Cutting the mustard (or the flesh)

The last 24 hours have been busy ones. I caught baby number 4 here yesterday (Tuesday) morning and then Tara and I went and spent the night at the clinic last night where we each caught two apiece more and missed a fifth because she was so quiet behind a curtain. The first baby was a special and difficult one, almost like the universe decided to dish out some of those hard knocks I was waiting for.

Before coming to Africa, I had heard that the clinics used some pretty harsh and outdated (arguably abusive) practices here. These include "fundal pressure" which means putting a large amount of your body weight onto the top of a womans uterus to literally force her baby down into the vagina, routine episiotmy --which is when scissors are used to cut a slice in the vaginal opening to widen it in order to birth the babys head, routine use of pitocin after birth which is a drug that causes uterine contractions to help control uterine bleeding postpartum, and that all women give birth on their backs here with a bedpan underneath them. Some of these things turn out to be not in practice or rarely in practice anymore, which is nice. What is or isnt done routinely also seems to vary between the three clinics we are working in. The harshest clinic Ive seen is the one Ive spent the most time in and where I caught 5 of the 6 babies Ive caught here so far. Some of these practices make some sense culturally. In America, most of the women I attend get to take weeks off work, can lie in bed for days post partum and heal their bodies. In Senegal, the day you give birth is a day off. The next day you care for the rest of your children, you wash, you cook, you clean, you carry 25 lbs of water on your head. You cannot afford to not suture small tears here, to allow them to bleed here, because their bodies dont get time to heal slowly like our mothers at home do. So maybe Pit routinely post partum isnt the worst thing in the world. Maybe suturing a lot, while traumatic to the tissues in our view, makes sense here because it means her vagina will withstand the weight the woman has to bear every day. I havent seen routine episiotmies, which was a relief, but the fundal pressure is common and is very VERY hard to watch, and is incredibly violent and traumatic to both mother and baby, in my humble opinion: there is no clinical reason for such a practice under normal circumstances, and potentially puts the baby in very grave danger due to placental separation and trauma to the baby. We are noticing a new thing (compared to trips past, according to our leader) which is that the clinics are also giving an anti-spasmotic medication via IV to most women "for the pain" which, as far as we can tell, only results in women still being in a great deal of pain but disoriented, with lethargic gacked-out babies who are slow to breathe, and high blood pressure readings post partum. This is not good public health medicine.

So my first baby last night was with a beauty queen of a mother. She was tall and lithe with delicate bone structure and an elegance in labor I couldnt help but marvel at. She responded to me immediately, letting me rub her back and rock her hips during contractions, taking my hand and jamming it into the places that hurt her and grabbing my wrist to keep me close whenever I needed to go assist Tara with something. She dilated quickly and was soon ready to push. On the table, I checked her dilation and the babys station (how low he was in her pelvis) and I noticed her vagina was particuarly small. Like three quarters or half the length of most vaginas Ive seen. Every womans body is different, but the sight made me nervous because the matrones at the clinic are notorious for being impatient with pushing; with a small openining, depending on her tissues, I was worried I may have a fight on my hands to give her the time she needed to stretch and open. After about 30 minutes of pushing, I noted some decellerations of the babys heart rate with her contractions and pushes which is characteristic of head compression. At home, these decels get my attention but doesnt make me worry necessarily. In the clinic, its a different story because I know there is rough treatment around the corner. At an hour of pushing, she was making slow but steady progress but the matrones were getting impatient. They kept wanting to put their fingers into her vagina to vigorously massage her tissues, so I would plunge my fingers in to her vagina to keep the matrones out whenever I could. But I noticed that, every time I did this, the mother reflexively reared back and kept her baby from coming down. A reasonable response to someone mucking about with your coo, if you ask me. I didnt know what to do -- it was them or me, but it was impeding her progress either way. Finally, I figured out that if I gave her counter pressure by placing my hand and a square of gauze outside of and just below her vagina, she was able to push effectively and I could cover the vaginal opening partially with the gauze to deter the matrones bossy fingers. However, this time buyer only lasted a short while. A bit after midnight, one of the matrones stood up on a stool next to the bed and began to plunge all her body weight into the top of the uterus. Pop, pop, pop the babys head appeared and diappeared from the opening of the perineum with each violent shove, like a whack-a-mole game. The mother cried out in pain and her eyes bulged. She grabbed at the matrones wrists to get her away. Tara got the doppler to listen to the baby after getting the matrone away momentarily. She listened and listened, and there was no heart beat. My own heart skipped. I impatiently grabbed the doppler away from her (sorry, Tara) and tried to listen myself. Nothing. My mind raced. The matrones had already pulled out scissors and were getting ready for more fundle pressure. The mothers tissues were nowhere close to stretching enough to allow the heads birth yet and I was afraid the trauma of the last big push by the matrone had hurt this kid. He needed to be born, NOW. I looked at the scissors. Again, it was either going to be them or it was going to be me. I picked up the scissors and looked at Tara. I was debating whether it was a waste of time to get Lidocaine to numb her first. Just do it Tara said. I inserted the scissors to the mothers right, under the tight band of her perineum and bit down into the flesh. The scissors were dull and the sickening feeling of having to saw down into her skin as she wailed in pain made my throat catch. I made as small an incision as I could, as cleanly as I could and pulled the scissors out. The matrones dug their fists into the mothers belly again and the head blossomed around fresh red blood. His head was born, but it didnt begin to turn with the next push. I wiped at his face and mouth and felt around for cord around his neck, but found a little hand up near his chin. I cant be sure, but I think his fingers closed around mine. He didnt budge. A minute passed, then another 30 seconds and I was getting antsy. Its normal for babies to take a contraction or two to restitute, so their shoulders can navigate the pelvis, but he wasnt turning. The mother was pushing hard and he wasnt moving at all. I couldnt reach his armpit from above, so I reached in for the hand underneath him but it slipped away in the blood and fluid. I tried again and it slipped again and then I saw the piece of gauze Id been covering her vagina with on the table. I grabbed it, wrapped it around his hand for traction and pulled and his arm came free. I hooked my fingers under his armpits and gave some traction and his little body spun out, looking grey and floppy. I passed him up to his mother and began to rub him up. Tara said she had the bag and mask ready. I dont think I was breathing either. For what seemed like an hour I talked to him, welcomed him, told him i knew that had been a hard trip getting here but I was so glad to see him and that things were nicer out here. When he finally cried and I did too. His heart rate was good, his color improved, his tone was great, he was a strong baby. I said, thats it; Thats what I came here for. I looked down at the mother and smiled at her through my tears. Her son was wailing on her belly. Her eyes filled with tears too. I held that baby for the next two hours, blessing him and thanking him for being so strong. The matrones teased me that he was my husband and asked my boyfriends name. I said my boyfriends name is Chris. They pointed to the baby "thats mister Chris" they laughed. Okay, whatever you say.

The rest of the night was a blur. Three more babies before we stumbled out of the clinic at 7 am begging for breakfast and a bed. I slept most of today, feeling full and victorious, having succeeded in scaring the shit out of myself in Africa, and rising to the occasion.

Its easy, in retrospect --knowing that the baby was okay, to doubt my choice to cut the episiotomy. Its not something I should expect to do in home practice, but I should be prepaed to do in an emergency. However, I think I made the right choice. I was afraid he was in danger and I did it to get him out as quickly as I could with the least trauma possible. So I stand by it. I feel haunted by it and a little guilty about it, but I know I did the best I could do in the situation I was given. And thats okay, I think. Thats all I can do.

xoxo L