La séptima semana/The seventh week Part II

Tuesday, July 13 and Wednesday, July 14

Before I knew it, it was time to come back to MLL for Birth Talks from 1-4pm. The student who had been caring for the baby during the PP period and I had planned to get pancakes and finish her interview that we had started in June, but she needed some time to rest at home. I enjoyed the reprieve, as well, and it felt nice to come to Birth Talks on a day when I was not also in the clinic so that I could really focus and absorb student’s experiences and concerns. As two students presented about births from earlier in June, I realized how many births I had witnessed in such a short period of time and realized that I was where I needed to be at the births. It’s sometimes hard to remember I have been in El Paso for seven weeks, six weeks of which have been in the clinic. Hearing these students process helped me remember just how much I had seen and been a part of in such a short period of time and was a perfect antidote for my disappointment in the morning. I was excited to share a doughnut with one of the students (she’s the one who made the hamburgers the night before) and she gave me some constructive criticism (which I am still learning how to take without taking it personally – I think I will be doing that for awhile) about improving my documentation skills. So many feedback and styles to consider and work with!

I spent Wednesday recording my fieldnotes from the Friday prior and Monday (I’m enjoying the recording as a nice change from writing!), completing readings on posterior presentation and water birth, and doing an interview with one of the housekeepers at MLL at Mercado Mayapan. I was grateful to hear her perspective and wanted to capture her experience doing “un poco de todo” (a little of everything) From being in charge of the majority of the cleaning in the birth center and school and filling up the ice cube boxes with water to helping incoming students with new words and phrases (I’ve learned techo for ceiling and pasillo for hallway recently) and painting doorway frames, she is a vital part of the birth center and I am grateful for all of the constant work she does. It couldn’t function without her and she brings a strong, warm presence to the community at MLL.

Thursday, July 15
I promise it won’t take as long to go through Thursday as it did Monday! With no labor checks or births Thursday night/early Friday morning (so weird when this happens and we actually sleep), I spent the majority of my time doing five citas, attending a small portion of the water birth class (I was bummed to miss out, but happy to help with a PP cita for another client whose birth I had attended on July 9), and enjoying some pork tenderloin marinated in Asian sesame dressing for dinner. We eat meat and well!

The morning was steadily busy and I did three citas before going to only an hour of our water birth class. My first cita was with a woman about 34 weeks along. While at first she seemed more interested in getting through the general questions and vitals of the cita, she later showed me a picture of her two-year old son on the phone and really warmed up. She had to have a pap smear done (this is recommended, but not required once women enter the third trimester at MLL) and since I have not learned how to do this, I always ask the woman if she’d prefer me to leave the room once another student has entered to do it. She said it was completely fine for me to stay and while she did not audibly complain, her face looked extremely uncomfortable. The staff-in-training midwife (this is a six-month program that students choose if they’d like to become a staff midwife at MLL after the one-year program) had done the pap smear and then began explaining and demonstrating how to do a breast exam. The midwife brought out a fake breast that felt like it had jello inside so that the client could search for lesions and abnormalities. For some reason, I really enjoyed this part of the cita and it reminded me what an important practice breast exams are in guarding against potential problems or complications.

It was then time for an initial (I am realizing I haven’t done an initial since this one) with a woman who had been waiting in the sala ever since I took my first cita. She had birthed at MLL four times before and was extremely familiar with everything. She was pregnant with her seventh child and told me how she was a vieja (old woman) when I asked whether she had signed the handout about the potential risks or complications giving birth past 35 years of age. I reassured her plenty of women give birth past this age with no problems or complications and that I trusted she would be perfectly fine. This seventh child was not expected, yet not unwelcomed, and she was very candid trying to remember all of her other children’s past birth histories. She had given birth to two of her children in the hospital and when I asked her about what she had and had not liked about her past birth experiences, she said that they had not treated her well in the hospitals in Mexico and that she had much been happier giving birth here. Her special request was that her husband be with her during labor. What struck me most during this cita was her family’s personal history and I felt at a loss for what to say or do. When I asked how many times her mother had been pregnant (we ask about the client’s mother and sister(s) pregnancy and birth histories), she at first said eleven, but then realized it was ten. I am always worried when I ask whether any of the children are no longer living and, sadly, this client told me four of her brothers and sisters had either passed right at birth, from cancer, or had been killed. While I have heard the phrase, “Midwives aren’t psychologists,” it’s still hard when faced with situations such as these to know what to say and do for the person when they have just revealed an extremely painful part of their past to a virtual stranger. I certainly don’t have the answers; just another aspect of being a midwife that’s hard.

I was already a bit late for class when I finished the initial, but the staff midwife asked if I could do a PP cita since a lot of women were waiting. I was so happy to find that the woman who had given birth Friday, 7/9 in the purple room was there with her family and that I would be able to do her five day PP cita. I really appreciate opportunities for continuity of care and it is one aspect of being in a clinic and working different shifts that is extremely difficult to satisfy. Right when I saw the woman, I could tell she was exhausted and discouraged. She spoke to me in a low tone in both the sala and the baby cita room, telling me that she had been having a lot of trouble breastfeeding due to the pain and that she had taken a rest yesterday, feeding her daughter with a biberón (bottle). She seemed like she felt down not only because it had been a hard process, but also because she felt guilty taking a day off to give herself a rest. I reassured her she was doing everything right and that it was an extremely difficult process at first. Again, however, I felt my lack of personal and general knowledge about breastfeeding affected my ability to comfort her and I find so often in PP citas that I am saying, “Podemos discutir con la titulada” (We can discuss with the midwife) instead of giving her solid advice or recommendations. The midwife encouraged her and told her that she could try a cream called Triple Nipple and the client eagerly wrote it down. While the woman did not seem annoyed or concerned about my relatively small knowledge about breastfeeding (she seemed happier to have someone listen to and validate her exasperation), I still noticed how those gaps of knowledge continually resurface when you’re learning new skills and practices.

It was already about 2:30pm by this point and there was only an hour and a half of class left. I was happy to get a break and head over to class, but had already missed the majority of it. I had barely eaten all day (I had just been taking bites of my gordita con papas – fried tortilla with potatoes and salsa inside) and decided to finish off my gordita. Luckily, I had a lot of water nearby because it was muy picante (very spicy)! While I was in class, we discussed the circulating theories about what causes babies to take their first breath and whether this is inhibited by being born in the water and how there has been some movement to take an Apgar at 1 minute 30 seconds with water births instead of the usual 1 minute since it takes a bit longer for newborns born in water to turn pink (babies born in the water usually look pretty purple, which is normal, but can be worrisome to parents). The midwife asked pairs of students to be either for or against water birth and advise her whether or not to do one hypothetically. I noticed a gray-haired woman sitting in the class and wondered who she was (I later discovered it was a student’s mom who was visiting and doing 24-hour shifts with her). The midwife teaching the class was leaving in just a few days to move to Germany to get married and the class all talked about how much they had enjoyed working with her and that she had a special spirit.

Class got out early around 3:30pm and I took a cita immediately upon my return. It’s strange, but this is the only cita I’ve done where I couldn’t and still cannot visualize the woman’s face. She had given birth at MLL before and was pregnant with her second son. There was a lot to do during this cita, from changing her due date (this happens all the time; if there is any question about dates, the woman is sent to a doctor with whom we work and he gives her a date, which is the final say-so; nice $100 for a dates consult, by the way) and giving her recommendations for reducing constipation and hemorrhoids, to giving her a diet sheet for gaining 4 pounds in one week (if clients gain more than 4 pounds in a week, there is concern over pre-eclampsia) and giving her some lab results. When the staff-in-training midwife checked all that new students must have checked – fundal height, heart tones, baby’s position, and blood pressure – she asked me why I still needed everything checked because I was doing such a good job and we had gotten all of the same things. While I appreciated compliment, I attributed it more to the fact that some bellies and babies are easier to palpate and listen to than others.

After washing some dishes and helping grate some cheese for bacon ranch potatoes (seriously, love this student!), another cita came in. I had just seen her on Monday and while I hesitated to take the cita at first (I was really excited about eating), I eventually decided to because of continuity of care and because I felt we were forming a closer relationship. The client was now at 40 weeks and SO ready to give birth to her fifth child. She seemed just as tired as last time and frustrated because she had been having contractions for a week and a half and was already 2-3 cm dilated (very normal for mom’s who have given birth before to be dilated for a couple of weeks prior to giving birth because their cervix has done it so many times). Based on the last cita, I knew this one would take awhile because this client had to have her glucose checked every time (her glucose was too high during her glucose tolerance test), a fetal-well being check per pre-eclampsia checks, going through the 40-week protocol, and doing all of the normal parts of a cita. I felt terrible that she had to lie on the plancha (exam table) for extended periods of time to have her belly checked by both the midwife and me and for the fetal well-being check because she said lying down is so uncomfortable. Her daughter and friend were patient as always waiting for the two or more hours it took to go through all of her cita, but I couldn’t help thinking how hard it must be each time to come in knowing you’d have to go through these various steps in a “higher-risk” pregnancy for midwives. I kept hoping she’d give birth by the time I returned to the clinic for further shifts, but as of right now, I still think her son is waiting inside. She thinks he doesn’t want to come out because of the violence in Juárez.

I spent the rest of the evening enjoying two big pieces of pork tenderloin with bacon ranch baked potatoes and a beautiful salad of broccoli, carrots, and green peppers drizzled with olive oil and garlic (yes, the healthiest thing on my plate :) I wasn’t around for too much of the cleaning inside because the other students had started it while I was finishing my cita and eating dinner. I had the chance to speak to both my mom and Sam, which is always so nice on shifts. When I returned inside, I helped clean up a lot of the dishes and mentioned my interested in drawing blood to the student who had made dinner and the staff midwife. They said I could practice on them and so I did! They taught me how to put on the turnicate, prepare the needle, and how to insert it into the vein. I didn’t draw blood from the staff midwife (she said I had probably missed the vein, but that it didn’t hurt), but did from the student. They each said it hadn’t hurt and that I had done a great job. The student told me I could have pulled out the needle a bit faster, though.

After this, it was time to get ready for bed. I was going to do couch with another student, but first helped the student who had made dinner take out some trash and laundry before lying down on the futon to the ticking sounds of the swamp cooler and fan. It was about 11pm when we went to bed and we didn’t rise until 7 am. There had been no births or labor checks, although I had had a strange dream about eating a cat (maybe something to do with drawing blood – really weird, I know, but at least I slept well). The last time I had done couch with this student there had been no labor checks or births either. It was nice to have had a relatively good night of sleep (a few phone calls to the clinic that the student answered, but calm other than that) and I felt ready to embrace the day visiting a local birth center, getting tea with the student, visiting the El Paso Museum of Art, and interviewing the staff midwife with whom I had just worked later in the day.

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.

La sexta semana/The sixth week Part III

I spent the rest of the afternoon doing rounds (checking fetal heart tones) with the student who was to be primary (this would be our second birth together in which I had been shadow primary) and checking fetal heart tones with the doppler. I also spent an hour with the Assistant Academic Director learning how to do PP citas. It was crazy to see all of the students sitting out in the sala together chatting and the office assistants joked that we had citas waiting. I had some chocolate pudding and carrot cake leftover from one of the staff midwives' birthdays and felt like I had done more eating than citas today! The young woman in the peach room labored mostly alone (her parents had left to get her some food - her parents were a fantastic couple and provided a lot of support in their presence) and when the primary inquired as to whether she was okay with this, she said she was fine. She tried to relax in the bed with calming music playing in the background. The student and I began staying in the room full time after she had eaten and began feeling much stronger urges to push. She was at 9cm and moved to the tub to prepare for the birth of her son. The student and I had been hearing screams from the purple room and were worried she was going to give birth at the same time as our client! Our client gave birth at 5:14pm to her son and I played the role of assist, providing towels, hats, and calling Apgar scores (the documenter did this because I am still learning how to call those) and really seeing how a water birth works. The midwife was literally back and forth between the rooms since the other woman was so close to giving birth, too; good thing there's a door connecting the peach and purple rooms!

Soon after this birth, birth team was called and I was asked to be documenter since one of the other students had gone to the hospital with a woman in pre-term labor. The woman gave birth at 6:17pm and was so gracious to all of us, thanking us over and over again for our being there during her birth. I was with her a very short time before having to leave to do a PP cita since there were citas waiting by this point. This would be my first PP cita alone and luckily I had had my lesson earlier in the day! The woman was here for her 12 day PP cita and seemed tired to me. She had a fifteen year old and five year old and said it was difficult having a baby again. The cita went very well and I was able to do everything, except check her fundus (checking her uterus to make sure it has contracted), the 12 day PP newborn screening (poor babies have to have their foot pricked again since they have it done on the day of their birth), and respirations for the baby (which is really difficult to learn). It was great to do a PP cita and spend time talking with the woman about her birth, breastfeeding, how everything was going, and any concerns or questions she had. It made me feel like I had gone through the entire cycle and spectrum of citas and care at MLL and I look forward to doing more. The client also had a calm, relaxed personality and it was nice to be with her energy after an hour of back to back births!

The night was young, though! I spent the next few hours checking in on the woman who had had the water birth, sitting down to some chicken and field greens with blue cheese dressing, cleaning more dishes (it really feels like they're never clean for very long), finding out the midwife's 2 month old baby had the same birthday as me!, and helping during the physical exam and newborn screening. During this span of time, a woman who had been in for a labor check, gone to eat, and returned settled into the rose room and another woman in labor (she was at 2cm, but progressing quickly and yelling a lot) had to settle into the divided sala since we had no rooms left. The student with whom I had been shadow primary and I worked hard to go through all of the paperwork and exams/screenings and I again interpreted as she explained how social security works. It was fun to weigh the baby and get guesses from everyone as to how much he weighed. The daughter spoke English (she was 18 and still had markings of pimples on her face, which reminded me how young she was) and her parents spoke mostly Spanish. She had been worried about whether she would be a good mom (the student had told her she would when she was laboring in the tub) and now when the student asked if she could believe she loved someone so much, she happily smiled and said no. She and her family left around 11:30 pm and it was special to have seen them through the labor, birth, PP, and out to the car to get the portabebe (carseat, which we had to loan to them because they had brought one that was too small and not safe for the car) strapped in and give lots of hugs.

There was no rest in sight as we returned to the clinic. We had to clean the peach room, treat laundry, clean the heaping piles of birth bowls at the lab sink, get the peach room ready for another potential birth (another woman came in for a labor check who had been coming a lot the past few days but remaining at the same dilation and we all rejoiced that she was someone's on-call who was not on shift so we could have extra support!), and be available to provide support in case the birth team in the sala needed it. The student and I out doing laundry together said I should be inside in case someone was needed and it was a good thing I was because I had to take the midwife's baby when it seemed like the woman was going to faint and all students were needed to make sure she didn't hemorrhage. Everything was alright and I was disconnected from the birth, holding her 2-month old daughter and letting all that needed to get done fade away for 20-30 minutes. I then had to get back to my date bleaching the peach room, cleaning the lab sink (that took an hour to an hour and a half) and then my best friends, the dishes, piling up in the sink. I took at break at some point to eat some cereal (a mix of Honey Nut Cheerios, vanilla almond, and Kashi Crunch) and my back was extremely sore. Luckily, laughs were abundant as the student who with whom I had just spent all day with during the peach room labor sit, birth, and postpartum laughed about things that seemed extremely hilarious at 2 in the morning (the purple room husband couldn't figure out how to get the faucet to turn to cold and we just lost it, along with the student's Mexican accent that was accentuated as she spoke in English). At about 3am, I always think I can do no more, but I realized you have to just make tea. I did birth art for the woman who had the water birth (you draw the baby's name, time and date of birth, and weight in pounds and grams) and checked on laundry when I could. I helped the student who had been working in the purple room clean up there (there was a terrible blood/rust stain on the plastic sheet and we had to use 100% to get even close to getting it out) and even though I wanted to lie down, I felt I needed to remain downstairs a little longer for the impending birth in the rose room.

I had been hearing groans from the rose room and at about 5 or 5:15am, birth team was called. I was to document at this birth and didn't see very much of it, which was unfortunate because the baby was born face up in the cull (amniotic sac) and the student said it was just beautiful. Because the PP period is so busy for primaries, the documenters usually start tying to do paperwork for that primary, so I returned to the midwives' table, happy to sit down and drink my now cold tea, and began writing her name on everything and looking through her initial interview to write down information for the creation of the birth certificate. I was in and out of this room for the next two hours, clarifying the baby's name, last name of the father, what time she wanted her postpartum appointments, doing birth art, and anything else the primary could think of, and she told me afterwards I had been like an angel to her. I was grateful to feel so much love from the students today and they all told me I should just stay at MLL because I fit in so naturally. I had never worked with the staff midwife on between 8pm and 8am and she said I had just come out of nowhere, but really seemed to fit right in.

I can't say I was too sad to leave the clinic when our shift was over after the craziest night ever - I have never been on shift during a day with four births - but I felt a great sense of peace and satisfaction having been present and worked so hard on different personal, interpersonal, and manual levels. I look forward to my upcoming shifts, classes on Posterior Presentation and Water Birth this week, a pancake date with a student to finish her interview (there's a restaurant called Crave where a short stack costs only $2), and potentially two more interviews this week. My dad and I will also be planning our northern route home through Abilene, Dallas, Shreveport, Birmingham, and Atlanta and I just can't believe how quickly July is going by. Thanks for continuing to read about this special, life-altering experience and I continue to be grateful for the phone calls, cards, text messages, and love!

La sexta semana/The sixth week Part II

I finished the initial around 1:30 and hurried over to Birth Talks since I had missed the last one. Two of the students were presenting today and I felt bad going back and forth to check on my boiling water for macaroni and cheese and missing a lot of the first student's presentation. She was discussing Aztec and Mexican traditions in relation to fertility, pregnancy, and birth and discussed temascales, which are sweat lodges that women use during their pregnancy and for fertility purposes. The second student (both of the students presenting were fourth quarter students, which means they have been here for nine months) presented an article that was written by a controversial midwife who has gone to jail who believes that tactos (dilation checks) are unnecessary and that midwives should pay more attention to the external signs of labor and impending birth. This led into an interesting discussion among students regarding the necessity of tactos (and telling women how many cm they are dilated), clocks in the rooms, and whether labor support is helpful or disruptive in a woman finding herself and her way through labor and childbirth. While I believe (and another student expressed this verbally) that every woman's needs and desires are different during labor and birth and that midwives and doulas must mold to those rather than their own expectations and beliefs, it is an interesting thought to ponder and the Director of the center and school commented that this time period (when the students have been here for 6-9 months) is a special one during which students feel more comfortable questioning protocols, approaching birth in different ways, and expressing and putting their beliefs into action.

When I returned to the clinic, I was disappointed to find that a woman I had done two citas with (pretty rare at MLL since you work on so many different days) had been transported to the hospital for either a kidney or UTI infection. One of the staff midwives had come in during Birth Talks saying a student needed to accompany the woman to the hospital and I felt I had a special connection with the client. I especially wished I had gone when I discussed how the transport went with the student who had gone and she said she had felt she couldn't offer much to the woman because she had not done any citas with her and she was quiet. I discovered on my next shift she had been given antibiotics for a UTI and that she had not been in pre-term labor at 34 weeks. This was yet another instance during which I missed having continuity of care with clients and being able to see the same woman over and over again and develop a deep, open relationship with her. She was definitely on my mind, because I had a dream about her that night at the clinic and in it, she told me she did not have an infection and was alright. At least I got that she was alright out of it!

I've returned from doing laundry now (big downpour on my way back!) and my plans for the afternoon have changed a bit because it turns out the mariachis are not playing this afternoon and that Mercado Mayapan is closed. I called MM and the housekeeper from Maternidad and she confirmed that a friend told her it was closed. We've decided to try for another Sunday in July and are going to get a meal there Tuesday afternoon. She also sounded enthusiastic about doing an interview with me and it will be great to have her perspective of work at MLL since she does so much of the cleaning that I always talk about all day long.

Back to Tuesday...A few more citas trickled in as the afternoon went on and I shadowed a postpartum cita with one of the students with whom I spend a lot of time. The Assistant Academic Director is going to teach me how to to PP citas, but since I've just gotten back, she hasn't had the chance to yet. I thought I would shadow one in the meantime just to understand the flow of it. This woman was coming for her 12-day PP cita and it seemed like she was doing very well. Her entire family came with her (her husband and five-year old son) and it made me think about how coming to MLL is always a family event; the majority of women come with their husbands/boyfriends/partners, one or more of their children, an in-law, or a friend and it is comforting to witness that level of familial support. Yet again, the learning we had done in the classroom really complemented this PP cita because just the day before we had learned about what to go over in PP citas. The students have already been doing them for a long time (so for them, it was probably a bit repetitive), but it really helped me feel ready to shadow and conduct them on my own. I helped with some interpreting (the woman was asking about the paternity acknowledgment and birth certificate) and took her vitals after we discussed her birthing experience. The funniest thing that happened during this cita was that just a few seconds after she removed her son's diaper, he started peeing everywhere! This reminded me of all the times my mom and aunt had told me about this happening with cousins when I was little and I we were all laughing so hard together. It was a really genuine moment; she kept saying Disculpe!/Excuse me! but I told her it was the best part of my day.

Once she left, it was time to do list, make dinner, and get ready for bed. I am trying to learn how to check more rooms of the birth center than my favorite, the rose room, and so I helped clean and restock the front cita area with one of the other students. I made a steak for dinner (surprise, surprise) with broccoli and enjoyed sitting at the midwives' table and chatting with everyone. It felt extremely relaxed and I was starting to think we wouldn't have any births in the evening/early morning. After talking to Sam and my mom a lot longer than I usually do, I got ready for bed and was doing couch by 10pm. The other student who asked if I would do it with her soon after she finished a chart review and we talked for awhile before drifting off to sleep. I could barely believe it when it was light outside but we had slept for 6-7 hours! There had been no births or labor checks, which was the first time that had happened on one of my shifts. We cleaned up around the clinic for the incoming shift and appreciated the many hours of sleep we had been able to get. They would come in handy for the shift on Friday!

Friday, July 9

The way I have been describing Friday in my fieldnotes and to those with whom I have processed it is that it was a strangely configured day, with barely any citas all day and then a crazy twelve hours between 5pm and 5am. Today was also the first day in the clinic that truly felt like 24 hours and it was long. In the morning, we all sat in the sala together chatting, which is a rare sight in the clinic! One woman came in just to have her PG (plasma glucose) test done and blood drawn and I had only two citas all day long. My first cita was with a first timer who was 36 weeks pregnant. She was so patient with me when I checked her hemoglobin - I had to prick her finger twice because the test strip will not give you an accurate reading if there's not enough blood and because it was out of range, the midwife had to check it again. She didn't even flinch, though, and said it really didn't bother her. She's the first woman who's told me that! We reviewed the signs and symptoms of labor since she was technically in dates to give birth now (even though a baby born before 37 weeks is considered premature under Texas laws) and I was excited to find strong fetal heart tones right away. The other prenatal cita I did was for a woman who was a third timer and had given birth at MLL twice before in the rose room. She had just had her initial a week ago and during the cita after that, there is always a lot to do. All of her family had come with her - her husband, her fifteen year old son, and her five year old son, and her five-year old really wanted to be with us the whole time. I couldn't understand why he kept laughing during the cita, but she said it was because of nervios (nerves). He seemed to calm down once I weighed him after weighing his mom and felt included :-) During this cita, I realized that despite the fact that I cannot do pap smears or physical exams, I was becoming more and more able to operate independently during citas and that my comfort level with reviewing necessary information, conducting the cita, and just conversing with the woman was getting better and better with every cita I did.

Lunchtime and the afternoon were extremely calm and I had time to sit down to lunch before washing a lot of dishes. A woman came in for a labor check around 12:50pm and she had just had her initial cita with us yesterday, which meant we had not received any information from the lab regarding her bloodwork. The staff midwife was a bit distressed about this because she said if a woman has problems that we do not yet know about, it can potentially be bad for her license, the students, and the clinic knowing so little about the woman's medical history and any conditions she has. There was another woman in labor in the purple room and I was up to be shadow assist for that birth and shadow primary for this one. I was excited to learn that she wanted to have a water birth and helped one of the students prepare the peach room for her. The rest of July 9 is continued on Part III; I never said I was concise, especially on busy days :-)