Homemade Pasta

I've got to share real quick about the dinner we just had. So good. Homemade ravioli with two different fillings and two different sauces. There were raviolis filled with butternut squash seasoned with nutmeg and raviolis filled with smoked salmon. There was cream sauce and tomato basil sauce. Of course I had to try everything. The meal was Gary's plan and we all pitched in to help. I used a pasta roller for the first time. Here are a few scenes taken with Gary and Louise's camera...

Walk in the Woods

This morning Andrey and I met our friends Louise and Gary (and their 2-year-old son Kai) at Campbell Park in Langley for a short walk. It was only a 3 km loop but was so enjoyable to be out in nature. It's amazing what you appreciate after doing without. Nature in North America is one of those things for us. Before we lived in the Philippines a walk like today wouldn't have been that remarkable but with the lack of open space and cool air in Cebu I was able to take in the simplicity of a walk in the woods this morning. Even though I felt cold, I reveled in the novelty of cool, crisp air on my face. What a joy to take a deep breath and inhale the fresh scent of evergreen trees and live in the moment.

Guess What We've Been Up To?

Yeah, Bennett!!!

We're told we have no idea....

Oh Canada

We made it to British Columbia yesterday afternoon. We flew to Manila Friday and stayed the night in a hotel. Saturday morning we flew 3 hours to Tokyo. After a 3-hour layover in Tokyo we flew the 9 hours to Seattle. The trip was seamless and each of our bags arrived intact.

We got a rental car, a meal and some strong coffee in the city then drove to Canada. The short 2.5 hour road trip was fun as it was a familiar route that Andrey and I used to drive so often early in our relationship. We reminisced over the many trips we took together back and forth between Seattle and BC. We arrived at 3:30 pm to the home of our friends, Sam & Torie who are graciously hosting us until Tuesday. They are in the middle of potty training their son Bennett. There is a lot of excitement surrounding trips to the toilet around here. We are happy to join in on the cheering and positive reinforcement.

It is so great to be here. The Pacific Northwest and the Lower Mainland of Canada are beautiful! I love the cool, crisp air, the mountains and the plentiful evergreen trees. Yesterday's weather was cool and drizzly. It reminded me of life in Seattle and made me ache for it.

We had a great sleep last night and today we are enjoying the Seahawks game and plenty of snacks. It's getting a little sunny now so I think we'll go for a walk or throw the football around after the game. It will be nice to get outside and breath the fresh air.

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.

Family Planning Fund Update

I learned that the Marie Stopes Clinic (initially mentioned here) is actively involved in abortion advocacy around the world and apparently does "medical abortions" in the Philippines. Not a big surprise since it is a secular organization that helps "support vital sexual and reproductive healthcare programmes in some of the world’s poorest regions" but it means that we can no longer advertise their services publicly at Glory Reborn(GRC) where I work. I especially can not publicly offer to fund ligation for our patients at their clinic. I completely understand how promoting an organization that actively advocates for the "protect[ion of] women from unwanted pregnancy" could not only jeopardize much of the funding GRC depends on but also presents a moral dichotomy within an openly Christian clinic that values the life of every embryo and fetus. I have been advised against giving out their brochures and detailing their available services during our group teaching times which I respectfully agree to and understand. I am disappointed however that one of the most accessible family planning options won't be available to as many women as I initially thought.

There are other family planning services available in Cebu City that I still need to learn about including at least one private hospital that apparently provides some discounted family planning services. Of course there is always the option of hiring one of our OB docs to perform ligation in the hospital but this will cost more than $150 as opposed to the $10 procedure at Maries Stopes. Unfortunately I'm finding these other options to be more difficult to make easily available to our patients. I do intend to research more fully about these other options but frankly I just don't have the time to commit to that right now.

Since learning more about Marie Stopes I have wondered what it means in terms of utilizing their extremely useful and inexpensive ligation services for the fertile, impoverished women I meet at GRC. Especially since I had already agreed to arrange ligation for one of my patients (read on for more about her situation) as soon as she delivers her 7th child later this month.

After thinking about it and given the inability to find another inexpensive option quickly I have decided that I am willing to take advantage of their ligation service for the few women that I personally encounter and whom I feel compelled to support in this way (at least until I can find a more ideal option). My heart still goes out to these women. Just last night I delivered an 8 pound 1 ounce baby boy to a 35 year old woman who was no taller than 5 feet. It was her 6th baby. She gave birth to her first baby at the age of 15. Given the size of her baby and her subsequent difficult delivery (I'll write about that in another post) we are suspecting gestational diabetes. She is one of many women in a similar situation whose risk of death in childbirth increases with each subsequent pregnancy. Thankfully, both mom and baby are going to be fine but what about my patient experiencing her 10th pregnancy?

I have mentioned her before. I'll call her Day. She goes to our church and we are in the same home group together. Her family is desperately poor as her husband does not work (Arghh!!) and the burden is on her to scrape money together to feed her family by sending her 13 year old son to collect garbage and by herself finding jobs doing other peoples' laundry. She is 41 years old and is due in the next week or two. Out of her 10 pregnancies, two babies were lost to miscarriage (which she had D&C afterwards each time) and another baby lost to premature labor at 5 months. Just her age and parity make her pregnancy a high-risk one. Add to that unrelenting anemia (her hemoglobin has actually gone done during her pregnancy despite FeSo4 supplementation), and polyhydramnios (too much water in the womb) which is likely related to gestational diabetes. The recent result of a glucose challenge test indicates this is the case. Also, according to a recent ultrasound the estimated weight of her baby is already more than 7 pounds and specifically the abdominal circumference of the baby is measuring large for it's gestational age (also consistent with gestational diabetes). My patient is about 4 feet 10 inches tall and weighs right around 100 pounds. This is a big baby considering her size. She is only just now 37 weeks and the baby will likely grow bigger in the coming weeks until she delivers. The weights of her previous babies have gotten bigger and bigger with each pregnancy. She has +1 edema in both legs and is extremely tired. About a month and a half ago she almost went into premature labor due to a urinary tract infection. We were able to diagnose and treat it in time to stop her contractions.

Just last week, I referred her to our OB doc as it became increasingly clear that she is too high-risk to deliver at GRC. She is now under the care of the (SCARY) city hospital which you can read about here. It is her only option. Well technically she could choose to deliver at home with a "hilot" or untrained birth attendant. Keep in mind that she has NO money. We have been covering all of her pregnancy/childbirth related costs (labs, meds, etc...) and have been providing food for her family since she found out she was pregnant. We have agreed to pay for all of her expenses at the hospital as well, otherwise she would have no way of accessing the needed care.

It seems the Lord has led me to take on patients that end up with complications and needing hospital care. They are patients that could barely afford the basic requirements to be a patient at Glory Reborn. I really don't know what these women would do otherwise. This is another area you could consider donating to as I feel compelled to support such families. I did it with Emily. I'll do it for Day. And I'm sure another will come along as there are plenty to choose from at any given time. So far, I've taken on those women that I feel God placed in my path for that reason - usually via meeting them at church and discovering they aren't undergoing any prenatal care and have no plans to deliver with a trained attendant because of poverty.

So my point in all of this is that Day desperately needs a solution to her fertility problem. Her life depends on it. Her husband is unwilling to undergo (free!) vasectomy and Day isn't even willing to try to talk him into it. The burden lies on her. She really needed ligation after her last baby (who is now age 2) and desired it but couldn't get the money together for it. Her family (especially her eldest daughter who is under a lot of pressure to provide for the family) couldn't believe she was pregnant the last time, much more so with the present pregnancy. Everyone in our church community was flabbergasted that it happened yet again. Day herself was very distressed at the news of another pregnancy. It is possible that if she didn't get ligated or do something else that it could happen again! At her age and given what her uterus has been through (add to that the anemia) she is at very high risk of hemorrhaging to death in childbirth. Especially after being stretched by a big baby and too much water, it will be that much harder for her uterus to contract properly which can cause failure to progress in labor and bleeding to death once the baby is born and her placenta separates from her uterus.

Given the need for it, I am currently willing to utilize the ligation service at Marie Stopes for Day and possibly other women like her (separate from GRC) until I can find a more suitable option. I have to be honest though that I am not completely comfortable with it as I know that surplus funds from the UK clinics (a large part likely from abortions done in the UK), go to funding the services I am interested in in the Philippines. I just wish it was much simpler but despite feeling torn, I don't know what else to do right now. It's still better than abortion profits just going into the pockets of doctors. At least its being used to go toward something that can prevent the desire for an abortion in other women here in the Philippines and around the world. Abortion is rampant in the Philippines but it is illegal and so many women take cytotic drugs to abort their babies. Sometimes it works, sometimes it doesn't. Some women experience life-threatening hemorrhaging in the process. This is a tough issue to work through.

Having said that, I completely understand if you do not want your donations to go to services at Marie Stopes. Just let me know and I will make sure your donation goes to another service provider (if I can arrange that) or to another pregnancy/childbirth-related need for an impoverished family.

I welcome any input, thoughts, advice, suggestions that you may have. I am open to hearing your thoughts and opinions, even if you don't agree with my decision to arrange for Day to be ligated at Marie Stopes. As I said, I am working through these issues myself and am open to discussion and appreciate what you can offer.

The 'rents have gone :-(

My parents left yesterday. It was strange waking up and coming into the living room and not finding my Dad watching CNN and offering to make me some fresh coffee. I felt a tinge of sadness this morning at their absence.

Let me tell you about my Mom & Dad. First of all, I am so incredibly blessed to have such wonderful parents. I took them for granted in my younger years but as the years go on I appreciate them more and more. I'd say my relationship with them today is the best it's ever been. Here are some of the things that I observed during our time together and some of the things I love about them.

• We laugh a lot together
• We can make fun of each other and have fun doing it without offending
• They are some of the most friendly people I have ever known. Wherever we took them in Cebu or elsewhere they engaged with the people around them. They smiled and said hi to nearly everyone they met and struck up conversations with many strangers. They looked for ways to bless and encourage people, telling them they appreciated them.
  
• They are laid back, flexible and willing to try new things
• They are generous, compassionate, and quick to serve others
  
• They are cheerful and happy and fun to be around
• They love people and make them feel at ease
• They value people - regardless of race, gender, economic status; They believe everyone deserves to be treated fairly and with respect. This belief is evident in how they treat others. This quality is so lacking in our world.
• They are a great encouragement to Andrey and I, regularly saying things that build us up and make us feel good. They are supportive of everything that we do.
  

If you have known my family in the past you know the challenges we've faced and endured, by God's grace. Our family hasn't always enjoyed harmonious relationships as many of us (I can speak for myself) experienced brokenness on many levels. But as a direct result of our hope and trust in a God who IS LOVE and offers transforming forgiveness that leads to healing, we are experiencing his joy and peace and life and healthy relationships with one another. I just want to give God all the glory for it truly is miraculous what he has done in our lives.

Thank you, Mom & Dad for your sacrifice in coming to visit us in Cebu. I know it wasn't easy to get here but you did it and I am so blessed and so happy to have gotten to share our life in Asia with you.

Back from the Beach, Last 2 days in Cebu for Mom & Dad

It's Friday morning. We got back to Cebu Wednesday afternoon. We had a wonderful time spending quality time with my parents. The weather was fantastic, the water perfect and the snorkeling, some of the best ever. I'll post pics later. We've been busy since we got back so I haven't had time to update the blog yet.

Yesterday Mom did a bit more ultrasound work at the clinic while Dad and I painted the new home-made shelves he made last week for the labor room. Today we're joining Andrey at work for prayer time and lunch. Tonight we have reservations at my favorite restaurant, The Gustavian for dinner.

Mom and Dad leave tomorrow. I'm sad to see them go but I know it won't be long before we see them again since we are heading to North America on the 19th. We'll spend the last 11 days of our month-long furlough in Alabama with all of my family members.