Adu! Sakit! Long Post

I thought I would fill everyone in on some of the subtleties of life around here. The title of my post is "Adu! Sakit!"...so I should explain. Adu means "ouch" or "oh my goodness". It is not uncommon to go through a labor and hear "adu" 200,000 times! Women here also feel a very strong urge to tell us that they are in pain..."sakit" means pain, in this case, contraction. The answer to every question is "sakit". "Adu, sakit" is pretty much all you hear from many of the women, the entire labor. These women are so strong! However, there is an interesting dynamic here. Despite their strength, the women here don't usually believe they are strong and often are convinced by their husbands that they are not strong. Women like to be catered to and adored and the men know this, but rarely are they actually adored. Public displays of affection are non-existent. Many of the first time mothers here have had sex once, gotten pregnant and then (because sex during pregnancy is taboo) not had sex again since. The guys are either very involved and catering to their every need during labor, or the guy is not around at all. Many of the guys hang back until labor gets really hard and then they are there through the end. Usually first time dads stay with the mom through the entire labor. I hate hearing the men say that their women are not strong because it is so untrue. However, the ladies do seem to enjoy playing up the "whoa is me" aspect of birth. I think this is because they don't get enough adoration on a daily basis, so now, in labor, this is a good opportunity to get everything they need!!!

Well, this blog is up to the minute, I tell you what! I just returned from a birth, just this moment! Another teenager, 17, who just spit the baby right out! She had only been here two hours while quickly dilating from 3cm to complete with about a 5 minute pushing phase! I am telling you ladies out there who are thirty-somethings (me included)...we missed our calling. Who says teen pregnancy is a bad thing?! From what I have seen it pretty much guarantees a quick and slippery birth and often with no tearing because the mama is so young the poor nutrition habits and toxicity of old age haven't caught up with her yet. The family is very happy. We often don't see the mama smile at all during labor, unlike in America, until the baby is born...then, she beams!

The above picture is of a first time mom I had the pleasure of helping. This baby was another nuchal arm baby! A nuchal arm is when the baby is born with its hand up by its head or neck. So, it only makes sense that more baby parts in addition to the head makes birth a little harder. In comparison, when the umbilical cord is around the neck it is called a nuchal cord. We seem to be having a run on nuchal arms lately. Things certainly do occur here in groups. We have also been having a stream of first time moms transported for "failure to progress". Really, it is very unusual for a woman to just stop dilating for no reason. It seems as though a poor head presentation is almost always to blame. Recently, we have had several first time moms whose baby's heads were extended rather than flexed, which is not a position conducive to birth. I have never seen so many women get "stuck" at more than 7cm for so long. These situations have required me to do a lot of vaginal exams to try to determine the baby's head position and troubleshoot the best course of action. So I have gotten a lot of practice determining suture lines, the lines where the bony plates of the baby's head meet. If a midwife can determine the position of the baby early in labor or when a problem arises then she can potentially solve the problem.

Here is the promised picture of the super tanker baby Antonio. This was the most interesting labor I have ever attended. This was an attempted homebirth that ended in a cesarean birth. This couple did such a great job! This picture doesn't do the baby justice, he is huge...4.5 kilos, 10lbs. Combine a 10lb baby with a really long labor, a rather flat pelvis and maternal exhaustion, and, well... For a first time, Asian mom this is a big deal! Check out her husband...he is 6ft and I am guessing over 250lbs.

Here I am doing fundal height measurements at our prenatal clinic that meets from 5-7pm on Sat, Tues, Thurs. Yesterday, prenatal clinic was nutso because we were a little short handed, we had 2 ibus in labor and we had all had a very busy few days, so we were dragging. We had two ibus that were more than 7cm dilation so I had to stay close. So I hung with the ladies while clinic happened. Of course, it was really busy because all of the pregnant mamas had skipped clinic 2 weeks ago because of full moon ceremony. I think we saw over 30 women in 3 hours, usually it just takes about 2 hours for the same amount.
That evening one of the babies born was born "in the caul". I think I explained this before? That is when the baby is born in the amniotic sac. It was a beautiful quiet, gentle birth by a mama who I could barely tell was in labor half the time. She seemed a little crampy most of the time and only got visibly uncomfortable during the last couple hours, this was her second baby. The first had apparently been a 3 hour labor! When she pushed, it kind of looked like she was just pushing out a little poop:) She didn't have to work hard at all. But there was the baby...hiding its head behind a bulging sac of water. In fact, a big fluid filled bubble the size of a softball was born before the head. The sac looked like a snow globe, you know the kind you shake so that it will snow inside the globe. Little sparkling specks of vernix (a cheesy white coating on the baby that protects her from the watery environment) were floating around in the sac as the contraction pressurized the water behind the sac and made it swirl. Beautiful! And auspicious.
This is a great representation of the birth rooms. This is the first time mama I am holding hands with in the above picture. The two birth rooms have these bamboo ladders in them and each has a birth tub. Each birth room can accommodate two women. When we get really busy we can do births in one of several other rooms, but not preferably. The ladders are really useful for support during squatting and for propping up a leg in a lunge. Most of the women like to just lie down during their labor. We really have to work to rally them to get up and be active. As you may know, being upright, changing position often, eating, drinking and urinating regularly are all very important to keep a labor functional and progressing. So a lot of what we do is encourage the mom to do all of these things. The local midwives tend to just leave the mama on her own...often they don't care if the ibu lies down the whole time, until the labor become dysfunctional, then they spring into action.
tears! Yeah! So I try to show by example how to improve things. Another great example is suturing. I believe I have described some of the problems with the techniques here previously. Briefly, the midwives here use techniques that increase scar tissue production and future tearing. I have been showing them more gently ways of suturing that reduces scar tissue and promotes better healing. Fun stuff! A prime reason for having the birth assistant volunteers is to provide labor support for these mamas who would otherwise have very little. They also provide comfort to the family by showing them that everything is normal, many families are very nervous about the out of hospital setting, despite that fact that the statistics for the clinic are much safer and healthier than the hospital. I have come to learn that the primary purpose of the volunteer midwives is to bring a little bit of the best of I haven't really explained how things work here. There is a paid staff of local midwives who hold Indonesian Licenses. Their training is hospital based. So here at this holistic, out of hospital birth setting some of them are a little lost. Overall though, this clinic is the shining light in the midst of a very dark health care situation, so beggars can't be choosers right? I guess, but as many of you know me...I always see more that can be done.
A big reason why I am here is to relieve Robin, the founder of the clinic and primary midwife. Although, Robin doesn't keep regular hours here or see clinic clients regularly. She kind of pops in as she sees fit. She also has a regular homebirth practice that mainly consists of western clientele. Robin, in my opinion, needs a sabbatical!!! She is the definition of a birth junkie. For more on Robin Google "Robin Lim". Another reason I am here is to relieve the local midwives and give them someone else to lean on when it gets busy. I am here to role model gentle birth practices really. Even though the care the clinic provides is highly superior to the hospital care...there are some problems here. The local midwives like to get the mama into lithotomy position (basically lying flat on their back) and crank their legs back with force. This position stretches the perineum taut and increases the likelihood of tears. It also is likely to cause fetal distress because this is a poor position for good blood flow to reach the uterus/baby. In addition, as if that weren't enough, you don't have the benefit of gravity in this position and it is not empowering for the mama. She is flat on her back...like a helpless little bug:( They also like to coach the mom into pushing as soon as she is completely dilated, which in my opinion is not appropriate ( really can't go into that here and now.) It has become a joke around here...the local midwives run around all of the time asking me, "complete?" They are fixated on 10 centimeters!!! If the mama isn't complete, they got nothin'. I called one of the midwives on this the other day and now we laugh about it, always asking each other, "complete?" A large part of my role here is to gently show the local midwives what can be improved, using laughter and lots of love. Because most of the women are poorly nourished and eat a lot of MSG they have poor tissue integrity and tear easily and severely. So it makes sense to try to use positions that prevent tears. I have had several first time moms give birth on hands and knees, with pretty big babies and no perineal tears. The volunteer midwives bring a little bit of the best of homebirth to Ubud every time we visit. Hopefully! Honestly, it was hard to figure out exactly what I was going to be doing when I arrived here. There was virtually no structure for integrating me into the system. I won't go into it now but, it is not what I expected and I was a bot disapointed. But here I am now..loving life, a full tilt birth junkie. We are a bunch of birth junkies, who need to get our fix!
Have to leave you with this lovely pic of one of my favorite couples. I just did a home visit for this couple yesterday, they just live around the corner. The parents were concerned about the umbilical cord and breastfeeding. A note to you new parents out there...as a general rule, there is usually nothing at all wrong, however sleep deprivation and a general lack of knowledge often makes you feel as though EVERYTHING is wrong. So a big part of what I did was to just reassure the couple and give a few pointers. I gave some breastfeeding postioning advice, provided some lanolin for sore nipples and checked out the naval, which was doing just fine. So fun going into the homes here. The families create compounds surrounding beautiful gardens that are meticulously cared for. In fact at this home, there was a lovely, small garden and the father said, "Please excuse the garden, the gardener is not good." But of course, it was lovely! Love to all...