Wednesday, December 12, 2007


Senegal part 2

Delivering babies in Senegal is very different from birthing at home, and from being in an American hospital, even the crappy ones like Kaiser Sunnyside (I thought it seemed dirty. I had no idea). There were three different clinics that we worked at. One was far from Mboro, and I actually didn't catch any babies there. The delivery room was smaller than most master bath rooms. It had one of the "typical" delivery tables---they are short and sturdy, mainly metal, nothing moves or stretches, or is remotely comfortable about them, I imagine not even to a cadaver. For the most part women give birth on their backs, like we did in the 1950's (and honestly more recently than that) only they don't put their legs up in stirrups. At the main clinic, there were two delivery tables and one, slightly more comfortable table (I did sleep on it one night) that the women labor on when they are 8-9 cm and close to pushing. The room at the main clinic was not much bigger than my bedroom. And it was much, much filthier. The walls have all been painted with a cheap, blue-grey colored paint that is actually more of a brown because of the dirt. I doubt that the walls have ever been scrubbed or washed. Aimee and I spent one evening disinfecting the delivery room as best we could. I swear it was the first time in at least 10 years that the beds had been moved and the walls behind them cleaned. And the bars on the end of the delivery tables, where women hold on as they push, and the edges of the bed that they lean over to spit or vomit, I doubt they had ever been scrubbed either. There were lots of layers to the grime. It was beyond gross. Honestly it was heartbreaking. I was blown away--I am not sure the matrones or the health administration has a concept of germs. For example, there was a limited supply of gloves so the matrones would just keep washing the ones that they had. And although they had working autoclaves (we tested them out) they "sterilized" the instruments in a chemical solution similar to bleach, but the strength of a cleaning product you might use on your kitchen floor and counters. Not strong enough to kill much of anything. And the instruments that were used, that I had to use, weren't very well scrubbed before soaking in the solution. Basically the scissors for cutting umbilical cords, the catheters for urine, the instruments you might, God forbid, use to cut an episiotomy, or repair a tear, they soaked in these plastic green buckets of diluted bleach and floating particles. Yuk. And there weren't many instrument sets, so if three women came in within an hour or two of each other, those instruments were used again, without soaking in the unsanitary bleachy water for very long. The whole picture still blows my mind. The beds, and the instruments, and the curtain. Yes, the curtain. There is a curtain at one of the clinics, that separates the delivery tables from the labor tables and from the outside world. Its purpose I suppose is to provide some sort of privacy. It hangs very close to the main delivery table, so close that when you are standing on one side of the table to support a pushing mom's leg, or to hold her hand or wipe her brow, you brush up against it. Actually it just hangs against you. The curtain is very, very old. And it is very, very dirty. I am sure it, like the walls and beds, rarely, if ever, gets washed. It is decorated with brown blood stains and holes, and dust. I am sure it has had amniotic fluid splashed against it, not to mention vomit. Birth can be very, very messy. Women shit, pee, bleed, gush. If it can come out, it will come out. And if there is a curtain or a table or a towel (I won't even describe those) to splash against, to stain, believe me, it will happen. And there aren't any washers and dryers or big buckets of bleach or cleaning staff, to tidy it all up.
But back to the birthing mothers. It was a big deal to try and get them to change positions. Women pushing on their backs don't have the help of gravity and in school we are taught that it is hard to push a baby's head under the pubic bone if the woman is flat on her back. I have to say that while it looks very uncomfortable, most of the Senegalese women had no trouble birthing their babes. There is more to birthing on the back than just discomfort and a lack of gravity, it can cause problems like decreased fetal heart rate. And at the clinics where I worked, if a mom pushed for more than an hour, the matrones were eager to cut an episiotomy. Not only are episiotomies something that midwives rarely, if ever do, but there is some form to how and when you do them. There was one birth where I literally had to push the matrone and her scissors away from me and the mom's perineum in order to keep her from cutting the episiotomy I had just refused to perform myself. The baby's head wasn't even crowning (meaning that it was still up near the pubic bone and I couldn't even see anything. Generally, if you do have to do the evil procedure, you do it when the head is trying to push past the last bits of tissue, when she is stretched wider than some of us would care to imagine). I thought that the matrone was going to push me back, or push me out of the delivery room, but she just shrugged and looked at me like I was out of my flippin' mind. Luckily we were able to get that particular mom off her back and onto her hands and knees. Getting a birthing mother to change positions, especially while pushing, is no easy thing, even when you can speak the language. We had the help of the matrones, some of whom thought we were nuts, and a beautifully constructed chart depicting a pregnant woman in hands and knees, on her side, in a squat, and being supported by her husband (the last option isn't an option in Senegal. Men are not allowed near the birth room). Hands and knees is a great position for pushing, and was our ideal, since there were no squat bars, and women who changed to their sides inevitably rolled back onto their backs. Some of the matrones were pleased to see that being in hands and knees brought the baby down faster. The sooner the women give birth, the sooner the matrones can return to their other duties (like helping patients who have come in for malaria treatments, premature labor, headaches, and the number one ailment "meti" which is pain). A couple of women upon realizing they could be in whatever position they wanted, grabbed onto that freedom for life. They labored on the floor (which was not as dirty as the clinic walls, it does get mopped most mornings), on various beds, on their sides, in a squat, in a supported squat, anything but their backs. Those births were great triumphs for us. One of my favorites though, was in the last week. A mom who was birthing her eighth or ninth baby was getting frustrated that the baby wasn't coming faster. I asked her if she would like to change positions. We pulled out the chart, pointed at the hands and knees woman, demonstrated the position ourselves. made grunting-pushing noises, told her in wolof/french that the baby would come faster this way. The mom looked at me like I was her worst nightmare. She basically told me that she'd given birth many times before and all of the babies came while she was on her back, and she wasn't going to change that now. And, the problem was that she had to pee and needed a catheter, and oh, where was her IV? Needless to say, she got her catheter and peed, and a long time later birthed the baby. I am sure she went home to her village and told the other women that she had been subjected to the midwifery ways of a white woman and that had caused her to have the longest push in all of her childbirthing history. And who knows, but she is probably right. While some women were very appreciate of our gentleness, I think other's probably thought they were part of something like a science experiment.

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