"i hate your job" "so do I"

on friday we were raised to a phase 3 level of security (there are 4 levels, and level 4 is a mandatory evacuation). the issue was a minor one, and we felt safe the entire time. it was more to make a point to the local authorities (about them taking our security seriously) than anything else. this meant that we were on lockdown in the compound for friday, saturday and sunday, with exceptions made only for life-saving measures at the hospital. my first exception was convincing gustavo to let me go deliver a baby that was breech. he insisted on coming with me, even though i reminded him that the threat had been against him which made him a liability in my opinion :) my second exception was yesterday when margret told me that a woman who was having her fourth baby had been pushing for 3 hours with no progress, and she thought she had a bandl's ring. i dragged carmenza along and we both agreed that the woman was fine, she was just pushing ineffectively. i spent the next 2 1/2 hours stimulating her push reflex (where you put two fingers into the vagina, with the pads of your fingers down, and apply downward pressure while she pushes) and carmenza told her over and over again how to push, while she continued to ignore us. we told her that she had to push properly because her baby's head had been compressed for too long, and it needed to come out. the heartrate was dropping and we were getting frustrated because she wasn't listening to anything anyone was telling her. the security on the roads is so bad now that we can't transport patients, even to save their lives, so we had to get her to deliver here. by the end of it my arms were aching from the exertion of trying to stimulate her push reflex. finally, finally she delivered a beautiful baby boy who we ended up resuscitating for quite awhile. i went home, back to captivity, leaving them under the care of my staff. that night i was lying in bed, sleepless. maybe i knew what was coming. margret called me on the radio to tell me that a patient had been transferred from gobe with a retained placenta. i told her i would come and as i was getting dressed i heard carmenza, also sleepless, at my door. i told her i had been about to see if she wanted to come too, so she went to put a shirt on over her pyjamas. i wasn't particularly concerned. manual removals can be dangerous but i've done them before and i know that i'm good at them. carmenza would give her some anaesthesia, i would go in and scrape the placenta off the uterine wall with my hand, and we would be home in bed in an hour or two. so, completely wrong. we get there and i find that the woman had delivered almost 2 days ago, and her cervix is almost completely closed. i can barely get my hand in to her vaginal canal, nevermind her uterus. she has a huge mass on her cervix that further limits the space available inside. the manual removals i've done have all been right after a delivery when everything is open and stretched out. this was like putting my entire arm into a vise. i won't try to explain how hard it was because there's no way that i could make myself understood. carmenza was there with me and even she had no idea why i was sweating so hard with the exertion and why i was wincing in pain until i asked her to try as her hands are much smaller than mine. then she got it. by the end of it, 3 hours later, we were blood-soaked. finally we had managed to manually dilate her enough to get our hands into her uterus, and i could grab the placenta. i couldn't take it out without taking her entire uterus out as well as it was completely attached to the wall. i started to rip it to shreds with my fingers and on carmenza's last turn she could pull it out piece by piece. throughout the entire procedure the woman, who was sedated, moaned in absolute agony. the umbilical cord was black and rotten, and she had a raging infection that was likely the reason that her baby had been born dead. it was awful and indescribable. we had a young, beautiful girl in the room beside us, in labour with her first child. the tba asked me to come check her as she was fully dilated. yeah, i say, she's definitely fully dilated... i can see the head. i look at her belly and i ask margret how high her fundal height is. she doesn't know so i measure it and, with the head at the introitus, she still measures 47cm. then someone volunteers that she's a fraternal twin. cool, i say, looks like we're delivering twins tonight. i leave my staff to move the woman with the placenta off the delivery table, clean everything and get the primi onto the table, as carmenza and i book it home to change our bloody clothes. we come back and get ready to deliver twins. by now it's 3 or 4am and we're exhausted from the two previous patients, both of which took unusual amounts of physical exertion. we had been told that the girl wasn't having contractions, which is why she hadn't delivered yet. no, she was having contractions, she just wasn't feeling them. and she hadn't delivered because her baby's head was caught at her huge circumsizion scar. she had been subjected to the worst kind of circumsizion- infibulation. she had been sewed closed, aside from one small hole. it was the first time i have ever this kind of mutilation and, appropriately, it was also the first time i've seen carmenza angry. she called the mother over and told her exactly what she thought of her having done this to her daughters. the delivery took hours and we were fading. she felt no pain with her contractions, prompting me to say to carmenza at one point "maybe she has leprosy", so we had to keep a hand on her gigantor belly and tell her when to push. she never pushed hard, which made sense because what motivation do you have to push if you aren't bothered by your contractions? we couldn't even use the age-old "it will all be over if you just push really hard a few more times" because she was so chill about being in labour, laughing with us, smiling with us. we were totally falling in love with her, in spite of the fact that we were so tired and just wanted her to deliver so we could go to bed. finally it became clear that she wasn't going to deliver, despite my having cut through her scar, my first episiotomy in my entire history as a midwife :( we hadn't been able to find a fetal heartbeat all night, and we were at a loss. we prepared to go home to talk to gustavo about helicoptering her to el geneina. as the entire night had been unfolding, the woman who had delivered the day before (ineffective pushing) had been lying in bed with her absolutely gorgeous baby boy who was rapidly going downhill. once when i walked by, she grabbed my leg and took my hand, putting it on his chest. he was burning with fever so i unwrapped him and showed her to fan him. we all somehow knew that he was dying, even though his heartrate and breathing were still good. everytime i walked by, i would see her husband sitting on the edge of the bed, holding the baby, staring sightless at the floor. the mother would look at me and beg me with her eyes to save him, but there was nothing we could do. as we started to head out of the delivery room to talk to gustavo, i saw the mother and the grandmother clutching his body, and i sat down beside them. the grandmother unwrapped him and when i felt his head it was cool- he was gone. his mother, who had just lost her 3rd child, rocked back and forth in an agony i can't even fathom. her motions were restless and lost. she moved constantly and with no apparent purpose. i told carmenza to go without me and i sat there and held her as she cried. slowly something amazing happened. between our three patients we had over a dozen women holding vigil out in our waiting shelter outside, some of them knowing each other, some not. one by one they entered the room, found a space and began to weep. the room filled with their grief as they joined the mother in mourning the loss of her son.
his father returned and he took his child in his arms. he looked up at me and said, in english, "my son.....my son.....". this was when i finally let myself cry. i asked him if he wanted a picture of him with his son and he said yes. then he wrapped him in white cloth and took him home.
carmenza came back and told me that gustavo was going to contact el geneina and try to get the patient on the helicopter, otherwise he was thinking of doing a road movement. we went home and waited for him to finish talking to the staff in el geneina on the sat phone. we sat outside with corinne and andi who had recently woken up, and none of us spoke much. finally gustavo came out and said "you're going to have to cut the baby into pieces to get him out". i won't tell you the words that came out of my mouth, but a rough translation is that there was no way in hell that was ever going to happen. carmenza refused as well. gustavo explained that this was all they would do in el geneina anyways, and that once the baby was that far into the birth canal there was no other way out. then he says that maybe we can do a craniotomy and again i rebel, as does carmenza. i tell him that if any of those things have to happen, i refuse to be there and i don't ever want to know about it- i will transfer the patient care completely. finally i ask if we can see if Save the Children (another ngo) has a vacuum extractor or forceps we can borrow. he and corinne agree to go on a search, and carmenza and i go to bed. twenty minutes later gustavo knocks on my door to tell me that he found a vacuum extractor in the anc. MY anc. i had been told that ours was broken and had been sent to el geneina for repairs, which wasn't exactly true. nice to know now that it was too late to save the baby from the day before. awesome. i go wake up carmenza and we go back to the hospital. corinne comes as well, which i think she definitely regretted. i had to cut two more episiotomies, bringing my total to 3 in one day....3 in the 7 years that i've been a midwife- f***ing circumsizions. i put the metal cup into her vagina and attach it to the baby's head. aicha starts the suction and i begin to pull him out by his scalp. i know that he's dead so the protocols go out the window- i just need to get him out. i pull and pull and pull, and as i pull i realize that it's not twins, it's one huge baby. i pull more, and slowly, slowly, slowly he begins to come. i finally get his head out, and i have pulled off patches of his scalp in the process. when the head comes out, her water comes as well. it is thick and black and the smell of it is enough to make us almost vomit. her infection was huge and the baby had been dead for awhile. the smell was overpowering. now i start trying to maneuver his body out and i can't get him out. it is the worst shoulder dystocia i have ever experienced. had he not died inside of her, he would have died in the delivery. i do everything that i know to do, and still he won't come. i pull with all of my might, making this the third patient in this one neverending day that i am manhandling. for 20 minutes i try, having carmenza apply suprapubic pressure, then trading places with her, then trading back. i use all of the strength that i have. when i feel his neck break in my hands, i step back and try not to pass out. this is a nightmare and any minute i'm going to wake up and be safe at home, in canada, in my yellow room. hawa, one of my hefty national staff, volunteers to try and i happily hand it over to her and step outside for a breath of fresh air. i go back in and i see corinne watching hawa. "welcome to labour and delivery" i say, as she has no experience in obstetrics and was interested in observing while here. "i hate your job" she tells me. "so do i" i reply. i go stand by hawa and as i stand beside her i hear the loud crack of his breaking bones and then she brings him out. she had managed to break his collar bone enough to get him out. his skin is coming off in patches and he smells as badly as the water did. i wrap him up and put him on the table so i can deal with the placenta. when the patient is stable i take the huge baby boy outside and bathe him. i think back to the first time i ever did this in the philippines and how i was crying so hard i couldn't see. this time i'm numb. i bathe him, i wrap him up in a clean towel and i bring him to show him to his mother. she moves the towel so she can better see him, she looks at me and smiles. he looks like her husband. i have wrapped his body and his skull so all she can see is his face, and his face is perfect. her twin sister and i wrap him completely in white cloth and his grandfather comes to take him. carmenza asks me if i'm going to suture her back up and i say no, i won't. she says that she'll suture her for me but she won't resew her closed either. she and aicha go speak to the husband, one of our workers, and explain to him that it's not good for her, it's not good for women. he tells them that he loves her and wants what is best for her and to not resew her. i fall in love with him that instant.
when it is all over, although in some ways it will never be over, we come home and i crawl into bed. it is early afternoon and life here is so loud you can barely hear yourself think, and i still sleep like the dead. i wake up and it's dark. i push my mosquito net aside and reach for my sandals in the darkness. i am paranoid about shaking them off before i put them on as i get way too many ant bites here. i shake them off, slip them on and walk across my room to turn on my light. when my light is on i look back towards my bed and see a dark shape right where my shoes had been. it runs when i approach it, and i can see that it is a scorpion. i chase it, step on it, remember bethany telling me that they always travel in pairs, and i leave my room, vowing never to enter it again. this is on top of my vow to never use the latrine again as last night gustavo was locked in there with a snake. i just want to come home.