Diplomacy

Diplomacy

Our first full day in Haiti is behind us. We arrived to Port au Prince to find some positive changes. There were new shops in the airport, less 'pushy' men wanting to help you for a buck at the baggage claim. It was a welcome surprise. We met Jackie, a Frontier Nursing School instructor, and quickly made friends. We thought at first that we were going to spend three hours sitting in the airport waiting for the last of our group to arrive, but soon found out there were other plans. We were picked up by Ranel and taken to La Maison Hotel, a quaint little establishment not far from the airport. Two of our friends from our last trip would be headed to Hinche with us this trip and they had spent the night at this hotel. Another friend from our last trip, Sarah, was on her way out, but stayed with us through lunch. It's only our second trip, but we are already making lifelong connections with other volunteers.

Over lunch we discuss past trips, current goings on and our lives in general. We find out that Jackie knows of two of our friends from Alaska through Frontier, she knows a good friend from residency as another instructor at Frontier and an OB residency friend of mine that practices in Athens, GA where she lives. I am struck by what a small world it is. Are we playing a game of 6 degrees of Glen Elrod here? It seems like everyone is either a friend already, or knows someone I know. Crazy!

The trip back is much the same. Dangerous drivers, winding narrow streets. It doesn't look like much has changed in Port au Prince, until we come up to the river bed. The last time I was here I distinctly remember this river bed. There were tent camps still set up from the earthquake in 2010. They are now gone. This WAS an entire city of displaced men and women. Now, they were gone. No sign that they had been there. Nothing really has taken their place, but there were no tent camps. One of the groups say that it has been mentioned that they were simply told to leave. It's not as though they miraculously found housing elsewhere, they were just told they could no longer be there. I'm hopeful that at least some of them found housing.

At the house in Hinche, much is the same. Ina May has had at least two litters of kitten since last we were here and rumor is that she is likely pregnant again. There is commotion from all of the volunteers, some transient, some more long term. The food smells the same. The layout is nearly the same. There is at least one new wall to make an upstairs area a dorm-like room, giving added privacy. The wi-fi has been upgraded and is actually very nice indeed.

In a lot of ways, it seems like we never left. The streets are the same, the people are the same, but behind the scenes, much is different. We, of course, are not in the need to know about the inner workings of Midwives for Haiti or any other agency in Haiti, but we know enough to know that there are significant challenges with the local hospital and other agencies. Typical issues; money, protocols and staffing seem to be a high priority.  

What struck us particularly though, is just how diplomatic everyone is regarding this change. Don't say exactly what you feel because that will likely put an end to your cause. Tread lightly, respectfully, and through small steps you may make change and progress. The system will not change overnight, it simply won't.

One of our friends from last trip, told us about an exciting event at her local hospital. They had asked the staff what they could do to improve their maternity section. One of the options proposed was to build a free standing birth center, staffed and run by nurses but without the 'hospital' extras- IVs, continuous monitoring, and with the option of waterbirth if desired. She talks about the support she got from the hospital, so far as to travel from her home state to Boston to see two working free standing birth centers that operate within a hospital system. But, she also tells of the backlash from the rest of the OB staff for promoting this center. Again, what struck me in her explaining the planning and development of this birth center, is the diplomacy with which she has gone about getting this off the ground.

Maybe we can all learn a bit about diplomacy, not because we are going to become Senators or commanders, but because you 'collect more flies with honey,' as the saying goes. The struggles to provide maternal care in Haiti go well beyond decisions we make on a day in and day out basis in our own practice, but yet we can still learn to do things more diplomatically and with more grace and humility.

Tomorrow starts our full and, hopefully, exciting week. Tara goes off to the mobile clinic and I head to meet with the Chief of Staff to see where I am needed this week. Until then, Bonswa.

Glen

My Own Motivations

Nearly a year and a half ago, I set out on a mission in search of an organization to become a part of, which would enable Glen and I to volunteer ourselves as birth professionals. I had many motivating factors, but the two most prominent was the desire to learn and the desire to give what I feel I could give the most of- my knowledge, my skill as a midwife, my time, myself.

After researching various organizations and regions in the world, I connected with an international non-profit organization who helped facilitate the training of midwives throughout the world, in many different countries. It was my plan to go serve in Uganda. However, as the details began falling into place, we found that not only with Glen being an obstetrician, but a MALE obstetrician, this would not be an option, as culturally this would be very difficult for the women in this particular area. I contemplated going alone and leaving Glen behind for this trip, but in the end, we found ourselves connected with a new organization- Midwives For Haiti. What was profound for me was that Haiti had the same, if not worse, challenges of Uganda, yet it was not half a world away- Haiti was in the back yard of my own country. Do you know how close Haiti is to us? If not, look at a map. That right there is an hour and a half plan ride from Miami. It is amazing how two places in the same world can be so many worlds apart.

So, in March of 2013- nearly exactly a year ago- Glen and I set out on our first volunteer trip to Haiti. If you have not done so already, I encourage you to go back through this blog and read of our journey in that first trip to Haiti. It will sadden you, anger you, but most importantly, inspire you. It will provide understanding as to why we are now preparing to go back.

Serving as a midwife in Haiti by volunteering with Midwives For Haiti is not entirely altruistic. Can it truly be altruistic if I feel the reward of personal gratification? Can it be considered altruistic if I am emotionally and spiritually rewarded by every single interaction I have with the beauty, strength, and faith that is Haiti? No. I go to Haiti because the country of Haiti is in dire need of trained, skilled birth attendants and I- even with little other resources- can help with that. But, I also feel drawn to Haiti for the lessons in life it provides. Haiti speaks to my heart the words which my brain already knows...we are not guaranteed anything in life, any outcome. We have God and eachother and nothing else. Our faith, mentality, and what we do for ourselves and for each other with how much or how little we have truly matters. That is what I know. That is what is reaffirmed to my heart when I think of Haiti.

So now, the night before we begin our journey to Miami and then onward to Haiti, we are almost all packed up and are so very excited! We have two large duffle bags, one filled with new baby gift packs (freezer bags each filled with a receiving blanket, onesie, hat, pair of socks, and a cloth diaper), and the other duffel bag filled with the medical supplies that we will use while there- delivery kits (made up of protective gowns, gloves, cord clamps, gauze, and bulb suctions), sterile needles, IV start kits, alcohol wipes, hand sanitizer, and antihemorrhagic drugs. Glen and I will fit our own personal items in a small carry-on bag. I'll pack a couple pairs of shorts and tanks, a dress for church, a bathing suit, headphones, my iPad, plenty of hair ties, the bare necessities of cosmetics, and a nice cocktail dress, to wear on my 30th birthday while in Miami.

This timing- turning 30, returning to Haiti, the culmination of the past year in mine and Glen's personal and professional life- feels pivotal. I have a lot to say. I hope you take the time to follow on our journey. I look forward to sharing it with you.

Tara

Top 5 Things Every Postpartum Woman Should Have... (And no, I'm not talking about breastpumps, breast pads, and nipple cream)

During pregnancy, a woman’s blood volume nearly doubles, as it works and grows to support the growing baby inside of her. Is this not a miraculous thing? As women, we often focus on our expanding bodies...beyond an expanding waistline, to expanding hips and breasts. (On those days when we feel oh-so-big, we need not forget that it is not simply the addition of fat, but fluid and blood expansion.)

The “work” of labor and delivery is truly LABOR- hard labor in all aspects- emotional, mental, and physical. It is arguably the equivalent of running a marathon...that you have not trained for...which you have no idea if it is a 5k or a full marathon. To labor and give birth is to use every muscle fiber in your body (which you will likely feel the day afterward!). I have had moms whose shoulders ache, whose thigh muscles throb as if they have been doing repetitive squats, and who have broken blood vessels in their eyes from the physical exertion that it took to birth their baby. This is not to portray birth as scary...this is to speak to the challenge that is birth and the power that is the female body. In additional to the exertion of the body, blood loss during delivery further depletes the woman's body.

After delivery, the body shifts from growing life intrauterine, to continuing to sustain and grow that life outside of the body, by way of breastfeeding. The task of producing rich breastmilk is further taxing. For all these reasons, the body may be deficient postpartum.

If the female body can grow, birth, and sustain life, what are we doing after such an accomplishment, to nurture that body? In our culture, we do not always hold this time- the postpartum period- in reverence. We fail to see and treat it as a sacred time. Yes, a baby has just been born. But so has a mother.

So, with all of that said, here is a list of the top 5 things every postpartum woman should have, some material comfort items, some not.

1) Depends/Disposable adult underwear
Yes, I know. It's not the coolest, sexiest, most attractive garment, but I promise you, it will be worth it. The first couple of days when bleeding is heavier, it is so nice to not have to worry about pad placement and ruining your underwear. Go to the bathroom ---> take off--->toss in trash--->replace. It's comfy, it's hassle free. Just.do.it.

2) Frozen witch hazel pads- they feel like heaven on your bottom and perineum after you have given birth, particularly if you have stitches for a vaginal/perineal tear. It's cold and soothing, and helps to reduce swelling. Take a heavy absorbancy sanitary pad, and moderately fill it with witch hazel. Be careful not to drench it...it will become a solid ice block in the freezer. Curve it slightly upward (as the curve of the body when it's in the underwear) and place it in the freezer. You can stack several.

3) Rest- I'm not talking about rest in the immediate hours after giving birth. I'm talking days. Weeks. I tell my moms for the first 3 days, stay in the comfort of your own space- your bed. Stay nearly naked (refer back to #1), skin to skin with your new baby. Rest. Nurse. Rest some more. Bond. Limit your visitors. You see? These things are interrelated. You're nearly naked, looking like a beautiful mess of a new mother, why have company over? We also need to keep in mind that company also brings unwelcome company- germs.
What more important task do you have than to establish breastfeeding, provide nutrients and antibodies to Baby, and get to know your new baby? You can do it all by resting and staying close to each other!

4) Nourishment- in the immediate days after birth and through the postpartum period, the body needs to be nourished and replenished. Hot teas, infusions, broths, and hearty soups are staples for this. In our house Glen makes a wonderful homemade broth from our leftover bones. It can be made from beef bones, or a turkey or chicken carcass. It's simple to make and nourishing to the body and mind. Best of all, you can do this ahead of time and freeze in large quantities. It's also easy enough that anyone- including Dad- can do it. Recipe at the end!

5) Time- I've learned, by being a midwife and 'practicing' in a country other than the U.S., as well as being the midwife to many women from various cultures and beliefs, that here in our (American) culture, the postpartum period isn't always held in high regard and provided Time.

Just yesterday (Friday), as I was leaving a 24 hour postpartum home visit, I said to mom, "Just in case you were considering it, please do not go to church on Sunday. Stay home. Rest."
Mom (who is from Guatemala) looked at me like I was crazy! "Ah...no. I stay home," she said. "In my culture, we do not go anywhere for 30 days after having baby." I was in awe. This is not the norm. Perhaps it should be.

Ever heard of the 4th trimester? It refers to the time from birth to the end of a baby's third month. At birth, the brain of the human infant is still immature (compared to other mammals). Human babies are fragile and vulnerable, depending on the constant care of their mother. At birth, they have innate reflexes and abilities- breathing, sucking, swallowing, pooping. As the end of the 4th trimester nears, they become increasingly more able- regulating their body temperature, interacting more, nursing less often, etc. Shouldn't this vulnerable, dependent time of the newborn tell us something important about the 4th trimester for the mother as well?

Indeed, I think so!

So forget about breastpumps, breastpads, nipple cream, and the various other gadgets and 'nice-to-haves' for now, and consider this simple, short list. Let us not forget about the 4th trimester for both mom and baby, and all the ways in which we can comfort, nurture, and support them both.




Nourishing Bone Broth

One big pot of water
2 tablespoons vinegar (helps to draw the minerals out of the bones)
. Can be substituted with lemon juice.
3 carrots, peeled and coarsely chopped
3 celery stalks, coarsely chopped

1 large onion, coarsely chopped
1 bunch each of parsley and thyme
2 Bay leaves
8 peppercorns
Marrow Bones- we only use organic, hormone-free animal bones such as beef bones, whole turkey, or whole chicken. You can either use a whole chicken with the meat still intact, or use the remaining carcass, after you have already eaten the meat for a previous meal.

• If using a whole chicken, cut off the wings, remove the neck and cut both into pieces. Remove the gizzards from the cavity. Like mentioned above, an already eaten off of chicken or turkey carcass is fine. Throw it in!
• Place marrow bones or chicken and pieces in a pot with water, vinegar, and all vegetables and herbs.
• Bring slowly to a boil, and remove the scum that rises to the top.
• Reduce heat, cover and low simmer for 6 to 8 hours.
• Salt and pepper to taste, or wait until consumption
• Strain the stock into another large pot. Remove the bones and any meat pieces with a slotted spoon. You can save the loose meat to be used for chicken/turkey noodle soup, etc.
• Cool in an ice bath (or, as my husband does during the wintertime, sticks it in the snow outside (this is not my favorite, as I tell him he's going to attract all the wild animals!), and refrigerate until the fat rises to the top and congeals. Skim off the layer of fat. Refrigerate up to 3-4 days or freeze for future use.

Deliverance

de.liv.er.ance

noun
1. the action of being rescued or set free.
   synonyms: liberation, release, delivery.


It never fails. Glen and I will be on our stroll through the grocery store- toddler in the cart and the 2 middles trailing behind, the 6 year old undoubtably asking if he can get an "example" from the cheese section, and the 8 year old complaining of the mundane boringness that is the grocery store.

As we walk the aisles, me having hot flashes and trying my best to not have a meltdown as I am trying to multitask with maintaining my thought process, have a coherent 'what do you want for dinner?' conversation with the husband and create dialogue with the children as to make this wonderful trip a well-rounded, learning adventure (ee-gads!), we run into a familiar face. Glen smiles and says hello, then looks at me and lets me know (as if I don't already know...), "I delivered her." It is doctor-speak at it's finest.

'I delivered her.' Delivered her? Delivered her of what, exactly? Are you Catholic? (Oh wait, yes you are.) Are you a priest? (I did indeed ask him this once. He rolled his eyes at me.) Delivered the baby? Then what did she, the woman, do? She did indeed deliver her baby, did she not?

Glen acknowledged the point behind my dramatics. He asked what I thought was better verbiage. I said, "How about 'caught'?" He then asked- "What about a cesarean birth? Did I 'catch' that baby?" Ok. Fair enough.

Historically- at least in my own circle of midwives- I have noticed that many midwives use the phrase "caught." With that notion, I have delivered three babies in my life, but have caught many.

That phrase is very midwifery-like. And I like the notion of it- thoughtful, sensitive, acknowledging of the primary source of power and labor-  the woman, not the midwife or doctor.
However, are we really just 'catching?' There has been a once or twice where the birth has been so precipitous that I have indeed been nothing more than loving, anticipating, welcoming hands. I have, quite literally, 'caught.' Mom shows up huffing and puffing- the majority of the hard work behind her- complete and pushing. No time for anything other than to catch a baby.

However, that's not the usual work of a midwife. To say that I do nothing more than 'catch' a baby is demeaning. And it's simply not accurate. I hold two lives under my responsibility and care. Monitoring vitals, heart tones, supporting, simply observing, not acting, but being prepared to act as necessary- should there be the need. THAT is a midwife, and then some. So I suppose my own verbiage of 'catching' is no better than 'delivered.'

Words are indeed powerful, and I am always ever so mindful of this. But whether it be 'catch' or 'deliver,' sometimes there is just no word that will do it full justice, in all respects.

What Say You?

Our practice definition of integrated is as follows:

In.te.grat.ed. The combination of separate elements to provide a harmonious, interrelated whole. 

This definition speaks of us, as a doctor and a midwife who are indeed separate elements, who are each independent practitioners, holding different skillsets, knowledge, and experiences, having been trained in vastly varying environments. But, as different as our training may have been, and as contrasting as our individual styles may be (ha!), we do indeed harmoniously practice together (well, perhaps I lie. Harmoniously, not always. Sometimes the boxing gloves nearly come out...) coming to each other to consult, share knowledge, and learn equally from each other. 

But what does that look like for a woman in our care? Patients usually choose one pathway- physician care or midwifery care. Some patients, on occasion, choose to do a blend of both.

Having individual clients allows us to give continuity of care, in a personalized way. I love having my "own" clients, as the relationship that develops between a midwife and the woman and her family is a cornerstone for birth. Understanding,Trust, Respect...which of course go both ways. 

An interesting thing has been happening lately. More and more people are choosing to forego the hospital and they are choosing 'Out-Of-Hospital' birth. Our Out-Of-Hospital birth rate for the coming months has sky-rocketed. Planned birth center and home birth is at an all-time high for us (hmmm...I wonder why?).

With the rising percentage of our patients choosing OOH birth, another interesting thing has begun to happen- patients are asking if their births can be attended by Glen, in addition to myself. And honestly, I go back and forth between whether this is good or bad. On one hand, I'm offended. No seriously. It offends me. I have had more than one client request if Glen can be there...you know, 'just in case.' In a professional, pleasant, but very overt way, I've had to put it out there. A midwife is trained to, and capable of, functioning independently. A midwife specializes in normal birth. A midwife is trained to recognize abnormal and is skilled to intervene when needed and seek a higher level of care, when appropriate. Having a doctor in attendance does not guarantee you a good or better outcome. You are no safer having a doctor at your birth center birth than you are having a midwife attend your birth center birth. And further, let's remember that statistics show that low-risk, healthy women with low-risk, healthy pregnancies have just as good, if not better, outcomes compared to low-risk moms within the hospital, under the care of a doctor. So...again...on one hand it might be looked at as offensive to the midwifery profession or even myself as a midwife. 

But, with my initial emotional feelings pushed aside, is there a positive to families desiring to have their Out-Of-Hospital birth attended by a physician?

Well yes, I suppose there is! Let's think about it: there is a vast demographic of women and their families who may not ever have considered delivering their baby outside of the hospital, who would have otherwise, without a second thought, delivered in the hospital setting (and therefore potentially encountered various restrictions and interventions that may not have been needed). If having a doctor attend their birth- so that they can have an unmedicated birth center waterbirth- opens the gateway for more families to feel comfortable choosing that, then one might argue, Why Not?

So, what say you?

The Countdown Is On

The bank asked us for a 'profit and loss statement.' We looked at each other as if they were speaking Chinese. We've never had one of those. We get our bills, we pay them. We bill for the services we provide. At the end of the year, we send things off to our accountant and magically, wonderfully, our taxes get done. Profit and loss? Hmmm.

Now, we have indeed done a profit and loss statement and I'm thinking I would have been just fine not seeing it all laid out in front of me. Ignorance may indeed be bliss!

Is it December yet? But oh, I suppose the stress, excitement, and anticipation is all part of the whole 'life experience,' eh, so why rush it? I better try and soak up this crazy time for everything it is...for come December, it will be but a memory.

Things are moving along and in about 10 weeks Integrated Women's Wellness should be moving in to our new home. 10 weeks! I can't say I'm feeling real, raw excitement yet. It seems surreal. This project has taken so much time and effort that I'm beginning to have a love-hate relationship with it. There was a point, long ago, that I was excited at the prospect of one day picking out wall colors and stain colors and art and fixtures and stone. Now decision-making feels like a full-time job in itself because the decisions seem to be continual. I'm not complaining. Just laughing at the irony of it. ;)

But with that said- today Glen and I made one of the best choices yet for the new space- we found a sleek, beautiful, leather sofa that pulls out to a queen-size bed. I find that amusing. To heck with the wall colors and fixtures! We care about sleep! Even between appointments or during lunch...we need a place to relax! A queen size bed to lay on...heaven! (Can you tell we are a doctor and a midwife?)

I'm excited about my sofa.



And well, perhaps a bit excited that the countdown is on...

The Birth of Wyatt- A planned homebirth, turned emergency c-section at 35 weeks

I had the honor of being Shelby's midwife throughout a completely normal, uneventful, uncomplicated pregnancy. Our last visit had been a home visit at 35 weeks, discussing the complications of pregnancy and birth, and preparing for her homebirth that would happen in the coming weeks.

The array of vitals and checks were all normal- no contractions, no leaking of fluid or abnormal discharge, blood pressure was great, plenty of fetal movement, ample amniotic fluid, and a fundal height that was within normal limits. Paisley- her daughter that would soon be a big sister- snoozed on the couch as we did our visit in the living room.

On the day that Shelby was 35 weeks and 3 days, I was headed out to Willow to do a 24 hour postpartum visit. The kids were loaded up to come along, and Glen was driving. I checked my messages and saw that there was a message from Shelby. I read the first sentence and immediately knew something was wrong. It said, "We might have a problem..."

Funny how powerful words are...and amazing the bond and relationship that is formed with midwifery care. I had spent nearly 8 months getting to know Shelby and her family. I knew her for her sweet, laid back, nonchalant personality. She never made a big deal about anything. Ever.
And now this...this "We might have a problem." I responded to her message and told her to head to the hospital and that I would let them know she was headed in. I looked at Glen and said to him, "This isn't good. I do not have a good feeling." For the duration of our drive to Willow, I was literally biting my nails. Glen called the hospital for me to let them know that Shelby was on her way. I sent a text to Rebecca (Dr. Wayman) to fill her in and let her know to expect Shelby. I asked her to please let me know what was going on as soon as she knew, and I would be coming in as soon as I was done with my home visit.

Through the flurry of events- calls and texts flying, information being shared- the beauty of it stood apparent to me. Shelby had only known me as her midwife and had not known Dr. Elrod or Dr. Wayman as her care providers. But yet they were on her team. We were a team. It is what I hope for every midwife and for every woman.

As it would be, things were not good. Shelby would very quickly find herself in an emergency c-section (though thankfully not so emergent that general anesthesia was required), at 35 weeks and 3 days.


This is the photo story of the birth of Wyatt- a planned home birth, turned emergency c-section.

Going into the O.R. Not the home waterbirth that was planned, but rather what ended up being needed.

Getting her spinal.

Dr. Wayman supporting Shelby as the spinal is placed, Dr. Elrod watching.

 

 

So full of emotions

 

Dad joins us.

The have a tough time getting baby out.



Still trying

Wyatt is born!



Dr. Elrod comes over and shows Shelby the placenta- Small and circumvallate.

Showing the amniotic membranes.

Sweet baby Wyatt- 3 lbs. 15 oz.

Dad stays with Wyatt as they prepare to transport him to the NICU at Providence.

Mom says hello and goodbye, before Wyatt is taken to the NICU.

And now, just a few weeks later, Wyatt is out of the NICU, thriving at home! (I had a photo of our recent visit at the office but it won't post!) There are so many facets to this story, teaching and reaffirming so much.

Mothers- your instincts and intuition are priceless. Never dismiss it or underestimate it!

Midwives- Always, always listen. Just as it is the same for being a mother, your instincts are one of your most valuable tools!

Care providers- Is this not what we should strive for? An integrated team? Midwives who know, support, and guide normal and healthy- but who are skilled to recognize abnormal and have the back up and collaboration of supportive physicians with a higher level of care.

It's a beautiful thing.