reading labor

I'm fairly perplexed that experienced Obstetra interns in Peru (and OB nurses in the States) have no ability to assess a woman's labor pattern via observation. Even some of the matriarchal Technicas (kind of a cross between a nurse and an orderly) haven't a clue.

A woman having her first baby got up out of bed to urinate. She was contracting every 4-5 minutes and very much still "here"; i.e. her level of consciousness had not altered appreciably. Still, once she became vertical, one of the interns alarmedly inquired if she needed to push.

Another woman lay in bed having back-to-back, strong contractions which required all of her energy and focus. She appeared to be in transition. She was not holding her breath nor was there any catch in her throat during contractions. Interns abruptly questioned her desire to push during her time of deepest work and most expansive opening.

Then there's ignorance of the period of quiescence. Often a woman's labor will crescendo as she opens, then pause before the expulsive phase begins. I witnessed this very pattern here one night. As the woman's formerly intense, frequent contractions became more widely spaced apart, the Obstetra lectured her interns on Friedman's curve and ordered an IV bolus of pitocin to speed things along. Oh, if only they had been more patient! The laboring mother was gathering her strength, rounding the peak, and about to accelerate once more.

I've witnessed nurses in the US ask women "Oh are you having one?" (a contraction; really, they can't tell?) and attempt to complete medical and social histories right in the middle of seriously surging concentration. Overreliance on external fetal monitors creates an inability to trust one's own senses.

It's so simple. You just observe with all your senses wide open. There are several external signs that a woman is completely dilated: the reddish purple line extending from anus to sacrum, the rise of her fundus to meet the sternum, the open point on the top of her head, the other open points on the bottom of her feet, and the horizontal crease running across her low abdomen. Some birth attendants can actually smell a change in the labor, or feel their own cervixes opening. When I accompany a laboring woman to the bathroom, I stand outside the door and listen. Is her breath even or is she holding it at all? Is she grunting or throaty? What noises are splashing into the toilet?

And,
it's so simple,
except when it isn't.

Last night I was working with a young woman having her first baby. Her contractions came in rapid succession, with tremulous vibrations rocking her entire body. She wanted to urinate and defecate but could not. As I squeezed her aching hips I could feel them pulsing open. So I added up all the signs and thought the baby's head was descending and she was probably in transition, about 8-9 centimeters dilated. Imagine my surprise to find her cervix 4-5 centimeters and the head very high in her pelvis.

Checked myself. Make no assumptions. Stay open. Stay humble.

taking stock

I'm halfway through my Peru trip.
I have received 7 babies, completed 6 postpartum visits & 6 newborn examinations.
I'm feeling like I am in pretty good shape and will be able to complete all of my state's "numbers" requirements (combined with prior experience).

I'm also realizing that shift work is so not for me. In a strange way I am looking forward to the return of my on-call lifestyle. One or two births per month sounds just peachy, especially with women who know that they have options and won't just lie down and take it! Right now I feel like I am midwifing with my hands tied behind my back.

Saturday night 5 babies were born, two to Quechua women in their beds in the dilation room. These indigenous women labor so differently than the others: no drama, no moaning and groaning, usually in an upright position. I caught one of those babies, untangling him from his cord on the way out.

Now that I have had my share of straightforward births, I asked to see some complications. In response I witnessed the lengthy emergence of a posteriorly positioned baby on Saturday, and a very unusual vaginal breech birth on Sunday.

The sauna beckons and I am exhausted, so the newest birth stories shall have to live in my head and heart a while longer...

Liz, Natalie, & Sunday at Hospital Antonio Lorena

unconventional hospital births, part three

on Thursday night's shift, 9 babies entered the world. two girls came first, almost at the same time. their mothers rested on gurneys in the recovery room, adjacent to the Sala de Parto, while two more mothers birthed, this time to two boys.

12:30 am: both gurneys and both delivery room tables are full of women, and in walks Elizabeth in hard, active labor. She is fully clothed. There is nowhere to put her so she stands in the center of the delivery room. As the Obstetra and Technica are pondering logistics, Zuki notices that Elizabeth is holding her breath and bearing down.

"Adrienne, get under there!" Zuki exhorts. I bend down, reach under Elizabeth's skirt and receive a slippery little girl into my arms.

The Obstetra comes to help me bring the baby up to her mother's arms, then she grabs the requisite hemostats and clamps/cuts the cord. Elizabeth is looking rather shell-shocked. She is assisted up onto a delivery room table to birth her placenta. Her legs, socks, and shoes are covered with blood and she is shaking. We fetch her some juice, check her pulse, and reassure her that all is well.

I did catch two more babies that night in the more usual hospital style. I am loving that these unusual experiences are finding me and birthing me as a midwife!

unconventional hospital births, part two

Tuesday night/Wednesday morning, several hours after Luisa's birth (below)...

Virginiana arrived at the hospital at 3:35 am, in active labor with her third child. Pregnant women are first seen and admitted through the gynecology section of the emergency room. So this mama didn't appear in the Sala de Dilatacion until close to 4 am.

She paced around, one hand affixed to her back, puffing through her surges. Also present were one other laboring woman, an intern, and me. Most of the staff (Obstetra & interns) were busy in the Sala de Parto, and the intern floated in and out.

I offered Virginiana some juice which she gladly quaffed. Around 4:15 the intern noticed V still had her street clothes on and promptly proffered a gown. V complied, leaving her undies in place, then climbed into bed and laid flat on her back. Women become subtly transformed when they don hospital vestments; the act establishes an immediate power differential. (read Birth as an American Rite of Passage by Robbie Davis-Floyd)

Despite her compliance with the system, V still labored very much in tune with her inner rhythms. She began to sound grunty at the peak of her contractions. I listened to her baby with my fetoscope and its heart sounded great. V said "Quiero pujar" so I ran into the bustling delivery room and dutifully notified the Obstetra. When I reentered the dilation/labor room, the intern asked me to take V's blood pressure. Um, hello? She wants to push and we are assessing vitals?!!

About 4:20 am the intern had left the room for a moment and returned. V told us again "Quiero pujar" and then mentioned something about cabeza. Alarmed, the intern pulled down in succession the sheets and V's underwear. We saw that Virginiana's bag of waters had burst, and a lime-sized portion of baby head glistened in her yoni.

"Get some gloves!" the intern commanded. Okay. Gloves on. I placed one hand on V's perineum and the other on the baby's head. It was textbook. The head emerged & restituted LOT to look at mama's right thigh. At the next contraction out she came, a 5 lb. peanut girl, covered in vernix.

By this point my friend Liz and a few interns had entered the room. Liz whispered "nice one" and somebody handed me hemostats and scissors. Gently and deliberately I separated baby from mama. A nursery nurse stood impatiently at the foot of the bed, towel ready to receive la niña.

An intern jabbed mama in the hip with pitocin as the Obstetra arrived to claim her authority over the scene. A few moments later V's abdominal contour changed as her womb visibly elongated, heralding placental separation. I began to reach for the umbilical cord but the Obstetra wouldn't have it. She then signaled when she felt it was time and I applied steady traction to birth the placenta. I was just about to begin twisting to coax out the trailing amnion & chorion when the Obstetra took over, so she could demonstrate her membrane-delivering prowess. Humph.

After cleanup and perineal assessment (no tears--yeah!) Virginiana remained in the same bed in the Sala de Dilatacion. Mama and baby reunited at 5:10 for cuddles and mama milk, and amazingly, the father was allowed in to see his family.

Birth is not an emergency. It's an emergence.

unconventional hospital births, part one

before reading this, please scroll down and read the previous post which sets the scene.

Luisa is a 25 year old mother of 2. I attended her second child´s birth earlier this morning. She was admitted to the hospital around 9:30 am yesterday, unusual because her cervix was only dilated 3 cm. She spent the day laboring in the maternidad room, and around midnight came to the dilatation room. Her cervix had not changed much and her baby was very high in her pelvis. She mostly labored upright, tuning into her body and changing positions at will. The busy staff left her alone while I took turns providing labor support to her and several other women. Luisa experienced a lot of low back pain and appreciated my counterpressure to her sacrum.

At 1:40 am she was assessed and found to be dilated to 9 cm. But the baby was still very high. The Obstetra (University-trained medical model quasi-midwife) decided to break her bag of waters and see if that would bring the baby's head down. If not, a cesarean section was threatened.

Luisa began to push a little at the peak of her contractions. This is really common as women open up the last 2 centimeters or so. The Obstetra and all her intern students were attending women in the delivery room, so I was alone with Luisa and Andrea. Luisa clearly felt uncomfortable sitting in the enlarging puddle of amniotic fluid, so she edged to the side of the bed and I dropped the wet linens on the floor beneath her legs. I placed a dry sheet behind her in case she decided to get back up there.

Her contractions became quite intense and she grabbed me and held on with each surge. Several times she cried out "Ayudame!" (Help me!).

At 2:25 or thereabouts, she stood up, clasped me with both hands, squatted down low and emitted a primal, guttural roar. I heard a sploosh! and assumed more amniotic fluid was emanating from her yoni. I looked down.

I saw 2 greyish-purple legs kicking around.

"OH MY GOD!" I yelled, scooping the baby off the floor and placing him onto the dry sheet on the bed. He was slightly blue but had excellent muscle tone, cry, and respiratory effort. Babies are really resilient.

Luisa stood next to the bed, still coming back from her labor journey, very much in an altered state. Blood trickled down her legs, mingling with the amniotic fluid and terminal meconium at her feet. Meanwhile her earthside baby was gently transitioning and pinking up thanks to his still-intact umbilical cord.

By this point the Obstetra and several interns had run into the room, assessed the situation, and gathered their tools. They immediately set to work cutting and clamping the umbilical cord, because that's their modus operandi. Baby boy was whisked away to nursery for evaluation. (He is totally fine.) Luisa reclined on the bed, where she received a routine shot of pitocin in her hip, and her placental delivery was actively facilitated. She did visit the delivery room after all this morning, for a second degree laceration repair. Probably she tore through the episiotomy site from her first baby. (Insert your own opinion about episiotomies and perineal integrity here.) All the while, the Obstetra chided her and tried to feed her a huge guilt sandwich for pushing out her baby onto the floor without telling anyone.


Lady, it's over. Birth happens. Let it go.


Luisa was a woman birthing in her power. What a privilege to witness.

institutional birth in Cuzco

Sala de parto

posing in the sala de dilatacion

sala de dilatacion
(notice the bigass oxygen tank with no wheels)

Sat in birth circle this afternoon, where we share our clinical experiences and ground them in different paradigms. Lots of tears and self-righteous indignation and outrage at what we are seeing and feeling. Whapio popped in at the end and dropped a little mind-blowing tidbit: "Your work here will be done when you feel so much gratitude that you don't want to leave the hospital. You will have learned humility, to truly serve, and that is midwifery.¨

based on my experiences and the stories of my sisters, I am starting to grasp an overall picture of hospital birth here:

-women are screened in the emergency room for admittance. they are assessed for vital signs, cervical dilation & effacement, integrity of membranes, and fetal heart tones. if between 4-5 cm dilation and there is room at the hospital, they are admitted.

-women labor in the Sala de Dilatacion--dilation room. husbands, sisters, parents or other significant others must stay in the hall behind 2 sets of double doors. Nobody updates them with any information. Patients are given a gown and assigned a bed. A few remain in their own clothing or some combination of hospital gown and their own vestments. Most women get right in bed and lie flat on their backs, alone, in a bright and often noisy room. In the hospital where I work, up to 4 women are in labor at once.

-amazingly to my North American mind, Fetal Heart Rate is seldom assessed. FHR is not routinely checked after Rupture of Membranes, whether Spontaneous (SROM) or Artificial (AROM). AROM is performed often, using a sterilized half of a hemostatic forceps.

-the women may drink, but it is not offered or encouraged. they also may get up to pee when they want to, but again this is not assessed or encouraged in any way.

-the room between the dilation room and the bathroom is a storage area containing a mop, a sink, and piles of stainless steel bedpans, stacked-up buckets containing placentas, and large orange trash cans full of blood and used gauze from prior births.

-a saline IV is routinely placed at approximately 8 cm dilation. It remains throughout birth and into the first hours postpartum.

-many chatty interns are present in the Dilation room but they do not provide any labor support. They occasionally assess vitals, insert an IV, check dilation, etc. but barely speak to the women for whom they are providing care. They will absentmindedly tap on a patient´s bed, place their clipboards on her legs, giggle about their boyfriends, dance to the radio, or noisily bounce the new birth ball gifted from our program. An aura of respect is sorely lacking.

-They don't like the women to get noisy when labor is intense, so there is lots of encouragement to be quiet and breathe. ¨Tranquile, Respire¨. If the woman cannot obey, they are given a medication similar to Demerol, without consent.

-Pitocin augmentation is common and again, given without consent. I have seen it administered several times at complete dilation, when labor often takes a natural pause as the womb-an gathers her energy for the next phase. I have witnessed it given 3 times within 2 hours to the same woman: via IV in the dilatation room, IV in the delivery room, and IM in the delivery room post-birth (she was not hemorrhaging).

-when it is time to push out the baby, the woman must walk to the Sala de Parto (Delivery Room), climb up onto a table, lie flat on her back or on a slight incline, and place her calves up into stirrups.

-every first-time mother, or woman having her first vaginal birth, receives a generous episiotomy. they fervently believe this helps prevent the perineal muscles from tearing. from every observation, it does exactly the opposite. sometimes the episiotomy is cut prior to full head crowning, rendering the woman's perineum a gushing mess.

-baby heads are grasped from the yoni and delivered, then roughly restituted prior to true physiologic restitution.

-baby is very briefly allowed to rest on mom's abdomen as its cord is immediately clamped and cut. then baby is whisked across the hall to be assessed, not to reunite with its mother for at least an hour.

-third stage: mom receives a shot of pitocin in her hip. her uterus is vigorously kneaded and massaged (yes, before the placenta is out). The cord is milked upwards and the hemostat re-clamped close to her introitus. Traction upwards and downwards is performed, ignoring the curve of carus, and often ignoring the need to guard the uterus above the pubis.

-after the placenta is delivered, the perineum is assessed and sutured, often painfully slowly.

-the woman is wheeled to a recovery room right next to the Sala de Parto. After an arbitrary length of time, someone brings her a baby wrapped in 3 or 4 layers of fabric. Babies generally remain with their mothers from this time forward. Eventually the mamatoto are wheeled to the Maternidad ward where they stay until they are stable. Average stay post-uncomplicated birth is 24 hours.

-cesarean sections are given for suspected oligohydramnios, placenta previa, and the common ¨big baby¨ diagnosis. For a cesarean, all women begin in Dilatacion where they change into a gown, hat, and long cloth boots. Next they must climb onto a gurney and receive an IV. They are wheeled down the hall, out 3 sets of double doors into the cold night, across a bumpy sidewalk, and through a courtyard to the building which houses the OR.


I have tried to keep many personal opinions out of this so you may formulate your own. It is quite easy to stand in judgment when the doctors, obstetras, interns, and technicas really do have positive intentions and are often doing what they can with very limited resources. Still, I cannot keep totally silent when I know in my heart and soul that birth can be so much more than a medicalized event!

More reflections soon on Vertical Birth laws, classist attitudes towards Quechua women, and some specific birth experiences.

las plantas

my heart is filled from encountering so many green friends here in the bellybutton of the world.

in our courtyard: comfrey, dandelions, plantain, roses, shepherd´s purse (true casa de las matronas, no?), nasturtiums, rosemary, geraniums & parsley.

around town: muña (a mint like poléo mint, somewhat of a cross between pennyroyal and spearmint), calendula, nettles, hollyhocks, sweet lil´malva neglecta, random plots of potatoes, lamb´s quarters, & snapdragons. the town is both verdant and litter-strewn, a strange combination. in the hills, nearly every available field and terrace is planted with corn or potatoes.

will post more on my hospital experiences when I am feeling less tired and better able to organize my thoughts.

bookends

yesterday morning I hiked up behind our casa to some ruins which overlook the city. at the top I could see the entire valley, encircling hills, and behind me sheep grazing on plains and the next mountain ridge. bonita! I sat for a while, catching my breath, eating some plums, and reveling in gratitude (and endorphins).

last night, coming down some stairs outside a cafe, I slipped and fell flat on my ass.

ashe´! so it is!

tonight is my first shift at Hospital Lorena, so I´ll be bringing ibuprofen & arnica along with my fetoscope & gloves. No matter what, birth and life go on.

soy en cusco!

travel was smooth & uneventful, though tiring...trying to nap under the bright lights at the Lima airport was made slightly less challenging due to the navy polyester blanket Delta gifted me. next trip, an eye pillow/mask is a definite must!

the glorious sunset on the Atlanta-Lima flight faded away so slowly, an amazing sight. and yes, Joshua, the toilets at the airport are automatic. (he likes to know these things)

when I fly, I call in various animal and plant spirits to guide and protect the plane. once when I was doing this, a woman two seats over was crossing herself in prayer to Jesus. I thought, great, the more protection we have, the better!

For the Lima to Cusco flight, I started per usual, calling yarrow to enwrap the plane, owl to inspect and then fly high above and behind as overseer, fox to trot in front and navigate. next I call birds to hold the strands of yarrow, and different birds come each time. friday´s guides were a small flock of doves and a condor. huh? i have never enountered a condor before.

well, upon arrival I learned our house in Cusco is called La Casa del Condor, and it is just down the street from a huge sculpted condor atop a pole, overlooking the city.

condor´s symbology includes:
-soaring above one´s limitations
-messenger to the gods, carrying our prayers
-teacher of ancient mysteries of life and death
-death and rebirth
-new visions
-riding the thermals of life to maximize one´s power and energy
-adapting to change

bienvenidos, indeed.

various & sundry birth notes

I'm on call for an imminent birth and I'm leaving in 5 days. Am I sleeping? No. Packing? No. Watching my Spanish DVD? A little. What I'm really doing is eating chocolate, browsing and blogging.

Thanks to Citizens for Midwifery I've learned that Sheri Menelli's book Journey Into Motherhood is a free e-book now. Every pregnant woman would be wise to turn off "A Baby Story" and read this positive, empowering, inspiring book instead.

This quote on the Unnecesarean blog made me chuckle, at first:
"Most American women have already had an OB rip them a new one with no evidence to back their decision—it’s called an episiotomy."

Then it made me sad.

There is some debate whether episiotomy or hysterectomy is the most frequent surgery performed on women. There is no question that most episiotomies are cut without a woman's fully informed consent.

Bewildered by this news story making the rounds. A woman gave birth on an airplane and the attending doctors are lauded as heroes. I think the woman is the true hero!

• the birth went fine, but upon landing the mother and baby were rushed to the hospital, strapped to a stretcher and bundled in what appears to be a giant carpet. what was the emergency, pray tell? it's too bad the doctors did not pronounce mother and baby healthy, sending them to their destination in a more peaceful fashion.
• one of the doctors reports: "we took the baby out...we took the placenta out." How powerful you are. Did you really remove these items from a passive woman's body, or were you perhaps honored to receive them as she gave birth?
• I'm ever so grateful somebody onboard donated some formula. Whatever else would the poor, starving newborn be able to eat?!!! (Imagine the headlines: Mother Gives Birth In Flight and Breastfeeds Infant. Scandalous.)