"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.

A Birth Mother

This week at the clinic a woman delivered a baby boy. She held him and breastfed him for the first hour of his life. During his first day he didn't have a name. The staff at Glory Reborn named him John. John's mother made the very difficult decision to give him up for adoption. She made the decision during her pregnancy due to financial reasons.

John's mother is a 34-year-old with two other children. She has an elementary school level education and is estranged from her husband. She knew she wasn't able to properly care for another child.

We had initially thought that baby John would go to one of the local orphanages the day after he was born (where he would likely be adopted from internationally) but the orphanage first needed to screen the mother for HIV, so the baby had to stay at Glory Reborn for another day. The mother also was not yet discharged. The staff took care of baby John while the mother rested alone. She initially was using a bed in our postpartum room with other moms and their babies.

On Wednesday evening during the night shift she heard her baby crying and fussing and she walked around the clinic looking for her baby. Hilary was in the midwives room feeding John. The mother asked me if she could see her baby. I said, "Of course." I brought her into the room where her child was being held and cared for. He was fussy and my gut feeling told me he knew that something was amiss. Where was his mother? Where was her smell? Her warmth? Her voice? This little seven pound infant must know that he's lost the only thing he's known in his short existence.

As John's mother looked at him she started to cry. With my hand on her shoulder I told her, "Talk to him. He would love to hear your voice." She looked at him and spoke a few soft words - something like, "Hi baby. It's okay baby." Something amazing happened. John immediately calmed. He opened his eyes and looked directly at her face. There was a knowing in his eyes. A knowing who this person was. It was the person he longed for. We stood there with this mother, looking at her baby and crying for what felt like an hour. We asked her if she would like to move downstairs so she wouldn't have to be around the other babies and wouldn't hear her baby crying as much either. She agreed.

When I let myself really think about this I cry. A deep, grief-filled cry. I cry and grieve the fact that this woman is in a position to have to make such a difficult choice because of poverty. I cry about this child losing the most significant person in his life and how this must impact him and how it will impact him for the rest of his life.

I tried to encourage this mother by telling her that I know several families who are adopting babies like hers and that he will be very well cared for. I told her I admired her for her decision and how incredibly difficult it must be. I don't know if I would be as brave as this woman. But as much as I know how loved this child will likely be, I still can not feel like this is the way it should be. It just isn't. Ideally, this woman would have been able to make the choice to not have another baby and would have had access to affordable family planning options. Second to that, this woman should be able to keep her baby and get the help she needs to care for him. Of course, when these things aren't options, then I think adoption is a beautiful and wonderful thing.

But I feel as if I've witnessed something very special. The love of a birth mother. And her difficulty in giving him up. I will cherish this experience. For it's possible that our child will come to us with no known history. One day I will share this story with my child, to help them understand what their birth mother must have gone through.

November Babies

I thought I'd share a few pics of some babies and moms who delivered in November from the latest monthly baby party. Aren't they cute?

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?

Learning and Teaching

Andrey's coming back tonight. Yay! He's been in Manila all week for meetings. I really prefer having that guy around and I'll be happy to pick him up from the airport later.

I worked last night and was delighted to get to rest for half the night because Tuesday night I was up till 5 a.m. with an 18-year-old first-time mama whose baby's father is considered 'unknown.' I find it sad on so many levels. The good things about this birth included a beautiful, precious little baby girl named Allyson and the fact that I felt really confident managing her labor and delivery. I'm starting to arrive at this place I couldn't imagine before. A place where I feel like I might actually know what I'm doing. There are still many-a-births when I don't feel this way but the number in which I do feel confident is increasing. I'm starting to feel like a real team member who contributes nearly as much as the nurses and midwives I work with that already have many years of experience.

The past few days I have been looking through tons of charts at the clinic of past births trying to find births that I either observed or managed and needed to be transported to hospital. I haven't kept of record of these because I didn't think I'd need to but turns out the North American Registry of Midwives (NARM) wants to know these in addition to the births I attended - delivered or assisted - as part of my application for the licensing exam. So I've been looking through charts. I found a few things that surprised me. In the past 5 months or so I have had the opportunity to instruct a couple of our newer staff-members (nurses getting trained in midwifery). There was a day when we had several births and Hilary was busy in the other room when a patient progressed faster than we expected and it was just me and one of the newer nurses in the room. Next thing we knew the baby's head was out and it's cord was wrapped around it's neck loosely. She panicked a little and I got to talk the her through what to do and I was surprisingly calm and relaxed (probably because cord wrap isn't that big of a deal, I may have reacted differently if it were an emergency or something serious) and was able to talk her through it instead of just taking over.

Then there was another birth I had forgotten about when a different nurse was handling the birth and she had trouble facilitating the birth of the baby's body after the head was out. I was able to instruct her and then stepped in to get it done after being instructed to do so by the supervisor on duty.

The reason I am mentioning these things is that I realize that I LOVE teaching! I love it! Who doesn't like to feel like they know what they are talking about? It's a good feeling and I'd love to do more of it. This is perfect as far as midwifery goes because there is a saying in midwifery (actually it's Midwifery Today's motto) - "Each one teach one." I have often thought about what it would be like to work as a midwife in another developing country on my own and how that would likely include training local midwives. There is a part of me that thinks it would be hard to not do births myself but I think I could really enjoy teaching.

One thing that has come out of becoming a midwife that I didn't expect is coming to understand and appreciate the significance of my father's two-decade career as a paramedic. When I took the Pediatric Advanced Life Support (PALS) class recently it occurred to me that this was the kind of stuff my Dad did knew how to do and did for so many years when I was a kid - handled trauma cases and managed a rescue car in a busy city, worked on a CareFlight helicopter. And then my Dad told me that he used to teach the PALS class. Wow! I had no idea how amazing my Dad was! I mean, I knew he was pretty great but I had no idea how skilled he was medically.

When I was a kid and somebody in my family got a bad cut or gash (usually one of my brothers), my mom and I immediately knew they needed stitches and always felt quite disappointed when my dad would say something like, "Na, it's fine. Just throw a butterfly bandage on it and it will be fine." My mom and I would usually think he was crazy and that he just didn't understand the seriousness of the laceration or we felt that the accident required more pity and babying (because that's what we would have wanted). Well, now I understand! It really wasn't a big deal and if it really were, it would have been handled appropriately. And even if there was a lot of blood, of course it wasn't a big deal considering the things my Dad saw and handled all the time at work. Sorry I underestimated you, Dad!

It's been so fun lately chatting with him about emergencies and trauma cases and growing as a care provider faced with these things or the possibility of these things. I love hearing his stories about starting out as a rookie and then growing into a confident paramedic that was able to sleep in the rescue car because by that time he had seen just about everything and was able to confidently slip in a few zzzz's on the way to a call. I learned also that he did quite a lot of teaching after he became an expert in his field. My Dad is extremely patient, kind and encouraging and I can clearly imagine him teaching a younger paramedic on the job. I feel like I may have some of these same skills. My mom is pretty great with these things, too. She teaches nurses to do ultrasound in pregnancy crisis centers around the US. I have seen her in action (she trained the GRC staff last year) and she's a great teacher, too - very patient and encouraging - so I've had great models.

My dad retired from the City of Tampa Fire Rescue department after he herniated two discs in his back from all the lifting over the years. I think these kind of jobs have a shorter life span than other careers and from what I can tell, most paramedics don't work as long as my dad did. I still don't know how he did it. I have a lot of respect for paramedics (like my friend, Melissa!), but I know I'm not called to that career. I am quite satisfied with the possibility of the rare, serious emergencies that midwifery brings and needing to be ready to handle them effectively should one arise. I never saw it before but given the careers of my parents, this midwifery thing seems quite appropriate. I never knew I'd get such enjoyment out of medical stuff but as it turns out some of my favorite things are poking people with needles to hook an IV or spending an hour suturing!!! Ha ha! The immediate, tangible result is so satisfying!

Adorable Christmas Cards Available

About a month ago we had a photo shoot during one of the baby parties at Glory Reborn in order to get photos for this year's Christmas cards.

I would just like to tell everyone that these cards are now available and they are SO CUTE! Please take a look at them and buy some to give to your family and friends this year. Go to http://shop.gloryreborn.com/collections/holiday-cards.

They are a bit pricey if you think of the cost per card but if you keep in mind that the purpose of making and selling these cards is to raise much-needed funds for the ever expanding programs at Glory Reborn. For example, two social workers were recently hired. They will be assessing the financial situation of our patients in order to determine those who need more assistance than what Glory Reborn usually provides. This will come in the form of free lab work and medicine. Currently, patients have to pay for these themselves but for some even these basic costs are too much. The new program is exciting as it will help us to determine who really needs the extra help so that they are not prevented from accessing the care they deserve.

The proceeds from the Christmas cards go directly into the programs at Glory Reborn that serve the women of Cebu, Philippines.

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.

Glory Reborn Video

Hilary & David recently had a video made about Glory Reborn. It will be used in some local fund-raising. We are praying and hoping that wealthy business people in Cebu want to support the work of Glory Reborn by helping us build a new facility. Thought you might enjoy seeing where I work.

Click here to watch the Glory Reborn video from David Overton on Vimeo.

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!

Hairy Baby

Did I get you to look because of the title of this post? As they say here, "So drama!" Yeah, it's really not that exciting. It's just that the director of Glory Reborn, who is also my friend, Hilary, sent me this picture of me holding a newborn with a ton of hair at one of our recent baby parties. She thought it was cute because the baby had so much hair. We have a baby party the first Tuesday of every month for all the babies born the previous month. We sing happy birthday, eat cake, give gifts and the staff get to hold lots of babies so the moms can eat cake. It's a highlight. Here I am with a baby with one luxuriously full head of hair.

Oh how I wish I had a picture of myself as a baby. My father used to call me Kojak, after the actor Telly Sevales who starred in the hit TV show in the 70s. That's because I was bald till I was nearly 2 years old. Quite the contrast to these Filipino babies who have an ample head of hair the day they are born.

Who loves ya, baby?