Busy Baby Season & the Making of a Midwife

September and October are the most busy months at Glory Reborn clinic. Last night was a good example of this. When I arrived we had six inpatients plus a woman in labor. Three patients had delivered the day before and two had delivered earlier in the day. The woman in labor was already active and lying on her left side since her blood pressure was borderline high. While we were doing endorsements (explaining of charts from one shift to the next), the woman in labor exclaimed that she was ready to push. I quickly checked her and determined that she was fully dilated. We transferred her upstairs and within 15 minutes her baby was born. Our postpartum room was full, which has three beds. Our delivery room was full (two beds) and our prenatal area was full (three beds). Thankfully, after the delivery we were able to send one of the postpartum patients home, giving us one free bed. That turned out to be exactly what we needed because at 9:30pm another woman in labor arrived and she too was fully dilated! I ran upstairs to tell my coworkers to hurry and transfer the last patient off of the OB table so we could bring the next one upstairs. They moved her and the bed was cleaned just in time.

I got to deliver the second baby, "Baby Jane," at 9:54pm. Whew! Both deliveries were so fast! After that, we ended up with 9 patients for the night. We had to transfer two to the annex in the back of the clinic so that our delivery room would have two free beds.

I feel like I am becoming better equipped to serve the women we see at GRC. For a long time I resisted the active management of our patients in labor as I believed that most births should be normal and would not need intervention except in a minority of cases. Because of this I have missed some key interventions/preventative actions that resulted in a few of my patients losing a bit more blood than they needed to. A few weeks ago I had a patient that hemorrhaged and it sobered me to the very real danger of excessive blood loss. It can happen so fast!

Hemorrhage is one of the top three causes of maternal death in the Philippines as is the case in most developing countries with poor maternal mortality rates. I have become aware of the necessity in changing the way in which I view my patients at Glory Reborn. By far the majority of our patients are high-risk and my management should reflect that.

I have written about this in the past - my need to reconcile the birth stories I read about in the West and my experience in midwifery in the Philippines. I have come to the following conclusions:

• I still believe that birth is a physiological process that should not be interfered with as long as it continues within the realm of normal. Expected management should be implored in known low-risk women.
• Most women will have normal pregnancies and deliveries if they enter pregnancy with a certain level of health, which sadly and in the majority of women, corresponds with socioeconomic status and level of education.
• Impoverished women, who have lower levels of education, less access to health care and family planning services, and know less about health and nutrition, tend to enter pregnancies malnourished with iron-deficiency anemia, and as is the case in the Philippines, higher parity (having had a greater number of pregnancies).
  
• These women end up with very poor nutrition - with numerous states of deficiency in the least including deficiencies of protein, iron, vitamins A & C, calcium, folic acid, zinc...
• The impact of poor nutrition is understated and is often overlooked.
  
• When compared to women in developing countries, the women in the Philippines have a MUCH greater risk of dying from infection, hemorrhage or pre-eclampsia.
  
• This warrants a different approach by me as a midwife as long as I am working among the poor in a developing country. (Numerous resources put forth by the World Health Organization further confirms the appropriateness of this.)
  
• Doing this will not ruin my ability to appropriately support healthier women in pregnancy and childbirth but will better equip me to handle life-threatening emergencies when they do occur.
  
• It is very appropriate and possible to "be on the safe side" for the women we serve at Glory Reborn while remaining in the realm of evidence-based practice.
• I must continually challenge myself to further improve my skills and judgment so that I can better discern the line where interventions become unnecessary and harmful.
  

So, the birth I handled last night confirmed to me that this approach is an appropriate one. Even though the patient's hemoglobin was normal (so was the last patient I delivered who hemorrhaged), I decided to hook her to IV fluids before she delivered just in case she hemorrhaged. This was only her second baby, but her labor was precipitous, which increased the risk of hemorrhage. I delivered her placenta actively (within several minutes) and sure enough her uterus did not contract well and she had a steady trickle of blood until the pitocin that we immediately infused into her IV took effect. She lost at about 400 cc of blood in those few short minutes. I believe it would have been worse had I not hooked IV and had to give pitocin intramuscularly, which takes longer to take effect and is less effective than pitocin administered via IV infusion.

Her placenta showed signs of poor nutrition. It was small with a very thin cord. Come to find out her husband is a smoker which further reduces the health of the placenta. In the end, her baby transitioned well to extra-uterine life with a birth weight of 2800 grams (only 300 grams away from being considered low birth weight. Babies who weigh less than 2,500 grams at birth have significantly increased risks of mental retardation, learning disabilities, stunted growth/development, and death when compared to babies in a normal weight range. Babies in the 2,500 - 3,000 gram category have lower risks of the above but are three times more likely to experience one or more of those things than babies who weigh more than 3,000 grams.

So, I am practicing a different kind of midwifery than I initially envisioned, but I am choosing to embrace it, learn as much as I can and do the best that I can. Who knows where this experience and will lead me? For now I am quite content and thankful for the opportunity to volunteer at Glory Reborn to grow in my skills as a midwife.