Hati-Hati

I am new to Indonesia and not Muslim, so it is not entirely clear to me if I offend.  The group of about eighty doctors, nurse wives and health assistants with whom I speak are leaning in—usually a good sign for a presenter.  The women are covered in brightly colored headscarves, which I see periodically nod up and down.  The men wear ornate batik shirts and look less enthusiastic but still their necks croon. 

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I am asking from the audience the unusual:  For them to resuscitate newly delivered babies between the legs of their mothers, umbilical cords intact.  The evidence is unequivocal.  Delaying the cutting of the umbilical cord for at least two minutes after delivery perfuses rich oxygenated blood to the newborn, increasing its blood volume by up to 30%-- perhaps the difference in a sick newborn’s fight to survive.  But when a baby comes out, there is not much slack, so if the baby is to receive the “extra” blood supply, it must essentially stay right there.  Strike 1:  Clinicians like to resuscitate babies on warming tables.  There, they are less disturbed by worried parents and arguably have the space, equipment and drugs to do their jobs.  Strike 2:  Even when a baby is well, caregivers usually clamp the umbilical cord as soon as the body is delivered.  In the 1970’s, multiple studies showed that you could prevent delivering mothers from bleeding to death by clamping the cord, by giving the mother a drug to constrict the uterus, and by exerting steady gentle traction on the cord to free the placenta from the uterus.  This protocol quickly became the standard even though the studies never focused on the outcome if the baby.  They also didn’t explain that the latter two interventions when performed alone produced the same results.  Strike 3:  Who the hell is this tall man, who doesn’t speak more than a handful of phrases in Bahasa, to tell us what to do anyway?  I mean he looks Chinese-Indonesian, so maybe he is retarded.  Also, the pink shirt that he is wearing is a little wrinkled.  Our dress we like pressed.

My interpreter Lisa is charming and good.  I say one thing.  She translates carefully but quickly. I speak no more than 2-3 sentences at a time to be clear.  Lisa follows in a flowing staccato.  R’s roll off her tongue in circular lilts.  She could be speaking ancient indigenous Spanish if we were in a different place.  Sometimes Lisa pauses upon hearing a medical term about which she is not familiar.  When a senior doctor yells out the correct pronunciation, she responds by smiling, bowing slightly, taking down notes, saying the word correctly and not repeating the same mistake again.  Our pattern would normally be tedious. This talk of thirty minutes is now at hour one.  But we are also talking about blue babies, women’s vaginas, and rubbery umbilical cords—inherently interesting topics I think.   

“So you ask,” I say, “How do you resuscitate a baby between a mother’s legs?”  Lisa follows, ”Begaimana kalian memperlakukan bayi di antara khaki ibu?  Begaimana?”

“Well can you imagine this?” I say stooping down to a quarter squat, “here’s the baby.”  I show the audience a dummy baby called a Neo-Natalie, a model that simulates a baby as a dark brown fluid filled bag of water with floppy head, elastic chest and wimpy legs.  I have a thick red towel under Miss Natalie.  “Imagine I am between the mothers legs,” I continue, ”hi Mom.  I am drying your baby.  I am stimulating your baby.  Notice everyone that I am stimulating the baby while drying it.  A wet baby is a dead baby.  Can you say that?  A wet baby is a dead baby.” 

For am moment, I wonder if I am being too glib.  I wonder if I am culturally incompetent to present a black baby doll to a bunch of Asians.  Can one even congratulate a mother after delivery between her legs?  I am twelve hours off the plane from New York City and a little sleep deprived.  Interspersed in the crowd, which by the way will repeat itself three times, is USAID our donor, partners including the WHO and I think my boss.  I am all at once overwhelmed, paranoid and alas, OCD.

“Bayi basah bayi mati.  Bayi basah bayi mati,” the audience is repeating, “A wet baby is a dead baby.  A wet baby is a dead baby.”

The chant brings me back from revelry.  “Position the baby to assess if the baby is breathing,” I continue, “Don’t forget to congratulate mom and dad.  Ibu, Ba Pak, congratulations.  I am just looking at your baby to see how it is doing.  I am keeping the baby here, Ibu, so baby can receive the last parts of your rich blood.  This is good for the baby.  But don’t wait for me.  Reach down and touch your baby’s head.  Reach down.  Feel it.  What a beautiful baby you have delivered don’t you think?”

The idea of talking to patient personably and at the perineum is foreign.  Most American doctors don’t act this way.  In Rwanda, the nurses I dealt with barked things like, “hold down your voice!”  The doctors didn’t talk. But this group of mostly midwives seem to understand what I am saying.  “Yes, we want to deliver the type of care we would want for our own families,” I say.

At this point, a doctor in the audience stands up and says in Indonesian, “If the baby is sick, then we need to clamp the cord.  I am a certified trainer in neonatal resuscitation and the baby should be resuscitated according to the guidelines.”

I wait for the translation to finish already knowing by the doctor’s tone the substance of his words.  I am hyper-aware not to offend; to cultivate a good first impression.  This experience I bring as an older man.  I stand there waiting, nodding in understanding and allowing the doctor to complete his main thoughts while not allowing him to drone.  “You are right,” I say in between a pause, “I was presenting the case of a well baby.  But would you agree that the current NRP guidelines doesn’t say anything about when to clamp the cord and where to resuscitate the baby?”

“Why can’t we give the first assisted breaths at the perineum?” I pose, “why must we cut the cord so early when we know the body’s arrangement and physiology is likely intentional and well designed. 

“But there’s no room,” a nurse towards the front of the room whispers.  “Tidak ada spasi disana,” the interpreter says.

“You are right,” I say, “Tell the mother to scoot her butt up.  We have a baby to resuscitate.  Deliver on the floor.  Bring in a small table.  Levitate. I don’t care what you do so long as you recognize what you are doing vis-à-vis the evidence and be creative in delivering to your patients the best possible care.”

The midwives chuckle.  The doctors look mad.  I am thinking how I have always preferred the company of midwives.   At the hospital where I used to work in San Francisco, midwives allowed the women to deliver in any position in which they felt comfortable.  Some delivered with feet at the head-board.  Others in a semi-circle, doggy style, back to bed with leg over scared looked husband’s shoulder.  One midwife hung a rope.  The midwives never rushed the mother, rarely insisting on vacuum extraction or escalating the intervention to caesarian section.  Over subsequent years, I came to admire and emulate this patient, patient-centered approach to care. 

“I know what I am presenting to you is different,” I say to the group, “But it’s not my opinion.  It’s the evidence of care.  What is currently happening in Indonesia is not good enough.  How do we know this?  Because Indonesia has among the highest neonatal death rates in Asia.  You are worse than Vietnam.  You are worse than Cambodia.”

“Don’t worry,” I say, acting out my words again on the water filled black baby doll, “You have time.  Drying and stimulating the baby.  30 seconds.  Positioning the baby to see if the baby is breathing 15 seconds.  Telling the mother as you go what you are doing 15 seconds.   Baby not breathing?  Shoulder roll, head tilt, bag-valve mask.  1 minute.  There, 2 minutes done.  Cut the cord and give baby to the parents or take to the resuscitation table as you are accustomed to doing.”

The translation runs, weaving two ways, two styles, two cultures in a playful tit for tat, yin and yang, Harold and Maude.  I recognize only a few Indonesian words.  “Anda… resuscitasi…sekali…bayi…oxygen… medis…daruwat.”  As I wait for words to catch up, slow, or wait, I remind myself to stop calling babies, babi, “pork” or “pig”, instead of bayi, “baby”.  I try to think how to say thank you or steamed rice or hot sauce on my t-shirt.  It’s minute 120.  We will soon break into groups for individual practice sessions.  I just got my second wind.  Five hours and three more years to go.

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