essentialmidwifery

Birthy Thoughts by Jane E. Drichta and Jodilyn Owen

Viola October 22, 2012

Filed under: Jane,Uganda — EssentialMidwifery @ 8:49 am
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There has been a woman in labor here at Shanti for the past two days.  Viola looks about my daughter Anna’s age, but she is actually 25, and this will be her third living child.  She is petite, commited to this labor, and really really working hard.  She is laboring out of site of the training, although we catch glimpes of her walking around the beautiful grounds, working with through her contractions with the help of an older woman.  I assume this is her mother-in-law, as they seem to be the most common labor attendants here.  She has captured all of our hearts; her labor is difficult, and she is so so tired.

We always say that third babies are the wild card.  While they are housed in an experienced uterus, it is one who has been stretched out.  Third babies can get into all sorts of wonky positions, causing a longer  (and depending on the position of the baby) more intense. labor.  Early this afternoon, one of the midwives asks if I would check her, as they would like to know if I can ascertain the position of the baby, and maybe give some suggestions to help.

When I enter the birth room, Viola is lying on a plastic sheet, moaning slightly, even when she is not actively contracting.  She is having a very difficult time relaxing between contractions, and she is holding her lower back.  I note where she is lying (her left side), and that she taps out a quick staccato rhythm with her right hand when she contracts.  She is sweating, shaking, and she is deep deep into that place we call Labor Land.  She does not glance up at me as I sit silently on the bed next to her, just letting her get used to my presence. Her belly is flat in front, from just above the umbilicus to a few inches below.  Her contractions are irregular, between 3 and 6 minutes apart, although when they do come, they are very strong. I ask her softly if I can feel her belly, and she nods quickly, just once.

Now, so far, my “examination” of her has been pure  observation, and observation is the heart of doula work.  If she’s clutching her back, there’s a good chance it probably hurts even in between contractions.  Lying instinctively on her left side is not only good for getting the maximum amount of oxygen to the baby, but can also help a baby rotate and come down into the birth canal.  And a flat front belly can indicate a baby who is hanging out in the occiput posterior position, also known as “sunnyside up.”  The baby’s spine is resting against the mother’s and this bone on bone action can cause the dreaded “back labor.”  And, from the shape of her belly, I can tell that the baby has not yet dropped down into the pelvis.  This is not uncommon in women who have had prior babies, so it doesn’t really concern me.   From the length of her labor, I can theorize that this baby is probably not only sunnyside up, most likely acynclitic as well, a situation where the baby’s head gets cocked off to one side or the other. This makes it harder for the baby to descend, as the surface area of the head is increased.

All of these things can be helped along (sometimes) by positioning exercises, which, coincidently, is exactly what we are teaching today!  So convenient.  The midwives have already used some of the exercises we showed them, but here is a great chance to illustrate how to read a labor, how to put all these little clues together and make a plan to get this baby shifted.  I knew that as soon at the baby worked out how to drop into the pelvis, Viola would not have to push long.  I could tell from the size of her belly and some gentle palpation that this was not a giant baby, and if she had birthed two full term babies previously, there should be plenty of room.

At this point, I pretty much knew all there was to know, and an internal exam was just going to be a formality.  She was most likely almost through dilating, but the baby was still high in the pelvis, trying to turn its head this way and that, searching for the way that fit him or her best.  The trick was going to be to give her enough time, and keep her energy up enough to let her body and her baby do their work.  She was very very tired, although she was eating pineapple and peeing frequently.  (This last is important, as a full bladder can impede a baby’s descent.  Think about how close the bladder is to the uterus, and you can see why.  For those readers without a uterus, I’m sure you can imagine.

I grab a glove from the box, and ask her permission to examine her.  She nods once and rolls over.  Sure enough, she is 9 cm dilated, but the baby is still floating.  As hard as she has been working, she’s going to have to do a bit more.  I explain how to position her on her left side, with her leg raised high on pillows, almost lying on her baby.  In the western obstetrical world, we call this position Modified Sims.  In Viola’s world, we call it resting comfortably.  I give the midwives a few more suggestions for when Viola is able to participate more actively, including the Captain Morgan (one leg on a chair, the other on the ground, swaying gently through contractions) and hands and knees, leaning over one of the new donated birth balls.  (Thank you, Simkin Center in Seattle!!).  I smile at her, check the heart tones of the baby to ensure that he or she is liking this position, (heart tones are perfect!) and leave her with the Ugandan midwives.

This goes on all afternoon.  Periodically I would be asked to check on her, and periodically I would go in and hang out with her, offering suggestions as we went.  Eventually the midwives start an IV, just to keep her hydrated in the Ugandan heat.  We also used the rebozo with her, and put her through a million different other positions.  She was a trooper though all of it.  Eventually it was time to leave, though, and Viola was still laboring.  I was certain she would either deliver that night, or be transported for an obstructed labor.

The next morning, I was delighted to find that she had birthed during the night.  Hooray!!  Photo: Baby Patrick and his gorgeous mother, Viola. Sometimes even 4th babies have two day labors.And sure enough, it had only taken two pushes .  Baby just had to find the way.  As Melinda and I sat admiring the baby, and telling Viola how wonderful she was, I asked his name.  “Jane, I want you to name him,” she replied, smiling.  I was shocked and honored.  Together we decided on Patrick, after my beloved husband.  It is a gift to get close enough to someone that they want you to name their baby.  A true gift  to connect on the most basic womanly level, though birth.  I hope Patrick lives a long and happy life.  I know he has a wonderful family, and I hope I can see him next time I return to Shanti.

 

Finally!–Jane October 10, 2012

Filed under: Uncategorized — EssentialMidwifery @ 7:49 pm
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I’m usually one of those people who sits and waits for everyone to get off the plane.  After all, we will all get there, and pushing and shoving isn’t going to get anyone anywhere faster.  Today, I barreled over 13 little old ladies, shoved 10 babies back toward the bathroom, and took out at least one nun in my haste to get out.  (I think it was a nun…I was a little distracted by the screaming.)

And finally, finally, I was outside, my feet on the tarmac, breathing in that Ugandan air.  I could smell charcoal, and burning garbage and jet fuel, strained through an almost visible gauzy screen made of equal parts heat and humidity.  It was glorious.

I have no idea why I feel so connected to this place, to this little tiny country, so far away from my day to day reality.  I do know that I’m not alone.  Over the years I have met many people who smile knowingly when I mention my love for Africa and Uganda in particular.  Maybe its some sort of species memory?  We all came from Africa, if we trace humanity back far enough.Maybe there is some sort of cellular recognition that occurs, a physiological or psychological deep breath that happens when we are so close to the place where we all began. A reset button, if you will. On the other hand, though, I know people who feel this way about Vegas, so there may be a few holes in this theory.

I think for me, it is the very real fact that everything seems possible here.  I want to put on a doula training in Uganda.  Poof.  Five months later,we’re standing here. Natalie wanted a birth center.  So she made one happen.  I don’t mean to devalue anyone’s hard work, for these projects obviously don’t come together as easily as all that.  There is a ton of work and fear and tears and paperwork to be lived through, but the point is that things feel possible here, in a way that I do not feel at home.

My (and the lovely Jodilyn’s)interactions with Washington State’s bureaucracy are long and storied, and I’ll be damned if I’m going to give them airtime here.  But suffice to say, they have beaten me down to such a state that I no longer believe in the midwifery dream in my home.  And it is very easy to let that attitude go viral all over my soul, and longer believe in anything.  Well, anything good.  Uganda is my antidote, my injection of hope, a periodic inoculation against the darkness that I fight almost constantly.

And speaking of darkness, it is dark here.  There are almost no lights on as we move into the terminal, collect our bags, and stand in the various customs and immigration lines.  Uganda tends to export her electricity, which is good for the GNP, I suppose, but bad for finding your way though the airport.  Eventually, though, all the formalities have been fulfilled, and I see Ben, our driver and my friend, waiting just outside.

He looks great, exactly the same as last year, and we exchange excited greetings and formalities.  Families are asked about, teasing about his idol Celine Dion commences, and before I know it, we are flying down bumpy roads towards the Guest House which will be our home for the next week and a half.  I fell asleep.

We arrive at the Guest House a few hours later.  It is beautiful, a series of rooms opening into a central courtyard.  And best of all?  A real toilet!  My obsession with all things toilet-y is well documented, and I am absolutely thrilled.  I immediately snap a pic for Anna, who will be so jealous.  Kelli, Best Roommate Ever, and I go over to the Common Room for a quick snack of fruit, and then we go to sleep almost immediately.

I awake to the sound of the Muslim Call to Prayer, just before dawn.  I’ve been asleep maybe three hours.  Hauntingly beautiful would be the clichéd way to describe it, but that doesn’t make it any less true.  I want to open the door so I can hear better, but it creaks like my grandmother’s knees, and I don’t want to wake Kelli, so I content myself with pressing my ear up against the door. The muezzin’s voice swirls like smoke, ruffling the banana leaves, gently lifting the pampas grass in the courtyard, and somehow harmonizing with the first birdsongs of the day.  It’s a sweet solitary moment, just me alone with my Uganda and my God.

Kelli wakes up, and we go off to eat some breakfast.  Fruit (Kasana is located smack dab in the middle of the pineapple capital of Uganda), bread, tea.  Like any good English girl, I tend to drink quite a bit of black tea, always with milk and sugar, because to do so otherwise is completely uncivilized.  This particular combination, the powdered, wont-quite-dissolve, floats on the surface and coats your tongue milk and the huge, brown sugar crystals?  (No fresh milk, as there is questionable electricity and thus questionable refrigeration.)  Pure Uganda.

Sara, one of the long term Shanti volunteers, arrives and leads us through some gentle yoga stretching.  Gah, I have got to find some way to love yoga.  It is a struggle for me.  I know it would be good for me (and my old, worn down broken back), but I just can’t get into it.  Ah well.  Its good to have goals. The whole time I’m supposed to be sitting with myself and meditating on different tensions in my body, my mind is drifting to the training.  (Well, and Johnny Depp, but those thoughts have the constancy of gravity with this girl.)

I have the utmost confidence in my fellow trainers.  They know their stuff, backwards and forwards, so I am completely not worried about their integrity or the validity of the information they will impart.  I know the participants will come away bursting with knowledge and skills.  I am not doing as much direct teaching as they are, as I have some other stuff at Shanti I want to get done (more on that later.)  I am intrigued to watch our different personalities and areas of expertise wind their way around the material.  We all have different ideas and different styles.  Boy, do we have different styles.  Melinda is straight, by the book, linear. She is able to see (and explain) so clearly how each piece of knowledge builds on the previous one, creating a solid ladder of information, with a clear beginning and end. Kristina lives in a world full of expansive language and heart led experience.  Her words are ladles, dipping into a delicious soup, each nourishing anecdote effortlessly brought to the surface. And me?  Who knows?  I just let things flow, trust things will go where they need to, and kick things back into play if they get too out of hand, It is a testimony to the professionalism of these two women that anything gets done at all.  Yet, it all seems to be coming together.  How?  Magic.  The magic of this land, the magic of women’s need to connect, the magic of story telling.  I’m excited to start.

In order to get down to Shanti, we are going to have to ride boda bodas.  These motorcycles taxis are the standard way to navigating Uganda.  They drive absolutely crazily, weaving in and out of trucks, cars and pedestrians like pop rocks on crack.  Luckily, we will take back roads, where the potholes are so bad that its impossible to go too fast.  I figure that the worst that could happen is a broken limb.  Certainly not death.  I was so proud of Melinda and Kristina.  I knew they were nervous, but they just plastered big fake smiles on their faces and sucked it up.  (Halfway through, though, I think they were enjoying it.  : )

In about 10 minutes, we pulled up to the gates of Shanti.  To say it felt like coming home is an understatement.  I really don’t have any words, so I won’t even try.  Let’s just say I was able to breath deeply and think clearly for the first time in a long time.  This place means so much to me.  I am unreasonably protective of it, and the people who make it what it is.  That is a bit condescending, I think.  They don’t need my protection,or admiration, but they have my love whether they want it or not.  Emma the lab tech was the first person I saw, followed quickly by the midwives I had worked so closely with last year.  Honey, the baby of Midwife SSanyu, was now a sturdy toddler, teething all over herself.  SSanyu herself was as beautiful and solid as ever, and Midwife Joy was there with her steady presence and quiet confidence.  New friends too:  Sister Mar, the head midwife.  I had sat in on her interview last year, and was overjoyed when Shanti was able to convince her to come and work there.  A midwife for over 30 years, she has both the chops and the humility that resides inside the very best in our profession.  She also has a wicked sense of humor, which is absolutely vital.  Another delight was Stella, a smart-as-a-whip midwife who came to SHanti with Sadie, the new project director.

But almost best of all (for how can there really be a “best”) was FLorence.  My facebook people know all about Florence, the Traditional Birth Attendant, who has been with Shanti since the first brick was laid.

Here is Florence talking with Joy, who is wearing scrubs.  We fundraised so hard for Florence to be able to take this training and to cover all her expenses for the next year.  She is everything good at Shanti, the mix of the traditional and the modern.  She is the Wise Woman archetype, the one in whom resides the old knowledge, yet open to the new.  She is shy and deferential when at work, seemingly intimidated by those she considers to be more knowledgeable or netter schooled than herself.  But get her alone or in a small group, and she opens right up, and WOW.  Birth goo runs in this woman’s veins.

We were lucky in that the Women’s Income Groups were both on site, and had their wares available for us to peruse and purchase.  These are all HIV positive women, working in collective with Shanti to create bags and beads.  Their work is beautiful, and I was happy to have the chance to pick up a few things missing from my Shanti collection.  I had TOTALLY regretted not getting a patchwork bag such as I had gifted both my mother and Jodilyn last year.  In fact, I considered swiping Jodilyn’s more than once; I’m happy Shanti was able to keep me from a burgeoning life of crime.

After shopping came lunch.  Now, those of you who followed me last year are more than aware of my feelings on Ugandan food.  It is nourishing, and always shared with great generosity of spirit and hospitality.  I appreciate it so much for what it represents.  However, it is not my favorite flavor palate.  It is not bad, just a bit bland.  And, there is very little variety. Almost every meal consists of matooke (smushed up plantains cooked in banana leaves) a starchy veggie like pumpkin or squash) rice and beans or potatoes covered in ground nut sauce.  Very dense, and very very filling.  Also, there was usually a side of delicious greens and the afore mentioned gorgeous pineapple.

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Then the training started, although I think by that time, we were mostly braindead.  I think it went well.  But too be honest, monkeys on broomsticks could have flown through the building screaming obscenities in Norwegian, and I probably would have just nodded and smiled.  It had been a very very long day.

 

Attachments, or the Lack Thereof-Jane October 8, 2012

Filed under: Uncategorized — EssentialMidwifery @ 12:30 am
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In the hippie dippy, woo-woo, Jedi Knight influenced world in which I dabble, I hear a lot about attachments.  Apparently we are supposed to become unattached to things, ideas, etc, because they only lead to misery. This is always a really big problem for me.  I’m attached to lots and lots of things.  Lots and lots. This trip is one big lesson in letting go.  I am very laid back, and (I like very much to think) creative and able to think on the fly, but it is always grounded in some very basic ideas about how I think the world should work.  Getting out of my own head and into another person’s reality is always challenging for me, and I’m already learning this in a big way. 

One thing I am completely unattached to is sleep. This is handy both as a midwife and as a traveller. I can never sleep before a trip.  I’m like a little kid, wide eyed and too excited to settle.  Last night was no exception, and I was awake long before the 4:40 am wake-up call.  Usually I like to get to the airport at the very last minute, but with international flights,especially those involving lots of connections, I like to make sure that we have tons of time for things to go wrong.  I also wanted to be available to settle Kristina and Kelli should they need it, or at the very least be a shoulder for them to cry on if needed.  They are both leaving young kids behind and that is so so big.  I really admire them for that, and hope I can be as supportive and loving as they need.

Luckily Pat didn’t have to work until a bit later in the morning, so he was available to take me to the airport.  We walked in, and I noticed a guy under the appointed sign that may or may not have been Randy, Kristina’s husband.  I’ve only ever seen him on the internets, and only from the neck up.  He was very big, and looked very cranky.  I smiled, and tried to send psychic messages to him as I came up the escalator.  Things like, “Your wife is awesome and cool.”  And “I promise she won’t get eaten by lions.”  And “The ebola outbreak is totally over, I swear on all that is holy.”  It didn’t seem to have much of an effect, so I was glad when Kristina came bustling over from across the terminal.  Kelli joined us soon after, her body and spirit radiating sadness from saying her own goodbyes.  But soon the excitement overtook us, and we bustled along to the international flight counter.

After a bit of discussion with the airline employee about where we were goingand how best to handle the change of airlines in Chicago  (Answer:  Grab you own luggage, Ladies, and re-check it before you leave for Brussels.), we were officially off.  Saying goodbye to Pat was hard as always. I swear, that man is a freaking saint.  He puts up with an awful lot from me, and never ever complains.  In fact, he never says anything except Big Nice Words, and for that I will always be grateful. 

Security was a breeze, and we were especially excited that Kristina’s henna got through unmolested.  I was officially attached to getting a lovely peacock or something on my hand whenever we found some travel downtime.  I love henna, the ritual, the smell, everything about it.  So hooray for TSA people who didn’t care about sticky, unidentifiable brown substances.

Breakfast and coffee were next, and I found out another thing I was unattached to:  my wallet.  Yes, I had left it at home in my purse, not transferring it to my backpack during the normal last minute rush.  Hmmm.  Was it possible to travel to Uganda without my wallet?  No money, no health insurance card, no driver’s license?  It was going to have to be.  Pat was at work, and there was no way to get it.  I did call him, and asked him to run some cash over to Kelli’s husband, so we could both work off her account, so at least I had access to cash.  I had my passport, so I’m sure it would all be fine.  Off we go to Chicago.

We changed airlines without a hitch, getting our luggage and re-checking it without a problem.  We drove the poor airline employee nuts at the check-in counter though, as we wanted to get boarding passes for the next two legs of our trip, rather than have to check in again in Brussels.  It was a big computer problem, as apparently they had just changed sysytems to DOS.  Yes, you heard me.  Apparently not only had we travelled to Chicago, we had also travelled to 1986.  Who knew Boeing was making time machines that looked like planes?  It was quite the Marty McFly moment.  But eventually we got it all figured out, got to the gate, and settled in to wait.  Henna at last!

I’m glad we are being unattached because it meant we weren’t worried at all when our plane left 45 minutes late,and we only had an hour layover in Brussels.  And there wan’t another flight to Uganda for three days.  Lucky we already had the boarding passes! But, we made a couple of contingency plans, texted Melinda who was meeting us in Belgium and told her to go on ahead if we missed the plane and just let nature (and several fabulous undoubtably union mechanics) take its course.  As it happened, we made the plane with fifteen minutes to spare, and we were on to the next leg of the trip, the one that would end with us in one of my very favorite places in the universe.

I’m a big believer in ambien for long plane flights, as I already have enough trouble sleeping under normal circumstances.  There is no way I can possibly sleep on a plane without a little pharmacological help.  So, I popped one of those bad boys and began to drift.  The last words I heard clearly were the flight attendant giving some poor girl hell.  her crime?  Not putting her cell phone away quickly enough. 

“I’m in charge of this cabin, and if I say you put that phone away, you will!” he barked.  Whew!  He needs to learn a bit about attachment to ego. (Not at all like me, of course.  I’m a Jedi knight on this trip, remember?)  Or, at the very least, attachment to observation or consistancy, as there was another girl chattering behind us, right up to the point that the plane began taxi-ing.  Kristina and I nicknamed him Napoleon, as he was short, French, and needed to a vacation in Elba or something.

After almost no time to me (thank you, sleeping pill) we were on final approach to Entebbe.  I tried to look across the aisle and see, but there were three people in my way, and it was dark.  I would have to wait a few more minutes before I would get my first glance of the place I had not been able to get out of my mind or heart in over a year.

 

Of netbooks, imodium and joy-Jane September 23, 2012

Filed under: Uncategorized — EssentialMidwifery @ 9:23 pm
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You know that feeling when you come home from work, take off your bra, (oh, you know you do!)and slide into some old, well worn, slippers?  That aaahhhhh made of contentment and peace?  That’s exactly how I feel right now, typing this on my old travelling netbook.  The keys are too small and clacky, the Internet speed is measured in seconds, and its been through three power cords.  I got this little beauty in 2008, when my father was ill, so I could carry it back and forth with me to St. Louis.  Since then, it has seen The Philippines, Uganda, Whidbey Island, Portland, London, and a bunch of other places, near and far.  And now we’re off again, back to Uganda to teach and learn and see.

Its is actually kind of a riot that I’m using this computer right now, as my regular laptop is sitting just over there on the counter, and I haven’t even left home.  But I wanted to get in the mood, indulge in a little travel foreplay, if you will.  I’ve already done most of the packing.  My clothes are drying right now: 3 skirts, 4 t shirts and a metric ton of underwear.  This girl has her priorities firmly in place.  I’ve sorted the drugs into catagories, and packed them in either the carry on or the regular rucksack:  Def Con 1 prescriptions, ie malaria prophylaxis, ambien for the plane. Def Con 1 non-prescription, incuding advil and tums.  Then we get down to the Def Con2 prescriptions, Cipro, Bactrin and a wee tiny bit of vicodin because this midwife’s back is not as young as it used to be.  And finally we have the Def Con 2 non-prescription, which basically includes everything else Walgreens sells with an emphasis on things that make you poop less.  Poop is a Big Deal in many of the places I frequent, and one bout of norovirus made me never take solid food for granted again.

I’ve also packed some donations of medical supplies, (although I have to run out and pick some more up), and the teaching supplies we need for the training.  We are all pack mules, but I feel like I’m as stripped down as possible.  I’m taking my doppler as well.  Please don’t judge me, birthy friends!  I come with love and good intention. I promise.   I know the controversy, and I’m consciously choosing to put that aside.  We have the luxury of choosing not to listen or get ultrasounds, or do any of the things that our accident of first world birth allows us to do.  If we feel our baby isn’t moving, or we have any concerns at all about her wellbeing, we have these technologies readily available to us.  But Ugandan women do not.  If their baby isn’t moving, they either go to the clinic where the midwives use steths and fetoscopes to try and get an idea of what is going on, or they don’t do anything and pray.  For the ten days that I’m there, they are going to have access to a doppler.  Hopefully it will just be used for happy doings; the vast majority of women I know love to hear that little heart jumping away in there, and I assume Ugandan women will enjoy it too.  And if it needs to be pulled out for a darker purpose, it will be there for that as well.

So now I’m down to the last errands.  Off to the ATM, Freddies, Kinkos, and my office to grab a few odds and ends.  And tonight I’m going to practice my Lugandan.  I wonder how you say, “Ready or not, here I come?”

 

Where are the birth stories?–Jane July 19, 2011

Filed under: Jane,Uganda — EssentialMidwifery @ 10:36 pm
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Ha!  You noticed!  There aren’t any.  Yes, there was not a single baby born during our stay in Uganda.  However, I learned so much anyway.  It really put the focus on prenatal care, and teaching, which is something I really love, so please believe me when I say that the trip was not in any way disappointing.  Good prenatal care is really the foundation of all midwifery work.  It is not only about meeting mothers where they are, but really peeling back the layers of who she is as a person, and showing her how she is absolutely the best mother for her baby.  It is about showing mothers what they already know, and how they are the experts both on their pregnancy and on their particular baby.  And it’s about convincing other people that no matter who this mother is, whether she is a 15 year old singlemama, or a 35 year attorney , they deserve respect and honor.  And in this case, it was doing all of this in a language I do not speak.

Many many women come to these rural centers never intending to deliver there; in many cases they live too far from the center to reliably make it in time.  In others, the pressure to birth in their village is just too strong.  But they come to Shanti anyway, to learn, to share their pregnancy experience, and to be with other women. Remember, these women cannot just look up a symptom on the internet.  They do not have electricity or running water.  And they may not have their mothers or grandmothers around to ask all those questions that a new mother has.  There are 3,000,ooo orphans in Uganda, victims of a brutal civil war in the 80s and 90s, AIDS, or other diseases.  These women are having children now, and are starved for information and love.

Shanti also functions of a de facto medical clinic, dispensing malaria treatments, parasite eradication protocols, and other basic supportive health care needs to pregnant women.  That’s something I would never see in Seattle, and I’m grateful for the chance to deepen my knowledge.  There is also a huge emphasis on post baby family planning.  It is vital that Uganda get its over population problem under control, or the many strides it has made will be for naught.  Safe, reliable birth control has to have a huge place in Uganda’s future, and I was very pleased to see it taken so seriously at Shanti.  The average Ugandan family has 8 children.  The death rate, thank goodness, is dropping, but the birth rate remains the same.  Clearly this is not sustainable, and is a huge obstacle to the empowerment of Ugandan women.  Choosing to have many children, as some of my most delightful clients at home do, is very different from it being forced upon you by circumstance.  Again, choice, choice, choice.

Immersing oneself in another culture is always challenging.  I am asking a lot of the midwives at Shanti, to reevaluate what they have been taught to do, and what they have been doing effectively in their previous jobs. In turn, I am reevaluating my own methods and work, making sure that they still match up with who I am, and what I believe is my purpose in this world.  And really, that is one of the most important things we can do, as midwives, or just as  human beings.  We keep examining, keep searching for clues as to how to find our true place, and if we are really lucky, we meet others who can help us, like I have both here in Uganda and at home.

 

The Story Unfolds–Jodilyn July 17, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 9:59 pm
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Yesterday was Sunday.  It has been raining and although I got myself all caked in mud on Friday in the name of going to market and getting out a bit, I stayed inside Saturday and had cabin fever by 5:30am Sunday morning.  The computer seemed like a trap I had no desire to lose my toes in so I decided to go to work.  I brought my umbrella to walk there.  It doesn’t rain for 10 or 15 feet and then the showers come on and frankly, they come on so fast and so hard that by the time my umbrella is up I am already drenched.  So I was mostly wet by the time I arrived but I passed one of my favorite midwives on her way home as I walked down the hill to the hospital.  She told me it was super busy and they will be happy to have my hands.

After that there is a giant blur but I will try to break it apart.  I walked in and put my backpack down in the lounge.  As I made my way to the board to see what was happening someone handed me a baby with directions to bathe and give it shots.  Oh Happy Work!!  I love love love floating these babies in warm water, watching as they unfold and look around and kick and relax.  Not to mention the baby cuddles which come in spades as I hold them in a towel to dry them off instead of rubbing their skin which I think must feel so sensitive in the first days after birth.  I brought baby to her mother and got them skin to skin, laying down in bed and then walked back to check the board which I had not managed to do.

“Jordilyrn!”  (every midwife here has their own version of my name, this I recognized as one of the senior midwives who walks with a limp but manages to lift mothers out of bed and scrub blood and muck out of sheets and do all of the hard labor involved in working here.)  I followed her voice to the delivery room and she told me she thought this mama was going fast.  She was opening the delivery kit and I looked at the mom, walked over to the counter and put on some gloves and turned around and caught the baby.  “Oh, you are going to do this delivery?”  She asked.  “Ummmm….you are welcome to but here is baby.”  A delighted laugh issued forth as she turned around again and saw baby already skin-to-skin with mom.  I offered to clean up and suture which she gratefully accepted.   I tidied up, sutured, and then got to scrubbing while the mother enjoyed her baby and her extended family came in to admire the new arrival.  I got mom to her bed, baby bathed and in bed with mom and then went to try again to look at the board and the charts.

The hallway was swarming with pregnant women.  They rub their own backs through contractions, reaching around and pushing up and down on their tailbones.  Sometimes their mothers or aunties or sister-in-laws will be there doing it for them and sometimes they will be sitting nearby chatting with the other mothers and aunties and sister-in laws.  Who is who?  I wonder about them.  I like to have my hands on a woman’s body before she births so I have an idea of her.  I want to know her name and what number child this is and if she tested positively or negatively for STDs.  I want to feel her belly and say hello to the baby.  I want to have a sense of her hygiene and some idea if her hemoglobin is beyond the low we think of as low.  I read through as many charts as I could but another page through the hallway, “Jordilyrn!”

I follow the call back to the delivery room where a young mother (and by young, I mean she is the exact age of my own daughter) is pacing back and forth, moaning.  I assume she is a first time mother because she is so young.  The midwife tells, me, “you stay with her.”  So I do.  I pick up her chart off the counter and see this is her second child.  The first was by cesarean section birth because the baby had been lying sideways in the belly.  OK, hooray!  A VBAC! I am really good at these.  I am smiling to myself and happy to be there.  I read the whole chart.  The doctor wants regular updates as to her progress and he wants her waters broken when the baby gets low enough.  OK, out of the range of things we would do to a VBAC but I am here on their turf.  I pause and watch her and start to think this through.  My rebellious VBAC self is screaming just to let her go and to have her baby before we call.  I rub her back and she wraps her lanky arm around my neck and strokes my shoulder.  She nuzzles her face into my neck and moans.  She is a child.  I feel her body, rubbing her hips and shoulders.  I look at her mother who is watching us and her daughter cries out to her, “Auwe Mommy!” I miss my girl.  Her mom is crying, watching her daughter like this.  She wipes her tears and shakes her head and comes to her daughter who launches herself from me to her mother.  She leans on her mother as I rub her back and talk in soothing soft words.  Telling her not to be afraid of what she is feeling.  Telling her she is safe and this is ok.

As her labor progresses I ask her if she wants me to check her.  She says she does.  I go and get my favorite nurse who acts as my translator.  She speaks softly to the moms and treats them gently.  I ask her to tell the mom that if the baby is low enough we can break her water, which will make her labor more intense.  I want to know if she wants me to do this or if she prefers not.  She wants me to if I can so I prepare ahead of the exam and confirm the plan with the head midwife.  I feel the baby, so low into the pelvis, and a bulging bag of waters ahead of it.  I snag the bag gently and it opens.  But the give of the bag was too easy and I felt it pull apart and rip down.  I listen to the baby as I think about what I felt.  Baby is doing great.  When I think about things not being as robust as I would expect them to feel or be here, I wonder right away about nutrition.  I ask the mom if she eats fish, chicken, beef, or ham.  No.  She eats island cabbage and white rice for dinner.  I park that in the back of my mind.  I tell the head midwife that she is nearly complete but since it is the first time she is pushing a baby out it could be a while. I don’t want the doctor cranky with me for calling too soon.

I walk back into the room and she is pushing.  I trot back out and say, “Nevermind.  She is pushing.  Calling Dr. B.”  The midwife comes into the room as the first of the head is showing with strict directions from the doctor to call if she has not delivered within an hour.  I ask her to stay.  I don’t feel good about friable tissue.  I see the telltale sign of bleeding from behind the baby.  I know what this is now, after having seen it so many times and know that she will be shredded on the inside and I want a witness to see that I did not do it to her by not cutting an episiotomy and that I have followed the doctor’s orders.  The midwife even remarked that she must be tearing on the inside.  Baby is born with three pushes, it is a beautiful wonderful birth.  And then the bleeding starts.  It is not pulsing, just gushing.  I feel for the uterus and can’t find it.  I make a map of her belly and start my search in quadrants.  I finally locate it but it is too low down.  Something is really really not right.  I rub and rub and it finally hardens beneath my hands.

I ask the midwife to start an IV and give her fluids and synto.  She gets it up fast.  We can’t run IVs as fast as mom is bleeding.  I take gauze and go in hard, looking for the source of the bleeding, thinking that if I can compress the tear it will stop.  It hurts mom.  I tell her I’m sorry and to take deep breaths.  I see one big tear, and what looks like the uterus, or the front of the uterus, or some other organ.  There is blood everywhere and it is hard to see but I know my landmarks and that is not one.  I start packing gauze into every tear I can find.  I am screaming in my head, “Protein!”  I know this is not the time to be thinking about nutrition and that I should be screaming other things in my head.  But I am frustrated with these women falling apart.  The doctor comes in and he is friendly and kind.  Blood is pouring over the gauze I have packed in her.  I am trying to convince her uterus to stay firm and I say outloud, “I would really like this uterus to stay firm.  Mama:  talk to your uterus, tell it to get hard.  Talk to your body.  Tell it to stop bleeding.”  It sounds bananas but this really does help when we do it at home.

I am dumping a bowl-full of blood out and putting the bowl back again.  And again.  I give the doctor the summary.  What has happened.  What I’ve felt.  What I’ve seen.  He takes my position and asks for a speculum.  I do not waste time removing my gloves and my bloody hands open the door and get out the kit he needs.  He confirms that the lower segment of the uterus has come down, he can see the rectum.  Everything is in the wrong place.  The one thing I know about this is that we can get it back up where it goes.  Sure enough he pushes the uterus back up and I can see it rolling up her belly.  I lock my hand in place on her belly to hold it there from the outside.  I massage it with my other hand.  It won’t stay hard despite the massive quantities of syntocin going into her through IV.  We place a second IV and draw blood to cross and match it, then hook her up to more fluids.  The doctor meanwhile is busy trying to find an apex to one of the tears so he can start suturing.  He eventually does it by feel.

He worked for 45 minutes with myself and another doctor assisting him.  She was bleeding the whole time.

He cleans up the best he can—the room is a flood of blood and looks like a hurricane has hit it as we tore open supplies and cracked bottles of medicine and fluids.  I am eager to clean up, I know it will feel soothing.  I ask for instructions from him—how often to do vitals (I did them twice as often), how much fluid to give, when to call him back.  I made a chart to record everything and put in consults to him once every 45 minutes for the first three hours.  He leaves and she has the shakes.  I chase him down and ask him how he feels about that.  He tells me to put some blankets on her and watch her vitals.  I do.  Her blood pressure tanks.   I get the senior midwife back again and she tells me to load on a plasma replacement gel and she will call the doctor and tell him that he wants us to do that.  I love that woman.  He tells us to load her with two doses of gel and keep running fluids until her pressure normalizes.  She has no urine output despite the now 4000 units of fluid we have put in.

I spent four hours with her, scrubbing the room to a shine while taking her pulse and temperature and blood pressure.  The grand-mother had taken the baby out to be with family.  I realized she needed a family member with her so I went to find her mom.  I saw her boyfriend there and I changed tactics.  I asked if he would come see her.  He too is just a teenager and he was scared witless.  I told him just to come talk with her.  She was in a sleep when we got to the room so I woke her and told her to say hello…I would later tell the doctor that this young man was the best medicine we gave her all day long.  I watched him step over his fear to be with her and encourage her.  She was shaking and pale and he spoke gently to her.  He looked up at me and said, “I think she is hungry.”  Teenagers are magnificent, capable, wonderful creatures.  I know they are busy finding out who they are but the sensitivity and depth of empathy they display when the chips are down are palpable.

I sent him to go get her some food and he returned with the source of her friable tissue….orange soda and white bread.  Frankly, I thought the sugar would do her good so did not object but made my way to the mom to ask her to go and get some milk.  She slowly ate and the combination of his company, the fluids, the food, and time seemed to be bringing her some strength.  At the end of the fourth hour her blood pressure looked pretty darn good and there was urine output again.

For my birthy people, don’t think I haven’t wondered if I had ignored orders and not broken her water if she would have shredded.  All I can offer up is past experiences here which tell me it did not make a difference whether the water was neatly emptied on a midwife’s schedule or came flying out all over me—this is so far beyond what we know of in America.  Poor nutrition here is not fast food and snickers bars.  It is a lifetime of orange soda, white bread, fried leafy greens and white rice.  No protein.   An entire lifetime of it.

It was already two hours past the end of the shift but the senior midwife had stayed with me to see this mom through.  I learned from this mother.  At home I always tell laboring moms who are having a long labor that they and the baby each have a story to tell and a journey to make, and we will understand it very clearly when it is all over, but cannot know it before then.  So too for the midwife.  The labor will tell its own story.  If I assume that each moment is the story I will be mired in parts instead of learning from the whole.  She was dying.  Then she was not.  And she did not.  And I worked hard and sweated and used everything I had available to me, including a consult to a very good physician to make it so.   We moved her to a postpartum room close to the midwives’ desk and got her settled with her baby, who forgave her the hours she had been away and eagerly looked at her and nursed well.

As I was dragging myself toward my backpack and home, I heard it again.  “Jordilyrn!”

I took a breath.  Really?  “Can you just check one mom before you go?”  Of course I can.  I brought mom into the admissions room.  A fourth time mom.  A posterior cervix.  No bleeding, no broken waters.  Hardly a contraction to speak of.  I saw Dr. B in the hall and asked him to come translate as she had no English.  “Can you ask her if she has any concerns?  I am wondering why she is here so early in labor if it is her 4th—she must feel something is happening.”  He skips my version and asks her all of the questions I already know how to ask and he tells me she should just go home.  She lives nearby and can come back later in more active labor.  Now a fourth time mother usually has a reason for calling a provider or showing up to a maternity ward.  I put her on the CTG to get a read on baby and contractions, just making sure everyone looked good before sending her home.  They looked stellar.  After 10 minutes I unpluged the machine from her and told her she could go home, or walk-about around here, or go into town with her sister for a girls night out…the choice was hers.  I helped her sit up.  She stood and there was a puddle of water.  I looked at her.  Her face had changed.  She was sweating and looking at me like I might  have the missing piece to a puzzle she has been working on for years.  “OK”  I say, “let’s go—right there”  I was pointing to the delivery room.  She is nodding slightly and making small deep questioning Scooby-doo-like noises.  “huhhhhh?”

I would like to pause to thank the two women I have been with as a doula who had posterior cervixes hardly dilated, followed by two contractions, followed by a baby.  Thank you.  I recognized in her what I was privileged enough to see in you.  I remember the nurses yammering on and on about how you couldn’t possibly be in labor, about how it will be several hours…I resolved not to be that person.

Mom took two steps up the stool to the bed and lay down.  I put on some gloves and turned around. I placed my hand gently on moms belly.  “Ok baby, today is your day.  Now is your moment.  Come to us gently and kiss your mama who has taken such good care of you.”  Mom smiled and pushed her baby out slowly.  A lovely pink healthy girl.  She did not cry.  She just lifted her head from mom’s chest and looked around.  “Welcome, welcome” I hum.  Mom was smiling dreamily from the baby to me and back again.  Auntywas laughing and crying.  I was waiting for the hemorrhage but it did not come.  I know how to do this birth.  I relax and smile and am thankful.  So thankful.  I feel the cord pulsing.  It pulsed for 19 minutes.  Aunty cut the cord.  Placenta came easily.  Hardly any bleeding.  “Surprise!” I say, laughing.  “Happy, Happy Birthday Baby…I’m so happy you are here ” I talk to the baby as I check to see if the cord has three vessels, if she is really as healthy and strong as I think she is.   Mom names her Jodilyn on the spot.  I can’t refuse.  I’m too happy.

 

Teaching a Birth–Jodilyn July 15, 2011

Filed under: Jodilyn,Vanuatu — EssentialMidwifery @ 4:33 am
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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.

 

Outside the Box–Jodilyn July 4, 2011

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

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

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

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

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

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

 

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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