Andrea’s Diary

I have just left the UK after a brief (for me) visit of 10 days during which I presented some workshops and had a short break with friends in Wales. I also spent time with Caroline Flint in London enabling me to catch up with her successful midwifery practice based around The Birth Centre in Tooting.

This Birth Centre was the first one ever established in the UK and has provided a lovely birth place for many babies over the years. As a model for midwifery care it is unequalled - being independent of the NHS system offers women complete freedom to have the birth and care they want without any of the restrictions that must be applied to those birth centres attached to maternity hospitals. It is just a shame that more centres like Caroline’s have not been established elsewhere and crazy that her achievements as a pioneer of the birth centre philosophy in the UK is rarely acknowledged by her peers. The “tall poppy” syndrome that we are so familiar with in Australia seems to have taken hold in the UK as well.

My impressions of UK midwifery, formed on this visit, is that is seems in the doldrums. The midwives I met this time talked about the chronic staff shortages, which have been going on for some time, but this time there seems to be a feeling that the problems will never be fixed. With the mass resignations looming as the average age of midwives advances, many were gloomy about the prospects for midwifery in the future and fear that births will become concentrated in the large hospitals as the only practical way of staffing maternity care. Too many doctors working in obstetrics are having a big influence on the way births are managed and the imposition of strict rules and guidelines (formulated by doctor dominated bodies like the National Institutes for Clinical Excellence - NICE) are overriding the expertise of midwives in facilitating normal births, leading to more and more caesareans. The once proud record of natural births that was the hallmark of British maternity services is under serious threat and the only way to escape the increasing production line approach seems to be having a home birth (if a woman is lucky enough to live in an area that will provide this mandated option).

More dynamic leadership of the Royal College of Midwives might also help. With morale amongst midwives at a very low point, the RCM has a big task ahead if it is to lift the spirits of midwives and take the strong political role needed to get the working conditions improved to attract and retain midwives in the system. What is needed is not just pay rises for midwives, but assertive efforts to have the voice of midwives heard equally with their medical colleagues as policies are formulated and services are planned and implemented. The RCM could also take the lead in establishing strong supportive structures to stamp out the horizontal violence that is endemic in many hospitals. I understand that the leadership of the RCM is about to change and that (gasp!) a man is even being considered for this post. What a refreshing change that might be - will the College be bold enough to take this idea on? The Australian College of Midwives employed a non-midwife as its CEO several years ago and it revolutionised their organisation, giving it new energy, a strong lobbying voice and better internal systems. Will the RCM look “outside the square” on this occasion?

The Birth International Conference in Sydney followed the same basic format as the event in New Zealand, except that to began on Friday afternoon and finished early on the Sunday afternoon. Since most participants were from interstate, this format made travelling easier and also provided for some extra downtime.

The speaking team was much the same as in New Zealand, but there were some variations:

Mary Nolan PhD, Professor of Perinatal Education at Worcester University, UK. Her Plenary presentation was “Childbirth Education - inclusive or exclusive?” and she facilitated workshop sessions on “Putting the WOW! Factor into classes” and “Managing cultural diversity“.

Penny Simkin, Physical Therapist and well-known international author and speaker. Her Plenary addressed the issue of “When sexual abuse survivors give birth” and her workshops were on the themes of “Pain in labour” and “Working with abuse survivors“.

Lorna Davies, Midwifery Educator and author from Christchurch, presented a Plenary on “The art of childbirth education” gave workshop sessions on “Creativity and self expression in prenatal programs“.

Paul Prichard, from Good Beginnings, presented a Plenary session on “Realising the potential of expectant and new fathers” and also facilitated workshops on “Inside the mind of the expectant father”.

Shea Caplice, Midwife and film maker, presented the film “Hannah’s Story” in one of the Plenary sessions.

Judy Cottrell, Midwifery educator from Auckland, presented her workshop on “Action teaching.”

Andrea Robertson, Director of Birth International ran workshops on “Beating educator burnout” and “Teaching birth basics: making birth easier”.

Julie Clarke, independent childbirth educator from Sydney gave workshops on “Getting started as an educator” and “‘I can do this!’ - teaching second stage”.

Allison Hilbig, Women’s health physiotherapist from Melbourne, gave two sessions on “Linking sexuality and birth“.

Lina Clerke, Midwife and childbirth educator, facilitated two workshops on “From fear to excitement about birth - changing mindsets“.

Alesa Koziol, childbirth educator from Melbourne, facilitated the workshops on “Teaching birth basics: drugs and interventions.”

Deb Galloway, Parent Education co-ordinator from John Hunter Hospital, Newcastle, ran the workshops on “Making connections with early parenting”.

Overall impressions of the event:

Once again, this was a very successful event. There were over 100 participants, who offered very positive feedback about the program, speakers and overall organisation.

The venue was praised for its location and setting by the beach, although some would have liked a more central venue so they could go shopping! The cost of t he accommodation was mentioned by some as expensive, but people appreciated the food and general atmosphere.

Some of the general comments included:

“This has really brought me back to the core essence of being woman and birthing with power!!”

“Brought everything into perspective and gave me ideas to work with.”

“Considering the cost, would have preferred to stay a few more hours to get to all the sessions.”

I enjoyed this…”because I learned so much gained new ideas as well as met so many amazing people.”

“The company of so many like-minded midwives - what’s not to enjoy, surrounded by all their enthusiasm. Always glad to hear how other people do things.”

“Catering magnificent”

“Expensive for the value, poor dietary choices.”

“Nice hotel but could have been in a cleaner area of Sydney.”

“Thanks for a wonderful weekend. I feel proud to be a midwife and childbirth educator. And now, even better equipped to care for women.”

“I’m so glad I came along.”

The Plenary sessions

These were enjoyed by everyone - many mentioned the moving film made by Shea Caplice of “Hannah’s Story”. Feedback included:

“Every student midwife and midwife needs to see Hannah Dahlen’s film - I will recommend this at work.”

“Congratulations on Hannah’s Story. Loads of admiration for all concerned.”

The workshops

Every workshop group is different and this can colour both the learning and the overall impression of the program. Many asked for a longer program another time so that all workshops could be attended - people don’t like to feel they have missed out on anything.

The program for Sydney had been devised in two streams, one for “beginners” and the other for more experienced educators. This attempt to tailor the workshop content to the needs of the participants seems to have been largely lost in translation - no-one mentioned that they had taken advantage of this strategy. I had listed learner outcomes for each session as a guide to both presenters and participants - this didn’t appear to work in all cases.

The feedback was very similar to the comments from the New Zealand group. People loved the diversity of programs yet the common themes that were present in the workshop sessions. The opportunity to try various teaching activities was appreciated and there was much praise for the skill, passion and expertise of the presenters.

This was a wonderful weekend for everyone concerned and we felt very pleased to have made such a professional, relevant and enjoyable event possible.

The first Conference that Birth International has presented in New Zealand was held on the weekend of March 8 and 9, 2008. The team of speakers, and their topics were:

Mary Nolan PhD, Professor of Perinatal Education at Worcester University, UK. Her Plenary presentation was “Childbirth Education - inclusive or exclusive?” and she facilitated workshop sessions on “Putting the WOW! factor into classes” and “Managing cultural diversity”.

Penny Simkin, Physical Therapist and well-known international author and speaker. Her Plenary addressed the issue of “When sexual abuse survivors give birth” and her workshops were on the themes of “Pain in labour” and “Working with abuse survivors”.

Andrea Robertson, Director of Birth International, closed with the Plenary session on “New challenges for childbirth educators” and ran workshops on “Beating educator burnout” and “Teaching birth basics: making birth easier”.

Bronny Handfield, independent educator from Melbourne, showed her DVD on “Birth in the Media” that forms part of her PhD thesis, and also facilitated workshop sessions of “Teaching birth basics: drugs and interventions”.

Julie Clarke, independent childbirth educator from Sydney gave workshops on “Parenting 101″ and “‘I can do this!’ - teaching second stage”.

Lorna Davies, Midwifery Educator and author from Christchurch, gave a session on “Creativity and self expression in prenatal programs“.

Deb Pattrick and Tracy Smith, the midwives who form the Core of Life program in Australia, facilitated sessions on “Working with the young and pregnant.”

Allison Hilbig, Women’s health physiotherapist from Melbourne, gave two sessions on “Linking sexuality and birth”.

Judy Cottrell, Midwifery educator from Auckland, presented her workshop on “Action teaching.”

Gerry Smith, midwife and IBCLC from Auckland, offer a program on “Motivating women to breastfeed.”

Overall impressions of the event:

The overwhelming response from participants was that this was an exciting, stimulating event that reignited enthusiasm for childbirth and parenting education and offered many helpful ideas and teaching tips that would be used in future programs.

The Heritage Hotel was a popular choice, and the facilities and food (with the notable exception of the soup on Saturday!) was praised. One person thought the chairs were too uncomfortable and a number of people commented they would have preferred chairs and tables for lunch.

The awful glitch with the A/V equipment on Saturday evening was remarkably well tolerated, no doubt helped by the glass of wine that was available, but this meant the program ran very late, causing problems for some. Saturday was certainly a long day.

The cost was a factor we could do little about - running quality events with overseas speakers is an expensive exercise. Several participants commented that Kiwis don’t mind “roughing it” to get a cheaper event, however I feel that this perpetuates the perception that childbirth educators are “not worth much”, and I prefer to offer as professional event as I can, within reason.

Plenary sessions

These were all praised as being worthwhile. Mary and Penny were applauded for succinct summaries of major issues and opened up conversations that could be continued later in workshops.

“Mary’s talk reduced me to tears in a very heart-warming way. I really appreciated her sharing her family’s story.”

“Interesting. Loved Bronny’s video.”

“Absolutely great closing speech, Andrea. Thank you.”

Workshop sessions

These were very popular and everyone enjoyed the many varied presentations. Speakers were asked to prepare an interactive session that enabled participants to gain skills and try new ideas. Feedback was extensive - here are some examples:

“The talk gave us some great tips on several topics that are often difficult to take - reinforced and revisited learning types - things we knew - but it is always good to be reminded of.”

“Absolutely fantastic looking at diversity and facilitation rather than teaching to or at.”

“Excellent course facilitation of session. Good ideas”

“Great! We are taking her principles straight back to classes! Fab presentation.”

“Very thought provoking. It gave me a new perspective on class participants and ideas.”

“Great. I got to sit in on one of my (s)heros! Great practical information that will really add substance to my classes.

“A very different and interesting session. Stimulating - great ideas. Loved the suggestions for using music, Pictionary etc - thank you. Loved the way you demonstrated your ideas.”

“Great workshop - very concise - they knew their stuff and kept to the point.”

“Wow! Great stuff - very motivating.”

“Good workshop. Definitely will make me tackle this issue more confidently in my classes.”

The event was a huge success, and as we packed up, we were anticipating a similar experience in Sydney, which was scheduled for the following weekend. We were not disappointed…..

I have received an email from Ruth Malik, my contact in India, who is setting up a new childbirth education service for Indian women. She has mounted a legal case to challenge the management of the birth of her second child, which she considers was an unnecessary caesarean birth. She has asked that I circulate the following petition that she has submitted to the Indian authorities, to provide information, support and encouragement for other women in India who may also feel their births were mismanaged. It is an interesting story, and one that will resonate with women in many countries, not just India.

MAY IT PLEASE THIS HON’BLE FORUM TO ACCEPT MY PLAINT AS UNDER:

This Complaint is against the Medical negligence/ Malpractice of the Respondent Doctor and the Hospital as a result of lack of due care, abrupt decision making in carrying out childbirth leading to Emergency Cesarean Section of the Complainant on 24th March 2006.

FACTS OF THE CASE

1. I am a foreign national married to an Indian. I have a 5 years old male child born by caesarean section.
2. . I consulted Respondent No 1 for my second pregnancy and expressed my strong desire for a normal vaginal delivery. She gave me full support for the same.
3. . On my due date (17.03.06) she examined me cursorily per abdomen and declared that I had a lazy uterus and my previous scar was paper thin and thus I was unlikely to be a suitable candidate for normal delivery. I was not satisfied by her statements so I approached another doctor at …… Healthcare Centre for second opinion ( Annexure A) regarding my chances of having normal child birth. They carried out Ultrasonography (Annexure B) and NST ( Non Stress Test) and assured me that all is well so I stayed home waiting for Labour.
4. . On 24.03.06, Respondent No 2 carried out CTG (cardiotopography) for which I had to lie on my back. A belt was tied around my abdomen to check baby’s heart rate. I felt uneasiness and incredible heat, they said after a few seconds that I would be taken up for surgery.
5. . Though I signed the informed consent for emergency Cesarean section, I was not convinced with the indication verbally given by the attending staff at Respondent No 2. They admitted me at 2.54pm and at 3.05 (Annexure C) I was in the operation theater for a surgery by Respondent No 1.
6. . In the operation theater, Respondent No 1 told me of being misinformed and the doctors who gave me second opinion as QUACK. This further added to my doubt regarding her decision for Cesarean section , but I was helpless for myself by that time.
7. . I had a baby girl, who was pink and healthy when shown to me in the operation theater. I could not relate her to the emergency scene I was shown to be suffering from.
8. . I was discharged from the hospital on 27.03.06, feeling confused and cheated.
9. . I went back to Respondent No 1 after ten months to clear my confusion and to find out what really had happened. She told me that I had rupture of membranes and fluid was leaking out. I pulled my discharge card (Annexure D) and asked her why it was not mentioned there. She grabbed it from me and quickly scribbled scar dehiscence in the mid portion of scar with herniation of membranes.
10. . Respondent No1 again tried to satisfy me by stating that I was lucky that I came in as soon as labour started. I was stunned and told her that I have never had been in labour. She was silent on this. By this time, the mental strain and agony was unbearable.
11. . I applied for and got my indoor case papers and discovered questionable discrepancies, evident of deficiencies of services suffered from both the Respondents as a consumer / an Expectant Mother and at last a Deceived Mother.
12. . What I inferred from my research was that I was wrongly stamped as an emergency cesarean section, what I really needed was careful support and monitoring for a few more days, which (duty of due care) was denied to me by both the Respondents.
13. . An evaluation of Respondent 1’s series of actions demonstrates that she intended the birth to consist of an emergency Caesarean section before I was given to chance to commence natural labour. I must conclude that the surgery was pre-planned by Respondent No 1.
14. . Childbirth is the Reproductive right of a woman. Normal childbirth has a more positive impact on the body, in establishing breast feeding and thus providing good growth parameters for the baby. Researches have further laid down the safety criteria of reproductive organs after normal deliveries. The humane bond between child and mother is being weakened by these increasing rates of intervention i. e. cesarean section. The modern medical technology aims at providing qualitative health care but what I experienced as a woman as well as a mother at Respondent No 2’s care, of being violated, deliberately abused by the doctors on whom I trusted for seeking help of experiencing a normal childbirth which was deserved in my case.
15. .I made a complete inquiry of my case and decided to raise my voice because it concerns the reproductive rights of so many women who have suffered from this deliberate negligence and left confused or misinformed by their gynecologists. When I compared this fact with other countries, I found that it is easy to see the standards for practice of major hospital abroad on the internet but impossible to get an ideal of practice of Gynaec/ Obstetrics in India. I wondered what human care and which standard of medical services is provided to a dependant consumer called “Patient” in these corporate hospitals.

THE MAIN DEFICIENCIES OF SERVICE I SUFFERED:

During my pre-delivery care.

1. . My doctor and I never had time to talk to each other which is highly unethical, and extremely dangerous for the patient. I felt I was a burden to my doctor rather than a woman paying a huge amount as a consumer for availing her medical services.
2. . My mother had all three children delivered normally ten days overdue. As a literate woman I assume that my post maturity may be because of this genetic factor. I mentioned this every time to my doctor during my regular ( Ante Natal Care) checkup in expecting a rational and scientific explanation from a qualified Medical professional What I got was as answer was, her silence.
3. . She was under professional obligation of satisfying my queries. But I was left confused. It was my right to know my status as an expectant mother and then only I would have been in a position to exercise my options about my baby’s birth. Respondent No 1 has totally neglected her duties as a medical professional.
4. . Because of this deliberate negligence of Respondent No 1, I had to seek second opinions from other professionals expending more time and money in my last few stressful days of pregnancy.

   During my stay at Hospital

5. . Respondent No 2 had supported Respondent No 1 in carrying out an unethical surgery, in interest of revenue generation.
6. . When I was admitted on 24.03.06 at 2.54pm at Respondent No 2, I was not having any pain, fluid leaking from vagina or decreased foetal movements etc. As a routine practice, a detailed history and complete checkup ( external and internal) has to carried out, but the attending doctor ( Registrar Gynecology) at Respondent No 2 did not examined me internally ( that is per vaginally). In her notes (Examination per Abdomen in Annexure C) my uterus was found to be relaxed (that means not in Labour) but in the consent form for surgery, I was stated to be in labour (that is Rhythmic contractions of uterus). Can this be possible or acceptable to man of rational thinking?
7. . It was a pre planned surgery on part of Respondent No 1. Respondent No 2 ( also being a healthcare professional) did not bother to inquire and justify the consultant’s decision and thus supported her in this deliberately planned act of negligence and money generating Malpractice.
8. . At the time of taking consent for the surgery, the reason given to me was postdated pregnancy overdue by 7 days. I was with 41 weeks gestational age on 24.03.07 I was not convinced this to be the reason for emergency cesarean but the hype was deliberately created by both the Respondent so as to avoid me in making decision about my surgery. They put me on the Operation table on 3.05pm. Is this brief time period with so many misinformation, can allow an expectant mother to understand the so called informed consent and assent to it?

   I was made to sign the consent under undue influence

9. . In the operation theater, when Respondent No2 labeled the second opinion giver professional as QUACK, I was surprised to see the dirty politics of medical fraternity, (in which ultimately innocent patients are being victimized.)
10. . Because of her abrupt decision about my cesarean section, I was prevented from experiencing the natural bliss of being a mother, left with an unnecessary scar on my abdomen and a feeling of guilt. I suffered a lot of mental agony and stress from this incident which is supposed to be a wonderful and blessed part of every woman’s life.
11. . Now I already have two unnecessary cesarean which had further reduced my chances of having normal delivery in future. My reproductive rights had been deliberately violated.
12. . I was denied by both Respondents the duty to care (careful monitoring of maternal and foetal well being) for at least few days, owed by me. So I would have equally exercised my choice in the process of decision making about child birth , signed the Informed consent with consensus, not with confusion . At last I may have achieved a normal vaginal birth and enjoyed the motherhood more healthier both physically and emotionally.
13. . Respondent No 1 failed in her obligation to reasonably pursue the option of a VBAC birth as we had previously discussed and agreed upon. By confusing me with unsound medical information she failed to serve my best interest as her patient and failed to provide appropriate services to me as a consumer of health care.

I am working on the report for the Iranian Ministry of Health and Medical Education and the UNPFA following our mission to Iran. We will be making a number of recommendations and suggestions regarding the provision of maternity care that will include: ideas for further training for midwives and obstetricians; the development of new birth centres; the implementation of prenatal education programs; access to research evidence and more appropriate reference books; provision of simple equipment to better enable physiologic births to take place in the current labour wards; and ultimately the reconstruction of maternity hospitals.

This last goal is a long term one, but we have been told that new hospitals are being built now and we have been asked to provide some information on building guidelines and service provision in Australia to help shape thinking in Iran.

The photos below illustrate the urgency of the problem. Until conditions like these are improved, there is very little hope that normal physiological births will occur in current labour wards. The main issue is the complete lack of privacy, which affects both women and midwives alike. Everything being done is on view and while this is a major problem for the labouring woman, the midwives and obstetricians are also vulnerable to being watched over by their peers and supervisors.

The hospital in which these photos were taken is typical of labour wards in public hospitals across Iran.

This is the entrance to the labour ward area.

The nurses station in the centre of the unit. The first stage rooms are on the right and left with the second stage room on the right at the end.

There are five beds in this room. A woman is labouring in the bed on either side of the one shown, behind the curtain. There are two other similar rooms in this unit.

Once on second stage, the mother is moved to this room, where three beds, side by side, are used for managing second stage. In this hospital, which has 1,000 births per month, it is common for two or three women to be giving birth at the same time in this room.

Fathers and relatives wait in this area while the birth is in progress. It was a busy waiting room, opening directly onto the road at the entrance to the hospital. Fathers will see their new baby in the post-natal ward, where women stay for 24 hours (uncomplicated birth) or 36 hours (caesarean birth) before discharge home.

After the excitement of the obstetricians workshop and the first waterbirth in the new birth centre came a change of pace for me as I facilitated a workshop with the midwives. A group of 50 had assembled and it was great to meet many of the midwives who had been in my previous group 18 month ago. There were lots of hugs and stories to be told and I spent much of the day having my photo taken (these new mobile phones make it easy!) with old and new friends.

The workshop itself was great. I had decided that the theme would be pre-natal education, as midwives have a major role to play in this area. Since my last visit, a number of programs have been launched to begin addressing the lack of prenatal education in Iran, which is very encouraging. During the day we explored the various kinds of programs that might be suitable, their location, format and content. We also had some fun trying a number of interactive activities that could be included in a program.

This group were very animated and the level of interaction and discussion was high. They were happy trying new games and were full of ideas for improving and extending the programs they had started.

Towards the end of the day, I received a message form one of the obstetricians in the previous group - she had returned home and already started using the new ideas we had presented. In the previous 24 hours she had assisted at two births - one a primip and the other expecting her 3rd baby. Both births were spontaneous, with no oxytocin used and intact perineums in both cases. She was ecstatic and so was Kirsten when I told her the good news. The final activity in the obstetrician’s group asked them to consider how they could make changes:

It seems that natural birth is Iran is getting started at long last. Tomorrow we have a meeting with UNFPA and the Ministry of Health to map out the next steps and explore ways of keeping this momentum going.

We’ve just completed our second workshop for obstetricians in Iran. This group was terrific and we have had many animated discussion about a whole variety of birth related issues. I think the absence of a cameraman in the room has helped - Iranian women feel very uncomfortable when men are around in situations like these and are unable to fully relax when a man is present.

Once again we were hoping that a woman would come into labour at the right time and we could provide a first hand experience for this group. Luck (or Allah) was on our side and when we arrived this morning for the final day, we were greeted with the news that a woman expecting her second baby was in labour and willing to try a normal physiological birth.

Dr Kirsten Small who is travelling with me was able to assist her in the new birth room. Here is Kirsten’s account of this exciting event:

What a day it turned out to be! There was a noticeable drop in numbers given the holiday today, but the obstetricians who were there were real keen. Not long after we started into the morning word came through that a woman had arrived in labour who would be suitable for me to care for during her birth. I’m not entirely sure, but I believe that this is Tehran’s first water birth outside of a research trial.

Here is her birth story -

Her name is Maryam and this is her second child. Her first child is a daughter and the scan says this is a boy. Her husband has just finished a night shift at a factory making knitted winter clothing. It is almost winter so they are working longer hours than usual.

Her last birth was - by Iranian standards - straight forward, a vaginal birth with an episiotomy in lithotomy position. Her pregnancy has been uncomplicated, she is at term, she started contracting at 7:30 am, and her membranes ruptured spontaneously at home. She arrived at the hospital soon after and had an admission VE (standard Iranian practice) revealing that she was 8 cm dilated. She was moved to the Birth Centre area and I came and met her, while Andrea brought the group to the room with the video screen to watch the events unfold. She was obviously in transition - making the noises women make in transition. Fataneh (Obstetrician who was in the first workshop) came with me, as did an obstetrician from Shiraz who has not done the workshop, and the same midwife that we had in the previous attempt. Fataneh told me that Maryam way saying “Please Allah don’t inflict this pain on one of your creatures” or words to that effect - much the same as the Australian version of “Jesus Christ this is f&*(ing ridiculous!”.

I started by sitting her backwards on a chair and rubbing her back, sitting behind her. She was bothered that she couldn’t see me and asked them to bring a mirror so she could keep an eye on what I was up to back there! I didn’t realize what was going on until the mirror was produced and it was explained so I moved to another chair and sat beside her. That didn’t last long as she was very restless and was soon on her feet rocking her hips and clutching at us for support. Fataneh was impressed that everything we had said about transition behavior was playing out in front of her eyes.

We heard involuntary pushing at the height of some of the contractions, and she said she felt like going to the toilet. We let her try without success, but I was keen to get her back from the toilet quickly. I didn’t want our demo birth to result in the child diving head first into the toilet bowl! Her toes were now curling and I showed Fataneh the legendary “red line” - which is of course dark brown in an Iranian woman.

We had been running the bath - which was tediously slow - and as it got to about 3 inches deep she climbed in - night dress and all. She rolled onto her knees and leaned on the edge of the bath. The bath is just a bit too shallow as with it up to maximum the water level was under her introitus. So we broke one of the rules and asked her to move for our convenience - into left lateral so that all the important bits were submerged. The pushing started to get more serious, but was a perfect demonstration of physiological pushing with a fair bit of open glottis pushing (aka screaming!) and a few short grunts in between. We had a few bath “floaters” and I had to try to explain what a strainer was and how to use it for this, and in the meantime we pretended they weren’t there. We also discussed using a mirror and a torch to make easier for the observer.

After about 20 minutes in the room the head came onto view, and it was basically about 5 contractions from then to birth. The shoulders were a little slow coming with the next contraction so I reached under to the posterior shoulder (which mostly delivers first underwater in my experience), to discover the babies hand emerging beside the head. I wiggled it free and WHOOSH - we had a baby, and the promised boy emerged at 9:55 am. He was bright and alert and breathed quickly. He went straight to his mother’s arms and we covered him with a warm wet towel. There had been absolutely no bleeding into the bath so I was pretty confident that the perineum was intact.

The Shirazi obstetrician was very quickly by my side with cord clamps and scissors and was a little confused when I said no to her kind offer. After about 5 minutes I asked Maryam if she would like to move and she said she would like to lie down on the bed. I took the blasted stirrups off the bed and tried to hide them where they couldn’t find them again (I don’t think I was very effective though). I took the baby in a small wrap and helped her to the bed. The group were getting restless so Andrea took them upstairs again for morning tea.

Once on the bed I checked the cord, which had stopped pulsating so it was clamped and cut. Farah (midwife and chief hospital childbirth educator) knows that we have fathers in our birth rooms all the time, so she went and grabbed Dad and the mother’s sister who where waiting in the always crowded reception area for news, and brought them in. Dad was pretty pleased and I told him that he had a very strong wife who gives birth easily, which made them both pretty happy. They had some questions for me - where was I from, why was I here, did I have children and so on, and whether the baby’s testicles were normal (just like an Australian father would!). At one point they expressed some concern as they didn’t think that they could afford to pay the foreign doctors fee for the birth (even in the public hospital there is a fee for care). I explained that the only payment I wanted was to be able to take her picture, which was met with much graciousness.

After 20 minutes there were no signs that the placenta was imminent (physiological third stage of course). I suspected that the presence of the father was inhibiting this, as the baby was feeding well, so we asked him to step out. I had a feel of her fundus and could feel that the placenta had separated and a gentle tug revealed easy cord lengthening, so I asked her to push again and we had a placenta. There was about 10 mls of blood loss (seriously!) and of course she was completely intact. Dad was returned to the room.

I have to say I was pretty relieved, and pleased with myself and Allah that it went according to plan so perfectly. Fataneh was impressed and I think we have changed her view of birth forever today. I wrote up some notes which will be translated into Farsi for her record, and returned to join Andrea and the group to report back. It would have been good to also simultaneously have been in the room with the group to see their reactions.

At lunchtime I took a photo of my own children and my camera to the postnatal ward. Mother and baby (who is named Amir-Mahdi) were resting quietly together. You can see them together in the photo. He weighed 3650 g and was 50 cm long - quite large by Iranian standards (did I mention the intact perineum?). I asked her if this was an easy birth and she said it was. So I asked her to tell her sister and all her friends that this is the hospital to come to if you want a great birth!

While this wonderful birth was unfolding, the rest of the group was in a room across the corridor, watching the event through a video link. We were joined by various other staff who had heard that something different was happening that was worth watching. It was fascinating to observe the group’s reaction to this event. There was concern that the birth was taking its time (30 minutes in second stage is quite normal, but these obstetricians are used to going in fast, using directed pushing and fundal pressure to speed the birth, cutting an episiotomy and pulling the baby out without delay, followed by immediate cord cutting and timely stitching. Sitting and patiently waiting is a skill they will need to learn if normal births are to occur. This birth was a revelation to many of them and will hopefully encourage them to try some of these techniques themselves.

It was an amazing day for us all!

The final day of the workshop was a bit crazy. The hunt was on for a woman that we could use to demonstrate a physiological birth and while we waited for someone to appear, we got on with discussing perineums and third stage.

In Iran, women (and obstetricians) believe that an episiotomy is important for preventing later prolapse and also for better sexual functioning after birth. Kirsten did a great job of explaining how cutting the perineum would have no impact on the pelvic floor muscles or the ligaments that support the uterus, as these structures are higher up and not in any way connected to the perineal tissues. She explained that it was the prolonged, over enthusiastic “push, push, push!” style of management that could cause the supporting ligaments to detach from the pelvic bones, leading to the vaginal tissues collapsing into a prolapse. We also talked about the impact of vaginal scarring on later sexual functioning, and the other potential problems associated with routine episiotomy (excessive blood loss, infection, increased pain and discomfort for the woman in the early post natal period etc).

Third stage is routinely actively managed and we spoke at length about how to achieve a physiologic third stage including the first contact between mother and baby.

There was still no sign of an appropriate woman in labour so after a break and another round of tea, we watched the film “Inner Strength”. Some of the scenes in this film were a revelation, causing some giggling, especially the close relationship between the mother and father during labour and the couple that do a lot of kissing and cuddling (a great way to raise oxytocin levels and increase the effectiveness of contractions!). The sounds the women make were also a surprise to many of our audience. As I pointed out at the end, the outcomes we listed for birth on our first day (healthy mother, healthy baby, increased self-esteem in the woman, low morbidity, good memories of birth etc) were clearly demonstrated in this film - this kind of immediate feedback that occurs in a natural birth requires no further exploration - the outcomes are obvious.

Just after morning tea it was discovered that a woman having her second child was in labour following a spontaneous onset. She was about 4 cm dilated with intact membranes. It was decided to offer her the chance to give birth in the new birth centre and she was moved to this area. A relative who works in the hospital was located as a companion (she got bored and didn’t stay in the end). Kirsten went to meet her and with the aid of an obstetrician and a midwife began the process of getting to know her.

The labour was not very well established and of course had slowed due to the transfer to hospital, so the group, who had been watching through a video link in an adjacent room decided to go and look at the area where the prenatal classes take place. Here are some pictures of the class rooms:

The exercise room.

Sign on the door of the video room for watching DVDs etc.

Each session concludes with a relaxation session on this carpeted area.

After lunch, the mother was still just labouring gently. She had been in the pool for a while, which she reported to be very soothing and was walking about. It was decided to carry on with our program, and although some people had left to catch flights back to the provinces, we looked at ways of achieving change in hospital settings and what would need to be done to implement physiological birth in hospitals. I also set out a selection of the wonderful Fotoset images for them to talk through.

Just as we were having our afternoon tea, the word came through the woman was now labouring well and would be getting back in the bath soon. She was 6 cms and powering along. Unfortunately, Kirsten and I had to leave to catch a flight to Isfahan for the weekend, so very reluctantly we left her in the capable hands of a midwife and supportive obstetrician. We will be very keen to hear how she gave birth when we return to the hospital next week for the next workshop.

Meanwhile, we have a couple of days off to explore Isfahan, a jewel in the crown of the Persian Empire and a city considered one of the most beautiful in the Muslim world.

Today was a very productive day at the workshop. We spent a lot of time exploring the practicalities of natural labour versus managed labour, challenging some entrenched practices and applauding some good management strategies.

On the plus side, pregnancy care is comprehensive and up-to-date and epidurals are rarely used in labour for easing pain. The hospital we are in has been designated as Baby Friendly since 1992, which is terrific. On the minus side, the induction and augmentation rate are at almost 100%, as hospitals struggle to manage large numbers of women through overcrowded, shared labour rooms. No privacy, shaving, enemas, restrictions on food and drink in labour, lack of a birth companion, routine episiotomy, lithotomy, and frequent separation of mother and baby at birth are common in all labours.

We spent time trying out comfort positions, using a chair, birth ball, and mat, the only equipment that would fit in the available space in most first stage rooms. Ideas for managing posterior labours were tried out (again not easy due to the coats and hijabs) and we explored how hot water in the form of wet towels could be utilised to ease labour pain. Most hospitals have no baths and showers are in short supply. Hot packs and hot, wet towels are a simple substitute.

The implications of the active management strategy being used here were also examined in detail, first using the “cascade of intervention” activity from the Essential Educator Kit and following up with group discussion around reasons for induction.

Second stage involved talking through normal physiology and demonstrating birth positions.

Here are some photos that Kirsten took yesterday and today:

Front entrance to the hospital with an orange banner announcing the new prenatal classes they have set up for pregnant women.

Workshop participants

Demonstrating how the pelvis works

The new labour and birth room. This room is not quite finished, and is due to open next week. The pool is terrific and there is plenty of space in each of the two birth rooms. An en-suite toilet and shower are also tucked into a corner. The lighting is very bright and will be replaced with dimmable lights (we were assured) and the flimsy plastic curtain separating the two rooms is to be replaced with a door to give better privacy.

The plan is that tomorrow we will try and facilitate a birth in this area as a demonstration to the group. We are hoping that a multip will be available in labour and be willing to give birth in this new area. Kirsten will supervise a couple of the midwives who will assist the woman, while a video camera feed to an adjacent room will make it possible for the large group to see what is happening without disturbing the labouring woman.

We also saw the regular labour rooms today, but were asked not to take photos. It was a dismal, old, cramped area with conditions that would be unimaginable in any hospital in Australia. There were three first stage rooms each with either four or five beds close together, with no curtain to provide even a modicum of privacy. In second stage women are moved to one of two rooms that have three delivery beds side by side in each. This is a Baby Friendly Hospital so at least mothers and babies are not separated at birth and spend either 24 hours together before going home (vaginal birth) or 48 hours in the hospital following a caesarean.

Tomorrow will be most interesting - I wonder if we will be able to show these obstetricians how natural birth can be achieved?

For the next two weeks I will be in Iran, once again facilitating workshops for the Ministry of Health. There will be three workshops, two three-day events for obstetricians and a one-day follow on program for the group of midwives I worked with last year.

I am travelling with Dr Kirsten Small, an obstetrician based at Selangor Private Hospital in Nambour. I was asked to bring a woman obstetrician with me this time as the main groups would be all doctors, and Kirsten was an obvious choice. Her role is to cover off the evidence that supports natural birth and to challenge re-thinking the standard obstetric approach to birth, which includes shaves, enemas, lithotomy and episiotomy. Inductions or augmentations are also routine and the caesarean rates are very high.

The first program began yesterday. We were lucky with the unbelievable traffic and actually arrived early, which is considered very bad in Iran. If you are early you clearly have nothing better to be doing, even at 8.15 in the morning! The group was about 40 people, and included some staff from the Ministry of Health as well as the obstetricians. After the opening ceremony, we got down to work.

We began with introductions. Each doctor told us where she was from, how many births they had in their unit and their caesarean rate. It is astonishing to hear how many maternity units have 1000 births per month - almost all were over 600 per month. The caesarean rates they quoted were for emergency surgery and averaged 30 - 40%. I am sure they were not including the elective caesareans in this number as the overall figure I know is around 60%. I think there was some under quoting going on as well.

Then came agenda setting. This was not an activity they were expecting, but we wanted to know what was important for them to discuss, and we made a list. The usual topics were there, including legal issues and changing women’s attitudes. It was clear they felt they were only doing what the woman wanted - a quick and painless surgical birth just like everyone else has experienced!

We ploughed on to explore the outcomes they wanted from births (healthy mother, healthy baby, low mortality, low morbidity, increased self esteem for women etc) and then I asked them to list the methods they used to assess whether these outcomes were being achieved. This was difficult for them as they hadn’t really thought beyond the statistical collection that is compiled and the feedback from women at the 7 and 42 days post natal visit.

Kirsten then presented a lovely slide presentation on natural birth, using some of Lynne Staff’s birth photos and some of her own. There were gasps at the end when one of Kirsten’s beautiful slides appeared on screen of a mother breastfeeding her baby, sitting on a birth stool, with the cord still attached and a second twin emerging by the breech.

Following this came a small group exercise to explore the role of the obstetrician, midwife and mother in achieving a natural birth. There was confusion all round as I used the colours of the rainbow to form small groups (”what is ‘violet’?, what colour is indigo?” etc) but eventually the group work got underway and ideas were accumulated.

The pelvis exercise was tackled after lunch. A large Persian rug (of course!) was rolled out on the floor and I was able to persuade most of the group to join me in exploring how the pelvis works. They were shy and I must say is wasn’t easy with everyone in full hijab, and with long coats over their clothes. Still, the message was conveyed and they were interested to discover how positioning can prevent or solve potential problems.

To consolidate the message I showed the second part of “Giving Birth, Being Born” which describes the cardinal movements of the baby using animation, the benefits of upright postures for labour and birth using clips from actual labours and clearly shows women giving birth without shaves, enemas and drugs.

It was a full day and we were all exhausted at the end. We battled back to our hotel through unbelievable traffic chaos (think dodgem cars writ large with stray pedestrians in amongst the moving mass and you’ll get the idea) and set about fine tuning today’s session.

At the start of the day we were confronted by a large mass of black shrouded women, looking grumpy and unwilling to be there. By the end of the day there were some smiles and nods happening and I could see a distinct softening in their attitudes and approach. Today we’ll concentrate on more of the practical measures they can use and tackle keeping women off the bed. One comment yesterday was that if women got off the bed and walked around in labour there would be “no way to control them”!

We are also hoping to see the labour rooms in the hospital toady as preparation for a planned activity for day three. We’ll take some photos and I will include them in my next report.