29 Sept 2012
Doña Ana is a well-respected midwife whose home is in Aldea Buena Vista, about an hour outside of Xela. The story goes that she delivered her first baby at age 11 when her midwife mother was busy with a different patient.
She is a traditional midwife in that her initial knowledge was passed down through generations of women. But she also has western medical training from attending various seminars and workshops. Doña Ana has been working with Pop Wuj for several years – arranging her home as a site for the mobile clinic, organizing her community for the public health projects, and allowing students to follow her.
It was the last weekend of Tiffany, a fellow Spanish student and a nurse in Minnesota, and she hadn’t worked with Doña Ana yet. Neither had I. We decided to brave the public transportation together on a Friday evening.
We followed the written instructions we’d been given to a busy street corner. Buses were coming and going in all four directions.
“On which corner do we stand?” I asked Tiffany.
She glanced around then shrugged.
I’d forgotten my water bottle so we stopped in a tienda to buy refreshments for what might be a long night. A boy who looked no more than six was standing behind the counter. I paid for my drink and asked him where we should wait for our bus.
“Ah, sí. Aquí!” he said, pointing just outside the store where indeed many buses seemed to be passing.
At this point his mother came out and sent him to the back for something. Just in case, I repeated my question. She pointed kitty-corner to where we were.
“It’s a good thing you thought to ask the mom,” Tiffany commented.
We stood on our corner and watched buses and minivans speed by, each with one young Guatemalan man leaning out the door yelling the destination. “Guate, Guate, Guate!” “Zunil, Zunil, Zunil!”
“They’re not slowing down,” Tiffany observed.
Our eyes followed the next bus that went by, and saw that several people had started to sprint after it.
“Nicki, we better get ready to make a dash for it.”
We spotted a dark blue minivan whose young man was yelling, “San Juan, San Juan, San Juan,” the transfer point to Doña Ana’s. Tiffany and I started running.
I think the driver, luckily, saw that we were gringas and slowed to almost a stop for us. Unluckily, every seat was full. Tiffany and I crouched on the side near the door. They let four more passengers on after us. Tiffany was in a slightly inappropriate position relative to the man sitting behind her; the boy in front of me was sitting on my right thigh, cramping my left lower back from trying to counterbalance his weight.
We couldn’t stop giggling from the ridiculousness of it all. Every time we went over a speed bump, looked at each other, or the young man let another person on, we giggled some more. I was worried Guatemalans would think Americans were crazy, laughing when they are super-uncomfortable. Yet laugh we did, most of the way to San Juan.
When we found the San Juan to Buena Vista minivan, the seats were empty. Thank goodness. Per our instructions, Tiffany told the driver, “Necesitamos la casa de la comadrona Ana.” We need midwife Ana’s house. The driver nodded and motioned for us to get on. I was impressed at her renown that even the bus drivers know where she lives.
He dropped us off at the side street that leads to the Doña Ana’s. We’d been there before, during mobile clinic, so we knew where to go. At the door we were enthusiastically greeted by three young girls. They immediately grabbed our hands and began pulling us through the main house to the courtyard.
Doña Ana’s home is actually a small three-building complex with a courtyard in the middle. Her clinic rooms are in the main house that faces the street. On the right of the courtyard is the house where, it seemed, the family sleeps. On the left is another structure.
The girls pulled us to the left, leading us up the outside staircase while shooing the dogs out of the way. At the top was our room for the night. There were two sets of bunk beds but only each of the bottom bunks had mattresses. After playing with the girls, greeting Doña Ana, and playing with the girls some more, we were told that we could go to sleep; we’d be awakened if there was a patient.
I fell into a fidgety sleep, punctuated by the hard bed and strange dreams. At first they incorporated the noise of five dogs barking. As the night turned into the wee hours of the morning the sound of my dreams morphed into a rooster’s crowing.
I jolted awake when I heard Doña Ana pounding on our metal door and calling for us to wake up. Turning on the light revealed Tiffany rubbing her eyes while scrambling to put on her shoes. My watch read 4:03am. We ran down the stairs and hurried to the sala del parto or the room of labour.
The calm and cool of the narrow room was like ice water on the urgency we had felt. In an old wooden bed on the left was a young woman. She was wearing traditional Mayan clothes and lying on her right side, facing Doña Ana.
Doña Ana was parallel to her patient, in what looked like a fully reclined dental patient’s chair. Her eyes were closed and she was covered in at least three wool blankets. She slowly sat up when she heard us come in and told us to sit. Tiffany and I sat opposite the patient, on the same side as our teacher for the night.
What followed was over an hour of both Guatemalan women dozing, in-between the patient softly moaning during contractions. Every so often Doña Ana would get up to make the young woman more comfortable. Tiffany and I stayed seated, soundlessly fighting off sleep.
In the quiet I was able to survey the room. There was a cabinet against the wall between Doña Ana and her patient. It was full of equipment that I was frankly surprised to find in a “traditional” midwife’s possession, including metal clamps, bulb syringes, latex gloves, isopropyl alcohol for sanitization. On the far right behind Doña Ana were a baby scale and an IV pole. I wondered if she routinely started IVs.
I’d started to slumber when Doña Ana moving about roused me. It was just after 5am. She was using her hand to check the patient’s cervix to see how open it was. At first I was taken aback.
Is she wearing gloves? I thought to myself. I hope she’s wearing a glove.
She withdrew her hand and the latex glove became visible. I found myself exhaling. I was so sleepy, I hadn’t heard her put it on.
“Ocho centímetros,” she said. “Faltan dos.”
The patient was eight centimetres dilated. She had two more to go. Doña Ana settled back into her chair. Tiffany and I looked at each other, looked at the patient, then looked at the floor as we settled in for another hour of waiting.
At 6:08am the patient’s moans became louder and more frequent. Doña Ana checked her again.
“Está completa.” She was complete. I was amazed at how similar the vocabulary was to what we use in the States.
Doña Ana started moving about the room getting everything ready. She put on a deep green lab coat buttoned to the top and a matching scrub hat. Turning to me, she asked if I wanted to check the patient.
Heck yes! I thought. That’s something you don’t get to do as a third-year medical student in the US. I clumsily put on gloves and approached the young woman. I started to tell her that I was going to check her cervix when Doña Ana said,
“Ella no habla Castellano.” She doesn’t speak Spanish.
But Doña Ana encouraged me to proceed. So I gently spread the patient’s legs and reached to feel her cervix. All I could feel was the baby’s head.
“La cabeza?” I asked.
Doña Ana moved so she was positioned by the patient’s legs and sat down. Tiffany and I went to stand at the foot of the bed for a better view.
In the US is a rehearsed method of labour coaching when the baby is close and the mother is actively pushing. During a contraction, a medical professional will count to ten while encouraging mom to push. This ten-count is done three times for every contraction. Doña Ana was speaking to her patient in varying rates of fast. The language was Mam, except for the occasional “Dios mio!” from the patient, so I did not understand what was happening. There did not seem to be counting.
When the talking became even more rapid, I took a better look and saw that the baby was crowning. Doña Ana moved closer to the mother and our view was blocked, but it looked like she pulled out the baby. Immediately she began cleaning it vigorously with soft towels she had laid out. At this point the baby hadn’t made any noise, but was not blue. She turned it slightly to rub its back then the crying started.
Doña Ana reached for a metal clamp, opened it, and clamped the umbilical cord. Two inches along closer to baby she double knotted a nylon cord. In between the clamp and the nylon she cut the cord.
After placing the baby on the baby scale she said, “Seis libras.” Six pounds.
From a shelf she brought down a small pile of neatly folded baby clothes, putting them and the baby on the reclining dental chair. Seeing us staring at the tiny thing, she asked us, “Quieren vestirle?” Do you want to dress him?
Tiffany and I moved to the chair. Realizing that we still did not know the sex, we checked. “Un hijo,” Tiffany whispered.
We put on his shirt and his sweater. We didn’t see any pants. Seeing a small cloth, I thought we were supposed to swaddle him in it. I was struggling to wrap it around his legs when Doña Ana came over. “Es para la cabeza.” It’s for his head. Oh.
She wrapped the cloth around his head the way I imagine a milkmaid would wear a bandana. She then swaddled him in a much bigger baby blanket.
While were dressing him she had delivered the placenta and wrapped the mother in a diaper. During the birth Tiffany and I didn’t notice a tear, and we didn’t see Doña Ana do any sewing, so we assumed patient hadn’t torn. Later I regretted forgetting to ask what she does if there is a tear in the vaginal wall.
Handing me the baby, she went to the mother and helped her stand. We crossed the hallway into another room where one middle-aged woman and two young men were sitting. Behind a screen, at the far end of the room, there was a bunk bed. As one of her helpers brought in a cup of tea Doña Ana situated the mother on the lower bunk.
Tiffany and I were standing awkwardly on the other side of the screen with whom I assumed were the rest of the family.
I whispered to Tiffany, “What should I do with the baby?”
She looked towards the two young men.
Of course, I thought. Dad will want to hold the baby.
I looked at the family and asked, “Quién es el Papá?” The middle-aged women smiled at the young man on her right.
After walking over to him I crouched down and said, “Su hijo.” Your son.
I extended my hands, moving to give him the baby. He lifted one hand, lifted the blanket from the baby’s face, slightly smiled and nodded. He then put his hand back on his lap.
He’s not going to hold the baby, I thought. I’m confused.
Just then I heard a familiar voice calling, “Chicas.” Tiffany and I followed the voice through an adjoining door into another room. Doña Ana said that we had to finish with the baby and instructed us to lay him on the bed. She then walked behind us and shut the door.
Seeing the candle and some matches on the bed, I was thankful that I’d been warned about this beforehand. Dona Ana used the baby blanket to cover all of the little one, except the center of his belly. She lit the candle and proceeded to start burning the cut end of the umbilical cord. For a few seconds the baby cried vigorously and I was worried that he could feel the burning, even though I was sure there’s no sensation in the cord. He soon stopped and was calm for the rest of the procedure. In the US we simply put on a plastic clip to keep the cord closed.
“This is the best way we have to make sure the cord is closed and to prevent infection,” Doña Ana said.
She held the candle to the cord for about five minutes, making sure to thoroughly cauterize the two umbilical arteries and one umbilical vein. Once she was finished we returned to the other room and she gave the baby to mom.
We sat for a while longer. Doña Ana said she monitors the mother for an hour to make sure there isn’t a hemorrhage. As the family was getting ready to leave Doña Ana told us we could go back to our room to rest more, if we wanted. At that point Tiffany and I were awake and didn’t want to go back to sleep on the lumpy beds. We went to our room and packed our things to go home.
On our way out we found Doña Ana working in her pharmacy, selling medication to a man who apparently needed something at 7.17 in the morning. We asked her to take a picture with us. She seemed excited and went to find her husband to take the picture. Waiting in the courtyard, we saw her coming down the stairs of the main house, her husband following behind her. She had removed her green lab coat and her hair was down and brushed. There was a black book in her hand, which she opened onto the bench next to us.
“Write down your names and addresses,” she said. “In case I ever make it to the States.”
Doña’s Ana’s husband took two pictures because Tiffany blinked in the first one. She hugged us goodbye, saying that we were welcome back anytime.
Good thing too, because once I was rested I thought of all the questions I had forgotten to ask her.