Wednesday, February 23, 2011
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.
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.
Tuesday, January 18, 2011
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!
Monday, January 10, 2011
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!
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.
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.
Sunday, December 19, 2010
Hospital Nuevo Amanecer en Vivo
A couple of low quality cell phone videos of Hospital Nuevo Amenecer to fill in the imagination!
Wednesday, December 08, 2010
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.
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.
Tuesday, November 30, 2010
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.
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.
Thursday, November 04, 2010
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.
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.
Monday, October 25, 2010
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.
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.
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.
Thursday, September 30, 2010
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.
Monday, August 24, 2009
Two years after Felix
Many of you may be unaware of the natural disaster that targeted the Miskito coast 2 years ago on September 4th. It is something that is still very alive and real to the families involved in lobster diving and fishing populating Northern Nicaragua. On September 4th Hurricane Felix touched down over the Cayos Miskito, leveling the fishing villages and taking many of its divers and fishermen with it.
The way the story was told to us was that the severity of the approaching storm was not revealed to the men and women working out at the Cayos. Evacuation was never mentioned. When it was apparent that a massive storm was making its way directly towards the keys, an area with little to no protection from the elements, many attempted to make their way back to shore. Of the boats that departed several were blown back to the key just as they had made progress. Others urged forward into the sea, never to be seen again. We were told that people from the keys decided to congregate at Maras, possibly due to the ring of mangroves that offered a minute amount of protection, and also due to the knowledge that the eye of the storm was to pass directly over Cayo Mikutu. Our boat captain and his crew had all passed the Hurricane at Cayo Maras, and survived. They explained how they filled their boat with people, and drove it into the mangroves, a set of brush-like trees. This was facilitated by the waves that were crashing above the tall trees, driving them into the vegetation. They tied themselves to the boat and prayed that they would make it through the lashing winds and roaring tides. Rigo, said that he was so glad that the storm hit at night, because it would have been such a horrible thing to watch all of the people that he knew and worked with be picked up and flung into the sea. He said the night was filled with screams and tears. When morning broke, the sky and ocean was calm, but all had been destroyed. Not a single house remained. The water was filled with bodies. He told me that of those most affected were the women who worked in the Keys. He estimated that at least 300 died, those who had not made it in a ship back, who feared going back in a ship, or who had stayed in the houses to weather the storm.
As we spent our week at Maras, we were often told stories of the horrible night, of the terrible morning identifying bodies. We were told that many men have dreams in the Keys of women coming up from the water, touching them, crying. People see images in the water. One man told us that while we were there that he had a dream in which a woman’s hair was wrapping around his neck, tighter and tighter, reaching up from the water. He startled awake, sitting bolt upright. Another woman who had not been there during the storm told me that she dreamed of a legless woman, climbing out of the water onto the dock, scooting her body forward with her arms, looking into the room filled with divers hanging in their hammocks. The woman said she peered straight into her eyes, and then she awoke.
I had visited the Keys about two and a half years earlier. They were bustling fishing villages at that time. Cayo Miskutu was so developed that there were churches, a military post, a hotel, many houses, and I am told, Direct TV. When we went to visit the key, there was a startling difference. The mangrove island, once lush and long, was decimated. Barren, grey trunks stuck out from the swampland that was once a green island, reputed to have a fresh water lagoon at its center. The many colorful, open-faced homes were gone. A total of 10-15 houses had been rebuilt. These stood sadly amongst the skeletons of houses past, their wooden posts forcing their heads out of the crystalline water.
We are also told that the harvest of lobster and fish has dramatically declined. Those who have been coming out to these traditional fishing lands for years believe that the high time of the keys has passed. I am honored to have had the opportunity to know these eclectic island, fishing villages, both before and after the storm.
Miskito Keyes
On Monday we set off for the Cayos Miskitos, a set of “islands” 50km off the coast. The plan was to be there over Cody’s birthday. A friend of Cody’s, Rigo, works for the prominent company Mar Azul, a lobster buyer based in Puerto Cabezas. They outfit him with a big, fast, speed boat and enough supplies for a week at the Keyes. So, we boarded the big, fast, speed boat on Monday afternoon, arriving at Cayo Whippling in just under an hour, a trip that had taken us all day when we made the journey two years earlier by sailboat. Whippling is either the most impressive or most unimpressive of the Keyes depending on your perspective. There is literally no island to this island. No land to speak of, not a mangrove to shake a stick at; only a set of 8-10 stilted, open faced, wooden houses topped off with zinc. The houses birth out of the blank horizon, standing tall like soldiers. We stopped at one of the homes to purchase the lobster that was being kept on ice there by a full bodied Miskito woman and her family, she clearly being the negotiante. I witnessed the first of many lobster tail transactions in which our shipmate Ricky would inspect each tail carefully for color, size, firmness, and damage. He wielded a short, yellow plastic ruler that was used to ensure that the lobster tails were long enough, i.e. old enough, for harvest and sale. 450 pounds of lobster later everything was loaded into white sack bags and moved into the icy belly of the boat, just in time to watch the sun fall below the horizon.
Before the sunset you could see with the naked eye our destination, Cayo Maras in the distance. This key is surrounded by a ring of mangroves that can easily be spotted during day light. At night it seemed that the key eluded us. When previously we were cruising at alta velocidad, we were now inching our way through the calm, Caribbean sea. The starts blanketed the night sky, the milky way creating a hazy gape above us. A large meteor cut across our view. It seemed like the journey would never end. We cut through the water slowly, deliberately, trying to avoid the abundant reefs that fill the distance between Whippling and Maras. I could feel the tension in the group. No one was talking. I started to ask myself, should it really take this long? Why aren’t we there yet? Soon thereafter I could hear the men asking each other softly in Spanish and the in Miskito: do you see it? The entrance? GPS was pulled out, but all of the coordinates had been erased. The dark of night hung all around us…I lay on my back staring up at the sky wondering if I should have made a wish on the first star I saw that night to ensure our safe arrival. After approximately 2.5 hours one of the men shouted out in Miskito that he saw the island. He pointed forward as we all strained our eyes and failed to see it. He said the entrance it keeps moving. Then, sure enough, the outline of the mangroves grew before us. I released a huge sigh of relief. We carefully slipped through the entrance to Maras key, rounding up next to the house that would be our home for the next week. After the 450lbs of lobster tails were unloaded we strung our hammocks and slept until the break of day. The morning revealed clusters of stilted homes standing firm in the Miskito Blue sea, a color that can never be described or mimicked, surrounded by lime green mangrove swamps bathed in the early morning light.
As a side note, on our return trip it took approximately 10 minutes to pass between Maras and Whippling. Cody says we were never lost, just moving slowly to prevent any unforeseen reef-boat altercations…still seems like it took a looong time to arrive!
Centering Pregnancy Nicaragua
During one of my volunteer shifts at Clinica BIlwi I told Myra about Centering Pregnancy, a form of prenatal care that I am being trained in that is done in a group. Women with approximatley the same due date are all brought together for their prenatal care for 2 hours. The first part of the session involves weighing the women, having them take their own blood pressures and record it in their charts. This is then followed by an hour in which we discuss certain topics pertinent to pregnanct women: nutrition, breastfeeding, birth control, domestic violence, process of labor and delivery, etc. Its an amazing way to teach women about their bodies, pregnancy, and delivery. Historicaly, women who attend the group are more prepared for thier delivery when the time comes.
I had noticed that many young women were coming to Clinical Bilwi for their prenatal care. They were between 15 and 18 years old, and had alot of questions, many of them were timid about asking. I also had noticed from my expereince at the hospital that most first time moms entered labor y parto very scared, and without any knowledge of what was in store for them. After bringing up the idea of Centering Pregnancy, Myra and I decided to offer a birth preparation class to the first time moms that lived in the Barrio Revolution. We started informing the women of the class, and had a plan to hold it at one of the pateint´s houses on Saturday morning. The women expressed alot of interest in this opportunity to have their questions and doubts spoken to.
The previous year I had sewn a uterus, complete with ovaries, a baby, bag of waters, placenta, and cord, and had left it at the Casa Materna. I stopped by to borrow it for the class. Armed with the model uterus, I made my way to the barrio Revoultion to meet with Myra and our group of women. When we arrived at the house the girl who was hosting the talk wasn´t there. Myra and I sat in the shade of an old building that once was a corner store to wait. After about 20 minutes Alma arrived. We chatted about her boyfriend, what she´s been eating, and I answered questions about life in the US. It soon became apparent that our "group" was going to consist of Alma, Myra, and I. We spent an hour with her, talking to her about what to expect, how she could relax during the birth, breastfeeding, post partum birth control, etc. All the things that you want to talk to pateints about, but often don´t have alot of time for. We also explained to her the things that are routinely done in a hospital in Nicaragua: you are given an IV, you will most likely be given Pitocin, you will have an episiotomy because its your first baby, you will get a shot of oxytocin after the birth, your baby will be taken away to be weighed, measured, and dressed before you can hold him. We then answered her questions about basic biology: where does a baby come from? how does a woman get pregnant? is it true that if you breath while you are pushing the baby out that it will move back into your belly?
An interesting thing that I learned during our session, is that women attending high school who become pregnant are kicked out of school. They are not allowed to attend classes, and once they have had a child they are not allowed to where the school uniform. This means that they are not able to return to school after they have delivered, except on weekends, or some evenings when all of the "bad girls" go. The burden of fertility is so high in a population such as the one in puerto cabezas. o sexual education is taught, young women are not offered birth control, men will not wear condoms, and if you get pregnant you are denied the opportunity to be educated.
Even though our Centering group only consisted of one woman, I think that the education will change the trajectory of her birth. I think she will be more confident to ask questions, and will also share what she has learned with other women in her community.
I had noticed that many young women were coming to Clinical Bilwi for their prenatal care. They were between 15 and 18 years old, and had alot of questions, many of them were timid about asking. I also had noticed from my expereince at the hospital that most first time moms entered labor y parto very scared, and without any knowledge of what was in store for them. After bringing up the idea of Centering Pregnancy, Myra and I decided to offer a birth preparation class to the first time moms that lived in the Barrio Revolution. We started informing the women of the class, and had a plan to hold it at one of the pateint´s houses on Saturday morning. The women expressed alot of interest in this opportunity to have their questions and doubts spoken to.
The previous year I had sewn a uterus, complete with ovaries, a baby, bag of waters, placenta, and cord, and had left it at the Casa Materna. I stopped by to borrow it for the class. Armed with the model uterus, I made my way to the barrio Revoultion to meet with Myra and our group of women. When we arrived at the house the girl who was hosting the talk wasn´t there. Myra and I sat in the shade of an old building that once was a corner store to wait. After about 20 minutes Alma arrived. We chatted about her boyfriend, what she´s been eating, and I answered questions about life in the US. It soon became apparent that our "group" was going to consist of Alma, Myra, and I. We spent an hour with her, talking to her about what to expect, how she could relax during the birth, breastfeeding, post partum birth control, etc. All the things that you want to talk to pateints about, but often don´t have alot of time for. We also explained to her the things that are routinely done in a hospital in Nicaragua: you are given an IV, you will most likely be given Pitocin, you will have an episiotomy because its your first baby, you will get a shot of oxytocin after the birth, your baby will be taken away to be weighed, measured, and dressed before you can hold him. We then answered her questions about basic biology: where does a baby come from? how does a woman get pregnant? is it true that if you breath while you are pushing the baby out that it will move back into your belly?
An interesting thing that I learned during our session, is that women attending high school who become pregnant are kicked out of school. They are not allowed to attend classes, and once they have had a child they are not allowed to where the school uniform. This means that they are not able to return to school after they have delivered, except on weekends, or some evenings when all of the "bad girls" go. The burden of fertility is so high in a population such as the one in puerto cabezas. o sexual education is taught, young women are not offered birth control, men will not wear condoms, and if you get pregnant you are denied the opportunity to be educated.
Even though our Centering group only consisted of one woman, I think that the education will change the trajectory of her birth. I think she will be more confident to ask questions, and will also share what she has learned with other women in her community.
La Prueba es Gratis
The last time that I had been in Port I had talked to a friend of mine about what clinic she thought was the best for women’s health. She had recommended a doctor at Clinica Bilwi, a social health service, telling me that they did the most gentle exams. From what I had witnessed last summer I was eager to meet someone who practiced woman centered care. I had heard of the clinic before, as they advertise themselves on the radio as a nonjudgmental health center that serves the lesbian, gay, and transsexual community as well as sex workers. This is a bold mission in a region where homophobia and prostitution is rampant.
After arriving in Port I made the appropriate arrangements to work at the clinic: walk to the clinic with a friend, who cooks delicious Chinese food, who knows Dr. Chamorro. A quick chat with him and Ingrid who runs the HIV testing clinic and I was set for my volunteer stint. I had explained that my interest was mostly in obstetrics and gynecology. The practice dedicates a large portion of its work hours to “capturing” pregnant women and bringing them into prenatal care; but it is still a general practice, and as I would learn a variety of people walk through the door in a disordered fashion throughout the day. Interruptions are the norm…you can be working with one patient, when another walks up requesting you to remove their big toe nail, or to repair the gash in their child’s head, for example.
I showed up the next morning promptly at 730 as instructed, only to wait until 9 for the doctor to arrive. Myra is a young red headed doctor born in Puerto Cabezas to German parents, who speaks perfect Costeno Spanish. She is at Clinic Bilwi as part of her servicio social, a two year residency that all doctors are required to do, in an area of need after completing medical school and before studying a specialty. She and I worked throughout the morning and afternoon, measuring bellies, listening to fetal heart sounds with a cardiac stethoscope, and treating “sindrome vaginal” in all of the patients. A difference in the practice in Port versus in San Francisco is that when a woman complains of some type of discharge there is no way to confirm if the woman does or does not have an infection. Rather than looking at the discharge under a microscope to determine if it is normal pregnancy mucus, a yeast infection, bacterial vaginal infection, or a sexually transmitted disease, the doctors treat for all of the above. Each woman would leave with a stack of pre-cut, brown, slips of paper with a MINSA stamp on them that served for prescriptions, to carry to the pharmacy to treat their vaginal syndrome.
I left the clinic at 1230, heading home for lunch. I had planned on going to the hospital for an evening of labor and delivery, but turns out that there were other plans in my barrio…
When I arrived at the house Cody was ecstatic; he had wanted to experiment with making chocolate from scratch and today was the day. He had brought five pounds of raw cacao to our neighbors across the street that have a mill for making pinolio, a blend of corn and spices that is mixed with water that we drink for breakfast….basically the Nicaraguan version of Carnation instant breakfast, only tastier, and prepared by your neighbor. Across the street there was lots of excitement and anticipation as the cacao was roasting over the fire. The kids would poke their heads into the wooden shack that held the mill, and circle anxiously around the cacao pods. Instead of heading to the hospital, I found myself in my scrubs cracking open the hot cacao pods to reveal the dark material inside that would become chocolate. My hands became black from the work, and more than a few cacao innards made it into my mouth and not into the bowl. When all of the meat had been freed from the pods we were ready for the grand experiment. No one had attempted to make chocolate before, but as people say in Port: La prueba es gratis…It never hurts to try! The mill got powered up and its operator began feeding the cacao into its mouth; on the other end a rich, chocolate syrup spurted forth into a plastic vessel. We all smiled and cheered the mill onward, the kids became giddy. We mixed the chocolate paste with sugar and powdered milk, feeding it back through the mill once more; it exited as a perfect chocolate solution. Fingers dipped into the mixture and squeals of delight were heard as we licked our hands, spoons, bowls. The first chocolate ever made in Puerto Cabezas was a success, and I have to admit that I have been enjoying my morning hot cocoa! I don’t think that I missed anything at the hospital that night more amazing than the birth of chocolate!
Friday, August 29, 2008
A Long and Winding Road
My last days in Nicaragua were spent adventuring deep into communities of the north atlantic coast. Cody was sent on a mission to inspect a small saw-mill operation in the pine wood savanna, and I eagerly accompanied him for a chance to explore and get out of the city. We boarded the sleek grey truck that virtually has no shocks left, leaving us bumping up and down the road as if we were in a truck pimped out with hydraulics in a live action hip-hop video. The road is bumpy, but our driver, Chaparo, is skilled at dodging the large craters that abound. It has been raining the past couple of days so at least the road is moist, no dust to cover us from head to toe, filling the gaps in our teeth as I have experienced in past adventures on the roads of the north atlantic coast. We wound our way through the grasslands, stopping to pee and realizing that the small yellow flowers that are populating the green fields were minuscule orchids. We head deeper and deeper into no-mans land. we pass communities from which women who have stayed at the Casa Materna live: Ena in Santa Marta, Tasba Raya, Tasba Pawni... At some point hours down the dirt highway we turn off and begin our ascent into pine, mahogany, and madrone covered hills with views of the mountains of Jinotepe in the distance. The scenery is breath taking. Eventually we weave our way up and down, over and through dark, earthy-mud to arrive at the saw mill. Now, i'm not the kind of girl that knows alot about saw mills...I leave that kind of knowledge of machines and engines to Cody...my interests are in health. What struck me the most about this saw mill and the small communities around it were how isolated they actually were. I finally understood the importance of a place like the Casa Materna. I could conjure up images of medical emergencies, sense the urgency, and palpate the despair of feeling trapped. What if someone cut their arm off on the saw mill? would they make it to the small clinic in Francia 1 hour away by vehicle in time? would they then make it to the hospital before it was too late? Just a few days prior a log (basically a tree) fell on one of the employees crushing him. A makeshift cot was made out of sheets and branches and then fashioned to the skidder (the only available vehicle) and he was then carried down to the health center, later to be transferred to the hospital. There are no emergency plans in place, and what happens if you have no access to any form of vehicle. I guess the answer was seen in my previous story of the man carrying his seizing wife on a bicycle to the medical post.
It was standing in a small community like this, drinking coconut water, and watching the women herding their many children when I really got it. I really understood how difficult it must be for a woman to a) make the choice to leave all her children, walk the 8 hours to the highway to then find a ride to Port, and then spend an indeterminate amount of time at the Casa Materna, or b)stay at home, birth her baby and pray that there are no complications. Access to healthcare is a common theme of discussion in the academic world of nursing/medicine, but we are usually talking about how to market medicine to encourage patients to engage in preventative health, or reach populations that are on the fringes of society (i.e. prostitutes, IV drug users, homeless, etc.); but in this case access to health is a strictly logistic issue. How on earth do you get to the hospital when you have a long and winding road separating you from it and no money to get there. How do you get medical care when your personal knowledge of risks, emergencies, and your own body is as limited as your access?
My last days in Nicaragua were spent in the lush tropical town of Waspam contemplating these questions. Waspam is the second largest city in the North Atlantic Coast. They have no super market, no gas station, they only sell tomatoes, onions, and cabbage in the market. What they do have is a fabulously long river that separates Nicaragua from Honduras with unknown quantities of indigenous people living along its borders. I had gotten to thinking back in Port about how we could provide better access to people, specifically women living out in these distant communities...Sonja and I had come up with a fabulous idea that has started to take more shape and became more important to me as I visited communities and sat in my hotel in Waspam listening to the rain patter outside. So the conception of our next project has taken place...it may be a pregnancy of more than nine months but it will be nourished and fed until the birth of Mairin Karna (Strong Woman) a one hour radio program on Women's Health is broadcast in Spanish, Miskito, and Mayagna throughout the North Atlantic Coast! Knowledge is power, and if we can reach the women out in the communities hopefully they will in turn be able to reach us!
Well I have ventured down my own long, winding road and have arrived once again in the US. I am on the brink of beginning my official studies to become a midwife and am ecstatic for the opportunity to learn more and become more skilled. I hope that all of my beloved readers have enjoyed this leg of the journey...stay tuned for more!
It was standing in a small community like this, drinking coconut water, and watching the women herding their many children when I really got it. I really understood how difficult it must be for a woman to a) make the choice to leave all her children, walk the 8 hours to the highway to then find a ride to Port, and then spend an indeterminate amount of time at the Casa Materna, or b)stay at home, birth her baby and pray that there are no complications. Access to healthcare is a common theme of discussion in the academic world of nursing/medicine, but we are usually talking about how to market medicine to encourage patients to engage in preventative health, or reach populations that are on the fringes of society (i.e. prostitutes, IV drug users, homeless, etc.); but in this case access to health is a strictly logistic issue. How on earth do you get to the hospital when you have a long and winding road separating you from it and no money to get there. How do you get medical care when your personal knowledge of risks, emergencies, and your own body is as limited as your access?
My last days in Nicaragua were spent in the lush tropical town of Waspam contemplating these questions. Waspam is the second largest city in the North Atlantic Coast. They have no super market, no gas station, they only sell tomatoes, onions, and cabbage in the market. What they do have is a fabulously long river that separates Nicaragua from Honduras with unknown quantities of indigenous people living along its borders. I had gotten to thinking back in Port about how we could provide better access to people, specifically women living out in these distant communities...Sonja and I had come up with a fabulous idea that has started to take more shape and became more important to me as I visited communities and sat in my hotel in Waspam listening to the rain patter outside. So the conception of our next project has taken place...it may be a pregnancy of more than nine months but it will be nourished and fed until the birth of Mairin Karna (Strong Woman) a one hour radio program on Women's Health is broadcast in Spanish, Miskito, and Mayagna throughout the North Atlantic Coast! Knowledge is power, and if we can reach the women out in the communities hopefully they will in turn be able to reach us!
Well I have ventured down my own long, winding road and have arrived once again in the US. I am on the brink of beginning my official studies to become a midwife and am ecstatic for the opportunity to learn more and become more skilled. I hope that all of my beloved readers have enjoyed this leg of the journey...stay tuned for more!
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