Jan 9, 2007

Twin Birth in the Himalayas

N with her twins, Stankyong and Tsering

In some ways, N's delivery and my own were uncannily similar.

We were both old to be having our first child, we both had twins, we both had them vaginally, and one was breech.

We were both outside the full day, having delivered babies in early May after a long, cold winter. But here our paths diverge.

Unlike me, N knew she would give birth at home, as her five older sisters had. Moreover, her sister–––a trained midwife with over 20 years experience across Zangskar–––would be her primary birth attendant. While my sister had helped deliver babies in a rural hospital in Uzbekistan and had worked for years in reproductive health, I don't think she would jump at the chance to deliver my twins at home.

Unlike me, N had conceived her twins naturally without drugs or other interventions. In fact, she didn't know she was having twins until the night they were born. She hadn't seen a single obstetrician or ultrasound technician during her entire pregnancy. Her first indication came at at six months when Lhaskyid, the midwife, noted that her belly was riding too high and out front for a single birth. N was so scared she wished this thought away the moment it was uttered.

Unlike me, N's exercise the day she went into labor had not been yoga, but watering her fields. She was laboring long before she knew she was in labor. She delivered on one of the busiest times of the year, when the entire village is engaged in 'first watering' or sgrol chu. This involves racing up and down sinous waterways to open and close the 'mouths' of the channels that wind their way through the landscape bringing wate to the barley fields. Climbing along this vast and spidery web of channels and subchannels is a strenuous job, even when the sun is not burning overhead.

It was her turn to go out from dawn to dusk, flooding each and every field, square meter by square meter. Flood the field too fast, and the seedlings are damaged; too slow, and your fields won't get done by the time your turn is up in the village-wide water rights scheme by which each household gets just enough water for its fields.

When N came back at the end of the day, she felt a slight ache in her back, but assumed it was just soreness from bending over the fields with her shovel all day. She said nothing, but fell asleep shortly after dinner in the kitchen while her sister cleaned up. A few hours later, L heard N cry out in her sleep.

“Ahhroohwahhh. Ahroohwahhh.”

When L heard this cry, she guessed that N was in labor. This was no random lament but one scripted for female pain, especially for labor. This cry is mostly by women and often to signify suffering above ordinary or mundane pain. It is a polite way of registering agony that does not disturb the mask of stoicism women wear in Zangskar.

L got up and looked around the kitchen for the implements she might soon need to use. Once she found a match and lit the kerosene lamp, she began to boil some water for tea. While N stayed snug in her warm blankets, L dug around in the cluttered shelves until she found her syringes and the ampules of glucose and epidosin (a muscle relaxant to relax the cervix that she used more and more often). She had sent them over to Karsha two weeks before her arrival, just to be safe. N heard her bustling about about next door in the parlor laying out a new set of rugs, a plastic sheet, and then some clean blankets for the imminent delivery.

It wouldn't do to deliver in the kitchen, N knew. The hearth was a sacred space for both the thab lha mo or hearth goddess and the subterranean klu, both of whom were responsible for household fertility and were offended by the blood of birth. While women are banished to the stables to avoid offending the klu on the Tibetan plateau and nearby Kargil, N was free to labor inside her home, in not the warmest but perhaps the cleanest room of the house.

When Lhaskyid 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 felt buttocks. As she manipulated her fingers around to be sure, she felt the little one’s lingam and almost cried out. Not because he was a boy, and she had just touched the organ that signified this. But because this baby was not headfirst. 

She had delivered many breeches in her life, but none of them twins, and always with a backup helper. She knew the problems a breech could cause---the cord could squeezed or tangled and cut off oxygen to the baby, or the head or shoulders could get stuck on the way out. Even more critically, Zangskar's only labor room, at the primary health clinic where she worked, had no emergency facilities for a cesarean. The nearest hospital was an 18-hour drive away, over a high pass that still lay under several feet of snow. 

L finished her exam, smiled, and told her sister she would soon have the baby. Then she went into the next room to think. She sent her mother off to call Karsha's most skilled birth attendant, a medical assistant, while she made some butter tea. 

The medical assistant was perplexed when he arrived. Lhaskyid had delivered many babies in her life and usually did so on her own. Why had she called him. When he performed his exam, he nearly gasped, but kept his face as straight as possible for N's benefit. Maybe it helped that he talked to Lhaskyid in Urdu rather than Zangskari so that N never suspected anything. Maybe it was that N never realized she had twins until after the whole thing was over and so she wasn’t overwhelmed from the beginning. Maybe it the fact that two very experienced birth attendants knew as much to follow the ‘hands off the breech’ policy. A few short hours, the twins were born, an hour apart, in perfect health. 

In the first year after their birth, N's twins had a few bouts of fever and diarrhea. My twins spent the first three months in the Intensive Care Nursery at Dartmouth Hospital with very few complications and showed no signs of prematurity at the end of twelve months. 

Both sets of twins, for very different reasons, outwitted the odds against them.

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