The Saturday after my birthday I went in to Labor and Delivery. Julia, one of the Midwives from my radio show group was working. When I came in she generously supported me in attending our patients and births that day.
When the shift began there was a 17 year old first time mom. Her labor had been moving slowly throughout the night and she struggled to keep her eyes open between contractions. On exam she measured 5cms, the same as the night before when she was sent over to labor y parto. As I've mentioned in earlier posts there is currently an initiative to include traditional practices in facility-based birth in an effort to respect and humanize birth in the RAAN. The young woman's mother passed a Styrofoam cup half full with brownish liquid, green particulate flowing throughout. The girl took it down in one drink. One hour later another batch of the brew was passed back to Labor y Parto where one of the maternity nurses bathed the girl’s abdomen and sacrum in sweeping circles with the tea blend. The tea herb, Escoba Lisa, is also referred to as Oxy-casera, a powerful labor inducer. It is rumored that the women who come into labor and delivery with powerful contractions and booming labors have been drinking these traditional remedies to hurry the labor process. Our patient moved slowly but surely though her labor to arrive at 8cms by the afternoon. An IV was started and oxytocin flowed at 8 drops per minute into her vein. The girl’s mother came back and held her hand as she cried out 'mamiki, uba latwan, mamiki, uba latwan' over and over during contractions; her own mother´s tears slipped down her cheek watching her daughter's pain. Another woman was called back to assist in the traditional healing of this young woman. She was a large (hermosa) woman with milk-chocolate skin and peroxide orange hair. She held a bundle of green plants waded into the palm of her hand. She crushed the plant she told me was named Africa, then rubbed it over the laboring woman's abdomen repetitively making the sign of the cross, then moving to her sacrum. The plants were squeezed and squeezed until a thick green juice was extract and dripped on the girl’s forehead. This was followed by fanning the patient and tucking the bundle of herbs between the woman's breasts.
As we awaited the birth of this woman's babe another adolescent patient was brought into the labor and delivery suite. She was 15 years old, measuring under 5 feet tall, and thick. Her black eyes stared out of her round face with fear, but she also had a look of control about her. She was a patient with preeclampsia, a disorder of high blood pressure that only affects pregnant women and puts both mother and baby at risk for complications and death. In the United States a high-risk patient like this would be receiving medications to prevent seizures, as well as strict vigilance of vital signs…but things are different here. She had an oxytocin drip going to induce her labor...the only cure for preeclampsia is delivery. I took her blood pressure which measured in at 140/100, high, but not so high that we were giving her the PRN blood pressure reducing medication that she was prescribed. The baby's heart rate was very reassuring. Soon after her arrival our traditional medicine patient was complete and ready push. The 15 year old was temporarily abandoned [or allowed to labor without intervention] as we attended to the birth of the other patient's little girl, petite at just 6 lbs and covered in creamy-white vernix, a protective coating that develops in the womb. After finishing up the suturing and writing a note about the birth I turned my attention back to the wide-eyed fifteen year old. I sat at her side and traced small circles on her lower back during her contractions. She would tell me that they hurt very bad when they were over, but she appeared to be coping very well. I checked her and she was 7 cms. About 30 minutes later her bag of water broke on its own revealing clear fluid. Most women's water is artificially broken here when they reach 7-8 cms. It was nice for me to witness her body taking on the process of birth without too much intervention. Shortly after the other midwife checked her and said that she was complete but that the head was still high, that it would be best for her to labor and let the head reach the perineum before getting her on the birthing table. This is also not commonly done as most practitioners are ready to get a woman pushing as soon as she is complete. I checked the baby's heart rate again and it continued to be reassuring. She lay onto the bed and I witnessed her begin to push. I guided her to push when she felt the need, that it was okay. After a couple of pushes she looked at me with her large eyes, grabbing her perineum saying 'its coming out'. I peeked down between her legs and knew she was feeling the pressure of the baby, but was still distant from delivery. No bulging, no crowning. I went into the delivery suite and grabbed a pair of gloves...just in case! As I walked in I started telling one of the doctors who was relaxing along the wall that I was actually more accustomed to attending deliveries in a bed rather than on the birthing table with women in the 'obstetric position'. He was surprised by this as well as the fact that more physicians attend births in the US than midwives, both cases being opposite her in Nicaragua. I went back and sat with the patient again, fanning her with the package of gloves. After about 15 minutes I went to check on my postpartum patient: firm fundus, normal blood pressure, nursing her baby. Her sister was back with her and asked me how much longer the laboring young woman had. I told her that she was close, but not yet. As I turned to walk out of the room the drawstring on my scrub pants got caught on something, coming undone, threatening to reveal my bottom to everyone present. I grabbed the strings at the exact same time that I looked up at my 15 year old patient bearing down with a two inch slit of her baby's hair peaking out. I dove into the room and struggled to get the gloves on that I had left there...I don´t know why that latex gets so sticky and uncooperative when you really need to get them on. I squatted next to the bed trying to keep my pants up as I flexed the baby's head and helped him arrive for his birthday. Julia arrived with a tray of instruments and graciously tied my pants back on for me. The young mother looked so proud and strong bringing this life into the world. The only things I know about her are that she is an adolescent, she doesn't know how to read or write, signing her chart with a thumb print, that she had preeclampsia, and that she was totally in love with her baby at first sight. Her big eyes filled with a pride and joy I haven´t seen in months as she reached out to touch her son laying across her abdomen. Her birth was simply beautiful. It was the most that I have felt like a midwife since I arrived...it was my best birthday gift.
Monday, October 25, 2010
Thursday, October 14, 2010
Preparacion de Parto
The Casa Materna is a home for pregnant women within the city of Puerto Cabezas. It is part of a strategy used in developing nations to reduce maternal mortality. Women, who often come from far away communities in order to have their birth at a facility attended by skilled birth attendants, stay at this home to await the swells and surges of labor. The Casa Materna provides medical attention 24hours a day and is a safe space for mothers to be home-away-from-home. The Casa Materna for me is a bit of a home-base where I can check in with nurses that I know, and also is the site of my weekly meetings with obstetric and maternal-infant health nurses to create the radio program Mairin Karnakira-Mujer Poderosa. On a recent visit to the Casa Materna I spoke with two pregnant women who had made the journey from their communities to have their births at Hospital Nuevo Amanecer. Both of them had delivered babies before in their homes. I asked them what made them decide to come here to Puerto Cabezas. One woman answered that previously she lived in Las Minas. There was a health clinic in the town and an obstetric nurse present. She felt safe in her community that if something went awry that she had medical attention quickly available. She explained that since then she had moved to a new community distant from any health center. It took her 3 hours walking to reach the road, and then an additional 8 hours in vehicle to get to the city. She came to the Casa Materna so that she would have medical care at her fingertips. The other woman said that she had been told that it was 'better' to have her baby in the hospital. That it is cleaner, and that there are physicians present if she were to need one if an emergency arose. I was glad to hear that these women made this type of informed choice for themselves and their birth. The rhetoric that NGOs and the Ministry of Health have been disseminating for some time was evident in the words that these women chose and in their desire to protect their health and pregnancy.
Today I provided a Birth Preparation class to the women present at the Casa Materna. There were a total of 34 women currently staying at the home. Of 34 women 3 were pregnant for the first time. Of the 31 remaining 31 had a previous home birth and only 1 woman had experienced a hospital delivery. We discussed the changes that happen to the cervix, its softening and opening, and how each pain of contraction is related to more opening. I used a hand sewn model that I made two years earlier to show the changes of the uterus, the birth of a milky white babydoll, and the burgundy-chiffon umbilical cord and placenta. I acted out a laboring woman and we all closed our eyes, laid our hands upon our bellies, and deep breathed together to alleviate the intensity of our labor pains. I decided to spend some time asking women what their expectations were for birthing in the hospital, and also sharing with them what would be different here versus at home. Women shared that they thought it would be cleaner, and that if there was an emergency there would be someone present to manage it. One woman shared how she heard that many maternal deaths were due to retained placenta and that she believed that if that happened at the hospital that they would have a way to resolve this problem. I asked the one woman who had birthed in the hospital what her experience was like. She said that she thought it was cleaner [a resounding theme!] and that she liked the birth table...she felt like it gave her strength. I explained to the group, watching them lay their hands gently across their swelling bellies, how they would be brought to L&D when they have 4-5cms of dilation, about the delivery bed and the obstetric position, about the manual exploration of their uterus postpartum, and how the nurses will dress their baby and the puerperal mother uniting them on a bed at the back of the room. One mother from the group thanked me for preparing her for the differences she could expect in the hospital.
I had a major revelation as I walked out of this Preparacion de Parto class: 1) these women want cleaner births 2) they wanted access to emergency medical services and 3) when you don't know what you are missing [water birth, low-lights with guided mediation, doulas, empowered homebirth, etc.] your birth experience can be good.
Today I provided a Birth Preparation class to the women present at the Casa Materna. There were a total of 34 women currently staying at the home. Of 34 women 3 were pregnant for the first time. Of the 31 remaining 31 had a previous home birth and only 1 woman had experienced a hospital delivery. We discussed the changes that happen to the cervix, its softening and opening, and how each pain of contraction is related to more opening. I used a hand sewn model that I made two years earlier to show the changes of the uterus, the birth of a milky white babydoll, and the burgundy-chiffon umbilical cord and placenta. I acted out a laboring woman and we all closed our eyes, laid our hands upon our bellies, and deep breathed together to alleviate the intensity of our labor pains. I decided to spend some time asking women what their expectations were for birthing in the hospital, and also sharing with them what would be different here versus at home. Women shared that they thought it would be cleaner, and that if there was an emergency there would be someone present to manage it. One woman shared how she heard that many maternal deaths were due to retained placenta and that she believed that if that happened at the hospital that they would have a way to resolve this problem. I asked the one woman who had birthed in the hospital what her experience was like. She said that she thought it was cleaner [a resounding theme!] and that she liked the birth table...she felt like it gave her strength. I explained to the group, watching them lay their hands gently across their swelling bellies, how they would be brought to L&D when they have 4-5cms of dilation, about the delivery bed and the obstetric position, about the manual exploration of their uterus postpartum, and how the nurses will dress their baby and the puerperal mother uniting them on a bed at the back of the room. One mother from the group thanked me for preparing her for the differences she could expect in the hospital.
I had a major revelation as I walked out of this Preparacion de Parto class: 1) these women want cleaner births 2) they wanted access to emergency medical services and 3) when you don't know what you are missing [water birth, low-lights with guided mediation, doulas, empowered homebirth, etc.] your birth experience can be good.
Saturday, October 09, 2010
Se Fue La Luz
Birth in Puerta Cabezas resembles birth anywhere in the world. Women breath hard between pursed lips, sweat beads above their upper lip, moans turn to grunts when the baby's head descends deep into the birth canal. The final pushes are accompanied by disbeleif and "no puedo mas"s. And then the head emerges, shoulders slip forward and the baby has arrived. The same languid looks are exchanged between mother and child...a regal look filled with pride and unconditional love.
The other day we had five laboring women crammed into the one room with two beds used for this purpose. Two women worked sillently through their labors, letting their fingers lite across their bellies as a contraction envolped them. Two other women struggled with their powerful contractions. I began massaging one woman's back as her contraction gripped her. One of the nursing students asked if that was helpful. I instructed her to ask the laboring woman who shook her head in agreement. The nursing student told me that she had never learned that massage could help a woman in labor. Later that evening I glanced into the labor roon as one of the older nurses bent over the same patient letting her hand trace circles across her low back. maybe I will have an influnce here.
All but four of our patients delivered on that day shift. Two of them back-to-back as the clock wound its way to 7. One woman was an adolescent girl, who often have fast and furious labors, who began pushing minutes before the lights went out [se fue la luz]. We waited for the back up generator to come on, but never heard its engine begin to roar. The labor and delivery suite without windows was pitch black. Sounds of the young woman breathing heavy and moaning as contractions built up once again filled the dark room. Two nursing students pulled out their cell phones with sterile gloves on and aimed them at the perineum. A docotor joined the team with green flashlight in tow as they hurried to force this baby out into the world. A light was finally fixed to a portable battery, and the baby was welcomed. I perfomed the newborn examination and began bundling the baby into its first clothes, as is the practice here. As the adolescent patient was being repaired, the next midwife on call had arrived and yelled 'tambikes', she's pushing, and ran into the room to help a woman who was about to have her fourth baby onto the birthing table. I wrapped the newly born baby into my arms to free the one newborn warmer, and aimed the green flashlight aloft. Four more pushes ushered her son into the world.
The other day we had five laboring women crammed into the one room with two beds used for this purpose. Two women worked sillently through their labors, letting their fingers lite across their bellies as a contraction envolped them. Two other women struggled with their powerful contractions. I began massaging one woman's back as her contraction gripped her. One of the nursing students asked if that was helpful. I instructed her to ask the laboring woman who shook her head in agreement. The nursing student told me that she had never learned that massage could help a woman in labor. Later that evening I glanced into the labor roon as one of the older nurses bent over the same patient letting her hand trace circles across her low back. maybe I will have an influnce here.
All but four of our patients delivered on that day shift. Two of them back-to-back as the clock wound its way to 7. One woman was an adolescent girl, who often have fast and furious labors, who began pushing minutes before the lights went out [se fue la luz]. We waited for the back up generator to come on, but never heard its engine begin to roar. The labor and delivery suite without windows was pitch black. Sounds of the young woman breathing heavy and moaning as contractions built up once again filled the dark room. Two nursing students pulled out their cell phones with sterile gloves on and aimed them at the perineum. A docotor joined the team with green flashlight in tow as they hurried to force this baby out into the world. A light was finally fixed to a portable battery, and the baby was welcomed. I perfomed the newborn examination and began bundling the baby into its first clothes, as is the practice here. As the adolescent patient was being repaired, the next midwife on call had arrived and yelled 'tambikes', she's pushing, and ran into the room to help a woman who was about to have her fourth baby onto the birthing table. I wrapped the newly born baby into my arms to free the one newborn warmer, and aimed the green flashlight aloft. Four more pushes ushered her son into the world.
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