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an exciting week in the clinic

June 25, 2010

Of course, just as things start to get interesting and I’m getting comfortable in a new place it’s time to leave. I have one more week left here in the clinic and then it’s tourist time!

On Wednesday one of the nurses asked me if I wanted to do something new and I said sure! Turns out we had two women in labor. One had ruptured her membranes and the doctor had ordered Pitocin, ayuno (fasting), and had her lay in bed on her left side and told her only to get up to go to the bathroom. Sound familiar to anyone? I never thought that laying in bed on your left side was the best way to get a labor moving and neither did any of the other nurses in the clinic. We were all talking about how she needed to be moving and walking around because she was not dilating flat on her back in bed. Finally this doctor that ordered the bedrest left and a new doctor came on in the afternoon and said she could walk around if she wanted. She was then worried that walking around was going to hurt the baby because the other doctor had said to stay in bed. We reassured her that it wouldn’t and she paced back in forth in the room. After that she quickly progressed from 5 to 7 to 8 to time to move to the Sala de Expulsion. Yeah, pretty much translates to Expulsion Room. I need to get a picture of it, because it’s pretty interesting. There were the knee stirrups for her legs and a very small bed for her to lay on and push. The pushing phase was the most different for me because at UNC I’ve pretty much seen women be able to push how they wanted and while many ended up in a semi reclined position no one was every put in stirrups.

I honestly don’t have the time or mentally energy to totally process the birth right now. It always takes some time for me, especially the more medicalized births.  It was the first episiotomy I’ve ever seen and therefore the first repair I’ve ever participated in. I’m pretty sure epiosiotomies are routine here. I had to hold the woman’s labia open while the doctor sewed up her perineum and the nurse explained why it’s so much better to cut than to tear. That was hard. I know that 45 minutes away from me they routinely cut episiotomies and it was routine in many hospitals not so long ago. To me that is the most insanely frustrating thing ever. There is absolutely no medical reason for routine episiotomies, they do not heal better than natural tears, and, with an episiotomy you’re always guaranteed a 2nd degree tear. Whereas if you tear naturally you only tear as much as you need, if you even tear at all. There is no reason to do that to a woman’s perineum, to her vagina, none at all. It would be one thing if the baby is in distress, but routine episiotomy is not about fetal distress, it’s about medical convenience. It’s about shaving 5-10 minutes off of a birth and speeding up your stitching. It makes me angry and this isn’t about Mexico or the U.S., it’s worldwide and it needs to stop. The thing I hate about obstetrics is they start doing things without much evidence (episiotomy, electronic fetal monitoring) but then you need to build up a mountain of evidence to make them stop doing things that harm people.

Oh look, I got all worked up. Back to the great week at the clinic after a few nursing notes.

So, the things that were different about this were the fact that I had to manually adjust the drip rate of the IV. That was hard. Does anyone from N360 remember our TA saying that we would only have to do this manually if we happened to be working in some developing country? Yeah, thanks for that lesson! Ugh, it took forever to get the drip rate adjusted. One time I was counting with the MD and she was like “eh, that’s 16, close enough (to 15)”. Then every hour you have to go back and check it again. One of the doctors had a doppler otherwise I would have had to use the Pinnard Horn, which I tried once, but it was hard to hear. I had to manually feel and count the contractions for 10 minutes every hour and that’s how we measured frequency. Then we did maternal vitals every hour. Also, after I upped the Pitocin I didn’t have to go in and check the fetal hearttones after 15 minutes like was protocol at UNC. They were like “just check it in an hour.” That made me a little nervous because I have had babies respond poorly in just the few minutes after upping Pitocin.

The other thing that was weird for me was that we got into full sterile surgical gear for the birth, but the dad and mom weren’t. It didn’t quite make sense why we needed full body coverage. Also, after the baby was out they just kind of put her on the table with the warming lamp and looked over at her every once in a while. They focused most of the time on trying to get the placenta out. The intial assessment didn’t happen until 40 minutes after the birth! I did wrap her up and show her to mom and have dad hold her, but mom couldn’t hold her until, well I couldn’t quite figure that out. Mom, dad and baby stayed the night. When I came in in the morning the baby was in bed with the mom nursing. There’s no separate bassinet for the baby, babies just stay in bed with mom. They left a little later in the morning and then came in today for the vaccines (BCG and Hep B) and the neonatal bloodwork.

I’m not sure what happened to the other laboring woman. She walked for a long time and then the medical team tried to convince her to go to Oaxaca for an induction, but apparently she said no and went home. She was a first time mom and at 39 or so weeks, there really wasn’t a reason for the induction.

Okay, so then Thursday was lots of fun too. Basically, I walked around the entire town with two other nurses vaccinating children under 5 against polio (Sabin vaccine-oral). First we stopped off at the town market in hopes of getting some kids there. We would see a young child, ask them how old they were and what section of town they lived in. Then we would check our list of those who needed the vaccine and have them go find a responsible adult so we could vaccinate them. Right there in the middle of the market. It was awesome.

After we had vaccinated all the children in the market we sat down and had breakfast. Every morning we have a breakfast break and this coincided with that break. Then we walked and walked and walked. I got sunburned. We had to haul around this heavy cooler with two tiny vials of vaccine that could have fit in my pocket. We all took turns with the cooler and our bread that we had bought at the market. I’m glad I decided against buying fruit! We had our list of houses and families that needed vaccines and basically just circled the town hunting people down. Sometimes it they would be home or other times we would ask a neighbor where they were or tell their sister to tell them that they needed to come to the clinic. We also knocked on some doors to remind people to bring their children in for height and weight checks. I think we did this for about 5 hours stopping a couple times for water or to look at the stuff in the shop of one of the families.

It was really great because I got to see the different types of houses in the community and how people lived. There’s really a huge difference, some people are relatively well off artisans or merchants and other people are very very poor. The nurses really play a role in educating the population on everything. They don’t do as much in the clinic, but you could really see their role when we went from house to house. If the house/yard/kitchen was in disarray and unsanitary the nurse would talk to them about how they need to keep the food separate from the animals (until they became food), food off the floor, separate the trash into one area of the yard, wash the dishes after every meal, etc. They also do family planning. Birth control is free at the clinic, anyone can just walk in and get an IUD, Implanon, or depo shot for free. I have not seen them dispensing the pill or other types of contraceptives At one house the nurse looked at the family with 4 children under the age of four and asked them point blank if they were using any form of birth control and they laughed said “more or less” then something to each other in Zapoteco and the nurse gave them a lecture, but then everyone was laughing and I think it was because they said they weren’t having sex, but I’m not sure. She would also tell the men that they had to help around the house. She was really awesome. We walked by one house and she peered over the fence and remarked at how clean the yard was. Then she said that she had talked to them before and they had worked hard on it. She would talk a lot to the families about how they needed to do things for their health and for their children as well.

Then today I thought we were going to be really busy because several families said they were going to bring their children in for vaccine updates or peso y tailla,  but only a few showed up.

For the weekend I plan to watch the World Cup games and gear up for my final week!

7 Comments leave one →
  1. June 26, 2010 12:11 am

    Again, a wonderful description of village life and a great tale about the birthing process. Episiotomies were SMP when I game birth (La Maze, no drugs at all), but the training didn’t advise us to buck the system. Who ever heard of a midwife or doula in South Bend, Indiana? I laughed, and nodded, and felt like I was right there with you. Great storytelling.

  2. Heather Hart permalink
    June 26, 2010 4:10 am

    Thank you for this, Amy. I am enjoying following your amazing nursing adventure and your opinions on nursing too.

  3. dad permalink
    July 4, 2010 12:02 pm

    the barbarism inflicted upon women in the practice of medicine, religion, (you name it) is horrifying.
    hope you’re enjoying the soccer. mexico was put out with the aid of an offside argentine goal, of course. Unless Uruaguay comes up with a couple of upsets, a European team will win the cup outside of europe for the first time in history.
    enjoy the tourism!

  4. aardvark permalink
    July 8, 2010 4:11 am

    LOL – had to laugh about manual drips being hard. I’m a 53 yr. old former Army medic and we did it in our sleep — takes a few seconds. What’s hard for me is auto BP cuffs that HURT and leave bruises in this old skin! I H-A-T-E them. Manuals are MUCH better. And no one knows how to take proper manuals anymore. God forbid electricity goes out! Glad you’re learning and enjoying yourself too :)

    Hope folks don’t take modern life and progress for granted — nor forget sometimes old ways CAN be better sometimes! And yes, episiotomies are stinky, a good midwife is worth her weight in gold; as is a sane, caring, educated doc — like the one who agreed with my suggestion I deliver in the labor room w/o the nut-so dash to delivery at the last second (done purely out of convention ;-)

  5. July 18, 2010 5:28 pm

    Okay, so where are you NOW and why haven’t we heard from you :) You owe it to your fans!

  6. Lindsey permalink
    September 2, 2010 3:03 pm

    Was that Juanita you were walking around the village with? That’s who I imagined- she is so outspoken I love it!

  7. Donna permalink
    September 16, 2010 3:34 pm

    Hi, Amy, where are you now? Are you back at school? Hope you had a fabulous trip and would love to hear how you are doing now, Donna

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