Fit To Be Tied.

The next birth happened a day or so later.

The young mother-to-be was alone but apparently unconcerned by this fact. Not all of the labours have companions.

So as she laboured, I taught the students how to evaluate her contractions and take her history. She was 20 years old and expecting her first child.

She readily admitted to taking traditional herbs to prepare her body for birth... and even to start her labour.

Since her contractions were strong and frequent, the nurse decided to do a vaginal exam at 10 am. The nurse was VERY aggressive during this exam, manually dilating her cervix despite the patient's vocal protestations.

Afterward the nurse informed us she was 90% effaced but only 6 cm dilated. But after such forceful manipulation of the cervix, I did not think it true for long.

Sure enough, an hour later her water broke and she immediately got pushy.

In fact, there was no stopping her. So we called for the nurse. 

The young mother was already fully dilated and wanting to push. The nurse tried to get her to focus and push effectively but she would have none of it.

All she wanted to do was scream. 

One scream was so piercing and so long, it could have shattered glass.

After some negotiation, we convinced her that screaming like that was not actually helping. In her defense, she did really try to push. But each time she did, she would close her legs and withdraw.

It was going no where. 

The nurse was not pleased and she argued with her.

She then tried to push again but ended up kicking the nurse and swatting her hands away.

The nurse was even less pleased with this behavior. 

After more negotiating, the young mother confessed that she needed help controlling herself and requested that two of the male medical students hold her down while she pushed.

Yes. She wanted them to forcibly hold her down so she would not hit or kick the nurse.

So they did.

Mind you, they seemed more than a bit surprised by this. I don't think either one of them woke that morning thinking that they'd have to tackle a pregnant woman while she pushed her baby out. But you know... some days are surprising like that.

I soon found myself out of my depths and stepped away from the melee to watch at the foot of the bed. The remaining two students shuffled a step closer to me with each new scream. One (who plans on being an obstetrician) was wide-eyed and mesmerized by the beauty of it all. The other (who is unlikely to choose obstetrics as a specialty) kept hiding her eyes and furtively glancing my way for assurances that the woman was not in fact dying.

Meanwhile the young mother continued to scream and abuse the staff while pushing. The nurse, more than likely frustrated with the abuse, decided to perform aggressive perineal stretching. The baby was born quickly but caused a significant 2nd degree tear in the process.

The placenta was pulled from her body within minutes of the birth with strong cord traction. It was so strong in fact, that the cord snapped, squirting blood all over the foot of the bed.

The nurse decided to suture the tear before presenting the baby to the mother. The young mother screamed and fought the sutures just about as much as she did the birth, despite being anesthetized.

When the nurse finished up the stitches, she reached down for the baby's ankles, lifted her high in the air and presented her genitals for the mother to see.

The young mother whispered, 'a girl' to herself and smiled.

Then the baby was taken off to be wrapped and weighed.

Normal?

Her contractions were strong and frequent when I first met her. She lay on the bed and her mother held her hand.

The pain contorted her face and forced the occasional groan, but she didn't seem to notice it much. For the most part, she was surprisingly quiet.

So quiet in fact, that I didn't think she was even close.

As a 17 year old G1 (aka: primigravida or woman pregnant for the first time), I expected things to go a little slower. But her body had other plans.

Shortly after we arrived, her waters broke and she started getting grunty. One of the students informed the head nurse, who started setting up the room.

She started pushing before the nurse was ready, so I encouraged her to breathe through contractions and taught her how to push effectively.

The grandmother, looking a mixture of exhausted-relief, excused herself to the corner of the room and said nothing. Absolutely nothing.

The mother pushed effectively despite the five extra medical student faces huddled around her bed. She didn't seem to notice or care in all the pain.

The nurse on duty expedited the birth by doing perineal stretching and the mother remained silent. She pushed only a handful of times before the head was born. The nurse didn't wait for the next contraction, she just reached inside and wrenched the shoulders free. Again, the mother made no noise.

The baby was out less than a minute when the cord was cut. She too made not a sound. Just like her mama.

The nurse grabbed the child by both feet and swung her in the air, presenting her upside down for the mother to see. The mother smiled when she saw it was a girl, then dropped her head back on the bed in a rush of exhaustion.

The nurse lay the child on her breast and it mewed quietly.

Within 3 minutes after the birth, the nurse aggressively massaged the mother's uterus and applied traction on the cord. The placenta wasn't budging. She forced it harder and massaged even more aggressively.

This continued until the nurse found herself with a torn placenta (only 5 minutes postpartum) and decided to do a manual extraction. Reaching her right hand in up to her elbow, the nurse extracted chunk after chunk of the placenta from the uterine wall. Each time she reached in, she came out with chunks, clots and membranes.

The mother made not a sound. 

Afterward, the nurse reached in repeatedly with non-sterile gauze to evacuate the uterus and vaginal canal of any remaining blood. But still the young, new mother remained silent.

Inside, I screamed for her. Inside, I cried out in pain.

For her.

How she remained so stoic... so quiet, I'm still not sure.

As I looked through the nurses' bloodied hands, several baffled expressions caught my eye. "What must these medical students be thinking?"

For many of them, this was their very first experience with birth. I shuddered to think that this was considered 'normal' in Mozambique.

Perhaps... it is normal.