La Parterita en Mendoza Parte 2

Finishing my final weeks in Mendoza has undoubtedly been the experience of a lifetime, both personally and professionally.

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Not only did I get the opportunity to meet and work with an incredible group of people throughout the placement, but I also had the opportunity to travel to Buenos Aires, meet some “familia,” and learn a little bit more what it means to be Argentinean.

As I mentioned in Parte 1 of my trip, things are very different in Mendoza, everything from the slow, easy pace of life to the routine practice of episiotomies on primagravidas. And what an odd balance of conservative and liberal interventions there are!  One day, while sitting around with other parteras drinking maté, we came to the discussion of prenatal care and genetic screening.   Interestingly enough, they don’t typically do any of our routine blood work for genetic screening, but on the other hand, will do 3 ultrasounds instead, at least one ultrasound each semester, starting around 12 weeks. It is in this way that they screen for physical abnormalities, fetal anatomy, and an estimated fetal weight at the end of the last trimester.

As a very ambitious homework assignment from my Spanish teacher, I took my official State Midwifery practice protocol and translated it into Spanish. Took a lot of time and effort on my part, but I definitely feel it helped to enable the other midwives to have a better understanding of the role and practices of the Nurse-Midwife (“la Enfermera-Partera”) in the United States.

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Most things were more or less the same, and some very different. Parteras in Mendoza pretty much only work in the practice of birth. It was explained to me that very rarely are their midwives involved in prenatal or postpartum care, and almost never involved in non-obstetric gynecologic care.They are also unable to prescribe medications outside of Oxytocin or cervical relaxants during labor, not even antibiotics. They also do not First Assist or participate at all in cesarean deliveries. On the other hand, their midwives will often deliver twins and breech births, although, they did mention that breech births often are by cesarean delivery unless the woman has been laboring well prior to arrival at the hospital.

versusIt still strikes me in amazement at the conservative approach they use with fetal monitoring however. Even for the “high risk” patients and patients on oxytocin, they only use the doppler to listen for fetal heart rate “every 30 minutes,” or whenever they finish another round of maté. Although I can’t blame them, sitting around in waiting is a practice that comes with the labor and delivery territory, feast or famine. But in the US, I feel like we always are at least trying to “seem” busy, whether it is watching the fetal monitors, comforting patients, doing CEU’s. In my hospital in Mendoza, there is no sense of really going above and beyond, and no one seems to mind either way. As if their practice of FHR monitoring didn’t shock me enough, the method they use for timing contractions is even stranger to me. Although they document contraction rate every 30 minutes with the fetal heart rate, it was explained to me that they count how many contractions there are in 10 minutes, measured by manual palpation. However, I have to say I don’t honestly think I ever saw anyone stand there for 10 minutes straight feeling for contractions. It was more, asking the mother how many she thinks she had in the last 10 minutes and going by that, although there are not actually any clocks in the room. Or taking a guess based on how often you can hear them call out from down the hall. It is also interesting the way they document everything. While each patient does have an official “chart,” (a pile of papers paper clipped together, in no particular organization), they will write their initial assessment (in more or less a similar format to our SOAP notes), and then all additional progress notes are written where ever seems like a good place, on no particular page in the chart. On my first day, I was really confused when trying to read the charts. Whereas in the United States we typically document cervical exams with brackets (for example: dilation/effacement/station), in Mendoza, they don’t seem to have much specific attention to effacement and station, but they use the same format not to document cervical exams, but on contraction monitoring. For example, # contractions in 10 minutes/length of contraction/intensity. Imagine trying to figure that out. It was very striking to me also, that keeping track of FHR decelerations and timing with contractions is much harder, because there is no tracings to review later. In this sense, one would imagine, especially since almost all the patients receive Oxytocin, that there would be a greater attention to a specific assessment of FHR in relation to timing and frequency of contractions. But no, not really of a whole lot of concern there. Interestingly enough, there were very few times I saw (or rather heard) fetal bradycardia. In those instances, there were no heroic interventions like putting on maternal oxygen, internal fetal monitoring, or even stopping the Oxytocin. Occasionally I saw they might tighten the clamp on the IV to slow the Oxytocin a bit, but the extent of interventions they generally take is just changing maternal position. Once the heart rate comes up after, the doctors seem pretty satisfied and don’t push the issue any further. And the most amazing part of it all, is that nearly all of these babies come out screaming, hardly ever needing resuscitative efforts, not even bulb suctioning. Go figure. Bulb1While on the topic of resuscitation, you will recall in the first blog that I mentioned there are no baby warmers or resuscitative devices kept in the room. If the baby is having a slower time getting started crying, they simply poke their head out the door, shout “Neo!” down the hall, and just keep drying and stimulating till the Neo team arrives. It might be 10-15 seconds before anyone shows up, and usually the baby is already crying by then. But if the baby did need further resuscitation, the Neo team would grab the baby and run about 30-50 feet down the hall to the nursery. Incredible.

Another interesting concept is that there is no such thing as an “obstetric nurse” in Mendoza. All nurses have more or less only basic training, can give IV medication and start IV’s but none are allowed to do vaginal exams or push with patients, only midwives and doctors.

Also very interesting and rare sight to see in the US: a patient was pushing in the dilation room, and the baby was not descending as expected, despite her pushing efforts. I have seen very often in the US sitting the patient up in order to implement the natural force of gravity, and letting the patient “labor down.” Occasionally they would do this in Mendoza, but for this patient, when the FHR started slowing, instead of having the patient just sit up and rest rather than push, the midwives instead had her stand and squat to push. They then said they will know how she is progressing based on the amount of bloody show dripping on the floor. What?!

IMAG1792As a midwife, we are taught to embrace women in their experience of childbirth. However, labor coaching is not a common practice for the midwives of Mendoza. Rather than sitting with a patient and massaging or coaching her (as I felt a need to do), the other midwives/docs sit around in their on-call room drinking maté and chatting until someone started pushing or until it was time to check FHR again. To me, I felt torn between the desire to help and be with these women during their pain, while other part of me also felt a need to establish myself in discussions with the other providers and participate with them, whether be it checking cervixes or discussing the weather. It was a struggle to keep a balance between both obligations, because its so uncommon to be actively engaged in the patient’s labor outside of routine monitoring and pushing etc. Despite my best efforts to teach and show them labor coaching techniques, my teaching often seemed in vain. After only a few minutes, the midwives would stop and encourage me to go with them to talk instead.

IMAG1786-1In professional sense, the experience in Mendoza has left me with a combination of feelings: intrigued,  terrified, enlightened, humbled, and thankful. When leaving for this trip, I had different plans about my participation as a Midwife in Mendoza, seeing it as being a sort of residency, an extention of my education of sorts. Boy was I in for a surprise. After all I saw from the first day onward, I certainly held myself with caution about what practices and routines I allowed myself to participate with. Taking everything with a grain of salt. Allowing myself to see and understand their practices, but not immerse myself enough to make habits or adopt them. Having a short and flexible schedule every day was helpful, knowing when things were becoming too overwhelming, and when I needed to take a step back.

I am beyond grateful for the experience, and recommend to anyone considering. Step out of the comfort zone, learn the unthinkable, appreciate what you do and what you have. From my time in Mendoza, I am taking back with me both the good and the bad, and ready to step into my new career with a new outlook for my profession. IMAG1794

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