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!