here we go a walking...

Sunrise over Dhaulagiri

Last week in Kathmandu.

So this is it! We are finishing up our time here as our colleagues are starting their placements in Uganda! You can follow their journey here https://ubcmidwiferyuganda2016.wordpress.com/2016/

The fatigue has set in for us. The last week has brought a new round of gastroenteritis to 2/3 of us and our lungs are struggling with the air quality again as well. Kristi and I especially were a bit sad to leave the gorgeous mountainside to return to the loud, polluted city, although it offers its own set of interesting things to do and see. :)

Poonhill with guide + porter

Central fireplace - Ghorepani

We had an excellent trek. We expected to have a lot of rain due to it being pre-monsoon season, but we were pleasantly rewarded with mostly sun for the first 2 days and only a little rain in the afternoon on our second 2 days. The rain generally comes in the late afternoon and on day 3 we were tucked into our guesthouse before the big downpour really began. The highlight of our trip was our time in the community of Ghorepani. For me, a mountain girl, being there, in the Nepali version of a snow-lodge, with central woodstove, great company, excellent food and games, surrounded by the magnificent mountains was just what this mountain girl's heart needed. We got up at 4am on our 3rd morning to hike to the top of Poon hill. The day before we met a mother daughter team that had tried to see the view from Poon hill and there had been clouds so they were unable to see the mountains. They were staying another night in hopes of a view. We were so pleased when we started our ascent in the dark to see the mountains, darker shapes on the horizon. When we reached the top we were able to watch the sunrise over the Annapurna range and see it sliver across the Dhaulagiri range. My heart was bursting with joy at how beautiful and majestic it was.

9 weeks of dal bhat and Marella still loves it!

Good morning Annapurna South

Doing a trek after my experience in Mugu and Baglung I feel was a good order of events. The effects of tourism are not benign, nor always positive. However, the children along the trekking route all looked as if they had enough food to eat, and water to drink and bathe with. Certainly sustenance is not the only thing that matters, but seeing the stark contrast between Mugu (remote with not many tourists) and Annapurna Conservation Area (many many tourists) made me realize that for this country, with tourism as their biggest industry, the money spent on trekking translates into less children starving and for that at least I am grateful. A curious thing I did notice along the way though, is that some of our serving staff were young women. One could be lulled into thinking they were just a family hotel and the children were helping out. Upon questioning it was discovered that no, most of the hotels are owned by people who live in the city, and the staff were not from the area but have moved for work. One girl who was 14 had left school and her family because they couldn't afford school for her. She was working she said to pay for school. I have my reservations from my other experiences that she will actually return to school. This is sad, but also I know that trafficking of girls for more horrifying things is quite common in Nepal and as unjust as it is, there are still worse things here that could happen to her. This doesn't stop me from hoping however, that one day all the girls get to go to school, and if they work in tourism, it is by choice and not force and they are compensated fairly for it.

Post birth happiness!

Back in Kathmandu we have spent 2 days helping MIDSON with teaching. Our role has been to use the living mannequin to demonstrate labour and birth  positions, normal delivery, management of nuchal cord, and neonatal resuscitation. We all have had our turn in the delivery pants now! We also were able to visit Thapatalli hospital and see their doctor led labour ward, nurse led birthing centre and the OR. We have 2 more observations: one is Tribhuvan University Teaching Hospital birth centre and the other is Aadharbhut Prasuti Tatha Prajanan Swasthya (APS) Birth Centre.

We look forward to finishing up our time here being able to see different places women can give birth in Kathmandu. Perhaps we will have more to say after our visits, however I am mindful that I will be giving this computer to its owner soon and may not be inspired to write more when I return home as I will be busy catching up with family and friends and finishing my 3rd year research project!

Thank you to our many friends, colleagues and teachers at MIDSON and Dhaulagiri Zonal Hospital. Without your work and kindness in opening your arms and your places of work to us we would have not had this incredible experience. We hope our collaboration can continue and that midwifery for Nepali women will be a reality very soon.

Thank you also to friends, family and colleagues back home, for following and supporting us. We look forward to discussions with many of you soon!

Rhododendron forest 

Marella's post, sorry so late!

Kristi, Cathy, Marella
Milan, Kripa, Janaki
midwives, nurses, friends

Last week in Baglung May 23-29

Cathy got confirmation from MIDSON that there was to be a health camp in Baktapur (near Kathmandu) on May 28-29. Cathy would be participating and as Krista was considering forgoing the trek she was leaning towards leaving with Cathy so she would have the opportunity to do a health camp (see her post!). Shortly thereafter it was decided that Krista and Cathy's last day on the ward would be Wed. May 25, travel to Pokhara May 26 and to Kathmandu on May 27.

Then we found out that there was to be a vehicle bandh (strike) on May 26 so they would not be able to get a taxi. A decision over dal bhat was made for them to leave for Pokhara May 25 after the day at the hospital. We were hoping that Krista would get one last catch before she left. As you can probably guess, although there were two labouring women who were fully dilated by 4pm, the woman Krista was looking after did not progress to delivery before 5pm which was the latest that her and Cathy could stay. They even stayed a bit afterwards and they barely made it to Pokhara before dark.

For Kristi and I however, it was also hectic as we were still very much engaged in the births at the hospital and did not even have a chance to say a proper goodbye. That day was long and both births had deviations from normal that really shifted the energy of the labour room. The woman I was attending with one of the SBA students had fetal heart rate decelerations that were not returning to baseline very quickly. Up until this point we had done all of our births with slow delivery of the head, and were now in the role of teaching that technique to reduce tearing which is better for mothers and for staff as they have to use less materials, and less time for suturing. However, it was then difficult for us to communicate that when we have an abnormal fetal heart rate, that takes priority over the perineum. The delivery ended up fine. A small second degree tear and a vigorous baby. However, this birth prompted us to think a lot about the potential repercussions of our teaching techniques across language and context.

We know that in a Canadian context where we are taking q5min. fetal heart tones that we feel comfortable having a slow delivery of the head. Protocol in Nepal however only required FHR q30min. This could make a huge difference to a baby with low oxygen reserves heading into second stage. As well, we know when we need to switch management based on an abnormal fetal heart rate and we are not sure that was communicated effectively to all we were working with. It highlighted some more difficulties of me of working in a context where different languages are spoken. We have difficulty enough in Canada communicating effectively. The language barrier, and the difference in context and protocol exacerbates that so much more. I think if I do future work in Nepal or elsewhere that working on language skills will be of utmost importance for me.

Some of the maternity care team at Dhaulagiri Zonal Hospital!

In the next few days Kristi and I maintained a similar routine to when Cathy and Krista were there. Showing up at the hospital between 9:30 and 10am. Visiting the Day 1 mothers and babies in the postpartum ward and giving out soaps and hats and blankets from the Canadian hazaramas (grandmothers) who kindly knitted many beautiful blankets and hats for the Nepali babies. To every baby we smiled and cooed and said "Kasto ramro baccha?!" How beautiful is this baby?! And they all were! After that we would go to the labour room and see what was happening. If there were labouring women we got filled in on their case, learned their names and introduced ourselves. Then we would alternate between doing labour support, clinical skills, and staying out of the way if there were already lots of people providing care. At this point it our placement we knew most of the staff we were working with, and all the students too. It was really nice because we had a rhythm and a camaraderie that made the work even more enjoyable. I really enjoyed being able to teach the students how to provide labour support, do newborn exams and do slow deliveries. We all were able to do 4 handed catches as the teacher. This gave me a greater appreciation for my second year preceptors! When doing hands-on slow delivery you really rely on your touch to know how much pressure to put on the baby's head based on the contraction strength and whether or not the mother is pushing too. With their hands on first you can't see or feel! Mostly it went really well and the nurses and students we did catches with really got it afterwards in a way they couldn't before from just observation. As well we heard accounts of a nurse who used the somersault maneuver 3 times in the last week and is so excited about how well it works so that she doesn't need to clamp and cut the cord at the perineum that she has been telling all the other nurses too! :)

Enjoying photos with the gifts

On our second to last day we had a party with the staff and students. We brought a cake and the gifts for the hospital including neonatal stethoscope, headlamps, flashlights, bp cuff and assorted other supplies. It was so fun to laugh and eat cake and take photos with everyone.

We also were able to spend some time with our friends we had made at the hospital in the last week. Kripa and Kabita took us to two different restaurants we had never tried and both were quite nice. We especially enjoyed going to Bamboo as we were sitting under a bamboo gazebo with hanging lights around. We enjoyed many jokes - english and nepali. We got this delicious peanut dish, peanut sandeko that had tomatoes, onions, lime and spices. When Kristi tried to pronounce it, Kabita and Kripa were in agony they were laughing so hard...apparently she requested rotten peanuts. At another point she told them she was going to throw something off a cliff, another mispronunciation. At the end of the night I requested the bill as Cathy would. "Dai, bill dinahous!" More laughing ensued...apparently what I said was correct but the flourish and accent was funny and they requested I ask again.

Possibly the funniest thing that happened was I was trying to describe a weird loud bird I had heard the night before. Kabita suggested rooster "Coo cree ka" and we said no, not "Cock a doodle do" and then we learned how to do Nepali rooster sound. And then I said "I know, tonight I will put my headlamp beside my bed so that when I hear the bird I will wake up and use my headlamp to see it and then we will know what kind of bird it is!" To which Kripa replied emphatically "Yes! We should use the headlamps to look at birds! We should use them for other things! Why always the Va-g-ina!? Why always the in-troitus?!" I think this is all of our newest favourite midwifery jokes. We had many on the trip. Most of them started by Cathy who had us in stitches many times on the trip. She has an incredible way of making us laugh even through the most depressing stories. We are missing her dearly at the moment.

Kripa, mero sathi!

The 29th was our last day at the hospital. The whole week we had been trying to have one last normal slow delivery catch so one of us could catch with Kripa. She really wanted to and so did we because we know, as the head nurse of the hospital, she has a lot of influence on the practice in the maternity ward. And we were so fortunate. We had a primip who progressed quickly and her and I were able to do a 4 handed catch together. Intact perineum, healthy mother and baby. It was a perfect end to my placement. Also, possibly the most delicious chubby Nepali baby ever. :)



The next morning Kristi and I headed for Pokhara to prepare for our trek which ended up being not too rainy and a really fantastic time. Perhaps we will blog about it later!

kasta ramro baccha!

Health Camps and Another Poem

I have been reluctant to write and share on the blog up until this point. So much of what I have seen and experienced while here in Nepal is difficult to articulate and I worry that my words won't be able to truly express what I want them to. But for the time being, I am going to put that worry aside and share a bit about my experience.

I am now sitting in my hotel room in Khatmandou. Cathy and I left Baglung in a hurry to avoid not being able to leave the following day as there was a scheduled transportation strike to take place throughout Nepal. We were leaving to come back to Khatmandou to help with a medical camp that was being held on the weekend. Marella and Kristi remained in Baglung for a few more days, finishing up the placement and then heading to Pokhara where they would then leave for trekking. I decided against going trekking. Having not come to Nepal prepared for trekking (meaning no hiking boots, socks or even a heavy sweater!), I decided that trekking during monsoon season would be difficult enough, let alone trekking during monsoon season without being prepared, so I decided to forgo the adventure. (Turns out that the universe must have known what was to come- my time here in Khatamandou has seen me napping on and off while trying to fight a nasty cold- I am thankful for making the right decision and for the rest!)

As for the medical camp that Cathy and I attended, it was a highlight for me and I am thankful that I got to attend and experience it. It was the Dadikhot Bhaktapur Humanitarian Reproductive Health Camp and it was organized by MIDSON and Direct Relief. It was held in a small health post that was  quickly transformed into a women's health facility upon arrival. For two full days, many different reproductive and health screenings and treatments were provided. Nurses, doctors, and community health post workers and students worked together to provide essential health services to the women in the community. Basic health care services like blood pressure measurement was provided upon registration. Cervical cancer screening known here as VIA testing (visual inspection of the cervix using acidic acid), as well as follow up and referral for further treatment if necessary was performed and women lined up out the door to wait patiently in line to be examined. As well, examination and treatment of vaginal and cervical infections was performed and antibiotics were prescribed and given to those who required them. Uterine prolapse examination, diagnosis, referral and follow up was provided. Antenatal checkups and postnatal checkups were provided. IUD insertion and removal, as well as family planning counselling and health education were all provided to the women in need. There was also a pharmacy on site where vitamins, medications such as antibiotics, anti-fungals, and pain medications, as well as super cereal (for women and children and used for treating malnourishment) were handed out to those in need, free of charge and given out right then and there.

It was interesting to see how efficient and organized the entire camp was. Before it began, I wondered how it would all work out, being held in such a small space and all, but I was amazed to see that it
did. Many women came the first day and even more on the second day when word spread around the community that the camp was being held. Women patiently awaited their turn, taking turns holding each other's babies so they could be examined. Everyone patiently waited in line to receive their prescriptions. The small health post was packed full of people, inside and out! It was a success.

Cathy wrote another poem and I wanted to share it here. Cathy and I had an amazing evening with Rashmi and her son, Sagan, who welcomed us into their home for a delicious meal and then took us on a walk about, sharing with us stories and history. It was a beautiful evening. Rashmi shared a story with us, which sparked a poem from Cathy:

The Beginnings of a Midwife:
for Rashmi
1958

A small child, wearing woven cotton clothes
plays with her sister on temple steps;
the father performs puja in the ancient shrine.
A woman strains under heavy load, the doka full of
firewood,
through cobble streets, to rest by the temple.
Sweat streaming
Backache pulsating
She kneels
and with a small groan, almost a sigh
A small wet infant slips out onto warm clay tiles.
The small child, eyes wide, creeps forward, watches the
placenta emerge.
The new mother asks for mustard oil
Drinks slowly from a bronze bowl
And rises, wraps the infant and placenta in her shawl
And moves toward her village.

~Cathy Ellis

I have so much more to say about my time here in Nepal but for the time being I will leave it at this post in the hope that the words I need to express myself fully will eventually come to me so that I might be able to share some of it in the future. All I know is that my heart feels both heaviness and lightness and a great uncertainty as to how to reconcile it all.