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.
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