Sunday, November 8, 2009

Birth in the non-supine position!

Monday, 9 Nov. P1010084Yesterday marked a momentous occasion in my stay here! Not only was it my 41st day (special only for its proximity to 42), but it was the first time I convinced anyone to try an upright position for pushing!

The women in our care here are equally afflicted by back labors and presumably posterior babies as our women back home. This is somewhat gratifying, because even though this is locally explained by laziness, it's probably not, and it means that there's not something we're doing especially wrong at home. (Or maybe we're all doing it wrong.) It's also super frustrating, because these back labors are long, difficult, feel very intense from the get-go, yet the contractions are poorly coordinated and somewhat ineffective. Iit's common to have someone coming in looking like very active labor and have her be at 2-3 cm. In fact, this weekend, we had a whole series who were at 2 cm for a full day! Logically we should send them home, because they're not in active labor. For various reasons this is not always possible, usually because they live far and don't have transport, and so we don't admit them but give them a bed in the extension ward. This leads to a feeling of still being in care though, with the accompanying requests for vaginal exams, which increases infection risk and frustration when the cervix is still 2 cm. I did send a few people home yesterday though! And one person "came back" only we hadn't discharged her and had no idea she was gone.

There are a number of positions that can facilitate a posterior or malpositioned baby to adjust his head position and make for an easier exit. These are usually assymetric and forward-leaning positions, and Penny Simkin's book The Labor Progress Handbook is invaluable for its illustrated suggestions. My success rate at recommending these positions is about 50%, I'd say. I usually demonstrate them for the family, my butt way up in the air, which has led to some photos (I want a copy of that, Amy!) and a lot of giggling. Some people can't be bothered, some are too tired already, some think they're just ridiculous, and some try them once or twice or only when I'm walking by.

My success rate at suggesting pushing positions, however, is like 2%. Most the midwives were trained in the flat-on-her-back school of pushing, grabbing one's legs or buttocks, holding the breath, and pushing pushing pushing. I never push it -- no pun intended -- but I suggest that she might want to try a squat, that it might be easier on hands and knees, that some people find they have more power kneeling, etc. It doesn't help that my limited Bislama -- and the apparent lack of word for 'squatting' in Bislama -- makes it difficult to explain what I'm talking about, leading to more instances of me climbing up on the adjoining bed and demonstrating.

P1010099S had back labor and a classic peanut-shaped belly, with lots of obvious fetal movement of small parts in front, suggesting the baby's back was along her back, facing front. This isn't always the case because babies are apparently like chubby owls and their bodies can be one way while their heads are basically the other, but still. She was pushing and making tiny progress, but it seemed like she'd greatly benefit from an upright position. When I suggested she try kneeling, and climbed up on the bed, hoisting up my gown to expose my knees, she actually did it! I couldn't believe it! And there was nobody around to yell at her and tell her to "slep strait!" just me and the student nurse who seemed delighted by this bizarre change in protocol. Once she'd gotten into position, I realized I had no idea how I would catch the baby. The delivery table was angled slightly, and I flitted from front to back trying to decide where would be the best place to be. There's a great birth video called Birth in the Squatting Position where babies just slide out onto the floor, and I've seen moms catch their own babies, so I knew it was entirely possible, but then I remembered a friend's thesis on obligate midwifery (based on the premise that babies are born facing back, requiring an attendant), and got confused. I figured it would sort itself out and positioned myself behind her as I had for the first couple babies I'd caught in the States, who were all born with their moms in hands and knees. Little by little, baby's head emerged, a millimeter at a time. It seemed painfully slow by Vanuatu standards, but this huge head -- part of a 3640g kiddo -- made it out with just the tiniest skid marks on the labia, no perineal tears at all! She was a primip, even! And the midwife who came in was delighted! She said maybe it was the first squatting birth in Vanuatu. I doubted this sincerely, but I hope the student nurse carries it forward -- she'll probably end up doing deliveries by herself in a small dispenary (clinic) on another island. (More about dispensaries when I finally get around to writing about my experience on Tanna.)

P1010157The rest of the day is a blur. The student nurse was on her way out when another mom was declared "fully" and she quickly had her baby. By the time I caught up with the paperwork on those two births, there were 3 more admissions, and two Australian med student friends came by to see if they could catch some births (since they're stationed on the med ward and haven't gotten the opportunity, I texted them to let them know we might have one that night). With them in tow, we managed a long, deep decel in a premature labor (thankfully resolved after adopting the open knee chest position, and hopefully the nifedipine stops her labor), a bunch more labor checks, some more admissions, and then two births! The first was a woman who'd been at 2 cm for 2 days and suddenly jumped to 8 cm with a very strong urge to push, and the next was a woman I'd sent home who came back at 9 cm and had a little boy! She also agreed to push in a kneeling position for a little while, and I think she ultimately delivered side-lying. I had a good time with Katie and David -- with Molly and Alex and Mel gone, and the Lycee students done with their observation, I've been missing having students to pal around with, especially those who will entertain my narrative teaching -- and they seemed happy to be deployed on various tasks and were quite helpful especially considering they insisted they'd only had a week of pregnancy so far. (I tried to go to Willy's presentation at his Lycee but missed it by a few hours, but he sent me his report! In French! Oh, the hilarity of my speaking French, especially throwing in Bislama words where my French fails.) I also feel like I've eased into new territory of feeling comfortable managing on my own, which is a nice feeling considering I've now finished my graduation requirements!

There was another woman who was ready to push right when I finished suturing the last one, but it was already midnight, the midwives were on their 3rd shift of the day, I'd been there for 14 hours, and we decided to go home. Pretty good day! And the busy-ness makes me think that maybe the October dry spell is broken. They only had 159 births in October. Pathetic! Why, back in April there were 278! And yes, I made a graph!

VCH Birth Stats

1 comment:

saralily13 said...

Finally - an update! - I was wondering what you were up to and missing all the birth stories. Happy babies!