La sexta semana/The sixth week Part I

¡Buenas tardes! It's a cloudy afternoon here in El Paso (July is the "rainy" season, which generally amounts to a lot of surrounding clouds and lightning, but no rain) and I am sitting at my usual table in the laundromat with a nice view of the tiny spots of green on the mostly sandy Franklin Mountains. I cannot believe how quickly this week has gone by! I knew the July session would be busier with shifts closer together, class twice a week, and keeping up with fieldnotes and personal matters somewhere in there, but I didn't know it would be so fast. Flying back into El Paso on Sunday, I felt a lot different than when I first arrived in June and had a better feeling in general about how my last four weeks here would go. On Monday, I was a bit worried in the morning when some of those lonely feelings came back, but once I went to class on Normal Postpartum and saw everyone again, it faded away. I enjoyed our Normal Postpartum class, especially since I will be learning how to do PP citas sometime soon and it will really round out the spectrum of care I can provide to the clients.

This week, I had my shifts on Tuesday and Friday (this session I will stop having shifts every Tuesday and Saturday like in June because I am on in the clinic every third day, which will give me experience working all days of the week, except for Wednesdays, for some reason) and did two interviews with students on Wednesday. On Thursday, we had a four hour class on Normal Newborn Adaptation, which was difficult because we learned all about the fetal circulatory system (Anatomy and Physiology, you would have been so helpful) and everyone's energy was really draining and tense due to the long class. On Saturday, I worked on writing up fieldnotes and catching up with some family and friends, but was so tired from my shift on Friday, that I worked pretty slowly. The demands of being a student and researcher are tough, especially when you've been up for nearly 40 hours!

Today, I finished up my fieldnotes from Tuesday and after doing my laundry (I just realized the detergent didn't dispense into one of them until 9 minutes were left in the cycle, so I may have to do some repeat washing, which is unfortunate since these washers only have 27 minute cycles for $2.50!), I will go to Mercado Mayapan with one of the housekeepers from MLL. She is so kind to me and always hugs and kisses me on the cheek when we see one another in the morning. She is a hard worker and I have a lot of respect for her. The theme at MM this month is Oaxaca and the mariachis always play on Sundays, so we'll enjoy eating and listening to them later this afternoon.

I apologize for not having many new pictures on this blog post! I have taken a lot of pictures of the clinic and school, but have very few of students because we don't have much time to take photos together and I am not sure how they would feel being posted on the blog, which I would need to mention to them. I would like to start trying for some pictures with students and plan to visit Mesilla and Las Cruces on this upcoming Friday or Saturday to get some presents for everyone back home, so hopefully there will be more to share! I've included photos that I haven't already, but they are from places that I have already visited, like the Franklin Mountains, and I've included some from inside the casita. Have a great week, everyone!

Tuesday, July 6

I had told both Sam and my mom that I hoped my first shift back wouldn't be too busy, especially not like the last Saturday I had worked, just so that I could adjust and get back in the groove again, and fortunately, the day was muy tranquilo (very calm). I only did two citas today and one of them was a postpartum in which I was shadowing and helping translate/interpret. And there were no births! We all joked that everyone had come in during the last two weekends (which were extremely busy) and that the energy around the lunar eclipse had brought everyone during that busy time. Since there were no citas waiting for the first hour/hour and a half we were there, I went to the hospital to visit some of our clients who had been transferred there with another student. I had not been to the hospital (for doula work) since February and had only visited a woman from the APPLES office in May and I can't believe how different it felt to be back there after having been in a birth center for five weeks. I distinctly felt like there was a barrier between not only the student, me, and the clients, but also the technology and ideology of hospital births. The interaction between the clients and us was strained and awkward (granted, I had not met two of the three before and they were likely on or had been on medications) and all I could think about was that the majority of women were giving birth in an environment that felt sterile and cold (at least in my opinion) and was driven by hospital protocols and technology rather than women's autonomous decision making. This was especially apparent when I saw a woman walking down the hall with IV tubing taped to her hand and all of our clients had this, as well, and when we went to check on a woman who was in the bathroom and the nurse opened the door for us to speak with her without asking the woman if that was okay with her (the student immediately closed the door when this happened). It was interesting to note the level of authority we had wearing our scrubs, as well, and how no one questioned from where we had come or why we were there because we blended in with the nurses and doctors. It was so different returning to the hospital after not being there for so long and having seen how care can be during pregnancy and birth with midwives at a birth center. I am grateful for the care hospitals can provide, especially in emergency situations and with serious illnesses, but this is not my view of birth, especially after seeing it in a more home-like setting.

Once we returned to the clinic, an initial was waiting and I decided to do her initial hopefully in time before Birth Talks began at 1pm. I had a pretty bad headache, perhaps due to a combination of jet lag, dehydration, and feeling so strange in the hospital, and I had the chance to take some Tylenol, snack on some pumpernickel bread (I feel like I eat constantly at the center, anytime I have a break), wash some dishes, and drink some water before beginning her initial at 11. What really stood out to me during this initial was that the client came with her suegra (mother-in-law) and she told me her mother was muy enfadada (very angry) she was pregnant at her age (I believe she was 18 or 19, which is a very common age for our first-time moms). Side note: I just noticed it smells like rain and it is indeed raining outside! The client told me she was excited about the pregnancy, though, despite experiencing a lot of ascos y mareos (morning sickness), which made sense because she was only 9 weeks into her pregnancy, because both of her sisters had had uterine complications and wouldn't be able to have any more children. I validated her excitement and she said her mom would probably come around to it soon. I am always grateful when clients confide in us about their feelings towards their pregnancy, why they chose to come to MLL, and their past experiences with trauma or abuse because I feel that MLL can serve as a safe haven for them to discuss and process what they're feeling, but feel that our support only goes so far because we often see different women depending on what day we're working and we can't change family dynamics or what's happening in Juárez. One of the midwives made a comment either today or sometime recently (or maybe I read it somewhere) that midwives were not psychologists and I find it difficult not to counsel or feel that I can help in some way, but discussing and processing is important, too, and at least we can do that together. Since this post is already pretty long, I'll continue the rest of Tuesday and Saturday on Part II!

La quinta semana/The fifth week

My week at home went by so quickly and I often questioned why some of the weeks that had seemed to crawl by in early June had not gone so fast! I spent a lot of time this week talking about and processing my experience with my mom, walking with my dad and dog, celebrating my dad's birthday, visiting Chapel Hill to see my apartment for next year and meet with Karen at this midpoint in my summer experience, resting, writing birth reports and reviews (I had nine to do, which will teach me to do them as I go!), organizing (I have so many notes and handouts from my first week of orientation and classes at MLL), and catching up with some good friends from high school and college. It was wonderful to be in the company of my family for a constant period of time and I appreciated every moment of our time talking and sharing meals and time together. You really appreciate home and the comforts of it more when you've left and come back.

I had some important realizations in regards to the research aspects of my time at MLL and received some important advice from my mom and Karen on the difficulties of keeping up with fieldnotes and doing field research. Both of them have told me that it is an aspect of the experience that I need to accept, despite the tedium of taking notes after a 24-hour shift, but I had not really been able to accept and keep up with that task in June. Perhaps it took getting away to shift my orientation to fieldnotes, but something did shift and I was able to come to a place of acceptance. I thought a lot about whether I would like to write a thesis when I return home, balancing the pros and cons of spending a good portion of my senior year researching, transcribing, and writing, and realized that I will not be able to make this decision until I have finished the July session and am back in Chapel Hill in school mode. I thought a lot more about whether I want to be a midwife, especially after receiving my DONA doula certification packet and thinking about whether my path is to be a doula, midwife, and childbirth educator. That, of course, cannot be decided or figured out in a week and I don't have any new answers to these big questions and thoughts. I think it will really take being back in Chapel Hill and comparing the different learning and working environments of UNC and MLL before I can know what will be next. It's interesting to note that this patience and waiting while in the midst of the process really mirrors the patient waiting that midwives and doulas must cultivate in their practices. Being home really made me realize how much I am learning about myself on both individual and interpersonal levels and that there is more left to absorb at MLL in July. I don't feel a sense of completion yet and am not sure if I will even feel that when I leave MLL in early August. I am grateful that the experience is still evolving, as am I. Thanks to everyone who's here to share the process of life with me :)

La cuarta semana/The fourth week Part II

I spent Thursday and Friday doing interviews with one of the now 2nd quarter students and with the Assistant Academic Director. I have been able to do about two interviews per week so far and I have only done them with students or staff who have personally told me after hearing about my research that they are interested. The interviews are lasting about 50-60 minutes on average and feel really comfortable. I am so grateful to have had the experience interviewing last semester and feel that the interviews have a pretty informal feel, as if they are conversations taking place between friends. I was also able to go for another hike in the Franklin Mountains with one of the short-term students and it reminded me how appreciative I am to have those mountains as a natural haven in a pretty urban area. Before I knew it, it was time for my Saturday shift. I had done a bit of packing, but would be rushing around the casita and to the airport after my busiest shift ever!

Saturday, June 26
Let me just start by saying WOW! This was the busiest day I have ever seen during my time at MLL so far and it coincided with the full moon and lunar eclipse! Today, I did seven citas, two of which were initials, and attended a labor and birth that lasted into the early hours of the morning. I began the day with an initial that I was only able to get about halfway through because the woman told me she was still bleeding a bit in the beginning of her second trimester. I asked one of the licensed midwives about this once the client told me and she referred her to see the obstetrician with whom MLL has a longstanding relationship. It was a shame that she had to leave before the initial was over with the concern of the well-being of her child and whether she would be able to receive care at MLL. She had previously given birth to her three children here and we are always so excited to have repeat clients. She asked me during the initial whether she would be able to see the same person throughout her period of care at MLL (the continuity of care/on-call I have mentioned before) and I told her that while I could likely do her citas in July, I would be leaving in early August. I was grateful that she had asked me this, though, and wish I could have an on-call client while I am here because your relationship has the potential to become even closer seeing the same woman throughout her pregnancy.

The clinic was hopping after this and I began taking cita after cita. Women were coming in for labor checks like crazy! And all of the birth rooms were filled up! One was in labor in the purple room, one was in her postpartum in the rose room, another was in labor in the peach room, and another was in labor in a divided part of the sala. Not only was the sala divided in half, it was also divided into quarters on the back side to accommodate the woman in labor and citas! Women were waiting for citas for 1-2 hours and the porch and hallways were filled with overflow from the tiny part of the sala available. One of the main things I learned today was how to work with everyone amidst tight quarters and with so few students available to do citas. The licensed midwives, who are generally checking citas, and keeping up with phone calls and chart reviews at the midwives' table were having to also incorporate citas because it was just so busy. I worked with a range of women today, a few of whom were getting closer to or had passed their estimated delivery dates, and others who were 6 or 7 months into their pregnancies. I did another initial in the afternoon with a client who had also given birth at MLL one time before - it was great to see another repeat client and I also noticed how much my Spanish improved (especially conjugating the past tense, which is most difficult for me!) with the intensity and demands of the day. While the afternoon began tapering off a bit, I was busy with citas until about 8 pm and then it was time to clean the clinic and make some dinner. I squeezed this in quickly before getting more into my role as shadow primary with a student with whom I have worked before.

The student and I were in for a long night and morning of rounds together. The young woman was a first-timer and had been reaching all of our limits for dilation (dilating 1 cm every 4 hours). She had been walking around outside a lot all day with her husband, had aromatic candles burning in the purple room, had drank a smoothie to hasten labor, and had taken hierbas (herbs). She had a very quiet demeanor and never verbally said anything or complained during contractions (at least when the student and I were there to check on her and fetal heart tones every thirty minutes). I really learned about dealing with family dynamics during this birth because her mother was pretty protective and did not seem to trust or appreciate what we were doing. This made for a bit of an awkward dynamic, especially mixed in with being absolutely exhausted after a crazy day in the clinic. The comic relief came with the student was fixing her hair and her clip made a line straight for the toilet. We were laughing so hard! At least we have a lot of bleach around!

At about 3:30am, the client began feeling ganas de empujar (desire to push). After a two-hour process during which the client had to receive oxygen due to low fetal heart tones, the licensed midwife had to do many different techniques, such as bone stretching (the midwife has to stretch the vaginal area so that the baby can be born), Ritgen's maneuver (the midwife has to reach inside and pull the baby's chin downward), the woman valiantly gave birth to her son (screaming with strong lungs) at 5:45 am. He had to be suctioned about twenty minutes later because he had some fluid remaining in his lungs that could not be resolved by lying him face down across his mother's belly, which contributed to the intensity and difficulty of this birth. I was documenting the 2nd stage for those two hours and was nodding out every few seconds. It was strange feeling so tired and seeing what looked like an extremely painful and traumatizing experience for the client. This was the most difficult birth I have attended and it made me question whether I could deal with such situations as a midwife. It seemed to push everyone involved and left me feeling uncertain and saddened at the experience for the woman who was now exhausted and swollen.

After the longest circle ever (18 minutes of explaining the previous day's events), I said goodbye to the short-term student who would be leaving in a few days and scrambled home to get ready for my trip back to the east coast. The flights back were painless and I felt so tired that I actually napped while on the airplane I think. This shift was quite an experience to end the month of June on and I am still processing what happened during that birth and accepting that natural childbirth can be extremely painful and difficult for the woman, her family, and the midwives present.

La cuarta semana/The fourth week Part I

Hola a todos!/Hello everyone! I know it has been a long time since my last blog post, but the last week of June was pretty busy at the clinic and then I went home for the week and enjoyed the reprieve from note and blog updating. It's interesting to write this post having been back to El Paso for a few days and having done my first shift of July yesterday, but I will try my best to pull you all into how the last week of the June intensive and my time at home felt. Throughout the posts, you will find some pictures of the purple room, the other half of the sala, and one of the students making some delicious chocolate pudding (the cravings and times we have them on shifts are fascinating, especially on busy days). Enjoy!

On Monday, June 21, I enjoyed spending the morning eating and chatting with Molly before heading to my second class at MLL, Normal First Stage of Labor. The class took place during a big four hour block, but I really enjoyed the material and it truly augmented what I had learned in my doula training and read in some supplemental books. I also found it nice to think back to the birth I had just attended on Saturday, June 19 and relate it to the themes that came up in class and with the student who had been the primary.

Tuesday, June 22
My fifth shift at MLL was steadily busy all day long, but I would soon realize that in comparison to the shift I would have on Saturday, today was relatively calm. It's all relative! My morning began a bit differently than usual because there were no women waiting for citas during the 8:00 hour and I had been assigned as shadow primary for a woman in labor in the purple room. Because there was only one woman waiting for a prenatal cita and one of the students was interested in the woman being her on-call client (the students have to have so many on-call clients for continuity of care), she took the cita and told me I could labor sit with the woman in labor. The woman had great support from her mother, who had given birth naturally seven times, and this birth was interesting (especially in comparison to the one I had attended on Saturday, June 19) because I couldn't really tell whether my presence was desired. Every labor and birth is individual and this woman (she was a fourth timer) seemed extremely uncomfortable and in a lot of pain. I had a hard time knowing what kind of support to provide because she labored in bed for most of the time and groaned/screamed through her contractions in labor and while pushing. This birth really reminded me that every woman experiences labor and birth differently and that midwives (and other labor support people) really have to mold to the woman's needs rather than their own vision of labor and birth. I remained with her and her mother until about 10:47am when her daughter was born and left shortly thereafter because the clinic was getting crowded with citas. It was also interesting to transition so quickly from a birth back to fast-paced citas; I had only been to one another day birth and time definitely feels more pressed balancing births and citas.

There are positives and negatives to working the same days each week, but one aspect that I love about it is seeing the same clients over and over again. I was happy to find a prenatal client who I had done a cita with the week prior waiting in the sala with her family. She was concerned because she was a few days past her estimated delivery date, but I reassured her this was normal, especially for a first-time mother. We also discussed it when la titulada (the licensed midwife) came in to check the cita, but she still seemed a bit worried. It's difficult to provide consolation and comfort in such instances and I tried my best to reassure her, but she definitely seemed a bit nervous and concerned.

I spent the rest of the afternoon doing two initials and missed Birth Talks, which is the class that takes place each Tuesday from 1-4pm during which students provide input and feedback on births and the way the clinic and school runs. I didn't mind missing Birth Talks, however, because I felt it was important to see the initial through and be completely present for the young woman and her mother. They had traveled nine hours to get to MLL from Coahuila, which is the state that borders Chihuahua (directly below El Paso) on the right. Tuesdays are a hard day for initials because all of the students are at Birth Talks from 1-4pm and I always feel that women come in during this time period for their first encounter with us. Because the initial generally takes up to three hours, I am always cognizant of how much time the women and their families are waiting and must travel afterwards.

I spent the rest of the afternoon, from about noon until 6:30pm, doing the initials, with lunch thrown in there around 4pm. What I love about initials is that you learn a woman's story, at least in terms of where she is from, what she does, if and where she has given birth and what those experiences were like, what preferences she has for this birth, and who will support her in the birth and postpartum. There are some aspects of initials that I find especially challenging, namely the personal questions and the nutritional counseling. The personal questions include inquiries about whether a woman has experienced emotional problems, physical domestic violence, if she feels safe in her home, and about her mother and (if she has any) sister(s)' medical histories. The young woman who I worked with in the first initial was my age and had experienced repeated instances of emotional abuse from her partner and did not want his name to appear on the birth certificate (we ask this question during the initial, as well). While I have taken numerous classes on being an ally to those who have experienced abuse or assault, all of that seems to fade away in the moment and I just try to be as validating and empathetic as possible. It is important to understand a woman's history of trauma and abuse because it can and does affect her experience in labor and birth, but it's hard to find a sensitive way of asking these questions to a woman you have only just met. Because this young woman was the first to tell me about the emotional abuse she experienced, I wonder how many other women who come to the clinic have experienced this and do not feel ready or able to say anything about it.

The other challenging aspect of initials (and my work at MLL thus far) is the nutritional counseling we are required to provide and the homework sheet we give to the women in which they fill in triangles with the portions of each food group (grains, vegetables, fruits, calcium, sweets) they have eaten each day. I believe that due to a combination of factors, such as my inexperience with nutritional teaching, issues of access and cuisine, and age, I feel uncomfortable telling a woman who may not be able to afford pan integral (whole wheat breads) or who is 36 years old what she should eat. This comes up in a lot of my citas and I noticed it yet again today, especially when I was with my second initial who was 35 and pregnant with her third child. While I believe a balanced diet is important throughout a person's entire lifespan, I struggle reconciling the aforementioned issues of access, cuisine, and differences in my and clients' ages in relation to diet and nutrition and will continue to ponder this during the July Intensive.

The evening brought a delicious hamburger (I have never craved meat like I do at MLL and in Texas!), chocolate pudding, open conversation with the students (I learned one went to the same university as Sam's best friend in Canada!) and a birth at 11:31 pm. A wonderful aspect of MLL is the wide range of births you experience and are a part of while you are there. This birth was calm, peaceful, and beautiful. I was up to be shadow assist (which means I would help check fetal heart tones after each contraction in the second stage of pushing, help determine the 1 and 5 minute Apgar scores, and help with replacing towels and hats once the baby is born), but did not get as involved in my role as I usually do. The student up to be assist offered for me to check the heart tones, but the woman was so in tune with herself inwardly and engaging with the baby as his head descended, that I didn't want to interrupt that probing around her belly for heart tones. This is yet another aspect of MLL that can be challenging because as a student, you should be learning and taking opportunities to do so, but during a birth, it feels so intrusive to take heart tones after every contraction with the doppler (part of protocols), especially if you're not seasoned at it. Something in me said to just sit back and so I did. The young woman held the assist's hand through the contractions and decided to stand up in the last few seconds of her second stage to give birth to her son. Her mother had wanted to catch, but he came so quickly it wasn't possible (this happens a lot)! She immediately returned to the bed and continued interacting with her son as she had done touching his hair as he was descending, moving him into a position to breastfeed within minutes. I left shortly thereafter after placing a new hat on his head and giving her a new towel, taking some laundry to be treated and then getting ready for a couple hours of sleep until it was time to clean the room at about 6:30 in the morning and finish up our shift.