We have now caught 12 beautiful babies between us! I should've posted sooner after our workshop as it has now been a week and things are starting to string together in my mind. I am hoping this post will suffice for now, especially for those who are interested in the clinical aspects of the placement, and I will try and share more stories later.
So the highlights include that all the births we have attended are SVDs, this is perhaps a bit misleading as we don't attend CS when they happen ;). Mostly G1s and G2s and a few G3s (amount of times they have been pregnant). We have encouraged all of the women to deliver side lying to prevent or limit tearing. We have had many intact perineums, even with primips, and some small 1st degree perineal tears and labial grazes. Each birth I feel like we make an impression on one of the nurses on how birth can be different and how even primips can deliver intact if you slow down the delivery. This part has been incredibly satisfying for me as we know by reading the birth ledger that most of the primips here are given an episiotomy and this really needs to change as it is harmful and painful and not at all necessary. We all have had new clinical situations to manage and have had to expel clots from the cervix. All of us have had the opportunity to suture at least twice - most of the suturing has been for tears we might even leave in Canada but due to infection risk and the likelihood of hard work shortly after birth we have been asked to suture the small tears. We don't mind. Our goal is an intact perineum but when there is suturing we (or at least some of us!) really enjoy doing it. It has the satisfaction of any other sewing project I think. There is a rhythm to it and a satisfaction when things are well approximated. Krista and Kristi have both done initial steps of a resus and Krista had to suction one baby.
This week we had a 3 baby day! After a normal SVD, Krista had retained membranes that needed to be teased out with gauze and clamps very slowly. While she was working on this with Cathy, Kristi had a bleed right after delivery. Her and I clamped and cut the cord, worked together to drain bladder, got oxytocin in the IV running wide open, delivered the placenta quickly and took care of baby (as he didn't need to be suctioned and it seems to be done routinely when we are not there). Although both things, retained membranes and postpartum bleed had the potential to result in a hemorrhage it is sort of a juxtaposition that as one team was moving so slowly and carefully the other needed to move quick. Midwives are so skilled and adaptable! We have patience and can move rapidly when needed. I was so proud of us this week.
My delivery that day was a primip who came into the ward in labour and 8cm dilated. This is very rare here. Most women come early because they do not want to travel in labour. Most women have an induction for postdates or end up being augmented with oxytocin for 'slow progress'. Unfortunately, I think that many of them are put on the partograph too early. They are supposed to be at least 4cm dilated with regular strong contractions. As the midwives reading this know, multips can sit at 4cm for weeks and not be in labour. Although the use of oxytocin is overused, we are not blind to why this is happening. Many women fear birth and travelling during birth or having a roadside delivery. After travelling to the rural health clinic and birth centre this week we really understand how difficult that would be in labour. It is very very bumpy and in the rainy season trecherous. The staff also want women to deliver in a reasonable time and when there is more staff (daytime) the doctor is around and doing a C/S is possible. This results in more inductions and deliveries during the day and less at night. We can see the parallels between here and rural Canada where staffing and transportation also play a role in clinical decision making. (more on this later)
Anyways, she came in labouring and moving and swaying on her own. I provided labour support; encouraging words, hip squeeze, sacral pressure. A first I didn't think she had a labour companion but then found out she didn't know if one was allowed! So then I invited in her sasu (mother in law) and bahini (little sister) who continued labour support with me. I kept her on the labour side of the ward as long as possible so she could have the support of her family. Here, family is not allowed in the delivery room, another thing that would be good to change, as it wouldn't affect the clinical management and it would make the world of difference for the mother's to have support. She delivered in L lateral position and I used a good portion of my strength to hold her baby in as I encouraged her to breathe "Lamo sass, chito sass" Slow breath, pant. She delivered a baby boy with a nuchal hand which I swept across his body, small labial graze with intact perineum, no suturing needed! :) Baby took a little bit to come around so Krista and Cathy took him to the warmer after delayed cord clamping because he still had a lot of fluid and was having a hard time breathing. After suctioning they observed him for awhile. The oxygen wasn't working otherwise I think they would've done blow by oxygen. Meanwhile, I attempted to deliver her placenta and felt the cord tear (equivalent of nails on the chalkboard). I got them to add oxytocin to her IV and waited and attempted to deliver it again, more tearing. At this point I asked Cathy to come and explained the situation. I was convinced the placenta was detached. I tried again, more tearing. I then felt up the cord to find the placenta. It was in the vagina so Cathy showed me how to sandwich it and pull it out. On examination the placenta was very sick looking. It was calcified all over, the cord was very thin and due to improper connection had almost pulled off the placenta. Given how unhealthy it was, Cathy said she was lucky the baby was living. Shortly after that we tucked them in to postpartum. It was such a wonderful end to our day. The mother was so fun, between contractions she smiled at me confidently and even laughed a bit at my Nepali. After birth she was all smiles and walked to the postpartum ward as if she hadn't just given birth. I saw them shortly after and she was smiling and getting him to latch. She is 18 years old.
We are learning that oxytocin births do not progress the way not augmented ones do. We knew this of course but it is still a bit surprising when someone goes from 5 or 6cm to head at perineum in under 30min! Kristi had a 5cm to delivery in the labour ward this week in under 20min. Unfortunately due to a glove malfunction and the rapid progression the baby's head came out before she or Cathy could slow it down. Afterwards they discovered that the reason the baby came so quickly is that the mother had a 3rd degree tear in her previous home delivery that was not repaired. This made the clinical situation make more sense - her pelvic floor muscles were not intact so were unable to slow the baby. As well she wasn't even fully dilated when she pushed her baby out, likely around 7cm as evidenced by her torn and ragged cervix. Our Nepali head nurse came and did the repair which involved 2 interrupted sutures on the cervix, attempted to bring together the old 3rd degree tear from the previous birth, which you cannot really do as there are no raw edges, however she needed to try so she could suture the 1st degree from this birth. Clinically it was fascinating for us. For the mother however it is very sad. She has a rectocele and no perineum and will need surgery eventually.
Off to the hospital now! Maybe more later from one of us. :)
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