Articles by Month: November 2007

Labour wards in Iran

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.

Posted by andrea at 08:50 AM

Midwives workshop in Iran

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.

Posted by andrea at 11:02 AM

Waterbirth in Iran

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!

Posted by andrea at 02:30 PM

Childbirth education in Iran

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.

Posted by andrea at 04:01 AM

Obstetricians workshop

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?

Posted by andrea at 01:06 PM