It is highly unlikely that anyone has ever actually died from happiness. I have taken anatomy and physiology four times over the course of this wandering life of mine, and it is completely uncommon for the limbic system to simply explode, leaving a patina of oxytocin dripping down one’s face. Uncommon , but not absolutely theoretically impossible, so I am leaving it open.
Before I left, Always Longsuffering Pat (hereafter to be known as ALP) Asked me if I were excited. No, not excited, with its adrenaline tinged barely concealed hysteria. Not excited, simply happy. Happy to see my friends, happy to go back to a place where, against any odds one can measure, I fell utterly and completely at home.
And now I am here, at whatever 8:30am means after crossing so many time and space barriers. And now at 8:30, I notice my happiness is tinged with joy. Joy and I are not well acquainted. We nodded at each other as we passed in the corridor in school, and she moved in for a bit when holding a newborn was a possibility, but we are not usually on a first name basis.
Except here, in a country most people cannot find on a map, now would they care to. We took the long/short way here. Long in frustration in that our first flight was cancelled, and we lost two pieces of luggage filled with medical supplies. But short in the way that bonding and laughter makes the time fly, and anticipation makes the breath be short.
Arriving in Entebbe airport and dealing with the lost luggage took the better part of two hours as we are passed from clerk to clerk. Finally it became obvious nothing else could be done that night and we went outside to meet out pick up.
Midnight in Uganda is the most midnight place ever, dark as dark, the Milky Way clearly visible, leading us somewhere just over the horizon. And waiting just outside was Ben, our driver and my friend. Hugs and greetings were exchanged and I may or may not have flipped a surreptitious tear to the red dirt below my feet.
Ben looked great, as did the new Project Coordinator, Salam, and one of the volunteers, Cara, an Australian who shares my hatred of birds. Clearly a woman of discriminating and refined taste.
After the usual journey of hours over pot hole invested roads, we arrived at out guest house in Kasana. It is a new one from last year, very conveniently located. The proprietor also owns the volunteer house we use at Shanti, so this is keeping it in the family. It is very comfortable and even has solar power, so we may end up with more power than I am used to there. May. Anything can happen. The linens here are so clean, and all monogrammed. Adrine has done a wonderful job. She is a business women with whom to be reckoned. If you remember our adventures with the electric showers last year…let’s just say we seem safe so far. And even hot water mostly. I am so happy. Adrine has done a beautiful job.
Like most women everywhere, Adrine was in constant motion. Women always move, right? When laboring, our hips sway, our bodies shake. Even if confined to bed, our feet will jiggle, our fists will clench. Unseen’ our cervixes will slowly open (and sometimes quickly close; remember to read beyond textbooks.) our hearts beat faster, we blink, our mouths open and close.
Just as artists swish paint brushes over canvases,women move through life in a state of creation. Creation is movement. As much as we would like, babies do not just fall out even the fastest twenty minute labor , while over quickly, brings a lot of physics and a lot of feelings to the table. And even the slowest 4 day, ctx q 10 until pushing, which then takes another three hours as that baby inchworms her way down…it too brings it’s own dance, it’s own perfect movement.
When babies become children, a woman’s movement increases. Running late, stopping by the store on the way to school, running in to drop off the lunch that was truly meant to be handmade, but is now covered in plastic wrap and branded with etching we hide under our coats, rushing to work or the doctor, or to the gym where before we move we have to pick our feet out of a quagmire of guilt and others’ ideas about our bodies, moving home or to the coffee shop, or to supportive meetings where, if we are lucky, we can move into projects of the family, of the heart, of the spirit.
Always moving. None can be still for long unless we schedule a meditation session, or time for prayer. But still, these are a conscious slowing, done on purpose, a respite, never completely still. We are after all women. We move.
I see this movement at Shanti, and not just In its laboring and birthing women, but in the project coordinators, in the volunteers, (almost exclusively women) who move across continents and philosophies, who move against cross cultural norms who seek to oppress, who say that our movement means nothing and we should be frozen.
I see it in the Ugandan staff, these most excellent midwives and support workers who are always always learning, stretching across the divide of what they have been taught and what they know is possible. Over the past four years, I have seen them come to a new place, one guided by intuition and love, a desire to move each birthing woman forward rather than backward.
So much movement. And while it is highly unlikely that I will die of happiness, literally, my heart is swelling like the Grinch at the end of that Christmas special with Boris Karloff. I am ready to move.
There and There Again: A Midwife’s Tale- Jane October 12, 2013
“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
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.
Winding Down…–Jodilyn July 25, 2011
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.
Teaching a Birth–Jodilyn July 15, 2011
Firstly, my world feels right again now that I see Jane online : ) I am taking this afternoon to read her blog entries and cannot wait to devour them.
This week felt like it was acutely about teaching, with some wonderful and challenging births and delicious babies as the centerpieces for the lessons. We got a whole new crew of students in. They are medical, midwifery and nursing students from Australia. We also got a fresh crew of local nursing students coming through and I have been really working with them as much as possible. Many of the nurses here start nursing school in grade 11 so they tend to be about 17 years old, although there are some older ones as well. They have no allowance while in school beyond what their families can afford so it can be quite challenging and I have heard the most inspiring personal stories from them. One single mom who worked at the supermarket and scrimped and saved and now owns a small plot of land of her own and is in school full time, another who is a father of three that live 45 miles away from the hospital and he could not afford the bus fair (about $5 a day) to and from school and home so he stayed with some family of his that live locally for the first year of school. The problem was that they had so many extended family members living with them there was no room to sleep on the floor so he slept every night upright in a chair so that he could stay here and keep going to school. AussieAide provided the nursing school with scholarship funds—half to be given out on merit and half on need and he was the recipient of one of the scholarships so now will finish school with a place to sleep. The stories go on and on of these young people getting themselves educated and contributing to their communities. Most of them will go to school for 3 years and then work supervised for 2 years and then become the primary care providers in rural settings, so they need to know how to do everything and do it well. I have tried to attach two of them to me, constantly teaching them and putting their hands on moms and babies—the New Zealand midwife here keeps them busy with meaningful projects and they are responsible for helping to clean and make the beds and assist in other duties in the nursery. I don’t know how they do it. I suppose it helps that they are young and excited about their work!
Yesterday we had a first time mom who kind of acted like an American mother—I was so surprised. She threw up in labor and hollered and even whined. I said, “oh, it feels like home…” mind you I said it with a big smile on my face. It is a new skill I have developed out of necessity to read the cultural cues here and it can be hard understanding where someone is at from watching them when they act like they are taking a stroll through the mall and don’t really make much of a fuss until it is time to push. At home I can almost always tell just by watching and listening how far along a mother is.
So one mama who was all out there with her labor was kind of fun. Normally I wait to see a head to write down that someone is fully dilated instead of checking and checking them. But she flew through her labor and had been checked a couple of times by other midwives. She felt like pushing and got up on the bed. I had been told to do an exam and then have the student do one so she could feel what a fully dilated cervix feels like. I did and felt a tight anterior lip (just some cervix along one side). I had the crew of aussie students standing at the back of the room watching and this nursing student there with me by the mother. So I talked about what I was feeling and had the student feel. Then I talked about using position changes such as hands and knees and asked the student to tell mom that if she would get on her hands and knees it makes more room for baby to do its work and might take away the urge to push she was feeling. The baby was super low. Much to my surprise she flipped right over. I can’t count the times I have asked moms to do this and they refuse—and look at me like I am idiot. They think it is acting like a dog and won’t have any part of it. I covered her with a blanket so she would not feel exposed and asked the NZ midwife to come in and do some acupressure. We did four contractions like that and then the mom, with a roar, flopped down on her side.
The NZ midwife did an exam and lifted the baby back out of the pelvis to try to get the pressure of mom’s bottom so she wouldn’t need to push as there was still some cervix left. I asked for one more round on her hands and knees which she did. She was screaming and moaning like the best of them—rocking her hips and grabbing onto her mother for dear life. I was quietly talking to the medical students—telling them this was all good and healthy and we are just watching her come into her power and birth is hard, hard work. The NZ midwife asked me to check again and I did, and I will share that she felt very very tight internally. And I said outloud, “that feels tight”. And then I looked up at all of the students watching me and the NZ midwife watching me and I just kept talking out loud, getting my thoughts out there. “Here’s the problem with internal exams. We get judgmental. I don’t know what this baby is going to do to find his way here. I am feeling her and thinking, ‘this is too tight’. But it won’t be, because it rarely ever is. Babies are born. Mamas birth. I just know too much about her body now because we have checked her too much. If I never checked her, all I would be doing is using position changes to shift the diameter of pelvis to help that head get applied correctly.” To which the NZ midwife replied, “Right-O”.
The mom was switching positions on her own now, sometimes on her side with her foot in my ribs. Sometimes on her back arching and lifting her bottom. Sometimes on her hands and knees and once she got into yoga’s Child Pose. And then there was grunting and pushing. And the tip of baby’s head. “Hello, Baby!” I said. Mama locked eyes with me, I smiled and gave her a big “Good on you! You are doing it!”. I placed her hand on that small strip of baby’s head. She jammed her foot onto my shoulder and brought the head out. Baby restituted. “Thank you baby” (I said to baby). “See how this baby is finding his way out, turning to birth its own shoulder with the next contraction” (I said to students) “ooooooooooh” (said the peanut gallery). “There’s a cord around the neck!” (alarm from a med student) I felt it. Plenty of slack but not enough to slip over the head. “First I am feeling if it will easily slip over the head…I am not worried, the neck is the safest place to park the cord for birth so I just think to myself, ‘here is one smart baby parking its cord in this nice protected cove of a neck’. And it has good slack but I can’t slip it over so we will somersault it out” The next contraction, “Just one small push now mama”. And she does. And I say quietly “somersault, somersault, and….somersault” as I support the baby through the loop of its cord and out of it again, the natural movements it would make with or without me there to help.
And swish….up to mama’s chest, ear on the heart. A baby in its new habitat, the one place that is designed to nurture, calm, and regulate it best: skin-to-skin, belly to belly, ear to heart with mama. Baby gives a cry and looks around. Students are clapping. Grandma is crying. Mama is over the moon, gazing up and away with her hands on her baby and a smile that would put the best Orbit Gum commercial to shame. There is no time for me to exhale as a spurt and gush of blood pour forth from mother and I am on again. “ok now I just look up at the clock and see the second hand—it is on the 35” I am feeling the uterus, rubbing it to make sure it is hard…it is. I take the student’s hand and place it on the organ, which feels like a grapefruit. “If this stops shortly than it is the placenta working its way apart from the uterus” If it is still going when we get to the 5 I will deal with that then. 15 seconds go by and the flood stops just. like. that. “Oh, this is just lovely…it is the placenta”. I tell one of the onlookers to grab some gloves and he can help me with the placenta when it is time. We feel the cord pulsing and talk about letting the baby reach homeostasis by waiting until it quits. We feel it quit slowly, from the bottom, working its way up to the baby’s umbilicus.
There are stars in the eyes of some of the students…I wonder I this is transformative for them and if so, which part? Is it the birth or is it this mother or is it seeing all of the intricate details from a provider’s perspective that is speaking to them? Or something I can’t guess at perhaps.
The cord is done pulsing. I ask the mother if it is ok if we separate baby from its placenta now. She nods yes. I clamp and milk the cord about two inches down and clamp again. I give the scissors to grandma. She looks at me in shock and amazement but takes them. I tell her to go in strong, and she does. And it still takes two tries to cut that miraculous tether which feeds life from one to the other. She is crying again and kissing her daughter all over her face…a thousand mama-kisses for her child and this incredible gift she has brought into their family.
I wrap the cord around the clamp and motion the med student over. He looks like any one of Julia’s friends…lanky and still a boy but trying out the world in new ways. I tell him to put his hand over mine, talk about guarding the uterus, the path the placenta has to travel to get to us. We ask the mother for one last small push and the placenta comes nicely out. I inspect it, I talk about what I am seeing and looking for and how to find it. I show the mom and grandma. They are stunned and excited to see the house where baby lived. I go and put it in the sink and encourage the students to put on gloves and feel it, and run their fingers along the membranes so they will see how strong that sack is and to keep their questions in their minds, we will talk after we are done and in another room.
I check the mother for tears, and she has one well placed tear. I confirm the apex with another midwife and then suture her. It worked really well. I am pleased as punch that I did that. But I am also so new to suturing that I never believe it works when I do it. More on that in a bit.
I see the door popping open in bits and look. It is the new mother’s father, anxious to see that his daughter is ok, surprised by the sight of his new grandson in her arms. I coax him in so that he can see them. His response is an echo of his wife’s as he holds his heart and plants a big kiss on his daughter’s forehead and then a small one on the new boy. Whispers rush fort from his mouth to the baby’s ear. A loving welcome to this world indeed, a new life celebrated with gratitude and affection. I feel lucky, lucky, lucky. I am witnessing love.
I kept a close eye on mom for the whole day, sure that she would bleed to death because I did not suture her correctly. Knowing intellectually that I did does not help. She is 18. She has rebounded 2 hours after the birth and is up walking around. I am behind her at every turn. Waiting for her to pass out in a good southern faint with her hand to her forehead and a big Scarlett O’hara sigh. She wants to shower. I can’t believe my eyes. She is just up and walking about. My doctor friend asks me, “why are you following her like that?”. I tell her the truth. “Because I sutured her and I must have done it wrong so she is going to bleed to death”. She looks me in the eye and sing-song says to me, “Jodilyn, come now. She is fine. You did alright. You are alright”. Oh. OK. I’m alright. She is fine. I believe my friend and wait for what I know is coming next… “however, if you noticed with this primip that she tore and did not tear so straight and if you had just cut an epis[iotomy] you would not even wonder about these things”. Nope. Nope. Nope. I shake my head at her and smile and go to meet the next mother.
War Stories-Jane July 12, 2011
It is just inevitable that when a group of like minded individuals get together, the war stories come out. (I know of what I speak, for I am the former wife of a F-15 pilot, and the now-wife of an SCA fighter.) This is especially true if there is a stoop involved, and some heavy warm air, maybe not quite enough work to fill the time, and some food to be shared. And so it was today at Shanti.
Annet began. “Jane, have you ever had the woman with the pre-eclampsia? She who had a fit? It happened to me, when I was alone here with Martha. It was night time, and the woman had not come to the clinic for two months. She only came when it was time for delivery. And she had great big pitting edema, and her blood pressure was so high. And I was so scared, and I told the mother of the mother that this was very dangerous, and that we had to go to hospital right away.”
“So I called Ben (the driver) but I could not get him on the phone, and she was starting to get worse. As I was thinking about what to do, her eyes rolled into her head, and she had a fit. She was shaking and not breathing well, and we were all alone at Shanti in the middle of the night. So I ran down the hill to the end of the road where there lives a boda man (Boda-bodas are motorcycle taxis and the drivers are known for insane traffic moves), and I banged on his door over and over again. Finally, he came to the door and I was screaming, ‘ I am a midwife, and this mother is going to die!’
So he came to Shanti and Martha and I were trying to balance this woman who was so out of it and without strength on the back of the boda. There is not really room for three people on the back of the boda, so Martha was standing up to make more room, and I was hanging on to the woman, and all I could think of was what if she had another fit on the way to hospital. And then it started to rain.
It rained all the way to hospital, when we finally got there. And she was already pushing on the boda, but she was actually only 6cm, so she had to wait. After a time, she did push out her baby, and she was ok. But I was so scared, and I did not know if I wanted to be a midwife anymore. I had to think about it a lot, but I decided that nobody else could have done better than me in that situation, so I might as well stay.”
So here’s a secret, and it is what I told Annet: Every midwife in the world has felt that fear. Everyone from the senior-est PhD Certified Nurse Midwife at Yale down to the youngest traditional birth attendant in a mud hut in Sudan. If they haven’t they are either lying, or a bad midwife. The fear is good. It keeps you and your clients grounded in the moment, and its in single moments when lives are lost or saved.
Midwifery is a lifestyle full of contradictions. You must do the schooling and learn the facts, but also be open to your intuition. You speak of honoring families, while neglecting your own.
But most importantly, like Annete, you have to humble yourself to the mother’s inner knowledge and respect her experience , yet be arrogant enough to act fast and hard when you have to. Its knowing that when a person’s life depends on you, nobody else can do it better. So you might as well stay.
The Star of the Show (almost)–Jodilyn July 6, 2011
quick post just to track the mayhem, and it’s mostly birthy updates for my non-birthy friends reading, skip to the end if you’d like where you will read a bit about after work…
Today I caught the 40th baby born in 6 days.
I had a first time mother who looked very healthy. Baby was coming down OP but rotated and either he had a hand up and shredded the mother on his way around or she had absolutely no tissue integrity…either way plenty of bleeding before baby was born. I actually asked one of the med students to whistle down a doctor because it looked like the placenta may have begun to separate ahead of the birth. I put the Doppler part of the CTG on mom’s belly and got good heart tones. I left it sitting on her belly for the duration of labor. Forgive me please, I know the dangers of Doppler but felt at that moment that I had to decide which was the greater worry and I chose monitoring baby’s immediate well being as my priority. Blood oozed forth and the doctor was poised to move. I had to get bossy with this mom who I had worked with all morning and had developed a connection with so she took my shift from gentle quiet talking midwife to bossy lady seriously. Baby’s head was born and blood was pouring over his face. After the body came I held him in a good drainage position for about 5-10 seconds and watched the fluid run from his mouth. He was vigorous and well but I did not want him to drink in mom’s blood if at all possible. When he seemed to have cleared the fluids I put him skin to skin on mom. I won’t get into it entirely but clearly there was something not right. Her tissue was so friable that even as the doctor sutured the many many tears new ones were opening up. After an hour and half she settled on packing her with gauze and waiting for a couple of hours to see if it would get easier. I left her for all of two minutes to go sit down and do the paperwork and have a drink of water. I forgot my pen so went back into the delivery room and there was mom, standing up wanting to walk to the bathroom. I had already mopped up the quite bloody floor and it was now coated again as she clearly had open tears that bled when she was walking. I slung her arm over my back and half carried her back to bed, got her a bed pan and gave a good finger wagging about staying in bed until we moved her out to the postpartum area. I mopped again and cleaned her off again. A second doctor came in to do the second repair as the first doc was worn down. I was worn down and I had only been holding the speculum and watching the progress (or lack thereof) and mopping!
One of the moments I love at homebirths is that dreamy time after mom has her baby and she is all settled in and the midwives have some time to rest and decompress or fall asleep in a heap all tangled up together on a too-small couch or some corner on the floor. Even when births go perfectly this time is still so valuable. So this birth, which had loaded me with adreniline, left me in need of collapsing in a heap to recover but alas (or awae as they say here…) I never did get that moment and left two hours after the shift was over. The second doc actually removed all of the stitches the first doc had placed and restitched the mom. We finally got to move her to a postpartum bed 6 hours after the birth. We had a big review of the birth after and I told them the only time I have seen this kind of tissue shredding was a mother who refused proper treatment for diabetes. They were testing her blood sugars when I left tonight.
The other birth I did today was in a supervisory role as a nursing student was finishing his last required birth. We had the Aussie med students in with us and it was a nice learning atmosphere. The mother was plagued by muscle cramps in her feet, calves, and arms. I tried unsuccessfully to get her sister to go and buy some bananas for her. So barring potassium all we had was our hands and all of us were rubbing her down. I kept my hand on her belly and she was skipping the contractions—not even able to think about pushing because of the pain of the other cramps. I taught the nursing student how to perch at the end of the bed and let her stretch her foot and leg by bracing her foot on his shoulder. It was a second time mom who was pushing with good contractions and not making any progress. I started to talk out loud about the things I was worried about and as it became clear that the baby was hung up on something and they had finished another delivery on the other side of the room, we wound up with several midwives in the room. I asked “how many midwives to deliver a baby?”…they started laughing and tossing out numbers and we decided it was less than were needed to figure out how to run the microwave and more than were needed for changing a light bulb. I was happy they were there as I knew we would need an extra hand and if the baby had a rough time then several extra hands seemed just fine to me. They loaded synto (what we call pitocin, they call syntocin—synthetic oxytocin) in via an IV and soon the baby was being ejected. Something was still clearly wrong as the baby was so slow to come forward. He turned out to have a tight nuchal cord which had no give at all. There was hardly room to clamp and cut on the perineum but we did it and he came right out. His cord was exceptionally short. He needed a bit of help to get going but came round quickly—a great big baby boy. I did half the suture job and another midwife finished it up as there was a lot of bleeding and I was worn down to the bone and couldn’t even see straight, and was frankly a bit traumatized by the other suturing job of the day.
I bathed some babies and got them into their nappies, got the moms settled in and finally looked up to see how late it was.
Now here’s the not birthy part of the day. I hustled over to the pool for a swim and was about half way through when I heard a loud horn of some sort. It was dark around the pool and in the pool and I am half blind so I had to stop and put my glasses on to see what the continuing blast was about. I looked up and there was a native Vanuatu man in kustom garb blowing a conch shell. I took a look around and it seems I was swimming in the middle of what was about to be some kind of show of kustom dancing and kava drinking for the hotel guests. There were a dozen dancers waiting behind the tree to come out and start the show. I jumped out of the pool, wrapped my lava-lava (sarong) around me and hustled back into the trees behind the dancers. I put a tshirt and skirt on over my swimsuit and watched the start of their show and then walked home, dripping wet, my flip-flops squeaking the whole way. I think, for the record, how amazing it is that I am not too embarrassed to relate this small story… : )
Outside the Box–Jodilyn July 4, 2011
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).
Continuity of Care–Jodilyn June 22, 2011
Being cared for by a provider who a woman gets to know and develop a trusting relationship with matters. Having that same provider care for that woman throughout her labor and birth matters. I had started to wonder if these truths, which seemed so fundamentally true in my little world, were true at all in the great big world I have come to. I have seen over the past two weeks women laboring alone in the hallway as providers buzz past them without a kind word, or any word at all for that matter. I have seen only two husbands present for the laboring and birthing. I have seen soon-to-be-grandmothers doing the hard work of massaging, nourishing, encouraging a mama—their daughters–in labor. I have seen everyone a mother knows scramble out of the room just after the birth as they have been taught that this is what they should do. I have seen babies parked in corners in bassinets. I have seen women wanting to stay upright or on their sides while providers bark at them to lay down flat and open their legs. I have seen mothers whose bodies were instructing them to perfection in the slow art of pushing out a baby told to push for sustained periods of time and I have watched them lose their breath trying to do so. I have seen providers trained without the understanding that after a baby’s head is born, the body will restitute to one side for the birth of the shoulders and body, reach inside and pull babies from their not-quite finished process. I have seen mothers whose eyes go flat as the providers are giving a series of cold harsh commands that deny the truth of what the woman and baby in front of them are doing in that moment. I have wondered: why do these loving connected people turn into the essence of 1950’s medical model when it comes to birth? How do these women accept what is done? Do they gather and tell their stories to each other or is this just parked away as one of the many things women here experience as part of their lives? Am I projecting all of this onto the women and it does not bother them at all?
Today I went in early and stayed late. I learned so much today about so many aspects of birth and this culture and the women here. Last week I did a day of prenatal clinic as you’ll recall if you’ve been reading. It was very insightful and helped me understand the charting and what kind of care is received before we see them during labor down on the maternity ward. That day I was shown how one visit typically goes and then thrown into a room by myself. One of the women came in and stopped me in my struggle with Bislama by telling me she speaks English. We had quite a long visit with her as she had some things going on and it took a while for me to find out what kind of tests (if any) I could order for her as well as for me to interpret the previous results from another test she had done (we measure differently to start with but I could not read the doctor’s writing at all—another thing that seems to be the same in any language! And for the LD fans out there, I thought right away to go to a pharmacist to have it interpreted but the pharmacy is three buildings away!) She is a very tall woman by American standards, but here, where I am tall, she is several heads above most of the people here. She is a calm, centered, and strong woman. Long and short of it, I just really enjoyed her and hoped very much I would be on duty for her birth. When I came in this morning she was there, in very early labor with her fourth child. She was unhappy with what she felt was prodromal labor (a long early labor that didn’t seem to be picking up in intensity). She asked me what I thought about her going outside for some exercise and I agreed that sounded like a good idea. I showed her the stomping I had been taught by some Kenyan woman many years ago and she headed out the door to “go find a hill to stomp down”. She came in a bit later looking more active and indeed when she was checked she had made quite a lot of progress. I understand her frustration as all around her women here have their babies after only a few short but intense hours of labor (we had one deliver in the car on the way to the hospital today btw) and woman after woman came through delivering while she walked the corridor with her mom. I checked in on her often and between other deliveries gave her mom a break and rubbed her back. I did manage something fun today with a dad who had missed the birth of his first baby and was adamant that he would not miss this one. He was so involved and loving with his wife. I had him discover the sex of the baby by picking up the legs and making eyes at him to look—he sang out as he announced “one smol boy!!” and then I had him cut the cord. Something very few men here have done. He loved it. It was a very celebratory moment and he kept checking on me the rest of the day and smiling proudly.
There are a handful of Australian medical students here and they are full of questions and eager to learn so I spent a lot of the day talking to them about what we do and why, and what they will see here and why not to do it. One student attached himself to me and he was blown away by simple things like comfort measures and acupressure points. He took his learning quite seriously and it was something else to see this 6’3 Australian doctor rubbing a mother’s back and asking if he was getting it right. There is the most amazing midwife here from New Zealand—she is here on a two year contract and is a wonderful teacher and mentor for the staff here, and for myself and the other volunteer midwives. I have learned from her to stake my claim to a birthing woman and I have learned that I would rather be alone, knowing I can call out for help at any time if I need it, and manage the birth the way I want to then to have some of the local midwives come in and start barking at the mothers. We can be having a gentle lovely birthing with an actively engaged mother and it can all get shut down in a second when the local midwives come in and tell the women to lay flat and stop talking and push until they are purple in the face. I have learned to speak up for what I want here in all new ways as I talk over them, coaxing the mother back to what is hers: her birthing.
Late in the afternoon around 2:30 this mother got into active busy labor. I stayed with her, as did the Australian doc. We massaged her and gave her water and told her how wonderful she was. She labored silently, smiling or grimacing when a contraction hit and then resting in between them. She sat upright on the bed for a while, then asked if it was ok if she took a walk-about (which means, as it suggests, that she wanted to be able to walk around). I encouraged her to do so, to follow her body and was so happy as the local providers all got busy elsewhere and left us alone. Her mother stayed with her and she had a lot of attention from the three of us. She became very hot and I used one of the gauze cuttings as a washcloth, wetting it with cold water and wiping her down. She made such happy moans and told me it felt sooo good. Around 3:30 she told us her other birth stories. We listened to her. We asked her questions. She said this number 4 baby was acting like her number 2 baby—taking a long long time to come. Around 3:50 she told me her husband is a sea-man, out on a ship due back tonight at 8pm. I said, “oh, now I see what is happening here—do you miss him?” She looked at me and smiled. Her contractions picked up and became very long. The Aussie doc had to leave and the other American midwife came on duty and offered to assist which I was so happy for. At 4:02 mom leaned back and arched her back and her waters burst forth like those from a damn, suddenly shattered. I felt the wetness seep into my scrubs and saw how far it reached across the room. I love that power—it shows us how strong those membranes are and how strong the contractions are! A local midwife wandered in and sure enough started barking at her. I spoke right over her and said the mother’s name. She looked up at me and I told her, “gently, gently, you keep doing what you are doing, you are perfect. Do not be afraid and do not rush, we are right here and your baby is fine.” The other American midwife spoke in such soothing low tones to her, talking slowly and never relenting until the other midwife stopped talking and just stood back and listened and watched. Slowly, slowly the baby crowned showing us a bit more of herself each minute. At 4:08 the baby was born with hardly a cry and I put her right on mom’s chest, skin to skin. The mother said, “she is happy here on my belly, she is not crying.” Smart mama. After we had her all cleaned up and resting and nursing her baby she told me she felt so fortunate to have come when I was there, to have had this birth where no one was commanding her to do this or that, to feel she could come up onto her elbows to birth the baby instead of laying flat. I finally got to ask my questions to a woman who could answer them fully and we talked about the treatment here and the perception of the treatment in great detail.
I told her that we believe babies are conceived in love and should come into this world surrounded by love to which she and her mother fully agreed. The midwife from New Zealand told her she needs to go and tell her women friends that this is what it should be like and this is what they should demand…to be respected and encouraged and trusted, that change comes best from the consumers. We talked about our families and she told me she had been a basketball player. I told her about Julia and that she loves basketball so much that in all of her school pictures she has her basketball with her. She replied a simple, “of course they do. A girl who loves basketball is all about basketball.” Fabulous. And in a delightful surprise I now have a very tall 4200 kilogram (9.3 lbs) baby named after me : ) . Tomorrow I am bringing in my camera as I must have a picture with this family!
Today I learned that it is not just about one birth or one mother and me doing the best I can for that woman and that baby. It is all about one birth and one mother and me doing the best I can for that woman and that baby. We don’t know when we are interacting with someone where that interaction will take them. And we certainly don’t know where it will take us. Her birth has taken me places. It was transformative for my understanding of who I can be, here and at home.
I have seen many wonderful things from the midwives here. I have seen them stop a postpartum hemorrhage with finesse. I have seen them mop and scrub and set up a bed for a mother with great concern for the details of cleanliness and infection prevention. I have seen them wrestling with what care plan to lay out for a complicated case. I have seen lights turn on in their minds when a new plan was introduced to try to understand why the babies who die here are dying. I have seen them attend to families as if they were their own. They have so much they do so well and I know they have the capacity for the rest. They were trained in this very specific way and I think with the work that this New Zealand midwife is doing they will continue to improve and grow as providers.
On a side note, the Aussie med students came in today with loads of boxes full of brand new and used hospital equipment, including a new pump for the Nursery/NICU, resuscitation equipment and so much more. It was very thrilling. For anyone planning on coming here, if you take Air Pacific you can bring as many bags as you’d like if they are under 50lbs. Please let me know if you are coming and I will email you a list of much needed supplies. It is worth the lug to get them here!
Walls of Heat, Walls of Rain–Jodilyn June 18, 2011
A note about the weather here: it has decided to act up. I got trapped in my room when sheets of, or rather buckets of rain were dumped down upon the island by fast moving clouds plowing their way across the Pacific. When it finally seemed to let up I headed out to do some errands, carefully placing things that matter to me in ziplocks, just in case. The roads are slippery here when coated with an inch of rain and silt and the going was slow. I finished a few of my errands, including one to purchase an umbrella, when the skies opened up again. I decided to wait it out over a book and a glass of apple juice, which oddly enough hit the spot–likely replenishing some much needed sugars that had been sucked out of my body on the river of sweat which poured forth. I sat in the back of this ice cream shop which is open to a view of the ocean. It was so strange watching 60+ year old Australian men drinking milk shakes, which is what was happening in multitudes. There were only two children in the entire shop. Actually, let me diverge for a moment and say these Australians really have me baffled. There are many (and I mean many) women well into their 50s, 60s, and 70s who walk around town wearing corn-rows braided from their foreheads back by the local women who charge a few hundred Vatu for the service. At first I found myself wondering but now when I see them I just think happy thoughts of women who are no longer 17 years old feeling just good enough in the sun and the surf to try things like this. So oi oi oi Aussie women, I give it to you for the braids and the male companions 20 years your junior and all the rest of the unmentionables as well!! And hooray for giant chocolate milkshakes—of all the things a man who wants to venture out and go crazy at the age of 60 might do, a chocolate milkshake seems like a safe foray into pleasure (and it’s decidedly Chlamydia-free)!
By the time I got back to my room I was caked in mud up to my knees…and not Seattle mud. This was the kind of mud fancy French people use for facials and it requires scrubbing to remove. I was soaked from head to knee in water from walking in the heat and rain so I took a cold shower and scrubbed my shins, calves, and feet for a very long time.
Ok, back to the weather and the ice cream shop as I seemed to have skipped that part. I became engrossed in my book when I felt I was being rained on. I looked up and saw that indeed, the rain was so strong outside it was spraying 8 feet into the non-window windows and I was getting a cool shower. I could hardly complain as just minutes prior the air had become heavy with heat. I waited a good 20 minutes for it to let up and then walked back to my room. The rest of the day was spent in this vicious cycle: heat builds, pressure builds, it feels like you are sitting in a hot cloud. Then it sounds like you are about to be run over by a train—this is the only way I can think to describe it: you are tied to a railroad track with your ear on the rail and you feel and hear the train bearing down on you at the same time. Then there is water. Everywhere. Then it gets louder (an island of tin roofs adds to the noise factor). And louder still. Heart rate increases. Are we *SURE* this complex has not slid down the hill into the ocean before? Where’s my flashlight?t (oh, in my hand) Maybe I should listen to some music? (nope, can’t hear it even when the ihome is on full volume!) What kind of bugs are being unearthed right now? What kind of snakes are slithering and where will they land? I hope the dog that charged me earlier today drowns. Remember Seattle?!!! It was so calm there…….Then it’s over. Then there are three blissful minutes of cool breezes and relief from the barometric pressure. Then you notice it feels funny to draw a full breath again as you are sitting in a hot cloud.
This went on for the better part of the afternoon and all the way into the early morning. So when it is not stunning here—sunny and wonderful and breezy if a bit humid, it is kind of stunning—a mighty show from Mother Nature I have never seen the likes of before.