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.

 

Drums, Lunch, and Doula Musings-Jane October 20, 2012

Filed under: Jane,Uganda — EssentialMidwifery @ 6:39 pm
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Our visit to the hospital over, it was time for a visit to the drum shop and then lunch.  Sadie wanted to get the large drum used at Shanti bonfires re-covered, and I think we were all interested in perhaps purchasing a percussive souvenir. Drums are such a part of Africa. It is a stereotype to say that the entire country of Uganda has rhythm, but I’m going to risk it.  I’ve seen folks drum on jerry cans when nothing else was available, and it ends up sounding just perfect.

I don’t know what the drum shop lady thought when a herd of mzungus descended on her; its entirely possible that she had never sold so many of her wares at one time, and it is equally possible that she was just sitting down to lunch, and we were a huge interruption.  The drums, however, were beautiful, and we all picked out our favorites.  Several of our gang’s had insects inside, so they set them outside their door back at the guest house, where they remained the rest of the trip. Some people have old room service trays.  We have buggy drums.

Here’s the drum lady.  She looks considerably happier than when we first arrived.

Drums bought, we were off to lunch.  It was a buffet style on the Anglican diocese grounds.  We ate here last year, and it was remarkable in that it was basically our only bites of animal protein the whole trip.  I’m such a carnivore.  I was completely looking forward to it again for that reason.  No mattooke today for this girl!  And, in fact, there it was, sitting in the covered dishes in all its glory”  A piece of stewed chicken.  I think it was a thigh.  I’m not sure.  I didn’t care.  I was just so so happy to be eating it.  i also knocked back a bottle fo the local ginger beer (non-alcoholic).  It was delicious!

The afternoon’s training was four hours on how to educate your clients, and politics and power dynamics in the birth room.  I could talk all day on these subjects.  The education piece is always tricksy for me.  A doula’s job, on the deepest level, is to help draw out what a mama already knows.  We always say we want a mother to trust herself and trust her body.  The easiest way to facilitate this is to help her understand that she already knows the answers to the deepest questions, which in turn builds her confidence that she can participate fully in this experience without fear.  With help, a mother is often able to access that internal knowledge about the larger philosophical questions of birth and life and death, and can be taught how to express them coherently, This is awesome and magnificent, and these moments keep me going as a doula.

However, when it comes to the shallow questions, the nitty gritty details about birthing, like “WIll I poop on the table?”  or “Will Hospital X let me have my baby on my chest right away?”  I am totally fine with just telling them the answers. Many doulas (and this is not a slam.  Really.  It is a stylistic difference.) feel that it is our job to provide resources, rather than provide specific information, so they tell their clients where they can find the information, rather than just sharing the information itself.  People remember things best when they have to work for them a little bit, of course, so there is a great argument for educating that way.

Me?  I think that one of the reasons they hired us is to make their lives just a bit easier on their Birthing Day.  And if I can do that by just saying,”You might poop.  Its a great thing.  It shows you’re pushing in exactly the right place, and chances are you won’t even know you did.”  then I probably will.  It seems like an oral tradition to me, sharing the sacred knowledge (Yeah, I think poop can be sacred.  its an odd life I lead.)  with the uninitiated, helping lead and prepare them for that time when they too will undo go the trials, the rite of passage, if you will, into motherhood.  American women today often don’t have time to completely research every little question they might have, evaluating sources, and wading through a swamp of google hits.  They wanted an expert in birth, and that is why they hired a doula.  And, to bring it back around to Uganda, most of these women don’t have Internet access, so asking question of their mothers, their sisters (read “their doulas”) is how they get information in the first place.

So that means, doulas, know your stuff.  Study up, keep abreast of current information, and don’t be afraid to say that you don’t know, that you will get back to them.  The only thing worse than no information is bad information.  And keep in mind, that at the basest, most primal level, mothers know how they need to give birth.  You’re just there to fill in the blanks

 

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

Filed under: Jane,Uganda,Uncategorized — EssentialMidwifery @ 7:03 pm
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We left the boy with tetanus, and make our way through the regular women’s ward, and then to the maternity section.  We file though in single file, like nuns in a procession, our hands folded, careful not to touch anything.  Our guide, Dr. Agaba, runs this place.  A shortish, roundish man in his early 50′s, Dr. Agaba has the patient resignation of one who has worked in healthcare for a long time, doing his best to do what he can, and knowing with all his being that it will never ever be enough.We actually met him yesterday, when he came out to visit Shanti, and was very interested on our doula training.  He smiles easily, and jokes with Sadie, Shanti’s project manager.  They seem to have a lovely relationship, built on respect and common purpose.

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

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

“It this your first baby?”

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

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

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

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

 

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

Filed under: Uganda,Uncategorized — EssentialMidwifery @ 12:27 am
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I can’t look away, and on some level, I don’t want to.  The young boy, maybe 7 years old, arches his back again, his entire body spasming, his face stuck in a grotesque and totally involuntary leer.  Sweat pours off his body, running down his neck, pooling on the black vinyl mattress. His mother, standing by his side, moves to support his head, but is stopped by a nurse, who explains softly that she could hurt his neck muscles, and to let the seizure take its course.  Not that it matters.  This boy has tetanus, and this boy is going to die.Tetanus is treated with metronidazole, diazepam, and tetanus immune globulin, none of which are available in this Level 4 Health Center that serves Kasana and the surrounding countryside.  The staff has only comfort measures to offer, and in this “hospital” nothing is comfortable.

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

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

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

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

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

 

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.

 

Back to Uganda! (Jane) August 11, 2012

Filed under: Birthy Thoughts,Jane,Not-so-birthy Thoughts,Uganda — EssentialMidwifery @ 7:07 pm
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Its official!  I’m headed back, and this time I’m bringing friends, some of whom I know, and some of whom I am looking forward to meeting.  In a few short weeks,  I’m leading a team of awesome doula trainers, and we will be sharing our knowledge and skills with the Ugandan midwives, several aspiring Canadian doulas, and each other.  Many of these women have never travelled internationally at all, let alone to a developing country.  I wish I could see the trip through their eyes, because I’m curious like that.  I want to know everything…why they want to come, what they hope to accomplish, how I can  support them.  We’ll discuss all of that, of course, and I will do the best I can, but in the end, it’s just like birthing.  (Hey, I’m a midwife.  I can make a birth metaphor out of two pieces of gum, a string, and a small poodle.  I’m McGyver with a doppler.)

Everyone who is going on this trip has different experience with birth, with travel, with education, with life.  As a leader, I feel it is my obligation to meet each participant where they are, to facilitate growth and provide a safe little cocoon in which to process and relax.  But I can’t force my idea of what they should be experiencing onto them.  It has been so interesting just to watch different folks’ reactions to the preparations, trying not to butt into their processes and tell them what I think they should do. Everyone has different ideas about vaccines, ebola danger, political instability, the lack of infrastructure, what technology to bring, etc etc etc.  I’ve tried so hard to offer choices, to tell them my experiences, and then just shut up and get out-of-the-way.  It’s not my birth, it’s not my birth, it’s not my birth.  I have no expectations around this trip, except to offer who I am, and then to sit back and let the labor take its course.

The constant, of course, is Uganda, with everything that that implies.  After all, Africa always wins.  Those of you who came along with me on the blog last year may remember that I couldn’t find string in Kasana, and had to disassemble a mop to make a project work.  (see, I wasn’t kidding with the McGyver bit.)  That experience has become my symbol of flexibility, of creative thinking, of letting go.  It will be so interesting to see what symbols the other team members gather, which little image or event worms its way into their brains, and stays with them back home.

All I can do is my very best, and trust the process.  After all, its always worked before.

 

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.

 

Gestational Age Workshop-Jane July 13, 2011

Filed under: Jane — EssentialMidwifery @ 11:39 pm
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So, let’s say you are living in an imaginary developing nation called, just for the sake of arugument, Huganda.  And in the great country of Huganda, there is little access to, well, anything. And that’s usually fairly ok, as you are a midwife, and make a pretty good salarly working for this NGO called, just for the sake of argument, Manti Huganda. 

Now, Manti Huganda has been trying so hard to do everything by the book in the great country of Huganda, as it is new and wants badly to be a recognizable force of positive change.  So Manti has some rules, like they do not accept anyone over 20 weeks, and they transfer mamas out of care when they hit 41.5 weeks, or if they deliver before 37 weeks. 

(Now we who live in the great country of (just for the sake of argument) Lamerica, or maybe Janada, especially those of us who may have some more liberal ideas about mothers and babies, and all of their inherent perfect timing in regards to birthing, may not understand these rules, and why Manti is interested in playing by them.  Its ok.  Just accept it.  In Huganda, rules can get you into a place, and then, you can work to change them.    It will be ok.)

But on a practical level, how can you abide by the rules you have set, if the mamas don’t?  What if they have no idea when the first day of their last period was, and they cannot afford a dating ultrasound?  What if they are measuring small because of bad nutrition?  Or, conversely, measuring big because of bad nutrition?  What if you, as the midwife, only had one tape measure anyway, and now its lost, and who knows if they even sell tape measures in Kasana? 

 (This is not as weird as it sounds.  We could not even buy string.  We were told four times that we would have to go to Kampala.  Finally, we bought stove wicks and pulled them apart.  And let’s not even get on the subject of zip locks.  I may, at one point have offered to trade both Anna and Rachel for a box of gallon sized.  )

Oh, and let’s also assume that Manti doesn’t have a gestational wheel, and has to rely on manual calculations.  I think someone should donate a few to them.  Let me know if you’d like to get in on that.  I know an organization called, for the sake of argument, deesentialschmidwifery, that will probably throw a few over the ocean. 

So if dates are not known, and ultrasounds are too expensive, and you’ve lost your tape measure, how do you determine gestational age?  This was the question the lovely Annet posed.  We were going to have to get creative.  Old School.

The first thing I asked our next ambiguously pregnant woman was whether or not they had felt the baby move.  Back in the day, this ws really the only reliable way you even knew you were pregnant for sure.  Until delivery, that is)  Most first time moms feel those first fluttery kicks around 16 weeks.  But some feel them as early as 13, and some as late as 25.  Second and subsequent pregnancies are usually felt earlier, but this is not a hard and fast rule.  So now, we can narrow our mama’s pregnancy to between 12 and 25 weeks.  Not extremely helpful.

Here’s where palpation comes in, and as its one of the things I like doing best in the world, I was eager to show these techniques to Annet and this lovely mother, who was wondering when the heck she was actually going to birth her first baby.  If she were only 12 weeks along, we would barely be able to feel her uterus just beginning to poke over her pubic bone. At 16 weeks, the top of the uterus would be about halfway between her pubic bone and her belly button, and by 20 weeks, it should be at just about the umbilicus.  And when the baby is done cooking, it should be about level with xyphoid process at the bottom of the sternum.

See?  That just clears it right up, doesn’t it?

Of course, there is always the copyrighted Shrugging technique, where the attendant smiles ruefully (this is an important part of the protocol), and slowly raises her shoulders towards the ears, holding the pose for a second or two, before lowering them, saying, “Well, we can always Ballard or Dubowitz them when they come out.”  These are assessment scales used to measure certain infant behaviors and physical properties to make an educated guess on the age of the baby.)

And that, my friends, is how we determine gestational age.  And also, just maybe, how we can get around a few of those pesky rules, and renew our trust that babies come when they are meant to, even if that time is “early” or “late.”  Even a baby that arrives unexpectedly, and needs some help, might be telling us that she was better out than in, that something in the interuterine environment was not as healthy as it could have been.  We can still believe in that baby and that mama’s innate wisdom, while providing the best support for both of them that we can.  And that, I believe, is more important than anything else.

 

Mean Girl-Jane

Filed under: Jane,Uganda — EssentialMidwifery @ 9:41 pm
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For the first time today, I felt threatened. It was not from the men who regularly ask me if I want an African lover. I mean, they are shouting from trucks, so even if I decided that, yes, I absolutely did want an African lover,right now, they would be long gone. They may need to work on their technique.

And it was not from the slightly sketchy guys at the Indian supermarket, who glare at me whenever I ask for something they do not carry, as if it is my fault. And it’s not even from the market men who happily cheat me, and charge me twice as much as a Ugandan, cause they smile when they do it, and we both sort of consider it a game.

No, my nemesis is a teenage girl. She approached Rachel, Anna, and I last evening, as we were walking back from the market, munching on some roasted corn. She stepped in front of Rachel quite aggressively, throwing her shoulders back and narrowing her eyes. She demanded to know where we were from, and when told spat out, “Give me your corn. I want it.”

Now, there was no way Rachel was going to give her the corn. It was good, and it was Rachel’s. The girl glared, told us she had no money (although she was carrying school papers, thus was getting an education, and was obviously not starving) and got a little up in Rachel’s face. It was classic bullying behavior, and it was not going to work. Eventually she gave up, said what I can only assume to be a few rude words, tossed her fake hair, and flounced off down the road with her friends.

Now, if that were the end of it, I would have forgotten it already. But this morning, she was outside her house, with her friends, on the road to Shanti. As I passed her, she looked me in the eye. I greeted her and kept walking. I heard her say, “That’s my friend,” loudly, in a way that was definitely not friendly. The hairs on the back of my neck did a little dance, and I was acutely aware that I was alone, carrying a bag with comparatively, quite a bit of money in .

Strange that of all the people I have encountered and all the places I have been, that I would feel intimidated by a run of the mill, common Mean Girl. I will watch out for her.

 

 
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