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VBAC-less in Seattle February 17, 2012

Filed under: Birthy Thoughts,Jane — EssentialMidwifery @ 12:49 am
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It is no secret that Jodilyn and I are completely and utterly committed to vaginal birth after caesarean. We believe in the right to birth your baby vaginally, whether in your own home, a hospital, a field, hanging from a trapeze…you get the idea.  We believe in intentional birth, one that is the fulfillment of carefully considered thought and soul work, and not one forced into an impersonal mold by circumstances.  In short, we believe that everyone has the right to birth the way they see fit.

Only, what happens when you can’t? We have been so lucky here in Seattle, because while the actual number of providers doing vbacs has remained fairly low, there has traditionally been a nice mixture of types of providers.  We have homebirth midwives, hospital midwives, family practice doctors, obstetricians, and even a few perinatologists.  Unfortunately this has changed radically over the past year.

Hospital midwives who do vbac are in short supply here in the greater Seattle area, and getting shorter.  We have lost two major midwifery groups, and one extremely popular independent practitioner.  We now have only two hospital midwifery groups in Seattle  proper who do vbacs, and one of those are severely restricted due to insurance limitations.  While we do have many doctors who deliver vbac babies, they are, in fact doctors.  They may be delightful people, but they practice under many limitations, some self imposed, some practice or hospital based, and some pushed upon them by insurance companies and malpractice issues.  They are not midwives.

And midwifery care IS the answer here.  If anyone needs the focused care and tender compassion of a midwife, it is the vbac-ing mother.  The long office visits, the search for answers from her last pregnancy, the wading through pages and pages of safety studies…these are not the exclusive territory of homebirth midwives.  It is the right  of ALL midwives, regardless of where they serve, to hold a woman as the tears come during prenatal visits, to flush with anger alongside her for indignities done, and questions left unanswered.  ALL midwives should be privileged to wipe the sweat from a laboring vbac-ing mama’s face, to bring her water, to sing to her softly in the tub.  And ALL midwives should have the opportunity to discover the humility and strength that  reside in their souls in a way that is only possible when they stand silent in the birthing space, the one solitary being who truly and absolutely believes in this mother, body and spirit.

It is honor beyond measure to attend these women in their most creative time.  And I am so sad for the midwives who are being denied this.  I want our sisters back.

 

The Quintessential Togetherness. January 31, 2012

Filed under: Birthy Thoughts,Jodilyn — EssentialMidwifery @ 7:13 am
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Well Harumph….

I’ve been thinking about the recent publicity regarding the rise in homebirth rates.  You’ll hear Jane and I repeating our mantra in our sleep, “relationship, relationship, relationship…it’s all about the relationship mothers have with their provider.”  Can the provider be trusted to provide continuity of care and individualized attention?  Can the provider be trusted to guard the space and values of each family they work with? Can the provider do their work without needing the spotlight,  a.k.a. can they in fact “catch” and not “deliver” ? Can they do it all while preserving the relationship most fundamental to humanity? Can they offer support, resources, and guidance without actually providing precise google-map type directions for how things will be, how long it will take to get there, and what roads parents will or will not take?  A midwife is constantly thinking “re-routing!” as she adjusts her services to meet the needs and wishes of her clients.  My grandfather used to point out (via drawings on napkins in restaurants) that the fastest way between two points is a straight line, but it’s not necessarily the right path to take.

Ok. Spoiler Alert:  I whole heartedly believe that the safest place for a woman to birth is where she feels safest.  Home.  Birth Center.  Hospital.   Riding a float in the Macy’s Day Parade.  What I’m about to say really isn’t about that, it’s about what I’ve seen and what I believe about why women are choosing homebirth.

The word “quintessential” is a pretty common  adjective.  It’s used to demonstrate the most likely or perfect example of something.  I was staring at the ceiling today, trying to take a wee break from studying (and by wee break, I mean a small interlude, not a bathroom run).  I was missing my friends and the strangers in Vanuatu who would never have let me sit at that table alone while staring at the ceiling.  I miss the togetherness of that culture. Which got me thinking about how we create close relationships.

I started to reflect on the births I have attended here in the greater Seattle area (because of course when I wonder about anything I have to wonder first if birth affects that thing and how exactly it accomplishes it).  The hundreds of them.  I see little flashes.  Early on, those first births as a hired and paid doula, where I was supposed to be smart about this stuff and know just what to do.  Running out to the waiting room to call a more experienced doula for ideas.  Learning to let the text book information sink to the back of my head and actually respond to the mother.  The way a woman’s face changed as she was pushing, and how time stood still and all I could see was the force of birthing.  More flashes of firsts:  The first time a nurse gave me (me!) the code to the nutrition room (oohlala) so I could retrieve some ice water (the sacred nectar of hospital birth).  The first time someone’s water broke on me (followed by two more times that same week).  The first time a mother I was working with went to the OR.  The first time I smelled thick meconium mixed with that metallic odor of too much blood which portends a massive hemorrhage which was also the first time I saw a mother and a baby in steep decline in the same moment.  The first time someone told me that they had attended a birth that seemed a lot like rape (I was notably judgmental about this statement and couldn’t believe that this woman was sooooo dramatic).  The first time I attended a birth that felt like watching someone be raped (after I finished throwing up I called the other doula to apologize and she lovingly let me vent).

The first time I went to a homebirth.  The first hospital birth after a run of eight homebirths.  The sheer terror I felt at the silence of that birth, at the language at that birth, so markedly different than the midwives I had just been over-exposed to.  Of the total lack of raw power and connection between the mother and baby during that labor.  The weird, unrelated chatting.  The way the staff spoke with the mother as if she was totally inept about absolutely everything.  The way they forced the baby to nurse without actually noticing what state of being the baby was in.  Don’t mind me, brand new person who never felt, heard, or saw anything in this world before, while I overstimulate you with all this rubbing, thumping, sucking, talking, and stuffing of your mother’s breast into your mouth while pressing on your head with a force most adults would not appreciate….

It’s clear they are doing their j-o-b’s as they were instructed to, but there was no consideration for the variables of humanity of the mother or the baby.  What about just watching as the mother explores her newborn in her own time, in her own way?  What about allowing them to teach each other about the comfort, security, and nourishment that mom has to offer and those incredible newborn gazes which suck us in and make us fall in love if the baby is in the right state and the experience is organic?

I have been to some stunningly beautiful hospital births.  But here’s the truth:  It’s not the same.  Even drug free and naked and vociferous, it is not the same.  And the reason why, I realized, as I stared up at that ceiling in anygivenseattlecoffeeshop, is the quintessential togetherness that pregnancy and birth so dramatically and eloquently demonstrate when left to their own devices.  Midwives know there is a mother and a baby.  We actually call them motherbaby.  They are a dyad.  Inextricable from one another.   The baby needs the mother for food and oxygen supply and comfort and love.  The mother needs the baby to help her come into her mother-self.  To see the power in her body and potential of life and the bulkiness of what it means to really really love.  To lose sight of the small stuff; the control, the management, the ability to shave her legs all by herself.

The language of a hospital birth separates mother from baby.  Blames the condition of the mother in any given moment on the baby.  Questions the mother’s ability to continue to provide nourishment and oxygen for her baby on this single day when she has been doing it to perfection for the previous 260-280 days of her life (unmonitored, without permission, without apology, without doubt). The baby is seen as an imminent threat, the mother as an unfit and incapable hostess.  The examples are too numerous to cite, just ask a doula for one or two and she’ll go pale and give you ten or twenty.

Motherbaby: Quintessential Togetherness.  Bound by blood and water, time and love.  She brings him life and security, he brings her motherhood—that gracious, spacious, place beyond measure where women are bolted to the basic cellular formula for the entire universe.  We don’t do it alone, we don’t do it separate from our babies in even one single way.  We do it together in concert with them in every single way.

I am a midwife now who sometimes attends births as a doula.  It’s a lot easier as a midwife.  The technical responsibilities are greater.  But I never have to listen to a provider try to crack apart a mother’s relationship with her baby.  I don’t have to think about what to say to try to help that mother find healing and strength and connectedness.   Everything I do is about promoting that relationship and sense of what is right for the two of them, at the same time, together.   Everything I do is about letting the mother’s sense of self and baby dictate what comes next.  My terms are not that she will follow my protocols or accept my rules.  My terms are that she seeks to understand what she does not, that she asks all of the questions that cross her mind, that she speaks her heart and shares her thoughts, hopes, fears, and desires.  My terms are that the two of them work through birthing together using all of the resources they want to.  Did you know that a mother and newborn know each other by smell within hours of life? They can pick each other out of a lineup with just their noses.  That is so incredibly intimate.  Who would ever mess with a system that provides for that level of connection?

It’s no wonder there’s been a 30% increase in homebirths of late… faced with the opportunity to spend the prenatal clinic hours with a provider who wants to promote and support that togetherness, faced with the opportunity to stay as together as they’ve been for the entire pregnancy during birthing, faced with the options that matter so deeply.  The decision isn’t the quick or the easy one, but it is clear why, for so many women, it is the right one.

 

Winding Down…–Jodilyn July 25, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 12:03 am
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Thursday was humid and sweaty.  I felt like I was  moving through Jello and time was going soooo sloooow.  One of the midwives asked me, “Will today ever end?”  I don’t know what was going on unless they all felt the effects of the humidity as well or this is just one of those common workplace occurrences where everyone has slow-days.

We had several moms in early labor and lots of paper work to catch-up on.  We attacked the paper work, the tidying that never ends, making empty beds, mopping up…on and on.  I did a bunch of newborn exams and spent a lot of time hanging out with the twin’s family.  The dad was there to help get mom and the girls home and we chatted about their older son’s reaction to the babies and seeing mom and dad holding them.  Parenting is a universal challenge—we talked about Touchpoints (thank you Dr. Brazelton) and I shared some stories from when the kids were little.  Dad owns a tour company and they invited me to come and see “their little island” which reminded me of MamaMia : )

Of course everyone decided to have their baby at the same time—we had four mamas going within ten minutes of each other and they threw me into one to work with a student.  I had assessed this mother throughout the day and she would only let me touch her, telling the student and the other senior midwife who came in that she would have none of their fingers in her body.  Ok.  I actually wanted to support this student through it as she needs the hands-on.  At this point, strangely, I am feeling like I have done a lot of births and don’t need to do more.  (time to come home?!)  But I understood her position and respected it.  To make a very long story short she had a super tight fit and pushed for an hour and half, which is like 4 hours of pushing at home—it is unheard of.  She was bleeding ahead of the baby and complaining of acute pain.  We kept tabs on the mother in the bed across from her and they were having parallel experiences.  We prepared for both of them to have some serious bleeds and just asked the doctors to come hang out.  All the other babies were born first—3 girls.  This mother was insisting that she wanted a boy.  I slipped in once, “ok, it might be a girl too” and then held my peace—she would have to make hers or not make hers when the baby was born and I just decided I am wrong to interfere with her hopes and push reality on her when she is clearly a)not ready for that idea and b)in possession of 50% chance of getting what she wants.  The other mother had a high tear that required suturing by a physician and after baby was born so did this mom.  Baby was indeed a boy (!) and she asked me to go out and tell dad.  I went to tell him—he was a young 20 years old.  I asked him to come and see the babe but he wanted to know first what it was.  I told him it was a boy and he told me he actually knew that already so it was no surprise to him—he had had a very strong dream and had no doubts.  He made the transition from playing it cool to being uber excited quite rapidly and jumped up and snapped my finger—a trick the locals do which he later gave me detailed instructions in so I can show Jeffrey.  He wooted and hollered and danced around and clapped me on the back and kept saying, “alright!  alright!”

Friday I filled out and folded dozens of “blue cards” which are health records that parents use keep to track immunizations, well-child visits and any notes a provider would like to make mention of.  I also filled out and folded dozens of birth certificates.  So the next many many babies born in this hospital will have my signature on their birth certificate.  Which is kind of funny, considering I am not even a citizen here.  I am doing a lot of newborn exams as I have to pass my exam in the fall and have to match my scoring to the examiner’s scoring in order to be certified.

The weekend was all atwitter with building booths around the perimeter of the park for a week of celebration.  The booths are made by stripping the bark off of branches and then notching them at the ends so they fit together.  A whole frame is made in this way.  Ceilings and walls are made of woven leaves.  Each booth is about 10×5 or 10×7, depending on the use and they all share a wall with the one next to them.  Everyone was busy preparing, either with the weaving or the framing and then the moving.  That’s right, the moving.  Families move into these booths and use the front to sell goods—mostly food–and the rear to sleep in.  It is like a week-long Seafair from the old days when peons like us could pitch tents and actually enjoy themselves without spending a fortune.  All Sunday afternoon people were hauling pots, pans, sleeping mats and household goods down to the park.  Many of the houses are empty.  Chicken road is well represented with a few booths that are triple-wides in a row.  So now it is easy to visit my friends, I just go to their corner of the park and hang out.

Sunday at 3:00 began the festivities of Children’s Day with a parade led by the Big Chiefs from several islands, the minister of finance of Vanuatu, and several other dignitaries.  Behind them came the band and then the children and then the stragglers.  This parade does not work like our parades where everyone starts at the start and ends at the end.  This one started with the Chiefs and the band and a few children and they parade around the neighborhood and people wait on the street to see them and then join in at the end of the line so that by the end of the parade, when the procession marched onto the field there was a hodge-podge of people of all ages tagging along.  The prize has to go to my father-in-law’s counterpart here who ran around the corner from his house, got a big hat and stuck a Vanuatu flag in it and then waited for his grandkids to come down the street.  They clearly thought they had lost him and laughed and laughed at his prank.  He swooped up one of them and joined in the parade.  I happened to have been on the corner he ran to and he told me his joke while he got his hat situated.  Grandpa’s are da bomb.  I have been listening to so many stories lately and a lot of them are about grandfathers.  I will share one in a later post.

The parade entered the field and the Big Chiefs were called to do an opening ceremony, which is actually a ceremony once reserved for the start of wars between villages, and the singing sounded much  more war-like than happy-Children’s-Day-like.  They went to the middle of the field and exchanged Kava.  There were several chiefs present and they started to dance in a circle.  After a moment a group of grandmothers (I kid you not, some of them are great-grandmothers) ran to the center of the field and started dancing around the chiefs, much to the delight of the onlookers.  The chief from Pentecost saw them and stepped out of the chief’s circle and danced with the grandmothers instead.  This was extremely popular and there were loud cat-calls from the audience, who stood around the perimeter of the field.

Then came the speeches.  I had been warned.  But I’ll just say that I listened to about 6 of them over an hour and a half and then headed back to my room to call home and say happy birthday to Jeffrey and drink water.  I could hear them talking for another 2 hours so it was a good decision.  I had the chance to skype with Jane and I’m not sure what exactly happened but there was an extremely high rate of laughter and accusations leveled at each other regarding something to do with acting like 12-year olds.  Looking back, I’m not sure if 12 isn’t too mature.  Either way, just one more thing making me feel ready to come home.  I talked a long time with the kids and Benjy as well which was so great–also, making me feel ready to come home.  I am really happy to have these feelings.  I was kind of worried when I got here about how I would manage to get on a plane and leave.  Ever.

The partying went into the wee hours of the morning and this morning was the only morning since I have been here that the neighborhood was not awake with the sun.  I walked to the pool and it was still pretty quiet with the exception of a few toddlers who rose at the usual hour and teenagers who hadn’t gone to bed yet.  This will continue on for a week—even now there is a huge game of soccer going on the field and a live band playing music.  And it’s only 10:00am.

I am winding down my work hours as I want to see some more sights here before returning home and am frankly wanting fresh air.  All of the weeks in the hospital and the fumes from the cleaning agent still make my eyes water and set my gagger off.  I have caught a lot of babies.  I have delivered quite a few.  I feel confident about suturing, dystocias, breeches, twins, internal exams, and mothers with friable tissue.  But not so confident that I will ever approach birth without knowing that regardless of what I know, the mother knows more and the baby knows more and as a team they know best about how to birth and be born.

And not so confident that I would ever assume I could midwife better, just because I midwife differently than my colleagues, mentors, or peers.  This place has knocked the judgment out of me.  I hope that I can go on to support those in my profession with an open heart and genuine curiosity about who they are and how they arrive at decision points.

And certainly not so confident that I will ever stop learning or wanting to know more about why things unfold in the way that they do.  I am so lucky that the people I work with are information seekers and that they not only put up with my endless energy for getting to the bottom of things but they one-up me or encourage me or sit patiently with me as we talk these things out again and again so that we can all be better for the families we serve.

 

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 July 19, 2011

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.

 

Knowledge vs Fear: a 12 round bout. –Jodilyn July 19, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 3:35 am
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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 8th 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.

 

Teaching a Birth–Jodilyn July 15, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 4:33 am
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Firstly, my world feels right again now that I see Jane online : )  I am taking this afternoon to read her blog entries and cannot wait to devour them.

This week felt like it was acutely about teaching, with some wonderful and challenging births and delicious babies as the centerpieces for the lessons.  We got a whole new crew of students in.  They are medical, midwifery and nursing students from Australia.  We also got a fresh crew of local nursing students coming through and I have been really working with them as much as possible.  Many of the nurses here start nursing school in grade 11 so they tend to be about 17 years old, although there are some older ones as well.  They have no allowance while in school beyond what their families can afford so it can be quite challenging and I have heard the most inspiring personal stories from them.  One single mom who worked at the supermarket and scrimped and saved and now owns a small plot of land of her own and is in school full time, another who is a father of three that live 45 miles away from the hospital and he could not afford the bus fair (about $5 a day) to and from school and home so he stayed with some family of his that live locally for the first year of school.  The problem was that they had so many extended family members living with them there was no room to sleep on the floor so he slept every night upright in a chair so that he could stay here and keep going to school.  AussieAide provided the nursing school with scholarship funds—half to be given out on merit and half on need and he was the recipient of one of the scholarships so now will finish school with a place to sleep.  The stories go on and on of these young people getting themselves educated and contributing to their communities.  Most of them will go to school for 3 years and then work supervised for 2 years and then become the primary care providers in rural settings, so they need to know how to do everything and do it well.  I have tried to attach two of them to me, constantly teaching them and putting their hands on moms and babies—the New Zealand midwife here keeps them busy with meaningful projects and they are responsible for helping to clean and make the beds and assist in other duties in the nursery.  I don’t know how they do it.  I suppose it helps that they are young and excited about their work!

Yesterday we had a first time mom who kind of acted like an American mother—I was so surprised.  She threw up in labor and hollered and even whined.  I said, “oh, it feels like home…” mind you I said it with a big smile on my face.  It is a new skill I have developed out of necessity to read the cultural cues here and it can be hard understanding where someone is at from watching them when they act like they are taking a stroll through the mall and don’t really make much of a fuss until it is time to push.  At home I can almost always tell just by watching and listening how far along a mother is.

So one mama who was all out there with her labor was kind of fun.  Normally I wait to see a head to write down that someone is fully dilated instead of checking and checking them.  But she flew through her labor and had been checked a couple of times by other midwives.  She felt like pushing and got up on the bed.  I had been told to do an exam and then have the student do one so she could feel what a fully dilated cervix feels like.  I did and felt a tight anterior lip (just some cervix along one side).  I had the crew of aussie students standing at the back of the room watching and this nursing student there with me by the mother.  So I talked about what I was feeling and had the student feel.  Then I talked about using position changes such as hands and knees and asked the student to tell mom that if she would get on her hands and knees it makes more room for baby to do its work and might take away the urge to push she was feeling.  The baby was super low.  Much to my surprise she flipped right over.  I can’t count the times I have asked moms to do this and they refuse—and look at me like I am idiot.  They think it is acting like a dog and won’t have any part of it.  I covered her with a blanket so she would not feel exposed and asked the NZ midwife to come in and do some acupressure.  We did four contractions like that and then the mom, with a roar, flopped down on her side.

The NZ midwife did an exam and lifted the baby back out of the pelvis to try to get the pressure of mom’s bottom so she wouldn’t need to push as there was still some cervix left.  I asked for one more round on her hands and knees which she did.  She was screaming and moaning like the best of them—rocking her hips and grabbing onto her mother for dear life.  I was quietly talking to the medical students—telling them this was all good and healthy and we are just watching her come into her power and birth is hard, hard work.   The NZ midwife asked me to check again and I did, and I will share that she felt very very tight internally.  And I said outloud, “that feels tight”.  And then I looked up at all of the students watching me and the NZ midwife watching me and I just kept talking out loud, getting my thoughts out there.  “Here’s the problem with internal exams.  We get judgmental.  I don’t know what this baby is going to do to find his way here.  I am feeling her and thinking, ‘this is too tight’.   But it won’t be, because it rarely ever is.  Babies are born.  Mamas birth.  I just know too much about her body now because we have checked her too much.  If I never checked her, all I would be doing is using position changes to shift the diameter of pelvis to help that head get applied correctly.”  To which the NZ midwife replied, “Right-O”.

The mom was switching positions on her own now, sometimes on her side with her foot in my ribs.  Sometimes on her back arching and lifting her bottom.  Sometimes on her hands and knees and once she got into yoga’s Child Pose.  And then there was grunting and pushing.  And the tip of baby’s head.  “Hello, Baby!” I said.  Mama locked eyes with me, I smiled and gave her a big “Good on you!  You are doing it!”.  I placed her hand on that small strip of baby’s head.   She jammed her foot onto my shoulder and brought the head out.  Baby restituted.  “Thank you baby” (I said to baby).  “See how this baby is finding his way out, turning to birth its own shoulder with the next contraction” (I said to students) “ooooooooooh” (said the peanut gallery).  “There’s a cord around the neck!” (alarm from a med student)  I felt it.  Plenty of slack but not enough to slip over the head.  “First I am feeling if it will easily slip over the head…I am not worried, the neck is the safest place to park the cord for birth so I just think to myself, ‘here is one smart baby parking its cord in this nice protected cove of a neck’.  And it has good slack but I can’t slip it over so we will somersault it out”  The next contraction, “Just one small push now mama”.  And she does.  And I say quietly “somersault, somersault, and….somersault” as I support the baby through the loop of its cord and out of it again, the natural movements it would make with or without me there to help.

And swish….up to mama’s chest, ear on the heart.  A baby in its new habitat, the one place that is designed to nurture, calm, and regulate it best:  skin-to-skin, belly to belly, ear to heart with mama.  Baby gives a cry and looks around.  Students are clapping.  Grandma is crying.  Mama is over the moon, gazing up and away with her hands on her baby and a smile that would put the best Orbit Gum commercial to shame.  There is no time for me to exhale as a spurt and gush of blood pour forth from mother and I am on again.  “ok now I just look up at the clock and see the second hand—it is on the 35”  I am feeling the uterus, rubbing it to make sure it is hard…it is.  I take the student’s hand and place it on the organ, which feels like a grapefruit.  “If this stops shortly than it is the placenta working its way apart from the uterus”  If it is still going when we get to the 5 I will deal with that then.  15 seconds go by and the flood stops just. like. that.  “Oh, this is just lovely…it is the placenta”.  I tell one of the onlookers to grab some gloves and he can help me with the placenta when it is time.  We feel the cord pulsing and talk about letting the baby reach homeostasis by waiting until it quits.   We feel it quit slowly, from the bottom, working its way up to the baby’s umbilicus.

There are stars in the eyes of some of the students…I wonder I this is transformative for them and if so, which part?  Is it the birth or is it this mother or is it seeing all of the intricate details from a provider’s perspective that is speaking to them?  Or something I can’t guess at perhaps.

The cord is done pulsing.  I ask the mother if it is ok if we separate baby from its placenta now.  She nods yes.  I clamp and milk the cord about two inches down and clamp again.  I give the scissors to grandma.  She looks at me in shock and amazement but takes them.  I tell her to go in strong, and she does.  And it still takes two tries to cut that miraculous tether which feeds life from one to the other.  She is crying again and kissing her daughter all over her face…a thousand mama-kisses for her child and this incredible gift she has brought into their family.

I wrap the cord around the clamp and motion the med student over.  He looks like any one of Julia’s friends…lanky and still a boy but trying out the world in new ways.  I tell him to put his hand over mine, talk about guarding the uterus, the path the placenta has to travel to get to us.  We ask the mother for one last small push and the placenta comes nicely out.  I inspect it, I talk about what I am seeing and looking for and how to find it.  I show the mom and grandma.  They are stunned and excited to see the house where baby lived.  I go and put it in the sink and encourage the students to put on gloves and feel it, and run their fingers along the membranes so they will see how strong that sack is and to keep their questions in their minds, we will talk after we are done and in another room.

I check the mother for tears, and she has one well placed tear.  I confirm the apex with another midwife and then suture her.  It worked really well.  I am pleased as punch that I did that.  But I am also so new to suturing that I never believe it works when I do it.  More on that in a bit.

I see the door popping open in bits and look.  It is the new mother’s father, anxious to see that his daughter is ok, surprised by the sight of his new grandson in her arms.  I coax him in so that he can see them.  His response is an echo of his wife’s as he holds his heart and plants a big kiss on his daughter’s forehead and then a small one on the new boy.  Whispers rush fort from his mouth to the baby’s ear.  A loving welcome to this world indeed, a new life celebrated with gratitude and affection.  I feel lucky, lucky, lucky.  I am witnessing love.

I kept a close eye on mom for the whole day, sure that she would bleed to death because I did not suture her correctly.  Knowing intellectually that I did does not help.  She is 18.  She has rebounded 2 hours after the birth and is up walking around.  I am behind her at every turn.  Waiting for her to pass out in a good southern faint with her hand to her forehead and a big Scarlett O’hara sigh.  She wants to shower.  I can’t believe my eyes.  She is just up and walking about.  My doctor friend asks me, “why are you following her like that?”.  I tell her the truth.  “Because I sutured her and I must have done it wrong so she is going to bleed to death”.  She looks me in the eye and sing-song says to me, “Jodilyn, come now.  She is fine.  You did alright.  You are alright”.  Oh.   OK.  I’m alright.  She is fine.  I believe my friend and wait for what I know is coming next… “however, if you noticed with this primip that she tore and did not tear so straight and if you had just cut an epis[iotomy] you would not even wonder about these things”.  Nope. Nope. Nope.  I shake my head at her and smile and go to meet the next mother.

 

War Stories-Jane July 12, 2011

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

 

Hemi One Midwife from America–Jodilyn July 5, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 9:18 am
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Today started early, up at 5:30 to get to the pool before work.  When I arrived there were two inductions underway.  I continued with part two of yesterday’s project in which they turned the big cabinet in the midwive’s lounge over to my organizational savvy.  It was a veritable field of gold—I found a lot of donated supplies hidden away.  There is a fear here about using these things, that someone will borrow them.  But leaving 6 new stethoscopes in their boxes in the cupboard for two years is not a much more effective use for them.   I refreshed the equipment and supplies in the delivery and exam rooms, filled a cabinet with donated baby clothes in the room where we bathe and examine the babies, and ran a bunch of toys and larger clothes down the pediatric wing where they were promptly given away for use.  I stacked up all of the pictures that have been taken of visiting midwives and students that were sent here as gifts and made them easier to browse through.  I compiled all of the stats books by order of which kind of stats are gathered within and gave a book on how to perform vasectomies to a urologist doctor who asked me why we didn’t want it.  I stared at him for a moment and then he burst into laughter…

I actually want to take a break in the orderliness I was imposing to talk about laughing here.  The laughter here stretches across the street and down entire blocks.  I know some of my neighbors by their laughs—long cackles and high pitched “hooeeeyys”, the stuttered giggles of small children and those huge open-mouthed-head-thrown-back deep laughs some of the men have. Laughter here is unmodulated, joy thrown forth from bodies that are aligned in ways that would make ballerinas in America green with envy.  The chest is thrown forward in a physical sharing of happiness.  It is not tempered or adjusted or toned-down in fear of being seen as flaunting or whatever it is that keeps us Americans from going the distance when it comes to joy.  There is clapping and hopping and quite often, shoulder shimmies.  Teenagers tend towards knee slapping and grandmothers do the same.  There is a culture of acceptance when it comes to joy.  No one tries to take it away or diminish it.  No one accuses the joyful party of being too joyful.  Here, joy is shared and bold and independent.

Which is how I got to talking about laughter…this doctor, so enjoying his joke.  I laughed and laughed with him until we were all laughed out.  I finished the distribution of supplies and complete organization of the cupboard and went to observe the med students doing their newborn exams.  They seem to have been taught by the resident here who does not seem to know why he is doing what he is doing and has thusly modified some of the elements of the exam and now they don’t make any sense.  I observed and helped answer their questions and then talked about some of the items.  Tomorrow we are going to go through a complete exam together so they can see an American Style exam, where I will talk through each item–what we are looking for and what the absence or over abundance of can mean.

I spent a few hours doing assessments on babies and scoring them, part of my certification requirements for the second certificate I am getting through the Brazelton Institute.  It is so stunning to do this assessment and talk through it with the parents and watch their eyes light up as they see the unique behaviors of their babies.  It feels in many ways like I am providing a deeper introduction to their child and that I get to be a witness to the discovering of baby as a unique and individual person that these mothers make.  One of the grandmothers wanted to sit in on the assessment with the mom—this was the grandmother of the new mother and she was elderly and half blind and mostly toothless and had one of those dispositions that makes me want to sit next to her all day long.  She exudes grandmotherliness.  I’m pretty sure that is not a word but you will all know what I mean.  As I worked through each item on the assessment the grandmother got so excited and starting say “whoop!whoop!” and slapping her knees every time the baby responded to me or I elicited a reflex from him.  The baby, as they tend to do with this assessment, became more and more engaged and interested the further we proceeded.  He stared at me constantly waiting to see what was next and performed like a champ for his great grandmother.  It feels magical in the moment, to see how capable and what depth there is to their personalities, even when they are only hours old.  The grandmother dissolved into fits of joy.  She was thrilled with his clear miracle-like abilities and proceeded to walk around the ward and tell all of the other grandmothers what her baby was doing.  Oh, the baby’s name?  Owen  : )

I spent the day doing these assessments between births and got a good number in.  There was another set of sticky shoulders on a beautiful tall baby girl, 4th girl to a mom who wanted a boy but promptly fell in love with this little one.  The local midwife had called me in to catch this baby and the mother had an absolute panic attack.  She was terrified of me.  I asked the local midwife to do it as I have no desire to be terrifying to a mother with a baby on the way out.  The midwife told her, “you no be fright, hemi one midwife from America” (don’t be afraid, she is an American midwife) and then she started to leave.  I said, “wait!  come back here, she is afraid and that is not good for her or baby”.  I talked gently to the mother and the other midwife stayed, and it was all good.  I took care of her and baby during her postpartum hours and I definitely grew on her as she got to know me better.  As for continuity of care from the start, there just wasn’t time.  She walked in pushing—something the women from her island are known to do.  They have super fast labors, don’t tend to need any suturing and get up and walk about shortly after the birth like nothing ever happened.  Now I know to try to get these women when they come in!!

I walked flip-flop time down Chicken Road on my way home.   I played my way through two dozen kids, giving high fives and watching different displays of childhood.  Like little peacocks they are eager to show me what they have done with their day and their creations and inventions are a pleasure to behold.  I did remove a sharp metal edge off of a little plastic pipe some of the boys were using as a trumpet, but other than that, it was all good.

 

Twins, Breech, A Baby who is Here to Stay–Jodilyn June 25, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 1:46 pm
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After six days of 8-12 hour shifts I happily collapsed Friday night, falling asleep to a light but steady rain.  Squalls woke me up and kept me up most of the night and I finally gave up and decided to walk up to the hospital to say goodbye to several mothers and babies who were checking out today.

The family who named their baby after me told me they will be having a party in a couple of weeks and will send someone to collect me for it : )

The next bed down was a first time mother who had no one with her for her labor or delivery except for me as her aunty and her husband were at work and she hadn’t thought to call them until she was already pushing.  I gave her lots and lots of good back rubs and managed to hold her hand right until the baby was born and then she held my arm while I caught her baby, who I somersaulted gently out of the cord that was around her neck and straight up to her mother’s chest.  Next in the row was a first time mother who was so tiny I had asked for a second pair of hands from the midwives who were eating lunch and watching French soap operas.  She had the body of a 10 year old and I just didn’t have a lot of confidence about the whole thing…of course she proved me wrong and delivered a 2700 kg baby over an intact perineum.  She was 20 years old and was clearly madly in love with her little baby when I saw her this morning.  Her young girlfriend had been with her and was cowering in a corner when mom started to push so I encouraged her to come and hold her friends hand and sit by her.  She had never been to a birth before, something I figured out when she nearly fainted as the baby was born.  She caught herself and rested her head on the pillow next to the new mother’s.  As soon as baby was settled on mom’s chest and I was sure the mother wasn’t going to do any excessive bleeding I went around the bed and kicked a chair under the friend.  She looked up at me and said “OH WOW” and then laughed and laughed.  The Tutu (grandmother) came in and started clapping and kissing her granddaughter who had just delivered and then kissing and hugging me in a great show of affection.  It is hard to argue with an octogenarian who wants to shower you with love, even while waiting for a placenta to deliver!

Next in row in the postpartum area was a second time mother who was up and looking like a beauty queen—as if she hadn’t ever given birth.  Aha!  So they have those mothers here as well!  Across from her were our most recently delivered twins.  The mother came in having had no prenatal care and in active labor.  The head midwife wanted the doctor I’ve been working a lot with to be primary on this delivery.  The other American midwife and I talked over what to expect with her extensively as the mother labored.  Since we had no idea about these babies and how they were situated inside—one sac or two, one placenta or two, we planned on taking preventive measures and doing the best we could.  It was clear that twin b was sitting breech so as we waited on the birth we reviewed the mechanics of breech birth with this doc who had never seen a breech birth before.  It was a great collaborative spirit and the other American midwife and I were happy that the doc was asking for instruction.  As the first baby came she asked if she should cut an episiotomy to which we both cried “no!”…so she waited.  She kept asking if we were sure about that but before she could finish the sentence twice the whole head was born.  Then she went to reach in and pull the baby out and we both cried “no!”  I told her, “the baby will come to you.  Just keep your hands there and let it come to you”  the other midwife was speaking in the calm soothing tones to the doctor I had seen her use with mothers so many times now and I smiled at what we were doing there…retraining her, talking about the baby’s ability to restitute on its own.  Sure enough the baby turned to one side and one shoulder slipped free, then the next, and the body quickly followed.  We clamped and cut the cord pretty quickly since we did not know if the twins had any of their vessels crossed so we wanted to keep the blood supply even between them.  The doc looked up at us, “boy you ladies are patient!!”  We provided some guidance for twin B and felt from the outside as it settled into a nice breech deep in the pelvis and after several minutes the mother felt like pushing again.  10 toes appeared first and they were so darn cute as they wiggled their way into the world.  We lifted mom way to the edge of the bed so that the baby would just hang on its own with no disturbance from any of us or a table which might block its way out.  I had repeated several times to the doctor the mantra “hands off the breech” and as the feet were fully born she went in to support them and we both said “no!  hands off the breech”.  I said “Dr. X, I know this is the hardest thing to do but you cannot touch that baby!”  The other midwife showed her the sweeping motion she could do once the head was born to bring the baby to mom.  Dr. X did a little dance to keep from touching the baby which I have subsequently showcased for her over and over again : )  Breech baby twin B arrived without drama after a proper hang and maneuvers,  all self-directed.  Dr X was quite thrilled with the whole event and I let her in on the little secret that most of what midwives do is wait and paperwork.

So I said goodbye to those moms as they were on their way out today and it was nice to be in there just in my “civies” which is what they call clothing that is not scrubs and to sit and relax with the moms.

One other case this week that I don’t think I wrote about was a couple who were in having their second child.  Their first had died on day two due to some very tragic circumstances and they were extremely traumatized.  They were terrified their baby that was just born this week was not doing well and he would die too.  I spent about an hour with them doing a whole newborn exam and assessment.  The father was so upset because the mother was refusing to sleep and the baby was already 20 hours old so she was into day two + of not sleeping.  He spoke great English which was wonderful as I could really talk him through everything.  I reassured him it was normal for mothers not to sleep and to be primally obsessed with their newborns under these circumstances and that it would take baby proving his intent to stay on day 3, 4, 5, and so on for her to start to buy-in to releasing the fear she has now.   The baby looked like a normal 1 day old but was very smooth in some ways that I didn’t love, although nothing tangible enough to really complain about.  I told her since she was awake she should provide kangaroo care for the baby since that will give him the best shot at regulating his heart and respiratory rates and give her the feeling that she is getting to know him and get a sense of who he is.  She loved this idea and immediately put the baby skin-to-skin under her lava-lava (sarong).  I modeled for them talking to the baby and I asked them to express their fears and then I retold them to the baby and asked him to understand how loved and wanted he is and to know that the fear they have is not because they believe he will not stay but because this is all they have known.  There is something really amazing about telling their stories to babies, as they tend to perk up and listen.  He did this and I encouraged her to talk and sing to him that night plenty.  I told them I would be back first thing in the morning to check on them all.  I spoke that night with the other American midwife about this baby and she agreed there was something not quite great about him. Even though we know that babies on day one will sleep the bulk of the hours of the day, it was hard not share the fear with the parents, and I’m not sure if that wasn’t what was causing us to see him in this way.   I skipped swimming in the morning to get there early and went straight to them.  He was nursing vigorously and showing off great muscle tone.  I asked her if I could bring the medical students by and share her story with them and talk to them about the assessment I was going to do again.  She agreed.  As I did the exam he was clearly totally present and accounted for and although he started out fussy (which frankly I was happy to see!), he slowly got interested in what we were doing and he landed in that wonderful state where he was primed to learn and play.  He showed off by tracking further than the average baby does and regulating his states beautifully.  The mother finally smiled as she watched the incredible language of her newborn and when I was done I passed him to her but he had seen her from the middle of the bed and was all-eyes for her, and she was taken in by him entirely.  It was incredible to see him win her confidence over and although she was exhausted she looked fresh and eager to be with him as we left them alone to discover each other.

 

 
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