Wednesday, March 1, 2017

Not Afraid to Care

"The 2014 West African Ebola outbreak killed 11,310 people. Liberian nursing assistant Salome Karwah was not one of them." says Time Magazine. "...as soon as she recovered, she returned to the hospital where she had been treated — the Médecins Sans Frontières (MSF, or Doctors Without Boarders) Ebola treatment unit just outside of the capital, Monrovia — to help other patients. Not only did she understand what they were going through, she was one of the rare people who could comfort the sick with hands-on touch. She could spoon-feed elderly sufferers, and rock feverish babies to sleep." wrote Aaryn Baker.

The Washington Post states,
"Last week, Karwah died as a result of complications from childbirth, and the lingering suspicions of Liberians toward Ebola survivors was partly to blame."

Three days after a cesarean birth on February 17th this year, Salome went home and began to convulse. Though her family rushed her back to the hospital, fear of contracting ebola through her saliva stopped the medical staff from treating her. Time reports, "They said she was an Ebola survivor,” says her sister by telephone. “They didn’t want contact with her fluids. They all gave her distance." Treatment may have included heparin if symptoms matched a blood clot, and magnesium sulfate IV if eclampsia was suspected. The anti-seizure medication diazepam may have been considered. But Salome got none of these treatments. Fear and not knowing how unlikely it was to resume an eboli viral infection prevented good medical care. Training may have saved this heroine's life. How bitter that she was so willing to serve eboli victims so these same medical staff members didn't have to risk contact and that later they let her die unnecessarily because they didn't want to risk contact.

The most common cause of seizures after childbirth may be eclampsia which can be seen as rapid shaking of the body, or convulsions. 

Lubarsky (1994) studied late postpartum eclampsia, most of which took place after hospital discharge. After 48 hours the risk lessens but eclampsia can strike two weeks or even three postpartum.

Sibai concluded that postpartum convulsions three days after birth are likely to be cerebral vein thrombosis (1980). Up to 30% of victims do not have headaches preceding convulsions, finds Coutinho (2015). Hormonal contraceptives, pregnancy and postpartum period increase risk. 

A 2012 case report also cites dural puncture from a difficult epidural. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3371498/
This woman was given diazepam to stop the seizure and magnesium sulfate through intravenous fluid injection until it was determined by spinal tap examination that a dural puncture was the cause.

So many health care workers and others who give selflessly are reeling from this tragic loss. Those who have worked in similar extreme conditions are all so close to the split of the courage and the fear and the human behavior reflecting the opposites. I can only assume the poignancy with which these fearless rescue worker must feel this news. 



Might I be correct in suspecting many Americans would assume that US medical workers would not bow to fear. We have evidence, we have protocols, hey, we have gloves! 


A recent series of emails with a breech bearing Mama is a common but seemingly less extreme example of fear stopping proper medical treatment.


The pain within this first email may not be blazing, but it's chronic and also epidemic. The loss is not only to be the parent struggling to find help in a society which turns away from natural breech birth but to be a midwife reading her desperation. 


A pregnant woman writes to a group of providers, seeking skills and willingness that is nearly extinct in the USA.
"I am almost 32 weeks pregnant.  My baby was head down but at my check up just presented breech.  I know its early, but my current provider will not even consider anything but a C-section if the baby remains breech.  ...
I have heard no hospitals in the twin cities offer vaginal breech delivery...

Please let me know if you or anyone you could recommend has experience with natural breech birth and still is willing to attend one, and would take me as a transfer patient at 32-33 weeks. Please include cost of service too ..." 

Compounding the sadness is that the outcomes of vaginal breech birth is similar to those of cesarean with a skilled provider. The problem is that the skills are rarely taught in schools and not many providers can travel to breech experts to attain training.

These obvious mourners, mothers and midwives, are not the only ones to grieve skills lost. Thomas van den Akker served birthing families in Malawi. He warns European physicians that there are also hidden victims of denying breech vaginal birth are the subsequent siblings who may die from cesarean after-effects of rupture in later pregnancy and the women and breechlings of low-resource countries whose care providers have now also lost the skills of breech delivery before a system of high-tech surgical suites can be supported in communities.
(Who pays the price? (Foreign) women, future siblings, 2016,Thomas van den Akker MD.PhD, Resident O&G at University Medical Centre, Leiden, The Netherlands as reported in the Amsterdam Breech Conference, 2016 Teach the Breech!) 
Thomas van den Akker at 2016 Teach the Breech
Breech skills retained in high-resource countries save lives in low-resource countries as well.

Cesareans replace the recommended procedures in spite of electricity not being available 24/7 in many rural hospitals. These same communities are devaluing and banning midwives and so lose their knowledge as well. Can the western medical invasion comprehend the resulting die-off caused by the inoculation of hybrid birth practices devoid of community networking and manual skills which need no electric lights to succeed?  Like a viral tsunami, surging western high-tech values wipes the cells of culture, birth, and family from the bed of hands-on skills. 


The late Abby Kinne teaching breech skills to a midwifery student.
Abby was a dedicated teacher to first responders and medical and midwifery students.
Who in her area has taken her place? Does anyone know breech like she did in her region? 
New understanding in physiologically-based exercises for what Carol Phillips coined body balancing seem to help women themselves achieve head-down fetal positions for their babies. Spinning Babies suggests self care and professional bodywork and other ways to help baby get head down before manual force of external cephalic version or skipping attempts at turning babies and going straight to cesarean. 

If no one is available for breech skills, then breech birth is more risky but parents who choose vaginal birth have the right and are, importantly, not wrong to choose vaginal birth. It is the responsibility of providers to insist on breech skill wisdom and to seek it, bring it to teaching venues, and preserve it in law and protocol. We must not find ourselves to afraid to act correctly. 

The same mother writes, 

Thanks so much, Gail!  I did a lot of exercises to try to help the baby turn, and thank God, she did turn head down in just a few days... I am just hoping and praying that she stays that way:)  

Thanks again for all your help and your warm response.

March is Womens History Month. http://womenshistorymonth.gov/about/


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Changing the Earth by supporting Birth

Mothers bring forth life; medical corporations do not. Birth can be simple, powerful and loving. Fetal positioning, natural birthing and practical help for normal birth.