Found this lovely story today

Dear Diary,

It has been a great week... starting with a baby last Sunday and leisurely postnatal care since. Breastfeeding is going well, the baby is gaining weight and I've had the privilege to witness at close hand a family integrate and welcome a new family member.

Last Sunday morning the call came in… not that I was aware of it as the night before I had gone to the movies with the expectant couple and had turned my phone volume down to avoid interruptions, and completely forgotten to turn the volume back up. On-call midwife no-no of the biggest order… thankfully with no serious consequences, but I have learned my lesson, and it won’t be happening again.

Neither the text saying things had started, but nobody was needed yet, nor the four phone calls that followed over the next couple of hours woke me on that glorious Sunday morning: one call from the doula; two from the dad; and one from the mother… Instead it was the knock on my front door from Kabir (the dad) that woke me up. I answered the door, half asleep, and he told me that things had started but they weren’t in a hurry… come over but take my time. I was in the midst of my morning routine, wondering why Kabir had come over and not simply called, and somewhere between making coffee and getting in the shower I checked my phone to discover the text and four missed calls… and only then did I realise that my volume was off, and had been since the night before… Wow!... I felt terrible. Really bad that they had been calling me and must have been worried as to why I hadn’t picked up. Really bad that Kabir had, had to come to me and knock on my door. Really bad that I hadn’t realised when he had come over, and hadn’t apologized immediately.

I was just out of the shower and about to drink my coffee when the doula called and said the waters had just released… no time for coffee… I jumped on my scooter and was at their house in a few minutes… luckily I’m living just down the road. I parked my bike still feeling bad… took a few deeps breaths and let it all go… no need to take that stress and feeling bad into the birth room… I could apologise later… I walked up the stairs breathing in calm and allowing myself to come fully into the present moment and quietly entered the birth room.

Layla and Kabir had planned for two close friends to be there to film the birth – Guy acting as cameraman, his partner Lotta as doula. I had been a bit nervous about how this camera presence might effect Layla and her labour, and how two people, never present at a birth before would add to the energy in the room… but when I arrived I could see that it was all fine… more than fine… Layla was deep into her flow in the pool. Guy was moving around with his camera – getting different angles, but she was hardly aware of him… she was already deep in the zone, and Lotta was perfectly tuned in. I organized my things, and felt into the calm, quiet, space - slowly and consciously adding my energy and my presence.

After the next contraction I listened in to the baby with the Sonicaid (Doppler) . All sounded well. I was grateful this baby had chosen a day time birth-day, as I had been worried about the lights that Guy had said he needed for filming, and how that might intrude on the much-needed cosy, dark space… but with daylight streaming through the windows the additional light they had made little difference. Their Indian landlady who lived downstairs was helping out, and she put a pot of water onto the boil so I could sterilize my instruments. They had organized a cloth to hang from the ceiling and Layla would move to her knees and hang on it during a contraction… moving back into a seated position leaning against the edge of the pool when the contraction faded. Lotta was feeding her morsels of fresh watermelon, Kabir was whispering words of support and encouragement into her ears and I was listening in to the baby and checking the water temperature.

Soon after arriving, Layla was pushing at the height of contractions, and when she knelt and hung from the hanging cloth, I could see a purple line extending from her anus and extending up between her buttocks… the infamous purple line, not visible when a woman is on her back, in a semi-recumbent position, but with Layla so mobile and getting on her knees to push I could see it very clearly. The rhombus of Michaelis, (written about by midwife Jean Sutton in an article in the The Practicing Midwife in 2000, which I don't have access to, so can't share with you, but is called: Birth without active pushing and a physiological second stage of labour), was also visible and I pointed it out to Lotta quietly so she could also observe the marvel of a woman’s body in action… those little telltale signs that labour is progressing and the baby is descending. No need for an internal examination when the body is communicating so clearly. To read more about this, Sara Wickham wrote a great piece for the Practicing Midwife, based on an interview with Jean Sutton, that you can read here (http://sarawickham.com/…/…/tpm8-the-rhombus-of-michaelis.pdf)

A little while later, Layla whispered to me that she was pushing, and did I think that was ok. I had a choice here… in antenatal visits she had said that she might want a VE to see how she was doing for reassurance that her cervix was opening. She had explained that since her last baby she had done a doula training and learned that sometimes women can have contractions that are not actually opening their cervix. I had explained how I generally prefer to stay away from VEs unless clinically indicated: like an obvious delay or lack of progression - a labour pattern that doesn’t seem to be changing, contractions not increasing in frequency, strength or duration, a woman who stays very chatty and does not seem to be going into the zone; or a query about baby’s position; or needing a fuller clinical picture for whatever reason; or early labour at a woman’s request. But that if all was well I preferred not to do an examination that usually resulted in an interruption of labour flow.

Choice time… Should I offer a VE even though I did not see any reason to do one?... Labour was clearly progressing... Or should I do what I thought was best? Since she hadn’t actually asked for a VE, I decided to wait and see… if she asked for one directly, I would oblige, so instead I encouraged her to listen to her body and trust what it was telling her:
“See how you feel not pushing. Try it, but if your body takes over and is pushing anyway, then trust that.”

Layla fell back into her labour trance, and with the next contraction was on her knees hanging on the cloth and pushing again. She never asked for a VE or any further reassurance… she was well in the zone. As we had discussed antenatally she kept a hand between her legs as the baby was descending and starting to crown, applying counter pressure as she needed… so I couldn’t see anything for a bit, till the crown of the baby’s head was getting bigger. She was very vocal and making incredible noises – instinctual, primal and loud. She looked at me suddenly, eyes wide open, almost afraid:
“Everything is burning.”
“I know - it’s intense. That’s your baby coming. Behind that burning is your baby in your arms. Do this bit nice and slow. Use your hands to control the head so it comes out nice and slowly.”

Crowning happened slowly and gently, and Layla controlled the delivery of the head beautifully. And then, just like that, the head was out. Layla looked beautiful – flushed, radiant and with that special look of wonderment that women have as they realize that there baby has just been or is about to be born. Time stood still. I checked my watch - a minute had passed… I breathed deeply and looked around at the expectant faces: total quiet and focus in the room… another minute passed…
“Layla. With the next contraction I want you to give a really big push. Ok?”
It was my gentle but firm midwife voice. I checked my watch again – three minutes had passed and not a contraction in sight. I asked her permission to feel if there was a cord around the neck – she nodded, and I checked – nothing. Another minute passed, the baby’s head had been out for four minutes now, and I was starting to get nervous, if the baby was stuck and we had to start doing manoeuvres we had already wasted four minutes waiting for the next contraction. I couldn’t see the baby’s face as it was facing towards the bottom of the pool, but the head looked a good colour. I asked her if I could check for shoulders – she agreed, and I popped my fingers down past the baby’s head, and swept them in all directions, but couldn’t feel anything holding this baby up. I breathed again and reminded myself to stay calm, and then at four and half minutes, the next contraction finally came,
“Nice big push now,” I said as I reached down and helped guide the baby out of the birth canal as she pushed. I was quick to remove my hands so Layla could lift her baby out of the water as she had wanted.

Four and a half whole minutes at the perineum… five minutes from the birth of head till the full emergence of the baby… what was that baby thinking? Relief flooded my body and I could feel the tension that had accrued in the five minutes of watching and waiting leave my body. A gorgeous baby girl – incredibly alert, and great tone, but had not yet had a breath – I asked Layla to turn her around so she was facing outwards and her body could open fully and lungs expand. That did the trick and she gave a small cry and gained an extra point for her 1 minute APGAR. Over the next few minutes her tone remained good and the cord was still pulsing but she was still blue-ish and had not yet another cry. It was as if all her attention was on life on the outside and she had forgotten that she also needed to breathe. I gently asked Layla to give her a couple of breaths – we had already discussed that sometimes babies need a little extra help breathing, and that this can be normal, so she was not concerned. That did the trick - the air from Layla’s mouth went straight into the baby’s small lungs, she started to cry and was nice and pink in no time. After that she was breathing just fine, but still not crying much – a gentle arrival and now in the arms of her mother, both of them still in the warmth of the pool, there was nothing to cry about really.

After some time of bobbing her head and thrusting it against Layla’s arm and breast, she found the nipple she was programmed to look for and self-attached. It is such a wonderful thing to witness, but not something most midwives see very often.
Us midwives can be impatient creatures of habit, and unfortunately working in certain environments can add to this. Working in hospitals and birth centres where the focus is on efficiency, cleaning the room and departing from it to the postnatal ward as quickly as possible; getting the baby latched is just another task to tick off on the long list of postnatal jobs. Newborns are operating on a totally different time frame to us… man, they’re slow… and watching a baby try to self attach can be almost painful to watch…. so slow, so inefficient… almost there… but not quite… no that’s not the nipple… that’s not even the breast… most midwives just want to help… and they do… positioning the baby, holding the breast, tickling baby’s nose with the nipple, so they open their mouths wide and then with a deft and experienced movement getting the baby on. We just want to help. But if you can sit on your hands, and bear to watch the slow and almost agonizing unfolding of a baby nuzzling, bobbing, grasping, missing, trying again, and then again and then finally at some point getting it, it’s a beautiful thing to witness. Working as I do, there is no rush… not before the baby is born and certainly not after. I have come to love watching the oh-so awkward dance a baby does trying to find the nipple.

Since the blood loss had been minimal, I was happy for Layla to stay in the pool for the birth of her placenta. I sat quietly by the edge of the pool… watching her and the baby. Baby was well, parents were ecstatic, Layla was radiant, and the water of the pool was still the same colour since the baby had been born, which meant she was not bleeding into the pool. About forty minutes later, Layla started to move her bottom around a bit looking slightly uncomfortable, and I knew it was probably her placenta. When the next contraction came I suggested she push and at the same time pull on the cord gently. She did this a little but said she felt some resistance, so I followed the cord up with my fingers and could feel that the placenta was just sitting there at the top of the vagina. I reassured her that the placenta had detached and she could pull gently, and would be so much more comfortable once the placenta was out. She had not enjoyed her actively managed third stage last time, and remembered it being uncomfortable and therefore seemed a little resistant to proceed. She tried pushing and pulling with the next contraction, and I offered to help. With the next contraction, while she pushed I gently pulled and a couple of minutes later we had a lovely placenta birthed and I plopped it into a bowl so it could float in the pool.

Yup… you read that correctly: I gently pulled on the cord during a physiological third stage. And yes I usually do. And yes, I know that we’re taught not to.

It’s funny this business around physiological third stages… what I was taught as a student both in theory and by most midwives in practice is that when you do a physiological third stage you are COMPLETELY HANDS OFF. Bear in mind that most of these midwives were not used to doing physiological third stages… hardly ever… even in low risk women… and I know this for a fact, because one night at the stand alone birth centre when we had no laboring women, I read through the entire birth records book where all the details of labour are recorded and there were VERY FEW/HARDLY ANY physiological third stages recorded… most women, despite being low risk enough to birth at the centre had their shot of syntocinon for an actively managed third stage.

However, what I have learned since through seeing and doing is that a little bit of help can speed the process up and reduce the work for the mum. I only did seven physiological third stages during my three-year training, and as I said, most of these were with midwives who were not very experienced, and therefore not very comfortable with them. One shift I was working with a midwife who did lots of physiological third stages, and once she was sure the placenta had detached, she started pulling gently on the cord as the woman pushed. Afterwards she guiltily told me not to tell anyone what I had seen, as we are supposed to be hands off, but in her experience a little pull helped. I had recently seen Cecily Begley present the 2012 MEET study (Midwives’ expertise in expectant management of the third stage of labour) at The Royal Society of Medicine, and had already heard about the gentle pulling on the cord to help the placenta out, and reassured my mentor. In the study (that I suggest you read), they interviewed 27 midwives experienced in facilitating physiological third stages (what they called expectant management) and 26 out of 27 of these midwives talked about giving a little pull to help the placenta out once it had fully detached. What I then saw with other midwives, who were completely hands off, was a whole lot of waiting and often interruption… remaining hands off meant getting the mum into different positions to help with gravity, getting her to blow into a closed fist and generally disturbing the bonding with her babe. What I had seen with the midwife who had guiltily told me her little secret, was that we disturbed the mum a lot less, and we had a placenta much sooner. In the physiological third stages that followed I wondered about the full hour it usually took to get the placenta out with other midwives, I wondered how long it had actually been sitting there detached, and how much sooner we could have had it out, with less disturbance if we had given a gentle pull. In cases where the mother wanted to change position, or move, or go to the toilet the placenta did come of its own accord much sooner… but in the instances where the mum was happily bonding with her baby where she was, it seemed a pity to get her to move.

Just before I qualified I went to the annual Birth Gathering and the lovely Becky Reed (of the Albany Practice), gave a brilliant presentation about how they managed physiological third stages of labour with the women in their practice… basically, once they’d seen the signs of detachment, they suggested that the woman guide her own placenta out, by gently pulling on the cord. here it was again: gentle pulling during a physiological third stage! The thinking being, that no woman is going to invert her own uterus, which of course makes sense - she is not going to pull too hard since she can feel what is going on inside her as the placenta comes down. But actually, nobody is going to invert a uterus if the placenta has completely detached and is sitting by the cervix or in the vagina. The art is in knowing that it has fully detached. So Layla’s birth was the first one where I got to try putting Becky’s experience into practice.

But let’s be clear: I’m not suggesting that mixed management of the third stage is a good idea… we have studies to tell us that this is not a good idea at all and can have disastrous results. I’m not fiddling with the fundus or doing controlled cord traction or pulling hard on a placenta when oxytocics have not been administered… But what I am suggesting is that we as midwives continue this conversation, so we can better serve women. It seems silly that so many midwives experienced with physiological third stages are secretly and guiltily helping the placenta out… doing ‘good by stealth’, but not adding this knowledge and experience to our shared wisdom and body of knowledge. I’m not sure that maintaining that a physiological third stage must be completely hands off is helpful, when a little bit of help at the right time, can so often clearly helpful.

If you are a midwife or a student midwife, please read Begley et al’s 2012 MEET Study, and let’s get talking, and thinking and learning. Certainly what I’ve learned by seeing and doing is to carefully help once I know the placenta is detached. Why wait for a placenta that is detached and sitting in the vagina? Why disturb a woman who is happily bonding with her baby and get her to move about in various positions so gravity can assist? ... So, if mum and baby are fine, I’m sitting close by and watchfully waiting… I’m not cleaning up or doing other tasks... I’m monitoring blood loss and carefully watching to see how the mum is feeling and behaving... a) so I know that there isn’t concealed blood loss behind the placenta that I can’t see, and b) so I catch the signs of detachment – maybe a gush of blood, but maybe not; maybe the cord lengthening, but again, maybe not - this can sometimes be hard to see when the baby is still attached to the cord; often however, the woman starts to look a teeny-weeny bit uncomfortable and if I’m watchfully waiting, I catch these signs, as as cramping starts up again or she shifts her bottom about, and I can reassure her that it’s now time for the placenta… Why?... Because this discomfort and heavy feeling usually indicates that the placenta has detached and is sitting at the cervix or come down into the vagina. And in terms of watchfully waiting, it gives me the opportunity to sit comfortably after being in all sorts of contorted and uncomfortable positions throughout labour and catch a breath and witness the utterly delicious time of meeting and bonding - a real perk of the job smile emoticon

As we know, midwifery is both an art and a science. But it seems that these days in the medical model, midwifery and birth have been boiled down to science only. We’ve lost and are losing so much of the art – vaginal breech; labour care and assessing progress (without routine VEs); working with the fetal ejection reflex (instead of directed pushing at full dilation of the cervix); physiological third stage of labour, and sadly the list goes on. What I’m suggesting around our third stage practice is indeed about art rather than science. I suggest it's time we got creative.

 

A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 14

Day 14 – Homecoming

 

And so at the end of the day, 14 days after I arrived scared, worried, and wondering what the near future had to offer, my time here in Karachi, Pakistan has drawn to a close. I am awaiting my transport to the airport; the much loved and trusted Muna will take me back to the place where we first met. It’s late at night and Sofia is asleep with her two babies. The beautiful new baby girl is to be named Lily May.

 

“She didn’t stop until she proved all of those, and more, that she could and would have her right of passage.”

 

Am I please to be going home? Oh yes, for sure I am excited and relieved that the day has finally come. I can’t wait to snuggle up with Sean and see the rest of my family. But am I glad I came, did I have a good time? Yes, I did. Am I upset to be leaving this wonderful family, this amazing contradictory country? Yes, I truly am. I met a wonderful, strong woman and her mother who showed me how hospitality should be done. I have met so many strong women when it comes to childbirth over my years as a midwife, so many who have fought for what they want in a country where normality and midwifery is the norm. But when you have a whole family, a whole society, and what appears to be a whole medical establishment to fight, most women would have given up. Not Sofia, the pocket rocket of just 21years old. She didn’t stop until she proved all of those, and more, that she could and would have her right of passage.

 

She took Lily May outside today to show her off to the staff and I could feel the pride in what she had achieved just oozing out of her. With her newborn baby girl in the sling and little Ebo on her hip I knew the love this little family had would see them through life’s tough times.

 

 

Dr Azra came by today. She had said she would help Sofia with obtaining a birth certificate, and once more we discussed what is so wrong with childbirth practices. She asked if I would come and speak to the teachers who teach the local lay midwives. Of course I would love to do something like this, but as I explained the problems is I have a mortgage to pay in the UK. Without hesitation she replied that she could put some sort of package together so I would be paid! Wow! I will certainly be keeping in touch with Dr Azra.

 

“It was as if she had been in on the full home birth plan anyway.”

 

We discussed Sofia’s homebirth, and although we had never been fully open about the homebirth being an absolute plan and instead had focused on “staying at home as long as possible”, our discussion appeared not to acknowledge that. It was as if she had been in on the full home birth plan anyway. She told us that many of her colleagues had given her a lot of flak for supporting Sofia’s birth plan (the one where Sofia had written “I do not consent to bla bla bla” all the standard interventions for a VBAC) so I say “Good on you Dr Azra.” I wish we had more doctors like her, and even more midwives, standing up for women’s’ informed choices worldwide.

 

We took some great photos of us all and we certainly look the A team in them, or maybe that should be the P (Pakistani) team. Right to the bitter end Muna and Sofia made sure I was neither bored or lonely and today they wanted to make sure I had missed nothing. So after a spot of lunch brought to us by the sweetest, ever-present maids; Rumi and Sunia, it was time for Muna to take me on our last excursion. We were off downtown to the market. On the way I was quite surprised to see lots of street sellers with huge hordes of valentines balloons! Of all the western cultures to hit the 3rd world, and one is red heart helium balloons on February 14th. As I knew Sofia would not be getting a Valentine this year I asked Sharif to pull over so I could buy her one. It was 50 Rupees (38 pence).

 

 

We arrived at the market, which was indoor, and housed many stalls filled floor to ceiling with fabrics. An amazing and abundant display of brocades and silks, cottons and chiffons. Each stall was like a mini theatre with stall keepers literally elevated on a stage displaying their wares to an audience of excited women sat on chairs facing them. I would have love to have purchased loads of the wonderful fabrics but using a needle is not one of my better skills!

 

 

After our outing I had to do the rounds of saying goodbye to people, and the first was Sofia’s grandmother (the baby who was born in the Caul). At 88 she is frail but she is sound of mind and has a lovely heart. She gave me a gift of a beautiful 2 tone soft cashmere pashmina, and it is not one of the cheap imitations either! The hug I gave her was genuine with affection and I was sad to think I would never see her again.

 

 

Back home Sofia gave me the glad news that her baby had finally had her 1st meconium poo which we had all been waiting for. I had already done her first day examination to check her hips, eyes and heart, so Sofia had no need to rush off to see a paediatrician any time soon. With all boxes ticked I was now content to go. The time had almost come. Just one last thing to do…

 

I wanted to see where this huge amount of food went that the family chef cooked every week. So not only was the boot loaded with the latest hot pot, but I contributed a huge amount of oranges for the grand price of £3 and jumped into the car.

 

 

Muna, as always, at my side, I was glad of her company when we arrived at the orphanage to deliver the food because the area felt anything but safe. Although we had two male staff members with us, Sharif and the chef, it still felt sinister when we stopped in a dark street hardly bigger than an alleyway and several males were hanging around. Then orphanage was really two apartment blocks; one for girls and one for boys; and although it was painted in bright colours it was pretty bare except for sofas and beds. There were no toys, books or games, and no TV from what I could see, but the kids were healthy and very happy to see us. Muna asked them about their backgrounds, and many still had at least one parent, but the common problem was that the parents could not feed them. One brother and sister had a mother who had re-married and there was not the choice to keep the kids. The ages ranged from 3 to 17 and all the kids went to school. Two of the older girls were even planning high school and university educations. This particular orphanage was set up by an English woman, and is run purely on donations from the communities.

 

 

Back home and dinner was with the whole family, including Azaan’s mother and aunt. It was probably the only meal I didn’t enjoy for the whole time and that was because it was a take away! All the lovely home cooking has spoilt me! Azaan presented me with another beautiful local fabric made wrap and said it was tradition to give such a gift to the person who had helped deliver your child. I was touched and honoured to receive such gratitude.

 

And now here I am and it’s over. My case is packed, the room is bare and all that is ahead of me is a long night’s journey…

I am coming home!

A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 13

Day 13 – Showtime

 

Last night we wound down with a very relaxed but also exciting evening of Henna tattooing. Sofia had said we need to be home by 6.30 because someone was coming to paint her belly. In the morning we had been ‘ooing and arhing’ over all wonders of artistic designs on pregnant bellies which Sofia found on the internet. I was expecting a grand artist to be coming, so was somewhat surprised therefore to find that it was Rumis’ daughter Fatima who was going to be our artist of the evening. Fatima is just 12 years old! I was doubtful that some of the intricate art from the pictures we saw could be replicated by such a young child. However, I have been delightfully surprised by many things about my time in Karachi and Fatima’s artistic skills were just one more such occasion because, boy oh boy, is she clever. The beautiful floral and bird design flowed up around Sofia’s pregnant bump all the way to between her breasts. Sofia was like an excited puppy dancing around showing off her new funky baby belly. We took lots of pictures and no woman could have appeared prouder of herself than this happy mum to be.

 

 

And so another day in this strange and interesting country was falling to a close. I felt tired and decided to take to my bed and try to sleep a lot earlier than usual. So 10.30pm saw me winding down and almost ready to fall asleep.

 

However, day 12 was determined to end on a bang and day 13 to be the ultimate day, the climax, the reason for me being here. The baby was on its way!

 

The long awaited knock came at approx. 11pm. I jumped up out of bed in a nanosecond and opened the door to find Sofia in a state of nervous excitement, “I am having contractions, it’s just started what do I do?” she asked. I lead her to the sofa and asked her to remember all the talking we had done. I reminded her that this could all stop, that it was early yet and could potentially go on for quite some time. Eventually, after lots of reassurance, I went back to bed, only for her to knock just 40 minutes later to tell me that water was running down her leg! It didn’t take long of observing Sofia for me to know that this labour was coming on fast and I was not going to be getting any sleep. Instead I cleaned my teeth, pulled on some clothes and began to do what I do best. I was once again in my element and supporting a woman in her hours of need.

“The room was filled with positivity, with love, with oxytocin, and with belief.”

 

All worries about us being in another country, Sofia having had a previous caesarean section, about post-partum, resuscitating babies and shoulder dystocia floated away to the back of my mind to be replaced with calm confidence and strong belief in the process that was beginning. I had done my skills drills in my mind over the preceding days and had all safety plans in place. I knew Sofia was making fully informed choices and we had mutual trust and a strong bond between us. It was going to be fine. There was no room for doubt, no room for worry. The room was filled with positivity, with love, with oxytocin, and with belief. There was only left for a little more love to enter the room, and that love would be bought by the two people yet to know that labour had begun, Azaan and Muna.

 

As Sofia called to be doused with ice water all over her body, to bring comfort from the heat-filling surges of power that were rushing through her body, I observed that labour was progressing fast. I could see, as she lay over the sofa with her back to me the Rhombus of Michaelis bulging proud, and as I massaged her back I could also spy the telling pink line of progress creeping up between her buttocks. I dialled Muna’s number from Sofia’s telephone and in turn she called Azaan to come too. Sunia, who had roused sleepily from her bed was, as per the plan, filling the pool. However, one glance at the ever deepening water and I was off in my mind arguing with myself about what I thought. The water was not the clear, crystal see through depths I was used to in the UK, but instead it was a murky yellow colour. Did this mean it wasn’t clean? Was this a problem for birthing the baby or was this just normal for here? I suddenly had horrible thoughts of a baby with legionaries disease flitting though my mind. Oh dear what to do?

 

“The Entonox we had fought so hard to find was some comfort to her.”

 

Sofia started to get expulsive whilst laying on her side on the sofa at around 01.30, and was just a little distressed. The Entonox we had fought so hard to find was some comfort to her, and she sucked on it during every contraction. Afterwards she said she was glad of the Entonox mask because it muffled the noises she needed to make and that helped her not worry about little Ebo hearing her. Once a concerned mother, always a concerned mother!

 

The ice cold flannels were giving her lots of comfort and she continued to ask that they be put all over her body. I looked over at the warm pool and thought she probably wouldn’t enjoy it anyway. However, she wanted to try it and so we helped her into the murkiness.

 

 

Unfortunately for the doubts and worries in my mind concerning the water quality, she found it to be heavenly. A vaginal examination in the pool found Sofia to be already 9 centimetres dilated. Wow! “I never got past 2 last time” she cried with a delighted smile on her face. She continued to be expulsive and I continued to fret about the water colour. I had taken my birth mirror all the way to Pakistan, but there was absolutely no chance of it allowing me to see if the birth was imminent in the yellow murky water. I was worried the birth was close, and by now the water issue was a high priority in my mind. I wanted to get her out of the pool! Sofia had now been pushing strongly, albeit prior to being fully dilated, for around 2 hours so I suggested “a change of position may help baby come down, so how about a quick walk around the room?” Sofia agreed happily, and out the murky water she got to my instant relief.

 

"Baby was gently born into my waiting hands at 04.16.”

 

A supported squat showed baby’s head clearly visible with a black mop of hair. It was now 03.35, and Sofia asked me “how much longer?” That typical, asked a million times over by women in labour, question. I felt confident to tell this brave woman that it would be minutes, not hours, before she would hold her baby. After a few supported squats Sofia wanted to lay on her side on the floor, and did so for the last bit of birthing her baby. As baby was gently born into my waiting hands at 04.16, I noticed a tiny hand up next to a shoulder, a hand that Sofia and I had regularly massaged up and away from the pain it had been causing in Sofia’s pubic bone in the last few days of pregnancy.

 

 

As Sofia reached down to receive her healthy baby daughter, her emotion was raw, and I could hardly see for the tears that coursed down my face. Within just a few minutes the placenta was also born with ease. No woman could ask for a more perfect birth. There was no damage to her perineum and no bleeding, just prefect physiology and a whole room full of positivity and love. There were tears and sobs from Muna, and Azaan too wiped his face as he was gazed on in wonder. It was an experience he could never have imagined, especially after the last traumatic birth of Ebo.

 

 

What a start to day 13, not unlucky in any form for this delighted new mother, her midwife and her very supportive wonderful mother Muna. We really were the dream team!

 

“Just like Mary Poppins the wind has changed and I am no longer needed.”

 

The end to day 13 was somewhat different to the exciting beginning. We all sat around lounging and eating snacks and sweets bought and prepared by the extended family and a few visitors who popped in to congratulate the new family. We let Dr Azra know that baby was born and all was well. She was delighted, and said she had been hoping that it would all go to plan and Sofia stayed home! She has offered to come and visit tomorrow so she can say she has seen Sofia and baby, which means she can sign paperwork and get a birth certificate. So now just like Mary Poppins the wind has changed and I am no longer needed. My job is done and I must think about leaving….it seems strange that after all this waiting and wondering that in the blink of an eye it is over. I don’t quite know how I feel about that.

A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 12

Day 12 – Reflections and Relaxation

 

I really had high hopes that after the lovely relaxing and laughter-filled day yesterday, that last night I would get a knock on my door. However, I have to be patient as I always tell women and accept that baby will come when she is ready. Sofia did tell me this morning that she had been aware of cramps during the night, so at least we are getting some positive signs.

 

Last night I finally finished, not only 2 seasons of Game of Thrones but also all my caramel eggs have now been, most enjoyably, eaten! So now both my milestones have come and gone. I am just praying now to my birth angels that the next milestone, my birthday, will not come and go with me still here and still waiting, because by then I am sure it will not be quite so patiently. The good news, however, is that when I told Sofia that my night watch ING (bit of a pun there on night watch MEN, for those readers who are Game of Throne fans) had come to an end, she instantly made a phone call and, hey presto, within 15 minutes’ series 3,4 and 5 were delivered to the door. There are some benefits in countries where the rules are not always the priority.

 

 

Talking to the maids about their experiences of childbirth is both amazing and shocking. Rumi has had 4 children, 2 of which she had at home and 2 in a village hospital. The two she had at home sound as if they were easy, straightforward and, most interestingly, the things she says and advice she gives to Sofia are spot on. Like walking and squatting cuts the pain and how hot water makes the milk flow from the breast and the baby flow from the body. She talks about those births with so much instinct and control. She describes how she knows that when the pains come close together the baby is close as well and that she removes her knickers just at the correct time.

 

“Woman’s rights in childbirth just did not exist, let alone basic compassion or respect in many places.”

 

However, as soon as she talks about her hospital births (don’t read “hospital” as anything you may have seen in the west) her whole manner changes and instead she talks about what she was allowed to do and what they told her was happening. How “they” know best because she knows nothing. It upset me to hear that they make the women remove their clothes and they are kept naked from as soon as contractions start. They are given no privacy from male hospital workers and if they refuse to do what they are told they are often slapped! I later discussed this with Dr Azra and she confirmed that woman’s rights in childbirth just did not exist, let alone basic compassion or respect in many places.

 

 

Sofia had to visit an aunt for lunch today and so I was left for a couple of hours to my own devices, which being a lover of my own company, I quite enjoyed. I am never completely alone because the house is always a bustle with the staff cooking or cleaning, or visiting from upstairs. The upstairs chef bought my lunch on a tray and I knew, as Sofia has previously told me, that he has a tendency for his dishes to be slightly spicier/hotter. I had buttered chicken, which is a curry in a creamy sauce, a fish dish, also in a green sauce of some kind, aubergines in a yoghurt dressing, a salad, which I love because the lemon dressing they add make them taste so divine, and to round it off and to mop up at the end, one of the light breads he makes called roti, similar to a naan but not so stodgy or large. It was lovely and watching the telly as I ate (or in this case my laptop) what could be better?

 

Sofia was back by 3.30, then it was off to the beauty spa we go. Sofia had received a gift voucher for treatments and at the rate of £3- £4 per treatment, I was not going to pass up a chance like that. I had chosen a leg wax, manicure and blow dry, and the leg wax was first. Being dark skinned most women here are hairy and hate it, so they are obsessed with hair removal. My hairs are fine, blond, and hardly visible, but still I dislike the odd stray ones on the bottom half of my legs so decided to get rid. After getting me to put on a very (not) flattering elasticated skirt I hopped up onto the table where she proceeded to apply the hot wax… With a knife! Yup I kid you not, a typical stainless steel knife you would eat your dinner with and she certainly was not gentle. Ouch! Putting the wax on hurt more than stripping it off and the ouch factor was not from the heat. But not only did she wax my legs, she waxed my TOES! I have not even ever seen any hairs on my toes!

 

 

Next came a very relaxing manicure. The manicurist sat me in a great big lazy boy recliner and turned off the lights while she made my short nails look as best she could. The blow dry came next which I loved best because I hate blow drying my own hair, well actually I CAN’T do it myself without a few heated rollers to help me. All finished and now to pay the bill, grand total of £10.32 (1600 Rupees). Bargain!

 

“Home is what you make it and this is where Sofia grew up and where her heart is.”

Yesterday I wrote quite a lot about the pollution and poverty and last night showing Sophie, my daughter, some of the pictures via email she asked ” why do they live there”? Knowing that Sofia has a British passport I have often wondered the same. However, home is what you make it and this is where Sofia grew up and where her heart is. To be honest it’s not all doom, gloom and dirt. As the days have passed I can honestly say I have grown to love being here despite all the issues. The shopping mall I went to was modern and bright and the beauty parlour and restaurants nice too. The beach was wonderful even if unlike western beaches where life is mostly vibrant and exciting. The area where Sofia lives might be a bit of a building site now, but that’s because it’s area 8 whereas area 7 is finished and looks very habitable with nice roads, big individually designed houses, clean streets, flowers and greenery (even though there are still beggars to remind you of the horrors not far away). But life is not all about how something appears on the outside or the difficulties we face, it is about how you feel on the inside and overcoming difficulties to see the positives. I feel very comfortable with this group of people, I feel happy to be here, I feel positive vibes, I feel almost at home… Almost!

A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 11

Day 11 – Due Date

It’s is Sofia’s due date today so the day called for keeping busy with a fun activity.

After our impromptu visit yesterday to the pretty grotty local beach, the plan was a trip to a “lovely beach” far different apparently from what I had already seen, and about an hour’s drive away.

 

The journey to this much further afield beach was worth the trip alone for the sights on the way, for if I thought I had seen Karachi at its worst in regards to dirt, pollution, rubbish poverty and grey, grey, grey, then I had a rude awakening. It truly was unexplainable but I will try. First a stop at the baker shop with sausage and chicken pastries – to supplement the picnic Muna had already prepared. Knowing Muna the picnic would consist of a tasty variety of foods fit for a king that she had “just thrown together”, so any purchased supplements, however delicious, I am sure would not be a patch on what we already have. While Muna shopped and the rest of us waited outside, we discussed the armed guard outside the fruit shop opposite, and I had them all in stitches with laughter as I did a John Wayne impression of ” your money or your apples”.

 

 

As we left the criss-cross, busy streets and huge billboards of Karachi behind we started to drive along a straight, quieter road with low concrete buildings either side. With no greenery or other scenic colours, it reminded me of driving through a cement works. Further driving and we were going through shanty towns of indescribable filth and decay. I took so many pictures from the windows of the car because the written description could never suffice.

 

 

Soon the grey gave way to vibrant colours as the roads began to be filled once more with huge colourful trucks. Muna explained that there is big business in customising the trucks, and we did see some pretty impressive decorations to the huge vehicles all around us. The vast, busy road we were on was a dual carriageway, and on the central reservation I noticed that someone had attempted to bring colour the landscape by planting palm trees in the middle, although sadly they had all died through, I am pretty sure, the dust and pollution. Most were now fallen black stumps of rotten vegetation. The few that were still standing had no trace of green left on the branches. They, like everything else, were a grey dust covered mess on the landscape.

 

 

All along the sides of the road the piles of garbage were smoking as if fires had been lit, but I am pretty sure it was the mixtures of gases produced by the waste and the heat of the sun that caused the ignition. I was dismayed to see the ever present scooters with families riding on them in amongst the trucks. One had a baby of around a year sitting ahead of daddy, and although a helmet would have been good, a face mask against the dust I sure would have been a better health protection.

 

"There are huts on the beach that are owned by the upper classes so that they had sun protection and somewhere to change.”

 

Eventually the roads started to clear and get wider, although by now this picture of a beautiful beach with palms trees had become a myth in my mind. After travelling through such awfulness how could a beautiful beach just appear? Sofia had told me that there are huts on the beach that are owned by the upper classes so that they had sun protection and somewhere to change, cook etc. and that we had managed to borrow one such hut from a friend. By now having seen the views from the car and knowing we were close to our destination I didn’t expect much. However, I was not disappointed when we finally arrived. About ten minutes away from our destination and the air suddenly began to get fresher and the landscape cleaner.

 

When we finally arrived I felt excited that this indeed would be a lovely day at the beach. The huts turned out to be concrete bungalows, although the owners had tried to individualise then with colourful doors, wooden window shutters and fenced off garden areas. The one we had use of had lovely Mediterranean blue shutters and doors, and although it was basic with concrete floors, it did have a terrace directly on the sandy beach and clean modern garden furniture.

 

 

The inside was as basic but again clean. It had 2 bathrooms and a kitchen, so all in all it was a nice place to spend the day. The surrounding areas was probably the nicest, cleanest place I had seen so far but still would make Leysdown on Sea look like paradise in relation to luxury, or even any amenities because there weren’t any! Sofia explained that very few Pakistani people would go to a beach for recreation.

 

The small cove had clean, soft sand and a warm blue green sea. Not in any way like the crystal depths of the clean Mediterranean Sea, but certainly on par with the cleanest of beaches in the UK. Muna, as I suspected, had packed delicious foods including a chicken drumstick casserole in a barbeque sauce, homemade couscous with mushrooms and all the pastries and fruits to supplement. By the time we arrived we were all ravenous and dug in deep. Sofia had been eating loads in the last day or so and saying she could not believe how hungry she was. Now I noticed she was walking around with a chicken drumstick stuck in her mouth even before she got Ebo settled on the terrace with a plate of food, such was her hunger. Hmmm… due date and suddenly starving hungry? Was this a sign? By now I was looking for signs in every action and word she said!

 

 

After we had eaten I sat in the sun (the first time since I had arrived) in shorts and a vest and gazed out at the wondrous view of the Arabian Sea. The place was deserted so getting our arms and legs out was of no concern and it was bliss. The sea just a few feet in front of us and the sky a beautiful deep blue. Finally, something pretty to look at! Of course Ebo, Sofia’s little boy, was mega excited and wanted to walk along the beach, so as soon as we were stuffed to the brim we all went paddling in the sea. The lack of beach culture means that, not only do Pakistani people pretty much avoid the beach, neither do they swim for fear of the sea. So it was with great hilarity that Sharif waded in up to his knees shrieking with exaggerated trepidation.

 

 

I left this lovely family to their hilarity and fun and wondered further round the picturesque little cove. I always have a deep sense of aloneness and loneliness when I am on a beach. The gentle sounds of the waves masking other sounds allowed me to go deep into my thoughts about my family and friends so far away right now. With the faces in mind of my darling Sean, the children I am so proud of, and the grandchildren I love so as my heart could break, I wrote a message in the hard packed wet sand to home. I took a picture of “I miss you” so I could send it to them and wondered what they were all doing at that exact moment.

 

 

As I tell women in labour, everything ends eventually, so as the lovely day drew to a close we fed the local dogs our leftovers and packed up our belongings. As the sun was getting cooler in the sky we all bundled back in to car and headed back home.

 

“On this same journey a friend of hers had been held up in her car at gunpoint and robbed.”

 

Sofia’s due date was drawing to a close and it didn’t look like baby was going to be born today. A little way down the road Sofia spotted an ice cream seller and we stopped for ice cream. I asked if was safe to get out of the car, Sofia said “no” but Muna said “yes” so being the person I am, I jumped out and did a little bit of videoing of the surroundings and the very funny little ice cream sellers bike. After Sharif had purchased the ice creams he called me back to get into the car. “Yes” said Muna “we don’t want you kidnapped do we”? Apparently on this same journey a friend of hers had been held up in her car at gunpoint and robbed and that is why they never drive themselves.

 

By the time we got back to Karachi rush-hour was underway and it was like a mixture of banger racing, donkey derby and whacky races with every man for himself. After going the wrong way round a roundabout (us and several other vehicles) and being waved on as if it was fine and dandy by the traffic police, I commented that there was no notion of lane observation. I burst into laughter when Muna, in her ever positive way replied “Oh no, the traffic here is very fluid.” I think if Muna was inspecting s**t she would only see the sweet corn…

 

So still no baby, but hey, I am a midwife… I have patience!

Birth Stools

Ladies….please be seated. Or why a birth stool can make a difference for women and midwives during labour and birth

I recently supported a woman who chose to give birth to her first baby at her local hospital.

When I got to her home, Jessica was in advanced labour choosing to remain in the bathroom and hopping on and off the toilet to help with the intensity of contractions. By the time we arrived at the labour ward and were shown into a room she had a strong urge to push. Brilliant! Jessica walked around swaying her hips, sat on the loo in the en-suite bathroom, leant against her husband and the walls for support.   Mother and baby were well and the expectation was for birth in due course. Time passed and Jessica was now obviously in active 2nd stage of labour.  She pushed hard.  Baby was well.  Mother was well.  Time passed.  Jessica continued to push and there were encouraging signs that birth would likely happen soon. 

I was mindful of the NHS midwife feeling tense; the ticking clock, ‘guidelines’ etc

The curtains which formed a screen over the door twitched, the door opened and closed and I heard murmurings of voices. 

‘I’m so tired, I just need to lie down!’ Jessica exclaimed. How many times as midwives have we heard women say this during labour? I certainly did when I had my babies.  It’s normal, it’s vocalising to those around how you feel, that you’d like it to stop soon please and welcome your baby. I reassured and encouraged her to carry on, remain upright and not get onto the bed which loomed larger than life in the centre of the room.

‘Have you got a birth stool?’ I asked the NHS midwife.

‘No’ she replied.

 I immediately left the room, returning within 5 minutes with a birth stool I had in my car.  When I re-entered the room I have to say I was flabbergasted!  Jessica was on her back on the bed with her legs in stirrups in a position called lithotomy (sometimes called a stranded beetle position).  And she had a CTG (fetal monitor) on. 

I gently and quietly encouraged her to get off the bed and sit on the birth stool which she did with support. And within a very short space of time, a healthy beautiful baby girl was born and passed straight into Jessica’s arms. You can read Jessica’s birth story here http://www.kentmidwiferypractice.com/birth-stories-home/files/jessica-birth-story.html

 

So what’s the deal with birth stools?! What are they and why are they such a brilliant aid for women and a clever resource for midwives.

A birth stool (or chair) is a device which supports a woman in a physiological upright position during labour and birth.  Women have always found physical support from friends and relatives laps during labour; the birth stool is just a practical enhancement of that.  Birth stools are low generally about 20-25cm of the ground to allow the woman to brace her feet against the ground and often have arms rests or hand holds for grip to provide extra leverage during the expulsive stage of labour.

Birth stools have been around for millenia when birth was ‘women’s business’ and before male doctors dominated.  Birth stools are seen globally. They are mentioned in the Bible and pictured on the walls of palaces in ancient Egypt. Women are seen giving birth in supported upright position in Asian, African and Native American art.

So why are they brilliant for women? Because women do not lie down on their backs when they’re in labour!  When women are free to choose, they move around stay upright and change position often. The availability of a birth stool is another way of supporting a position change whilst remaining upright.  The evidence from research clearly demonstrates the benefits of upright position with 6 randomised controlled trials so far (Lawrence et al 2009) showing a reduction in length of labour, less use of drugs to control pain and greater maternal satisfaction. Women who are flat on their backs are also more likely to have inventions like episiotomies and instrumental birth (De Jonge et al 2004).

And what about midwives… what can a birth stool do for her? A midwife can influence positions women adopt in labour (De Jonge et al 2004a). Her role is to facilitate a normal birth and provide as many ‘props’ as she can to help a woman remain upright (Shallow 2003)  And how much more satisfying for a midwife to support a woman birth her baby normally in an upright position instead of being an obstetrician’s assistant in a forceps delivery?  Many midwives are likely to be unfamiliar and lacking in confidence in use of a birth stool, do not know when to suggest women try it or don’t even know where it’s kept! Watch Virginia Howes demonstrating the use of a birth stool here https://www.youtube.com/watch?v=RrXR7dK4Y2k

 

I did a quick ring round to another 7 local obstetric units in the South East and only 2 had birth stools in the labour ward.  Some of the midwives I spoke with said they sometimes borrow a stool from the birth centre if there’s one attached to the unit. That’s pleasing to hear but not ideal as this means that women attending the birth centre would be denied use of it.  The availability of a birth stool (or not) could mean the difference between normal vaginal birth and possible instrumental delivery by forceps or ventouse with all the side effects of that for women.

Many midwives have their own birth stools, women can buy them but any lowish stool, adapting two chairs and the good old toilet work well too!

 

So I would like to see ALL birth environments have a birth stool available (not just Birth Centres or Midwifery Led Units) and ALL midwives embracing their use enthusiastically to help support women in upright positions and increasing normal births.

 

References

De Jonge A, Teunissen T, Lagro-Janssen A (2004) Supine position compared to other positions during the second stage of labour: a meta-analytic review. Journal of Psychosomatic Obstetrics & Gynaecology, 25:35-45

De Jonge A & Lagro-Janssen A (2004a) Birthing positions: a qualitative study into the view of women about various birthing positions. Journal of Psychosomatic Obstetrics & Gynaecology 25:47-55

Lawrence A, Lewis L, Hofmeyr J et al (2009) Maternal positions and mobility during the first stage of labour. Cochrane Systematic reviews. Issue 4.

A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 10

Day 10 – Sightseeing

 

After a slow start, today turned out to be quite an adventure. Drugs are cheap and everything is apparently available to purchase here, so Muna took me downtown to see if I could replenish my supply at a fraction of the cost from prices in the UK… a very cute helpful little Pakistani pharmacist is looking into my order and will come back to us tomorrow. The journey there saw the usual parade of beggars but also a few transvestites, who are generally ostracised by their family and society, so need to beg for a living. We drove down tiny streets the type of which I hadn’t previously seen and it appeared that the shops were all spilling into their neighbours. The types of shops ranged from those selling fruit and groceries to fixing bags and selling bicycles. There were elderly and deformed old men and women sitting at the curb side and a poor dog with a shocking, festering wound on it is haunches the size of a tea plate just walking along the road. I wonder if you eventually become immune to such atrocities?

 

 

The search for Entonox continued, but finally we appeared to have a breakthrough with a company that will rent us a cylinder, although they needed us to to meet the agent at a hospital on the other side of town. They were also renting us the equipment to use the Entonox and I was delighted that it was an identical set to that which I have in the UK, only brand spanking new! I was happy. So now if Sofia needs pain relief in labour it will not be a matter of giving up her dream of a home birth and instead transfer to hospital to get it.

 

“Huge and vast with the dark, dirty sea on one side and the concrete Jungle of crumbling buildings of Karachi on the other.”

 

On the journey home Muna decided that a trip to the beach was on the cards. As I have said before Munas’ dedication to Karachi is commendable and she appears to overlook the horrors I see on a daily basis and instead points out “beautiful this” and “beautiful that”. I have yet to see anything that I could in all honestly attribute the adjective “beautiful” to, except maybe the wonderful array of flowers at the Golf Club or planted around the ‘oasis houses’ as I have begun to regard them as. And so as we pulled up at the beach she was pointing out the beauty all around but all I could see was a beach like no other. Huge and vast with the dark, dirty sea on one side and the concrete Jungle of crumbling buildings of Karachi on the other. I wondered at the many families all around who were obviously enjoying the sunshine and cool breeze. I have to admit at least it had lovely light, sparkly, soft sand. However, I would not have wanted to walk barefoot on the sand for the visible rubbish atop it made me wonder about what dangers lay beneath!

 

We started to walk towards the hard, packed, wet sand nearer to the far out tide. We were instantly approached by a man plying his trade. His trade was a huge, brightly decorated, saddle carpeted camel. I had no desire to ride the beast but took a few pictures instead.

 

 

Next came what I can only describe as truly my worse ever nightmare. A man carrying a cloth bag across his back and a musical instrument held in front which appeared to be some sort of trumpet. I stopped to take a picture and Sofia, not knowing what an impact her words would have said “he is a snake charmer he has cobras in that bag!” My horror showed on my face. Did I run? Did I scream? Did I break out into a cold sweat? Oh yes all three because my real snake phobia is the only thing in life that can completely disarm me. As my feet peddled the sand I felt like I was trying to run in one of those dreams where you get nowhere fast. Sofia fell about laughing as she chased after me to give reassurance he wouldn’t be getting those slippery blighters out of the bag to do his snake charming unless I paid him! I thought how my darling Sean would have laughed had he seen that little episode.

 

 

Further down the beach we went to find horses waiting to be ridden, more camels along with quad bikes and beach buggies for hire. Many food sellers with rickety barrows of wares or trays of goods slung around their necks. The ice cream man with his half bike-half trolley and tinny music was such a funny sight to see. The ever present, lovely Sharif, the trusted family driver, asked if I wanted to try the food but the last thing I wanted was Deli belly so I politely declined. Nothing looked new or well-kept, everything had a feeling of old and decaying but it was clear that families, like they do the world over, were enjoying the fun relaxed atmosphere. Muna, Sofia and I resorted to acting like silly school girls as we pointed, nudged each other, and giggled at one of the stallion horses, who was keen to show us his particular type of wares. Woah big boy!

 

 

One the way home we stopped in a supermarket and, although it was messy and dusty underfoot, I have to say the products available had many English brands and they even had guys packing the bags at the checkouts…they don’t even have that in Sainsbury. It’s such an oxymoron of a country!

 

A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 9

Day 9 – Bling

 

Corruption is big business in Pakistan, and Karachi sees its fair share of it. It was one of the first things Muna had told me about when she collected me from the airport. Corruption and the complete lack of accountability. Earlier in the week I went to the cinema. The trip was more for the experience rather than the film itself. I wanted to experience normal life for the Pakistani people who could afford such luxuries. The auditorium was much the same as any other worldwide and the nachos just as delicious, but as I sat there munching away, waiting for the film to start, to my horror the lights suddenly came up bright, the loud booming sounds of what obviously was the national anthem started and everyone commenced to stand. I was embarrassed and every part of my anarchistic personality (OK, not quite as bad as that) wanted to stay seated, however I did not want to draw even more attention to myself. I was already the only white, western, lone female in the auditorium, so nachos in hand and frantically wiping my chin of cheese sauce, I stood and listened to the stomping sounds of the song which, although I knew the ethos, I certainly could not understand the language.

 

“Sofia had already told me that the best way to earn a living from corruption here in Karachi is to join the police force.”

 

At its conclusion I quickly sunk back in to my big comfy seat, relieved when the lights dimmed and I once more had my anonymity. I presumed the film would now begin, but no, first we had the adverts and I was surprised and pleased to see an advert calling for Pakistanis to reject corruption. I supposed that the Government funded such an advert but I also had a sneaky suspicion that within that same Government, corruption was rife. Sofia had already told me that the best way to earn a living from corruption here Karachi is to join the police force, where you will be paid such a poor salary (hardly enough to feed your family) that you have to make it up to a living wage somehow. What better way to supplement your earnings than by using a bit of extortion on the 100’s of moped riders? Pull them over, threaten them with prison for some actual or invented driving misdemeanour, or hand over a fine which went straight into the policeman’s pocket!

I just thought I would mention that because day 9 has been pretty uneventful. Sofia went out this morning to sort out some banking issues, so I spent the best part of the day feet up and watching movies until around 5pm when the typical and usual trip out was decided upon, and I once again became the centre point for the excursion.

 

Oh yes, and Muna sent me an email with a link to the write up about the comedy at the Literary festival. If you click on this link you can see from the photo just how packed it was and read about all the satire comedy that was going on ( I am sure I can see the back of my red head down at the front on the left hand side).

 

I had noticed some pretty shoes in the shopping Malls earlier in the week which, unlike the expensive ones made by Sofia’s cousin, were within my budget. Muna had told me she would take me to some other cheap but nice shoe shops and today was the day!

Arriving at the street where the many shoes shops were I was no longer surprised to see the armed guards outside, but still took the obligatory photo to prove it.

 

 

I entered what felt like an Aladdin’s cave of bling. The shoes were beautiful. All manner of styles and all manner of coloured beads, stones and designs. I wanted sandals and I was spoilt for choice! With padded innersoles they felt so comfortable on my feet, unlike the hard flat bottoms of most of the UK sandals.

 

IMG_3493.jpg

 

It was so hard to choose from the vast array of pretty styles. They made me wish I could buy lots and take them all home, but I calmed down eventually and settled on 3 pairs. The final price made me smile with delight, for who doesn’t love a bargain? Three pairs of well-made comfy pretty sandals for £30! Result.

 

 

Then home to, as usual, a delicious dinner of several new foods I had never tried, and that was end of day 9. Pretty mundane day really; still no baby and just a bit of sparkle to ward off the homesickness…

A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 8

Day 8 – Home Comforts

 

Last night after my usual indulgence of a caramel egg accompanied by an episode of Game of Thrones I settled down to sleep. I had been asleep a while, but was aware that the night was early when I heard Sofia’s small 2-year-old boy crying loudly. The crying went on for some time and I could also hear Sofia’s raised voice and that of her estranged husband Azaan. I learnt this morning that Sofia, at the end of her tether with her 39 plus weeks of pregnancy, an unwell child and a horrible cold, had an understandable meltdown when Ebo was restless and unwilling to sleep.

 

“She was fast becoming a much loved surrogate daughter and I wanted her to feel better.”

 

In desperation she had called Muna to come for support. Azaan had seen Muna arrive at the house from his location, visiting his mother upstairs. He had come into the house and taken the little boy from Sofia in a supposed answer to her stress, which upset Sofia even more and she had spent a first ever enforced night away from little Ebo. She looked tired, drained and sad, and instinctively I put my arms around her and held her close. She was fast becoming a much loved surrogate daughter and I wanted her to feel better.

 

As an outsider I could see the dynamics of everyone’s feelings and points of view when personal issue came up for discussion. Of course my 100% sympathies lie with Sofia, but when a young couple meet in their teens, parenthood is also hard on a young man of 21.

 

“Often the beautiful melodious sounds of him singing his favourite Adele songs can be heard echoing through the building.”

 

So today Sofia understandably wanted to spend as little time as possible in the house where Azaan works and her in laws live in close proximity. As well as being a film producer, Azaan is an accomplished musician and singer, and often the beautiful melodious sounds of him singing his favourite Adele songs can be heard echoing through the building. Add problems of love to the situation and I could empathise with Sofia’s desire to escape. So at noon it was off to Muna’s house we went. A nice picnic on the grass in the garden discussing all aspects of post-natal care whiled away the hours of a quiet Sunday. I had taken my laptop, thinking that a quiet afternoon may mean I would watch a movie of some sort, but I kidded myself that they wouldn’t have something planned, and by 4pm we were in the car being driven to meet yet another family friend who “would love to meet Virginia”.

 

 

Auntie Arlya was a lovely woman who had lived a lot in USA. She and her husband had 4 kids ranging from 19 to 5 years old. All dressed very western and in a lovely big house behind yet another high wall, I was intrigued by the accomplishments of the children of parents who encouraged them to be responsible entrepreneurs. One of the boys of around 13 kept chickens and made chicken feed that he sold, one kept a vegetable patch, and the 16-year-old daughter made exquisite high end sandals. They showed me her workshop in the basement and the shoe collection. All very beautiful with amazing decorations and adornments of glass stones and beads in various colours and designs. All the different kinds and colours of leather was spread out on racks, as every pair of shoes is hand made. The prices however were not cheap for being made in Pakistan. A pair I very much liked were £30, and in Pakistan that’s a lot of money, so asked why they were so expensive? The answer was that they were being sold to high end Pakistanis and they could afford it! Fair play to her I suppose.

 

Accompanied with our tea we were served delicious homemade cottage cheese. Delicate mounds of mouth-watering softness with added herbs, spices and flavourings. Look out family of mine; I will be trying the recipe myself because it sounds very easy to make indeed. Whilst chatting about food the topic of sweets came up, and I happened to mention one of my favourites is liquorice. Oh boy I should have stayed quiet! Cue driver and we are off on a mission to the imported sweetie shop to find Virginia her home comforts. In a little side street, typical with small higgledy piggledy shops (although surprisingly free of the usual rubbish and filth) we came to a brightly lit modern shop, the contents of which made me long for home and my sofa in front of the TV.

 

 

Full from ceiling to floor with every confectionary Sainsbury has to offer, even Sainsbury’s own brands. Every chocolate biscuit and sweet I could very wish for filled the shelves. Unfortunately, the much craved for liquorice was nowhere to be seen, but knowing Muna as I have come to, I suspect it won’t be long before she tracks some down.

 

 

And so after a day that had an emotional start we ended on a high and a fun evening chatting and laughing. Little Ebo thought it would be hilarious to use the air pump needed for pumping up Sofia’s birth ball for pumping up mummy’s tummy instead… a tummy my enquiring hands and eyes noticed had grown considerably in the week I had been here!

A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 7

Day 7 – Literary Festival

 

Today I finally woke at a reasonable time and found at 09.30 Muna was already here and wondering if I would like to accompany her to the Karachi literary festival, where she excitedly said I would meet lots of feminist and free thinking woman like me! It was being held in a Hotel and we had to go through the usual security checks. There are armed guards at every establishment, but anywhere where groups gather they also search your bags and you go through metal detectors. This event also had armed guards looking down on us from the hotel rooftops. Far from making me feel safe it hits home about the daily dangers.

 

Once inside however it was awash with exhibition stands and stage/seating areas inside and out. I was astounded at the amount of presentations going on. There were many scholars running sessions and talking about all sorts of issues, but the one that caught our attention was “laughter, the best medicine”. The speakers were 2 Pakistani men and one Indian, who were stand-up comics. They were here to discuss the place of satire comedy in the life of a Muslim. I have never seen such a packed audience. The auditorium had a seating capacity of more than some west end shows, and still people packed in to stand.

 

 

The place was in uproar with laughter and I was frustrated that I didn’t understand more. One joke went along this line: “I was robbed a while ago in Karachi. I was sitting in my car when a man approached and held his gun to the window, he was saying “mobile phone arsehole mobile phone arsehole”, but quite honestly I didn’t know if he wanted to rob me or have a relationship with me.”

 

This was from a comedian named Saad Haroon. He was asked by the audience how he knew he was successful and he answered that the death threats on YouTube gave him great confidence about that! You must watch this parody to Pretty Woman he performed called “Burka woman”;  he certainly had me laughing!

 

And so it was home once again through the dirty, decaying mess that is Karachi. We stopped for some fruit from one of the many street sellers and once again I was approached by a dirty shoeless boy of around 7 begging for money. The 100 Rupees I gave him will feed him for a week as long as a corrupt policeman or other adults doesn’t take it from him.

 

It breaks my heart to see all the beggars, but the ones that hurt the most are the deformed and maimed who beg at the cars that are stopped in traffic. Muna opened the window an inch at one such stop and handed a note out of the window to a man who had a bony useless arm hanging from his body. There is no welfare or help for such people. Seeing such extreme sides to society is so hard and so confusing. The roads are full of expensive, nice cars and yet overflowing with disease ridden rubbish, debris and filth. Most houses and buildings are decaying and grey on barren, sandy building site landscapes, and then there are odd new ornate building with high walls and surrounded by greenery and beautiful bougainvillea.

 

 

A conversation with Dr Azra left me heartbroken about the plight of pregnant women in Pakistan. Whilst around 50% of babies are born at home they are not the happy, planned, safe home births of the West; they are women who cannot access health care. With one of the highest infant and maternal death rates worldwide, the poorest, the least healthy and those far away from any clinics of hospitals have no choice but to suffer in silence. “Half the babies die” said Azra and my stomach felt heavy with the lack of power to change such a situation. “However good job they can’t all come to the hospitals, because we couldn’t cope if they did” she added. My thoughts at that moment were how lucky we were to be able to get health care free at the point of delivery in the UK.

 

Once back home we found Sofia having had a nesting day of sorting out all her baby clothes in preparation for her baby daughter, who we all hope will put in an appearance soon. We are still trying to source Entonox, but strangely enough in a country where you can purchase just about any drug over the counter it is proving quite difficult. The gas companies will only sell it to clinics and hospitals. I have emailed Dr Azra, who is going to try and pull a few strings, so fingers crossed.

 

The day is drawing to a close now, I enjoy this part of the day; when I go to my room get into bed, eat one of the caramel eggs I bought with me from the UK (my comfort food) and watch Game Of Thrones on my lap top. I have 5 eggs left….is that a sign of how many days before this baby finally puts in an appearance?

A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 6

Day 6 – Cultural Differences

Late last night, when I was just about ready to check into my bed, Muna arrived! The culture here that the day starts late and ends even later. While that fits in with my current jet lag, it’s hard to get my head around. I still feel terribly guilty getting up at 10.30 when I hardly ever sleep in beyond 8am at home. Can you believe Azaan, Sofia’s estranged husband has just left to go to the dentist and it 9pm?!

 

So, back to Muna’s late arrival, because I just have to mention that once again she arrived with food! This time it was desert. Typical/local delicious sweets made from carrots, honey and nuts – a strange combination but no more so I suppose than our carrot cake. Sofia was in a restless mood and I did allow myself to hope it was the sign of something to come, but it was her 2-year-old Ebo who put paid to that by being unwell and keeping her up all night. Suppress that oxytocin and call in adrenaline!

 

I managed to finish the first series of Game Of Thrones by 2am and then had a bumpy night of sleep awake cycles of 2 hours until 10.30. The culture of servants continues to amaze me. I have learnt in some households it very formal, and the lady of the house would be addressed as Ma’am, however in Sofia and Muna’s house they appear to be more like family and have been employed for many years. Many of them live in and have their own quarters at the back of the house in the basement, although I have yet to see it. Sunia is going home tomorrow as it’s her day off. At seventeen years old, she must go to take her salary home to her family. On Fridays the servants cook food enough for 80 people and take it to the local homeless shelter. I only learnt that last night and, if I am still here next week, that’s something I would like to see!

 

 

Today Muna took us to the sea front (not the beach) where locals fish for crabs. We walked along the sea wall watching the fishermen, all the time being aware of the strange looks we were getting. With no woman other than us around, the sight of 4 in one go consisting of one Pakistani (maid Sunia), one white woman dressed as a Pakistani (Muna), one westerner (me) and one very pregnant woman, made for quite a picture… Literally, as we did see a group of young men taking a picture of us as we headed back to the car. As usual the area was littered with rubbish, but certainly not as bad as the piles of it in other areas of down town Karachi.

 

 

Then it was on to lunch at the golf club and as we entered the grounds you could be forgiven if you thought we had stepped through a time warp back into colonial India in the days of the British rule. Pristine road and beautiful gardens. Only the signs “ladies parking”, “ladies swimming pool” and “ladies gym” gave it away that we were still in segregated Pakistan.

 

 

On the way home they stopped to show me the local supermarket where you could pretty much buy everything you wanted including imported goods with names I recognised. The isles were narrow and the shelves stacked high but the thing that fascinated me the most was the armed guards at the entrance and exit…..yup armed guards at the supermarket!

 

 

Soon it was time for the highlight of my day; I had planned to go to the cinema! Although I was going alone I was driven there and back and Muna came in to show me the ropes. She need not have bothered, it could have been a cinema anywhere with its multi screens, nachos, popcorn and coke, I was well at home. The theatre was large and the seats big and comfy. I settled down to watch my movie but nearly jumped out of my seat when the soundtrack began, why was it so deafeningly loud? I soon realised why…forget the niceties of people being quiet, throughout the film they were arriving late, leaving early, chatting away and using mobile phones…. lucky it was very dark and very loud and I could easily absorb myself in the action.

 

And so another day ends here in Pakistan. I am committed to Sofia and to helping her to achieve her dream birth and they are treating me like royalty, but the homesickness is creeping in around the edges and I am longing for familiar sights and smells of home and the faces and love of my family.

A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 5

Day 5 – Paperwork, Preparations and a Pool

 

“Please” I woke up saying “please let’s have a relaxed day of no restaurants, lunches, trips out, family visits, discussions or debates”. I am exhausted with the loveliness of it all. The best thing is I slept quite well so I am feeling much better than the horrible way I felt yesterday.

 

It appears that IMUK and my lovely sister midwife Jacqui have the uncanny knack of asking me to prepare a newsletter for IMUK just as I am about to go on holiday, or in this case, abroad to work, where the internet is not perfect and picking up the phone to discuss things is impossible. So, yet again, an email arrived with my instructions for the newsletter the night before I came away. I have been trying my best to get it done within my very busy schedule of educating my hosts while they socially overwhelm and pamper me. So anyway, last night I suggested we have a restful at home day today so I can finish the IMUK newsletter and get up to date with emails and communication with family.

 

Following my typical breakfast served on a tray at around 11am (jet lag still keeps me awake till around 2am and asleep until 10.30) I started on my newsletter and emails. Good progress was being made and I could finally see the wood for the trees when Sofia says “Mum is coming over with a friend to meet you Virginia and bringing coffee and muffins.” Oh my sweet tubby tummy! More food. I was, however, on this occasion the best I could be, and declined the lovely blueberry muffins.

 

 

Sofia was adopted so is nothing like her mum, Muna who is a wonderful mixture of east meets west; large, blonde and pink, but wears Pakistani clothes and covers her head. A Dutch woman by birth, she has open eyes to the problems of and in Pakistan, but is also a loyal protector of her adopted country. She constantly points out things of beauty amongst a lot of ugliness. The odd façade, or old historic building amongst a jungle of concrete and filth. She is Muslim, but a fierce supporter of women’s’ rights. Outspoken, a woman not unlike myself who appears not to worry about the odd buck of convention. She has a deep understanding of World politics in relation to Islamic state and its origins (the CIA have a lot to answer for about the current situation and the rise of terrorism, although I didn’t need Muna to tell me that!). So the next couple of hours is spent in yet another girly chat on the sofa talking about birth, politics and funny life stories.

 

 

Muffins cleared and guests departed I once again was back into furious typing on my laptop, when I received a couple of emails from Muna. She is looking into how to obtain some Entonox because she tells me you can get anything here! She wanted to know the mix, as the gas company make it to order. BOC UK has a great web site and I was able to confirm it is a 50/50 mix of O2 and nitrous oxide, and so we await to see what the ever resourceful Muna can come up with. I have bought with me everything else you could want to have for a safe home birth, but somehow I don’t think customs or security would have been happy with gas cylinders on the aircraft. Sofia, like many confident women, may not need any pain management but having it available is sometimes crutch enough.

 

Almost by magic, Sofia’s birth pool arrived, having been blown up by the outdoors staff… although birth pool is a far stretch of the imagination. Rather, it is a deep child’s paddling pool, but as Sofia is a tiny woman, (we were discussing nicknames last night and I suggested pocket rocket for Sofia) it is just about OK for her to labour and birth in. I gave instructions about how it should be cleaned and the maids got to work.

 

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Sofia informed me after our little interaction with the pool that she wanted to go to the park with her little Ebo. I declined her invite to accompany her and instead sat and had a lovely lunch/tea (it was now 5pm) while watching an episode of Game of Thrones on my laptop…..Bliss! I am coming into the series late in its life but I have to admit defeat concerning the iconic series. My son Matthew and partner Sean have long since told me it is an excellent programme, and I have to concede they were right because after years of saying “Game of Thrones? fantasy? Phwer! Load of rubbish, I’m not interested in watching that” I am hooked, it is really addictive and I love it!

 

And so as the day comes to a close, I wonder if tonight will be the night that labour starts and another woman in my care will begin her journey of birth and a new life will begin….