essentialmidwifery

Birthy Thoughts by Jane E. Drichta and Jodilyn Owen

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

Filed under: Jane,Uganda,Uncategorized — EssentialMidwifery @ 7:03 pm
Tags: , , , ,

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

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

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

“It this your first baby?”

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

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

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

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

 

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

Filed under: Uganda,Uncategorized — EssentialMidwifery @ 12:27 am
Tags: , , , , , , , , , , , , , ,

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

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

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

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

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

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

 

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

Filed under: Birthy Thoughts,Jane and Jodilyn — EssentialMidwifery @ 4:17 pm
Tags: , , , , , , , , , , , , , , , , ,

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
Tags: , , , , , , , , ,

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.

 

Waiting to be saved–Jodilyn July 12, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 1:53 am
Tags: , , , , , ,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Outside the Box–Jodilyn July 4, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 12:09 pm
Tags: , , , , , , ,

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).

 

Context -Jane June 21, 2011

Filed under: Jane,Uganda,Uncategorized — EssentialMidwifery @ 10:14 pm
Tags: , , , , , ,

Do you remember being 16?  The intensity and power that comes with knowing exactly what you DON’T want, while being completely confused as to what you do?  Everything matters so hard at 16.  You have the most delicious sense of invulnerability, with a healthy smattering of self-righteousness and passion thrown in for good measure.  Its wonderful and delicious and frightening, and I miss it.

Anna, on the other hand, will not miss it.  Those of you who know me well know just how hard a year this has been for my daughter.  She has had a series of absolutely bizarre health problems, which has caused no small measure of stress in her academic and personal lives.  It has been so difficult watching her struggle; seeing our children in serious pain or seriously lost is the dark dark side of parenting.  Its Darth Vader, and not the whiney prequel version.  This is the Admiral Motti-choking, chopping off Luke’s hand, bad-ass terrifying version, the dark side that demands respect.

I hate those parents who always gloom and doom the next developmental stage (“You think infancy is hard?  Wait until they start walking!  That’s when it gets really bad!”  Or “Toilet training is nothing!  Wait until 12, when they slam the door off its hinges!”)  I do not want to be that parent.  To those of you who have young teenagers, don’t take anything I say seriously.  I’m sure your child’s sophomore year will be just fine.  I wish you a year of giggles, of staying out too late, of pushing the boundaries just enough to stretch, but not enough to snap.  I wish you student council elections, good grades and some, but not too much, heartbreak.

But for us, well, this was a year we would both rather put behind us.  I have never known the depths of frustration, the depths of anger I could feel toward my sweet blue-eyes baby until now, that baby I have loved so hard and strong for so many years. I never knew I could be driven to tears, over and over, as the exact wrong thing came out of my mouth at the exactly the wrong time.  I never knew how many times I would drive her to tears.  As the year went on, and things became more and more complicated, the phone calls and email between the guidance counselor and home became more and more frequent, it seemed our relationship would break.  We circled each other warily, unable to speak even the smallest of words without a miscommunication, and its attendant, drama encrusted argument. 

 It was awful. I hope nobody out there, no matter how much I dislike you, has to go through what we did.  I hope my worst enemy is spared the year of blackness that began with terror in the emergency room at Seattle Children’s Hospital, moved through uncaring and inflexible teachers, and ended with Anna not even purchasing a yearbook, as she just wanted this year to disappear.  There are scars on our hearts from this year; I can only hope they are not permenant.

But as school is finally getting out for the summer, and we prepare for this trip, we enter a new phase.  The last few days,  as we pack our brand new, bright blue backpacks, fill our carry-ons with passports and loaded Kindles, have been wonderful.  She sees a new start, an end to the crazy.  She is a rising junior, a young adult looking forward to this huge undertaking.  When she returns, she will have seen and done things that most Americans will never experience, and she is ready to make it her own.

Midwifing babies?  Piece of cake. Midwifing myself? Not so simple. 

 

Hooray for Pis Pis!–Jodilyn June 18, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 8:42 am
Tags: , , , , , , ,

Hooray for Pis Pis!

A baby I delivered a couple of days ago was labeled “unable to pis pis” (aka pass urine, pee, piss, etc…)  I immediately went to check the charts to see if the baby had a 2-vessel cord as this can be a marker for genitourinary issues.  But of course, they don’t do newborn exams here in the immediate postpartum and there were no notes.  I sat down and worked out a flow chart for babies who no pis pis and then took it with me to examine the baby.  The cord was too dried to see good remnants of the typical A-A-V (artery, artery, vein) arrangement so I could not rule out a missing artery.  I worked my way down my chart (very officially written on the little 4×5 notebook I keep in my pocket!) and I could not find anything.  Cursing myself for leaving the phone number of a certain ND friend who likes to solve mysteries at my room, I redid my checklist.  Still nothing.  The baby was breastfeeding well and at the very least I would think we would see a distended bladder or feel fluid in the abdomen.  But this perky baby was the picture of perfection.  The pediatrician called in meanwhile and told us to tell the mother to wait a week and if still no pis pis then they will do a scan (ultrasound).  I’d like to see anyone wait a week while we don’t pee—puhlease.  Another midwife and I decided that was no good.  I felt that the wrong people might be being accused of retentiveness and turned my thoughts to the pediatrician who had diagnosed the problem and decided to wait a week to investigate it.  This baby was the aforementioned first boy, youngest sibling of 3 girls, whose father had clapped me on the back many, many times.  I was not going to let him slide down the slippery slope over the course of a week.  Having decided that either one of two things was happening, one being there was something I could neither see nor feel and that something did not bother the baby at all and two being that the diagnosis was wrong, I decided upon a course of action.  I went to visit baby N every 15 minutes and I took a good look and feel in his nappy.  I was posted and on the job, refusing to jump into anything else that would divert my attention.  That is, until the little 2 year old sibling of an almost-born baby climbed into my lap.  We laughed, we plei-pleid (played), we drew pictures in my notebook which she loovvveed.  Her grandmother tried to dissuade her from my person but neither of us would have any of it.  We made fishy noises as she was excited by the fish-mobile hanging in the hallway.  We skipped and marched in little circles.  This little activity made me very popular with the locals who were milling about taking care of their loved ones.  Maybe we play differently or maybe they were just happy to see a white girl who likes children, either way I got claps and smiles aplenty.  And every 15 minutes my new friend would toddle behind me down the corridor to watch me stick my hand in a baby’s nappy.

At the 2hr check, wonder of wonders, miracles of miracles, Pis Pis!!!  I admit I had grown anxious and was wondering who I was going to have to corner to get this baby cared for but all such thoughts fled my mind as I did  a happy pis pis dance with the toddler and baby N’s grandmother!  I then strutted down the hall like the proud mamahen I was and announced to the midwives and nurses  “We have Pis Pis!!”  They stared at me and then I remembered to put that in the correct vernacular to be a little more clear that it wasn’t “us” that had pis pis, but the baby who belongs to M who has pis pis.  “OOOOH,” they said and started laughing at me.   I decided to hunt down the pediatrician so returned my little friend to her family, giving her the piece of paper she had scribbled on.

I learned today that to get to pediatrics if one takes the wrong corridor, one has to walk the length of geriatrics.  As I walked through some of the old people reached out and I stopped and held their hands and talked with them.  These are such a lovely, heart-led people.  The first thing they share with me isn’t who they are or what they do, it’s just a warm smile and a bit of silence.  I made my way slowly through geriatrics and then across to peds.  I found the doctor and shared the good pis pis news then went to see if there were any kids who might want to plei plei.  One of the mothers of the ortho babies who are stuck in one place because their legs are casted and suspended from a rope contraption had fallen into a deep sleep while nursing her baby.  The Baby was wiggly and fussy so I quietly went and sat next to the bed and played with him…mom didn’t even stir one bit.  We played peek-a-boo, pet Jodilyn’s bracelet, and we said the letter “o” in quite a few different ways until he got tired and closed his eyes for a nap with mama.  I taught an older kid in a wheelchair the hand-slapping game, even though things were weighted on his side as he had an IV in one hand and I was unable to slap that one with any real intention.  My hands plenty red from my big loss, I headed back up to maternity.

Medicine here is strictly clinical—very much like the 1950s in America.  But it has been shown how much joy and human touch and concern improves clinical outcomes and I am unsure why this hasn’t reached this little island of joyful connected people yet.  I’d like to go over to Papua New Guinea where these docs are trained and get into their minds a bit about “bed side manner”.    Somebody comment and tell me the name of that Robin Williams movie where he cheers up patients? We should show it at the next staff training.

Meanwhile, I am headed back later tonight as we have 3 premature labors (mothers who are all between 26 and 28 weeks along) in the works…

 

 
Follow

Get every new post delivered to your Inbox.

Join 754 other followers