it's all about improvising

as much as i support the fact that our tba's deliver the women in the kneeling position, i had to find a way to explain to them that part of their technique was making the delivery harder on the women, not easier. as the woman kneels, the tba lies in front of her and puts both of her arms through the space under the woman, between her legs. with both of her hands she reaches up and cups the butt area, and pulls forward as hard as she can as the woman pushes. their reason for doing this is because of their concern that the woman will tear towards her rectum (i think- i didn't completely understand the explanation). in the first delivery that i saw one of them doing this, the baby was big, the mom was small, and the last thing we needed was a tba making the pelvic outlet smaller. the midwife with me was mariam, who doesn't speak english, so i couldn't explain to either of them why i wanted the tba to stop doing it. each time she would go to do it i would just say "lalala!" (nonono!), and she would look at mariam for an explanation, and mariam would just shrug. i radioed for one of the nurses who speaks english to come translate for me, and i tried to explain through him, but they still just seemed confused. dilemma: how do you explain to women who have absolutely NO medical understanding that there is only one moveable bone in the pelvis and that that bone needs the freedom to move back to make room for big babies? how do i get them to understand that, by pulling that bone forward, they are actually making the space available for the baby smaller, and are making it harder for the woman to give birth? i thought of showing them pictures of the pelvic bones in the obstetrics textbook we have here, but these are women who would likely have a hard time grasping the concept of visualizing the pictures in 3D. i thought longingly of the pelvic bones i had in afghanistan, and the life-sized pregnant dummy that i used to train my students there. i smiled at the memory of making cervixes out of playdough stolen from an operation Christmas child box, to teach them how to check the different cervical dilations. and then i got an idea.... i kept an eye out for a couple of days before i finally found something that would work. in our shower we have a small, white, plastic garbage can, and i stole it and replaced it with one of the bigger, coloured ones. the next step was finding scissors or an exacto-knife, of which we have neither in the entire compound. i finally end up borrowing andi's blunt swiss army knife, and i pray that i won't sacrifice too many fingers for this project. i sit in my room with my obstetrics book open, my pencil in one hand, the newly cleaned garbage can in the other. i sketch a pelvis onto the garbage can and i start to carve through the hard plastic. by the time i'm done, i have a plastic, anatomically correct pelvis. at the next lesson i had with the tba's, i showed them the baby's passage through the pelvic bones and, by manoeuvring the little plastic tailbone, i could show them the effect that their technique had. it was awesome- they totally got it and not a single one of them has done it in a birth since. the other benefit of the new pelvis has been that i can use it and our "baby" (the dirtiest, ugliest, most ghetto hand-made doll on the planet) to explain other complications- namely shoulder dystocias.

in my remaining 5 months i have to train these women as much as is humanly possible as once i leave my position likely won't be replaced. in a perfect world there would be births all day long and each of the midwives would be at enough births with me, and see enough complications, to be completely trained and competent by the time i leave. seeing as how births are notoriously unpredictable, and most of them prefer to happen at night when only the most competent midwives are on call, i don't see this happening. this has lead to my next case of improvising. if i don't have real patients giving birth to real babies, i will use fake patients giving birth to our ghetto baby. the last few afternoons i have taken the midwives into our delivery room and we have simulated births, with me throwing in random complications for them to "handle". one of them happily climbs up onto the delivery table and shoves ghetto baby up her shirt, and one at a time the tba's and midwives "deliver" the baby according to what i tell them is happening. "the baby's head is out but the body won't come, what do you do?" "there is a tight cord around the neck, how are you going to handle it?" "the baby isn't breathing...." "the mom is bleeding....." and so on and so on. my hope is that by practicing enough they will get a feel for things and when the time comes they will know how to handle it in reality, or will at least be comfortable with it enough not to panic.

my next project is one that has me wishing i hadn't cheated my way through sewing class in grade 8. i've decided to try to sew together a dummy like the plastic one i had in afghanistan. i figure if i can sew a pair of pants and a shirt together, then stuff the clothes with cotton or something, i can put my plastic pelvis in there and make a cloth uterus and vagina, and we can do some more realistic simulations. as much as my midwives and tba's are all very quick to whip a breast out to feed ghetto baby, i don't imagine they would be super excited about the idea of taking their underwear off in the name of training.

on a more serious note: the security situation around habillah is getting more and more tense. the number of ngo's being robbed on the roads outside of the village has increased a lot in the last week, and yesterday one of the drivers didn't stop when they were ambushed and their car was shot at, and hit twice, as they sped away. no one was hurt, but no thanks to the idiot driver. everyone knows that when you are held up you stop, you keep your hands where they can see them, you get out of the car and lie face down on the ground, you take the contents of your pockets and put it on the ground in front of you, and you do exactly what they tell you to do, with no sudden movements. if you want to get shot, you keep driving or you run. the people from unhcr came by the other day to ask us if we were travelling along a certain road as they had to get a message to some refugees there and no one was allowed to drive that road because of the security issues. we say no, we aren't allowed to travel on that road now either and the woman says "well if YOU guys aren't using that road then NO ONE is using that road". msf has a rep for being kind of hardcore. by the way we are now, officially, the only expats in habillah who haven't been attacked in any way. yes kate, i just knocked on wood :)