Betana

We set off in the late morning, later than hoped for but before I had expected we would actually depart. I climbed into the front seat of the white Land Cruiser, the kind that are famed for their ability to drive up, over, and through any river or swath of mud. Today we were heading for Betana, a community only 40 minutes drive south of Puerto Cabezas along the dirt highway to Managua. Over the past several months I started volunteering for an organization called CAIMCA. They provide health services to women with a special focus on women suffering from domestic violence. Under the same roof there are lawyers, psychologists, nurses, and a physician to support women by providing medical care and guidance through the legal system when filing a complaint against an abuser. My role at CAIMCA has been to perform Pap smears in the mornings, free of charge to any woman that wants to be tested. Our goal for this day was to head out to the community to provide the same service. One of the female leaders of the community had petitioned to have us come out to the women to perform Pap smears, rather than take the women to Puerto Cabezas; the 50 who had listed their names in a worn, yellowed notebook stating their desire for cervical cancer screening.

We arrived in Betana dusted by a thin layer of clay colored dirt. We pulled to the side of the road to ask a woman emerging from the tall grasses where the health center was. She turned her back towards us and pointed to a one story, pink, cement building just across the field. The health center sat squat upon a low rise in the plain, flanked by stilted wooden homes painted emerald green and Caribbean Sea blue. The Land Cruiser bowled up and over the ditch, through the grasses to park in front of the health center. It appear locked and dark. A passerby informed us that the nurse, along with the key to the health center, was in Waspan, a town 6 hours north of us.

We gathered our supplies and lugged them across a one plank bridge that guided us across a muddy ditch, passing through the chain link fence to the health center. The condoms, speculums, anti-parasite syrup, gloves, etc. were seated upon a wooden bench flush against the health center’s rose colored wall. As the four of us sat and chatted about what a speculum is, a thick legged woman in a hand stitched black tank and skirt with red flowers blooming across her chest ambled through the gate. This was the community leader who had organized the Pap smear event. She explained that she had expected us on Tuesday. All the women had arrived early and patiently waited for us; but we hadn’t arrived. Today was Thursday. She stated that we could make it work, but many of the women were out in the fields planting and would not return in time to receive the service. And she confirmed that the nurse was in Waspan so we would not be able to use the health center.

Ingenuity is a common quality amongst the people of the Miskito coast that have learned to reuse, recycle, and reinvent objects. When I think of the lifespan of an electronic device in the RAAN versus in the United States it has been rewired and reworked various times, buying it at least 10 more years. So when we knew that we couldn’t use the health center it was a simple transition to transform the school house into a clinic room with some simple equipment: one table, three sheets, two clothes pins, a flashlight, and a chair. I draped a yellow sheet edged with eyelet over the table and voila we had an area for examination. The clothes pins were used to hang a white sheet printed with climbing green vines dotted by delicate pink flowers to the side of the table creating a privacy curtain. I pulled an old-fashioned wooden school chair with built in writing plank to the side of the table and lined up the necessary supplies: lubricant, Pap smear kit, gloves. I dressed the flashlight in a latex glove to help me visualize the mysterious insides of the women that I would be examining. The bag of 40 sterilized speculums individually wrapped in torn white sheets held closed by masking tape sat to the side of my makeshift equipment table. Ready to begin.

Slowly but surely the women began to arrive, lining up outside the school house with curiosity. Elida would ask them their names, age, date of last menstrual period, and whether they had previously received a Pap smear in Miskito, and then pass them back to First Grade Classroom A for their exam. One woman after another came to receive her care, many for the first time in her life. I used my basic Miskito to ask them to climb onto the table, lie back and relax. The first few exams were quick and uneventful.

A woman, 68 years old, mother of twelve children came into the examination room. She wore a simple black polyester skirt, hemmed to hang at the knee, black cotton t-shirt, and hot pink bandana covering her long salt and pepper hair. She removed her undergarments and climbed nimbly onto the table. She didn’t complain of any pain or discomfort, she actually didn’t say anything to me, just got onto the table and lay back, knees bent and folded into each other in a shy, protective manner. I donned my gloves and prepared my field for the Pap smear, opening up the plastic case to reveal the glass slide, and inching out the wooden and plastic brushes that I would use to take the sample. I placed my hands gently across the woman’s knees and encouraged her to let her legs fall open. With a sigh of embarrassment she began to open her legs, and then shot her hand down between them to hide something. From between her fingers I could see the pale-peach color of something. It looked thick and muscular. I said some soothing words that I can’t quite remember because I was just as shocked as this woman was at what was hanging between her legs. As she lifted her hand it became clear that three-quarters of her uterus had fallen out from her vagina and sat between her legs. I slumped back into my wooden chair and let the image fully settle in. Now, I have seen uterine prolapses before. A bit of tissue protruding through the vagina, more so with a push referred to as the Valsalva maneuver. But, never in my life had I seen a prolapse like this. I could see cervix, discolored and dry, the upward curving of the upside-down pear shape of the uterus, and the thick muscular layers of the organ. I stood, removed my gloves, lowered the woman’s black skirt, and helped to lift her to a seated position.

“How long have you had this problem?”

“I noticed that it came down, and stayed down about two years ago when I was lifting a bucket of water. Before it would stay inside, but not now.”

Two years. Possibly longer.

“Does it hurt?”

“A little bit.”

I guided the woman outside to the community leader and had her explain in Miskito that she had a severe uterine prolapse and that she would need to be seen in the hospital in Puerto Cabezas. I imagine that the ObGyn will recommend a total hysterectomy. I can’t imagine that there is another remedy for a prolapse so severe.

I was shocked by the presence of this grave uterine prolapse, but by the time I lifted the skirt of the fifth woman whose uterus hung down between her legs it was less shocking and more disturbing. There was a pattern that I was noticing: older age, many, many babies, and a history of hard living with planting, hauling buckets of water, and hand washing. I imagine that in the history of these women there were also some prolonged labors with extended periods of pushing to get their babies out into the world. What began to stun me the most was how close these women were to the city, and yet completely isolated from general gynecological care. Two years? How does a woman cope with having her uterus bulging out from her vagina for two years? Why didn’t she seek care sooner? Is it the cost of bus fare to get to the city, the need to be at home to mind the house and children, or shame? Hopefully these five women will make the journey to Puerto Cabezas this Tuesday with the community leader to be seen at the hospital. Hopefully they will be treated with kindness and concern and not discrimination and ridicule for delaying treatment. Hopefully these women will receive the care that they need and live the rest of their days with more comfort and dignity.

Progress!

After many months of work on the radio program Mairin Karnakira-Mujer Poderosa there have finally been a couple of successes...Below you will find the first page of the first completed chapter! I didn't include the whole thing because each one is about 11 pages long. The first is page one of Chapter 1 of the nine chapter series completed and in Spanish, the second is page one of Chapter 1 completed and translated into Miskitu!!! It feels like such an accomplishment. I apologize to those readers who don't read Spanish or Miskitu, there are no English scripts!

RADIO NOVELA: MAIRIN KARNAKIRA (MUJER PODEROSA)

Capítulo 1: Atención prenatal

CONTROL: FADE IN SONIDO DE OLAS FADE OUT A FADE IN MÚSICA]

CONTROL: FADE IN DE MÚSICA A SONIDO DE RÍO DURANTE LA NARRACIÓN

LOC: Usted está escuchando: Mairin Karnakira (Mujer Poderosa), una historia que sigue los pasos de cuatro mujeres Miskitas embarazadas: Vilma, Carolina, Mari, y Jenny. Ellas viven en la comunidad de Li Prana, la que se encuentra ubicada la orilla del mar y por ella pasa un río de agua muy clara y fresca para bañarse.

CONTROL: SONIDO DEL MAR A FADE IN DE SONIDO DE MOTOR DE PANGA LUEGO ENTRA NARRACIÓN. ENTRA MÚSICA

LOC: A la comunidad de Li Prana no se puede llegar por tierra, está a tres horas en panga al norte de Bilwi, Puerto Cabezas, Nicaragua. Al llegar, se ven muchas casas de madera pintadas en colores brillantes como rosado, azul y celeste. En la comunidad también hay muchos árboles frutales como el mango, nancite, pejibay, corozo, y muchos manglares con muchos ríos que se deslizan como serpientes de agua hacia las barras del litoral y la gente se deleita con sus frutos, tanto de los árboles como los que les dan los ríos y el mar.

CONTROL: SONIDO DE VIENTO ENTRE ARBOLES FADE IN SONIDO DE OLAS A FADE IN MÚSICA

LOC: La mayoría de los hombres que viven en Li Prana trabajan en el mar, por eso casi toda de la gente come mucho pescado, otros mariscos y carne de tortuga. Pero también, los habitantes comen yuca, plátano y arroz que cosechan en la misma comunidad. Todos cultivos tradicionales para la subsistencia familiar.

LOC: En Li Prana, como ya dijimos, viven las cuatro mujeres embarazadas de nuestra historia: Vilma que está casada con José, quien es carpintero y están esperando su primer bebé. Jenny, una adolescente soltera, también esperando su primer bebé. Carolina que está casada con Mario, un pescador y tendrá su segundo bebé y Mari que está casada con Edgar quien trabaja en el mar como buzo, ella va a tener su quinto bebé. Acompáñenos para saber qué pasará con estas mujeres de Li Prana.

CONTROL: SONIDO DE OLAS A FADE IN VIENTO SUAVE

LOC: Es un hermoso día soleado y con viento fresco en Li Prana, es temprano y todavía no hace calor. Las cuatro mujeres de nuestra historia: Vilma, Mari, Carolina y Jenny están lavando su ropa a la orilla del río.




RADIO NOVELA: MAIRIN KARNAKIRA (MUJER PODEROSA) MISKITU
Capítulo 1: Atención prenatal
CONTROL: FADE IN SONIDO DE OLAS FADE OUT A FADE IN MÚSICA]
CONTROL: FADE IN DE MÚSICA A SONIDO DE RÍO DURANTE LA NARRACIÓN
LOC: Man walisma: Mairin karnira, miskitu mairin kwihra wahlwal nahki auyaba dahra: Vilma, Carolina, Mary an Jenny. Witi naniba, kabu un ra tawan lupia kum Li Prana wiba ra iwi bangwisa, an bak sin awala sangni kum luwisa, aihtabaia dukiara kahula.
CONTROL: SONIDO DEL MAR A FADE IN DE SONIDO DE MOTOR DE PANGA LUEGO ENTRA NARRACIÓN. ENTRA MÚSICA
LOC: Li Prana Tawanka lupiara, sip sauhkak waras, Bilwi Puerto Cabezas Nicaragua wina yahbra tanira awar yuhmpa pitka sa. Auma Taim kaiksma, tat watla pint dingkan mapla sat sat, paura sangni an sangni pihs baku. Baku sin tawanka lupiara dus ma nani manis sa: mangu, krabu, supa, suyat baku an laulu manis, awala ailal wal, piuta baku kabu tanira iswisa an arbar kat, baku wal upla nani ba ai lilia bangwisa, dusma nani aima saki ba wal, awala nani wina, kabu wina saki ba wal sin.
CONTROL: SONIDO DE VIENTO ENTRE ARBOLES FADE IN SONIDO DE OLAS A FADE IN MÚSICA
LOC: Li Pranara iwi waitnika nani ba aihkika kabu unra wark taki banghwisa, ba mita upla sut inska pisa, kum kum ba wasi an kusua wina. Bara, uplika nani ba sin pisa, yauhra, platu an rais. Silp tawan kat mangki sakisa patitara natka kat, ai pamalika raya brikaia dukiara.
LOC: Aisi kata baku, Li Pranara mairin kwihra wahlwal iwi ba dukiara, yawan aisisa. Vilma ba José wal aimaya, witin ba dus warkka daukisa.(carpintero wiba). Witin nani ba pas ai luhpia briaiaba, bila kaikisa. Jeny ba tiara kura mayas kum, witin sin, pas ai luhpia baikaia bila kaikisa. Inska mamiskra Mario maya, Carolina sin ai luhpia pas ba ninka briaisa. Mari lika Edgar, kabu ra wark tatakrika, buzu kum maya. Witin ba ai luhpia numba matsip ba baikaia bila kaikisa. Kaisa yula kahbaia, naha Li Prana mairka nani wal, dia takbia sapa.
CONTROL: SONIDO DE OLAS A FADE IN VIENTO SUAVE
LOC: Li Prana ra yua kum lapta ingsa, pasa kauhla an kau titan sa, an kau bitni apu. Wan aisanka tilara mairin wahlwal na: Vilma, Mari, Carolina an Jeny, awala un ra kuala subi bahgwisa.
[SONIDO DEL RÍO Y DE MUJERES RIÉNDOSE]
LOC: Witin nani ai kwihrka nahki paliba dukiara pana pana aisi banhgwisa. Nahki pil muniba, ai sibrinka kum kum an nahki ai dara waliba dukiara. Vilma aisiba walpi.
VILMA: Ay Mari, Na pyua nan na swapri pali aidaukisa kuala suban ai daukras, plun piakaia ra sin pas kata apia baku sna. Naha na pas kwihra tiwri. ¿Naku ai daukina, bakusa ki?

Some images from the hospital...

RADIO + BIRTH CENSUS



FETAL MONITOR



THE "PIXIS"



THE FAMOUS HANDFOLDED GAUZE

Before and After

BEFORE AND AFTER....AND LITTLE LI MAE!

From Daukura with Baby

It was about four years ago that I arrived in Daukura for the first time. The panga ride up the coast was more than harrowing as the drunken captain pumped his fist in the sky, weaving his way in wide circles through waves, his thick plated gold chains slapping against his chest. The driver’s precarious maneuvering left us without diesel sooner than what is the norm. He rocked clumsily along with the waves as he tried to switch the plastic tubing from one bright blue tank of fuel to the next. I can imagine him, one eye closed, trying to focus on where he was going to insert the tube when the large rouge wave came letting the panga slip onto its side, throwing me halfway into the Caribbean Sea. As the boat righted itself he was able to get the tubing in and the boat started again, at the same time that it was filling with water. There was not a pail, bucket, or water jug on board to bail out the sea water whose level was slowly rising. Many hands and a little innovation later threw the water overboard.

Soon after, as we pulled into a community different from my final destination, I gladly jumped ship, setting my feet in Daukura.

It was in Daukura that I met Anhet. A Miskito woman who speaks excellent Spanish due to working abroad in Guatemala and later in Panama. We created an instant friendship. As I have passed the years visiting Puerto Cabezas I always take the opportunity to visit my friend when she is in town.

When I first arrived in September there was a rumor about Anhet. I knew that she had been in Panama working, but everyone said she was back. They said she was pregnant. I eagerly sought her out in the house of her cousin. A stilted wooden home painted a rich lilac color. A house so large with a fence so famous that when giving the direction to a taxi driver you simply say “Kelvin’s house”. I saw my friend lounging on the terrace, seated at a wooden bench, an obvious belly protruding up from under her billowy red shirt. Her due date was set for March, and I would be here.

We discussed what she wanted for her birth. She told me of how her mother and her two aunts are both midwives. But her mother was afraid. She didn’t want Anhet to have a homebirth with her. We talked about having a home birth where I attended her, but in the end she felt that what she wanted was to birth in the hospital. I made Anhet a promise that day that I hoped I could keep: to give her tender loving care during her labor and attend her delivery in the hospital.

So the months wore on. Anhet’s belly grew and stretched with the new life growing within her. We talked of labor, love, and newborns. She went for an ultrasound. We smiled together, our eyes softened, as we read the report. She was expecting a baby girl. She pulled miniature dresses in pastel colors and tiny red socks ringed with tulle out from plastic bags to show me her preparations. The days ran together as Anhet’s time came closer and closer. I had a moment of panic as I realized I would be out of town for five days the second week of March. I crossed my fingers that I would be able to keep my promise to her. Dios primero, as people say here.

On Sunday I headed to the beach. I left my phone at home, as usual, where I knew it would be safe and out of the reach of thieves. I basked in the warm February sun, enjoying the light glinting off the white caps. My friend’s son ran circles around me, standing on his hands, attempting back flips. When I made it home later in the evening there were eight missed calls on my phone. Anhet.

“Estoy mal amiga. Desde la manana he tenido dolores.” (Friend, I’m bad. I’ve been having pains since the morning)

So I filled my bag with some sterile gloves and my stethoscope and headed off to
Loma Verde, a growing community on the outskirts of Port where Anhet lives. The taxi dropped me off in front of the lime green cement home wringed by a wood and chain fence. I opened the slated gate and walked inside. When I passed the threshold there was that quiet hush that accompanies the beginning of labor. It’s like a dense cloud of expectation of those around, the cousins and aunties holding back their breath through tight lipped smiles each time a contraction grabs someone they love; and also there is that shift in energy as the world prepares itself to greet another being. But Anhet was still smiling. I knew it was early, and she had a long road ahead of her.

After chatting at the large wooden table in the kitchen we moved into the bedroom. Anhet lay across the king size mattress shrouded by a light blue lace mosquito net. Her baby lay as a mound over her abdomen, her tiny limbs pushing and probing through her skin. I kicked off my shoes and curled my legs underneath me, adjusting myself at her side. I pulled my stethoscope from my purse, inserted the ear pieces, and then laid the rounded bell up against her belly. Transported through the tubing to my ears was that familiar fast paced tick-tick-tick of her baby’s heartbeat. One after another I passed the earpieces to expecting mother, cousin, expecting grandmother, and auntie while carefully holding the bell in place which later left a small circular impression on her skin. We counted her contractions: every five minutes, but short and light.

Two weeks earlier Anhet had an ultrasound. Her mother, the midwife, felt that the baby was in an unusual position, and the ultrasound showed Anhet’s little girl seated in the pelvis rather than head down. I wanted to assure myself that this little girl had flipped into a head down position to ensure a safer labor and delivery. I laid my hands upon her belly, grasping one side of the fetus as I palpated with the other hand.

“Feels like feet over here,” prodding against the upper right quadrant.

I moved my hand above the pubic bone and grasped a hard round globe. The baby’s head. The aunties and Anhet’s mother with their years of experience agreed that the baby had back flipped, nestling its head into Anhet’s pelvis. To double check what I really was feeling I recommended a vaginal exam. My fingers felt along the soft, fleshy cervix, and I was able to insert two fingers side-by-side through the cervix to feel the familiar round hardness of bone and skull.

So I went home, to try to sleep with my cell phone tucked up against my ear, waiting for the call. At 6:00 am when my alarm went off I still hadn’t heard from Anhet. I hopped under thee cold spray of water in my shower then donned my scrubs, downed a cup of earl grey tea, and finished off a bowl of fresh fruit. Off to the hospital.

When I arrived at the hospital I found Anhet in the maternity wing, a stuffy room hot from the midmorning sun streaming through the wall of windows. Mattresses line the perimeter of the room, each one filled with a woman awaiting her time. My friend sat at the edge of her bed, freshly bathed, her moist dark hair curling into rings. She wore a pastel floral house dress. She still smiled, but looked tired, and her contractions now caused her to pinch her breath off shortly. The matriarchs of her family surrounded her, each one advising and consoling her in lilting Miskito. Soon enough Anhet would be ushered back to Labor and Delivery where her contractions would mount in number and intensity.

A couple of hours later the double wooden doors clacked open, and in shuffled Anhet, eyes red and moist with recent tears. She was at that moment in labor when women realize that those early contractions were just the warm up and that things were just going to get heavier. I helped my friend to the bathroom where she scooped cool water from the fifty gallon barrel with a cut off plastic jug, rinsing her body. She changed into the hospital gown, opened to the front as is the custom, but which always gapes open precariously at the right breast.

I settled in for the next couple of hours to support my friend through her labor. The contractions swelled up inside of Anhet who found it most comfortable to stand, bracing her palms against the wall, fingers splayed open, her legs firmly planted underneath her hips. With each fresh wave I reminded Anhet to breath deeply, to let the pain drift out with her exhalation.

“Wind cum, respira profunda (breath deeply).”

During the break between contractions I found my mind drifting back to those days in Daukura when Anhet and I first met. I thought of the stilted house, painted white and trimmed in green, the rocking chairs lined up in rows on the terrace. Mostly, I thought of the night when I bathed in the kitchen. Anhet had brought a bucket of water with a plastic bowl into the wooden room, setting a cake of soap on the windowsill. She closed the door behind her telling me she would stand guard. I had stripped off my sea-salted cloths and began to throw water onto my head, letting it drip down my shoulders to my feet. The cool water cut through the thick heat of the night. Anhet and I whispered through the slats in the wooden planks of the wall. We discussed boys and birth control. Our friendship was solidified in those moments talking through the wall as the water formed a moist puddle at my feet, dripping through the cracks into the earth below.

The contractions came and went, coming closer and closer, like the tide riding the shore. The labor and delivery room was empty aside from the midwife, Anhet and I. I allowed her family to come in one at a time, the midwives eager to see Anhet’s progress and pass on words of wisdom. Her aunt’s arms embraced her during contractions, the fingers of her left hand open wide, browned and wrinkled, expertly cupping the uterine fundus as she must have done countless times to other laboring women. She asked whether we should give Anhet some herbs to speed her labor. I thought she was progressing fine, so better not to intervene.

I examined Anhet: 7 centimeters. I felt disappointed as she had been 7 centimeters two hours ago when I had examined her. This was the first labor and delivery of a friend that I had attended as a midwife. I wanted everything to go smoothly for her, but also knew how labors can stall and problems can arise. The baby’s head had dropped significantly into the birth canal though, giving me hope that she would make her appearance soon enough. Thirty minutes later Anhet complained of increasing pressure, saying she felt like something was going to fall out.

I donned a glove and examined my friend once again. She was completely dilated and my fingers braised up against her daughter’s head just millimeters from the mouth of her womb. With two courageous pushes her little girl’s head crowned and extended into the world. A tight cord around her neck held her back for an instant. I set two clamps and cut the pulsing cord that had transported oxygen and nutrients to this being for the last nine months. Her body came slipping out with the next push as I raised her up onto her mother’s abdomen. 4:13pm February 28th. She had arrived.

Una amigita

The Ironies of Life and Death

On Tuesday morning I found myself once again folding gauze. Doubling the upper edge downward, drawing in the two sides, and then giving a fold-flip maneuver to tuck the wiry threads back in on themselves creating a somewhat misshapen 4x4 square. I tossed each pad of gauze into the open mouth of the stainless steel cylinder, years older than I, as the midwife, a student nurse and I chatted about relationships, episiotomies, and seafood soups. The small radio that sits atop of the Nicaraguan birth records buzzed in the background as soul reggae music washed in and out on the airwaves, accompanied by the hiss of the air conditioner. The three of us sat dressed in our clean scrubs, the student in her hand-sewn mint green top-and-bottom that signified her rank as entering her third year of studies, waiting for what the day had to offer. Occasionally, the entire day can be passed like this, without even a single patient gracing the new labor and delivery ward. We might just sit and stare at the walls, painted burgundy from the midsection down, and ivory up to the top, complaining again and again about how the delivery suite is too small and we run circles around one another. One of us will then make a comment about how difficult it will be to address an emergency in the tight 15x15 foot space where two obstetric tables, one neonatal warmer, two lamps, a table with gauze and D&C supplies, a sink, a cupboard, two nurses, a nursing student, a physician, and a laboring mother may all be crammed into at the same time.

The joy, and sometimes the terror of obstetrics is the unexpected. Just as on this Tuesday, one never knows what the day will bring. So at 11 am without a whisper of a patient, and a maternity ward bereft of patients I started to become bored. Twelve hours is a long time to fold gauze. And then I heard the now familiar clunk-clunk of the two sets of double wooden doors being forced open by a patient’s foot and the clambering wheels of the wheelchair as the driver negotiates the chair around the receptacle full of dirty linens, the yellow trash barrel, and decomposing cardboard box full with random medical supplies in his midst. The physician was driving, clutching a bag of IV fluids with 5 units of oxytocin with one hand, guiding the patient haphazardly with the other.

We helped the patient onto the expulsion table, a bright blue gym mat over a metal base, thick white plastic thigh supports at the practitioner’s end, a metal IV pole by the patient’s head. The young woman, dark circles under her eyes, thin and lackluster, was a first time mother whose baby had passed away, and well before his time. At 26 weeks the woman barely had a pregnancy bump. Her labor had been induced to relieve her of carrying this burden. She arrived in my hands with a fully dilated cervix. I gingerly reached my fingers inside to assess how near the patient was to delivery. My fingers came up against a joint, an arm, and a smooth roll of the shoulder, rather than the most common fetal presentation which is the solid skull. I felt panic rise in me. How would this baby deliver? I voiced my concern to the physician, “The shoulder is presenting, how is this baby going to deliver?” With a push on the patient’s abdomen he reassured me that it would be just fine, contrary to my instincts. But one brave push later the small arm made its way from womb to world, followed by its adjoining shoulder, then back, followed by bottom and legs that effortlessly slid up and out. Lastly, the head emerged as I delivered this shoulder-breech, expired preemie. The cord was cut and clamped. The baby lay limp and discolored on the green surgical drape. He weighed in at 1050g. The placenta slid forth soon after the delivery, small and misshapen by infarcts marking its slow shutdown as the fetus no longer thrived. I once again found myself reflecting on the nature of life and death. The wheel that keeps turning as one leaves this earth and another one is ushered in. For this young mother her birth brought death. Her sorrow profound.

No sooner had I let the placenta slip into the rectangular stainless steel basin at the foot of the patient, when I heard that familiar clang of wheelchair, patient, and practitioner against wooden doors. A frenzy of energy exploded as the nurses shouted in Miskito, and the patient grunted with force. I tore my soiled gloves from my hands, and reached for a new packet, tearing the rough paper open, letting out a spray of white talc. I struggled to pull the gloves on with speed. I don’t think I could describe what the patient looks like in detail to this day. All I saw was the telltale puffed cheeks, moist brow, and white-knuckles clutching the arms of the wheelchair that told me this baby was coming NOW! Right hand covered. I lowered the left glove about half way on to my hand when I witnessed the head and body of a vigorous, pink baby girl slip out from under her mothers black floor length skirt dotted with white flowers, famed by the wooden doorway. The physician gracefully arced his bare left hand from shoulder height to wheelchair height to stay the child as I swept in, less gracefully, with gloved right hand to catch the body. The other midwife scrambled to the side of the wheelchair to place clamps about the umbilical cord. Clamp-clamp-cut, and I was carrying the newborn, fists punching, legs kicking, to the newborn warmer,

This is the irony of birth, life, and death. I felt the wheel of life spinning as within 5 minutes I witnessed the birth of this first time mother’s deceased babe, and then a baby deliver herself from a woman who is a mother many times over.

Anhet

At 7 months pregnant

WaWa Bar Mobile Clinic

A group of Nursing students from Ithaca, New York came to visit Puerto Cabezas for 10 days. Here are a couple of fotos from a medical brigade that I attended with them in WaWa Bar. It was fun having them here!

What does it take to write a radio program?

I am a midwife. I understand the physiologic impulses that make the uterus contract and release to bring a child to light. I can explain the mechanisms of action of various birth control methods. Surprisingly, I have the kinetic memory to insert a speculum, even when I haven’t performed a Pap smear in 6 months. As a midwife I had never considered myself a writer/producer of a radio soap opera!

Two years ago when the idea of creating a radio soap opera was just taking form I easily began writing for grants. The RAAN suffers one of the highest rates of maternal mortality in the west, with estimates of 287/100,000 maternal deaths annually. The concept of writing a radio program seemed flawless: create a radio show in the format of a soap opera that will be interesting and informative. We will name it Mairin Karnakira (Strong Woman in Miskito). Women can listen to messages regarding how to care for themselves during pregnancy and how to identify obstetric danger signs if they arise. Easy as pie…so I thought!

So what does it take to write and produce a radio soap opera in Puerto Cabezas, Nicaragua? First and foremost: patience. Plans move at the speed of growing grass in Puerto Cabezas. Working on the North Atlantic Coast provides a daily lesson in living in the present. Secondly, on paper a project may appear to be a piece of cake, but once the steps are divided up into tasty slices, you realize that you may have bitten off more than you can chew! So here is where I began, and here is where we have arrived four months later.

For two months a group of Miskito Obstetric Nurses (otherwise known as midwifes!) would meet with me at the Casa Materna to discuss a pertinent maternal health topic that would make up the content for the radio show chapters. The meetings were planned for 3pm. The first attendant would usually arrive at 320, and by 345 half to three-quarters of the participants would be present. I would draw out my digital recorder, placing it haphazardly on a rocking chair in the middle of a circle formed by these knowledgeable nurses, and slip into Spanish focus group mode. After approximately an hour of discussion I would press the red stop button and thank the nurses for their time. Each week after our discussions I would begin the painstaking task of transcribing the recordings to preserve the exact language that the nurses used to describe obstetric events. Next, with my transcribed document open and a crisp blank document on the computer desktop I would begin writing the radio soap opera chapter. Now, for those who have never written a radio soap opera its much more challenging than you could ever imagine. You must create characters that are real, that are easy to relate to, and most importantly that are interesting. You must reach deep inside to find the creative spring that will flow words out onto the page, to paint the scenery and emotions with audible words, and create a thread that can be woven from one chapter to the next. Did I mention that if you were writing this radio-soap opera in Puerto Cabezas Nicaragua you would also be writing it in your second language? Did I also mention that along the way your laptop would fizzle out and die?

Well, all difficulties aside by December 18th the nine proposed chapters, totalling 125 pages, of Mairin Karnakira have been completed. My producer told me that I deserve an honorary doctorate in Spanish for my efforts! Now we are in editing stage. First the chapters will go to the Spanish professor at URRACAN, the local university, for her to edit to the point that they will sound like a native Spanish speaker from the region wrote them. Second, they go to the radio producer who will edit them for radio content, meaning that she will add in the sound details and narrations that I have surely left out. Then, the chapters will go to the Integrated Medicine students at URRACAN who will edit the chapters for their medical and traditional medical content to make sure the messages are clear.

So, four months later, for those waiting for the radio show update, we are in print edit mode. Fingers crossed, hopefully we will begin recruiting our actors and start recording in February…better make that fingers and toes crossed!

Bullets

To understand a culture there must be some knowledge of the history of its place. The events that occur throughout a culture’s and country’s gestation are woven into the fabric of its existence, its threads made up of varied lengths and colors. Civil war weaves its ways through the rich fabric of Nicaraguan history: south versus north, pacific versus costeño, Spanish versus Miskito, Sandinista versus Contra. The war ended in the late 1980s but its effects are present everyday. For example, the population demographics of Nicaragua have been molded into a demographic donut: the young and old form the spongy outer ring with a large void in the center where the 20+ to middle age would have existed if not for being leveled during the war. Within this demographic donut you will also find many more women (not so many female soldiers) than men living in current day Nicaragua.

At dinner the other night a friend of mine from the hospital casually slipped a war story into our conversation. As I listened to her words I considered how I don’t have any war stories to drop at a cocktail party or off-handedly mention to a passenger sitting by my side in a taxi. It’s just not part of my history.

She was telling me an anecdote from a previous conversation with a colegue of hers. Both women of the same age, early thirties, both specialist physicians in a far away corner of Nicaragua. One grew up in Managua the capital and the other grew up in Rosita, a mining area of the RAAN.

“Remember the Babamama doll?” asks the physician from Managua.

“No.” says the physician from Rosita, shaking her head, wrinkling her brow as she tries to remember if the doll’s name is familiar.

“How about the Candy doll? Or that one cartoon?”

“No, not that one either.”

“Really?!”

“Look, we didn’t have television, and we didn’t have those dolls. All we had were bullets. We played with bullets,” she says while she laughs and spoons another bite of seafood cocktail into her mouth.

She then went on to tell me how the only toys available at that time were a little black doll for girls and a toy gun for boys. Oh, the irony (or strategy) of sensitizing young boys to guns in a war zone. And to further make her point she says, what mother wants to buy her son a toy gun during a war, but then again what mother won’t buy her son the only toy in town.

She also related stories of air raids. She explained that every home had dug an L-shaped “safe haven” in the back patio in case the town was under attack. Her father cared for their L-shaped trench, flattening its black dirt, ensuring its safety. She went on to tell me about the night that ¨the war came¨in 1988. They were ordered to hole up into their safe haven. As they made their way toward their L-shaped home, they discovered, to their surprise, that the earthen trench was filled with water; there would be no entering! She relays these stories with bright eyes, a laugh at the corners of her mouth. Then she says, “It’s terrible to live through war. It’s terrible,” then quickly goes back to nibbling on her fish cocktail stained red with tomatoes.

Just a little taste of one woman’s history in Nicaragua.

Obstetras

Hospital Nuevo Amanecer en Vivo

A couple of low quality cell phone videos of Hospital Nuevo Amenecer to fill in the imagination!

600-715pm

The lights flickered and dimmed. The dark of dusk fell over the barrio as the lights went out in the Cocal. They say that in December the lights fail more often than not. Everyday for the past week the lights have gone out at least one time. I found myself lighting the way with my cell phone, its small square of yellow guiding me through my dark home. I searched for my teal green scrubs and pulled them on, feeling my way for the drawstring that distinguishes the front from the back of the shapeless pants. I locked up the top of my home and walked down the stairs to the kitchen to throw together a simple dinner to bring to the hospital. There had been avocados in the market earlier that morning, so I threw one in my bag with a package of mini toasts. Outside the lingering light from sunset carved out silhouettes of trees, buildings, and neighbours walking to their homes. Armed with my cell phone I passed through the metal gate and dared to trudge through the thick clay colored mud that currently lines the alley from my house to the street. At the mouth of the river that is my alley I awaited a taxi to whisk me though the pitch black for a night shift at Hospital Nuevo Amanecer.

As we sped down the gravel road there was a stillness that I could detect in the air. When the lights go out the chugging generator of the city quiets itself, and the black night draws people into their homes, away from the possible dangers lurking in the shadows. Quite nights like these make for lovely births.

I entered the hospital and walked back to Labor and delivery at 600pm. The delicate hum of the air conditioner whispered in the background mingling with the heavy breathing of two women in labor. One, the 43 year old matron, preparing to have her ninth baby stood in the corner providing guidance to the other, 20 year old first time mom. It was a crap shoot who would deliver first, but I placed my bets on the experienced matron. I led her to the delivery table, carting the small plastic bag of blood that was transfusing into her vein. An older woman, with anemia, and a history of many deliveries is at high risk for a hemorrhage after birth. I mentally prepared myself for the worst, running through my steps for managing a postpartum hemorrhage. The matron climbed onto the table, telling me that this was her fifth delivery in the hospital. She grinned, revealing a smile only half full with teeth. She was complete and began bearing down like a professional. I was the only midwife available to attend the delivery as the other one had stepped out. Gradually her baby´s head made its journey from inside to outside. Her neck was rounded by a tight loop of cord too tight to slip over her head. A quick somersault and the baby´s body was delivered and the cord then removed. No hemorrhage. That was at 700 pm. As I am waiting, and waiting for the placenta to deliver I´m starting to become concerned that she might have a retained placenta as I hear the deep guttural groans of a pregnant woman who is ready to bring her child to light. Finally the placenta slips out and I pass the multiparous patient off to the young physician for her to inspect.

I slip my head into the labor room and see the first time mom eyes wide with surprise staring up at me. I whisper to her, “its time” and help her to her feet. We move to the delivery table and she clambers her way up onto the blue vinyl cushion. The black curls on her baby´s head are just barely visible as she begins to bear down with all her strength. The midwife comes up to me and asks me if I’m going to cut. I shake my head no. “I think she´ll stretch”. “Don’t do it then” she says. I sense the still black night outside, hear the buzz of the air conditioner, and feel honoured to be sealed up in this labor and delivery suite at the end of the earth. The first time mom pushes with control to deliver her baby boy, tight nuchal cord, with one hand reaching up and out into the world. She delivered beautifully and empowered. Of course there was a little tear, but nothing a little suturing couldn´t fix. That was at 715 pm.

Sexy Underpants

A night at the hospital is always full of surprises. You never know what it will hold. Some nights nothing happens and I will pass the hours trying to sleep on a mattress that we open up on the floor, lying next to another nurse clad in white from head-to-toe while people come and go, knocking on the door, eating fried plantains, and searching for nursing students.

Last night began slowly. An empty labor and delivery room is nothing new to me. I often start my shifts either day or night chatting with the nursing students and midwives. When it is a night shift I often hope for one of two things: that the night will be slow and we will sleep, or that it will be so busy that the 13 hours will fly by.

At 830 still no patients. I spent an hour talking to one of the physicians, and then a friend came by for a visit. I sat outside in the thick night air, watching the moisture create halos around the street lights. We talked and watched pregnant women holding large bellies stream by, but not one of them in labor. Suddenly I heard the electronic samba of my phone ringing. It was the doctor. He needed me to come back and attend a birth. Some how a pregnant mother, cervix completely dilated slipped past me into the labor and delivery suite. I hurried back my clogs clacking against the smooth concrete floor, opened the door to Labor y parto, and approached the labouring mom. One look at her told me this baby was definitely on its way. The other midwife had stepped out, so it was just me, the nursing student, and the physician who was busy scribbling a note, back turned to the patient. I suited up into my surgical green cloth gown and donned a set of gloves significantly too large for me, tugging at the floppy latex thumbs to keep them from falling off. The mother began to push and a bulging bag of waters was instantly visible, black curled hairs from the babies head swaying beneath the membranes. Now, in the majority of deliveries the baby follows a certain dance that I have referred to before as the cardinal movements. The baby descends into the birth canal, flexes his head downward with his eyes pointed towards the mother’s back. When the baby begins to crown the head extends up and out of the birth canal, turning slightly to one side. Following this the shoulders take a turn so that they are parallel to the birth canal and with this a fold at the hip and the baby’s body slips into the world. That is, that most babies are born this way. As this mom began to push I applied my fingers to the baby’s head, creating pressure so that his head would not fly out and tear the mother. To my surprise this little one popped out, sunny side up, eyes to the ceiling, gazing directly into my own. He quickly slide into my hands and up onto his mothers belly. This technically is called a direct occiput posterior delivery, but there was nothing technical about this delivery, it was simply one human being being born staring into the eyes of another supporting his head.

Later that night we had another delivery. A very sweet woman delivering her second baby. She progressed rapidly to complete and we brought her to the delivery table. She was scared, but with gentle support she was able to find her inner strength and bring her child to light.

There are certain things in life that make someone feel like a midwife. One is empowering a woman to birth her baby with the power that she innately has. Another is teaching another woman how to attend a delivery. Last night was when I transcended from student to midwife to teacher. As I prepared myself to attend this delivery the nursing student whispered in my ear, ¨will you let me try this delivery¨. She put her gloves on and laid her hands on the woman’s perineum. She was brave and I noted that her hands were steady and her eyes clear. I felt the fear or apprehension that any teacher must have when the give over the reins to their student as I laid my hands over hers, applying pressure against the mother’s perineum trying to prevent any tearing. It’s very difficult to let go as a practitioner. I wanted the best for this patient, but also wanted to give this student an opportunity to learn the art of midwifery. Together ours hands pressed, flexed, and welcomed this babe. As the head slid forward we both checked for a cord. We both grasped our hands alongside the babies head to ease the shoulders up and out of the birth canal. The student was exhilarated as she placed the newborn up on her mother’s abdomen. I was proud to have had the opportunity to share my skills, although new skills, with this student. We delivered the placenta together, me whispering instruction into her ear. We inspected her perineum and discovered a mild tear that would require suturing. And there I was, a new practitioner instructing a nursing student in how to ease the silver half-moon needle into the red tissue, rounding it up and out. It was an amazing lesson in midwifery to support the growth of another student, and quite a personal lesson in letting go.

One of the most midwifery related actions that we do at Hospital Nuevo Amanecer is dress our patients after the delivery. We carefully bath them with wiry gauze that has been hand folded when there is nothing else to do in the labor and delivery suite. We remove the dried blood and streaks of amniotic fluid. We then help the mother to cross her legs together and slip on her undergarments in which we have placed several absorbent kotex pads. Our patient had been sobbing through the delivery and was still weeping as we cleaned and prepared her. As we pulled the underpants out of a green plastic bag that her husband had brought for her she began laughing hysterically. We all broke down, laughing like crazy as she said ¨of all the underpants, this is what he brings me? I have a mountain of underwear and he sends me back these? These sexy underwear?¨ And we all laughed until it hurt as we helped her slip on the chocolate brown, satin panties with a large cut out key hole and silk bow in front.

Birth and Death

The saddest moment of a pregnancy must certainly be when a woman hears that her baby has died. All of the hopes and dreams that she had for this unborn and unknown being lost like grains of sand slipping through ones fingers. Part of the psychological transition into motherhood comes when the woman feels the first flutters and twirls of the growing fetus within her womb. She identifies at once that this creature is of her, but is its own unique life coming to being. With this acknowledgment she begins to wonder, will she have my curly hair, will he bear the family nose, will she be kind, will he be funny...and just like that, before the child is even born the parents have cultivated a garden of hopes for their little one.

I can't begin to understand the sadness that my patient felt when she went to the clinic, concerned that her baby hadn't been kicking within her for the past two days and discovered that her baby had died. Surely the nurse or doctor applied cold gel to the plastic tip of the hand held doppler and searched in vain for the quick click-click-click of the baby's heartbeat. They probably told her that they were sorry, that it was too late, that her baby hadn't made it. After this heartbreaking news they must have informed her that she would need to go to the hospital to have her labor induced.

When I met her she was 5 centimetres dilated in labor with her first baby who had died. She was exhausted, her golden skin looked sallow, her eyes sunken with a far away look. Sweat beaded on her forehead and upper lip. She grasped her IV pole from which a bag dripped oxytocin into her veins. A cruel twist of fate this labor. Normally a labor of love and pain, women know that on the other side they will greet their long awaited baby. In a developed county this woman would be offered pain medication or an epidural to ease her through the difficult labor. Here it is not an option. With each contraction she reeled in pain. She moved from sitting to standing, to lying, lacking the strength or will to move gracefully between positions. She could not find comfort and cried out to God to see her through as each contraction surged through her. I sat with her and tried to calm her, knowing that her suffering was deep.

When her cervix was completely dilated we brought her to the delivery suite. She lay on the table, forlorn. She pushed bravely. I guided her, my hands fearful, never having delivered a baby that would not be alive. The delivery was difficult. Normally a baby rotates into the mother’s pelvis in a dance called the cardinal movements. The head flexes, then extends as it’s born, followed by a 45 degree turn at which time the shoulders align vertically before the rest of the body is expelled. But a baby that has died does not know the movements. The head does not gently extend, the shoulders do not rotate. The baby's body would not deliver. I found myself stepping aside as one of the doctors with more strength moved in to extract the baby. I had wanted so badly for the delivery to be gentle, to offer this woman just that small kindness after so much suffering, but it was not meant to be. I stood at her side as the baby was lifted to her abdomen. I wrapped her in the sterile green surgical drapes and carried her to the neonatal warmer, gently placing her onto the bed. It was overwhelming that she did not breath. Her right arm curled up towards her tiny mouth, left arm over her belly. Her small legs were pulled upwards in a tuck. She looked ready to take her first breath, ready to startle and fan her arms up and out into the world. She was perfect.

I moistened some gauze and began to wipe her face, eyes, hair, trying to make her as clean as possible given the conditions and lack of running water. She had been expecting a little girl. Her family passed back a rose pink princess dress with puffed sleeves and layers of sparkly tulle. After measuring and weighing her I fitted her white cloth diaper on. I smoothed the pink princess dress down over her little body, placed the pink hat over her moist black hair. I pressed her left foot onto an inkpad and placed a foot print on a piece of paper for the family to take home, then slipped on her pink socks. She looked like a newborn Cinderella.

One of the nurses brought her daughter over to her mother, whose eyes welled with tears. The baby was brought out to family waiting in the hall.

I wanted this blog to be a tribute to this brave woman. A remembrance for her daughter.

The Birthday Gift

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.

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.

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.

Number 43

...or the first baby I delivered in Nicaragua since arriving...or the first baby I delivered since becoming a CNM!

I had gone to the hospital earlier in the week. It was a day shift. As I entered the Labor and Delivery suite it was teeming with people. Currently there are a group of 8 Norwegian Nursing students here, three of them were present and accounted for, two third year Nicaraguan nursing students, two midwives, one doctor, two med students, and one adolescent patient be readied to go to c-section. She had arrived at the hospital the evening before after pushing for hours at home. When she came to the hospital she was 3cms dilated. After several hours in the hospital, rupture bag of waters, and pitocin she never progressed past 8cms, so was sent back to surgery. It has started to emerge through my time here and some research in Guatemala that women are instructed to begin pushing as soon as they experience strong contractions. Many women become quite exhausted with the work of pushing up against a closed cervix...and then end up in the hospital being wheeled into surgery. That day there were 4 c-sections and no more laboring patients, so I headed home for the day, deciding that a night shift might be more interesting, and at least less crowded.

So last night I went in to Labor and Delivery to be on shift with my friend the midwife Martina. We had a labor patient already there. She paced back and forth with uncomfortable, yet mild contractions. She was a G3P2 at 39 3/7 (for those who care!) who had been sent to labor and delivery at 5cms at 4pm, at 7pm when I checked her cervix was unchanged. The physician on call decided it was time to augment her labor and she was given pitocin (5units in 1000cc, 8drops/min) 30 minutes later she had a desire to push. I checked her again and she was 8cms with an intact bag of water. I ruptured her membranes to reveal moderate meconium (which came first the oxytocin or the meconium we will never know). 5 minutes later the mother pushed courageously and silently to the birth of her vigorous baby boy. She has two daughters already and was planning on having a tubal ligation, so was quite ecstatic to welcome her son into the world.

All-in-all it was a gentle, uncomplicated delivery. I had been feeling nervous about attending a birth since it has been almost 4 months since my last one...but I guess it’s somewhat like riding a bike, especially when you have all that excellent training behind you! It felt natural to be there supporting the woman, flexing the baby’s head, gently unhooking the two rings of cord that were about the babies neck. It’s also such a great opportunity to work with women in a surprisingly low intervention setting. No electronic fetal heart monitors, no tocometers, no IV pumps...Just a set of hands on a belly and a watch to count contractions, a handheld doppler, and a baby warmer.

One of the things that I love about being in this setting is the exchange of ideas that occurs. I have the opportunity to learn how things are done in this setting: using the partogram, charting in a different language, etc. And the midwives have the opportunity to ask me questions about birth in the U.S. The most recent conversation has been about the position that women birth in the States. Most deliveries at Hospital Nuevo Amanecer are done in the lithotomy position, that is flat on the back with legs in stirrups. I explained to the midwives that women also deliver in that position in the US, but as midwives we are trained to attend women in a variety of positions such as standing, squatting, hands and knees, etc. The nurses were so excited about this, and asked me to bring them pictures that explain how to attend women in these positions...Where is my trusty Varney's Midwifery when I need it! They explained to me that there have been women who have refused to get on the birthing table (yay!) so they have delivered their babies standing or sitting, but they wanted more instruction on this. They also say that ultimately it is the woman's choice where and how she wants to deliver.