At eleven in the morning, the car that we take to transport moms to the nearest hospital, which is forty-five minutes away down a dirt and rock path, is not here. It’s out making an airport run. If there is a true emergency, basically we’re screwed.
Since 4am I have been primary midwife to a twenty-one-year-old mama. She is five feet ten inches tall with huge hands and feet, perfect milk chocolate skin, big sweet eyes surrounded by lush, dark and naturally curly eyelashes and the highest of high cheekbones of which I am officially envious. She is now seven centimeters with a bulging bag. In between calls of (click click) “Heeeey-soos” (Jesus) (click click) “Heeeey-soooos bamn fos” (Jesus give me strength) (click click), her first baby is making its way.
Mom has been complaining that the contractions won’t stop. Are the contractions really tetonic? Is she having back labor? Or is it a translation thing? Every time I need to listen to the baby’s heart beat with my doppler on her belly to make sure the baby is tolerating labor, she shoos my hand away with a flick of her long fingers while flipping back her head in what I see as a dramatic gesture and says, “No. Mal.” Does it hurt because the placenta is abrupting? Or maybe she doesn’t like the goop I use to listen with the doppler? Again, I will never know due to the translation thing.
Babies are really great communicators while in labor and they do it through the heart tones — a healthy range being between 120 and 160. The heart tones on this baby are good . . . up until they aren’t. A few strange dips down to 90, back up to 140, then back down to 90 in a rolling rhythm that would be soothing if I were meditating, but have me on edge in the birth room because they remind me of the sinusoidal pattern I heard the other day — which, looking back, announced the placenta abruption we found after the birth of the sixth-time mom (no trauma or drama, but yes it did abrupt and I’ll save that story for another day). So, I have PTSD from the last birth. Combine that heart tone pattern with the previous complaints and I’m nervous, so I do what any good midwife does and consults. I ask Midwife Christy to come downstairs and listen to make sure I’m not completely crazy.
Christy, who has twenty-five years more experience than me just kinda shrugs her head and says in the kindest southern drawl, “Well, what are we gonna do? The car isn’t here, so we can’t get her to the hospital in an emergency. I guess if it goes down to 90 and doesn’t go back up, break her bag of water and call me.” Well, that’s not even remotely reassuring. I go upstairs to consult with Midwife Jocelyn. She says the same thing but in different words, “Yup, they have crazy heart tones over here.”
I go back downstairs to the birth room. I am vigilant with my listening and, low and behold, that rolling pattern disappears into thin air. Do I rule out abruption? What about low lying placenta? She hasn’t had an ultrasound, and I swear to god that the placenta is nowhere to be found on the anterior belly, but maybe it is low and posterior? Doesn’t malnutrition lead to a poor placenta? Why does her belly have a funny shape to it? What would I do in Los Angeles? Well, I wouldn’t be in this situation in LA because I would have met this mom earlier than tonight, I would have made sure I knew what her hemoglobin levels were along with her Hep B status, and if I was really concerned, I’d send her to my back up OB to find out where the fuckin’ placenta is . . . I cut my internal dialog short, because really, it’s all moot. Even if there was an emergency, the car for transport is not here and the hospital is at least forty-five minutes away down a dirt and rock path.
My assistant Rachel and I hear a couple of dips down to 100, but nothing in that sinusoidal pattern again. I’m assuming this means cord compression which is not an emergency.
For the next couple of hours I’m still tracking that cord, the kidney bean shape of her uterus, the fact that she is one of the few Haitians that actually bleeds when she dilates, her complaints that the contractions don’t stop, and her pain when I use the doppler to listen to the baby. Malnourishment is no longer the exception, it’s the rule, and the hemoglobin levels are not even a consideration.
Two hours later we are at eight centimeters which means we are getting close to having a baby. The contractions are slowing down, she is complaining of exhaustion and, as much as she asks, Jesus does not seem to be giving her the strength that she needs. This mama is unusual for the Haitians I’ve met as she has been at it all night. I’m concerned about the baby’s position.
Her mother is with her, singing and holding her. I suggest she get on all fours as a way to change baby’s position because maybe the baby is posterior and that’s why her belly has a funny shape and her contractions hurt in back? “Non, non, non.” That idea is whisked away with a flick of her long fingers and the flip of the head. Haitian women are not interested in any positions other than sitting on the floor or using the birth stool.
I lift her up off the stool and suggest a walk. She clings onto me and drapes her arms over my neck. This gorgeous woman and I begin to slow dance. She nuzzles up into me. I repeat to her softly, “Jeee-sooos avec ou” (Jesus is with you). I feel the room shift. We get the potency going. She squats while hanging off of my neck, and next thing you know, the water breaks. Bingo. Now we are gonna have a baby.
My assistant and I kinda cozy up together the way that I do at home and I feel the excitement I get just before the baby is born. There is a bit of oxytocin in the room, the heart tones sound great, now I just need to wait for her to have that overwhelming urge to push. Because she is twenty-one, it should be easy.
Nope. Wrong again.
She complains of pain. I suggest a new position and that idea is, yes dear people, whisked away with a flick of her long fingers and the flip of the head. She is finally ten centimeters and pushing. I get a few little poops out of her so I know the head is descending and she is pushing in the right place, but I don’t see the rectum area opening up to let me know that the baby is really coming down. I suggest she do something different with her legs and I am poo-pooed, as though I have insulted her. She is complaining of being tired. I give her some honey and finally she listens to one of my suggestions and gets onto the bed to lie on her side. We are two hours in — which is unusually long for a first time mom in Haiti — and she is shouting “Ede mwen!” (Help me!) and yelling in a high pitch scream that keeps rising, “Map mouri! Map Mouriiiiiiii!“ (I am going to die!)
Mom is pushing, I only have caput, the soft molding part of the head, coming down which is good, but I really need the boney part of the head to present itself. Plus her perineal floor is tight, as though she’s been doing pilates for years which can be a challenge for birthing vaginally.
We are back on the stool again and the heart tones are down to 90 and not going back up. “Stand up and lean back,” I say with the command of the primary midwife in the room. “Kampee e pilye deye,” says the translator softly.
Mom clicks a few times and then dismisses me. She refuses to change her position. The heartbeat hovers at 90 and it is not recovering. I ask the translator to get Midwife Christy. “So, Christy, we are down to 90 now, I’ve only got caput coming under the bone, a tight perineal bowl, she won’t listen to me, and I don’t speak Creole.” The emergency vacuum extractor that OBs use in hospitals, that I adamantly opposed when I arrived, is starting to look like a good idea, even though I know the head isn’t low enough for it.
Calmly, because we both realize that we’re dancing on the edge of a true emergency and the nearest hospital is miles away in a van that’s not here, she says, “We need to get that baby out now. Get her in to the McRoberts position.” (Mom needs to be straight on the floor with her legs pulled back to pop that baby under the pubic bone.)
With Mom squatting, the heart tones are now down at 70 and I command her to stand up again to help her baby get oxygen. I ignore her hand flicks. With her standing, we are at 90 as a baseline and Mom is screaming that she is in pain, asking Jesus to give her strength. She still flips her head back in dismissal at everything I say.
In marches Marie, the Haitian Midwife. I’m doing my best to get Mom into McRoberts position — which is like a fucking joke because people here barely touch mothers. So the three women I need to help me all speak Creole and “hold her legs back, down and up by her ears” doesn’t translate.
Midwife Marie and Midwife Christy are having it out about positions while I’m trying to put some stretch into her hard as a rock perineal floor. My hands are inside her and I am hurting her as I try to make some room for the baby — whose heart rate is now somewhere between 60 and 90 — to come down under her pubic bone.
Marie does not want the mom on her back and Christy is insisting that it will work. Meanwhile, I’ve got the translator on one leg, my assistant on the other, grandma trying to lift Mom’s body as I keep saying, “No, her head needs to be on ground!” while Mom is whining at a high pitch “Mal. Maaaaaal. Maaaaaaal!!” And, if she could, I am sure she would flick her hands and throw her head back, but I have her pinned on the floor in a terrible example of McRoberts so she can’t. At this point I am feeling like the most useless and cruel midwife on the planet. What the hell happened to my intention of gentle birthing?
Marie takes over the room with her Creole and Christy and I just look at each other and shrug. It isn’t that we don’t trust Marie, it is that we are sitting in a figurative dark room unable to see where the door is that opens up to having this baby, while Marie seems to have night vision. So, we sit back and watch.
Marie commands Mom to get on the birth stool. I’m thinking to myself, “Good luck with that position. I had her there thirty minutes ago and she won’t let the baby down, even there.” Christy is thinking the same thing and whispers to me that her tailbone will be in the way.
We are now at twenty minutes of baby’s heart rate consistently somewhere under 90, averaging at 60 and even a few 40s. I’m so out of my comfort zone that I’m not even remotely panicked. As I watch Marie boss this mom around, ignoring the flicks of her hands, I cringe. I have entered into full surrender of what I think things should look like and I’m becoming desensitized.
That is when I see Marie do something I’ve never seen before. With Mom sitting on the birth stool, she has her lift her legs up and plant them on the edge of the seat. Basically she is in McRoberts, but upright in some kind of suspended squat, getting that tailbone out of the way. Marie commands her to push, and wouldn’t you know it, that baby starts to come down. Three pushes later — with all three midwives screaming, “Pouse!! Pooouse!!!” (push), with a perineum that is torn to shreds way in back and no episiotomy (though we might as well have done it based on the perineal tear), that damn kid comes out kicking and screaming as though hanging out for twenty minutes with a heart rate around 60 is no big deal.
After the usual shock and disconnect from mom that I know is normal over here, we convince Mom that suturing her would be a really good idea so that she can go to the bathroom and have good sex again. Marie assists me as I suture. This process turns into its own mini nightmare given that I am unable to see anything inside the folds of her vagina and she continues to click and scream “Hee-sooos” and “No. No. NO!” (as she scoots away from me to the other end of the bed even though she is completely numb from the lidocaine). I feel like the most abusive midwife in the whole world.
After an hour of suturing, with mom and baby stable, I look both ways to make sure that the Mack truck that has been running me over all day is gone, and leave the room to decompress with Midwife Christy and Jocelyn.
I’m angry. I’m so angry, I’m on the verge of tears.
I’m angry that I don’t speak the language. I’m angry that the way for this mom to birth this baby was with screams of “Pouse! Pouse!” (push). I’m angry that the mom did not respond to my gentle choices, nor could I communicate my authority as a midwife through my translator when I knew things were urgent. I’m angry that the translator practically whispered everything I said — never mind the fact that he hates being at births. I’m angry that being loving and respectful of the birthing process doesn’t translate into an easy, peaceful, gentle labor. I am feeling useless as a midwife, and yes, my ego is bruised.
I turn to Christy (who is also president of her state’s midwifery association) and say, “Christy, I’m a really good midwife, I swear. At home I know what to do.” Christy just looks at me and laughs. “Elizabeth,” she says sweetly in that southern drawl of hers, “Since my first year as an apprentice twenty-five years ago I had not asked another midwife into the room. For every birth here, I have asked Marie to come into the room to help me. It’s intense here.” I feel a bit better.
Midwife Jocelyn looks at me with her huge compassionate eyes and nods, “I know what you mean. I get it. The heart tones are all over the place, yet the babies seem to come out just fine, most of the time. When I first got here, I asked Marie to come into almost every birth. Needing her is getting less frequent, but I’ve been here for four months.”
I know we don’t have the luxury of hour-long prenatals and most times the moms have never met me before. I get that everyone is living in poverty and that people are just surviving. I also get the obvious limitations of language and culture. But what I don’t get is that maybe everything that I have been taught about babies’ heart rates isn’t true.
Are babies really that different over here? Is there something about how the Haitian body is made that makes malnutrition and low hemoglobin a non-issues for making and birthing babies? Maybe these kids have to have survival imprints from moment one or they will never be able to survive long term? Or is everything that I have learned about heart tones, decelerations, and emergency situations completely and utterly untrue? Maybe we really are truly fooling ourselves in America about low heart tones and they don’t lead to flaccid babies? Maybe babies are supposed to have low heart tones for twenty minutes while they come down? Maybe we are all just fooling ourselves into thinking that we have a modicum of a clue.
Maybe I ask too many questions and I just need to go to bed.
I go one more time to check in with mama and baby in the postpartum room. Mama immediately looks at me with those luscious eyes and says, “Merci. Merci. Merci!” I’m kinda in shock because I thought she wanted nothing to do with me. Grand-mama looks at my shocked face and with a big smile says, “Merci” over and over again to me while pointing to her heart.
And now I’m completely confused. What are they talking about? I feel like such a lame midwife. I had no idea how to get this kid out. I literally physically forced Mom into positions with her fighting back and then I tortured the Mom with suturing! And they’re thanking me?
I’m at a loss for words. It’s like a three-ring circus over here.
Elizabeth is a true Birth Junkie at heart and owns an environmentally respectful birthing center in Los Angeles where she is part of a growing birth movement to bring the spiritual wisdom of lovingly supporting all choices into consciousness so class divides can be erased, judgements between midwifery and obstetrical care can be healed and families everywhere can begin with kindness and compassion. You can follow her on Twitter, Facebook, Instagram and the old fashion way, her web site: www.gracefull.com