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.