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.

Adoption Update

As of July 8, we have been waiting 19 months since approval of the adoption board of the Philippines. I just heard about a non-Filipino family that was recently matched with a child. They waited 21 months. To my knowledge however, there are still numerous families waiting for a match that have already waited close to two years. We still have no idea when our day will come but there have been a few encouraging developments lately that I will share at the end of this note. Before I do that, I need to vent a little about something we are working on.

Our agency in the US recently informed us that the Adoption Board of the Philippines created a new form titled, "Type of child acceptable to Family." They encouraged us to fill out this new form and submit it to them so they can forward it to the adoption board for us. We filled a similar form out during our first home study. The new form has been updated and expanded and is more specific, listing more than double the number of conditions included on the original form.

This form was probably my least favorite thing about this adoption process so far, besides the long wait. Just look at the title - type of child acceptable?? I despise the thought of having to think through and decide the type of child we find acceptable.

Here is the list, word for word (there's a box to check next to each condition either 'accept' or 'not accept':

Birth Condition - Premature, undescended testicle, umbilical hernia, physical abnormalities (cleft lip, cleft palate)

Eye Condition - Visual acuity abnormalities, strabismus

Ear Condition - Hearing impairment, ear deformity

Heart Problems - heart murmur, heart defect (may require surgery)

Hematologic Disorder - G6PD, thalasemia, others

Infectious Disease - Hepatitis B, First degree infection under medication

Orthopedic Problems - Hand anomalies, leg anomalies (bowed leg), foot anomalies (requiring cane, leg braces, or splint), facial feature anomalies

Emotional and Social Development - Autism, ADHD, known history of physical/sexual abuse

Developmental Delays - Cerebral palsy, seizures, speech related problems (stuttering, lisps, etc.), gross motor delay, hyperactivity, slight developmental delay, global developmental delay, speech delay, metal retardation (mild)

Parental Background - No known information; History of: drug use, alcohol use, emotional illness (e.g. depression), mental illness (e.g. schizophrenia, psychosis), mentally challenged, with criminal record, child of rape, child of incest

Other - lactose intolerance, skin conditions (eczema, dermatitis), bronchial asthma, hypo/hyperthyroidism, needing surgical procedure(s), large hemangioma (which will disappear over time), dental carries

I have so many problems with this form! My mind just goes berserk when I read each condition. Premature? Are we talking 3 months or 3 weeks premature? Alcohol/drug abuse in the mother - was this during pregnancy? If so, how much alcohol? What kind of drugs? How was the child affected? Cerebral palsy - Is this really considered a developmental delay? What degree are we talking? Seizures? What is the underlying condition causing them? How severe? How often? Hematologic disorders - what does "others" refer to? Infectious disease - Do I only need to consider Hep B? What about HIV & TB? Why aren't those on the list? I could go on....

Aside from these things, and the over-arching dislike for such a list is the problem I have with playing God, so to speak. I mean, I understand why we have to fill out such form but geez, this has got to be my least favorite part of the adoption process because of the knowing that by checking a 'not accept' box, I am eliminating an actual child in need of a family. It just seems wrong to have to choose.

Now it would be fine if the choice was between a child considered to be "normal" and a child with certain special needs but these aren't the options (I was naive early on to think it was this black and white) and even if they were, who are we to limit our choice to a "normal" child? Of course parents of biological children would choose to give birth to a healthy, normal child but given the option of having a child with some form of challenge (as is the case in all adoptive children), who would want the responsibility to pick and choose that which they would be faced with? Normally, you get pregnant, you pray for the best, do the best you can to take care of yourself and then be prepared to take on whatever your child presents with, because that child is your child.

Whatever boxes we check, we have to be willing to take a child with such a condition. If we check the box and then we're presented with a child with that condition, we have very little grounds to reject that referral. So we'd better be darned sure we are willing to take whatever we check "accept." But how do we know? We are not familiar with many of these conditions and what impact they have on the child. I have some research to do.

Besides, even if I fill out a form and feel pretty confident that I can "handle" the conditions I checked off, the child we get is not just a list of conditions. He/she is a child with complex genetic and environmental make-up that blend together into something unique. You just truly have no idea what you are going to get! So I guess in the end, all we can do is fill out the form the best we can and trust God with the result, knowing that ultimately, what we receive will be from Him and we will accept and deal with whatever we are faced with, because that child will be our child. Still, I don't have to like the process.

So with this, I am asking for your support in prayer in the next day or so as Andrey and I fill out this new form. Our hope is that we will be led by the Holy Spirit to check those boxes that we feel we are willing to take on, even if it is something we'd rather not deal with.

It's not realistic to just check 'not accept' on most boxes as I really believe it eliminates 90% of children waiting for a family. We also know that regardless of what may be said of a child's health status, there may be other conditions present and in different degrees than stated. Frankly, we are prepared for some challenges and feel ready to take on whatever our child presents with. Maybe it's not even about what we feel we can handle but about what we feel led by God to be open to taking on. As I write, I realize this may be a attitude in which to approach this list. So really, it's up to the Lord to guide us! Simple as that! There is just no way I can rely on my own human wisdom in this. What we need is divine wisdom and discernment and as you pray with us for that, I will expect to be lead. Okay, I feel better about this now.

I have two more (positive) things I want to mention. Our agency also encouraged all families who have been waiting longer than a year to write a brief card to the adoption board including a few updated family photos, that says something like, "We are eagerly awaiting the referral of our child... here are some recent photos." We are happy to get the chance to do this and have already printed three photos to include in our note. One of Andrey with his (Filipino) staff, one of me at work at the clinic with my (Filipino) co-workers and one of us together on our recent trip to India. If you couldn't tell, the choice of photos is very strategic for us and hope they will show that we are well integrated into Philippines society and familiar with Asian culture in general.

Now I've saved the best for last. Something very encouraging came to our attention a few days ago. Our social worker in Manila who works for Holt's partner agency emailed us to tell us that she recently wrote a letter to the adoption board, "appealing to the Board to consider [us] soonest for a referral due to [us] have been living in Cebu, Philippines since 2007."

Our social worker actually wanted us to write a letter to the adoption board like this many months ago but our agency in the US said we'd better not as we hadn't waited even 18 months yet at that time. Well the day after our 19 months mark, our social worker took the liberty (likely with the approval of the US agency), to send such a letter. I got very excited when I read that!

Thanks for your support and prayers! We so blessed to have so many family and friends supporting us in this journey. Lord bless you today!

Feet in Two Worlds

So here we are in an unreal place - the Shangri La Resort in Cebu. We're here because some visitors (staff and supporters of the work my husband does) are treating us to two nights here.

(photo taken from Shangri La Cebu website)

Now, don't get me wrong because I am very thankful to be here, I just feel the need to reflect on my experiences this past week and how the disparity between two worlds makes me feel.

It's as if the other world, the world known by the poor, is the reality. And this, here, is just contrived and made up to anesthetize one's self to the true reality that exists just beyond this estate.*

In the past week,

• I went with two women to the hospital for a check up to have IUDs removed. One woman was found to have extremely high blood pressure. We were sent to the ER and I was able to help with some meds to try to get her BP down (not effective). The woman eventually signed out of the hospital against medical advice with dangerously high blood pressure because she has no money for the recommended admission and lab tests. I was unable to convince her to check in at a less expensive hospital where we could assist in the cost. She said she felt fine. We prayed together and I took her home.

• I walked around a slum area alone, a little lost when I didn't have a way to meet up with friends I had meant to connect with. Friends meet in this community several times a week to get to know people there and disciple new believers. I've been joining lately and have been able to help with some medical needs of some of the women there. I felt insecure and embarrassed as I walked around and asked for directions. People stared and smiled and said something like, "Look! There's an Americana." I was concerned about the mud created from the last rain getting on my jeans. I almost lost my rubber flip flop to the mud that attempted to swallow it. I eventually found someone I knew and she took me to a shack of a home where the woman with high B/P lived, who I had taken to the hospital the day before. We visited for a while and we prayed together for healing. Then I went home feeling pleased with myself for not giving up and trying to find my way for the first time by myself in an unfamiliar place and was happy it at least resulted in something small.

• I visited a woman who lives near some fish ponds in a place that regularly gets flooded during rainy season. I got to give my first depo shot as a certified professional midwife. She told me I could post the following photo (It felt significant that I was administering family planning for the first time as an autonomous midwife). To get there, we walked on raised bamboo paths that were built over muddy, stagnant, garbage-filled water. I walked carefully for fear that I'd fall in.

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• I joined in a bible study with new believers who live in either a neighborhood like the photos below or on the street. We read together from Psalm 107 and asked them to share what part they could relate to. Two women in particular said they could relate to this: "Some wandered in desert wastelands, finding no way to a city where they could settle. They were hungry and thirsty, and their lives ebbed away. Then they cried out to the Lord in their trouble, and he delivered them from their distress." I heard stories how these women and their children hadn't eaten all day and how they cried out to God and suddenly, seemingly out of nowhere, they had food. One of the women shared how her 9-month-old son had become extremely ill. His eyes were rolling in the back of his head, he wouldn't eat, and was vomiting. She prayed. A friend of mine from our church community happened to be in the area at an unusual time and suddenly ran into this woman and her child. They were able to admit the child at the public hospital where he received treatment for potassium deficiency. For this woman, this was a clear answer to her prayer for help. Thank you, Jesus!

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• I toured the public hospital with 30 American teenaged volunteers from Texas. I walked around the hospital feeling disgusted like I sometimes do when I walk through other parts of the city that feel spiritually oppressive and dark. We spent much time in the pediatric ward, praying for families and children. I met a young man in a stairwell whose girlfriend just lost their baby at only 6 months gestation. I saw an old woman in the ER on whom the staff was performing CPR and nobody seemed to make the effort to cover her body clothed only in undergarments. There was a crowd that gathered to watch and I couldn't bear to take in the show or know what may eventually happen. The whole scene just felt so undignified. I felt totally unprepared to walk around and minister to people so I just translated for the volunteers. I struggled with a strong desire to leave as soon as possible and not think about this place.

• On my last night shift I assisted the delivery of a growth-restricted baby who weighed only 2.1 kg (4 lbs, 10 oz) and watched his young parents look utterly hopeless because they only had 200 pesos and they were going to need money to pay for meds/supplies/care for their baby. I knew they already had a special needs child who was also growth-restricted in the womb. I noticed during delivery that the corners of the mom's mouth were bleeding possibly due to vitamin B and/or vitamin C deficiency while she had to forcefully and quickly push her baby out because his heart slowed down to 50 as his cord was trapped between his head and the mother's pelvis and then was born completely white and floppy with a heart rate of only 70 (normal is 120-160) and us resuscitating him with an ambu bag. He survived and we stayed up all night monitoring him.

So these are some of the places and events that filled my week and now I'm here at the Shangri La and it feels like a fantasy land - so not real! Life just goes on satisfying one's need for pleasure, perhaps to pacify the need for something greater, while the reality for the poor carries on with no end in sight. I recognize my own feelings of inadequacy and selfishness. I can not be satisfied any longer with such pleasures in excess - for in the darkness of the night lately I wake and sense the struggles of the poor and suffering and I can do nothing but carry their burdens to the Father and pray for wisdom regarding my role in it all.

*I am not judging those who take time to rest in a beautiful place, as we often do. I am speaking against the portion of the world that seems to carry on with a fantasy life oblivious to the plight of the poor, which is also a life I have tasted.

Anniversary Week (8 years!)

Yikes! How does this happen? Weeks go by and I haven't blogged. After about a month of slower days things suddenly became busy. There is much to update and I'm not sure where to start. Well I wanted to post about our anniversary so I'll start with that.

Andrey and I had a nice anniversary. A bit strange, but nice. Strange in that it was an all around untypical day. I worked all night at the clinic the night before and stayed late well into the morning to help as there were three women in labor (including the woman I was up with all night; poor thing was having a very long difficult labor making just enough progress for us to be able to keep her in the clinic), four postpartum moms and their babies, about five women waiting for a pap smear and tetanus shots, and new patients waiting to be interviewed. I stuck around to help as long as I could but eventually had to leave to get some rest. There were several extra staff around by then to help. I was disappointed I wasn't physically able to stick around long enough to see my patient deliver. I haven't had a birth in SO LONG so I was really hoping to get to deliver her baby. Okay, so that was beside the point. Needless to say I was tired.

Andrey was tired because he was up in the middle of the night to watch the World Cup final at 2:30 am. He had a few friends over. So he slept a bit in the morning then went to work when I arrived home around 11. Then I slept while he worked for a few hours. When he came home he woke me up and I stumbled out of our bedroom in a fog to find some beautiful lilies and roses in a vase on the table. What a nice surprise!

The afternoon was strange because we just puttered around the house and were a bit lazy together. By the evening we finally decided to go out for dinner, which we did and shared a bottle of wine that just about put me to sleep, but it was nice to get out.

After eight years, I'd say, we don't look half bad. It's our love that keeps us looking youthful. ;-)

I just have to give props to my wonderful husband. He is still my favorite person to be with. We laugh together often, get along great and make a great team. I knew he was the right one to marry but I didn't know how perfect he was for me until after we got married. Since then, I have been amazed at how the Lord gave me something even better than I could have asked for or imagined. Wow. I'm still blown away by that.

Andrey continually amazes me at how kind he is to me when I'm not the most lovable. He just seems to know what I need. He is affectionate and encouraging. He speaks loving, kind words to me daily - especially first thing in the morning when I am too sleepy to return the kindness.

He is a joy and a blessing and I am so very thankful for him. The lesson? Delight yourself in the Lord (and wait for His plan to unfold) and he will give you the desires of your heart (Psalm 37), even before you even know what those true desires are. God is good. We experience His goodness and love in each other daily.

So I guess this has turned into an anniversary post. Will update the rest soon...