Midwifery is 'With Woman'

A mother of four prays for rice.  She doesn't have enough to feed her kids.  She had a baby last month. Her husband is out of work.  There is a job.  It's his, but only if he can come up with 300 pesos up-front for a uniform.

I have never gone unwillingly without food.  I have no idea what it's like to be hungry and wonder where my next meal will come from, much less worry about my children's next meal.  I want to have a baby so badly and often wonder why it is so difficult for us when there are plenty of women out there who have more than they would have chosen.  Our stories and experiences could not be more different.

She is my friend, inasmuch as I've been given the opportunity to come alongside her during her pregnancy, to add to the minimal prenatal care she was receiving - to pray for her during her labor and to help her pay her clinic bill so she can go home the day after she delivered a healthy baby boy.  I checked on them a few days after she delivered to screen for any problems since the private clinic told her to come back after a week... so they could remove the cord clamp.  She and her husband saved one-third of the clinic's normal delivery cost during her pregnancy and that was not easy for them.  By the grace of God her husband had work during that time.

To deliver with a trained midwife at a private clinic or a doctor at the public hospital (and both options can be sketchy) it costs at least 3,000 pesos ($70 USD) if everything goes normally.  When urban poor Filipinos live on less than $2 USD a day, how can they be expected to afford basic maternity care? And when things go wrong?. . . 

I cared for her during her last pregnancy three years ago, back when I was still only dreaming of becoming a mom.  Her labor was long.  Too long for the protocols at the clinic where I worked so she had to be transferred to hospital.  I made sure she and her husband had what they needed to deliver there and she ended up delivering normally without any augmentation.  They were so grateful they gave me a beautiful silver necklace with a bamboo and silver charm in the shape of a slipper.  I didn't want to take it but knew it was their way of doing what they could to pay me back so I received it with joy.

I want to be with woman nearly as much as I want to be with child.  When I care for a woman such as this I find myself in an overly-enthusiastic, nearly-giddy state.  These people must think I'm crazy, I tell myself, but they already do - not because of my over-excitement at getting to do a baby and mom check-up after my first 16 months of motherhood, but because I do not fit their presuppositions about white women.

Being white is synonymous with being rich and while compared to them I am exceptionally rich, it's true that I don't fit the description of a rich mommy in the Philippines because I don't bring my nanny along or even have one and I do drive my own car, a dirty one at that.  In the Philippines, if you can afford a car you can afford a driver, and a driver then keeps your car pristine and clean at all times. Image is highly-valued by Filipinos and I pretty much drive around town in a car that looks like it just drove in from a long road trip...  all the way from America. 

I've been doing a lot of day-dreaming and praying lately.  I LOVE being a mom but I also recently realized that I REALLY miss working as a midwife.  I want to come alongside women in my neighborhood as they walk through pregnancy, birth and the postpartum period.  I want to become their friend, learn about their lives and see where it leads. 

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.

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.

"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.