First Days at Abundant Grace of God Maternity Clinic

I'm in Northern Luzon this week and next. I'm doing a short, 2-week internship at a charity clinic run by a Canadian midwife called, Abundant Grace of God Maternity Clinic. It's rustic and rural and really peaceful.

It actually reminds me of the house I used to stay in when I traveled to a small town in Thailand near the Burma border for my work with Babies at Risk. The bathroom is outside with a squat toilet and cold water shower. I did my laundry by hand today. No aircon, but we do have internet. There are lot of different kinds of creatures around - dogs, chickens, pigs, toads, lizards, cockroaches, flies, mosquitos, grasshoppers, centipedes and several other random creepy crawlies. I guess this is "roughing it" for me. I don't mind it. Today I really enjoyed the quiet as I did my washing by hand outside on a beautifully warm and sunny day. No need to hurry, just time to wring out the laundry and think about the three birth experiences I just had.

The staff here are wonderful. There are three Filipina midwives and three American midwives, including the director of the clinic. Everyone pretty much lives here and the midwives take turns caring for the women who arrive in labor. When it's your turn you do everything for that woman - from admission to discharge and all her postpartum check-ups.

I arrived on Monday in the afternoon and they were just finishing up with a birth. I hung out and got accustomed with the staff and clinic that first day. Tuesday morning when I woke up around 7:00 I was told a woman had just arrived and she was 9 cm dilated. The director initially offered me to take the first woman in labor but I opted to observe the first and take the second instead. I wanted to see how they do things here first.

So I got to observe that birth and it was beautiful. It was the woman's second baby. At around 8 a.m. she delivered in hands & knees position and didn't tear. The placenta was delivered by expectant management (as opposed to active management). She bled about 300 cc when pushing out her placenta so an IV injection of pitocin was given and the bleeding stopped. Baby was healthy and spent the first hour with his mom, breastfeeding like a pro.

Just before 10:00 a.m. a 17-year-old woman in labor with her first child arrived. It was my turn. Initial exam revealed she was 7 cm dilated so we admitted her. She was very calm and relaxed and stayed this way until the afternoon. Her pain seemed to not be increasing. Her next exam was done at 3 pm and she was still 7 cm but her cervix was thinner and the baby's head was lower and well engaged in her pelvis. We decided to wait another two hours before intervening. At 5:00 p.m. she was 8 cm dilated. We decided to do AROM (artificial rupture of membranes) as the patient was getting very tired. Her labor had started the previous night at midnight and she didn't get much sleep. We encouraged her to eat and drink throughout the day to keep her energy up.

After explaining the procedure to the woman and gaining her consent, AROM was done. The water was clear. A half an hour later there was a clear change in her disposition. The pain had really increased and she was having a hard time managing it. By 9:00 p.m., she was 9+ cm dilated, meaning there was a lip of cervix left. Although she had the urge to push, we encouraged her to breathe as best she could and wait for the rest of the cervix to move out of the way. We had her get into a kneeling position leaning forward on a birth ball. This seemed to do wonders. It wasn't before long that she had an even stronger, uncontrollable urge to push.

We let her push according to her urges and it was unclear that baby was moving down so I did a quite check just to confirm the lip was gone and it was. At 9:30 pm she was fully dilated. She was really tired and wanted to lie down. We encouraged her to at least lie on her side as it's a better position for many reasons but after trying it she felt really uncomfortable and pushing was difficult on her side. She wanted to lie on her back so she did.

She pushed like a pro! The only direction I gave was to listen to my instructions to pant when the head was crowning. (We explained this ahead of time.) She did several short pushes with each contraction and by 9:54 p.m. the head was crowning. I had her pant during a contraction and then when it was over encouraged her to give tiny little pushes to ease the baby's head out. She did this so well, the baby's head emerged slowly with only a first degree labial tear that would not require suturing. Perineum intact. I almost couldn't believe it! Baby was born at 9:55 p.m.

The delivery of the placenta was managed expectantly, meaning no prophylactic pitocin and no routine controlled cord traction. We waited till the mom had a contraction and the urge to push. During this time there were signs of placental separation and her fundus was monitored for signs of excessive bleeding. Eight minutes after birth her bleeding became concerning. We encouraged the patient to push and I gently pulled on the cord to assist. Her placenta was delivered one minute later and with it came a big gush of blood so an injection of pitocin was given. With fundal massage and the pitocin the bleeding stopped. The cord was clamped and cut after the placenta was delivered.

I think for me, after processing this birth, I would have given the pitocin earlier. Even though the mom wasn't anemic, it was unnecessary for her to lose that much blood. But I followed the advice of the other midwives because I wanted to do things the way they do here so I can learn other ways of doing things and in the end it turned out fine. This is my first experience with expectant management of third stage.

We got the mom and baby settled around 1:30 a.m. and I was able to rest till 3:00 when I got up to check my patient's vitals and bleeding and make sure she urinated. When I came downstairs there was a woman in active labor pregnant with her eighth child. Her midwife asked me if I could chart as she was pushing already. She told me that the head had just become visible with pushing. She also asked me to check the heart tones of the baby. I grabbed the chart and made the note. Then I grabbed the doppler and approached the patient to find that the head was already out. I think the mom only pushed twice.

I got to assist for the rest of the birth, wiping and covering the baby and bulb suctioning the mouth and nose, assigning apgar scores and monitoring vitals signs while the baby breastfed. I couldn't believe it when this woman, considered high-risk because of how many babies she's had, only bled about 100cc and pitocin was never given. It wasn't needed. I was literally shocked at this. Her third stage was truly physiological. With the first contraction after the birth, she pushed her placenta out. Amazing.

I could go home happy with what I experienced in my first 36 hours at this clinic. I was so high on these births that even though I only slept for a few hours that night I felt energetic all day the next. This is exactly what I was looking for. To get to experience another way of doing things that is truer to the midwifery model of care. I may not adapt everything I see here as my own personal approach but I am learning that the type of midwifery I want to practice is definitely closer to what they do here and it is possible in a developing country. I sense my recent disillusionment with birth disintegrating and my trust in birth returning.