July 8, 2008
First delivery call!
Tuesday morning we had just gotten the kids settled into their new school classes when I had the opportunity to accompany Nanay Meralyn on a house call for a delivery. We rushed back to the mountain clinic and gathered up our supplies. I threw my charting documents, prenatal kit, delivery kit, newborn resuscitation kit into my backpack along with a bottle of water, my headlamp and a clean bandana; Nanay packed sterile cloths and a hanging scale into two basins, and grabbed her home visit kit. To help with translation and provide support, Josephine and Ping also came along.
To get to the simple home of this farmer and his labouring wife, we had to hike for over 45 minutes with Nanay leading our entourage at full tilt. After reaching the summit of the first slope I was so out of breath and dripping with sweat I thought I was going to collapse or at least throw up, but we had just started! Nothing to do but keep going and hope the feeling passed. After the second climb I started to get the hang of it; then, magically, we reached the summit of the hills and walked on the highlands with valley on either side. It was positively gorgeous landscape. In midwifery school I never imagined I would be hiking into a birth with my kit on my back. I had hoped that we would be able to discuss the situation on our way, but Nanay was leading the pack always at least 20 paces ahead and I was too hot and winded to have a conversation! As we passed each house Nanay would call out greetings and get directions. It was quite fun once I no longer needed to desperately gasp for air, though I was nervous about what was awaiting me on this first birth in rural Philippines.
Finally we start to descend into the valley on our left, all the while I am thinking, ‘what goes down must come back up’… imagine hiking home with your equipment after a birth! There below us lay the home of this newly-wed couple having their first baby. The mother-to-be was already 34, old age for a first baby in these parts. The house was very simple, a one-room bamboo hut on stilts, with a pen for their goats, and chickens and puppies roaming the grounds. On the north and west sides there lay lovely a corn field almost ready to be harvested, on the west cassava underground with their vibrant green leaves bursting through the thick brown soil, and to the south the most incredible avocado tree literally dripping with giant soft and delicious avocados which we were fed shortly after our arrival. The home was tiny but very clean; no toilet or running water, but the raised and slatted bamboo floor was spotless and the air smelled fresh and sweet.
There were about 12 relatives in the house, on the small porch, and in the yard cooking and chatting. At first the fire was built under the house so the heat was passing through the slatted floor into the house so it was literally a sauna, but thankfully that fire was put out as the sun rose higher in the sky and a new fire was started off to the side!
It was 10:15 when we arrived. The labouring mother, Conception, or Connie, was lying flat on her back, not looking much like a woman in labour to me! Nanay went about checking her vital signs, and then I followed with an abdominal exam, feeling the position of the baby and listened to the FHR, first with my fetoscope and then with my Doppler so the parents could hear the FHR. I palpated for contractions and felt mild contractions about once every 8 minutes. The story took almost one hour to unfold, all the while Connie lying on her back covered in a blanket. It seemed that her pains started the previous night, she didn’t sleep well, and that morning she was still having pains coming and going, no fluid or bloody show yet. This information was difficult to gather, let alone get a full history of the pregnancy! After this we continued to eat and socialize with the family as they churned out snack after snack, avocado with muscovado sugar, cassava roasted in banana leaves, fresh ripe bananas, and rice with sardines.
As we snacked, I started to make suggestions about the labour. Everything has a process to follow, believe me; this was very hard to do for a variety of reasons, the biggest one being a huge language and culture barrier. Luckily, the father of the baby was very happy to have me, so this helped immensely. Mainly I felt it imperative that we get Connie up off her back and walking and swaying and moving her body. Periodically I listened to the FHR, perhaps every 30 – 45 mins, not too worried with schedule since I felt she was still quite early in labour.
Finally, at 12:00 I was starting to think that all of this socializing was getting us nowhere and I wanted a more complete picture of what was going on here. I could see that Connie was acting more like a labouring woman. I asked if I could again palpate contractions, and perhaps do an internal exam to see if the cervix was at all dilated. This took some negotiating, since I gather now from discussing with a CHW, the local hilots do not do much in the way of physical examinations of mom or baby; but consent was gained. After explaining through patchy translation how the exam works, I discovered that she was 1 cm dilated, 2 cm long, soft, vertex -1, ROT to ROP with SROM for clear fluid! Although I had been assured a few times that nothing was coming from her vagina, I was most definitely touching hair and that was for sure clear fluid pooling on the blanket. After more complicated and raucous discussion among the many women in the room, I finally discerned that, indeed, fluid had started leaking in small amounts at 08:00 that morning. Now we have a 34 year old primip with PROM and a posterior baby, to boot.
Damn! In my quest to make my backpack lighter I ditched my castor oil at the mountain clinic. Of course, now I want it! On the bright side, I think the baby is a nice small peanut and judging by how low it is sitting, I think she can push it out. At this point I am thinking about how the sun sets at 18:00 and we have to hike an hour to get to the clinic and the road. I tell Nanay what I am worried about: PROM, infection, I think we should be headed to the hospital if labour isn’t starting by night time, and how to transport if a fever starts or augment/induction turns out to be necessary. We discuss the transport process again: hike for 45-60 minutes, ask the Barangay Captain to use the Barangay jeep, then drive 2-3 hours to the hospital in Guihulgnan City. OK. I tell Nanay that if she isn’t in good labour by 18:00 we should go to the clinic cottages, as the transport process is ridiculous and we can’t facilitate it from here. Vital signs are stable, fluid is clear; FHR is good, nice accels - all reassuring stuff so we should enjoy the native coffee and the view with a plan in place.
Thinking that I want the labour to get going, I ask Nanay if there is a local alternative to castor oil. A tiny little woman with a long grey braid and a big smile appeared from out of nowhere and started to perform some kind of a ritual – a faith healer! How exciting for me to have the chance to witness. The healer proceeded to massage Connie’s belly with oil (which I later learned is snake oil) and to chant prayers to the baby.
Some time about 13:45 I needed to stretch my legs and pee in the corn fields. After a time I went back into the house and discovered Nanay starting to get Connie to push! Glancing at my watch I see it is 14:22. No way is this baby coming. I gently ask Nanay what is going on. She told me that ‘plenty of water’ was coming and the vagina was parting and was completely convinced it was time to push. OK, I tell Nanay that I am sure it is too early, but she has Connie down on the floor semi-sitting and is doing her thing; I have no other choice but to give this pushing business time to prove it useless. At least since Connie is now only contracting once every 15 mins for less than 45 seconds I am not worried about causing harm. Finally, after over 1 hour and only 4 pushes, I tell Nanay that I am certain that nothing is happening and we should stop this pushing in order to observe the labour – now Nanay is willing to have me step in. I sit quietly with my hand on Connie’s belly and feel contractions about every 8 minutes, mild to moderate; I gather that the contractions are still irregular and Connie was only pushing with the moderate and ignoring the mild.
Now it is close to 17:00. I tell Nanay that the labour is still very early and we should go to the clinic cottages now before it gets dark. To confirm this, against my better judgement I do another exam, sure enough, just as I expected, 2 cm dilated, 2 cm long, though there is some show on the glove now, fluid still nice and clear. I explain to the family that the womb is still mostly closed and the baby is not coming yet, but since the water is leaking we may need to be closer to help if it is needed. I also explain that the walk will likely get the labour going since the baby is so low it will help the cervix open. Finally, there is electric light, a cell phone, and intermittent cell signal at the clinic. At the clinic cottage we can wait until tomorrow morning to go to the hospital if needed, but at least we will be close if we have to go overnight.
OK, they agree! This is too easy. Everyone is bustling about packing up clothes, food, blankets, even a chicken tied by its feet and a long bamboo pole. But what is going on now? I peek back in the house and see Nanay has her pushing again!
It is hard to convey the scene that unfolded. There are now 13 people in the tiny steamy house, the faith healer is chanting and throwing flowers, men are saying prayers, women are all talking over each other shouting suggestions. I literally thought I was going to lose it – this was the most outside my comfort zone I had been the entire trip. I can laugh now, but at the time all I could do was do breathe deeply and remind myself that by tomorrow it would all be a memory – and a darn good one! Speaking loudly and clearly I stated again that the baby was not coming now and we should go before dark. I learned the day after from Mamay Amy that the father of the baby told everyone to listen to me and that we should leave – thank goodness because I think it was the right decision.
Now we set off. Connie is walking with her husband and a relative on either side to support her when she has pains. I show Connie how to slow dance with her husband when a pain comes. I am certain the walk will be a great help, and feel that we are doing the right thing as already the contractions are picking up. But what is happening now? Connie didn’t sleep last night and she is too tired to walk the rest of the way – the thunder is starting and the rains threaten. Like magic a man appears from the woods on a horse followed by a couple more men. They wrap blankets around Connie and tie her to the bamboo pole, and now we are off at great speed. I practically run with them the rest of the way to the clinic, leaving the family trailing behind with their iron pots and chickens. My adrenaline is now rushing and I barely notice the climbing.
As we descend the last decline we run into Mamay Amy who was on her way to look for us, worried we had been gone for so long and it was almost dark now. Nanay runs to the clinic cottage to turn on the lights and make a place for Connie while Mamay heads off to find Aiyanas and the kids and tell them I am back.
The trip was brilliant! At 18:00 Connie is looking like a woman in rocking labour. I joke with Nanay and Connie’s husband that this is what a woman in labour looks like! After a pee and a good drink, we get Connie side-lying and encourage her to rest between contractions, using massage to help her relax. I set out my delivery kit, my PPH meds, my newborn resuscitation kit and my suture kit, along with some extra gloves, cloths for the newborn and extra gauze. At about 19:00 she is starting to make grunty noises and I see perineal bulging! Time to set up our instruments and place a clean drape; I laugh as I look at my light blue tank top and jeans, so Mamay brings me a rubber apron. I tell Nanay about when to coach Connie to pant; I quickly coach Ping how to listen to the FHR with my Doppler between pushes. As the head starts to crown, the room fills with relatives all shouting encouragements. I am calling out “Pant! Pant!” and everyone else is chanting, “Sigue! Sigue!” Ah, well, what can I do but roll with it? So, in a dimly lit cottage in rural Philippines I perform my first-ever somersault manoeuvre as I feel the nuchal cord and yet Connie is pushing like a woman possessed and the family is all yelling for more! At 19:50, following a giant push, the baby is out, unravelled from the nuchal cord, and up onto Connie; with a good rub of the clean towel the baby cries! The cord is no longer pulsing, so I clamp and have the father do the honours with cutting the cord. It’s a baby girl!
Now the placenta; I am doing expectant management since my access to PPH medications is so limited. I have to say, I am a hard-core active management kind of gal, so this is the moment that makes me hold my breath. After a cuddle and a quick attempt at a breast-feed to get the oxytocin flowing, we get Connie up in a squat, and at 20:05 we have an intact placenta and about 300 cc of blood loss, which I suspect is now bleeding from her perineum. Uterus nice and firm; BP is great. Second degree laceration sutured beautifully, I must say, thanks to the Mountain Equipment Coop headlamp I brought for just this occasion.
Finally, my favourite part, the newborn exam. What a perfect little rosebud of a baby girl, weighing in at 2820 grams. Everyone is elated, and they name the baby girl Sophia! What a great tribute.
The family will spend a few days in one of the clinic cottages so we can do our postpartum care without hiking each direction – thank goodness! As it turned out, one of the relatives is the leader of the People’s Organization (hence the men appearing by magic) so even Aiyanas had a good experience talking with them while I did the birth.
My first home birth since graduation, a beautiful birth, a memorable story!
