Jan 9, 2009

Two Births, Two Twins, Two Boys.

Two boys, both twins, my son on right, my friend N's son on left.
Two boys: the one on the right is my son and the one of the left is my friend N's son. Both were born vaginally and both were part of pair of twins one of whom was breech. But there the similarity ends.

N delivered her twins at term and at home in rural Zangskar at 12,000 ft. She was attended by her sister, a midwife, and the local pharmacist. My son and daughter were delivered at 26 weeks in a stainless steel operating theatre at Dartmouth hospital, attended by no less than four obstetricians, several obstetric residents, three anesthesiologists, two neonatologist, a few neonatology residents, and a dozen nurses.
N's labor and delivery took all of six hours. I was in early labor for four days and active labor for 27 hours, with an obstetric team that was willing to be as patient as modern obstetrics would allow.

N received a single shot of muscle relaxant called epidocin (valethamate bromide) used to relax the cervix and speed up dilation. When I asked to deliver my preterm twins naturally, the doctors looked at me with pity or morbid fascination. Despite resistance, I received the following drugs: magnesium (accidentally) to slow my labor (abandoned once it emerged an amniotic sac had broken), antibiotics to prevent infection (habitually used for preterm births), IV fluids for rehydration (no evidence of benefit other than the ease of administering further drugs), steriod shots to hasten fetal lung development (good evidence of benefit), pitocin to speed up my labor (painful, mixed evidence of benefits), and an epidural just before I pushed my first twin out (anecdotal evidence, as my OB insisted that she didn't want me crawling up the operating table like a former patient as she reached into my uterus to pull out the second twin, who was breech).

If I had delivered my twins in Zangskar, they would have had little chance of survival. If Nyima had delivered her twins in the US, she would have had trouble finding a midwife willing to do a homebirth for twins and no chance finding a doctor willing to do a vaginal delivery where the first or presenting twin was breech. It was luck that I, not she, had the antenatal hemorrhage. Roughly half of all maternal deaths in Nepal and a third of maternal deaths in India and Tibet are due to hemorrhage, and even in the US, hemorrhage remains a major cause of maternal death. Rather than enumerating statistics, let't turn to N's delivery in the rural Himalaya.


Neither N nor her sister Lhaskyid, the midwife, was sure N was having twins nor a breech until the day of her delivery.

When L performed her first internal exam, shortly after N went into labor, she discovered two things in rapid succession. First, N was already ‘two fingers’ (3 cm) dilated after only an hour of labor. But the real surprise lay beyond the cervix. Rather than the comforting roundness of a head, she could feel buttocks. She nearly cried out because this baby was not headfirst.

L had delivered many breech babies in her life, but none of them were twins. She knew the problems a breech could cause---cord entrapment or cord prolapse in which the oxygen to the baby gets cut off, or head and shoulder entrapment in which the baby gets stuck on its way out. Most critically, she knew that in any of these scenarios, there was no option for an emergency cesarean or any of the other life saving measures for baby or mother in Zangskar. The nearest hospital was a 22 hour drive over a high pass that was still blocked by several feet of snow.

L thought of her mother, who had died almost 33 years earlier, after delivering her ninth child, a few years after N's birth. L, only six at the time, recalled the palpable fear in the kitchen as the two most prominent Tibetan doctors in all of Zangskar appeared at their door that night, one after the other. Although the second doctor performed best while inebriated and the first was more familiar with astrology and the texts of Tibetan medicine, neither had been able to do much to prevent her mother from bleeding to death after she expelled a lifeless infant.

L finished her internal exam, smiled, and told her sister that she would soon deliver. Almost in tears, she returned to the kitchen where her stepmother was churning the butter tea. She took the wooden tea churn and sent her stepmother off to call one of Karsha's more skilled birth attendant, a local pharmacist.

The pharmacist arrived perplexed, for he knew that L had delivered many babies in her career. After he performed an internal exam at L's suggestion, he went into the hallway and said "kam log", which mean vomit, the Zangskari equivalent of "oh shit". He and L resolved to labor strategy in Urdu rather than Zangskari so that N never suspected how difficult this delivery might be, nor that she was having twins. While L rubbed her sister's back and made sure that she stayed warm, she also knew to keep her ‘hands off the breech’. It was not long before N pushed out the first twin, a boy who came feetfirst. Although Zangskaris prefer a man to cut the umbilical cord, when L yielded the scissors nobody objected. While L knew to put the baby to N's breast to keep the oxytocin---biology's natural pain medication---flowing, N caught her breath and recovered some strength. A twin girl arrived shortly afterwards, slipping easily past a cervix already widened by her brother. L reached down to catch the second baby, cut the cord, wiped the baby dry and handed him to her mother who cried in relief.

Both of these stories are about “skilled attendance at delivery”, something the WHO measures and counts across the globe. This quantification has brought funding and a measure of attention to the problem of women dying in childbirth. Yet ethnography can provide an equally powerful way of suggesting what ‘skilled delivery’ or ‘humanized birth’ might mean. N and my delivery shared several critical features including the skilled management of twins and breech positioning. Yet they differ in one key regard; I had far choices more choices than N and most of the women in Zangskar. In India this year, roughly 16 million women will deliver at home and roughly 13 million will lack access to skilled attendance at birth. They deserve more, and ethnography may have a critical role to play.