Back in the Trenches

Who would think checking cervical dilation would be exciting but after more than a year sitting on the bench, as I completed language study and waited for work permit, that simple skill felt good to be doing again. Funny, to think just 7 years ago I barely could find a cervix let alone tell you how far it was dilated. I had some awesome teachers and preceptors guide me to this point and hopefully now I can do the same for others. For several months now at the hospital, I have reviewed charts, shared advice as I was able, and talked through situations and problems with our medical and nursing staff. Occasionally, I would help out with a precipitous delivery or CPR in an emergency.

This week though I finally have my work visa and so can start working with and training our staff here. Today, it was a first-time mom with spontaneous rupture of membranes with no signs of labor and an OP baby. After checking her cervix and placing misoprostol, I spent time talking the staff through different positions the mom could be in that might help the baby turn. Typically laboring moms here spend most of their time on their back and occasionally on their side.

Then I went to see the mom who had an emergency c-section on because she came in seizing from eclampsia. She had a little 35 weeker who weighs just over 2 kg (4 1/2 pounds). He was busy being very upset at the lack of mommy time and breastmilk and since mom was now conscious I took him to the ICU for a visit where he promptly latched on and breastfed for close to 30 minutes. I wish I had been able to take a picture because he was so cute as he ate but my hands were busy holding him close and plus it felt like an invasion of their privacy.

There are two other little ones in the ICU and I don't know whether they will make it. One is a 32-weeker who weighs 1500 grams (just a little over 3 pounds) and the other is a 1-month old who only weighs 1600 grams (almost 3 1/2 pounds). He is obviously failing to thrive and his older twin has already died. Finally, there is also a toddler from an interior village with a very bad pneumonia who has been on the ventilator for almost 20 days now.

So just because I can finally get back in the trenches doesn't mean all the days are going to be happy ones. But I do have to admit I am glad to be getting my hands dirty again and soon the new school year will start and I will have a chance to shape some young minds and skills from the beginning.

Oh and by evening the laboring mom had delivered after a trip to the toilet (squatty potty) resulted in baby turning and a rapid delivery for a first time mom. :)

And so it begins...

Ibu Deen

This handsome fellow was born yesterday at our hospital via c-section. His mom, Ibu (Mrs.) Deen, has been a patient at the hospital for almost a month now. She is from an interior village about 4-5 hours from the hospital, 2 of those hours on dirt and very bumpy roads.

About 30 weeks into her pregnancy she started having vaginal bleeding and her local midwife sent her out to the government hospital nearest their village. She was then referred by the government hospital to us because they do not have an obstetrician/gynecologist on staff right now. An ultrasound showed that she had a complete placenta previa, which is where the placenta is implanted right above the cervix, which blocks the exit of the baby when it is suppose to be born. This complication can cause both mom and baby to die very quickly if she goes into labor or starts to bleed. 

After she was admitted to our hospital we found out she was contracting, so she was given medication to try and stop those contractions. She was also given a steroid injection to speed up the development of the baby, specifically his lungs, because if he was born then he would have been too early and most likely would have died. The bleeding slowed down, so for the next several weeks she laid in her bed in the ward on complete bedrest. Finally she reached 36 weeks (8 months) and we let her go a relative's house in a nearby town (her village would have been too far away and with the bad roads would have been a huge risk). But less than 24 hours later she started bleeding again and she was readmitted to the hospital. The decision was made to do a c-section.

So at 36 weeks and 2 days this little one was born. He weighs 2.5 kg (5 pounds 5 ounces) and after needing a little help with oxygen during transition, he is hanging out with mom in the ward. Because he is early he is having some problems with his temperature and with breastfeeding but overall he is doing great and will hopefully work through those issues quickly. Mom is doing well also, did not bleed too much during the surgery, and is now recovering.

This one will go down in the books as a life saved from a complication that could have taken both the mom (leaving two other kids without a mom) and baby. The system worked like planned. Just a few weeks after I arrived, we lost a baby just like this one. She had started bleeding a lot and the baby had passed away before she even got to us. The baby was perfect and almost at its due date. We did a c-section and she lived but it was a close call.

Listening to the Stories

So this is one of those blog posts that should have been written a couple of months ago but I just haven't gotten around to it. It is about my visit to Bethesda Hospital in October. I knew I was only going to be there for a couple of days, so my biggest priority was seeing old friends and making new ones. It was also a chance to listen - to hear the stories of current joys and challenges of the ministry there. Honestly, it could have been more encouraging because there are a lot of challenges right now but it was also a blessing to see so many serving every day.

I had the brief chance to talk with our current Indonesian obstetrician/gynecologist, who at the moment is also the director of our nursing school. He gave every indication that he is looking forward to partnering in the work together. I am not sure exactly what that will look like but am hopeful. He and others shared a few stories with me from Zaal Bidan (OB Unit). 

One was a patient who had come in that week. Many of our patients are referred from clinics and even other hospitals for a variety of reasons. This patient had been referred to us because of a post-partum hemorrhage (heavy bleeding after the birth of the baby, which can be fatal if not treated quickly and correctly). It turned out her uterus had prolapsed into her vagina. Thankfully it was able to be returned to its normal location and with a blood transfusion and antibiotics she was expected to fully recover. 

Another patient though did not have as good of an outcome and she was also a transfer. Apparently during the birth there had been a shoulder dystocia. The head of the baby had delivered but the shoulders got stuck. This is one of the emergencies of OB medicine. So she was transferred like that and the baby died during the transfer. There are number of maneuvers that can be tried to correct the problem and help the baby be born. We are not sure if any of those were tried or what exactly happen. Once she arrived at our hospital, we were able to start her on Pitocin, to make her contractions stronger again, and with one of those maneuvers the baby was born. 

These are just a couple of the stories I heard during my few days at Bethesda Hospital. One of the doctors after telling me some of the stories, asked me if I was going to run away and never come back. I have to admit the thought did cross my mind but it was also a good reminder of the great needs that still exist here in Indonesia and around the world. Moms and babies are dying and many of these deaths could be prevented!  

I will be moving to the hospital in March, after I complete my language study. I anticipate the first few months will be spent learning more about the situation and how I can best use my skills to fit the needs. I do know that this is going to be a very stretching and challenging ministry! 

Celebrating National Midwifery Week

Birth has been in the news a lot lately. Stories on the rising c-section rate and Duchess Kate giving birth to a future heir to the throne of England are just two examples. This week we once again recognize and celebrate the work midwives are doing around the US. Over 300,000 babies (7% of all births in the US) were "caught" by midwives in the US in 2011 (the last year for which we have statistics). Did you know that midwives provide more than just care for pregnant women?

Last year, the American College of Nurse Midwives launched Our Moment of Truth, to help women know their options and to know more about the care midwives provide. You can head over to the web page here. There you can read about the care midwives provide through the lifespan, from caring for teenagers to caring for women all the way through menopause. They also bust a few myths about midwives. Last but not least, there is a place to read stories of midwives in action from others just like you. You can also share your own story.

Sexual Violence Towards Women in Asia.

More than one in ten men surveyed in six Asian countries said they had raped a woman who was not their partner and that figure rose to nearly one in four when wives and girlfriends were included among victims.

That was the lead to a recent story in The Economist about violence against women in Asia, including Indonesia. The Lancet recently completed a study into the subject and the statistics paint a distressing picture for women living in Asia.

The culture has to change around the world and especially in these countries when only 55% of the men stated they felt guilty and less than 25% were sent to prison for their crimes. I wish I had the answer on how to prevent these horrible crimes or at least punish the perpetrators. The sad reality is though, that as a health care provider for women, more often than not I will be dealing with the aftermath. So instead I will be focusing on how to help them heal.  

Pictures of Bottles in Coffins

For several days now I have seen this graphic popping up on my Facebook feed and in several of the blogs that I follow. It is creating quite the storm and getting lots of negative feedback. I completely understand how many in the developed world would find this offensive. I would be the first to tell women I am working with in the US, that while I recommend breastfeeding, I know that is not possible for some women. I think it is important to support them in whatever they decide and for them to not feel any guilt over choosing not to or not being able to.

What I think is being overlooked though in all the negative feedback is that the statistic is from the WORLD Health Organization (i.e. an organization that predominately works with people in the developing world). Now I have not had the time to find and research that specific statistic but other statistics show a similar story. For example, they show us that 4 million children die each year around the world, the majority of them in the developing world. It is estimated that 1.3 of those children could be saved each year with exclusive breastfeeding for the first 6 months and partial breastfeeding (solid food added) through the first year. In fact, they are also discovering in the developing world, in places like Ghana and Nepal that initiating breastfeeding in that first day and especially in the first hour is critical to a baby's survival. In fact, 20% more babies survive if they breastfeed in that first hour of life.

Here in Indonesia there are entire store aisles that are devoted to baby milk formula. There are billboards, advertisements on Facebook (in fact there is one on my feed right now from Enfagrow), and brochures with free samples at lots of health care facilities. They show happy, Einstein-like, musical virtuoso kids that sleep during long road trips and through the night. Not a bad thing if you have enough money to afford the very expensive formula and have clean water to mix it with, but that is rare in many homes across Indonesia and other places in the developing world. Instead they make the formula stretch by only putting a small percentage of the recommended amount in the bottle and make it with unclean water. So the baby slowly loses weight because they are not getting enough calories and then they get sick from the water. In little ones they can quickly get dehydrated and then they die. In places like Indonesia, too counter those magic pictures of formula fed babies they need graphics like the one above.

This week is World Breastfeeding Week and I think this week and every week of the year we need help each mother make the decision that is right for her and her baby. It is important she know the facts and the risks for where she is living. Then we need to support her in that decision and make sure she has the resources she needs!

The logo for this year's World Breastfeeding Week (August 1st-7th)

Back to Work

Well it didn’t even take a week before the questions while I was out and about began and the phone started ringing with questions. The news has spread quickly (not that I was trying to keep it a secret) that I am nurse and midwife. It started with simple things like a rash -- of course it had to be a dermatology question, definitely not my specialty :) I have to admit though after a year "off" from nursing, it is good to be using those skills again! 

This afternoon it was a missionary’s kid who had gotten hit in the head with a swing and had a head laceration. I told them I would be happy to go to the clinic/hospital with them but didn’t have the supplies here to do any suturing. Their response – oh don’t worry we have all of that. So in they walk to the house with this huge bag packed with all sorts of medical equipment including suturing kits and IV fluids. I guess it pays to be prepared when you are serving overseas! Thankfully the laceration wasn’t long or too deep and had mostly stopped bleeding on its own. So we found some superglue and sealed it up.

It pays to be prepared! 

Serving in Indonesia, you would expect that most of my patients would be Indonesians and they are but providing care to expats and missionaries also takes up some of my time. Being sick is never fun and can be a bit scary, especially in a foreign country where you don’t know the system or the doctors. There are some great doctors in Indonesia and there are also some not so great ones. The problem is in knowing whom you can trust.

Thankfully one of my friends, a nurse I worked with at Bethesda Hospital several years ago, anticipated this need. She is currently in the US for a couple of months on home assignment but she is normally one of those who gets these problems and questions. When I arrived there was a present in my room from her. I opened it up to discover these…

They are Indonesian drug books. In the back they list all the medications by their brand name (the name they are in the US) along with a list of the generic names (not the same as the US) they are called in Indonesia, with page numbers. It allows you to look medications up and get dosage information and warnings specific to Indonesia. There is also an online version and I have already bookmarked it on my phone.

Hopefully, most of the needs I will encounter here away from the hospital will be few and not too serious. Thankfully, I am also living with my teammate who is a doctor, although he is frequently at the hospital or doing other traveling, like he was today.