The Placenta & Cord Burning

In Balinese culture (and many other cultures around the world) the placenta is considered sacred. At the clinic, this is respected and the cord is not cut for a while, if at all.

Some women choose "lotus birth" - when the cord is never cut and the baby is separated from his placenta when his cord loosens and falls off. However, most women choose for the cord to be cut within the day because the placenta can be given as an offering in their family temple. The placenta, cord, and flowers (placed right after the birth) are wrapped and placed in a ceramic jar and are eventually buried.

How does the clinic honor this? After the birth, the midwives wait a minimum of 3 hours. Then the cord is cleaned at the cutting site, clamped, cut, and then checked for 3 vessels. The only time a cord would be cut sooner (never immediately at the birth) would be if the baby needs to be transferred to the hospital or if the health department was coming. The health department does not understand or respect delayed cord clamping and cutting.

If not chosing a lotus birth or cutting after 3 hours, there is another option: the parents will have the cord burnt. This is an amazing sight! I now know how to do this and have had the priviledge of doing it for one of my clients.

To burn the cord, two small pieces of cardboard, each with a narrow slit cut into it, are place around the cord to protect the baby's stomach. The mother usually places her hand behind the cardboard to make sure it doesn't get too hot. Then the cord is stretched over a bowl and held in place as one of the midwives and the father hold a candle on each side and begin to burn the cord. They again sing the Gayatri Mantra. The cord hisses and pops and smokes, and in about 10 - 15 minutes, it chars and breaks off. Less than 10cm is left on the baby. The candles are placed, still burning, upright into the wax at the bottom of the bowl and remain burning until they burn down to nothing. Blowing out a candle can signify blowing out a life.

Not only is cord burning a spiritual or religious decision, it is also a safe decision. There is no chance for tetanus by cutting it. This method can be done in any birth setting around the world, especially in countries where there are no instruments for cutting a cord or no way to sterilize the instruments. Newborn babies like cord burning as well. A screaming baby turns instantly quiet and alert and dozes off during the cord burning.

A Typical Clinic Birth

I managed to see a variety of births at the birth clinic. For some reason I ended up with the difficult ones full of complications. But there were some wonderful beautiful births as well. Here is a normal birth!

"Made" (pronounced Ma-Day) arrives with her husband at 3am. She slides off the back of their motorcycle where she rode side-saddle for anywhere from 5 to 30 minutes in labor. It is actually not as common for women to arrive in the middle of the night because that would mean driving past graveyards in the pitch-black night with a chance of encountering ghosts. But this is Made's second baby and she knows she is in labor. While she walks along the front porch dealing with a contraction, her husband "Wayan" knocks on the midwives' door.

The midwives share one big room. Two double beds are pushed together for anywhere from 2 - 5 midwives to share during the night, wrapped up in sarongs or a mosquito net. One midwife gets up to answer the knock, pushing her glasses back onto her face. Tonight it is "Ibu Agung" that checks on Made with me trailing behind to help with taking a blood pressure and gathering supplies. (If we hear a mom bellowing from the parking lot, one of us scrambles to make sure everything is laid out in case of a fast birth). Made is taken into a prenatal room where Ibu Agung checks her dilation and asks questions to make sure labor has really begun. 5cm dilated and laboring well, and wanting a water birth.

While the mother labors in her room, I begin to fill the water tub, put down a slip-proof mat on the floor, find extra towels, and make sure all of the supplies are ready: homeopathy, herbs, resus equipment, sterile gloves, yunan bayao, etc. The mother takes a sip out of her large water bottle and hands it to me. I take it to the fridge in the midwives' room and put 3 large squirts of liquid chlorophyll into it. When I get back water tub isn't ready yet so I help the dad help Made through a few contractions. Every 30 minutes or so I listen to the baby's heart and record everything on the chart. Her contractions get stronger and she gets into the tub. I tell the other midwives that Made is progressing quickly and a they get out of bed and wait around.

On my way to the clinic that night, I collected flowers. As I walked out of my house, I pulled a few from the trees as I passed and picked up more off of the street as I went, using the flashlight on my phone so I don't trip over rocks in the road. The flowers are for any births to come that night. I retrieved the flowers from earlier and dropped them into the water tub with Made. She takes a deep breath and smiles at me. I ask, "Bagus?" Good? She nods ands closes her eyes. During one contraction her water breaks and I lean down into the tub with the doppler to check on the baby. He or she is just fine, and I can see Made's labia beginning to open as she begins to push.

I have a baby blanket over my shoulder and the dad has a baby hat in his shirt to keep it warm. My senior midwife breezes in and squeezes my arm. I smile and say, hey you finally woke up! Even after 3000 babies, she can't help but come to births. Sometimes the clinic will call her to come with a difficult birth, and other times, she just wakes up and knows somehow that she should come. Made is so happy that she came as her first baby was also born at the clinic.

We all watch as the baby's head begins to appear and the midwives begin to sing the Gayatri Song. It is the most revered Hindu prayer and the first thing a baby hears. All of the midwives and the father sing... an amazing sound as it echoes through the room. Outside the birthroom it is silent. The mothers with newborns in the postpartum room have heard the labor and listen in anticipation. The family members outside hold their breaths. Made's firstborn, a daughter, is brought in by her mother-in-law to watch. I reach down to slow the baby's head down from tearing through and soon my whole hand is filled with a soft baby's face. I check for a cord and there is none. And the a baby slides out into the water, into my hands, and then is lifted up onto the mother's chest while the room echoes in song. Chills go down my spine!

I lay the blanket over the baby, and a midwife puts the warmed hat onto the baby's head. We wait for a few minutes as the water drains, scooping out bits of blood and membranes, while waiting for the placenta. The mother shifts uncomfortably and I catch the placenta as it slides out. I inspect it quickly for any missing parts, wash it off in the tub and carefully place it in a bowl, without clamping or cutting the cord. I scoop out the flowers, rinse them off, and place on top of the placenta. Made looks down at her baby and lifts a little leg. She sighs a huge sigh of relief.... a boy! Now that she has birthed a boy, she can stop having babies.

As soon as she can, Made gets up and is showered off while one of the midwives takes the baby and placenta to the bed. She dries off with help and lays down where the baby is immediately putting him to her breast. The senior midwife and I check her perineum and discover no tears! Made has already drunk her yunan bayao drink to help prevent hemorrhage and I sprinkle dried yunan bayao over the tender tissues to help them heal. I take a warm wash cloth and wipe her down again, and help her put on underwear with pads. The dad helps me take one of her sarongs and lay it over her, tucking her and baby in together.

By now, the student midwives have finished cleaning the tub and putting things away. I make sure the placenta bowl is close enough to the baby so it doesn't pull on his cord. He is beautiful and the mother is sleeping. I quietly close the door behind me and will check on her off and on until later in the day. I look at my watch and it is 8am. On that day, it is one birth finished and three to go.

Prenatal care - clinic style

The clinic that I worked at this summer does assembly line prenatal care for 100s of women but in a very non-assembly line way. Each woman does get one-on-one care from the midwives. There are 3 prenatal days, and each day sees 20-50 women.

Here is a typical prenatal visit by "Ketut" at 34 weeks along: Ketut walks into the clinic with her husband and approaches the intake desk. She hands over her special green government card that her pregnancy stats are kept on, takes a number from the pile, and sits down to wait. When there is a seat available at the intake desk, the Indonesian student midwives take her card, find her prenatal form, check the pregnancy wheel for her current weeks of gestation, and weigh her.

The foreign student midwife (me for the 1st hour most days) takes her blood pressure, attempts to speak with her just a little, even if just to ask her name again and how many children she has. Ketut then goes to sit and wait until her number is called from the prenatal room. When she enters the room, there are 2 beds for 2 appointments to happen at once. There are 4 senior midwives and usually 2 student midwives. The student asks the mother to lay down on the bed, measures the fundus, palpates for position, listens to the baby, checks for swelling, checks the eyes for anemia, and asks a few questions.

The student relates the info to the senior midwife who records it. If the student is unsure of position or has another question, the midwife will help out. Urine is not checked unless there is reason to suspect that something is up. Ketut sits up on the bed and talks with the midwives for a few minutes, either chatting about life or discussing issues that need covering. If she hasn't gotten a tetanus shot this pregnancy, she is required by the government to have one done right there. She is then given a tiny ziplock bag with prenatal vitamins. (A one month supply if coming 1x a month, 2 week supply if coming 2x a month, and 1 week supply if coming every week). With no more questions, she is on her way until her next appointment. As she leaves the property she puts a small donation in the box, usually around 20-50 cents.

Of course this type of appointment could be better but in this setting, it's so much better than any other options. The mothers sit together and chat about their pregnancies. If they come on an acupuncture day, they may be sent to acupuncture for breech baby, high blood pressure, or something else. If they come on a prenatal yoga day (the most popular day!), they can participate as much as they can.

For me as a student, I went in thinking I would just be a beginner. But taking blood pressures was no big deal. Palpating, which was totally self-taught, thanks to my many pregnant friends who let me practice on them, ended up being a great skill of mine. The senior midwives actually let me teach the Indonesian student midwives! If I ever had a question about head engagement, or baby position, I would call someone over to double check for me. My favorite prenatal was when a twin mom came in. I got to palpate the twins and find their heartbeats. I ran to the office to get my own twin-birth pics and ephasized that yes she can birth them vaginally and breastfeed them too!

Prenatal days were whirlwinds of activity. Some nights I walked home with aching ears from using the stethoscope for 2 hours straight! Some women I would see more than once, and some up to 3 or 4 times. If I was lucky, I'd be on shift when they came in to birth. With a relationship already made, the mother would feel comfortable having me at the birth.