The story of Miriam and her Twins

On a Monday, as I was unloading things from my car to check a young mom to be who was in early labor, an old mini pickup stopped along side my car and a lady got out. She looked a bit familiar. She came over to me and said “Do you remember me”. I thought for a moment, and then the memories came flooding back to me. This was the mother of Miriam. Miriam had called me in my first year doing home births, when Miriam was 17 and pregnant with her first child. “You are Miriam's mom!” I said. The lady said “Yes, and I am so glad to have found you. Miriam is pregnant again, and this time she is pregnant with twins. Miriam is close to her due date and I am sure that she wants you to care for her again. Miriam lives close, could you go and visit her?” “OK” I said “But first I must go and check this mom to see how she is doing. If she is not close to delivering, then I can come to your house and you can show me where Miriam lives."

I am in the Colonia of Morita, Tijuana. It's a poor place and one of many in Tijuana. These places are settled mostly by newcomers to Tijuana. Many are young couples who have come from Southern Mexican states in search of the many jobs created locally by the NAFTA treaty. Typically in these poor places, most of the houses in this Communities are built out of used materials. In the early years of these new communities, all the roads are dirt. In the summer months there is a tremendous amount of dust from passing cars and busses. In the winter, you have to contend with mud. When it rains, many streets become impassable. You learn to drive as close to the mom's house as you can get and walk the rest of the way.

I went in and checked Rosa Maria, and found that she was in very early labor. Rosa Maria was not going to have her baby any time soon, so I reassured her that everything was OK and told her that I needed to leave for a bit. I left for Miriam's mothers house, which was about 3 blocks away. When I arrived, a younger sister of Miriam came out to my car. She said that she would show me where Miriam lived. I was thinking that it has been almost 2 years sense I have seen Miriam. Miriam is very soft spoken and as soon as you meet her, you will like her. We soon arrived where Miriam was staying, a 2 room rental house made from old garage doors.

Above is a photo of Miriam and her 2 year old son in front of her house the day that I went there. Miriam was very happy to see me, and she showed me her recent ultrasounds. They definitely were showing twins. Miriam was unsure of her last menstrual period. The ultrasound stated that Miriam was about 33 weeks along with her twin pregnancy. The ultrasounds showed that her boy is head down and in her pelvis and on her right side. The girl is breach and on her left side and mostly behind the boy. I could easily hear the boy’s heartbeat, but it took me a bit to locate the girl because she was somewhat behind the boy. The babies were both active and reactive. I talked to Miriam about eating well, to prevent premature labor, and if premature labor should start, what to do. I now knew where she lives, so I will start doing visits with her. Miriam has no medical insurance so Miriam has been seen at the old downtown Tijuana General hospital where they gave her the standard response for a twin pregnancy "Better to have a cesarean" they told her. Even though Miriam does not want a cesarean, she understood that there are more risks for a twin birth, especially for the second baby. I told Miriam that I would do some studying on twin births, their risks, etc. and we would then discuss all of the risks, when I would visit Miriam next Saturday. As I was driving home, I thought aloud "Lord, please guide us, because neither one of us knows much about what we are up against".

One day a few months after Miriam's first birth, I saw her in an open-air market. I was remarking to Miriam how beautiful her first birth went, especially for a young, 17-year-old first time mom. Miriam told me, that she was studying to be a nurse and that she had read a lot about birth and had asked a lot of questions. The memory of her birth came back to me, hers was a beautiful birth. Miriam was my 5th. patient. We had learned together about birth.

It turned out that the call to Rosa Maria's house that day was a false alarm. As I drove home, I knew that Miriam wanted to have her twins with me. But this was a BIG responsibility for me, as this would be my first twin birth. I needed to do a lot of studying about twin births and all of the possible difficulties that could crop up during a twin birth. As I drove home, I was thinking about how beautiful it is to have a mom come back to you, because you did a previous birth for her and she trusts you. Miriam will be my first repeat birth, but TWINS! I am caught between the desire to take care of Miriam with her next birth, a milestone for me and the trepidations of doing my first twin birth. I will gather some opinions and experiences from the Midwifes that I know on the Midwifes email lists. I will translate them into Spanish, along with a "Twins" information Document from another mom on the Internet. Miriam is going to make up her mind on my next visit with her, if she wants to birth her twins in her home.

When I visited Miriam the next Saturday, she had had a chance to think about things. After talking to Miriam for a few minutes, it was apparent to me that the only thing that Miriam wanted to hear from me, is if I would take care of her. Apparently, Miriam and her mother had talked about risks, etc., and how her previous birth went, so she had already made up her mind on where she wanted to birth. Miriam was only waiting to hear from me if I thought that I was ready to do a twin birth and that I would take care of her. I reiterated about risks, both in the hospital setting, with the proposed cesarean section and I talked again about the risks of a twin home birth. I think that the chances of a good outcome for Miriam are very good, as she had a normal, natural birth with her last baby when Miriam was 17. I re-stressed the importance rest, nutrition and hydration. I calculated Miriam's due date from her last known menstrual period as May 22. Her recent April 6 ultrasound lists her estimated due date as June 7. I know that the my knowledge and experience, and those who will be assisting will be very important. I have contacted my very experienced Tijuana Midwife friend who lives about 25 minutes away from Miriam's house and she will assist me during the delivery.

A bit before 8 PM one evening, I got a call from my sister in law. She said that she received a call from the husband of Miriam. He told my Sister in law that Miriam had not been feeling well and that they took Miriam by Ambulance to some hospital. I immediately grabbed some clothes, jumped into my car and headed for Tijuana. How could this happen, I was thinking. Was Miriam bleeding, or something just routine. I was very sad and distraught about the thought that Miriam might be forced to deliver in a hospital. I arrived about 2 hours later at their house and was met by Miriam's husband. He told me that he didn't know what happened, because he was at work. It it had something to do with nearby neighbor. We went to the neighbor's house where the husband told us that his wife was very concerned about Miriam. Miriam wasn't eating, and was having contractions. They had tried to call me, but said that they could not get the call to go through, and the recordings were in English, so that they did not understand why. This neighbor then called an ambulance, and the ambulance took Miriam to the old Tijuana General Hospital. So I decided to go to the Tijuana General Hospital and maybe somehow salvage this. Miriam's husband went with me to the hospital. It is quite difficult to get any information at this hospital, as there is an unmanned information window, which they check about every 15-20 minutes. After waiting about 15 minutes, a doctor opened the door to the triage area and called to someone in the waiting room. Miriam's husband took this opportunity to stick his foot in the door and ask the doctor if he or any other doctor had seen a young women carrying twins? The doctor said that "Yes, he had checked a young women about 1 hour ago who was pregnant with twins. She was not in active labor." The doctor also said that "We tried to talk the young women into doing a Cesarean Section on her, as she was very close to her due date. We told her that a Cesarean Section would be faster for her and safer for the babies. The young women told us that she only wanted to be checked. She told us that a Partero (Midwife) was going to attend to her birth". That raised the hackles of the staff. They could not believe that a women pregnant with twins would deliberately choose to do this so they made Miriam sign a statement, saying that she wanted no further care and wanted to leave the hospital. That would release the hospital from all further liability. Miriam signed their form and left the hospital. So then we knew Miriam was not in the hospitals clutches, but where was she? I was outside wondering around, asking everyone if they had seen a very pregnant young mom leaving the hospital. An older couple remembered her leaving with another women, but they had no idea which way they went. I talked to all of the taxi drivers out front, but no one had seen her. Just then my cell phone rang. It was Miriam and she was talking very fast. I couldn't understand what she was saying, so I ran back inside as fast as I could to give the phone to her Miriam's husband. By the time I found him, the call ended. A few minutes later, my cell phone rang again and it was Miriam. I immediately handed the cell phone to her husband and Miriam told him that they had walked to the "Gray and Orange bus line" waiting area. He knew what street the Gray and Orange bus line ran on, so we left the hospital, found the street and began to drive the length of it. By this time, it is 10:45 PM and dark outside. We drive and drive but we cannot find Miriam. How are we going to find Miriam? Finally after about 45 minutes, Miriam calls again. This time she gives us the names of the streets. It was in a slightly different area, but we soon found Miriam and took her home. Miriam had walked about 10 blocks to get to the bus stop. Even though she was now VERY big, the walk did not seem to faze her. At was now about 11:45 PM. Miriam's husband soon excused himself, as he needed to get up at 4 AM. I began to check Miriam and listen to her babies. They were rather active, and responsive to your touch. A few minutes later, the husband of neighbor lady came over and began to talk to us about the fact that they were very worried about Miriam. They were worried that Miriam could now not return to the Tijuana General Hospital, as she had signed the paper releasing them from further liability. I guess that they thought that Miriam could not be seen there again. He further told me that he and some other neighbors were "putting a fund together, as they knew a nearby doctor who would do a cesarean for a reduced rate". It was certain at this point, that these neighbors thought that it was rather dangerous for Miriam to have her babies at home so were making plans for Miriam to do otherwise. I looked at Miriam's eyes and I could tell that she did not like what she was hearing. The man appeared to have been drinking and was talking rather loudly and scaring Miriam's little boy. Finally, the man left. Miriam began to explain how the day had happened. The neighbor lady had come over to visit Miriam. Miriam did not have any desires to eat and was just lying around and having mild contractions. After trying to call me and apparently not knowing that they needed a long distance calling card for their telephone to make the call, the neighbor lady began to panic and called an ambulance. The rest, you know. Miriam said when she was in the Hospital, they treated her very gruffly and hurting her when doing a vaginal check (2 doctors) and when feeling the baby's positions. One doctor would not believe that she was carrying twins. Miriam said that there was a lot of blood on the floor and the place had a bad odor about it. She has no desires to deliver there, in any manor. Miriam told me again that she has no fear of having her babies at home.

As I was checking Miriam that night (photo above) I noticed that she had protein in her urine. It was no surprise to me, as I knew that she had not been eating well for several days. I told her to please go and eat something, your babies need it. When I checked her refrigerator, it was then apparent that there was very little food in the house. The problem, always the same, Money. I told Miriam that I would bring some food to her this weekend. As we sat talking and watching her babies move in her very big tummy I looked at my watch. It was now about 12:30 AM. I still had a 2 hour drive home and work the next morning. I told Miriam to please be careful, stay away from her neighbor and to call me if she should have more contractions.

As I was driving home, I was thinking about telling the neighbor lady next time that I was there to take up a fund for some food for Miriam rather then collecting money for a cesarean. Miriam wanted to birth her babies normally. I collected some some food donations that week, and had them ready for my next trip to Tijuana. I knew that Miriam could call at any time.

I visited Miriam Saturday and she was feeling better. She had been eating better, so her contractions had backed off. I gave her the food that I had collected. She would now need it even more, as she and her boyfriend had separated. Miriam and her 2 year old boy were the only one's in the little house. Miriam was now only 3 days from her due date. A miracle I thought, considering the stress that has taken place in her life recently. The babies felt big, so I was thinking that she will be calling very soon. The meddlesome neighbor has backed off, which is a big relief. My planned helpers would be my Tijuana Midwife Angelica and Miriam's mom. And maybe some others, depends on what Miriam wants. Miriam despite her many late twin pregnancy discomforts, continues to be very positive and has not wavered in her plans to deliver at home. My worry continues to be with the ever continuing "Cellular telephone problem". This is the perils of living in one country and doing prenatal care and births in another. I just hope that when Miriam needs to call, her call will come through.

On the evening of May 23rd., just as I was getting into bed, my phone rang. It was 10:05 PM and It was a younger sister of Miriam, saying that Miriam had started labor and could I come. I told her "Yes I will leave in a few moments and I will be there in about 2-2½ hours." Miriam's sister said that Miriam was now in their house, not in hers. I knew where the house was, as that house is where Miriam gave birth with me to her first son almost 2 years ago. I didn't know why Miriam was at her mothers house. Maybe she just happened to be there, or maybe she wanted some distance from the persistent bothersome neighbor which had talked Miriam into taking an Ambulance ride to the old downtown Tijuana General Hospital last week.

When I pulled up to where Miriam's mother's was, Miriam was outside waiting for me. When we went inside, Miriam was alone. The rest of her family was asleep! Miriam's mother and sisters were in the next room snoring. Were they so unworried about this soon to be twin birth, that they may just have considered this to be just another "body function"?

Above left is Miriam shortly after I arrived at Miriam's mothers house. I had given Miriam specific instructions to call me early, so that I would have ample time to prepare for this twin birth. It was no surprise that Miriam had not started to dilate when I checked her, shortly after arriving. She shows me a wet spot on the bed, clear fluid, which later I attribute this to the girl baby, as she never did show any signs of rupturing later. About 3 hours later, Miriam had started to dilate, 2-3 cm. I decide that it is time to go and get Angelica, the other Tijuana Midwife that I had planned to assist me with this delivery. Angelica lives about 20 minutes away, almost all on dirt roads. After arriving at Angelica's house, I pound and pound on Angelica's door. I am hollering her name, seemingly waking everyone in the neighborhood, except Angelica. Angelica finally responds and tells me that she just went to bed, as she also has a mom in labor. Soon, Angelica comes out and gets into my car. Angelica tells me that we must first go by her patient's house, so Angelica can check her. Luckily, Angelica's patient lives on the way to Miriam's house. Angelica's patient is dilated the same amount as Miriam, except that Angelica's patient was been at the same dilation sense early evening. We continue on to Miriam's mom's house. It is now an hour later and Miriam is having stronger contractions, although she is only slightly more dilated in the last hour. I can feel the membranes bulging with the contractions, so I decide to ask Miriam to get up, and please walk for awhile. (Right photo) I can see that she is now starting to have stronger and more effective contractions. At 4:50 AM, Miriam gets back on the bed and on her knees and leans against the wall and starts pushing, with her back toward me. At 4:54 AM, I have Miriam's new son in my hands. The mood instantly changes in the room, we start moving about and I cut and clamp off the cord to her newborn and hand him to Angelica. A bit later, I ask Miriam, to please lay down, as I want her in a better position, for her breech daughter. There are no photos of the births, because I was too concerned about other things. After about 10 minutes of no contractions, very slowly, Miriam starts to have more contractions, as we clean up her new son. Miriam's 2 year old son comes in and sees and hears his new brother. We weigh this new little one, 3.4 Kgs. Good size for a twin. I am constantly checking the fetal heart tones on Miriam's unborn daughter. I now see that Miriam is passing a lot of clots so I am worried about early placental separation. Thank goodness the unborn girl continues to have a strong and unwavering heartbeat. Finally Miriam's contractions are becoming very strong again, and almost as painful as with the first baby. About 5:45 AM, Miriam is getting the urge to push, and at 5:49 AM, she pushes out a little breech girl, 55 minutes after the first twin. Other then the fact that this baby's genitals are a bit swollen, because of her breech exit, she is healthy, pink, wide eyed, and breathing well from the start, as was the first baby. The girl weighs in at 2.5 Kgs., small, but just a miniature of the other. Now, the room is full of Miriam's sisters and her mother. The placentas came out about 12 minutes later, as one big placenta. It was the biggest that I have ever seen. I had a small cord one side and a large one on the other. It appears that Miriam is now going to bleed, so I start to clean up everything, and then a few minutes later, I see the signs that I don't like, but am very ready for. I wait a few minutes more, checking her uterus, it feels very hard, but she continues to bleed, I know her BP is OK, as I checked it earlier, so Angelica prepares an injection of Ergotrate, and just a few moments later Miriam's bleeding stops. Miriam is now nursing her girl. Although I am quite tired at this point, I am on cloud 9 now, SO happy that all turned out well.

Miriam's never wavering decision to have her babies at home probably had a number reasons behind it. She certainly did not like what the medical community was offering as an alternative. She had a very nice first homebirth with me and I am sure that had contributed heavily to her decision to have her twins at home. I asked Miriam, as I do all of my mom's, "Miriam, are you scared to have your babies at home?" A simple, soft spoken "No" was her answer, with a smile. Later, Miriam's mother remarked about Miriam's decision about where she wanted to birth. Miriam had told her mom earlier, that "I want to have my babies with the Partero, I feel safe with him." That made me feel very proud. As I think back about her birth and before, I was struck not only about Miriam's extreme calmness during this event, but also Miriam's family's reaction during her labor and birth. I had asked Miriam, how many sisters do you have, when I visited her one weekend."5" she said. "I am the oldest, the rest live here". I made the comment "You better keep the paper with my number, as someday one of your sisters may need my help." She said "Yes, I intend to keep your number." The thing that I found different about this family is their attitude toward birth. It seems that even in Mexico, where many people still choose home birth, most worry about possible complications. And a Twin home birth, even more. (Remember Miriam's neighbor, the ambulance, and the ride to the hospital) To me, Miriam always showed me a lot of courage and self-confidence. For Miriam, I think that she just has an inherent trust in birth. Even Poverty and Hunger did not keep Miriam from having a normal, natural birth for her babies. What a fantastic women.

Jerry

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