful for the docs who will reflect with me and talk through these things with me.  I am learning here.  Birth is different here.  But it is their normal and they can reassure me that I could not have done something to change what happened because that is what happens here.  We argue about episiotomies a lot.  Sometimes I think they are right, but mostly I think I am right about that one.  There is nothing as satisfying to me as when someone peers over my shoulder and says, “that perineum is too thick!” and then a mother has her baby with no tears.  And there is nothing more satisfying to them as when the mother tears plenty and they can gripe about how they would not have to suture in such a crooked line if I had only cut the epis…

We had a beautiful birth of a baby born in the caul yesterday—the membranes did not rupture at all and I peeled them back off the baby.  I have seen babies born asleep before and I have seen babies born without any life in them before.  This one was so odd.  It appeared to be in a very deep sleep with a good pink color.  I thought, here is a baby born asleep.  But even sleeping babies have tone to their muscles.  I was talking a student through the birth and had her swoop the baby up skin-to-skin on the mother’s chest.  I immediately saw something was very wrong with the cord.  It was spiraled in both directions and pockets of vessels were clustered like grapes all the way down the cord.  I instructed the mother to watch for any signs of hemorrhage while I attended to the baby.  I give the babies time to come around but put my hand on the baby’s back to feel if it was responding to being here.  There was very thick vernix on the back.  I put my stethoscope on and prayed to hear any kind of movement.  A strong heart beat.  That is great.  But no breathing efforts and no muscle tone.  I rubbed the soles of the feet.  No response.  I ran two reflex tests on the feet.  Nothing.  A baby will reflexively curl its toes around a finger placed beneath them.  A baby will reflexively make crawling movements if the foot is pushed up.  A baby will reflexively lift its toes if you stroke a thumb down the outside bottom of its foot.  Nothing.

Still good color, still good heart beat.  I asked one of the students to go and grab the first doc or midwife they see.  There is a reason we don’t do births alone at home—two brains is just better than one.  Help is never quick in coming here so I let my body take over and did not rely on even the idea that anyone would be in there to save this baby, to save me from not being able to save this baby.  I felt the cord.  It was so odd feeling, rough and bumpy.  I could not feel any pulse in it meaning the connection between the placenta and the baby was done.  I clamped and cut it quickly, knowing that I had to cut through several large vessels and it was going to create a mess.  Did I care?  No.  I wanted this baby to live and needed access.  Sure enough there was a burst of blood—like popping a balloon—when I cut it.  I heard it landing on my shirt.  Time and space were gone, just this baby in my arms and red dots on my shirt.  The table is too small to work on a baby with the mother already on it so I put the baby in full drainage posture.  The third baby of the week I had held in this posture but the first to be there separated from the placenta and the first to not respond within 3 seconds.

I walked towards the table and turned the baby over so I could see it.  Observation.  Baby’s eyes, dead.  Still a pink body.  I looked at everything.  I could not see anything wrong.  I listened again.  Good heart rate, still steady.  More drainage posture and massaging the baby from rump to crown.  Talking to the baby, “come baby, come.  please come.  we want you here.  it is time to breathe and come and stay and play soccer barefoot in the street”.   Finally.  The door opens.  A midwife comes in.  She takes a look at the scene and says “mmmm….floppy”.  YES! I scream in my head.  So save this baby.  Save me from not being able to save this baby.

I continued to massage the baby and talk to the baby waiting for this midwife to come and rescue us both.  She goes over to the counter and looks at the chart.  I called her name and asked to please come see the baby.  She walks over to me s-l-o-w-l-y.  Let me say that I asked her later so I can tell you.  She was not walking slowly because she wanted to torture me.  She was walking slowly because I was doing what she would do and she knew it would work.  She has seen this so many many times and it was not bothersome to her.  I, on the other hand, could measure her footsteps in hours and months.  She slapped it’s butt twice for good measure and I continued on rubbing and yammering and pleading and wondering why the other midwife wasn’t taking the baby from me to make it right.  Massaging a baby and begging it to join this world is easy compared with taking one single breath of my own after that baby, 7 minutes post birth, gave the faintest of squeals.  Seven minutes is an eternity.  I held still and listened.  Silence again.  I kept on, lighter now, rubbing, thanking baby for that good effort and asking for more.  I felt like I was asking King Tut himself for a drop of gold.  I put the baby down on the warming table and listened to the lungs…crackle-air-crackle-air-squeeeeeek.  The last from the baby’s mouth.  More lung sounds—that glorious noise of an empty pocket, no longer fluid filled.  I could hear the fluid push out with each sputter and sneeze the baby gave.  She opened her eyes and looked at me.  Really looked at me.  Eyes that were there and here and present and accounted for.  Thank you baby.  Tankyiou Tumaaaaaassssss (thank you so very very much) I said.  I slung the baby back into a drainage posture and out came some of the mucus I had hoped to see eight minutes earlier.  In the end I helped the baby and saved myself by letting go of the idea that I needed someone else to do both and just doing the best I could.

I walked the baby back to mom and put her on the mother’s chest, wrapped the mothers hands around her baby and smiled at her.  Her fear melted to joy and I turned my attention to my next worry:  the cord and whatever we would see for a placenta.  I put one of the students on the other end of my stethoscope with the bell on the baby’s back.  I told her I wanted to hear from her every thirty seconds for the next three minutes and that she was doing it not because I don’t believe the baby, but because I want reassurance and was willing to be selfish about it, and she, meanwhile could hear the lovely noises lungs make when they are working.  The cord was still remarkable.  Part of me thought I made it up but there it was, with vessels falling out of it.   One of the students asked if it was worms.  I almost threw up—give me human bodies in all their misery and I can handle it, but worms?  Not so much.  I swallowed hard.  I heard someone ask, “How would worms get inside the cord?”

The placenta was coming and I took over from the student, had her place her hand on top of mine as I did not want to put traction on it, not knowing what was going to break.  I eased it slowly out.  It was a tiny thing but appeared complete if strange.  There were two exposed vessels which led from the placenta about two inches up where the base of the cord seemed to start.  The insertion is what we call Battledore or Marginal–and the truest form of it as the vessels emerged from the very side of the placenta.   A two vessel cord is normally indicative of congenital problems but when I looked at the top of the cord there were three vessels at the baby’s end.  I checked the baby’s stump and there were three vessels there.  I marveled at how the system will find its way despite all of the forces that seem to be working against it.  I put it in the bowl and told them we would inspect it later.  This was my third birth since walking through the door that morning and it was only 11:30am—there would be one more within the hour.  She was my second suture job of the day.  A task I am not as good at as I would really like to be although I have to think it will be easier at home where our moms are not giving birth on their backs and have much better nutrition.

I did not stop moving until 3:30—making beds, moving moms, getting them settled, washing the sheets and rubber mats, bathing babies, giving shots, capping IVs…I feel the back-breaking connection with women who scrubbed linens clean with a bristle brush and muscle power.  How the whole world must have looked to the generation of women who finally stood upright as they dropped the laundry into a machine and pushed a button, then turned and walked away. It must have been like watching the sun set with a glass of red wine and nothing else on the mind.

I had the distinct pleasure of bathing the baby girl I had worked so hard on.  We use wide buckets for bathing them and I filled it with warm water for her.  She had three or four aunties who came to meet her and I invited them in to watch the bath.  I floated her in the tub, supporting her head.  She relaxed and unfolded, opened her eyes and looked up with a great curiosity.  Here in my hands was the little soul that had not arrived in her body until 7 minutes after she arrived on this earth.  I almost started to cry from relief but the busy hallways were calling me to get on with it.  I told her the story of her birth and I told her how very, very happy I am that she was here with us and how much her aunties love her.  At one point she looked over at them and they burst into a fit of giggles and sighs.  She is the most lovely little creature.  I told them she was born in the caul and that this portends great things in many cultures—she is one special girl.  I asked them if they wanted to get her dressed and they fell upon her in a storm of cooing and baby oil—they massaged her gently and dressed her and talked to her and argued about the best way to fold a nappy.

I sat down to drink water and fill out paperwork.  It was a hot and humid day.  I was a mess of sweat from the heat, sweat from the fear and adrenaline, blood, baby poop, vernix, dried amniotic fluid, and whatever else had attached itself to me by then.  The ironic thing is that I had finally decided to wear a surgeon’s gown for the births to keep clean and had gotten one but gave it to the student to wear.

I cleaned up the delivery rooms, now silent after all that we had done there.  I found the head midwife and told her it was all clean and the paper work was done and she told me to go and get some air and a clean shirt and to see them again tomorrow.