La séptima semana/The seventh week Part I

¡Buenas tardes! I hope all of you are having a lovely week. It’s been very hot in El Paso recently! We’ve been hitting 100° and I’m looking forward to upper 80s and lower 90s temperatures next week. From what I’ve heard, I have nothing to complain about compared to the East coast, though! It’s hard to believe July is already halfway over. This month has flown by and I can’t believe how full my weeks have been. Last week was especially busy and it felt like every day, whether in the birth center, class, or touring around El Paso, was teeming with so much. With only a week and a half left in El Paso, I am starting to feel pressed for time to complete interviews (there’s been a sudden rush of interest and I am supposedly going to get 10 in over the next 11 days) and sad that my time here is coming to an end. I believe that my time here is not quite finished yet, however, and I sense that I’ll come back to Maternidad and El Paso. My research adviser told me in an email last week to start thinking about the bigger picture in terms of where this summer is bringing me in terms of my thesis and career. As I ate a strange concoction of cake flavors (vanilla, banana, jelly icing holding it together, and vanilla icing with chocolate sprinkles on top brought in by one of the student’s on-call clients) on this week’s Monday afternoon after class, I spoke with one of the students about how midwifery is a lifestyle and not a job. I told her it would be hard to do anything else after loving this deep work so much. I’m not making any final decisions now, but I am certainly leaning more in the direction of becoming a midwife and am feeling how hard it will be to leave all that I am learning and absorbing in just a short while. Thank you all for your constant feedback and support – it has meant so much to me this summer and I look forward to seeing many of you in person soon!

Monday, July 12

Monday began with a morning birth at 9:24am, which I had never seen or been to before at Maternidad (most that I have seen have been at night or in the early morning hours). As we stood together at circle hearing the update from the previous shift about citas, initials, labor checks, and births, one of our clients walked in going through intense contractions and was already at 9cm! After getting settled into the rose room, she said she actually wanted a water birth and we prepared the peach room and tub for her. During this time, I was doing list (checking all of the emergency boxes, supply cabinets, oxygen tanks, NNR machines) in the rooms in a more disorganized manner that I usually do because I knew birth team would be called relatively soon and I was up to be documenter. Birth team was called around 8:45am and luckily I was next door checking the purple room. The bathroom soon became crowded with the primary, assist, the client’s sister, the licensed midwife, and me all in there. I couldn’t help but notice how long the client’s eyelashes were and saw the clumps of mascara run off her face as she wiped her face off. After about 30 minutes of pushing in the water, the staff midwife said she needed to get out and move to the bed because the contractions had slowed down too much and because she seemed scared to allow her child to pass under her pelvic bone and into the birth canal. While I agreed that the water seemed to have had more of a relaxing effect, I wondered if we needed to move her out of the water so quickly (this was her first child and it is very normal for a first-timer to push for up to two hours in her first birth); it made the situation feel a bit managed. Soon after moving out of the water, her contractions intensified again and she gave birth to her daughter at 9:24am. Her placenta was born shortly thereafter and she received one injection of Pitocin to help slow down her bleeding (this happens in a lot of the births). The documenter leaves pretty soon after the placenta is born, taking laundry to be added to the washer and dryer that never seem to get a rest and beginning the stack of paperwork that leads to the creation of the birth certificate and other information.

I was not able to get into any of this paperwork, however, because as soon as I left the room, one of the students asked me to help with a fetal well-being check for a client who was 41+4 weeks along and would be receiving a castor oil smoothie to provocar el trabajo de parto (get labor going – we can only care for clients until they are 42 weeks). During a fetal well-being check, one student uses the doppler (or fetoscope if the heart tones are really audible) and calls out beats every 15 seconds and the other student documents these and also notes whenever the client says the fetus has moved. We do this for about five minutes after the student has gotten a three-minute baseline. What you want to see is a deceleration or acceleration of at least 4 beats when there is fetal movement two or more times. This means the check was reactive and that all is okay with the fetus. After taking three minutes of heart tones with this client, there had been no movement. I have noticed this happen during these tests and always wonder whether you should/can expect fetal movement in a period of time in which you are really looking for it. Regardless, it is important for us to note the movements and change in heart rate because otherwise, there could be a problem or we’d have to transfer/consult the client to a doctor or hospital. The student told the client how important it was for her baby to move and that she needed to talk to him. She began speaking to him and lightly stroking her belly. Her niece sitting in my favorite rocking chair in the rose room chimed in, as well. I was amazed that he moved two to three times in the next two minutes and saw firsthand what a difference it had seemed to make for him to hear her voice. It was a special moment and we were relieved.

It was cita time after this and I was happy to do a postpartum cita with one of the women who had given birth in the water on the Friday before in the peach room (July 9). I love when I see clients over and over again and have the chance to develop more of a relationship with them, especially when I have been to their birth. Women only have to come for the three-day PP cita if they have had sutures (she did not) or if there was meconium (which means the baby pooped while in the amniotic sac). Since there had been light meconium, she had to come in for a cita and said they’d be visiting the pediatrician this afternoon (we consult to a pediatrician just to make sure the lungs are okay). I feel like the women spend so much time with us and their pediatricians in the first few days postpartum! This was only my second PP cita solo and I am still learning how to get the flow right since you are checking on both the mom and baby. It’s much different than a prenatal cita, but I really like PP citas. I notice some gaps in my knowledge when I do PP citas, though, because a lot of the women have questions about breastfeeding or the color of their baby’s poop that I don’t exactly know how to answer. Luckily, there’s a beautiful painting in the baby cita room that has a yellowish color that everyone points to for how the poop should look J This young woman’s main concerns were about her son’s poop (she said it seemed like diarrhea, which the staff midwife said was normal) and the umbilical cord (which had not fallen off yet, but appeared normal). Her parents came with her and I was so happy to see them again. They were so kind, gracious, and patient with me and said I was muy amable (very kind) and I told them what a beautiful family they were. The father of the baby was still in Juárez (I’ve noticed a lot of the husbands/boyfriends/partners are not able to cross) and would hopefully be meeting his son for the first time tonight on his birthday). The cita went very well, but I did worry that with so little knowledge about the postpartum period (I’ve been to two classes on it, but know so little about breastfeeding recommendations) that I make women feel uncomfortable or that I may not be picking up on things that are issues or concerns. The staff midwife said everything was great, but I’m still getting used to checking respirations on the baby and answering those questions more from the standpoint of what I feel than what I actually know.

After this, it was time for an initial with a very outgoing, lively woman who was excited to be having her first child. This felt like the best initial I had ever done (it was my seventh initial) and it reaffirmed how much I love the time spent with women during initials. I believe because this woman and I had a similar level of outgoingness, it made our interaction smoother and I felt more confident speaking Spanish and communicating with her. She said she had heard about MLL on la radio and that she hadn’t felt too different in her pregnancy thus far. She was enthusiastic about her pregnancy, though, and was eager to share about herself and listen to everything from nutritional recommendations to how to prevent urinary tract infections. I was happy to have worked with her and realized how much our similar modes of communication had made the initial flow so well. I was about thirty minutes late for our class on Posterior Presentation, but was there for enough time to absorb a lot of information about how to provide support and recommendations to women through their pregnancies and births if the fetus is in this position (this type of presentation means the baby is face up and his/her back is parallel with the woman’s spine, causing severe back pain, especially during labor). The class was a combination of discussing recommendations and watching movies and I enjoyed it immensely. I was also grateful to have had some time with the Director of MLL since I have not gotten to know her very well.

After class, it was time to head back to the birth center and into an initial that would last for a very long time – about three hours. When I first saw the datos personales (personal information sheet), I was shocked to see the young woman was 18 and her husband was 58. My mind started going in a lot of different directions and I feel that she, too, found admitting this awkward and uncomfortable. When I asked her if she had any comments about their relationship (this is on the first page of the initial), she just said “Pues, es mayor que yo” (Well, he’s older than me). This initial felt far different from the one I had done before class. I wasn’t conveying thoughts or information as well and there was a strange dynamic between the client and me. When she asked if I had any children, for some reason, I said my age along with no and she said I was muy joven (very young). It felt strange for an 18 year old to tell me I was young, while during the initial I kept thinking about how she was three years younger than me. She had a lot of questions, from whether it was okay to name her baby the name she had picked out to whether she could bring in English music to listen to during labor, and was concerned about how badly she had felt in the first trimester. She was almost 11 weeks along and had had a very difficult time with morning sickness. While I tried to reassure her that this was part of the first trimester and that it would likely fade away in the second, I still felt that I couldn’t really comfort her. She cringed when she had her blood taken (and the blood wasn’t coming out of her veins well, so she was stuck in each arm) and her husband arrived at the end to pick her up. I felt like he was very attentive, but I could tell the client was really ready to leave. She left a little before 7:00pm and I mulled over the initial internally and with the staff midwife.

Hamburgers stuffed with parsley and garlic were cooking once I walked into the kitchen and I was hungry! One of the students was making them for us, along with potatoes sautéed in butter (she’s got my heart!). The staff midwife and I felt like vultures in the kitchen, peeking at some of the hamburgers already out on the plate, eating Pepperjack cheese to tide our hunger, and eventually digging into a hamburger once the student gave us the go ahead. I sat down to the delicious hamburger, potatoes, and a glass of milk, but another cita came in around 7:30 or 7:45 and it seemed like the other students were busy with either initials or PP citas, so I decided to take it. I had been hearing about the woman who came for her cita because she was due any day and was really ready to give birth to her fifth child (she has four girls and the fifth will be a boy). She appeared tired and had a tos (cough) for which she had received medication from her doctor. This cita took 2-2.5 hours because she was blue dot for GTT (high glucose, which can lead to gestational diabetes) and we had to do PIH checks for pre-eclampsia, which meant we had to do a fetal well-being check like I had done earlier in the day, ask if she was experiencing any signs and symptoms of pre-eclampsia, and be sure to give her a fetal movement chart so that she could note any changes in her son’s movement. Despite being so exhausted, she was extremely patient with me and the other students as there was so much to do during her cita. She had a calm, patient demeanor and had a calming effect on me. She was not able to call for her ride to pick her and her daughter up until 10:30pm and by this point, the woman who had been in twelve hours before (I did a FWB check with another student) came back in having strong contractions.

I had been switched to shadow primary for the second birth on the rotation (I was supposed to be shadow assist, but was happy to be switched into a more active role throughout the labor and birth) and began checking heart tones with the primary student (she’s the one who I have probably attended the most births with and has been pregnant nine times, so she has an extremely calming effect during births). This birth was interesting and different because the woman was so in tune with herself that she only heard what her cunada (sister-in-law) was saying, who repeated everything the student and I said. When she first came to the birth center, she was at 3cm, but was progressing very fast. At around 11 or 11:15 pm, her sister-in-law came out to find the student and me (we were sitting on the futon watching everyone do list, feeling a bit guilty, but also storing up energy for the birth) and told us she thought it was time. The woman was having a strong urge to push and her son’s head was slightly visible with pushes. I went to get the staff midwife and assist and they entered calmly and quietly. The woman moved to the birth stool after about 15 minutes of pushing and gave birth to her son at 11:39pm. She was filled with emotion and cried into the arms of her sister-in-law as she took in all that had just happened. She looked at her son draining on the pillow in front of her and started talking to him, saying “No llores” (Don’t cry). I was tearing up sitting in the rocking chair documenting and was not prepared for what transpired next.

I began hearing a dripping sound into the silver bowl below the woman that would catch the placenta. In seconds, this sound turned into three or more cups of blood on the floor. The staff midwife asked if I could draw up a pitocin, but I had not learned; luckily the assist was quick with this. The staff midwife and primary quickly moved her onto the bed as I sort of froze not knowing what to do and feeling in the way. She told me to get students to help clean up; I could only find one and then she was calling me back in to document the 2 pitocins and 1 methergine given, along with the woman’s blood pressure and position changes. It felt like a whirlwind; I was shocked. By this point, the client had lost 4 or more cups of blood and was still bleeding. Our limit was 5 cups before transport. I felt like I needed to leave the room as quickly as possible and hoped I had not been a hindrance in helping the woman. I took some dirty instruments and laundry basket to the lab sink area and noticed blood on the front of my shirt. I went to wash it off with hydrogen peroxide and detergent immediately and then came back into the kitchen to send Sam a text message and begin cleaning up at the lab sink. I felt tears forming in the back of my eyes and wanted to start sobbing. As I cleaned blood and meconium off of the birth stool, the fact that she would be transported to the hospital popped into my mind and minutes later the primary came out saying she was still bleeding and not long after that the midwife asked me to get one of the students to begin writing up the transport papers. Another whirlwind. The EMS arrived around 12:30am within 5 minutes or less of being called and I volunteered to go to the hospital to be with the client or find out information about her status.

As I drove to the hospital, I held more tears back and wished so much for someone outside of the situation with whom I could process. The hospital proved no nicer. On both the postpartum and labor and delivery floors, the nurses spoke like a pre-recorded message, telling me they could give no information to those who were not family members and that the client was now in their care and no longer our client (that it not at all the way we view a transport and the client is welcome to attend PP citas with us if she wishes). I waited in the hospital about an hour and could only find out that she was still with the doctor (the EMS told me more than the receptionist at L&D and said she seemed to be doing pretty well so far). At about 1:45am, I inquired about the client again and the receptionist said I wasn’t going to learn anything no matter how long I stayed. The students at the birth center told me to “come home” and I drove back discouraged and saddened all over again.

Back at the birth center, more difficulties awaited as I helped a student listen to and document heart tones that seemed pretty high (up to 43 and our limit is 40). I again went to get the staff midwife because we keep getting rates above 39-40, and she told me that this too was an emergency and that the client needed to get on left-side lie, be given oxygen, and drink fluids because she was dehydrated. This helped lower the heart tones and she was admitted in labor. I had been applying pressure to her hips during contractions and I noticed how concerned her mother looked. This client was later transferred to the hospital because of thick meconium and gave birth there. I recognized her and had been working in the clinic many days during which she had come in for citas and was disappointed at this outcome for her.

After scheduling PP citas for the woman transferred to the hospital (I wanted to help the student who was still checking in on the newborn; the sister-in-law had stayed at MLL to care for him and I saw her daughter on the way out to the hospital to visit her aunt) and copying some birth report/review pages, I was so thankful to lie down from 4-7am and get in three hours of sleep after a busy, hard day. I helped the student who had been doing rounds for the baby until 5:45am clean the rose room and then went to change and fold laundry before leaving the clinic after circle. This had been a tough shift in terms of births and it was the first time I felt more in the way than helpful. I learned the woman had received two bags of blood in a blood transfusion and was so shocked at how, in literally seconds, the birth had gone from sheer joy to emergency. This birth presented yet another challenge as to whether or not I could be a midwife and maintain that balance of acting quickly, yet remaining calm. I noted that I felt restricted in births as documenter and wished I could play a more active role after having been to and helped at 15 this summer. I am so grateful to have been to these, but I just feel my role in births is remaining stagnant and that I am not able to do as much as I would like to learn more. I spent a long time talking to my mom and Sam about these feelings before heading off to Birth Talks around 12:30pm.