On becoming a midwife

Home Sweet Home

levinrad — Sat, 29 Aug 2009 22:57:55 +0000

Now that I am home, it almost feels like a dream. So much is the same, and yet I feel so different. My tears are drying, and I am deeply breathing in the love and comfort of my home and my family. It will take awhile to sort through all that I learned and integrate it into my life and practice here. For now, I am simply being . . . in this familiar space that is somehow new . . . eager to root myself in this next phase of my evolution as a midwife.

Deepest gratitude for everyone’s support and your encouraging words. Your love and belief in me and my ability to do this has sustained me. You will forever be part of my midwifery journey.

I am disappearing into the loving arms of my bana for a few days. When I emerge, I will finally share more photos . . .

It’s not about the numbers, but . . .

levinrad — Wed, 26 Aug 2009 23:22:52 +0000

12 births as primary midwife

10 assists

18 initial pre-natals

27 post-partum visits

13 newborn exams

2 more days, 1 shift left

levinrad — Tue, 25 Aug 2009 08:49:17 +0000

I am in the midst of gathering my things, getting forms signed, and shedding a few tears in the process. Yes, I miss my bana, my family, my friends and my own bed, but I have anchored deeply here. I feel that a little piece of myself will remain here in the memories of the families I have cared for . . . who I still care for, and who care for me.

I am sad. And grateful. And forever changed.

Baby #10

levinrad — Sun, 23 Aug 2009 00:44:47 +0000

This baby was another one who was eager to join the world. He’s the 2nd child for this 20 year old mom. Her labor began at 4:00 am, she came to the clinic at 8:10 am and was a stretchy 8 cm, IBOW, +1 station with a well-applied head, 90% effaced, sutures at 9/3. I encouraged her to labor wherever felt best for her but not to go too far. She went out to be with her bana and labor outside where it is cooler (or atleast less stuffy). I quickly set up the birth cart, checked the deep suction machine, and put the O2 in place (standard protocol here). It was clear from her exam that her body would (most likely) just open up and let her baby out once her water broke.

At 9:02, the mom comes rushing out of the CR. She had gone there with bowel pressure, her water broke and the baby was coming. Her baby was born at 9:04. The head was born OA, no nuchal cord, but wasn’t restituting and the face was changing color. I quickly moved the mom into McRoberts (hyper-flex her hips) and the baby quickly restituted and was born LOA with some gentle guidance by my hands. Her placenta was born 20 minutes later with trailing membranes. The final bit of membranes was holding on by a thread. I quickly asked for a hemostat, but the strand had already broken. It looked like the final bit came out with the blood flow. I checked visually (after clearing the blood with gauze) and the supervisor agreed it looked like it had all come out.

It was a beautiful birth. A sweet baby boy, 5 lbs 14 oz ( a common size here), A/S 8/8 (-1 tone, -1 color).

The mother took awhile to “re-join us” after the birth. She was very quiet, eyes closed for a long time, a little shocky even though her vitals were normal. She wasn’t interested in being with the baby until she was more back inside herself. Once she settled in, everything seemed normal until she was moved into the post-partum area to rest and be monitored for a few hours until time to go home. Her pulse became elevated. 108, 104, 112, 108 . . . normal pulses post-partum if the mother is exhausted. Then it rose to 120. Hmmmm. Not so normal, definitely of concern. It could simply be due to maternal exhaustion. Or it could be due to retained placental fragments or membranes or blood clots that need to be expelled so the uterus can clamp down properly. Her uterus had been firm with every check, so it seemed fine, but the pulse could be our 1 indicator that there is still something inside and it was imperative we listen to it. We encouraged her to really rest, but she was having difficulty with this and the next check (1 hour later) her pulse was 124. We asked the mother to take a bath (which here is actually just pouring water over you from a bucket, the traditional Filipino way to shower/bathe) then to try and rest again. I guided her about visualization, and how to calm her heartbeat. 1 hour later, still 120. The supervisor amd I were concerned. 1 more hour and the pulse came down 108. A sigh of relief, but we were still concerned to send this mom home without knowing for sure if her uterus was empty. The supervisor did an IE and was happy to report that everything seemed normal. The mother, baby and bana smiled and quickly left so that they could home and finally really rest. It’s a catch-22. The mother’s pulse is high because she needs to rest, but we can’t let her go home and really rest until her pulse is 100 or below. Oy. Ah, homebirth . . . how I look forward to the comfort and safety of homebirth. And yet, I will miss serving women in this way . . . women whose safest option is to birth at this clinic, who receive compassionate, skilled care in a way that they wouldn’t elsewhere. I have visions of being the midwife to underserved women in NYC but am not sure how that will manifest. I am keeping myself open . . .

Balut

levinrad — Fri, 21 Aug 2009 11:08:32 +0000

The time had come. I declared my intention to eat balut to the Filipino midwives on shift last night, as well as to the guard and offered to buy everyone a round of balut (including the mother I was monitoring in post-partum). Everyone was put on high alert for the balut man, who usually drives past our clinic at 5:00 a.m. and 8:30/9:00 pm. He uses an old fashioned bike horn (think ah-OOO-gah ah-OOO-gah) to let people know he’s near, but tonight I was afraid I wouldn’t hear him, or I’d be about to catch a baby and miss him. I figured that I had better eat balut now, because if I like it I will want to eat it again before I leave. For those of you who don’t know what balut is, it’s a a fertilized duck (or chicken) egg with a nearly-developed embryo inside that is boiled and eaten in the shell. It is commonly sold as streetfood in the Philippines. If you want to see pix or get more info, check out http://en.wikipedia.org/wiki/Balut_%28egg%29.

I was in the postpartum room when I heard the Filipino supervisor shouting “balut! balut!” I gave the mother I was attending an apologetic smile and ran out the door. The guard was waving down the balut man, the supervisor was still shouting . . . quite a sight.

Bottomline, I ate it and I liked it. I think. It’s pretty upsetting to look at, but I had quite an audience at that point so I just closed my eyes and opened my mouth and ate it in one bite. Honestly, I mostly tasted the vinegar and salt it’s served with, and the ducky juice surrounding it. This was one of the younger embryos. The supervisor wanted one of the older ones but for some reason they won’t be around until October. Apparently those have feathers and a harder beak. Mine was 14 or 16 days and very soft. Thank goodness.

I woke up to the sound of the balut horn this morning. It made me smile. I will be having balut again tomorrow.

16 hours later . . .

levinrad — Thu, 20 Aug 2009 15:50:52 +0000

A double shift today – day and swing (6:00 am-10:00 pm). The day started out with a very fast labor . . . I could tell by the way this mom got out of the taxi that her baby would be here soon. I was ‘chart-er’ for this birth, and it was nice to just sit back and observe. Something I hadn’t done in a while. And the umbilical cord had a false knot, something I’d never seen before. So interesting.

Then the day was just quiet. For hours. It has been so busy lately, it felt like the birthroom needed some time to re-boot. Which is fine, except I only have a few shifts left and am eager to grow just a little bit more before returning home. I am feeling more confident, but am not confident that my confidence will stay with me. Twisted . . . I know. Anyway, although I had been “next up” on day shift, there were new midwives on in the afternoon and I was no longer 1st. That is, until the 2nd year student who was 1st up offered to have me jump the queue. So I was first up when a 38+ week 35 yo G4P3 mom walked in at 3:15. It was an amazing IE to experience – she was a very stretchy 8 cm, BOW intact, head NOT engaged, maybe -2/-3 station. I started thinking like a midwife, which felt really good – best case scenario: the head engages, her water breaks, and the baby is born quickly and easily. worst case scenario: the water breaks before the head engages and the cord prolapses which is definitely not a good situation. I started thinking of all the possibilities and what would need to happen and just stayed close to her and really tried to connect with her and the baby. I really trusted her to listen to the wisdom of her body and labor how she needed to and I hoped for the best (but prepared for the worst). She was laboring in the outside waiting area with her bana (it’s cooler there) and made a couple of quick runs to the CR. I wondered if I would be catching a baby over the toilet . . . always a possibility. She went out to be with her bana and moments later came booking in with her legs shining (her BOW broke and she had strict instructions if it did, to come in immediately so that I could monitor the baby and evaluate the situation). The baby was born just a few minutes later. The head had engaged well, no prolapsed cord, a beautiful quick birth. That being said, it was such a quick birth that the mother was in a minor state of shock after the baby came. I had heard that could happen but had never seen it. It took her a little while to come back to herself and finally connect to the baby, but it did happen eventually. Until she did, I just really connected to her and was the thread between her and her chubby 7lb 9oz son. She was amazing and strong and I was so grateful to have been her midwife. And that baby latched on moments after the birth and didn’t let go for an hour and a half. Beautiful.

Also of note – I sutured yesterday for the 2nd time, this time with the director of the program as my guide. The needle that was given to me was larger than pictured on the package, not ideal, but I was instructed to use it (supplies are costly here) I offered to pay for the 2nd suture but no go. The needle kept slipping in the needle holder, and I had to keep taking out the needle and inserting it again. That part was awful. No one wants to stick a mom more than is absolutely necessary. That being said, I didn’t get freaked out and just did my best to take care of this woman and do a good repair with the situation that presented. I think I did an ok job and am still amazed at how naturally suturing comes to me. Thanks Mom and Bubbe for passing on your sewing lineage!

Catch #8

levinrad — Wed, 19 Aug 2009 09:13:54 +0000

Wow, what a shift. We ended up with 7 laboring moms and numerous baby checks. It was a very full shift and surprisingly calm. Babies were being born left and right but no chaos, we were just really really focussed. And in the midst of it all, the Dept of Health paid a surprise visit with 30 people to check out our facility. One visitor made herself at home by walking into the station where I was about to catch a baby. sheesh.

So, the G2 mom had a beautiful, uncomplicated birth at 10:20 this morning. We didn’t even use the bulb syringe, which we rarely use at home but seem to use at every birth here. This baby boy had a very peaceful entry into this world.

The G1 mom hadn’t had her baby before I left at 4:00. I discovered an unusual pulse . . . it kept skipping a beat, and her BP was wacky. It hadn’t been discovered before, and that may be because it only happens occasionally and we only listen for 15 secs. A good reason to listen longer. I’m not sure how this will evolve. Of course, I’m hoping for the best.

In the midst of it all, I saw one of my families for their 1 week baby check. When I told them that this would be our last visit together, I had a hard time holding back my tears when I saw that the bana had started to cry. Then the mother. Everyone cried but the baby, who had just had a heel stick for her newborn screening and barely made a peep. This family and I had really connected and I am deeply sad that I will not see them again. They were a gift and a blessing.

Double shift tomorrow. A good night’s sleep tonight.

Another busy shift

levinrad — Tue, 18 Aug 2009 23:52:17 +0000

I arrived at the usual 5:45 for day shift and was relieved to see the board (where we keep track of labors). It had been a very quiet night, not a single labor or post-partum. The 1st hour of day shift was also peaceful, and I enjoyed my coffee without interruption. Suddenly, 1 labor arrived, then a second, then a third, then a fourth, then a fifth. All the beds are full, so hopefully a baby will be born soon. I am currently assigned 2 of these moms . . . a G1 with BOW rutpured and 5 cm, and a G2 at 6-7 with BOW intact. Both of my moms are out, walking with their banas . . . curious to see who has their baby 1st. I’m really glad I got a good night’s sleep!

Hard shifts

levinrad — Tue, 18 Aug 2009 13:02:39 +0000

My last 2 shifts have been unusually full. It felt as if a new labor was walking in every few minutes. That wasn’t the reality, but that’s definitely how it felt. And last night, we had fewer midwives than usual – 1 supervising midwife, 1 2nd year student, 1 intern who hasn’t assisted yet and me. One Primip who had been laboring for many, many hours finally gave birth to a beautiful baby boy. Sadly, she had a 4th degree tear and ended up transferring to DMC for repair. Another primip had been laboring for hours as well and her baby just wasn’t descending. I went with her as she transported, and she was clearly afraid. I did my best to surround her with light and prayed with her and her bana for protection for her and her baby, for wisdom for the doctors who will care for her, and for the healthy transition of this family. Prayer is an integral part of life here and it felt like it provided this family a moment of comfort . In addition to those moms, we had 6 or 7 other labors last night. I labored throughout the night with a 30 yo G2P1 whose other child was born 9 years ago. She had been laboring with grace for many hours, but as the night progressed she was getting tired. Her IEs showed very little change (she was admitted at 11:oopm at 7cm and hovered at 8-9 for most of the night until her baby was born) and she was getting tired. Also, a small bulging BOW presented at the initial IE and the supervisor felt that there might be particulate matter there, indicating possible thick meconium. When it came time to change shifts, the mom looked at me and was very clear that she needed me to stay with her. So I stayed. Her baby was born at 8:14 a.m., with a lot of hands-on assistance, some by me, but a great deal by the supervising midwife. AROM w/thick mec, lots of perineal pressure, supporting a cervical lip . . . The baby’s descent was slow, but he was coming. His head was born while she was on the stool, and I was amazed at how much I could guard the perineum in that position. No tear, thank goodness. The body did not come quickly, so we shifted her onto her back, and the baby was born moments later with a loose nuchal cord. Deep suction, lots of stim, A/S 6/8. The baby was in good health overall, but I noticed some retractions early on that seemed to go away quickly. Hopefully they won’t return. Also, the baby’s sucking reflex was m.i.a. Sometimes that happens with deep suction, but it is definitely of concern. There was a notable gush of blood after the baby was born, and then a steady trickle. Once the ebl reached 500, the supervisor tried the cherry pop maneuver, which was unsuccessful, so she did a manual removal. The placenta had a velamentous insertion. Pix will follow when I’m back home.

Both mother and baby seemed alright when I left at noon . . . it was a difficult transition for them . . . I will see them tomorrow and hope that the tide is turning for them.

I have recently come to understand in a very deep way that many of the moms I have worked with here would have been considered high risk in the US. This is mostly due to their poor nutrition and health history. As such, we see an inordinate amount of complications here, and therefore many more interventions. This is not the normal birth I know, but it has become the birth that has given me the most hands-on experience. I am looking forward to being back in the homebirth setting, re-framing the lessons I’m learning here. For now, I am feeling a little overwhelmed honestly, and afraid that I’m not learning anything. I go into that space sometimes when I watch another midwife make choices that I wouldn’t have made. Would that baby have been born last night without those interventions? Would her placenta have come on its own? I trust the intuition and experience of the midwives here, particularly with this community of mothers. I just wonder how I will get to the point of knowing when to intervene and when to keep your hands out of the situation . . . I am trusting my own learning process, except when I’m not

initial pre-natals complete!

levinrad — Mon, 17 Aug 2009 05:27:02 +0000

One of my goals for my time here was to complete 16 initial pre-natals, as it’s difficult to obtain them at home. Since I was only scheduled for 2 pre-natal clinic shifts for the whole time I was here (and 1 of them was before I knew any Visayan), I had “insinuated myself” (with permission) in my “down time” in a couple of other shifts. The midwives were always hapy for another set of hands, since it meant their work day would be done sooner (we just keep working until all the appointments are complete. sometimes that’s noon, sometimes that’s 2:00).

I just got back from my final scheduled pre-natal clinic shift. Total initial exams conducted =18! A big sigh of relief to have that over with. Even if I don’t catch another baby, my time here was worth it just for the initials. Well, honestly, I’ll be pretty happy if I catch a few more babies . . . 4 would be great, 5 even better, etc. etc. etc. I have 9 shifts left . . . ok, babies, I’m ready!