Brave Woman

Adventures of a future nurse-midwife

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Cheerful

Posted by Lucille on June 7, 2011 at 10:25 PM Comments comments (0)

We are tired, and things we want to do when we get back are starting to be a regular topic of conversation. People compare their prioritized lists, yearning for good food, hot showers, and constant electricity so much it's intoxicating. Personally, it is not that I don't like it here, or that I've seen enough, but just that I'm saturated. I have learned more things more quickly than I can ever remember doing in my life, and my ability to absorb anything else new is waning.

Our weary and homesick crew piled in the ambulance and prepared to tour the country and seek out the most exotic, once-in-a-lifetime experiences we could find. I had looked forward to travel week since before this whole thing began, but I hadn't realized how much we would have seen by that point and how strongly we would long for something familiar, and for a few minutes I worried that our 'vacation' would feel like a trudge to the finish line.

But then I remembered that our group leader is amazing.

As we pulled out onto the road, the ambulance hit the first bump, and we all hit our heads on the ceiling. Breaths were drawn, probably preparing to curse, and then our group leader started laughing. We looked up at her in surprise, and she just kept laughing, on and on for minutes, until we all started to laugh with her. She was relentlessly cheerful. Every time something happened (mud flew through the window, the toilet paper fell in a puddle, the back door flew open on the road), she started laughing, and soon we were all laughing so hard we could barely breathe. My tired and saturated brain has absorbed one more lesson: when you feel like you can't go farther, laugh. It looks like this week is going to be awesome after all.

Midwifery Revised

Posted by Lucille on June 7, 2011 at 10:20 PM Comments comments (0)

I spent a lot of time in the maternity unit on this trip, enough to be able to correct or at least shed more light on my first impressions. The rough nurse did not work there again. I did see him, a couple times, usually in outpatient trying to tell the Cuban doctors what to do. He reprimanded me for not greeting him. That's the funny thing about greetings, if I didn't greet you, you probably didn't greet me either. The head of maternity kept him out of her ward.

I did not see another woman catheterized after that first day, so I guess that is less routine than I had originally thought. I don't know why they catheterized that particular woman. By the few drops of urine that were released I can't believe it was necessary. Like a lot of things here, the procedures that are routine and the quality of care patients get depends a lot on the individual provider. There are women who have worked here for decades, meaning they probably completed their educations during the height of the industrialization of childbirth, and despite their good intentions I would rather give birth in the middle of the market place surrounded by goats and donkeys and poop than come near them. There are other women that deliver wonderful care. Okay, not wonderful by US standards, but for the conditions, resources, and education they have, the care they give their patients is remarkable. We witnessed several births that were truly empowering.

One of the things I had the most trouble with was what I had originally labeled infanticide. When a woman came in from the recovery room with a dead newborn, I looked away, but not before I recognized her as a woman I had worked with, who had seemed excited to have a baby. Angry, sad, and confused, I turned to the midwife as soon as she left. "Why don't the women feed their babies?"

"It's tradition."

I didn't say anything, but I was thinking, "What kind of messed up tradition is that?!" so she explained.

"You know that many babies die here,” she said. I nodded. "So there are some traditions we have to deal with that."

"Like not naming it until the eighth day," I said.

She nodded. "This is another of those. After the birth, the mother is vulnerable to loving the baby. It is important that she not love the baby until it is named, because it is quite possible that it will die. And after the birth, she is vulnerable. So our tradition is that for the first few hours after the birth, the mother takes care of herself. She rests, she eats, she talks with her family. Then, after she goes home, when she is recovered, she takes care of the baby."

I nodded. This was not ideal (I paused and corrected myself, this is not something I'm familiar with-) but I could see how, in a way, it made sense. The problem, then, occurs when women don't go home right away, when hemorrhage or low hemoglobin or something else keeps them in the hospital for longer than a few hours. Of course, they don't have clocks, people can't tell them, "If you're still there after three hours, though, better to feed your baby where you are." The only standardization of time is whether they're at the hospital or at home, so this is what they use. I sat there staring at the floor, where red water was slowly winding toward the drain, trying to break this down.

So babies are dying...because their mothers are afraid...because babies are dying. Babies are dying because they're dying. I preferred this to thinking of it as infanticide, but the systematic nature of it troubled me. How do you break through something like this? But I already know. One brave woman at a time.

I thought back to two months ago, when we had just arrived in Brikama in the middle of the night, and a man came by our hut to give me a Gambian name: Jainaba, meaning Brave Woman. Suddenly my eyes were full of tears.

One thing I didn't know until the end of the trip was that only 40% of women go to a health center. A few deliver alone, but for the most part everyone else uses traditional birth attendants. This may be one of my few regrets for this trip. Traditional medicine is condemned so strongly by those at the hospital that it would have been nearly impossible to connect with one, but it would have been quite an experience to go with a traditional attendant to a birth, to see one more way, one more system with all its intricacies and singularities, of caring for a mother during labor.

Dance Party

Posted by Lucille on June 7, 2011 at 10:20 PM Comments comments (0)

We kicked off our goodbye party with music and dancing in one of the RCH rooms. Everyone was there.

Someone had brought a boombox, and we formed a big dance circle in the middle. The Cuban doctors can dance. I tried to copy them but it felt like my spine was stiff. I never learned to move my hips like that. I tried to copy other people by moving my hands and feet like they did and hoping my body would follow, but it didn't work right. "I need to take some dance classes in college," I thought, "Because this is embarrassing."

After a while we settled down and people started going around the room and thanking us. We were the first American volunteers here and they talked a lot about how much they appreciated our help and enjoyed getting to know us. Someone from our team started crying, which got me crying, while we thanked them over and over again for everything they've done for us and told them how much we'll miss them and that we hope to come back. I was looking around at everyone and remembering everything we'd done together and how much they'd taught me. I spent so much time and effort trying to get to Africa, and getting here didn't satisfy that drive, but leaving Africa-- this, sitting here, tears pouring down my face, looking around at my African family-- this was what it was all leading up to.

Someone put on a last song and everyone got up to dance. I joined the group and this time it was no problem to follow the beat, smiling through tears, flowing with the music. Apparently I'm a better dancer when I'm crying.

The electricity cut out in the middle of the song, and this seemed so perfect and representative of our time here that we all started laughing, and kept laughing for a very long time.

I Didn't Think It Could Get Crazier, But...

Posted by Lucille on June 7, 2011 at 10:10 PM Comments comments (0)

Today was our last day of work, and we were planning to throw a party for the people at the hospital at 1:00. We all went to maternity hoping for a breech birth.

"But not a primip," the midwife told us.

"No, not a primip. A grand multip breech birth."

"Or twins," I said, "I would settle for twins."

This is a conversation we've had a few times. Most of the births happen at night and only a few come in during the day, so we weren't expecting anything to happen. Then a tiny little woman came in with a huge belly that looked like it should make her fall over.

"How many babies are in there?" someone asked.

"Just one," the midwife said, "I checked."

Our group leader shook her head. "Either that's a fifteen pound baby, or somebody's hiding."

The midwife looked at the woman's chart, and saw that her hemoglobin had been low in February, with a request to repeat it that was never completed. They collected a blood sample and sent it to the lab. Her hemoglobin was even lower. They called the ambulance to transfer her to Banjul.

We worked with her for about an hour, providing counter pressure, bringing water, and holding the barf bucket. This was the highest risk birth we'd encountered, and we were sure she'd be leaving any minute, so our focus was on keeping her comfortable until the ambulance arrived.

The midwife decided to check her. "Eight centimeters."

"Where's the ambulance?"

"Still in Banjul."

There was a pause. "She's not going to make it there...She's delivering these babies here."

Everyone was silent for a minute while the weight of this responsibility settled over us. Two of my teammates, who were holding the woman's back, just stood there staring. The woman's belly was so full it looked like it was going to pop (it didn't), and her eyes were rolling as she rocked from side to side. Whatever the outcome, we were going to see this birth through.

The midwife left to track down someone from her tribe who could donate blood in case she needed it, which left the nine of us, one midwifery student and eight people with no formal training, in charge. None of us spoke the woman's language.

Despite being nervous, we were all pretty excited, because we knew this would be a once in a lifetime experience.

We got into the rhythm of assisting a birth. When the woman was nearing transition and vocalizing pretty heavily, we learned how to do two person counter pressure. I think this falls into the exception category of the 'don't do anything you wouldn't do in the US' rule. When a woman with extremely low hemoglobin is giving birth to twins and you're the only one there, you do what you have to do. It took a lot of strength (if we pulled back at all, she would communicate that we needed to push harder), so we were taking turns. While I was taking a break I thought about massaging her back, but I didn't really know what I was doing and stopped quickly. I've had reason before to view massage as an essential life skill- why it's not included in general education baffles me. I need to find a way to learn this in college.

The first baby started coming down. Our midwifery student asked permission and did a quick exam, and got meconium on her glove. After five weeks of waiting for one, on our last day, in our last hour, we got our breech birth.

The midwife had wanted to put her on saline, but they were out. (Think about that: the hospital was out of saline. Can you imagine that happening in the US?) They put her on glucose, but she moved around a lot during contractions and kept pulling the needle out. As far as I know, delivering twins vaginally in the US is pretty rare. Delivering them without pain medication is almost unheard of. The blood transfusion didn't work out, so she was about to deliver breech twins with no medical support of any kind. She was alert and coherent through the whole thing. As the baby was crowning (Is it called crowning when it's butt first?), she decided she did not particularly like the table she was on and wanted to move to another one. We gaped at her, but didn't say no, so the mother swung her legs down, waddled across the room, and heaved her swollen body onto the other table. We just shook our heads in disbelief. "She's putting American women to shame."

Unfortunately, my experience with this birth was tainted by my own anxiety. I did not go into it with a lot of confidence that it could be done, so I was looking for signs that things were about to go wrong the whole way. Underneath this, though, was a powerful lesson in nonverbal communication. I was up by her head, and I noticed that if I was tense, she would tense up, too. If I took deep and calming breaths, she would copy me. When I traded positions to watch the baby come out, I was wondering how the butt could possibly fit through such a small opening. Her legs were shaking and she was clearly starting to doubt herself and losing energy. It occurred to me that my expression was stern and observational (and probably a little bit worried), so I switched it to an encouraging smile and we all started praising her when the baby inched forward. She composed herself and started pushing with new energy, and, slowly but surely, she eased open and pushed out a baby girl.

The baby girl was blue and not breathing. In a second the atmosphere fell as the baby was whisked away, and a team member started chest compressions and stimulation. Someone grabbed one of those bags they use to help people breathe and handed it to someone. I have no idea if that person was trained to use it, and I know she'd never used it on a premature baby, but she took it without missing a beat and started resuscitation.

I felt a little overwhelmed and stepped outside to get some fresh air. Her whole family was out there, and they hurriedly gathered around me. "How is she? How's my wife? Is it just one baby?"

I was still trying to get the image of an infant inflated by the mechanical pressure of a bag out of my head. Am I even authorized to make a report?

"There are at least two babies, maybe more. The first one has been born. It came out butt first, so she’s very tired. But she's doing well. I'm sorry, I have to go..."

They were still resuscitating the baby. Its heart was beating and every now and then it would give a small cry, but nothing consistent. The mother had been left alone, so I went over to her. She was trying to get a better look at her baby. I turned around to see what she was seeing, and it wasn't pretty, watching the baby get hit on the back and have it's lungs forced open with air. Should you let a woman see her baby like that? I shifted so that I was blocking her view, thinking that if she motioned for me to move, I would, but instead she nodded and directed her attention inward. Her second baby was born headfirst and without trouble a short time later, followed by the two placentas.

The second baby wasn't breathing. For a few minutes, two team members alternated between the two babies, and then the lights flickered and the electricity came back on. We took them to a small heated tray and put the first one on oxygen. They were both breathing now, the second one stronger than the first. We took turns stimulating them, and I went over to the mother. She was tired but more alert than I expected, waved me over, and said in English, "Thank you." I started to answer, but she was looking over my shoulder, trying to peek at the two infants. "What are they?" she asked.

"Both girls."

"Two girls," she nodded, smiling. "If they live, I will name one after you."

Her family came in a few minutes later to clean her up and coo over the babies, and I left to let her get some rest.

I liked that on our last day, just like our first day, we were all working together in maternity. It seemed like a nice way to bring things full circle. A bright and compassionate German student was working with us, the brand new volunteer like I had been, and I got to show her around and teach her what I'd learned.

We were significantly late for our own party, and none of us cared.


How Do You Say 'None of Your Business' in Mandinka?

Posted by Lucille on June 7, 2011 at 10:05 PM Comments comments (0)

I went to cook today (I took an extra shift so that I could take pictures) and got into a conversation with the village elder, who has always struck me as regal and dignified.

"How old are you?"

"Eighteen."

"Oh! You are very young. How many years of school?"

"Seven more. Four for university, and three to be a midwife."

"Seven?! Are you married? (I shook my head.) When do you want to marry?"

"I don't know. Probably when I'm done with school. Maybe ten years."

"Ten YEARS? But don't you want a son?"

"Of course. I'd love to have children."

"If you wait ten years you will not be able to have a son."

I laughed. "People marry later in the US. We'll see."

"But you have a boyfriend?"

I smiled. "Yes."

"Then you will have a son. You are probably woman now." (He gestures to my belly.)

"What?"

"If you have a boyfriend, within one year you will have a child, you'll see."

I did not know what to say. Dating and contraception weren't part of his culture when he was younger, so the first thing that came to mind was, "Boyfriend and husband are a little different..."

"No they're not. If you go up and down (picture this with gestures), it's all the same."

I was still staring at him, thinking, "Oh my god did the village elder really just do the pelvic thrust?!"

"Unless you are taking medicine to not have a child. Are you taking medicine?"

How did I get into this conversation with a 90 year old again?!

Crazy, Crazy Day

Posted by Lucille on June 7, 2011 at 10:05 PM Comments comments (0)

I was supposed to be in Hands On Care, but there wasn’t much for me to do so I went to maternity. A woman came in and asked us to help her. My team member has more doula experience than me. She worked with the woman for a while, and then backed off to give me the opportunity to gain experience. The mom was fabulous. Besides speaking English, she wasn't shy about directing me and explained clearly where she wanted me to push and how to do it better. I wasn't sure how she would take the dynamic of two people caring for her, but she got it without missing a beat and started asking me for help keeping her comfortable and calling my team member over whenever she had a medical question. Over the first half hour she showed me all of the things she needed me to do, and we got into this rhythm so that as she approached transition and didn't want to talk much anymore we could communicate without words. I was completely focused, responding to her touch, a glance, or a flick of her hand, and later just following her breath. Time was measured in contractions, not the other way around. I started to feel my uterus contracting with hers. I don't even know if that's possible, but it happened.

I got to see some Sphincter Law in action. A midwife examined her. Another of the midwives asked for a report from across the room. "Almost fully dilated," she said, "Nearly there."

"Well that can't be right," the other midwife said, "She was only at six centimeters when she came in."

A few minutes later she came over and, entirely without preamble, spread the mother’s knees and shoved her fingers in. I'd kind of gotten into this heady, floating space, and this crude act completely shocked me out of it. I probably jumped a foot back from the bed. Apparently it shocked the mother too, because the midwife felt around for a minute, frowned, and said, "Hmm, I must have measured wrong before. She is only at four centimeters now." It took her an hour to get to ten centimeters again.

During this time, her own mother came in and tied a strip of cloth around her right calf. A lot of the tribal people believe this is good luck and will protect a woman in labor. When the midwife next came in, she denounced it as superstition, undid the cloth, and scolded the woman in labor for believing in such nonsense. She threw the cloth on a nearby table and left. The woman seemed distressed. Her next contraction was the most difficult so far, she had to hold on to my neck to get through it and still cried out in pain. When she relaxed, I motioned for her to keep quiet and tied the strip of cloth back around her leg. She smiled gratefully and her next contraction was much easier. She felt the urge to push soon after that, and within an hour delivered a healthy baby boy.

I sat with her for a minute and told her how well she'd done while my team member cleaned and weighed the baby, and she nodded and thanked me. After a minute I went over to look at her son. "Your baby is beautiful!"

She laughed. "When you come back from America, he can be your husband!" A woman had come in for a stillbirth who was bleeding profusely, so I said goodbye to the mother and accompanied the other woman on the transfer to Banjul. I'd complained earlier that there were no seatbelts--this time there were no seats, and the one time I decided to check we were going 150 km/h in a 30 km zone. We also drove in the other lane a lot. There were a number of close calls, but we made it to Banjul safely, dropped the woman off in maternity, and then made a stop in the neonatal unit. There were some seriously sick babies in there, but also a few that had been discharged and were waiting for a ride back to Brikama, which I found reassuring. People don't just go to Banjul. Sometimes they come back.


Cockroaches

Posted by Lucille on June 7, 2011 at 10:00 PM Comments comments (0)

"Lucille, there are cockroaches in the fridge."

"Okay, awesome."

About five minutes later one crawled up my pants.

Schlichting

Posted by Lucille on June 7, 2011 at 10:00 PM Comments comments (0)

We've been hoping to get a breech birth in maternity because that's not something we're likely to see in the US, but I was moved to Hands On Care.

"Hey, if it looks like you're going to get a breech birth, you should come and give me a heads up, okay?"

"Literally!"

Tubab

Posted by Lucille on June 7, 2011 at 10:00 PM Comments comments (0)

A team member and I were walking back from work.

"Isama!" someone called. (Good morning!)

"Ha," she answered. (Yes.)

"Cortanante?" (How are you?)

"Tanante." (I'm well.)

A little kid that was watching called out, "Tubab!" (White person!)

And once the call had been made, kids ran out from everywhere, yelling, "Tubab, tubab, tubab!"

"Isama," she said. (Good morning.)

"Tubab, tubab, tubab!"

"Ha. Cortanante?"

"Tubab, tubab, tubab!"

She took a deep breath and turned around. "Mofino!" (Black person!)

"HA!" The children fell over each other laughing and ran to tell their friends.


Would You Rather

Posted by Lucille on June 7, 2011 at 9:55 PM Comments comments (0)

The electricity was out yesterday, and in seeking a way to entertain ourselves, we decided to play would you rather. We started with the traditional, "Give up oral sex or cheese?" but the questions rapidly became more African in nature.

"Be a patient in inpatient or maternity?"

"Lick a fish in the fish market or eat spicy benachin?"

"Have no water or no electricity?"

People from the lodge joined in, and hilarity ensued. We didn't go to bed for hours.


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HIPAA Disclaimer

Sometimes I have the privilege of being a part of intimate, powerful moments in other people’s lives. I cannot and would not share these stories, because they are not mine to tell. However, they touch my life and become part of my own story. When I share these moments here, you can trust that I have not broken anyone’s confidentiality. The characters are invented. They are not real, but could be. I take creative license to communicate the essence of my experience while respecting the privacy of others.