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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La Parterita en Mendoza- Parte 1

 

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For those they haven’t been in the loop, I have spent the last week and a half living and working in beautiful Mendoza, Argentina. I have been working with midwives here in a very busy public hospital, in a high risk obstetric unit.  While I always knew from the beginning that things were going to be really different here, I had no idea the extent of how much I would be surprised by. Also, the language barrier caught me quite off guard on my first day. I have had pretty good knowledge of the Spanish language before coming here, being able to translate and speak with patients at work etc. I knew how to ask questions, take a 

medical history, instruct someone through child birth, and give discharge education. ImageBut it never occured to me that it wouldn’t be the patients I would have difficulty talking to, but rather the staff. Being able to have normal everyday discussions became the biggest obstacle. Also, I never realized until being here how much of my knowledge of Spanish was quite dependent on “Spanglish,” and being able to throw in a word or two in English if I didn’t know how to say them. Here at the hospital NO ONE knows ANY English. Nada. So it was definitely a bit of a struggle my first couple days to be able to keep my mind in constant focus every minute to what’s being said, and training myself to stop translating in my head, but rather to simply think in Spanish. Fortunately, we have a really great Spanish teacher at the house who comes a couple hours twice a week to do lessons. I am happy to say I can finally speak outside of the present tense at last! This has definitely opened the field for conversation in the hospital, and I am becoming quite confident in my ability to talk with other people in the hospital about the differences between their practices and ours in the States, the things that quite literally blew my mind. ImageFor starters, when women come in labor, they are taken into a “dilation room,” which has about 6 or 7 “beds,” which are more like a table with a paperthin mattress, and they are required to basically lay there and suffer until they are complete. No epidurals, no pain medicine, no visitors with them, just sitting or laying on the beds sobbing and moaning for hours. There is absolutely no privacy, they do vaginal exams in front of everyone else, and the door of the room wide open, but no one seems to mind it nonetheless. What really surprised me however, is  when they do get to completely dilated, the woman holds her bag of IV fluid and Pitocin, and walk down the hall to the delivery room, dripping amniotic fluid and bloody show on the floor like nothing.Then they go into the delivery room which is basically a metal table with stirrups (if they are lucky) otherwise there is just 2 metal poles they have to prop their feet against. No pillows, no adjustable bed, nada. Not even a baby warmer, no oxygen or resuscitation supplies, nothing. 

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And because I understand we in America are probably a bit overly aggressive about 

continuous fetal monitoring, I was not surprised that they only listen for heart tones every 30 minutes. Even the patients on Pitocin. 

But I was quite surprised that, even after the long walk down the hall with the baby basically crowing, they really don’t monitor the baby while she’s pushing, except when they were using forceps to deliver. And might I add no pain medication is given. The patients are draped with this “sterile” white cloth and instructed to push right away, the doors of the room wide open and everything.Image What really astonished me, one of the midwives told me that for primagravidas, it is routine to just go ahead and cut a mediolateral episiotomy before they start pushing. They do give some lidocaine first, but I couldn’t help but feel the pain of it for the patient.

ImageAs if that wasn’t enough torture for this sheltered little midwife, they have a tech or one of the other nurses or doctors stand or straddle the head of the bed, and apply fundal pressure. Knowing that just the mention of fundal pressure could cost you your license, I felt mortified at the site. After all is said and done, the patient and her baby are put on a stretcher to cuddle and bond in the hallway for a few hours until they are taken to the postpartum unit. ImageAfter a first impression like that, it was hard to get the courage to go back. But the following day, it was a little better in the hospital, as there was a class of medical students there, and they invited me to join in their class for the day. I still mostly was just observing things, helping to get some heart tones and check a cervix here and there, but I felt more confident in communicating with the others, and the professor there was very helpful and very easy to understand. But after a few hours of paying super close attention to every word around you, it gets quite mentally exhausting. After a beautiful walk home in the Mendoza sunshine, it was time for Spanish class and “social activities” with the roommates.  

The end of the first week definitely wrapped up on a good note. There are different midwives every day, and where as the midwives there on the other days were not unfriendly, they were not able to slow down and interact with me as much as the midwives there on Friday, which was a guy midwife and a woman midwife. After having seen the work flow from the previous days, I had a little bit better idea of how everything works, who is who, etc., and so there was less need for them to explain all that, and we were able to have really good conversations (in Spanish), drink Mate, and they were very facilitating to me, letting me check dilation and they even let me assist to deliver 3 babies today, which was really great.  

This past week was a bit funky in terms of the work week, because Monday and Tuesday there were problems with the buses working, and the bus never showed up. So I spent the day being productive with my Spanish studies. Wednesday I went in, but it seemed like it was “C-section day.” When I arrived, there were about 7 patients all gowned and prepped for surgery. ImagePossibly a day for the residents to practice their surgical skills I suppose. There were a couple midwife students from Mendoza there with me that day, so it was nice to be able to bond and work with them, as I still basically see myself in the student role. However, the same way I needed to do so many deliveries in order to graduate, they also do, and we did have one vaginal birth we did do. The patient came in contracting every 1-2 minutes, and before they even checked her in the dilation room, I could already see the head presenting. Thinking were just going to have a baby in the bed, I went ahead and grabbed my gloves, and to my surprise, they actually had her get up and walk down to the delivery room. By the time the patient was on the table the head was crowning, and the student still had not got her gloves on. I went ahead and kept my hands supporting the perineum, and basically told her to get her gloves on or I’m going to deliver this baby myself. Like any ambitious midwife student, she made the sacrifice of trying to get the other glove on, and delivered the rest of the baby with only one glove. Priceless. ImageAnd, ironically, as much as I am not a fan of doing routine episiotomy for first pregnancy births, this was the first one that they didn’t cut (obviously there was no time), and go figure, she gets a third degree tear. 

While a lot of the practices here have reason behind it, some of their habits will never fail to surprise me. Particularly, the common use of open toed sandals, flip flops, and even heels. One day, after a resident put a foley catheter in for a c-section patient, there weren’t any foley bags, so she just tied a glove around the end of the catheter and taped it instead. I also don’t ever think I will understand the “sterile technique” here either. A doctor might put on sterile gloves to do a cervical exam, and then dip her sterile gloved fingers into the jar of KY jelly they use for the fetal heart monitor. What?!

Nonetheless, I am having a really great experience out here. I am so much better able to appreciate not only the quality of the healthcare back home, but also the philosophy behind it, driven by empathy, compassion, and lawsuits. It is so strange to see these high risk women, no prenatal care, minimal fetal monitoring, and strangely aggressive birth interventions have babies that always come out screaming, with no need for oxygen, suction, or calculating Apgar scores. Yet back home, we practice with such strict protocol, doing everything by the book, and still seem to have more problems with babies needing some resuscitative efforts. It is both very humbling and enlightening to acknowledge such a concept. I feel like in comparing the conservative/aggressive nature of birth interventions here versus the US, I don’t really find  that one medical culture necessarily has does or doesn’t do more than the other, but they almost sort of compliment each other like a Yin and Yang, by being more aggressive in some practices, and more conservative with others. And its not that they do these interventions just because thats what they were told, but they just take a position on the other side of the controversy than we do for that specific intervention. Between learning the language and learning their practices and philosophies, it has definitely been a very mind stimulating process thus far. And as such, makes a perfect welcome for a doing some wine tasting after work. Image