essentialmidwifery

Birthy Thoughts by Jane E. Drichta and Jodilyn Owen

“False Labor”: Misnomer of Grand Proportions–Jodilyn May 21, 2012

The language of pregnancy and birth showcase our society’s beliefs with perfect clarity. I can think of dozens of phrases that divide mother from baby, spirit from body, mind from health, and mother from inner knowledge. I want to look at just one phrase to showcase the way we approach these linguistic faux pas in midwifery care, and how we get to the bottom of events in pregnancy that can be difficult or seemingly in need of a cure.

We can attribute the language of divisiveness to many sinister roots and spend all day railing at The Machine and The Man–but why spin in circles when we can gain some insight instead?  Something I’ve learned over the years and hundreds of births: the roots lie beneath layers of asphalt, cement, cobblestone, and packed dirt. The energy required to dig them up and cultivate new soil and plant new trees is the work of modern midwifery. Meanwhile, we like to say we “forgive” those who have attached themselves to the practices that stem from these roots because that is their only paradigm and how they were trained. While that’s fair to some extent, each of us is responsible for lifting our heads so that we can partake of a broader vision. I know it’s not politically correct—but shame on all of us who are entrenched in one way of thinking, talking, and acting. And a double shame if that tunnel vision limits the experience of something so fundamental as the birth of a baby and a mother: the building blocks of any society. (And yes, this cuts both ways–midwifery care and homebirth are not the right fit for every woman.) What makes one person or another apt to lift their eyes and stretch their perspective or practice? I would call it holistic curiosity, and it should be taught in every medical and midwifery school. Actually, scratch that. It should be taught in every elementary school.

It is unfathomable to me that any person could witness birth and think only of the moving parts and mechanics of it, but there is where the roots of modern birth and the language and rituals that surround it lie. The medicalized perspective of birthing must work very hard to connect the parts that authentic midwifery honors as inextricably bound together. There are wonderful OB’s and OB nurses who see the whole woman—this is really not a message about them, it is a message about the environment, language, and curiosity that we surround ourselves with.

Back to the misnomer we are looking into: “False Labor”. This term is typically applied to bouts of contractions a mother has between 37 weeks and the onset of rhythmical contractions that get stronger and longer and culminate in birth. A contraction is an activity of the muscle. A mother cannot make her uterus contract the way we can flex our biceps. The uterus contracts in response to internal stimulation—be it from any of several maternal or fetal hormones, movement from the baby, an orgasm, or changes in the lower neck of the uterus called the cervix.

The idea that the body would generate activity, heat, and motion for false purposes is nothing short of absurd. Every contraction has a purpose. Each one massages baby, helps baby adjust its position in the pelvis, and stimulates receptor systems for hormones we need to birth our babies. Emotionally, contractions pull us inward and force us to spend time with our bodies and babies. They pull our attention from the world, the clock, the to-do lists. They teach us lessons about control and surrender. Often times in our busy lives it is the norm to be in a state of disconnect with our bodies. Mothering needs us present in our bodies. It demands that we feel and sense and respond to these feelings and sensations in order to ensure the very survival of our species. Contractions that come and go, sometimes for nights on end, and in fits and spurts help us acquire and practice these skills.

“False Labor?” I don’t think so. The body is wise and begs the mind’s attendance in this wisdom. A provider who looks a mother in the eye and tell her that this wisdom is “false”, and demands that she separate her wise body from her knowing sense of her truths does not see a whole woman in front of her. Midwifery care, at its very best, does not get lost in the mechanics, but honors the wisdom of the whole mother and her baby. It sees them work together in harmony to bring about motherhood in its richest, fullest sense, and babyhood with the right I wish every baby on this planet had—the right to a mother who has integrated her body and mind and honors her senses, her knowledge, her gut, and her heart and can be present for her baby. “False Labor?” I don’t think so. The next time we meet a mother who is contracting in these patterns, we can stand in awe at the integration of mother and baby, spirit and body, mind and health, and mother with her inner knowledge—and know, with absolute certainty, that there is nothing false about it.

 

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

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

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.

 

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.

 

Outside the Box–Jodilyn July 4, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 12:09 pm
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I worked from 7-6 today so this shall be short.  Firstly I have heard from the expert in Kangaroo Mother Care who kindly answered my desperate email with a calm, reassuring, and point by point plan for getting these premies onto their mothers and out of the incubators.  This is colossal good news and I am thrilled to have a plan moving forward and to see that the things I had started were at least near the mark if not on the mark.  So hooray!

Today was the day of mothers and babies who decided to do everything outside the box.  I manually rotated an OT baby who was all hung up and malpositioned.  I know it sounds funny but when I try the tricks of the trade I have only read about and expected to rarely to never use, and they work, it is a really really great experience.  There was a case of turtling and sticky shoulders and I went right in and retrieved the stuck child.  And there was a case of a cervix which repeatedly went from fully dilated down to 8cm and back again.  I couldn’t believe my fingers so I went to ask another midwife to come in.  She checked her and pronounced, “fully!” so I told her to wait for a few minutes and check again and then she said “8 cms…oh yes, sometimes the cervix needs to do that, it will be ok” and she trotted off.  Of course mother was ok and baby was ok and it all worked out fine.  At home we rarely to never do internal exams so although I know from seeing so many hospital births with regular internal exams that the cervix will do this and the myth of smooth 0-10 cms is just a myth, it was so bizarre to feel it.  I am trying to layer my innate trust of birth, of mothers, and of babies into all of the actions I am involved in from moment to moment.  Labors here are rarely like they are at home for a variety of reasons and just letting that be and going where these labors take me takes a lot of thinking-through in the moment.

One thing that is not different here is my unofficial 2-minute rule.  After years of observing babies being born and specifically the ones who are allowed to come to breathing on their own I have found that at the 120 second mark babies who don’t breath just after birth (as most do) either begin breathing well on their own or it is time to give them some help to get going.

I know this seems like a long time but babies come with reserves on hand—they are designed to take the time they need and to endure through extremely long, strong contractions and the pressures and squeezes they get at birth.  Everything works for a reason.  Mom’s contractions as or just after the head is born squeeze the torso and lungs and push fluids from the nose and mouth.  The placenta continues to push oxygen and nutrients into the baby for many minutes after birth as the final third of baby’s blood volume is transferred to the baby through the cord.  Cocktails of hormones turn the mother and baby on to each other.  A thousand unseen yet precise and valuable processes are unfolding in the baby, in the mother, and between the two.  We do not interrupt these unless it is absolutely clear that baby or mother need extra help.  So having seen so many babies come to on their own at the 2 minute point I know to be patient and wait, to leave the baby skin to skin with mom and let her talk to and rub her baby as mothers naturally do.

At one of the births today I was suspicious about a baby and I was watching the clock tick slowly away, waiting for the 2 minute mark as I was doing some gentle encouraging.  At exactly the two minutes I started to move in to give a little more help and the other midwife said to me in the quietest of tones, “I think you may need to help that little person out”.  I smiled because she was facing away from the clock but called it right on the mark.  Within the half-second baby let out a big wail and there you have it, two midwives and a baby all agreeing that it was time to get going at the same time!

After work I walked to the market while chatting on the phone with Benjy, bought loads of veggies then stumbled home, wiped out and ready for bed.  Just in case you are wondering what is on the news as I write this…“an australian man was fined today at the airport for not declaring his nuts” (they are showing a picture of two bags of roasted pistachios).

 

Pigs and Bats June 27, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 12:27 am
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Just a quick note to tell you that Sunday morning started out with me getting chased by a pig on the way to the pool (enter the usual rescue heroes an old lady with no teeth and an umbrella to beat him back and masses of small boys under six with pebbles and pig-wrestling skills).  For the record it was a Giant Pig and not the cute pink kind with the curly tail.  We looked eye-to-eye and after he added some snorting and grunting to the posturing I decided he could win and bolted.

The midwife here from New Zealand and her husband took us American girls on a round-the-island tour where we sampled coffee from Tanna, saw black sand beaches, and stood in the roaring wind with our feet in the warm turquoise waters of the south pacific.  The weather was stormy but we had a great day.  I shouldn’t forget to mention the one beach we stopped at where some locals had trapped some bats (which I think they call flying foxes) and were prepping them for a good ole fashion BBQ.  The other American midwife and I were making gagging gestures—I believe at one point she said she would rather eat a locust than one of those bats—while they explained how they grill ‘em up.  Apparantly the armpit is quite succulent we were told, while he spread the wings out to show us.  These creatures look like squirrels with bad-ass teeth and leather wings.  They should be the mascot for a biker gang.   I really can’t go on about it, it is making me a bit queasy.  We ended the day with an outdoor movie down at the NumbaWan Café where they string up a screen just in front of the ocean and use a projector with DVD to show the movie.  It was quite fun and I discovered that they do have ice cream here but it doesn’t taste at all like ours.  There is finally sun again after a week of squalls and rain, though it is entirely blustery, which I am just trying to enjoy as the humidity has been blown away for now.

And for the record, when I went this morning to swim the pig had been thoroughly detained in the back of the property again so I called him a name and walked slowly by.

 

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

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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