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.

Rato mato chiplo bato, mero sati and alpeshor gufa

May 21 –  Red mud slippery, my friend and alpeshor cave.

Today my Canadian comrades have fallen ill. This sucks immensely as we had planned for hiking today with our friend Kripa from the hospital. I went alone to meet her at the hospital gate. I did not make yesterday’s mistake of failing to make coffee before I left, and instead I waiting for tatopani (hot water) so I could mix myself Via before leaving. I made it in a metal cup and drank it at the hospital while I waited for her to meet me. Once she arrived we set off to take a local bus to Kushma where we would begin our day by crossing the longest and highest suspension bridges. I had yet to travel by local bus so was pleased when we climbed aboard with its fancy painting and coloured window shades. On the bus Kripa met the healthpost in charge of Pusma and we were able to walk with him through town until we reached a cable car. 

After some consultation we paid the fare for the cable car and climbed in. This was a fancy cable car – one car on each side, operating similar to a gondola and passing slowly in the middle. After the cable car ride we walked by an old aiport, now a grassy field, and wound our way up a narrow track past people’s farms. On the way we saw monkeys in the fields, a gorgeous pine forest and mysterious, beautiful mists. After we walked for some time and met a few people we started to make our way down over a hill, into the forest and eventually to the bridge. Here there was a curious restaurant and we had a masala omelet that was very tasty with onions, red and green peppers and chilis mixed in. The theme of the restaurant seemed to be fairytale woodlands meets Greek mythology and our stools were made to look like carved stumps. After this we had a pleasantly swaying walk across the bridge. On the other side we walked through a pine forest that smelled so fresh and clean. The smell reminded me of home, but the pines looked different – they had few branches near their bottoms and all the foliage near the top. We then crossed another big suspension bridge, this one the longest. This led to a cave we had decided to visit. On the other side we saw the sign for the cave and headed off.

As we were walking we heard drumming and singing. We decided to check it out. It was a large gathering of people, mostly women sitting in the group, men hanging back. A woman on the road told us they were a Christian group. I was surprised. Nepal has less than 0.45% of its population following Christianity. We were curious so we got closer. The men were preparing a goat as we approached. Other men spoke to Kripa and laughed at the suggestion that they were Christian, assuring us that no, they were a Hindi group and they met every Saturday to sing and pray and feast on a goat. Frankly, I was relieved. There are challenging things about all religions and belief systems, and Hinduism has its share of undesirable qualities are well. However, I find the Mission work somehow unethical. It isn’t fair to come to another county and culture and build nice hospitals and schools and provide desperately poor people with the necessities of life and then tell them everything about their religion and culture is wrong and they need to convert to be saved.

We continue on towards the cave. When we got there we were met by a yogi. He offered to lead us through the cave. He had two flashlights for us and a headlamp for himself. After Kripa made prayers we made our way down into the cave. It kept dropping, down and down we went. After some ways and at least 3 long ladders we got to see some impressive stalactites and stalagmites. Some of them he identified as the various Hindu deities, Shiva and Parvarti, Ganesha etc. It was a very nice cave. Then Kripa informed me he said we needed to go through thigh deep water or go back. I thought we had gone quite far and was under the false assumption that wading through water would result in getting out sooner so I agreed and removed my boots and socks. Barefoot we walked down over a cliff holding onto ropes for support. Then we began to wade. At times the water was at the base of my bottom. I preferred when I could see the bottom at least to place my feet as I was afraid I would step off into some abyss or roll my ankle. Around 45-50min. later we finally saw light! Boy were we relieved. As much as we loved the cave after about 15min. of stepping on precariously slippery rocks covered in bat faeces or alternatively wading barefoot through water down rocky steps we were ready to be finished. After seeing light however, we were very excited we had done it. After confirming with the yogi we are certain we came down 750m inside the cave! And then we traveled down the steep hill to a bridge at the bottom of the cliffs, at least another 200m.

After crossing the lowest bridge of the day we headed up the other side. At one fork in the path Kripa decided we should go left. Soon our little foot path got steeper, then it disappeared. Just before this I had commented, “Kripa, I think this is not the people path, this is the goat path.” Sure enough, soon I was leading us across an unstable small waterfall and edging us along the cliff using semi stable stones and tufts of grass to get us to a path again. With relief we made it to the other side laughing. After a switch back we then had one last steep climb and we were in Kushma town again. We drank a very refreshing cool Coca Cola as Kripa told the young women and children at the shop about our adventure. They had a hard time believing we had come through the whole cave. They also asked if Kripa was my guide, to which she assured them, no I was her friend. Later on the bus (after she had been asked about being a guide again) we had a laugh about this and decided that I guess it made sense, not a lot of visitors probably become good friends with the locals in their travels. I am glad that I have been able to make such a wonderful friend here in Baglung. We had such an excellent adventure today! Oh and I should mention, I wore hiking boots and bare feet today. Kripa wore flip flops and bare feet and managed just as well or better than I!

a blog for the birth lovers

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. :)

easy peasy nepalesey

Labour positions and labour support

The last two days we spent doing our training with a group of 12 nurses from the hospital and 10 students in the SBA (Skilled Birth Attendant) training. We covered similar topics to the training in Mugu including labour and birth positions, 3 ways to deal with nuchal cord including the somersault manouver, APH and PPH management including manual removal of placenta and bimanual compression, breech, and Helping Babies breathe. We were fortunate that Rashmi from MIDSON was able to join us to teach some of the sessions, as well as the head nurse, Janaki, from the hospital. It was an enjoyable two days, although a bit exhausting. I fell easily back into my role of labouring living mannequin and got many compliments on my acting skills. Kristi also had a turn wearing the labour pants. Unfortunately there is now a 4th degree tear in the pants and they will need a significant repair before next session!

Post hands and knees delivery by experienced nurse, Debi, in the photo controlled
cord traction after active management of 3rd stage.

Giving our own 'gift of love' to the participant who
scored highest on the blood loss quiz

Helping Babies Breathe

We spent a lot of time focusing on normal birth including different birth positions such as left lateral and slow delivery of the head (to reduce tearing), delayed cord clamping (to increase baby's blood supply and reduce risk of anemia), and not using suction on breathing or crying babies (because it is harmful and unnecessary). Our training was very well received. We got asked lots of good questions and we found it valuable to review and demonstrate and teach as it increased our own confidence in our skills as well. Throughout the training we had lots of requests for photos and today at the end we were presented with a tika and gifts of love from the Baglung nurses. We were a bit emotional over how wonderful it was. After that there were many many photos and I believe Cathy summed it up best when she said "What are we, in a wedding or something?"

Receiving tika and gift of love

Teaching team with tika and gifts of love (L)

All the participants

Rashmi and Mickey both leave tomorrow. Rashmi back to Kathmandu and Mickey to an area affected by the earthquake where Cathy, Mickey and team went last year. His hope is to connect with a girl they met last year with severe anemia, to see how she is doing since her blood transfusions and new iron regime and to bring more iron. He will then head back to Canada. We are sad to see them go. Mickey has taken over the role of photographer since his arrival and I have appreciated not having to worry about taking too many photos. He also has an excellent sense of humour, we have had many laughs these past 2 weeks and we have learned many useful things from him, including how to play Hearts. :) Rashmi also has been a fun addition to our team and I have enjoyed learning from her and hearing her stories and it seems as if she just arrived and now she needs to go.

We also have never had our arms, legs and bottoms grabbed so much. ;) In Nepali culture it is very normal to grab the arms or bottoms or cheeks of your female friends. We take it as a compliment that our new nurse friends here feel so warmly towards us that they latch on to us the way they do with their friends here.

Our well loved women's health team

Tomorrow we will head back to the hospital to attend more births!

photos!

Heading off on our first day

 Here are some photos to go with our last two posts! The next 2 days we will be in our training course. More updates to come.

OR

Delivery room

Resuscitation/baby exam station

Teaching L lateral slow delivery

That's a baby I'm holding on the mom #birthhigh

Kristi's first Nepali catch

Krista's first Nepali catch

fresh beautiful chori (daughter)