Day 2- Birth Plans
I woke up this morning wondering what the day ahead would hold as I was going with Sofia to consult with a doctor. Sofia wants a home VBAC but her extended family are not supportive due to worries about safety. Pakistanis, no matter how westernised, are very patriarchal, and when a woman marries into a family she becomes a daughter of the in laws, to the extent that official and medical forms often ask her to document her husband’s father's name. The family were causing Sofia, and indeed themselves, quite a lot of stress due to Sofia’s birth choices. It appeared that the worry had little to do with the previous caesarean section, and more due just to them being ill informed about birth in general and knowing Sofia did not have a doctor involved. I was keen, for obvious reasons, to know the procedure should a problem occur in labour, and where we would head to. So Sofia found a female obstetrician who said she would like to meet me and supported Sofia in her plan for a VBAC.
The system in Pakistan is archaic to say the least. There is no simply turning up at a hospital, because if she is not booked with a doctor the administration would turn a woman away even in an emergency! One hospital even turned away an unmarried women. Later the baby died, but their view was that at least their reputation remained intact, because they had maintained honour in not condoning pregnancy outside of marriage.
Ok, so birth plan A) is that Sofia has a home VBAC with no problems, and then following the birth, she tells the family if need be that baby came too soon to get to the hospital. Plan B) is that, in case she changes her mind at any point, she needs to book a doctor who will be supportive of a physiological VBAC in hospital as well as being on hand for plan C) which is an emergency trip to the hospital should we need help. We are accompanied by Sofia’s mother Muna, who is in fact a Dutch woman married to a Pakistani. Muna knows the system very well and is fully supportive of her daughter, and the only other person in the household who knows about plan A (other than the two maids Sunea and Rumi who I will bring into the story a bit later).
Before heading off to the hospital we went to Muna’s house for lunch, and while there I was introduced to Sofia’s grandmother who is 88 years old. While frail of body her mind is sharp and we began to share a few stories. I told her about one of my clients in UK who has had 10 babies, and I told the story of the biggest baby whose birth I attended who weighed 12 lbs 120z and was born at home, and she shared stories back with me.
She told stories of German doctors who were prisoners of of war in WWII and working in the military hospital near to where she was living with her soldier husband. She told me about her year-old first born son, who had died during the migration from India to the new country of Pakistan after the war. Finally, she told the story of her own birth, which she had heard being told many times when she was a child. When she was born she was contained in the membrane sac and the midwives of the village were scared of what they could see. They had never encountered such a thing, presumed it to be some sort of deformity and thought the baby was dead. You can just imagine that the baby may have not been initially moving and was not yet breathing. One midwife apparently wanted to throw the baby in the garbage, but another midwife who they all knew as being the brave one came forward and said they should investigate further. She pulled a reed from the roof and proceeded to pierce the sac with the sharp pointed end. Of course lo and behold a healthy baby girl was within, who instantly breathed and lived long healthy life to now be telling me this story. I was delighted to hear it, and told her that was known as being born in the caul and is very rare. It is said by fisherman folk lore that those born thus would not experience death by drowning.
After this fascinating insight we went off to the hospital though down-town Karachi. We had deliberately chosen the busiest rush hour time of day and we told Sharif to put his foot down. I wanted to know how fast we could reasonably expect to get to the hospital in an emergency.
Past all the colourful buses, swerving and horn-tooting through traffic like you have never seen it before we drove. Past shanti towns and crowded streets, past schools and other official buildings only just visible behind high walls with barbed wire atop, and closely guarded by armed men outside. Shops all crowded together, their wares spilling onto the streets, and high poles dotted everywhere with so many electrical and telephone wires attached, spiraling up and around, that it was impossible to see where one ended and the next one began. But most fascinating of all about this diverse and strange place was the huge wide piles and piles of rotting, stinking and decaying rubbish left absolutely anywhere and everywhere. I don’t think I will ever complain about UK streets again because of a few empty water bottles and crisp bags.
We finally arrived at the private hospital in well under 30 minutes, which was perfectly acceptable to me. There are ambulance services but really they are no more than taxis, as the drivers are not medically trained and the culture of hooting and tooting that goes on gets largely ignored so, Muna informed me, no one gets out of the way for ambulances. I reasoned, therefore, that I trusted Sharif to drive us in an emergency rather than wait around for a dubious ambulance.
The hospital was a bit like an old, scruffy NHS one, only dustier. Everywhere there was a brownish yellow décor with an atmospheric sense that a smoking ban had not long been enforced. This was not the hospital Sofia had used for the birth of her first baby, nor was it the doctor who had given the advice which led to the resulting caesarean section, but a female obstetrician who Sofia knew to be more woman-centred. Sofia’s story was that, at 38 weeks pregnant, her doctor had concluded the baby was not growing and advised induction of labour. Sofia had not put up any objection as she was not fully informed and had absolute trust in the advice she had received. The induction had failed, because of course at 38 weeks her baby and body were not ready, and after many hours of pain and distress and no progress into active labour, fetal distress had been diagnosed and a caesarean section performed. Her baby boy was born well, healthy and a whopping 7lbs! Sofia was traumatised and distraught. It does not take an expert to know something did not quite add up!
The Sofia of today is a whole lot different; she is educated in birth issues and is strong in her determination to do things different and retain control. The evening before Sofia showed me a birth plan she had written. It was a typical birth plan to be found on many an advisory birth internet site, with references about no CTG monitoring required and no cutting cords, amongst other issues, but it had lots of “unless necessary” written everywhere in it, so I encouraged her to re-write it in a firmer way. “I do not consent to …” gives less leeway to anything being done without consent because it was deemed “necessary” at that time.
When we were finally shown into the doctor’s office and the birth plan was being read I wondered if my suggestions or a firmer birth plan would be met with hostility. Once she had read the plan Dr Azra slid the piece of A4 paper back across the desk to Sofia, and basically said there was nothing in it that she had a problem with.
“There is nothing in there that can’t be found in text books or good evidence papers” she said and I slowly let out my tightly held breath.
She went on to say that as long as Sofia was taking responsibility for her own decisions she was supportive of her choices. Whilst Sofia did not tell Dr Azra directly she planned a home birth, she did say she was planning on staying home for as long as possible with me as her home support, and may come in at the end of the labour. Muna did not say much, and I was aware that she was uncomfortable not discussing plan A with the doctor. Muna had already spoken to Sofia’s previous doctor from her last pregnancy and so was well aware that support for a home VBAC was virtually impossible. I felt that this lovely doctor was truly supportive. We discussed a plan should Sofia require a repeat caesarean section and we discussed how we could achieve all Sofia’s wishes including me going into theatre. I sometimes have to fight to achieve such continuity in the UK, and yet here was this doctor offering it to me as a professional courtesy and in Sofia’s best interest.
We were finally shown the labour rooms, which were an exact replica of UK labour rooms (except with more pillows). It was almost time to leave, but not before Dr Azra asked me if I would like to come and speak to the doctors and nurses (and Alvera, the one midwife at the hospital) about practice in the UK. She told me she had trained in the UK, and she certainly appeared to be aware of all current evidence. She explained that Pakistani women still demanded their enemas and shaves, and would freak out at being given their baby for skin to skin without it being cleaned and wrapped. I responded with my usual response when women are blamed for the current poor practices which continue in childbirth: “We professionals introduced all these procedures, so now we must find a way to undo the status quo… never blame women”.
I think Dr Azra liked me!
I felt comfortable and reassured as I could possibly be with the safe birth plans we had put into place.
Once home, Sofia and I discussed with her two maids how her labour and plan A) must remain a secret from the rest of the family and from her mother in law, who lives in an apartment upstairs, to save stress and worry all round. The maids are loyal to Sofia (there is rivalry between the upstairs staff and downstairs staff) so they were delighted to be in on the secret and be part of such excitement. Rumi told us that she had two of her four babies at home and that she loved being at home. She told us about a special plant that is used in labour. It is called Bibi Maryam ka phool, and consists of a bundle of closed knot roots that are put into water. The flower is a help to the labouring women, and once the baby is about to be born the flower opens up.
“When the pains get fast the Dai must go and sit down in the corner and be quiet.”
I told Rumi, being the knowledgeable midwife I am, that it is important a woman is not disturbed in labour. However, it seems I am not the only one with knowledge because speaking in Urdu and Sofia translating she replied that when the pains get fast the Dai (village lay midwife who has been taught her trade through the generations) must go and sit down in the corner and be quiet! Yes, that told me!
Following such a fascinating day, when I thought nothing more could happen, I was served a delicious meal cooked by Rumi. However, I didn’t look close and proceeded to eat what I thought was a green bean atop some tasty buttered chicken. What happened next invited looks of astonishment as they all watched me run to the fridge, grab yoghurt, and greedily pour it into my inferno of a mouth, while Sofia laughed her head off at me. I had eaten a very hot chilli!
So no baby yet and feelings of homesickness coming on. But I was also feeling that this place was growing on me, and these wonderful people were a long lost family.