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.

"Brown Out" during the Night Shift

I'm not sure why Filipinos call a power outage a brown out. When the power goes out in the Philippines, there isn't even a little power coming through. There is simply no power. Last night while at work at the clinic, we had a "brown out."

Thankfully my patient delivered ~30 minutes before the delivery room went dark (and I might add that she delivered ~30 minutes after I arrived and was told she was only 4 centimeters dilated and not in active labor! Just goes to show you should never think you know how fast or how slow a woman will have her baby. And you better listen when a woman says she's needs to push. At least there is usually a very clear difference between a 'i think maybe i need to push' urge and the urge that can. not. be. stopped. That baby is coming! Can you say 'precipitous labor'!?). It was already oppressively hot. Accompany that with the loss of the electric fan and the sweat that was already beading on my forehead quickly began pouring down my face as well as every bodily crevice. Breathable cotton undergarments? That don't make no difference when they're drenched, child. Believe you me.

Ode to hot season in the Philippines

There is a heat the rest of the year that becomes bearable. That not when it's summertime in the Philippines. The word hot takes on new meaning. "I don't remember it being this bad last year!" Oh how quickly we forget.

Summertime.

When you daydream about a city-sized dehumidifier. When the aircon barely makes a dent and the electric fan becomes a must add-on. When you uncharacteristically desire a walk by the river on a windy winter day in Saskatoon. When you lose your mind with disgust for your present stickiness and plan your days to stay close to home and that "cold" shower. When the cold shower isn't cold anymore!!! When you resort to drinking salt water to replace the massive salty water loss. When you can drink 4 glasses of water in 15 minutes and still not have the urge to pee! When looking on the bright side has you thinking, "I must at least be sweating out some toxins!"

Our brown out, which lasted about an hour afforded me the unique opportunity to suture in a very romantic setting - by candle light. The only thing is, you can't get the light source very close to the patient or you will sacrifice the sterile field (or light your patient on fire). Thankfully we also had a small flashlight and an extra visiting volunteer to hold it while I sutured. This was a first for me. The power came on just as I was tying off so I was able to inspect the stitches clearly to ensure I did a decent enough job. Success.

Our patient is positive for hepatitis B but did not prepare the essential immunoglobulin injection for her baby after months of reminders. They simply didn't have the money. And the clinic just so happened to be out of hepatitis B vaccine, which all babies get. When the clinic is out of hepa-B vaccine it usually reflects a city or province-wide shortage as sometimes even the Department of Health is "out of stock." Nice. This baby first needed the hepatitis B vaccine injection, to be followed by the immunoglobulin 6-12 hours later.

What to do? We sent the patient's husband out to look for the vaccine with borrowed money from the clinic. The patient and her husband only had 500 pesos (~$11) to their name. It was after 10 pm. He didn't come back till after 11:30 reporting the pharmacies he went to were out of stock. This baby really needed this vaccine.

Thankfully I had my car. He and I went to seven different pharmacies before we found the vaccine. It took over an hour, driving all around town to find it. Thank God we did.

That was my first shift since the end of March (what a way to come back to work!) and my last 12-hour shift in a while. We are trying out a new schedule format next month with 8-9 hour shifts. At least then I will be showering off 9 hours of unimpeded sweat instead of 12. I wonder if I will notice a difference.

The Morning After (first home birth)

Thankful for this moment
to ponder and reflect
on the occasion of an anticipated beginning

After a night that brought breath and birth
I contemplate the wonder and amazement
of an event that left me in awe

I've seen it many times before
but this was like no other...

At home, in comfort and security
with family and familiarity
she confidently and gracefully
surrendered to the strength of her body
from which life flowed

A highly-anticipated event
prepared for and prayed for
sought after and welcomed
the jubilant arrival of their son

This child, long-awaited and deeply loved
received gently into the arms of his mother
beneath the adoring, joyful gaze of his father
brought into the wholeness of an intact family
this new soul, carefully designed by the Life-Giver

i am deeply humbled
to have been witness
to such simplicity and significance

Today's Births & Thoughts

It was a busy day at the clinic. We had prenatal exams all morning. Then we had two births just after lunch, 45 minutes apart. No anemic patients. No IV fluids needed. No meconium-stained amniotic fluid. No hemorrhage. Just two, refreshingly normal births. I realize how much I enjoy those when they happen. Truly a joy.

A not-so-great part of the day was examining a 16-year-old patient who came in complaining of pain in her lower abdomen. She's 32 weeks pregnant. The most common reasons for this are a UTI, normal pregnancy-related discomfort, or premature labor. I was pretty sure it was probably one of the first two possibilities as we quite often get women, especially first-time mommies, coming in thinking something is wrong when it really is just normal, practice contractions or normal, pregnancy-related aches and pains. But to be safe, I needed to rule out premature labor just to make sure. So I routinely had her get ready for a quick internal exam not thinking much of it.

I was shocked as I could immediately feel the baby's head because it was so low in the pelvis, and her cervix was at least 5 centimeters open already. I think I may have even gasped. The baby's head felt soft - not the typical well-developed, hard bones of the term fetus skull. I really wasn't expecting this and of course, neither was this teenager. Poor girl. I told her my findings as I discovered them and she looked at me and said innocently and ignorantly, "Is that bad?" I had to tell her that yes, this was bad and we have to transport her to the hospital right away. The really sad thing is that I know the baby is probably not going to make it. They don't have money for a private hospital and the public hospital does not have any incubators. We had to send her there anyway. Just terrible.

You know, I have seen and heard of some pretty tough things at the clinic over the past two years but for some reason this today made me feel more sad than usual. I'm really not sure why though. More than not knowing why this story makes me feel sad is the perplexity at why I don't always feel such sadness with the other tough things I've experienced. Like when my patient's baby died (at the same public hospital) after it's cord became pinched between her head her mom's pelvis in labor and the hospital didn't even do a C-section to save the baby. Again, this is what being poor in the Philippines means. No money + emergency medical need = no care + unnecessary death. I remember feeling numb about that experience. I wasn't there when the baby actually died although I did listen to the baby's heart beat slower and slower with each contraction. That was awful as I was so helpless to do anything about it.

Well who knows why you feel some things more than others? We are human after all. I think we just can't go through life feeling everything, otherwise we couldn't function. But the opposite end of the spectrum isn't good either - never feeling anything and disconnecting from the pain around us. So I'm thankful for the sadness I felt today. I want to strike the right balance of feeling. I want to be affected in some way by the suffering I see, and I want it to make me feel at least a little uncomfortable. That way I am more likely to act. It just feels right to have to deal with it, struggle with it, ask hard questions. Examine myself and my own calling and abilities. I may not always be able to do anything but many times I will be able to do something and will hopefully have the courage to do it. On the other hand, if I let myself shut off, I fear I'd become a hard-hearted person who loves being cushy, comfortable and complacent. Where's the adventure in that?

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.

Back to Work, A Birth Story, and the Practice of Midwifery Among the Poor

Yesterday was my first shift at the clinic since our trip to North America. I felt a little nervous about going back, as I usually do after a long break. I'm typically a little nervous that I will have forgotten how to do something or that I'll be a little rusty from being out of practice, but after a busy labor and birth-filled day, I am happy to report that I didn't forget and I didn't feel rusty. I just slipped right back in to sweaty, busy clinic life.

A 24-year-old woman in labor with her third child arrived just before 10. The rest of the staff was in our weekly meeting so I was the one to receive her. This meant I would be the one to deliver her baby and I was quite happy about that. I wondered if I would get a birth on my first shift back.

She said her contractions were coming every five minutes. She was 39 weeks and 3 days. Her blood count was uncommonly good and she didn't report any major complications in her previous pregnancies. All very reassuring things. Upon examination and monitoring her I found out that she was 3 cm dilated, her blood pressure was slightly elevated and her contractions were indeed coming every 5-6 minutes and they were moderately strong. She was very relaxed even though it was apparent that her contractions were painful.

After I hung out with her a while timing her contractions and noticing her blood pressure was borderline high between contractions, I asked her how she was feeling about giving birth, which would likely be this afternoon. Was she excited? Nervous? Worried? I tried to get an idea of what was going on inside her mind. I find it's not easy to read some of our moms. Most are very reserved with their emotions and I was trying to see if there was an emotional reason for her B/P to be on the high-side. She didn't say much at first, then as I asked her again she just shrugged her shoulders and said something to the effect of, Whatever, man, totally fine. Like what's the big deal? Okay right. No big deal. At least she wasn't worried about anything. That certainly can't hurt while in labor. (Assuming she's telling me the truth.)

As the day went on she progressed well. Four hours after she was admitted she was 6 cm dilated and her contractions were every 4-5 minutes. Within an hour after that, I knew she was reaching transition as her contractions grew stronger and were coming every 2 minutes. Her blood pressure continued to rise. I transferred her upstairs and had her lie on her left side. She continued to do an excellent job of keeping her body relaxed through the intensely strong and painful contractions but she clearly appreciated support through each contraction. Between me and her boyfriend rubbing her back and talking her through, I think we were able to give her the support she needed.

As her labor intensified, her blood pressure rose and became disconcertingly high. I called Hilary in who was busy with lots of new patients downstairs. (Each month we offer free labs in order to fill our available space for patients so there were numerous new patients waiting to have their interview and first check-up.) Usually we would transport a patient with high B/P but I knew she was getting close and at the public hospital they would likely leave her unattended without monitoring her properly. Since she was progressing well and was asymptomatic, we decided to keep her at the clinic and do what we could to help her deliver safely.

We hooked her to IV fluids just in case it became a true emergency and we either had to take her to hospital or infuse hydralazine to bring her B/P down. I did an IE and she was 9cm and the bag of waters was at +2 station. After a contraction I rupture her bag of waters. The water was a dark brownish-green color, "moderate meconium stain." She said she wanted to push but I doubted it was a physiological urge since she wasn't instinctively bearing down and also because I knew she wasn't yet fully dilated. It was best to let her uterus do its job and wait for the physiological urge to push. She would have to continue breathing until she really had the undeniably strong urge to push. And when this happens, it will be undeniable. So she stayed lying on her left side and we encouraged her to breath deeply through each contraction and try to stay relaxed. She did this well although we could tell it was very difficult.

Within 20 minutes it was clear that the baby's head had reached the pelvic floor as she couldn't do anything else but begin bearing down. Her B/P continued to rise beyond what is normal. We tried to get her to only push as much as she had to but to breath when she was able. Again, she did such a good job trying this and I knew it was extremely difficult to do, but I knew the baby's head was coming down and all we had to do was wait a couple more contractions, get her to breath and the baby's head would be visible. And soon it was.

With the next contraction and with her doing more breathing than pushing, the head was emerging. Her perineum was taut and bulged with about a 2-inch circle of the baby's head just behind it when her contraction ended. I wanted her to stay as relaxed as possible in order to keep the tissues oxygenated and give them a few moments to stretch. I have read that this can help prevent a tear by letting crowning happen slowly (when possible!). I was amazed at her ability to relax and breath! I thought, this is amazing! This will really help. We waited for the next contraction. At the beginning of the next contraction and with a small push, the head was out but I could tell that she tore. The body followed and the baby was placed on its mother's belly just as the room filled with the sound of his first cry. Another baby boy! (Their third.) He weighed 7 pounds 6 ounces. It was almost 4 pm.

I waited for the cord to stop pulsing before we clamped and cut it. The baby was placed at the breast while our nurse dried him, put a dry blanket over him and checked his vital signs. The placenta was delivered after eight minutes and pitocin was added to her IV. Hilary said in her experience that women with high B/P in labor tend to bleed.

I was surprised to discover that this mom had about seven first degree tears. Five of them would have to be sutured. I spent the next two hours suturing! Poor gal! Don't worry, we do give local anesthesia. It was a challenging suturing job for me and I was grateful that Hilary was there to guide me. I learned a lot with this one but I'm am disappointed and confused why she tore so badly. First baby, okay maybe but the third? Most of our women tear and I still wonder why it happens so often. What are we doing wrong? Hilary says a simple episiotomy would have prevented all those tears but I keep believing that it shouldn't have to be this way. But after tear after tear after difficult tear I can't help but wonder. But you never know that a woman will tear so badly until after and at each birth I am always hoping for the best! Do our moms tear more often? If so, why? Of course I don't know what is normal because at this point I don't know any different. Anyway...

What a way to come back to work! By the time we got mom and baby settled, got everything cleaned up and I finished the paperwork, my shift was over and it was time to go home. Even though there are many elements to this birth that I need to process and evaluate in my mind, I feel very satisfied to have gotten the chance to work with this young mother. I did a lot of praying for her throughout the day and so I give glory to God for helping us and helping her safely deliver a healthy baby without a trip to the hospital!

This is exactly the kind of situation that is clearly out of the scope of practice for midwives in N. America. There are many reasons for that and it's good that that's the way it is, but I am beginning to realize that working with the poor in a developing country is practically a different career than practicing midwifery in a developed country. It's just so different. I know the midwifery I am able to practice in the Philippines is not possible back home. I am starting to wrestle with this reality as I develop in my mind where and how I'd like to use my midwifery skills. Do I want to be limited to working with low-risk women, many of whom have several options available to them? Or do I want to work with women considered to be "high-risk" because of their age, their high fertility rates, their poor nutrition levels - who have little to no options for giving birth in what would be considered to be a safe place? I'd say the majority of the women we see at Glory Reborn would be considered "high-risk," but we are compelled to work with them because of their lack of options and we are able to work with them and care for them beyond the scope of midwifery in the West because we have two obstetricians who have agreed to oversee our cases. I'm glad for this. It's good for the moms we serve.

In the spectrum of developing countries, the Philippines is not as bad as many other countries like Afghanistan and Haiti, and those in West Africa. I'm not saying it's not bad here because it is, considering how much better it could be. I was recently looking at maternal and infant mortality rates in Haiti and it's so much worse than the Philippines! Although about half as bad as West African countries and Afghanistan, Haiti's maternal mortality rate is three times that of the Philippines. And the infant mortality rate is ~2.5 times that of the Phils. Haiti is clearly the worst in the Western Hemisphere, which is not a surprise since it is the poorest country in the Western Hemisphere.

We have friends who are working with orphans in Haiti and I hear stories about how bad it is there and how they need midwives! One of the babies our friends adopted was orphaned because her mother died in childbirth. I can't help but dream (am I crazy?) of working in a place like Haiti where only 26% of all births are attended by skilled health personnel (only 6% are attended among those in the lowest wealth quintile!). This figure is 60% of all births in the Philippines, with 25% attended births among the poorest, versus 92% among the wealthiest! This is outrageous! It is well documented that one of the best ways to improve maternal and infant mortality rates is to have access to and utilize a trained health care provider during pregnancy and birth. Midwifery saves lives!

I am compelled to use midwifery in the developing world but to do that is to choose to practice a different kind of midwifery. Different than the dreamy natural birth stories I hear of friends in North America attended by midwives, which are wonderful and great and well, that's why I call them dreamy. I must, I believe, in order to be a good midwife, experience natural birth in the West. Learning what those midwives know will enable me to only intervene when it is really necessary. I try to do this now but it is hard without experience on my side and those with experience telling me this is what is needed to keep our moms and babies safe. I don't want to lose my trust of birth and God's enabling of women to give birth. I get sad expecting, trusting things to go as they should and then they don't. Fine, if that is the case in the minority of cases. But the majority? I struggle with this.

I understand that our women aren't birthing under ideal conditions. Malnutrition is rampant and I think its effects are underestimated. Plus lack of access to decent health care must play a role in their health level coming into pregnancy and birth. I am learning in the health care debate in my own country that those without health insurance access less health care and are subsequently sicker and have higher mortality and morbidity rates. This has to be a factor here as all medical costs are out-of-pocket. The only social insurance is for those with full-time jobs who pay taxes and the health coverage they get is not worth much. Arg! It's just so frustrating!

Other factors that I can see include lack of basic education regarding how the body works, cultural factors that keep poor women from thinking for themselves and being empowered to affect how her pregnancy and birth is handled, and simply poverty. Not having the money to treat basic infections, buy nutritious food, get care when it is needed to even maintain a minimum level of health. We do provide education at Glory Reborn but just a few teachings here and there is simply not enough to change the way people think and approach the births of their babies.

Okay, that's it for now. Just needed to vent a little and process some of the stuff running around in my head.
p.s. I took these photos last week at the monthly Glory Reborn baby party. We had a photo shoot so Hilary could get photos for some upcoming Christmas cards she's making that will be for sale on the GRC website. They're just so cute I had to add some. I'll post more later.

What a week...

It has been a full week. Andrey left for Seattle Monday morning for a big meeting. He'll be back on Saturday. I worked all day Monday and we were busy. I got to attempt an external cephalic version (ECV) on a patient (with the help and guidance of a real midwife, of course). An ECV is a procedure done to manipulate a baby's position from breech to head down. It didn't work. I was disappointed, not only for our patient who really wanted it to work, but for myself as I've never done this before and it's one of the skills I'm supposed to know how to do in order to graduate.

We also saw one of our patients who is pregnant with twins. She's 36 weeks and both babies are head down and so we had been planning to deliver her at our clinic but then her last routine complete blood count revealed that she was severely anemic and would need blood transfusion. She would no longer be able to deliver at Glory. Again, disappointed for our patient, as she has delivered all of her babies at our clinic but also disappointed for me because I really want to see a twin delivery.

I texted our obstetrician who also happens to be the head OB at the city hospital and asked her if I could observe the delivery. She said she'd try to coordinate with the residents on duty and that she'd call me when the patient was in active labor.

She texted me at 4 on Tuesday morning. The patient was 5 cm and in active labor. It could go fast so she advised me to go right away but when I arrived at the city hospital she was resting and didn't seem to be in active labor. I waited until the next IE at 6 am and she was still 5 cm. I had lots to do that day so I left and asked the docs to kindly text me when she was closer.

Nobody ended up calling me when the patient delivered normally at around noon so unfortunately I missed it but that was for the best because I had appointments to see two patients at the clinic that morning that I couldn't skip out on. One was a postpartum check-up on my last continuity patient who delivered last month. The other was a prenatal check-up on an extra continuity patient I decided to take on just in case the National College of Midwifery wasn't satisfied with my first three. It's extra experience. I've been providing all of her prenatal care for the past 2 months.

Just as I was finished and getting ready to leave, the patient who's baby was in breech position returned. This time I got to attempt ECV again, with Hilary's help, and it worked! It was amazing! With lots of gooey gel and hand manipulations over this woman's belly and prayer. We'll see if baby stays in this position. If not, we are going to let her try and delivery vaginally since it's not her first baby. So that wouldn't be so bad because I'd love to see a breech delivery.

Just as I was about to leave, my last last continuity patient returned in labor - the one who had been in earlier that morning for a routine check-up. She had actually been in early labor when I saw her. When she came back a few hours later she was 5 cm and getting active very quickly. This was at noon. So I stayed and expected to be there for the rest of the day until she delivered.

Let's just say she had what is called a precipitous labor. I didn't even have to do another IE. One minute I was rubbing her back during a contraction and the next she was bearing down spontaneously (without warning!). Remember she just came in 2 hours ago and was 5 cm dilated. She was so quiet and calm that I didn't realize that her baby was quickly on it's way. I pleaded with her to quickly walk upstairs to the delivery room and to not push. Perhaps she was as shocked as I was that it was happening so fast. We got her on the bed and donned our gloves. We told her it was okay to push and in that very instant I was supporting her baby's head and shoulders as it made it's surprisingly forceful appearance. I was not expecting this because her water did not break. Right before she pushed I could feel the bag of water bulging under my hand as I lightly held an absorbent pad over the opening so I wouldn't get splashed. It never splashed or burst. I'm not sure what happened except that her baby was born with the bag practically still intact. Somehow it must of torn as it wasn't covering the head as I held him. His cord was wrapped around his body twice so I untangled him and placed him on his momma's belly as she sighed relief. Whew!

Patients with precipitous labor tend to bleed a lot after birth. Her placenta was delivered after 8 minutes and she had minimal bleeding up to this point and several minutes after. However, a few minutes after her placenta was out, it was as if her uterus sighed in relief as well and decided to stop contracting. So her uterus remained boggy and blood flowed intermittently. Nothing too scary or dangerous, but enough to warrant medication to help her uterus contract. The medication took several minutes to kick in but it did and the bleeding stopped.

These are the cases that it is scary to think about what would happen if they had delivered at home without a trained attendant and without necessary medication to stop bleeding.

Here are a few interesting statistics that I gathered while doing my community health assignment today.

• A woman's lifetime risk of maternal death is 1 in 7300 in developed countries versus 1 in 75 in developing countries.
  
• Among Filipino women, the lifetime risk of dying from maternal causes in one in 100.
• The four major killers are: severe bleeding (25%), infections (15%), hypertensive disorders (12%) and obstructed labor (8%). Complications after unsafe abortion cause 13% of maternal deaths. Globally, about 80% of maternal deaths are due to these causes. The other 20% are from indirect causes, which include diseases that are complicated or worsened by pregnancy, such as malaria, anemia and HIV. Women also die because of poor health at conception and a lack of necessary and adequate care essential for a healthy pregnancy and delivery.
• 40% of births in the Philippines do not have a trained attendant present.

The World Health Report 2005 - Make every mother and child count. Genva, World Health Organization, 2005 (www.who.int/whr/2005/en) and World Health Organization Philippines Health Situation and Trend (www.wpro.who.int/countries/2007/phl/health_situation.htm)

Back to Tuesday. I finally left the clinic around 5 pm, went home and relaxed for the rest of the evening. Wednesday I worked on the computer in the morning and ran errands in the afternoon then I worked the night shift. Our shift was busy with 2 postpartum patients, 2 prenatal patients sick with fever and a primigravida in labor. I helped a newer staff deliver the baby around 1 am with Hilary supervising us. It was fun to be teaching someone else. It made me feel like I knew a few things.

By 3 am we got to rest for a few hours. At 7 another patient arrived in labor. When Hilary checked her she was fully dilated with compound presentation. The baby's elbow was very close to making an exit. Not good. Hilary yelled to me to get the car ready. Thankfully our driver was there so I didn't have to drive. Within 5 minutes we were on our way to the hospital. Thank God our patient was from outside the city so we could take her to the provincial hospital and not have to go to the city hospital where we have seen babies die for lack of the necessary action to perform an emergency cesarean section.

At the provincial hospital they attended to the patient right away and the doctors were actually nice to us. What a welcome contrast to the city hospital! We heard later that she delivered a healthy baby by C-section.

I spent most of the day at home at Thursday getting stuff done. And today, Friday, I got two more midwifery assignments done. Yeah! Only 3 more to go and then I am DONE. Like really done. I'll be working all day on assignments again tomorrow.

I haven't cooked much this week. It's interesting how little motivation I have to cook just for myself. I get so much more joy out of cooking for the two of us.

Andrey will be back late tomorrow night and then Sunday is our 7th anniversary! We'll have the whole day to hang out and celebrate. Not sure how we'll spend the day yet but it will hopefully include champagne.

Another Learning Experience to add to the list of Complicated Births

WARNING: Descriptive birth story with a photo of an abnormal placenta. Only read if you're really interested...

I delivered a baby last night. It happened to be my third of three required continuity patients necessary for the completion of my clinical requirements to become a midwife.

It was a tough delivery and I learned a lot. I want to share the details of my patient in order to illustrate why most of the births we see at Glory Reborn don't end up being considered normal. My patient is just one example of so many other like her that we see every day.

My patient is a 28-year-old G8 P6213, which means this is her 8th pregnancy. Of the previous 7, all but one fetus made it to a viable age. She had 2 premature deliveries, 1 miscarriage, and currently has 3 living children.

The two premature babies she had (one at 5 months, one at 6-7 months) died within a month after birth. Another child died at 18 months from an infection. Thus the 3 living children. Until last night. Now she has four living children, praise God.

Her first 5 deliveries took place at home with a traditional birth attendant (hilot). Hilots are not medically trained. They rely on traditional 'wisdom' and folklore. They don't have B/P cuffs or any method of listening to the heart rate of the baby. Therefore they don't monitor blood pressure in labor or the baby's heart beat. They don't carry pitocin (to prevent/treat a woman from bleeding to death). They don't do prenatal care. They don't suture tears and apparently don't refer women for suturing even when it is essential (as in the case of fourth degree tears). They basically are called in at the last minute to catch the baby and cut the cord. And they get paid for this. Sometimes more than what we charge at Glory. Crazy. I have a whole host of stories about hilots but I think you get the picture.

My patient's previous premature labors likely could have been prevented through routine prenatal care and treatment of common infections or dehydration.

Throughout this pregnancy, my patient was diagnosed with and treated for a severe UTI, and another common infection in pregnancy. She took good vitamins for her mild anemia. She had regular check ups.

The last baby my patient delivered had a midwife for an attendant. Apparently her labor lasted for seven days. When she finally went to the midwifery clinic (not Glory Reborn) they were able to artificially rupture her membranes (AROM) to get her to progress. It worked and within two hours, her baby was born.

This labor started out very similar to the last, according to my patient. She had been having mild to moderate contractions every 10 minutes for days. She came in to Glory Reborn yesterday at 11:00 am at 4 cm dilated, head -3 station (head high in pelvis). We gave her some herbs to help strengthen her contractions, which, for a while made them come every 5-6 minutes but they were still very mild. She progressed to 6 cm after 8 hours.

Thankfully the heart rate of the baby stayed normal enough for us to not need to hurry things up. We would have liked to do AROM but that is contraindicated when the head is not yet engaged in the pelvis because of the risk of cord prolapse.

When we did an IE at 7 pm we found a tiny little hand and fingers up towards the top of the head. This is risky because if her water were to break spontaneously the baby's arm could extend past the head and make vaginal delivery either extremely difficult or impossible. She was still only 6 cm dilated and the head not yet engaged. We called our obstetrician for advice. She said to wait two more hours and see what happens. We tried to move the hand back and out of the way but it didn't work. We let the patient rest and her contractions slowed to every 10 minutes again. Two hours later she was 7 cm dilated, head at -2 station (still not engaged) with compound presentation (still nuchal hand but at least now the hand was at the side of the head instead of the top). We called our Dr. again. She said we could try slow, controlled AROM with an assistant gently guiding the baby's head into the pelvis while the other held the baby's hand back.

This was risky but considering the alternative - hospital transport of a patient with no money and an almost useless public hospital with no such thing as a stat C-section even if it became necessary to save the baby's life - we explained the risks and options to the mother and she discussed it with her husband and they agreed to go ahead with it. We made a hospital transport plan in case we were unsuccessful and the hand slipped through the cervix before the head.

I was able to poke a tiny hole in the amniotic sac and then slipped one finger through it so I could control how fast the water drained, while at the same time pushed upward against the baby's hand with my other fingers, while the other staff gently held the baby low in the pelvis. The AROM immediately resulted in strong, frequent contractions. We also did nipple stimulation and gave her more herbs. After about 30 mins of slow leaking of her water the baby's head began to fill the pelvis and the hand was completely out of the way. Whew! During this time she showed signs of partial separation of the placenta as there was a big clot that came out and also the water was blood-stained. Thankfully the baby's heart rate stayed within normal limits but this had us on-guard.

The contractions were coming frequently and the baby's head started to descend and it was finally at 0 station (engaged, fully filling the pelvis). Then the baby's heart rate dipped down so slow to 60 beats per minute during a contraction. This was way too low! Normal head compression would cause the heart rate to dip down to 100 but not 60. This was a sign of either the beginning of placental separation or cord compression. We connected the mom to oxygen and stimulated the baby's head. After the contraction the heart rate went back to normal. She was still 9cm but she had to push that baby out! As with other women who have had so many of babies, the cervix is very soft and stretchy and usually will just move out of the way when the baby's head moves down. But our patient didn't push well during the contraction that caused the baby's heart to slow and so the baby's head stayed where it was. With the next contraction the heart rate dipped again. The last time I heard a heart rate that low was when we transported a patient with cord prolapse and the baby died because the public hospital would not do a stat C-section. So this was now a real emergency.

Hilary stepped in and put hard pressure on the posterior vaginal wall to stimulate the right kind of push from the mom and we all demanded that she Push. Now. Hard! Hilary alerted the staff to get ready for resuscitation. The patient did exactly what we demanded and the baby's head was suddenly visible, then crowning. We told her to keep pushing. Then the head was out. It rotated normally but the cord of the baby was wrapped tightly around it shoulders. I slipped my hands beneath the cord and slipped if over the shoulders and applied traction to deliver the baby immediately. Thank God the baby cried immediately and resuscitation was not necessary. Thank you God. We were all praying like crazy!

Also because our patient was G8 and anemic and had possible partial separation of her placenta, we prepared for hemorrhage. We infused her IV with pitocin after the baby was born (we usually always wait till after the placenta is delivered but this was a unique case). Thankfully the placenta was delivered within 5 minutes and it was intact. She didn't hemorrhage. And there was no tear. Praise God.

Her placenta had an abnormal shape. It was a circumvallate placenta, which is associated with prenatal bleeding especially during the 2nd trimester, placental abruption (separation of placenta in utero), multigravity (more than 4 pregnancies) and placental insufficiency, which can lead to intrauterine growth restriction (IUGR). IUGR is associated with malnutrition. My patient's husband is a smoker and has no job. She sells fruit when she can but mainly they depend on family for food and they commonly do not have enough to eat. She also had some bleeding in her second trimester. So interesting.

Here's a photo of a circumvallate placenta. My patient's looks so similar to this, expect smaller and with a very thin cord.


Within 20 minutes the baby was breast feeding and mom was smiling. Baby Lenzy weighed 2,550 grams (5 pounds 10 ounces). I'm so thankful everything turned out okay. Hilary was so fantastic at staying calm and instructing me and the rest of the team. I have to admit I started to panic at one point. Not majorly but I did say, "Oh God, Oh God" when I thought the placenta was separating. I'm embarrassed about that now but I'm thankful that Hilary was there to tell me, "Don't panic. Stay calm."

It's experiences like these that I wonder if I can do this. Be a midwife. I'm still not to the point where I am 100% managing the birth by myself (unless it's normal or a slight variation of normal). But that must come with time, right? I know I am getting great experience and I feel fairly confident in handling some complications, like hemorrhage but it's hard to know how I will react and handle other emergencies when they happen. It's a big, scary unknown. So far, I've always had someone with me, which of course is the way it should be as I am still a student, but in those times of emergencies there isn't time for my supervisor to ask me, "ok, what are you going to do or what do you think we should do." No, there is just only time for the supervisor to tell me directly what to do, so I have no idea what I would have done.

In fact, I meant to blog about a couple of other emergencies that I had last month during deliveries. I learned a lot from those too. I got to deliver a posterior shoulder because the baby's body wouldn't deliver spontaneously after the head was born and needed assistance (it was almost shoulder dystocia but not really a true case). Another time I attempted to manually remove a placenta as it was abnormally attached, possible due to previous uterine scarring and/or the abnormal shape of her uterus. It was scary because she was really bleeding. In both cases, my supervisor was excellent at calmly instructing me what to do and I was able to do it. Well, I wasn't successful at removing the placenta but I did get in there and try and now feel confident that I know what to do next time. It was my first time after all!

I just needed to process that birth, so thanks for reading if you made it to the end! When I read about these beautiful, natural, water births at home with midwives with healthy, empowered, educated women I feel I am living in a parallel universe. Then I remind myself that the maternal mortality ratio (MMR) and the infant mortalitie rate (IMR) in the Philippines, especially among the urban poor, are much worse than that of the U.S. and Canada. That has to count for something!

Starved Baby Boy

Can I just tell you another ridiculously shameful story of crap that happens in the Philippines that I have the joy of witnessing? It would be oh so easy to assign 100% of the blame on the poor excuse of a city hospital here but in this case the mother herself left me bewildered.

Last week we had to transport a patient to the hospital because she was in early labor and the heart beat of her baby decelerated to a dangerous level. This patient was 38 weeks pregnant with a fundal height (belly measurement) that reached 30 centimeters at its largest. At the time of admission her fundal height was 28 cm. This is incredibly small.

During the first half of her pregnancy her belly was growing as expected but since about 20 weeks or so, the growth of the baby really started to lag and never caught up. All through her chart there is evidence that our staff advised her to eat well and take her vitamins. Numerous midwives explained to her the importance of good nutrition in pregnancy and the risk to the baby if it doesn't get the nutrition it needs and doesn't grow well. She claimed she didn't have money for food, yet there was evidence that she actually did have more choices available to her.

In fact, she was spending her money on white bread and fortified, powdered chocolate milk drink, which has a lot more sugar than protein. We know for one that the milk powder is a lot more expensive than fresh vegetables and eggs, for example. And since she apparently had no problem paying for meds we prescribed for an infection she had and the lab work we required, several of us agreed that something just wasn't right about her story.

We have numerous women in our clinic who have very little money and who truly struggle to eat well and pay for needed labs and meds but this woman didn't fit the usual profile. Most of these patients still find a way to eat at least three meals a day. It may not be the ideal diet but at least it's not one that induces the level of malnutrition seen in this woman and her baby. In addition, our women who are truly impoverished do not have a husband with a decent, stable job like this woman does. And this was her first baby so it's not like she had many other mouths to feed. Each midwife attempted to get to the root of the problem but she maintained that it was a financial problem that kept her from eating.

So that brings us to this point, where we were last week with this patient in early labor and her baby giving us some very nonreassuring signs of its well-being. Unfortunately she was only 2 cm dilated so there wasn't much we could to facilitate delivery. We hooked her to IV. We filled a bag of medical supplies and gave it to her husband to hand over at the hospital to alleviate some of the cost just like we do for all of our patients who get transported. I called the OB resident and told her we were coming. We took her to the city hospital. After waiting over 30 minutes for a doctor to see our patient, the OB finally determined she needed an emergency C-section.

They informed me that the provincial hospital (the only other public hospital in the city) is closed for two weeks for fumigation just like it does every year and that because of this our patient was 5th in line for C-Section.

24 hours later... Yes, 24 hours later our patient had her C-section. Although I haven't confirmed this, we heard that the woman just ahead of our patient, in line for C-section because of dangerously high blood pressure (preeclampsia), went into eclamptic shock and died - waiting for C-S.

As for our patient, she delivered a three and a half pound baby boy. He required resuscitation at birth. Once he was stable they did a gestational age exam and determined that he was indeed 38 weeks (full-term) and therefore was confirmed to have suffered from intrauterine growth restriction (IUGR), which is in most cases a result of extremely poor nutrition. It was exactly as we had suspected. That in and of itself is more than enough for a little baby to be up against.

Unfortunately though, in addition to this the baby clearly experienced hypoxia due to the decelerations of his heart beat and was likely in metabolic acidosis at birth. (Acidosis is what happens when there is deprivation of positively-charged oxygen molecules in the tissues and organs, and there is a subsequent build up in hydrogen ions, which have a negative or acidic charge. Organ and tissue damage is certain when prolonged.)

God knows what additional damage has been done just by leaving him in so long. His heart rate was dipping down to 80 beats per minute when we took them to hospital, which is always an emergency situation. A normal fetal heart rate is 120-160. Since then (a week ago) the baby has stayed in the ICU (which is really just a small room adjacent to the pedia ward with 3-4 babies to a bed, no incubators, and only 1 oxygen tank) and has been receiving meds for metabolic acidosis. We learned yesterday that he coded again and had to be resuscitated again. So far, he's still alive.

According to the obstetrician that works closely with our clinic and who saw our patient in the hospital, the patient admitted she didn't eat because she didn't want a big baby. I can't say for sure that this truly was the reason why she decided to starve her baby but the thought of it is heart-breaking. Awful. Awful. Awful.

Fast Birth

I worked last night. My shift started at 7:45 pm. At 8 pm a 27-year-old mother arrived in labor with her 4th child. She was 8 centimeters dilated and having strong, frequent, regular contractions. She asked to pull down the curtains around one of our beds downstairs for privacy. Of course, no problem. At 8:55 she declared, "I need to push!" We all rushed upstairs and got her onto the delivery table. She said, "I really need to push!" We said, "Wait. Just breathe," while I quickly put on a gown and sterile gloves. "Ok. Go ahead," I said. She bore down and I could already see the head. The amniotic sac was still intact so I reached in to gently pinch it after her first push. Immediately she started pushing again and suddenly, the head was crowning, the head was out, the body was out - baby out! All in one push. The time was 8:57 pm. I guess she really did have to push! While her baby was being suctioned on her abdomen she said, "Thank you, Lord. Thank you, Lord. Thank you" with a big smile on her face. Her husband was also there, smiling.

Adorable little baby girl named Sherly. 6 pounds 12 ounces. Healthy, pink, cute, round-faced, head full of gorgeous black hair, champion breastfeeder. Sherly.

What could be more fun than to take part in stuff like this!!?? What a privilege.

Tuesday's Two Deliveries

I worked the day shift on Tuesday. When I arrived there was a woman in labor. This was her second baby. She progressed well throughout the day and I was her main labor support person. She's a sweet, cheerful woman. It was great working with her as she labored throughout the day. At around 4pm she gave birth to a healthy 7 1/2 pound baby boy. Here she is on Thursday morning.
Around 6 pm, while we were just finishing up in the delivery room, my continuity patient arrived in labor. Let me first explain what a continuity patient is.

A continuity patient is someone that I am responsible for caring for throughout pregnancy, delivery, and postpartum. I am required to have 3 continuity patients in order to complete my midwifery training. I have had 4 continuity patients in the past that for various reasons all ended up delivering in the hospital. Of course it's mostly unfortunate for them because that means they had some sort of complication - either during their pregnancy or during their labor - that required us to transfer their care to the hospital. But it's also a bummer for me because even though I cared for them for many months, I can't use that experience toward my requirements.

I've been praying (selfishly) for both of my continuity patients (the other is due in April) to have a healthy pregnancy and birth because I really want the opportunity to deliver their babies and care for them afterward as well, and of course, satisfy some of my requirements in the process.

I am happy to say that my first continuity patient (in photo below) delivered a healthy baby girl on Tuesday. Yeah! She arrived at 6pm and gave birth at 9:30 pm. It was the kind of birth I always hope for. She had very strong, effective and appropriately frequent contractions. Her labor progressed normally - quickly even. I was surprised at how quickly things were progressing and how amazing my patient was at remaining calm and in control. She was impressive. Clearly she had done this before. This was her 4th baby. I asked her if her other labors were like this one and she told me yes. I knew her past labors were fast so I knew to be on my toes.

Things couldn't have gone better. She didn't bleed and she didn't tear. She spent all of Wednesday at the clinic then was discharged early Thursday morning. Here she is with her incredibly cute baby girl (Kianna Jee) and husband just before they were sent home.

I really enjoyed working with this woman. As you can see she's quite tiny but thanks to her compliant nature she took my advice on taking vitamins that helped increase her appetite and then ate a lot more than she would have otherwise (including lots of protein!!!). Her baby weighed 6 1/2 pounds. Perfect! She even successfully increased her hemoglobin throughout her pregnancy by consistently purchasing good quality iron supplements and taking them as advised - every day! It's a simple thing but you have no idea how hard it can be to get patients to comply with just this one important thing. She really was a joy to work with.

She expressed an interest in family planning advice (she's only 27) so I'm going to make sure she finds something that works for both her and her husband. If things go as she hopes, she won't be back to our clinic for a while.

Thank God for this new life! Did I mention how cute the baby is?? She has chubby cheeks and when she cries she has a pouty lower lip that sticks out! She feeds like a champ, too!

Delivery

I delivered a baby today. A 7.5 pound baby boy to a first-time mother of 20 years. I was actually only planning to work during the morning prenatal check-ups but then one of the women who came for a routine check up got an exam that revealed she was 4 cm dilated. She claimed she didn't feel any pain. There were signs she was having contractions as her belly would tighten frequently. Four hours later she was 6 centimeters dilated and still no pain or sign of even the slightest discomfort! We all were amazed and kept asking her, "Really? No pain yet?" She just giggled and said, Nope, not yet. So we gave her some herbal medicine to strengthen contractions and waited another 2 hours. Next check up she was 7 centimeters. Still no pain.

The baby's head was well engaged in her pelvis so we decided to break her water. Almost immediately she went from no signs of labor to being in very active labor. She started sweating profusely and her toes were curling. I stayed with her and encouraged her to breath and keep her body relaxed, which she was already an expert at somehow. Amazing.

She started to bear down spontaneously. She said she wanted to push. We encouraged her to breath. She really insisted she was ready. So we took her upstairs to the delivery room. Checked to see if she really was ready and she was 9+ centimeters dilated. We supported her cervix and waited for the baby's head to move low enough for the cervix to slip behind the baby's head, which was accomplished after about 20 minutes.

After trying several positions and finding the right one that allowed her to push effectively and after about 1 hour of pushing, her baby was born. Cute baby James Ronald.

Thankfully the placenta was delivered without incident but her uterus was just so reluctant to contract adequately that we had to give her pitocin intramuscularly and then soon after when it became apparent this wasn't enough, we hooked her to Dextrose IV and added more pitocin to the IV fluids. After that, her uterus had enough power to contract properly. Whew.

I ended the day by spending an hour and a half suturing in three different areas. Ouch. I used to be so dead against episiotomy but one has to wonder, could three jagged tears in difficult to heal areas be prevented by inflicting one straight tear? I honestly don't know but it makes me wonder. All primis (first time mothers) in hospitals and most clinics in the Philippines get routine episiotomies. I have to say, I can kind of understand it. I still have never cut an episiotomy and I'm not sure I ever could unless it were an emergency but I can at least say I understand where others are coming from. I really felt for this poor young mom who will have a very sore bum for a few weeks. I will say, that with Hilary's help and expertise, our young mom will look as good as new once the healing is done. And that's what we told her. "You'll be back to beautiful." Despite her discomfort, she gave us a genuine smile and said, "Thanks."

Sunday Night Dichotomy

Sunday night was the busiest night shift I've worked so far. In addition to our 5 inpatients and their babies (a couple of them needed to be watched closely), we had two women in labor.

The first woman came in at 5 centimeters dilated. She progressed beautifully from 5-10 cm in just a few hours. It was her 2nd baby and I was hoping and praying for just one normal delivery. What a refreshing idea! She did not disappoint. This woman was one of those women that I am in awe of as I watch them labor. She was calm and confident (what a difference confidence makes!).

As I said, she progressed well and quickly. Her husband did a fantastic job providing labor support. It also helps when the partner is confident and not afraid of the whole process like most of our guys. Although, just as his son was born he rushed out to the hallway to vomit. He had to leave until after the placenta was born and out of site. Hee hee. I'm getting ahead of myself though...

So my patient did great. She stayed relaxed and calm and before long she felt the urge to push. It's also nice to get to be hands off for a change. We checked her to see if she was indeed ready and she was fully dilated with the bag of waters still intact. She pushed for about five minutes. And as soon as her water broke her baby was out in the next push. Amazing. All I did was simply catch her six and a half pound baby boy. She didn't bleed abnormally. The amniotic fluid wasn't stained with meconium. There were no abnormal heart tones. The baby didn't need deep suctioning. What a happy and beautiful and refreshingly normal birth! I really needed that. (Never mind the mother, it's all about me right? ha ha) But seriously, it is just so nice to see and experience a normal birth. Most births are in fact normal but I just haven't seen one in a while.
She did tear, however. Which meant I got to suture for 1.5 hours. This month has been great for suturing practice!

Just before this first patient delivered, another woman in labor arrived. A primie at 5cm and having a very difficult time remaining calm. She was the polar opposite of the first patient. Not to begrudge her it's just that most of our primies are very young and immature and not well-prepared. The father of the baby was not in the picture and so she was all alone except for her father who was all she had, I guess and he kept his distance.

To make a long story short, we had to transport her to the public hospital at 5 a.m. We couldn't get her to stop pushing prematurely. Her cervix was almost fully dilated (about 9cm) but was getting swollen. We tried absolutely everything to get her to relax and breathe through contractions until she was "fully" but she just couldn't do it. So our only option was to manage her cervix while she pushed in addition to continuing to do what we could to get her to relax and breathe and she did become fully dilated pretty soon after that. But she couldn't push effectively no matter how much advice and support we gave her. And she refused to try other positions. She was exhausted. She just kept gripping the table, my arms, her legs. She put all her energy into every other part of her body besides where her energy really needed to be focused. The poor girl was in agony. She pushed like this for over an hour and during that time, the baby's head became in view but failed to move beyond a certain point. And her water broke. And it was stained with thick meconium (fetal poop) which is a sign of fetal distress and is very dangerous because the longer the baby is inside, the more likely it is to aspirate the meconium. The fluid was such a color as to indicate that the baby had pooped a long time before.

So even though she was close to delivering we felt it best that she deliver in the hospital where the baby could have better emergency care. So there go the hazard lights on my car again as I drive us to hospital.

We heard later the baby was delivered using fundal pressure and episiotomy (routine at the hospital). Her 5-pound baby needed resuscitation and oxygen and will be held for observation.

Tiring? Yes. I got home and was in bed by 8:30 and slept till almost noon. I've never been so tired after a night shift. Last night I slept for 10 hours. I dreamt I delivered a baby on a bed in someone's home. The shoulder was stuck and I pulled on the baby too hard and hurt it's neck. The baby's body was twisted in a freakish way and I knew I had just damaged it's spine. It was a traumatic experience. When I awoke I sighed with relief that it was only a dream.

A Rough Night. A Sad Story.

Night shift last night was busy. We had two women in labor and four staff members. A midwife and a nurse attended a 21-year-old, first-time mother. Hilary and me took care of a 39-year-old mother of four. I'll try and write this quickly as I'm very tired and need a nap.

The first-time mom arrived yesterday morning at 3 centimeters dilated and labored in the clinic all day. Sometime after 8 pm she was reaching transition and was transferred upstairs to the labor room. Around 9 pm our other mom arrived. Smiling. Moderately strong contractions. Clearly a pro after doing this four times before. Seven centimeters dilated. Amniotic sac intact. Wanted her husband nearby. It was clear they both were a little excited about meeting their new baby soon. The mood was light and happy. We've seen many women like this deliver their babies quickly and (seemingly) easily as their bodies are quite familiar with the process. This mom was remarkable. After I did her internal exam she said softly and kindly, "thank you." We laughed and said, "We cause you pain and you say thanks?" What a sweet woman!

Due to her age and high parity (many pregnancies) we inserted a heplock so we could give her IV fluids or meds more readily during or after birth if needed. On our initial assessment we noticed the baby's heart rate slowed slightly during contractions so we took her upstairs to the labor room and hooked her to our electronic fetal monitor. With it we can track the baby's heart rate in relation to contractions, fetal movement and the position of the mother. We can also assess the strength of contractions. The baby's heart rate decelerated during contractions but only slightly, which could have several possible causes.

Some decelerations are normal due to head compression as the baby descends through the pelvis. The baby can handle these generally as long as labor is progressing and delivery is not far away. Sometimes decels can happen if the cord is wrapped around the baby's neck so we considered this as a possibility as well. Again, not necessarily a huge problem if the cord isn't tight, which is the case most of the time and as long as delivery is not delayed and the heart tones don't stay low.

Another possible cause is cord compression, which many times can be remedied by a change in position. So we asked the mother to lie on her side, then her other side, then squatting, then standing. While in the squatting position, the heart tones seemed to improve. Great, we thought. She stayed in that position for about 20 minutes. The baby's heart was fine but mom's legs were getting tired. We asked her if she wanted to stand for a few minutes to give her legs a break. She did.

Hilary and I didn't like what was happening to the baby's heart rate after she stood up. With contractions the baby's heart rate dipped to a very dangerous level. We started to become concerned and knew we needed to do what we could to help get this baby delivered ASAP. We immediately had her return to the bed. Hilary checked her cervix again to see how close she was to delivery and suddenly felt a piece of cord that was pinched between the baby's head and the mother's pelvis on her left side.

This uncommon, ominous discovery alerted an emergency - occult cord prolapse as it's called is extremely dangerous. Hilary said, "We gotta go to the hospital now!" One of the Filipino midwives explained to the mother and father what was happening and what we needed to do. Hilary kept her hand inside putting pressure on the baby's head to keep it off of the cord. Surprisingly, the mother's amniotic sac still had not ruptured, which was good as that usually causes the baby's head to descend further into the pelvis.

Also at this time, our younger mom was starting to push her baby out. Thank God one of the nurse-midwives who is also a supervisor lives just next door so we called her to stay with the other two staff members and the patient that was pushing. Meanwhile I ran to get the car. The security guard and our patient's husband carried our patient down the stairs and placed her in the back of our car with Hilary still putting pressure on the baby's head.

The hazard lights went on and I drove as fast and as safely as I could to the city hospital about 10 minutes away from the clinic, honking the horn all along so people would get out of our way.

It took several minutes to find a stretcher. An old woman was shooed off of a stretcher so it could be wheeled outside where I was parked. Our patient was transferred to the stretcher by the guard and the patient's husband and she was wheeled into the ER.

I've written about this hospital many times already. It's dirty, chaotic and awful. And it's the only option for the poor. There is no triage system. There is an abundance of clueless nursing students and usually no OB doctor to be found until we continuously ask to have him or her called. Hilary continued applying pressure. I listened to the baby's heart beat with our handheld doppler, a basic tool the hospital doesn't own.

Hilary and I asked for the doctor. Ten minutes later she showed up and moved to see a patient next to us in labor with high blood pressure that arrived after us. She eventually makes her way over and after appraising the patient and confirming what we report is true, she tells us that the patient needs a C-section but they have no anesthesiologist. We think of what the other hospital options are but the family has only a little money. No other hospital in the city will take them without a large deposit in cash. But even if that were an option, we didn't have time to take her anywhere else. She needed an emergency C-section!

The next moments were filled with the doctor asking us for lab work information and then asking the patient her entire past obstetrical history including whether she's had boys or girls and how much her babies weighed in the past.

The mother's amniotic sac ruptured spontaneously and the baby's head began exerting more pressure on the cord. The heart rate slowed even more. She suddenly had a very strong urge to push. They replaced Hilary with an intern who then provided the pressure on the baby's head. For the next hour, our patient desperately hung onto my arm while Hilary and I coached her to breath through each contractions and ordered her to look in our eyes and NOT push. We told her she was doing a great job and she was. It must have been very hard for her not to push. She did her best at breathing. You could see the panic in her eyes. Tons of activity going on around her and so much of it confusing. As I heard the baby's heart beat get disturbingly slow with each contraction, I felt helpless. thump.......thump..........thump.........thump........all I could do was pray.

They told us that the OR was busy (which contradicted what was said earlier) and that our patient would be next in line. They began to prep her for surgery by taking her clothes off, cleaning her abdomen with betadine and shaving her. They hooked her to IV fluids and checked her vital signs.

We felt there was nothing else we could do. We needed to get back to the clinic to our other patient. We explained what was happening to our brave patient and we layed our hands on her and prayed aloud. She looked at us with sincere eyes and said, "Thank you. Thank you."

We made it back to the clinic soon after and focused on the first patient who's baby delivered within minutes of our arrival. She had a healthy baby boy with a few breathing difficulties at first but after some suction and oxygen he was fine. Mom needed a few stitches but overall was fine. Grandma was ecstatic. We rejoiced with the young mom. "You did it! Look how cute your baby is!"

It was 3:00 a.m. when we got our new mom & baby settled and the labor room all cleaned up. Hilary called the city hospital for a report on our patient. They never did a C-section. Apparently, two hours after we left she delivered a baby girl with no heart beat. Her cord was wrapped around her head three times - twice around her neck and once around the top of her head, which was the portion that was pinched. We found out later they named her Angel. The hospital didn't even let them see her before they took her to the morgue.

Given what we learned, it is unclear whether there was anything that we could have done differently or whether an emergency C-section would have avoided this from happening. But that's no excuse for how this family's situation was handled at the hospital.

That's about all I can share for now. There is a whole other post about the atrocities that happen here everyday in this country to those who are not considered to be worth the time or money to be given basic care by their government. It's an injustice that angers me. Such an unnecessary tragedy. Please pray for the grieving parents of baby Angel.

And Another!

Yesterday I got to deliver another baby. To another primie! She came in when she was in early labor so I ended up working with her ALL day. She was ready to push just as my shift ended 12 hours later so of course I stayed to deliver her baby. It was a long & difficult labor for her but she did it! And it was another boy! What's up with all the baby boys lately?? This little guy weighed 6 pounds and boy was he cute! I am so proud of his mama who did such an amazing job controlling her intense need to push so her baby's head could be delivered slowly, thereby reducing the risk of a bad tear. Great job, mommy!

Even though my day yesterday was long and tiring, I didn't feel exhausted by the end. I felt energized and happy. I guess that's what it's like to be doing what you love. I'm so thankful for this opportunity.

Another Birth!

I worked last night and got to deliver another baby. I'm so happy that babies are being born during my shifts! I have increased from two shifts a week to three, so that helps as well.

Interestingly, the birth last night was so similar to the two we had on Wednesday night - a first-time mom ("primie"), age 19 or 20, giving birth to a boy weighing around 3 kg, some tearing & suturing and some hemorrhaging. Crazy. So perhaps we can say I'm fairly comfortable now with that particular type of birth? I emphasize "fairly." I'm getting there. I will say though, that it is refreshing to deliver babies that have a healthy birth weight. I love that.

In the year and a half I've been at the clinic I've noticed that certain situations and complications happen in groups. It's very strange but it really does happen like that where for example, all the babies in a week will end up needing phototherapy for jaundice, or IV meds for infection, or we'll have many cases of hemorrhage, or transport to hospital for induction due to slow progress, or a slough of normal births (love those!), or premature rupture of membranes, or whatever. I guess this week is the week of primies who progress beautifully but tear and need suturing and some form of intervention for blood loss.

The suture job I did last night took me nearly two hours as it was definitely the most challenging case I've had so far. It was great experience - especially with Hilary talking me through and assisting me the entire time. I'm learning so much from her!

I have come to believe that catching the baby is actually the easy part (and the most fun). What is challenging is managing a birth appropriately, i.e. knowing when to intervene or transfer care; managing & treating blood loss; assessing tears and suturing them up properly; newborn assessment, etc... Those are the hard parts.

So I only got a few hours of sleep again last night but I can't complain. I'm having a great time. :-)

Busy Night

Last night I worked a shift at the clinic for the first time since we got back. It was a busy one. I had the privilege of catching two baby boys. How fun! And I got to suture again. Not fun for the mom but good practice for me.

When I arrived at 7:30 pm there was a woman in labor who had been admitted 2 hours prior and was found to be 7 centimeters dilated. She progressed quickly and gave birth to her first child just before 9 o'clock. Unfortunately for the mom, her son's hand was pressed against his face as he was exiting her body. That was the likely reason why she ended up with a second degree tear. Not fun for her but it did mean I got to get more suturing practice. I think I'm starting to get the swing of it.

Ten minutes after our first patient delivered, another woman in labor arrived. She was about 6 centimeters dilated. Clearly we were busy with all of our post-birth duties so it was good that the second patient didn't require a lot of attention. Our nurse on staff was able to attend to her while we focused on suturing and monitoring the health of both mom and the new baby while they got to know each other upstairs. By 11, the mom and new baby were settled in their bed and the labor room was cleaned and ready to go so we brought our newest patient upstairs. She too was a first-time mom. To be honest, she did not appear to be in active labor so we doubted whether she was actually progressing. She barely grimaced or made a sound during contractions. She whimpered a little and reached for her lower back with each set of pain. She kept saying she wanted to push so we explained to her why it's not a good idea to do that until she is at least dilated to 10 centimeters. Over the next hour she labored beautifully while we did what we could to support and encourage her. Despite her calm disposition it became clear that her contractions were indeed quite strong. I love watching a pregnant belly contract. You can see it change shape as it tightens and does its work at sending the baby on its way. It's amazing to watch.

In response to her increasing discomfort and desire to push we checked her progress. It was now midnight. I was pleased to find she had progressed to 9+ centimeters, with only a small portion of the cervix remaining. We broke her water and by the end of the next contraction she was fully dilated and ready to push. She was relieved to finally be given the green light to do so. (On a side note: we aren't trying to be mean when we don't let a woman push as soon as she says she's ready without checking her progress. An exception to this would be a woman who clearly has an unavoidable urge to push. We have numerous women who are accustomed to pushing well before it is time. Doing this can cause a lot of problems, from cervical swelling to maternal exhaustion, to malpresentation so we find it best to avoid this.)

It took our mom some time to find a way of pushing that was effective. She alternated between a semi-sitting position and a full squat. She ended up pushing for about 45 minutes, which is perfectly normal for a first time mom. The baby descended little by little until finally it was crowning. We encouraged the mom to breath and let the baby's head ease out slowly. She was a trooper at responding to our directions.

The baby's head was born, then with the next contraction the entire body was delivered. And would you believe that this baby ALSO had his hand up close to the top of his head so that his elbow was at shoulder level. This too caused quite a bad tear. Probably the worst I've seen yet. Hilary had to do the suturing as it was very close to being a 4th degree tear. Poor mommy. That's going to take some time to heal.

After another suturing job, getting another mom and baby settled, and checking vital signs on the other four mother & baby pairs we were able to sleep for a couple of hours. That was at 4 this morning. With that, I'll sign off. I'm going to try and get some more rest.

Finally, A Delivery...

During my last night shift on Sunday I finally got to deliver a baby. I was up all night but didn't complain because it was exactly what I had been hoping for on my shifts the past 2 months that have been so quiet. Well, not necessarily quiet. There has been lots to do - just no babies born while I've been working. It seemed that women were either giving birth just before my shift or were coming in in labor just at the end of my shift. I felt disappointed a few times recently, so I was happy when at 9 pm, just as we were getting another woman and the baby she gave birth to just before I arrived on shift at 7:45 pm settled, a mother arrived in active labor. She was to give birth to her 6th baby. She is 35 years old.

This woman was such a champ. She was clearly in a lot of pain but she had her own way of dealing with it that signaled the staff around her to give her her space. I can tune into that, no problem.

I was impressed with this woman because she didn't change the way she labored to fit the setting of a clinic full of relative strangers. You'd be surprised that the majority of our women seem to find a way (to my dismay) to follow along with what their culture's definition of appropriate ways to handle labor. They try hard not to make noise or show extreme emotion. Numerous times I have observed women in labor being "shooshed" as soon as they start to make a little noise. They are shooshed because their family members are perhaps embarrassed by them. In a culture where saving face and harmony (that is, a surface-level harmony - not harmony from working things out through healthy confrontation) are some of the highest values, I am not surprised by this. Things are to be kept peaceful and calm and happy on the outside and this spills over even in labor.

Our patient moved and squatted and moaned and breathed and walked and spoke, "Ohhhh Ginooo! Ohhh Ginooo!" meaning, Oh God, Oh God. She spoke to her baby as if to plead with him to hurry up and help her out a little. Her contractions were strong and powerful and seemed to be more effective than those of many other women I've seen. At the end of a contraction she would shake it off and say, "Wooh!" and then she'd relax and sit for the 2 or 3 minutes break that was afforded her before the next surge of intensity came.

Her husband told us soon after they arrived that we were to bear with her because she made noise in labor. She herself echoed the same thing to us and said something like, "Forgive me for what I'm about to do." Later on, after it became apparent what she and her husband were preparing us for her husband apologized to us on her behalf. To me, this is very normal and I found it funny that they were so worried about what we would think. Personally, I could care less. As long as it's effective and instinctual, I say go for it lady! Make all the noise you need to or want. You're the one with a small human traveling through your body, not me. Besides, she was doing a great job at breathing and keeping her mouth and face relaxed.

For several reasons it was clear that she was to give birth to a large baby as compared to her size. Her last baby was 7 pounds, 4 ounces and it's shoulder was stuck for 3 minutes (called shoulder dystocia) before it was born at our clinic 3 years ago. As we reviewed her history we learned that she had insisted (successfully) on starting to push while she was still only 7 or 8 centimeters dilated (why they let her do this was a mystery to me). This shouldn't have happened and was likely a contributing factor in the shoulder dystocia since not giving the baby adequate time to rotate and get lined up properly in the birth canal prior to adding the extra pressure of pushing can contribute to this complication.

I was on shift with my boss and preceptor Hilary. We decided we weren't going to let her push until the baby's head was visible or unless she had an uncontrollable urge to do so.

At 9 pm when we admitted her she was 5 centimeters dilated. Three hours later (we usually wait to do exams every 4 hours) after she begged us to check her because she was convinced it was time to push, she was 6-7 cm. Two hours after that she was 8 cm and still pleading with us to let her push. We continued to insist that she couldn't and tried as best we could to explain why it wasn't a good idea. There were numerous times that we caught her pushing anyway and so we really had to watch her closely and keep getting her to breath and relax instead of push. As we stayed with her and helped her focus on breathing during her contractions while rubbing her back, numerous times she apologized to us for keeping us awake all night. Can you believe that? She was apologizing! So unnecessary. I really didn't want her worrying about us. We tried to assure her that it was our job and that we were happy to do it. Clearly she was appreciative and so happy not to have to labor alone like women usually do in the hospitals in the Philippines.

Now at 8 cm, she started to really get tired and run out of energy and seemed to be moving toward despair. We hooked her up to a dextrose IV (we had already inserted a heplock as we do with all women with high parity so that we can be more prepared to manage hemorrhage) and encouraged her to try to lie on her side, continue her breathing, try and rest between contractions and let the baby continue to descend. After two hours of doing as we suggested, I was surprised to still find some cervix remaining. She was 9 cm and the anterior portion of her cervix was very swollen (likely from the premature, prohibited pushing). I learned from Hilary that women who have had a lot of babies can sometimes have a cervix that is very floppy with poor muscle tone and can sometimes have a hard time getting out of the way. At this point we really needed to actively manage the anterior lip of her cervix, otherwise we would have to consider transporting her to hospital care due to the slowing of progress. Besides, her contractions seemed to have slowed and grown less intense which is also consistent with women who have had a lot of babies. Their uteri can get tired out in the middle of labor and stop contracting. This can cause a failure to progress and also predisposes to hemorrhage after the baby and placenta are delivered.

So we had her stand and lean forward onto the bed (we tried squatting at first but this didn't seem to be as effective). If her contractions were to become strong enough again to cause fetal descent while pressure was applied to the anterior lip then we would just encourage her to breath through contractions and still not let her push. Thankfully, once she was vertical again her contractions did intensify and as I supported the cervix, I could really feel the baby's head coming down. It only took 2 contractions before the cervix was gone and she was fully dilated and to our surprise, it was only one more contraction before the head was crowning. And she still wasn't pushing! Her powerful uterus had found it's second wind! That and the fact that gravity is really helpful.

We had to get her to the OB table immediately. (We have a bed and an OB table in our delivery room. For better management of potential shoulder dystocia we decided to have her deliver on the table). Amazingly, with my hand supporting the top of the baby's head and us instructing her not to push and just breath, the impressive mom quickly complying with our instructions to move and she was successfully transferred to the table. At this point she was in between contractions so the baby's head eased out slowly. I reached beyond the head to feel for any cord and found the cord wrapped around the baby's neck but it was loose enough to slip over the head. The baby rotated perfectly and both Hilary and I were happy to see the top edge of the anterior shoulder meaning it wasn't stuck behind the mother's pubic bone. We encouraged the mother to push the rest of her baby out but the baby didn't come easily. He was big compared to his mother's size. So I applied downward traction while supporting the head to try and deliver the anterior shoulder. It wedged out only slightly so I applied upward traction, then again downward. With this and after about 1 minute of wedging the baby out, the anterior shoulder was freed and the baby was delivered.

He was very blue, floppy and not breathing. Hilary had to give 7 puffs of O2 using the ampu-bag while I and the other assistants stimulated the baby and checked his heart rate, which was reassuringly strong and normal. Soon the room was filled with the sounds of a crying baby. Praise God.

I was just so thankful that after the usual signs of placental separation, the mother only had one other gush of blood (pitocin was then added to her IV fluids) and her placenta was delivered normally. I was worried that if she was hemorrhaging that I would have to handle it by myself since Hilary was tied up with the baby. But I did my job and kept a close eye to make sure she wasn't bleeding abnormally. We have seen so many women on the verge of hemorrhaging (500 cc blood loss or more) that we are all extra sensitive to it and every time a woman loses 200cc or less, I feel so relieved. I was also happy to find that she didn't tear at all (not surprising for a women whose body had been through this 5 times already).

Her placenta was lobulated and that was the first one I had seen like that. It was the usual round shape but with an extra lobe off to the side. Very interesting.

Afterwards, once mom and baby were stable, the tired but happy mom looked each of us in the eye and told us, "thank you." She was sincerely grateful. This is one of my favorite moments to experience.

Her baby boy weighed 8 pounds, 1 ounce and his poor little face looked like it had been beat up a little. Being born was a little rough on him, poor baby. He had quite a big head considering the size of his petite mother who I'm sure was shorter than 5 feet tall.

Afterwards when all the staff were goo-goo-ing and gaa-gaa-ing over the new baby one of the midwives commented on how fair and pink the baby's skin was. The father spoke up and told us that this was the case because when they "made it," they left the fluorescent light on. We all laughed so hard. Mom & Dad laughed too but it was clear that they really believed it to be true. So funny.