Sunday, August 3, 2008
Maternal and Child Health on Negros
August 2, 2008
In the Philippines, 10 mothers die daily due to pregnancy and childbirth related causes. On Negros, 0.81% of pregnant women die in pregnancy or during childbirth. 13 of over 1,000 newborn babies die.
We understand that this is because the basic and chronic problems in health are not addressed and indeed are allowed to worsen as the majority of the population lives in dire poverty. It all boils down to the reality that the government priorities foreign debt and the military over the health of the people!
For the national situation, see my earlier blog entry 'National Situation'.
Trinidad is but one of 33 Barangays in the ‘city’ of Guihulgnan, Negros Oriental; Trinidad Barangay itself is composed of many small sitios, each with a population in the low thousands. This community is about as rural as it gets; very few of the extremely modest 1 or 2 room bamboo houses has direct access to the road, so reaching most homes involves a 20 minute to several hour hike.
This means that women and their families have very limited geographical access to health care services. But the problem goes much deeper, and encompasses not only the geographical, but includes the social, ideological, political and economic.
The social barriers include the burden placed on the family when the mother is absent from her childcare and household duties in order to access far-away and expensive health services. When it takes several hours a day to prepare meals over open fires, and either you cook or you don’t eat, there is no other option for many families except to try and farm out their children or bring them into the city. The usual 'choice' is to not go to the health centre or hospital at all.
The ideological barriers are difficult to express. There is an acceptance that women take a risk of dying for having a baby that would never be socially-acceptable in Canada. Children with deformities are prayed for and then left to find ways to compensate. My perception of risk is completely altered by this experience.
The political barriers run deep to the corruption of the Philippine national government and the patronage-focus of the provincial and local governments. If you are poor and have no money to pay for your kidney dialysis or blood pressure medication – go see the mayor and ask for a favour because you voted for her in the last election! No social services for the people as state responsibility, but rather stop-gap measures from the politicians looking for support and votes. In an emergency, in order to use the municipal truck for transportation, you first must see the Barangay Capitan! Meanwhile, the injured or sick person is already dead while their families scramble to find transport. This very situation happened last weekend and the teenager with the head trauma died.
The economic barriers are the most maddening, and yet provide an explanation for the geographical, social and ideological barriers. The political corruption and foreign-debt and military focus of the national expenditure leaves the people on the brink of disaster.
The Personal is the Political
We started the basic midwifery skills training for local CHWs and hilots that I led last week with each woman sharing a situation where she felt that she needed more support or knowledge to deal with a woman or baby in her care. Every participant shared a story of a woman or baby, or both, dying for lack of proper care, medicines, or treatment.
The stories were saddening, but it was also heart-warming to see how excited these women who all attend deliveries yet live in far-flung areas were to sit in one room together and share their experiences and their ideas. I really emphasized as much as possible the importance of continuing to share like this, but also to go to see the Barangay Capitan together and light a fire under his chair about the need for medicines, equipment and proper emergency transport!
The stories included women and their unborn babies dying from eclamptic seizures due to undiagnosed and untreated high blood pressure; one woman shared that a woman was brought to the clinic with a BP of 220/120, and died just outside the door of the clinic while they were trying to get her to the hospital. Many participants had the experience of prolonged labour or malposition where the baby was already dead by the time it was born. Nanay shared a story of a newborn that developed severe jaundice, the parents could not afford the hospital and would not transfer when Nanay insisted, shortly after the baby was dead.
The response from the government to the shockingly poor maternal-child health statistics and the hardships and dangers faced by pregnant and labouring women has been complete inaction and silence.
International UN organizations, such as UNICEF, have a response almost as lacking as the Philippine Government. Here in the Kalabaklabakan Mountain Clinic sit two large boxes of midwifery equipment and medications. There are no instructions on how to use the equipment and no manuals on managing delivery or emergencies! To top it off, the kits lack ANY postpartum hemorrhage medications! There is even magnesium sulphate to treat severe hypertension and eclamptic convulsions, but no oxytocin or ergot! I am shocked. The kits are great but where is the needed support to put them into use?
There Are No Personal Solutions to Political Problems
It was a goal of mine to attend deliveries in the Philippines, and I knew I would help out with some training along the way. It wasn’t until I was actually out here in Guihulgnan that it really hit me how fundamental health skills training is to the strength of the People’s Organization and the survival of the community as a whole.
Considering this, I cannot be disappointed that it is so hard to get out to the deliveries, but be happy with the deliveries I get. It is shocking how dangerous it is to give birth here, and if I could, I would stay here for a year and train everyone! So now I let go of the pleasure of delivering babies and focus on doing the best trainings that I possibly can while I am here – and in as many creative ways as I can, too! I have been asked to give 4 more formal trainings, plus to keep training with each prenatal visit, and any deliveries that occur during my stay.
It was incredibly inspiring to design and facilitate a two-day basic skills and emergency training with local Community Health Workers (CHWs – work for the People’s Organization), Barangay Health Workers (BHWs – work for the local health unit), and Hilots (traditional birth attendants). We covered what to do in a basic prenatal visit, what abnormal findings mean, when you can treat at home and when to go to hospital, doing a normal delivery, the midwifery kit, and then some emergencies such as hemorrhage (with no meds!), shoulder dystocia, breech, and prolonged labour. For the CHWs at Kalabaklabakan, I reviewed the uses of the essential medications for pregnancy and delivery, minus the PPH drugs (!), since UNICEF didn’t send those!
Training of health workers is the best and most lasting contribution I can make; knowledge and skills in the hands of the health workers leads to a better life for the whole community and is a significant contribution to the movement!
In the Philippines, 10 mothers die daily due to pregnancy and childbirth related causes. On Negros, 0.81% of pregnant women die in pregnancy or during childbirth. 13 of over 1,000 newborn babies die.
We understand that this is because the basic and chronic problems in health are not addressed and indeed are allowed to worsen as the majority of the population lives in dire poverty. It all boils down to the reality that the government priorities foreign debt and the military over the health of the people!
For the national situation, see my earlier blog entry 'National Situation'.
Trinidad is but one of 33 Barangays in the ‘city’ of Guihulgnan, Negros Oriental; Trinidad Barangay itself is composed of many small sitios, each with a population in the low thousands. This community is about as rural as it gets; very few of the extremely modest 1 or 2 room bamboo houses has direct access to the road, so reaching most homes involves a 20 minute to several hour hike.
This means that women and their families have very limited geographical access to health care services. But the problem goes much deeper, and encompasses not only the geographical, but includes the social, ideological, political and economic.
The social barriers include the burden placed on the family when the mother is absent from her childcare and household duties in order to access far-away and expensive health services. When it takes several hours a day to prepare meals over open fires, and either you cook or you don’t eat, there is no other option for many families except to try and farm out their children or bring them into the city. The usual 'choice' is to not go to the health centre or hospital at all.
The ideological barriers are difficult to express. There is an acceptance that women take a risk of dying for having a baby that would never be socially-acceptable in Canada. Children with deformities are prayed for and then left to find ways to compensate. My perception of risk is completely altered by this experience.
The political barriers run deep to the corruption of the Philippine national government and the patronage-focus of the provincial and local governments. If you are poor and have no money to pay for your kidney dialysis or blood pressure medication – go see the mayor and ask for a favour because you voted for her in the last election! No social services for the people as state responsibility, but rather stop-gap measures from the politicians looking for support and votes. In an emergency, in order to use the municipal truck for transportation, you first must see the Barangay Capitan! Meanwhile, the injured or sick person is already dead while their families scramble to find transport. This very situation happened last weekend and the teenager with the head trauma died.
The economic barriers are the most maddening, and yet provide an explanation for the geographical, social and ideological barriers. The political corruption and foreign-debt and military focus of the national expenditure leaves the people on the brink of disaster.
The Personal is the Political
We started the basic midwifery skills training for local CHWs and hilots that I led last week with each woman sharing a situation where she felt that she needed more support or knowledge to deal with a woman or baby in her care. Every participant shared a story of a woman or baby, or both, dying for lack of proper care, medicines, or treatment.
The stories were saddening, but it was also heart-warming to see how excited these women who all attend deliveries yet live in far-flung areas were to sit in one room together and share their experiences and their ideas. I really emphasized as much as possible the importance of continuing to share like this, but also to go to see the Barangay Capitan together and light a fire under his chair about the need for medicines, equipment and proper emergency transport!
The stories included women and their unborn babies dying from eclamptic seizures due to undiagnosed and untreated high blood pressure; one woman shared that a woman was brought to the clinic with a BP of 220/120, and died just outside the door of the clinic while they were trying to get her to the hospital. Many participants had the experience of prolonged labour or malposition where the baby was already dead by the time it was born. Nanay shared a story of a newborn that developed severe jaundice, the parents could not afford the hospital and would not transfer when Nanay insisted, shortly after the baby was dead.
The response from the government to the shockingly poor maternal-child health statistics and the hardships and dangers faced by pregnant and labouring women has been complete inaction and silence.
International UN organizations, such as UNICEF, have a response almost as lacking as the Philippine Government. Here in the Kalabaklabakan Mountain Clinic sit two large boxes of midwifery equipment and medications. There are no instructions on how to use the equipment and no manuals on managing delivery or emergencies! To top it off, the kits lack ANY postpartum hemorrhage medications! There is even magnesium sulphate to treat severe hypertension and eclamptic convulsions, but no oxytocin or ergot! I am shocked. The kits are great but where is the needed support to put them into use?
There Are No Personal Solutions to Political Problems
It was a goal of mine to attend deliveries in the Philippines, and I knew I would help out with some training along the way. It wasn’t until I was actually out here in Guihulgnan that it really hit me how fundamental health skills training is to the strength of the People’s Organization and the survival of the community as a whole.
Considering this, I cannot be disappointed that it is so hard to get out to the deliveries, but be happy with the deliveries I get. It is shocking how dangerous it is to give birth here, and if I could, I would stay here for a year and train everyone! So now I let go of the pleasure of delivering babies and focus on doing the best trainings that I possibly can while I am here – and in as many creative ways as I can, too! I have been asked to give 4 more formal trainings, plus to keep training with each prenatal visit, and any deliveries that occur during my stay.
It was incredibly inspiring to design and facilitate a two-day basic skills and emergency training with local Community Health Workers (CHWs – work for the People’s Organization), Barangay Health Workers (BHWs – work for the local health unit), and Hilots (traditional birth attendants). We covered what to do in a basic prenatal visit, what abnormal findings mean, when you can treat at home and when to go to hospital, doing a normal delivery, the midwifery kit, and then some emergencies such as hemorrhage (with no meds!), shoulder dystocia, breech, and prolonged labour. For the CHWs at Kalabaklabakan, I reviewed the uses of the essential medications for pregnancy and delivery, minus the PPH drugs (!), since UNICEF didn’t send those!
Training of health workers is the best and most lasting contribution I can make; knowledge and skills in the hands of the health workers leads to a better life for the whole community and is a significant contribution to the movement!
Congenital Abnormalities Undiagnosed and Untreated
Walking the market or visiting the school, the health worker in Barangay Trinidad can witness many birth defects which have gone unrepaired and untreated; neglect of the corrupt Philippine government. My first experience of this was on my first day in the Barangay – it becomes a matter of fact once you digest that there is no treatment available. In some cases, I wonder, are there other potentially-debilitating defects associated which have been undiagnosed? What are the long-term health consequences of such defects? As a midwife who performs neonatal examinations, I know that where there is one defect, there very well may be others. In particular, when I see children with a mid-line defect, such as a cleft lip/palate, I wonder how extensive of a physical examination has the child had, if any at all?
Some of the more common-place ones I have witnessed:
Partial blindness from malformed eye: There is a boy with an abnormal eye in Billy’s basketball play group. He does not play basketball, but sits on the sidelines and observes the game with the younger kids. Vision impairment will have a major effect on his ability to earn a livelihood in a rural peasant community. I imagine, however, that the child learns to compensate with his good eye as much as possible; but with the common tool of the peasant being the machete, and knowing the regularity with which the health workers repair machete wounds, it must be a risky compensation.
Deafness & impaired speech: There are 3 children who are mostly deaf and who hence have impaired speech in a family of 6 children. The parents wonder why this is happening to them, but no medical professional has ever visited them and reviewed their medical history and pedigree; there are no services available to this family, and no funding for the children. Women in the community have no access to iodized salt, and goiter is fairly commonplace among women of childbearing age and this might be the root of the deafness. I have not seen anyone using signing with these children, and when I asked Nanay if his parents use sign language, she was unsure.
Cleft lip/palate: Although I have seen other unrepaired clefts, there is a girl in Sophia’s play group that must be about 10 who has a marked cleft, and for some reason, this strikes me as the most regretful neglect of the Philippine health care system. Perhaps it is because I am very knowledgeable about the available intrapartum diagnosis, neonatal nutritional monitoring and support, early structural and cosmetic repair, dental care, and counselling available in Canada for parents of and children with a cleft. It makes it hard to look the politicians in the eye when we meet when I know the suffering of these children.
Club foot: There is a young boy of perhaps 10 who walks on his ankle bone as his foot is markedly clubbed. The ankle appears to have a dense layer of scar tissue, but I do wonder about pressure wounds and circulation issues, not to mention, life-long pain.
Extra digits: A minor and virtually non-issue, but a large number I am seeing, and something that we would not even question repairing in Canada.
I know this entry is disjointed, but my time is so tight and I only have access to the internet very sporadically, and then only for an hour at a time. It might be another month before we have internet again, so take care everyone!
Some of the more common-place ones I have witnessed:
Partial blindness from malformed eye: There is a boy with an abnormal eye in Billy’s basketball play group. He does not play basketball, but sits on the sidelines and observes the game with the younger kids. Vision impairment will have a major effect on his ability to earn a livelihood in a rural peasant community. I imagine, however, that the child learns to compensate with his good eye as much as possible; but with the common tool of the peasant being the machete, and knowing the regularity with which the health workers repair machete wounds, it must be a risky compensation.
Deafness & impaired speech: There are 3 children who are mostly deaf and who hence have impaired speech in a family of 6 children. The parents wonder why this is happening to them, but no medical professional has ever visited them and reviewed their medical history and pedigree; there are no services available to this family, and no funding for the children. Women in the community have no access to iodized salt, and goiter is fairly commonplace among women of childbearing age and this might be the root of the deafness. I have not seen anyone using signing with these children, and when I asked Nanay if his parents use sign language, she was unsure.
Cleft lip/palate: Although I have seen other unrepaired clefts, there is a girl in Sophia’s play group that must be about 10 who has a marked cleft, and for some reason, this strikes me as the most regretful neglect of the Philippine health care system. Perhaps it is because I am very knowledgeable about the available intrapartum diagnosis, neonatal nutritional monitoring and support, early structural and cosmetic repair, dental care, and counselling available in Canada for parents of and children with a cleft. It makes it hard to look the politicians in the eye when we meet when I know the suffering of these children.
Club foot: There is a young boy of perhaps 10 who walks on his ankle bone as his foot is markedly clubbed. The ankle appears to have a dense layer of scar tissue, but I do wonder about pressure wounds and circulation issues, not to mention, life-long pain.
Extra digits: A minor and virtually non-issue, but a large number I am seeing, and something that we would not even question repairing in Canada.
I know this entry is disjointed, but my time is so tight and I only have access to the internet very sporadically, and then only for an hour at a time. It might be another month before we have internet again, so take care everyone!
Sunday, July 27, 2008
Birth of Baby Sophia -- Kalabaklabakan Mountains
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!
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