essentialmidwifery

Birthy Thoughts by Jane E. Drichta and Jodilyn Owen

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

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

 

Winding Down…–Jodilyn July 25, 2011

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

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

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

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

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

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

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

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

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

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

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

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

 

Waiting to be saved–Jodilyn July 12, 2011

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

 

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

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

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

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

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

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

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

 

Continuity of Care–Jodilyn June 22, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 11:34 am
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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!

 

Today I… –Jodilyn June 19, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 7:37 am
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Today I…

  • caught a million babies.  (ok, maybe not that many but all four beds in one room were full the whole shift)
  • got pis pis’d on–the women today decided to empty their bladders just before pushing,  while laying supine, so it actually squirts up in an arc.  Surprise to me!  And a Quick Learning Curve—I only got tagged once.
  • I had a MAJOR postpartum hemorrhage from one first time mom.  And I managed it.  I had to order people around as I don’t have six hands but i did that effectively.  It really sucks when there is a river of blood pouring out of a woman.
  • I got pooped on by two babies who decided to show me just what they thought of the way their days went down.  I would probably crap on someone if I had to do what they did too…at least they are cute.
  • I calmly replaced the needles on two shots a nurse was prepping to give a newborn to baby size instead of man size needles. (yikes)  And then I explained to the babies my plan and gave them their shots (every baby gets hep B and vit k here)
  • I gave first baths to several babies who were all alert and interested in me.  I sang them silly songs.
  • I taught a young aunt how to bathe her niece and dress her.   I just pretend I know what I’m doing when it comes to these nappies—they are not like our diapers at home.  So now the aunt will always put them on wrong until one day, one of her family members points it out to her and she realizes what a ignoramus I really am when it come to under garments for newborns : )
  • I helped a nervous new dad to sit down while his wife was asleep and I put the baby in his arms and it was magical
  • I almost passed out (somewhere in the middle of the babies and heat I realized the weekend people don’t use the AC in the delivery rooms OR the fans…and I had been so busy I hadn’t had time to drink.  I had the mute nurse (who is so sweet) stand where I was standing and pretend to be me while I went into the midwive’s “lounge” and lay down and drank 40 oz of water straight.  It really, really helped.  Then I got up and got back to it.  I made a comment about it being hot and one of the other midwives said “it’s hot sistah, you said it!” and I looked around and everyone was drenched in sweat running down their bodies.  I made eyes at the AC and one of them flipped the on switch.  Too little too late, 4 women, their moms or sisters or both, 2 midwives, 2 nursing students, one doctor…too much heat for one rickety old window AC.  At least I had 40 more oz to sweat out.
  • After my shift I went to visit the kids down the hill and I made wheelchair races for siblings in the childrens ortho ward.  There are no Rules here for kids.  It is a dream come true.  They get to play and keep score and fight it out if there is a disagreement.  It is like Childhood Unleashed and it is such a relief!  Kids learning to think and problem solve without adults telling them every little step they should take.  It’s Fabu!   Anyway, we went outside where there are long sort of empty pathways with hills and raced around in a giant rectangle.  I ran behind them urging them ever faster.  One of the boys had a little sister jump on his lap who was about my nieces size and she held on for dear life as he plummeted down the hill.  I should mention that the wheelchairs are old wooden things that don’t resemble what we know about wheel chairs at all.  It was FUN!  The old people laughed and clapped for the kids.  I visited my little friend whose mom was sleeping yesterday.  He had his whole family with him today and had the run of his dad’s cell phone which was playing music.  We showed off our mad peek-a-boo skills.
  • I got to skype with Jeffrey and Benjy and wish B a happy Father’s day and say goodbye to Jeffrey as he gets ready for camp tomorrow!

It was a great, great day.  And now I will collapse.  Goodnight to all!

 

 
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