Monday, December 5, 2016

A Tale of Two Babies

I returned last weekend from a trip to the island of Java where I got to be present for two births. I am definitely convinced after these experiences that every mom deserves someone to be with her, to be her support person, her advocate, her defender. Let's just say I think doulas are awesome and every women should have one! And while I like being in that role, catching babies is still more fun :)

Back to those babies... One of my teammates had baby number four. A boy to add to their three girls. Then I got an added bonus and got to catch a baby at home for a mom whose really quick labor made it difficult to get to the hospital.

So first baby born was David. Remember this birth story? Well that is David's big sister and after her birth we were glad to be very close to the hospital this time instead more than an hour away. Once again though this baby made us wait past its official due date. I arrived the day before her due date figuring that would put me early enough but hopefully not too early that I was in the way for too long. We had some fun days getting out and about to see things in the city of Jogya where they live now.

Her parents arrived almost a week after the baby was due and we were still waiting. Her mom went to a doctor's appointment with us and baby was looking good on ultrasound (albeit big compared to an Indonesian baby) which had the doctor a bit freaked out. So after reviewing the good results he was ready to schedule her for a c-section. We put that plan on hold until for another week, figuring waiting until 42 weeks was ok, since mom and baby were both healthy. That afternoon we tried a couple of induction tricks at home but went to bed expecting a full night sleep as she had never gone into labor in the middle of the night. But shortly after 4 am there was a knock on the door with the word that she was contracting. So we got ready to head to the hospital.

It was a small hospital where she planned to deliver and the doctor lived and worked across the city, so we wanted to give them plenty of time to get things ready and call him in. Unfortunately, because it was a small hospital they only had a one nicer delivery room. The other was smaller, the bed was more uncomfortable and there was no place to sit except the bed or the toilet. We tried to be moved to her postpartum room for labor as she was not dilated much yet but that was on a different floor and they didn't like that idea. So in the end she spent most of the time on the toilet propped up with pillows. We did a couple of dancing contractions and she did try to rest on the bed for awhile but all in all it wasn't the most comfortable place to labor. And she has rip roaring labors so not much time to rest between contractions. The other room opened up so then we moved there with a more comfortable bed and a place to sit but we didn't really get to enjoy it, as her water broke shortly after we moved while she was hanging on me during a contraction. The urge to push came not too much later but no doctor yet so they wanted her to wait, which as many know is next to impossible. Thankfully as she got to work of pushing, the doctor showed up. It was at this point I quickly realized I hadn't talked through some of the things Americans do and don't do that are sometimes still done in Indonesia. So as I stopped the nurse from pushing down on her fundus (top of her uterus), the doctor pulled out the episiotomy scissors (definitely not normal for a 4th baby anywhere I know including our hospital here in Indonesia). Thankfully little David came quickly, was much smaller than they expected and did well.

A few hours later they were moved to a postpartum room and we all got to catch a nap. Then it was time for the big sisters to meet their little brother...

That evening the parents stayed in the hospital, so grandparents and I did dinner and bedtime. I think the kids were glad when parents came home the next day :)

So our newest teammate is David Allen, born just after 9:30 am (five hours of labor) and he is a cutie...

After a few days of hanging out with them I headed north by a car to the town where I did language study to enjoy some time with friends there. I figured it was also a good place to celebrate Thanksgiving and I also knew of two fairly new arrivals to Indonesia with New Tribes Mission who were pregnant and either already late or were due soon were there so I figured it would be good to check in with them. So that first day there I met with both of them. They had a good support team and plans for people to go with them to the hospital etc. This was however back to the situation where the hospital was an hour away and one mom in particular had a history of really fast labors. So all week I kept the phone close but as the week drew to a close I planned to go to a Thanksgiving potluck on Friday around and then catch an evening flight back to my island.

Friday morning though one of the ladies called me to tell she was having stomach problems. Many moms know labor frequently starts with some diarrhea but this seemed like more than that and having just moved to Indonesia a few months ago there were other possibilities. So we talked about hydrating etc. We also talked about how this could start labor so her team including childcare and driver should keep their phone close.

She called me back around 11:30 to tell me contractions had started but were 5-10 minutes apart. She was huffing and puffing though so I told her it was time to go to the hospital. Then half an hour later I got a call from the person in charge of driving them to the hospital (part of the org's leadership) to say she was contracting hard and fast and they didn't think they could make it to the hospital. So instead I went over to their house. I had minimal equipment with me (doppler, gloves, a stethoscope) but it was obvious she was in hard, fast labor and already in transition. So we had a choice to try and get her to a nearby birth center type hospital but they have a pretty bad reputation and chances are she would deliver in the car. In the end we decided to stay home and do our best there. In the end I got to catch a beautiful little boy name Lias. He was a stargazer (OP) though so that complicated things a bit. Thankfully he cried right away and did great skin-to-skin, mastering breastfeeding quickly. The placenta came without problem shortly after. Then we had to figure out how to get out of the fact that we had done a home birth and they would need a letter from a doctor to get a birth certificate. Plus we needed to separate baby from the placenta and I didn't have the equipment for that and it was debatable if mom needed a few stitches. So then we did get the midwives from the local birth center to help us out. They had a great time with the fact we had a home birth and fun with taking care of an expat mom and baby. We didn't have a baby scale so we used a piece of cloth and a luggage scale to figure out how much little Lias weighed. In the end mom and baby did great and I still got to catch my evening flight but I did miss the Thanksgiving potluck. There is nothing like catching a baby at home, although a few more supplies would have been helpful!  

Monday, November 23, 2015

Welcoming a New Baby to the Team

Time for another birth story of a new teammate. Apparently, I should add accompanying teammates during their births to my job description :) It is one of my biggest blessings and privileges to help teammates during their births. Once again it wasn't what we had expected but in the end we had a healthy mom and baby.

(I should mention that I won't be calling these teammates by their names or telling you where they live in Indonesia so some of the sentences might seem a bit awkward)

One of our new families is in language study is in one of the bigger cities in Indonesia in preparation for serving. They have three kids (including twin boys) already and shortly after they arrived they became pregnant with baby number #4. This momma has always delivered before her due date and this time around she had a couple of dates. The one given by the doctor and the one she knew was right a week later. Just to be on the safe side though I headed out a few days before the due date given by the doctor. Once again though we got to wait. Wait right past the doctor's due and then her due date till she was a week overdue. Since she had never been overdue before it was a surprise to us all and we were strongly debating the pros and cons of inducing labor. Being a midwife and they a family who prefers the more natural route we weren't fans of the idea but also realized it might be time. An ultrasound though showed the fluid level was good and he wasn't too big or too small. Still there was a lot of pressure from the doctor to induce so we agreed for the following morning hoping things would happen in the meantime on their own. 

And things did start slowly and surely overnight. We made the decision to go the hospital on the earlier side of things this time, especially since traffic in their city can be quite a nightmare and their hospital was across the city. Once we got to the hospital she was only a bit more dilated than the night before at the doctor's office and the doctor recommended induction but it was obvious to us that things were getting started slowly but surely on their own, so we declined. A few hours later she was in active labor hanging out on a labor ball we had brought much to the Indonesian staff surprise as they had only seen those in Facebook and YouTube videos. It was way more comfortable than their bed though! 

At her next check she was 8 cm and headed into transition with some spontaneous pushes at the peak of the contractions. The Indonesian midwife who so far had been really supportive of our plans and working well with us (minus her contraction monitoring method which involved poking her fingers into my teammates stomach during a contraction) though wasn't ready to call the doctor. After another 30 minutes in a bed and an increasing urge to push we more strongly suggested it was time to call the doctor but the midwife checked her and she was still 8 cm so wasn't willing to make the call yet. 

That was kind of the end of my patience so I encouraged my teammate to switch to a hands and knees position in the bed. I let her know it was ok to push with contractions and she could have the baby in that position if she wanted too. Apparently that position though really worried the Indonesian midwife and nurse in the room and they were making all sorts of worried looks and talking amongst themselves. My focus was on my teammate though and within a contraction or two she started pushing in earnest which really worried the Indonesian staff and they were quick to order her to turn around in the bed and stop pushing. At this point though baby was coming and despite the Indonesian midwifes attempt to push the baby back in my teammate pushed hard and fast and he came flying out. While he cried right away he did take some help getting going and was quite blue for awhile as I think those final contractions and ejection into the word were quite a shock to him too. The doctor did make it in time for the placenta though which was good as there was some increased bleeding which required several medications to help get it stopped. 

All in all at the end we had a healthy mom and baby even though in retrospect there are some things I would have done differently. For example, I should have thrown out my doula hat earlier and put on my midwife hat and been a bit more willing to offend as I think we would have had a better birth. She would have done fabulous delivering in the upright position I think instead of having to change positions etc which made things feel panicked at the end and not well handled. Overall I was impressed at the amount of equipment and how prepared the hospital was but found it odd that they thought measuring fetal heart tones every couple of hours (or more!) was acceptable. And despite my teammate having a postpartum hemorrhage her blood pressure wasn't measure once either during labor or in the early postpartum period until we had been transferred to the postpartum floor. I was also quite concerned to see the Indonesian midwife so hesitant to call the doctor even though birth was obviously not far away. There are not many women I know who have had babies before and when laboring without pain medication can manage to not push when ordered. 

Here are a few pictures of some time with them. 

The happy moments after birth - well ok the baby was less happy

Our birthing team minus Grandma who was taking the picture

Home from the hospital with big sister and brothers

Sunday, September 20, 2015

Empty arms, Broken hearts

She was suppose to go home with a beautiful baby girl. This was their first baby and they had waited anxiously for many months to meet her. Because of one those true blue obstetric emergencies though, she went home with empty arms.

It was a Monday morning and the labor ward was busy with 3 moms in labor. Two of the moms were at increased risk and she should have been low-risk. We don't routinely do continuous fetal monitoring on our low risk moms - we only have one monitor. It was noisy in the labor ward as the three moms all labored together in an 8-bed ward with their families plus several postpartum patients and their babies.

Somewhere around morning shift change though her water broke, the umbilical cord prolapsed and came down into the birth canal before the baby. For those that don't know obstetrics this means that with every contraction the baby's head compresses the umbilical cord cutting off the blood supply to the baby. As the labor progresses and the baby comes down the birth canal eventually the blood supply will be cut-off completely and the baby will die. Sometimes this happens in minutes and other times it can take longer depending on how much of the cord has dropped down. Once the problem happens though you have several emergency interventions that need to be done quickly, including doing a c-section usually, to save the life of the baby.

We did well for the most part, although there were complications including the fact that operating room team had to be called in and the fact that with two other high-risk moms in labor we were short-staffed. In the end we just couldn't move fast enough and we lost the baby. The other two moms and their babies both did well though and so did the other mom who came in completely dilated and pushing in the midst of all of this.

In recent weeks we have lost several moms and babies. Moms have gone home with empty arms and families have gone home with broken hearts. It has been hard. They died from the complications that are common killers of moms and babies around the world.

I have to admit I have struggled to figure out the best way I can be involved in our obstetric care here at the hospital. It is even harder knowing the level of care that exists in the U.S. with such well-trained teams, ready at a moments notice to use all sorts of equipment and medication to save the life of a mom or baby. Deaths happen in the U.S. though too, even with all of that. I want to improve our care here and I have so many dreams for what could be!

Wednesday, May 27, 2015

That New Mother's Glow

I recently had the privilege of providing labor support and catching the baby of one our employees in the finance department at the nursing school. It came in the midst of a busy week and really a very busy day. Things were busy at the Nursing School with the seniors doing their final presentations (like a thesis but at the associate degree level). I had a teammate who had motorbike accident and hurt his knee, so we were in the process of trying to get him to Malaysia for MRI (no machine available here in this part of Indonesia). I was helping support an expat mom here in Indonesia who was having a miscarriage. And it was Ladies Bible Study night. As I wrapped up the work day Ibu (Mrs) Milka came to me with a few questions and asked if I thought she was going to be having the baby soon. After a quick exam on a set of chairs in our conference room I let her know the baby had dropped very low into the pelvis and had palpated a couple of decently strong contractions. I said based on that it could be tonight or several days still but I suspected it would be soon.

Just a few hours later I got a call from the maternity ward saying she had been admitted in labor and was asking for me. So I headed down to the hospital to do labor support and just be around in case she needed anything. It is always a bit awkward when your patients are friends and co-workers, because you don't really know how much care they want you to provide and how much they want you to see. When I walked into the labor ward though that all went out the window as she was obviously in transition. That is an overwhelming time for anyone and it didn't take me long to switch into midwife mode. With the first sign she was getting ready to push, I was the one checking her and then helping her get moved to the delivery room. I grabbed an apron and sterile gloves and as she moved her water broke and baby was crowing with the wave of water. A few minutes later Baby Gabriel joined us with a big cry. It wasn't long till we had her settled back in the ward with her baby where he nursed like a champ.

I took this picture shortly before I went home. Her look of joy and peace just stopped me. In the midst of the busyness it was good to stop and remember how beautiful a new mom looks. Gotta love that oxytocin!

Sunday, May 10, 2015

Happy Mother's Day - The Importance of Mom

It is Mother's Day again in the United States. A day of celebration, of remembering all the amazing things moms do, of attempts at breakfast in bed by husbands and kids, flowers and cards. It is also a tough day though for those women who are struggling with infertility, miscarriages, or the loss of a child. Remember them today and reach out to them and let them know you know they are hurting. 

Moms are important and that message was reinforced for me these past two weeks as a mom in our community passed away. She was the younger sister of the women who helps me in my house with laundry, cooking, and cleaning. That death has rippled through the community as her three kids (ages, 1, 5, and 7) have been sent to live with other family members. Now, they all have another child to feed, clothe, and pay the school fees for. The chances just increased dramatically that these children, especially the 1-year-old, will struggle and may not survive. These happens frequently across Indonesia after a mom dies. Moms are really important! 

To end on a happy note though I want to celebrate my mom! She and my dad recently visited and it was so good to see here and have some precious long conversations. I miss her a lot and I know the feeling is mutual! 

Happy Mother's Day Mom! 

The Birth of a New Teammate

I had the privilege recently of serving one of our new teammates as she gave birth to daughter #3. It didn't go exactly as either of us had hoped or planned but in the end it went well. So here is the story...

Katrina arrived in Indonesia pregnant with baby #3. The transition to a new country with a new language is tough enough and then she added to it two daughters not yet four years old plus being in her 3rd trimester with baby #3 and you have one brave and tough momma. So when labor started before her due date (which is very unusual for her!) she didn't feel ready and was really tired. We as a team knew this was going to be tough but we had set her up with an American woman to serve as her translator and doula during her time in the hospital but in recent conversation with team members it was decided it would be wise if I came down to be with them also. I could help around the house and with the kids etc plus be there for the birth. I was expecting to head down a few days before her due date and stay for at least a week but then the phone call came that she was in labor already I threw a few days worth of things in a bag and headed down. Although as the crow flies it isn't that far but because we are on different island it takes a 5-hour car trip followed by two flights each about 90 minutes long followed by another 1-hour car trip. In the end her contractions slowed back down though and we spent a couple of weeks hanging out. Contractions would come and go and there were several times we thought we were headed for the hospital but in the end they would fade away again.

We kept picking a day that would be good to have a baby, for example at the beginning of the break they had from language school and there were days we tried to avoid like the days Ash (dad and our driver to the hospital) needed to see the dentist. Finally, though miss Charlotte picked her own time. Katrina was 10 days past her due date and we were headed to the doctor's office the next day and most likely going to need to consider a pitocin induction, which neither of us wanted. So Katrina told her husband that she was going to be in labor by the time he got from language school at 4 pm. She had said this at least a dozen times over the last few weeks, so it didn't get much attention from Ash. But we had a plan as soon as he headed out the door, that involved her breast pump and more exercises to get baby in a good position for birth. She wasn't at that long before her water broke. No big gush just leaking with contractions, which were becoming more frequent and stronger. Ash came home to see her sitting on her ball with a towel and all of us watching a movie, so imagine his surprise when we told him we were almost ready to head to the hospital. So then there was lots of rushing around as we finished packing and getting the girls fed before taking them to a friend's house.

It is an hour plus trip to the hospital and poor Ash had his wife telling him to slow down because every bump hurt and the midwife telling him to get there fast. When were still 20 minutes from the hospital she was complete and pushing, which had this midwife making sure the gloves and some equipment were close. It was probably one of the longest car rides of my life and oh did I mention it was a brand new car!

We made it to the hospital though and there is nothing like the sound of a woman pushing to get people moving at a hospital, no matter what country that hospital is in! Somehow she got into a wheelchair and from there to the ER where they transferred to a gurney and then from there to the 5th floor delivery room, with a gloved and masked ER doctor at the ready in case baby decided to join us in the elevator. In the end though there was time and Katrina's doctor made it and with just a few pushes Miss Charlotte joined us sunnyside up (OP). Soon she was breastfeeding like a champ and thankfully proved to be a pretty calm baby, because now there are 3 kids under 4 years old in their house :)

So while I don't think either Katrina or I were fan of her doing most of the hard work of labor in the car, it all worked out in the end and we had a healthy mom and baby.

Headed home from the hospital

Wednesday, November 19, 2014

Training to Take Care of our Tiniest Patients

You have heard the stats on this blog before - babies, and a lot of them, are dying here in Indonesia and around the world just shortly after they were born. The stats I heard recently, said it was one every 3 minutes or almost 500 every day in Indonesia. It is hard though living those stats every day.

There are many things we lack here in Indonesia including equipment, supplies, and in many cases well-trained people. In many cases however that is just because they have not had much training. Education in Indonesia is heavy on the theory and short on the practicing. Our staff have hearts that are eager to serve and a desire to learn.

A couple of weeks ago, our hospital hosted an updated neonatal seminar and workshop for not only our hospital employees but also for staff of government and private clinics and hospitals throughout our province. The main speaker was an Indonesian neonatalogy doctor from Jakarta. It was a great review for me and a great chance for my Indonesian co-workers to learn some of the newer methods and skills for caring for our tiniest patients.

One of the big draws was the opportunity to practice some of the skills like neonatal resuscitation. This has been one of my biggest concerns in observing the care we provide here - I would walk into a delivery room that had no equipment set-up and ready for baby, even though baby was close to crowning and was known to have meconium stained amniotic fluid. Today I walked into the delivery room to find a similar patient story but this time the ambu bag was ready to go and the suction was all set-up! We still have lots of work and practicing to do but it is a big step in the right direction!!

For fun here is a video of the first group to practice neonatal resuscitation during our workshop. They completely failed but in their defense it was an ICU nurse and ER nurse and they don't do many neonatal resuscitations on a regular basis. In the video, they are simulating receiving a premature infant who had just been born by c-section. The baby started off crying but then quickly started grunting with nasal flaring and the oxygen saturation did not increase as it was suppose to, so they should have started giving the baby oxygen but didn't.

One of my goals is to do regular simulations like this with all of the staff, so we know that all the equipment works and it is as routine as possible.

Sorry it is an Bahasa Indonesian and a video of the simulation being shown on the big screen, so everyone can learn from the process :)