One of our anticipated highlights of this Nepal placement was a teaching workshop that was supposed to happen May 5-7 in Jomsom (in Mustang.) Our anticipation for this workshop grew after we had the chance to run a few teaching sessions to a very eager and responsive group of nurses in Baglung. Due to our early departure from Nepal we were not able to complete this particular workshop… but I thought some of you might be still interested in what the workshops schedule was supposed to be! And so, here it is:

I want to take a moment to write at least a little about our experience of the Nepal Earthquake of 2015/2072. Thousands of people have died and many more have been injured. People have lost homes. Whole villages are flattened. And even now almost two weeks later, aftershocks continue causing for many a rise in pulse and fear, as well as being a constant reminder of what has happened. Many people are still unable to live in their homes; instead, they sleep outside, under tarps if they have them, and weather the monsoon rains which have started a month early this year.

Our experience does not compare with those communities that bore the brunt of the earthquake’s magnitude, but before I can move on to share stories of birth and midwifery and learning, I feel a need and desire to tell our story (from my perspective; Jac and Emma – you can write from yours too!)

We had just arrived in Baglung and were in the midst of bartering for a better price in our hotel room with the manager when it happened. The walls started shaking and the floor started rolling under my feet which I have never experienced before. We ran out of the hotel as the manager yelled “Earthquake!” – and he fell really hard on the stone stairs as we came down from the 2^nd floor. Everyone was running to the street and we followed suit. The streets in Baglung in our neighbourhood were only one lane wide (ie. very narrow!) and most of the buildings lining the streets were one, two or three storied old brick or concrete buildings, some topped with tin roofs held down with large rocks. There was also one huge glass building that no one wanted to be close to! Small groups of people huddled together, some standing in the middle of the dirt street, others crowding under tin overhangs. Cathy, Jacquie and I remained in the street and Emma ran for cover under the frame of a concrete building that was under construction. I know what she was thinking. As a child I was taught that the safest place – other than a wide, open space – is to stand in a door frame: everything will fall around it, but it is likely to remain upright and you safe under it. But – there was a huge piece of concrete overhang that seemed precarious from our vantage point, so we called her back over to us after a few moments.

It was actually pretty quiet in the streets. Some people were calling out to one another, but the stillness in the midst of such force was startling to me: this massive earthshaking power occurred, but in it’s pause people crowded together in silence, and then as you wait together, you wonder if it’s done. But then it’s not done, and the earth shakes again with a power that is impossible to articulate.

The first big aftershock (or was it simply a continuation of the original earthquake?) occurred within a minute or two and that was really the only moment I felt afraid – but I did feel afraid. The four of us huddled together as the ground shook and rolled and buildings swayed and (some) rocks fell. And oh how I prayed. It lasted for about 30 seconds if not longer (at least that is what is in my memory; who knows, maybe it was only 10 seconds, maybe it was a full minute.) After it stopped an old Nepali woman came over to us exclaiming something in Nepali with a look of gratefulness on her face and she patted our faces and grabbed Cathy for a hug. My best guess is she was glad that we – and everyone around us – were safe, that nothing had crumbled in our midst.

We spent the rest of the day in the courtyard of the hotel. Most of the town went to an open field a few blocks away and our hotel manager (clearly a leader in Baglung!) brought tea to the 2000 or so people who gathered there. We felt best remaining with other Nepali hotel guests who also stayed at the hotel. The sun was hot and the “open field” would have been crowded. Our courtyard felt open enough and offered some shade and access to bathroom facilities. Jacquie, Emma and Cathy immediately called their families (& UBC) to let them know an earthquake had occurred and we were safe. It was ~1230am back home, so I decided to wait to call mine. I wasn’t convinced the quake would make international news (little did I know…) and wanted my folks to get a full night sleep before waking them up!! Thankfully Jacquie’s husband saw news images appearing online by 1am, and he called my parents right away to let them know we were safe. I was also able to talk to them later in the day. That decision to call right away was such a good call by Cathy, and we felt grateful to know that our families knew we were safe. And it was happening all around us. Locals at the hotel and in the streets were all on cel phones, trying hard to get in touch with their loved ones around the country. All around people asked, “Is your family safe? How is your home?”

The earthquake did disturb some normal routines which ended up being a little unfortunate (for me and Jac in particular!). An older woman scooped out some of the rice from our dinner pot to feed her granddaughters. This is not a bad thing in and of itself, but we noticed that she did so with her hand… her *left* hand. We remembered this little detail later that night as I suffered from the worst diarrhea and vomiting I’ve had to date! Oh man. Jacquie suffered along with me and poor Emma had to listen to us all night long! Oh we had some good laughs about it, which provided some major comic relief in the midst of the many aftershocks! Suffice it to say, none of us slept a wink and Jac and I were pretty weak so we decided to hold off going in for our first day at the hospital. This was a good thing as there was another major aftershock (~6.7) that next day in addition to the ongoing smaller ones. I fell running from the hotel with the big shock and sent Cathy and my computers flying (which I had grabbed in haste) out of my hands and onto the pavement (thankfully they didn’t get smashed!). I also scraped my hip, knee and gauged a little chunk from my hand, but we cleaned and bandaged right away and it’s been healing nicely ever since. Our hotel manager who fell with the original earthquake pulled out a back brace, but apart from these two minor injuries we didn’t hear of anyone sustaining anything major.

The earthquake changed our trip. Over the next week we started our official clinical placement in the hospital (which was awesome, and I will write more in another post), but the ongoing aftershocks and the daily communication with UBC, DFATD, and our families made it difficult to forget. The news images that began to appear in the days to come showed us the extent of the quake which we had been blind to over that first 24 hours. The devastation and horror so many Nepali’s faced and continue to face is impossible to explain. In Kathmandu bodies were being pulled from buildings and rubble everyday over that first week. In fact bodies were being pulled from a building that crumbled right beside our guesthouse the day we returned to Kathmandu a week after the quake. All week, 24 hours a day, bodies were burned in a park in central Kathmandu. I can’t imagine this on top of all the fear and uncertainty of that first week. On our drive back to Kathmandu we saw many houses standing… but we also say many houses that had either crumbled or tipped “in tact” to the side.

UBC made the decision to call us home, and while we understand the reasons I found it difficult to leave. Selfishly, I am so disappointed to have this placement cut off short. I was loving it, and the next portion of our journey was to take us into the rural areas. We were so looking forward to both the trekking in the mountains and also (especially!) teaching in the tiny health posts. Cathy has connections in small villages from all the work she has done here over the years, and they had asked her to come and teach specifically about STIs and to address their primary concern: neonatal mortality. We were so excited to be a part of that. But even as I worked to let go of my disappointment, I found myself wishing I had the skill to be a true help, to stay and be a part of relief effort. But the truth is I know I would have been another body to feed and outsider to watch over had I remained. What makes me feel better about leaving is that because we left, our instructor “Foreign Nurse #74” Cathy and Dr. Mickey have partnered with our trekking guide Bishnu (a true leader in his community) and his “team” to provide medical aid, shelter and food/water to villages that have been drastically destroyed.

Because our trip was cancelled, they have been free to offer true help and I can’t wait to hear more of the fruit of their efforts.

Anyways, I think that’s it. I’m sure I’ll have more to share in time, but for now… this is it.

Pictured here: Our last night in Kathmandu before heading out. We have many more thoughts to blog, and will do our best to share them in the weeks to come. In the meantime let it be known that we “the girls” would like to send a huge shout out of gratitude to our awesome instructor “The Cathy” and our amazing guide, helper, and new friend “The Bish” (ie. Bishnu). You are both the best.

Just a quick update for those following. We arrived in Baglung, which is about 80km west of Pokhara on Saturday about a half hour before the earthquake hit. We safely made our way into the road during the first tremor and stayed together with the locals. We are staying at a hotel that has both a new building and an older building and after that experience promptly agreed on a room in the new building. The subsequent night was tumultuous, but we made it through safely, with our earthquake plan in place. It takes us less than 30 seconds to get out to the courtyard of our hotel.

Last night was a much better night. We slept well and headed off to the hospital in the morning, where two women are being induced. The hospital has been our most welcoming yet! We really feel we’ll be able to get the hands-on experience we’ve been craving, as well as bringing some love and peace to the women here.

After lunch today, we find ourselves once again in the courtyard (which is our most favourite place in the daytime) observing as men from the community setup a little square, with bricks and tree branches, colorful metallic flags and sand. In broken English we found out that these are preparations for a wedding that is happening tomorrow! About 500 people are apparently attending! We are quite excited and planning to wear our fancy kurtas! This is such a lovely reminder that life must carry on. And that the people here feel strongly that the worst is hopefully over.

It’s been so lovely to chat with our loved ones over the last few days. We will hit 72 hours around noon tomorrow, which is when they will start moving patients back up into floors above the first in the hospital. I think once we make that milestone we will start to feel more like ourselves again.

Our love and prayers go out to those less fortunate. We are doing well and are so lucky to be where we are. Sending lots of love home. For those inclined, please keep praying and sending love and good thoughts. Our friends in Kathmandu at last check were doing okay.

Why was yesterday such a great day?

1. We had our first “sleep in” day – right up to 7:30am!

2. And then we awoke to Cathy peeking her head in our room and saying, “There’s a surprise outside!” What was the surprise? A total blue sky and the first clear view of the stunning Annapurna Range of mountains. We rushed up to the roof, giddy with anticipation, and were rewarded with amazing views of the massive mountains which have so far been covered by the clouds.

3. We had fun at Antenatal clinic at Gandaki Hospital, learning from the student nurses as they performed belly palpations and listened to fetal heart rates. Dozens and dozens of women were lined up and offered us welcoming smiles. It was good to be in the midst of pregnant women.

4. Our new placement in Baglung was approved! We’ll head out tomorrow.

5. We spent the afternoon at Lakeside and had our fave – Lassi’s.

6. We got our government approved letter to officially arrange our teaching workshop in Jomsom in early May.

7. We met Dharma Shila, a MIDSON member and nurse who will present the MIDSON portion of the workshop. She was so lovely and we look forward to getting to know her better. We are also glad to be working in collaboration with MIDSON for these workshops.

8. Our “peak” of the day: sitting in the little restaurant around the corner from our guesthouse showing Dharma Shila and Neelam (another MIDSON nurse) several videos (in Nepali language) about physiologic birth and watching for danger signs in newborns  to provide timely care. As soon as the other women in the restaurant heard the Nepali language they gathered around to watch too! It was so great. Three of the women who gathered were a grandmother, mother and daughter watching what good care immediately after birth could look like (and the videos are filmed in Nepal).

We head to Baglung tomorrow to attend births at a smaller hospital, with a supportive OB. Because it is quite rural, we may not have access to internet for at least a week. We’ll be adventuring, learning and are hoping to bring the midwifery way of birth to women in that community. Lucky for you, we will be keeping track of our thoughts and stories with pen and paper!

We’ll be back in Pokhara on May 2. And hope to get a few posts up upon our return…just in case you don’t hear from us in the interim.

In total, we spent 4 days in the Pokhara Gandaki Hospital. We observed for two days in labour and delivery, and spent two days in the antenatal clinic. While we have a LOT to write about, and much to think about because of this experience, we have also learned what we are made of.

All of the births we witnessed were very medicalized. Control by medicine seemed very important. It is far from birth as a psychosexual experience that I’ve been reading about in Sheila Kitzinger’s book, Birth and Sex (which at the moment, is also keeping me sane). In fact, it’s not even close to birth at home. Though to say I didn’t expect it wouldn’t be true – Cathy had briefed us on what birth was like at this hospital before we arrived. That said, seeing it in person is a lot different from hearing about it in anticipation.

The typical labour and birth at this particular hospital includes oxytocin induction (without prostaglandins first) or augmentation, labouring without support or pain medication in the first stage room (on benches, amongst 7 other women). Then, once full dilation is achieved, the woman is helped to the second stage room. There are three delivery tables in a room the size of our Midwifery Lab (for those who don’t know, it is small). The woman is put on the table, usually propped up (which is good), and instructed to push with contractions. Student nurses crowd each woman as she is pushing – with the other birthing women on tables in the room looking on in anticipation of their impending birth, or in relief of it being over.

Despite the use of oxytocin, fetal heart monitoring is done periodically with Pinard horns and fetoscopes. Once the head is visible, infiltration is conducted (if the woman protests the needle, then anaesthetic is not given) and an episiotomy is cut (without consent and with or without anaesthetic). With a few more pushes, the baby is born, placed swiftly on mom’s abdomen and wiped off. At the same time, the cord is immediately clamped and cut, and baby whisked off to the warmer. None of the babies we observed being born needed any resuscitation, and we were present for 7 births. Then the baby is bundled, handed off to a family member outside of the birthing unit, and the woman receives active management for the birth of the placenta.

Following the birth of the placenta, the women are sutured. They do infiltrate with lignocaine 2% diluted with sterile water, but don’t wait long enough for it to take effect or put in enough to adequately freeze the area being sutured (based on the squirming, screaming and heavy breathing of the women being sutured). During the time we were there, I found myself with two different women throughout the day, looking into their eyes, breathing with them, helping them maintain control over the pain of being sutured with inadequate anaesthetic. The nurses suturing don’t seem to connect the reaction of the woman to their handywork, which is very troubling, given that all the nurses are women themselves and this is a teaching hospital. Once the nurses finish suturing, the women are rolled off the table (as another woman is brought in) and directed to the postnatal room (of multiple women, babies and families). The whole process got us to thinking: if only the women weren’t cut, most wouldn’t need suturing, or would need very little, and would quickly be able to hop off the table with their babies and together head to the postnatal ward.

So, after watching this scene repeat itself 7 times, we decided we had had enough and needed to get ourselves to the nice part of Pokhara to decompress. We watched a particularly meaningful birth video from home (thank you Jessa!) and ordered some comfort food at our most favourite restaurant.

Maintaining control over our own emotions during such emotionally-charged moments has proven difficult, but very important. I can’t say I didn’t want to lose it multiple times over the course of that one day in labour and delivery. I also can’t say I didn’t choke back tears between births. This is so far from our norm and from the type of birth we wish for any of our clients. I am often left wondering how we got so lucky to be in Canada at a time when this sort of birth is foreign.

There is lots that needs to change based on these simple observations. Things that are as easy as reducing the number of students in the delivery room and inducing and augmenting labour only when medically indicated would be a good start. More difficult is encouraging system-wide change in order to comply with Nepali Health Policy, which includes immediate skin-to-skin, delayed cord clamping, restrictive episiotomy, and breastfeeding within the first hour.

However, what is most clear to me is how badly Nepal needs midwifery. The women of Nepal want midwives. In light of our experience in L&D, we took yesterday off to plan for a trip to an adjacent region that has fewer births, but is more open to change. In the evening, after our packing and debriefing, we hosted two maternity nurses at our guest house’s restaurant, discussed normal birth and showed several videos in Nepali about immediate postpartum care for mum and babe, and 8 danger signs in the newborn baby. What was remarkable was how intrigued each woman was! Our guest house owner, her mother and her daughter even tuned in as soon as we put the videos on. They locked all the doors to “keep the boys out!” It was so reaffirming to know that the work we are doing is important, and valued by the very women who have or will be accessing care.

And so, today, on the eve of our departure for another town, we find ourselves in tourist Pokhara once again to celebrate with lassis and tell our friends and family back home that despite the ups and downs of this journey, we are doing fine, and will continue striving to improve care for women in this part of the world.

Much love home.

I was sick yesterday (good ol’ whatchamacallit’s revenge….) so I missed our official first day on labour & delivery of Gandaki Hospital, a Western Region Referral Hospital (fyi – the levels of hospitals are: National Referral Hospitals, Regional Referral Hospitals, District Referral Hospitals, Primary Health Care Centres, and different levels of Health Posts.) I made up for it today though – by noon we had witnessed 7 births! We are still only allowed to observe at this point, but we are using this time to become familiar with the local practices and get to know the nurses and nursing students.

The birth environment here is so different than at home. Women labour in the “first stage room”, which has about 8 beds/benches. When they are fully dilated and ready to push they are brought into the delivery room which has three beds. The beds have rusty frames with black plastic cushioned tops that get wiped down between women. The walls are lined with supplies and there is a table in the corner where the nurses sit to record details from the birth.

The most shocking part (to me) of the delivery room was the number of students crowding around each woman as she pushes. At one point today I counted 18 student nurses – not including us! For three women! We are so accustomed to protecting women’s privacy during birth, and it feels unusual (and to be honest, a little uncomfortable) to see so many women crowding in to watch a woman birth, and stare in between contractions. The other shocking part is that all the women who birthed today received an episiotomy – some with analgesia, some without – but none were clinically indicated. The Nepali government policy is that episiotomies should be restricted to those cases that require it (ie. emergencies or with forceps). Unfortunately, this hospital (and many others we are told) does not practice according to updated guidelines, and every woman is cut. The women were pushing beautifully. Babies heart rates were fine. Jacquie took on the role of “suturing doula”, tending to women while their epi’s (as the nurses like to call them) were sutured. Four other aspects of labour care we would like to challenge are the fact that the nurses do not wait for restitution and pull on babies heads at birth, babies are not kept skin to skin with mom, breastfeeding does not happen within the first hour, and delayed cord clamping is not carried out.

We can’t wait until we are allowed to be “hands on” so we can demonstrate a more “hands off” delivery technique. We’re feeling pretty passionate about no episiotomies unless clinically indicated! But, babies were healthy. So that is great.

(from a few days ago! internet has been a bit sparse)

We’ve been eating a lot of starch here in Nepal – my fave! The most starchy so far? Our deep fried potato sandwich! It came to $0.35 each. We enjoyed “Joyous celebration” together to celebrate our good find, lol!

Cathy got the license she needed to preceptor us after a crazy rigmarole! She was sent all over the city tracking down signatures, documents, letters of invitation, and basically sent through numerous hoops – but she worked her way through them all and we are loving her kind persistence. We’re grateful, and we have now officially bought our bus tickets and we leave for Pokhara Sunday.