Maternity Care in Bosnia

In the past few months I've learnt a lot about the maternity system here in Bosnia.  This is because I met some Bosnian ladies who are interested in natural birth and these women shared with me their birth stories as well as their knowledge about the system here.  I have also gone around asking quite a few ladies I meet in everyday life about how they felt about their births.  I would have loved to know so much of this stuff when I was pregnant, so that's why I'm sharing it now.  I guess it should be taken with a grain of salt, since it's based on second hand information in some cases.

Midwifery in Bosnia
Midwives aren't very well thought of in Bosnia. The word used to describe them, "babica" also means "grandmother", so it's not surprising that people associate homebirth with poor families who can't afford to go to hospital and just get a 'grandmother' to help.  Such midwives quite possibly still exist in the countryside, but in the city, it seems that midwives only practice in hospitals. There is a course available for training midwives, but it is only a highschool degree from the medical highschool in Jazero (maybe there are others in other parts of the country). Beyond this highschool qualification, there are some short courses offered by the Centar Fenix and that is about it!  I spoke to a girl who I know who goes to the medical highschool.  She will become a midwife only if she doesn't fulfill her dream of becoming a footballer!  None of her friends want to be midwives either if they can help it.  It seems more like a low-level job that they will do if they can't find anything else.  (As a side-note, I asked her if she had witnessed a birth and she said, not yet, but she had seen an abortion. Hmmm...) Not surprisingly, those that do decide to work as a midwife finish their training in the hospital by watching doctors (obstetricians) practice and being instructed by them.  They end up being like obstetric assistants who are probably very out of touch with what it means to a woman to have a baby (especially when starting out fresh from highschool).

Apparently, the training for midwives before the war was more complete and so the older generation of midwives are more skilled, for example with breech birth and twins. Despite this, even they don't have much autonomy within normal hospitals.  They supervise the labor but aren't able to administer medications or perform medical procedures and must call in the doctor (who works in shifts) for the birth.  Apparently, there were some midwife led birthing units in the countryside, but these have been progressively closed in accordance with a policy of closing smaller maternity hospitals to redirect women to larger, more "equipped" hospitals in the so-called interest of safety. I say "so-called" because, actually, by sending women to centralized units and closing down local ones, you are making it more likely that women may give birth on the way to the hospital, which is probably the least safe option.

Birthing Options
The only real option women have is to go to their local public maternity hospital.  There are no private hospitals in the capital, but I've heard there is one in Pale (Republika Srpska) and also one other private hospital in Banja Luka (also Republika Srpska).  Homebirth is commonly thought to be illegal.  It is probably not actually illegal, maybe just a grey area, but perhaps there was a push to discourage it at some point because it seems like it used to be common but isn't anymore.  It is now considered an uncultured thing only peasants would do.  This combined with the minimal training of midwives and obstetricians' general preference for hospitals and that leaves you with a situation of no homebirths. In any case, no one I know has found a health care practitioner based in Bosnia who will assist them in a homebirth.  It may be possible to bring in a midwife from another country, but it would be difficult to get back-up from the hospital. Birthing centres do not exist either.  Apparently midwife-led maternity units used to exist. Maybe a couple still do, but I'm not sure how they would compare to what I would think of as a birth centre. I think they would really be more like a normal hospital, only without obstetric back-up.

Prenatal Care
Pregnancy is rather medicalized.  There are only two options for prenatal care - seeing the doctors in the public system (in a clinic known as Dom Zdravlije or the hospital) or seeing a private obstetrician-gynecologist.  Women, even those in the public sector, are advised to have an ultrasound at least once a month for the entire pregnancy.  Doctors do not palpate the belly to examine the baby's position or growth, they rely exclusively on ultrasounds.  They have short appointments with their patients where there isn't much time to talk about diet or lifestyle, but they do quite a number of tests and examinations.  Some women are given additional medications which seem excessive to me, such as hormonal medications to "keep" the pregnancy or prevent contractions. At 36 weeks, the woman books into the hospital and starts having weekly examinations, including CTG, ultrasounds, vaginal examinations and possibly more. If a women reaches her due date, she is sometimes encouraged to have an induction immediately or if she prefers to wait, more frequent (even daily) monitoring is done and in a friend's case, amnioscopies were ordered frequently to check for meconium staining. The last is quite an invasive and risky procedure that has little benefit in helping the outcome. This isn't all bad by any means, some of these things can be quite useful, but what I'm noting is lack of the continuity of care midwifery model as well as excessive use of technology and tests.

Hospital Birth Practices
Based on listening to the birth stories from a few women, it appears to me that doctors in Bosnia prefer to "actively manage" labor and birth.  That is, there is a specified time-frame within which a woman must dilate and also push out the baby before which time they will intervene to speed things along.  In accordance with this view, and other beliefs (many of which are not evidence- based), the following interventions are common:

• routine shave and enema upon admission (expectation that shave should be done before going to hospital)
• frequent artificial breaking of waters
• frequent chemical augmentation through artificial oxytocin drip
• artificial rupture of membranes
• pushing lying on back (lithomy position) on birthing table
• panic if baby is not pushed out in a few pushes
• use of fundal pressure to increase speed of birthing (doctor or nurse pushes on the top of the uterus to increase the force of pushing putting extra pressure on the vaginal wall muscles and increasing the likelihood of perineal and pelvic floor damage)
• routine use of episiotomy for first time mothers (and frequently otherwise)
• immediate cord clamping
• a quick cuddle and picture with mum and then off to the nursery baby goes to be weighed, measured, vaccinated, given vitamin K injection, quite possibly fed formula or sugar water before being returned.
• actively managed delivery of the placenta - use of injection to initiate contractions and control bleeding
• mum gets her episitomy sewn up and rests while baby has his or her examinations with strangers
• mum gets to breastfeed her baby a few hours after birth (maybe 4 or more). 
• The baby is quite possibly full of formula when it comes time to be nursed.  (The national hospital, Abdullah Nakas hospital is supposed to be a baby friendly hospital, but according to one woman who had an insider's view of it, she found that the baby friendly standards were not being adhered to as they should be.)

Also, it seems like there was an insistence on laboring in bed, in some hospitals through use of CTG monitor (meaning you are strapped to a monitor) and drips, in others simply because they want patients to be in bed.
Water birth is supposedly available in the national hospital, but few (if any) women have been actually allowed to give birth in water.  Probably because of a general mistrust of water birth and their belief in the need for episiotomy. The C-section rate is about as high as in western countries - approaching 30%. Doctors work on shifts and you can't know who will be on shift when you go into labor, but I have heard of women bribing doctors to give them a non-medically necessary C-section when their preferred doctor is on shift. This is probably because of the (in my opinion) terrible vaginal birth option that hospitals offer as the only alternative.  By the way, C-sections are usually done under general anesthesia, rather than epidural.  I also heard of one woman who was offered an induction (as a favor) when her doctor was on shift so that she could birth with her doctor.  Further, although some of the older midwives and doctors have skills in things like breech birth, the newer doctors are trained to opt more frequently for C-sections, so I hear often about women having c-sections for 'big babies', twins, VBAC and breech.  In terms of breech, apparently only one doctor offers external version (to externally flip a breech baby).

It goes without saying that in such a medicalized environment, doctors would likely be incredibly "cautious" when it comes to premature rupture of membranes and presence of even lightly stained meconium in waters.

There are probably exceptions to the list of interventions I have given.  Maybe some doctors are more liberal in allowing different positions for labor or birth and so forth. I have read one positive birth story in which a woman who was having her second child did not have an episiotomy and the doctor massaged her perineam instead.  I'd tend to think that that is the exception rather than the rule, sadly.

Conditions in Hospitals
Generally only one person can be with the birthing woman.  When I first wrote this article, there was one doula in  Sarajevo, apparently. She could only attend births by pretending to be a cousin but eventually was recognized and not allowed to come anymore.  Since then, in 2016, a number of women trained to be Doulas with Dona International - the first training session of this kind in Bosia-Herzegovina.  It remains to be seen whether they will be allowed into hospitals.  Fathers are allowed under certain circumstances I'm not so clear about.  Perhaps you have to be in a special room because generally there aren't single rooms.  The national hospital has rooms for two people (though it's not so busy, so often the room is to oneself), and Jazero hospital has rooms for four. So, not so sure about the rules for participation of men, but I've heard a few stories which make it seem like men are not welcomed as they should be.

The large hospitals are quite well equipped.  I think that they probably okay at managing genuinely complicated births... but then again, there was one comment from a friend that indicated that some high tech equipment that was donated is just sitting there not being used because staff don't know how to use it.

Finally, and I think this is the most serious problem, women are not treated in a way that respects their right to informed consent.  Routine procedures are administered without asking the patient or explaining what they are for.  If the woman protests, she is seen as challenging the doctor's authority and is labelled as uncooperative.  Most women see the hospital policies as laws and don't feel like they have the right to go against hospital policy for example to decline an episiotomy or request to nurse their baby immediately after birth.  I have also heard stories that amounted to abuse, such as not allowing a woman to see her baby for many hours or scolding a woman for wanting to birth in an unconventional fashion.

How Women Feel
Many of the things I've said about the situation here are not very encouraging when it comes to my personal perspective.  I think what they are doing is far too medicalized and many of their procedures (not to mention their attitudes towards patients) are genuinely harmful.  Having said that, I have asked some women around the neighbourhood how they felt about their birth and most seemed kind of okay with it all.  I think that's partly because they don't know anything else.  Popular culture tells us birth is scary and painful, so when that's what they get, they're not surprised. Its also in some cases because they genuinely believe that what the hospitals offer is great care.  Once again because of cultural conditioning, they believe that a short labor is better (since it's painful and difficult anyway, using drugs to speed it up must be good, right?). And, those who have means are happy they can bribe a doctor for an elective C-section and skip all the horror. Some of those who are poor may simply be happy to have any access to maternity care, since the alternative would be an unassisted birth.

Those who know more about the situation from family or previous births may just accept whatever the hospital does and live with it.  They may know it's bad but they take an attitude of non-resistance as a way to get through.  For example, if you know delayed cord clamping just isn't an option, you don't trouble yourself to make a fuss and ask for it. Just like I don't usually bother asking the taxi drivers at the airport to use the meter.  I know they aren't going to do that and they will charge about four times the normal rate and if I argue with them, I'll just end up stressed and anxious, so I can't be bothered causing a fuss.  However, I have heard from some women who are really passionate about natural birth.  They really argued for what they wanted and made it happen.  I suppose that's what it takes.  As sad as it is, that's probably what's needed to make a change in the hospitals' attitude.

Of course, I should say that some women may have had a good experience - perhaps they ended up with a more compassionate doctor or they had some kind of social standing and were treated better because of that. 

What can be done?
If a woman wants to have a natural birth in Bosnia that doesn't include many of the standard hospital practices, what can she do?  I believe women need to inform themselves about the situation, about their rights and make their choices known to their caregivers, ideally before the birth.  People should realize that hospital policies are not laws they have to obey.  Also, just because they sign something upon admission that says they consent to what the doctors will do does not mean they can't withdraw their consent. It should be possible to make a signed statement withdrawing consent if necessary.  In other countries, patients have sued hospitals for assault if a doctor performed, say, an unwanted episiotomy or coerced someone into an unnecessary C-section.  Both hospitals in Sarajevo have nice sounding patient rights published on their websites, so being aware of these rights could be helpful.

But, as I say, it's probably better to make your preferences known before the birth, as having to argue during labour isn't going to be easy (or helpful for the progress of your labour).  Since it's not necessarily known who will be on staff when you go into labour, maybe it's worth preparing a written document that you can ask as many doctors as possible to read and sign, before the birth.  I really don't know if it would work, but it's worth a try!

Beyond that, the other option is a systemic change - there needs to be a reviving of the midwifery profession here with proper tertiary education and training, there needs to be safe homebirthing options with back-up from hospitals and there needs to be midwife led birthing centres set up.  I focus on midwives because the midwifery profession is about understanding and supporting normal birth.  Obstetrics is a branch of surgery that is needed for complicated pregnancies and births, but when obstetrics takes over all births, it makes normal birth unnecessarily medicalized.

Conclusion
In a country where government services are under-resourced, it seems surprising that a rather expensive, overly medicalized maternity system exists.  The midwifery continuity of care model, including homebirths and birth centres for lower risk pregnancies, would be significantly cheaper.  Perhaps the system reflects a desire not to be backwards - having a lots of ultrasounds and having a C-section are sometimes seen as symbols of sophistication.  Moving towards a new model would take a major cultural change - it would take a greater humility from hospitals that another way is valid and it would take women believing that a less medicalized birth is possible, safe and even enjoyable and progressive.

Thomas's Birth Story

Here is the story of my first child's birth and a bit about the pregnancy. For more info about why I decided to have a natural birth, see this post.

My husband, Lessan, myself and our friend Mona planning for a camp for youth 

When planning to have a child, we didn’t want to unduly impact upon our volunteer work in Bosnia and had therefore assumed we would remain there for the birth.  However, after about four or five months, I began to realize that it would be incredibly challenging for us to birth in a Bosnian hospital.  We realized that it was very important for us to have a natural birth, without unnecessary medical intervention if possible, in a very calm environment. My preference became going to a birth centre or having a home birth, but unfortunately, neither of these options are available in Bosnia.  Furthermore, although one of the hospitals seemed to give some credence to natural childbirth (it didn’t even offer epidural), it had some strange practices I couldn’t abide by, including routine episiotomy for first-time mothers and limiting the involvement of fathers in the birth.

So, with much consternation and stress, my husband, Lessan, and I made the difficult decision to leave our post for three months and have the baby in Australia.  This had the advantages of allowing us more control over the birth experience as well as being able to share this special time with our families.

After some investigation into the options, we decided to hire a private midwife with experience in home births.  We found a wonderful midwife who lives in the Adelaide hills called Julie Garrat.  She was accredited with Medicare, which reduced some of the costs.  We really liked her stance towards childbirth, which included accepting it as a divinely designed process which we need to trust.  She also knew about our Faith (the Baha’I Faith) and had a good impression of it.  We were really grateful that she accepted to take me on, even though I was still overseas and would only be arriving 6 or 7 weeks before the birth - many other midwives we spoke to wanted to follow the whole pregnancy. 

We discovered that most airlines allow you to travel between the 28^th and 36^th week of pregnancy with a letter from your doctor, so we planned the travel for when I was 34 weeks. My gynocologist was happy to approve the trip.

When investigating natural childbirth, I had come across the concept of “Hynobirthing”, a way of having a comfortable labour through self-hypnosis.  I was convinced that natural childbirth was the safest for mother and child, and also very satisfying for the mother, but I had been exposed to many traumatic birth experiences, so I was unsure how I would cope without medication.  Hypnobirthing became my source of strength and hope.  I ordered a “hypnobabies” course online and did my best to follow it once it arrived, at about week 30.  I really enjoyed doing the readings with my husband, Lessan, as it helped us come to a common vision about what we wanted.  I also enjoyed the relaxing nature of the self-hynosis sessions; however, I found it challenging to keep up with the required practice (five times a day).

I also did my best to start my pregnancy at a good weight and in good health and continued to eat well and exercise as much as I could to try to stay low-risk.  For example, I did pilates to have the strength to give birth and did a lot of fetal positioning exercises from early in the pregnancy, daily from the spinning babies website to try to make sure my baby’s head had enough room to go down, and stay down (which, fortunately it did).

We arrived in Adelaide on 7 April after a long trip with an overnight stopover in Dubai.  For the next six weeks, we spent time with Lessan’s family, making arrangements for the birth.  We visited a GP who could refer us to Julie.  We were assured by her that Julie was a well-respected midwife.  And, though this wasn't the case for Julie, we heard from the Dr that some independent midwives were not well regarded by hospitals and sometimes the transfer to hospital was complicated.  The general feeling towards homebirth in Adelaide was not as open as I'd hoped it would be.  I.e. the fact that to get Medicare coverage, you had to get a referral from a Dr, but I guess we were happy to jump through those hoops, since we knew it wasn't even an option in many other countries. For more on this issue, see this article.

Julie followed the rest of my pregnancy, visiting once a week for a chat and check-up. She checked the baby's size by measuring my fundal height, it's position and engagement by feeling my belly, as well as checking my blood pressure and the baby's heart rate.  It was really a novel experience having my belly palpitated.  I enjoyed it very much, as it felt like there was more of a connection between me and the caregiver.  In Bosnia, I had been seeing an OB-GYN (seeing a midwife wasn't an option) and she had never examined me with her hands, she only checked the baby with her ultra-sound machine, and did this at every visit (weeks 6, 9, 12, 16, 20, 24, 28, 32 etc..).  I would have much preferred to have a Dr that usually examined me with their hands, rather than exclusively taking ultrasounds, but we couldn't find one! Apparently, in Australia, they only do two ultrasounds routinely, at weeks 12 and 20, and more if necessary.  Plus, my OB-GYN seemed to want to check my blood and urine quite frequently, whereas in Australia they only do it twice unless there's a problem.  That seems reasonable to me.  Nevertheless, since I'd become accustomed to the interventionist model in Bosnia, it took me a little while to get used to the lower-tech approach and still feel like the midwife was 'doing something'. I guess I'd also gotten used to seeing the baby, which is kind of reassuring, but not really necessary.

Nesting complete at the birth location

We took some time to finalize where we would have the birth.  We couldn’t have it at my in-law’s place, where we were staying, but fortunately found another family who lived in the hills who were happy to host us for a few weeks.  They had had all three of their children at home, so they were really supportive and understanding about our choice.  We moved into their place a week before my estimated due date and basically just relaxed and hoped the baby would come.  For most of that week, there hadn't been much sign of impending labour, except for a few Braxton Hicks contractions, which I'd already been having for a while.

On 19 May (the day before my due date), we went out with some family members for a visit to a nearby village. That morning, I started to get excited because I had had many more Braxton Hicks contractions and they continued almost all day. Sadly, it all stopped that evening.  However, that day a fair bit of clear/yellow fluid started flowing.  I called Julie about it and she agreed that it probably was just vaginal fluid.  But, by Wednesday 23 May, I started to wonder if it could be amniotic fluid.  Julie came over and had a look at my pad.  She couldn’t be sure, but was tempted to think it was amniotic fluid after all.  If it was, she assured us that it was from a small tear at the top of the uterus.  The only concern was that it could lead to infection, but she thought this to be incredibly unlikely.  As a precaution, she suggested I take my temperature every 4 hours.  If I wanted to test for sure whether it was amniotic fluid, I could go to the hospital, but if they found out that I did have a leak, they would fully break the waters in the hopes of starting labour.  If it didn’t start in the next 24 hours, they would proceed with stronger and stronger induction methods.  It would mean a very different journey to the one we hoped to tread.  Just contemplating this possibility was very unpleasant; however, I was ready to take that route if it was deemed the best for the baby.  In the end, though, we concluded that the risk to the baby was very small by just waiting for labour to start naturally and by being careful to avoid infection.  We went to the pharmacy and got some supplements and spent a bit of disturbed night wondering if everything would be okay.  I even called Julie at midnight to tell her that the waters were now red, but she assured me that this was fine; it just meant there were changes happening in the cervix.

By this time, our hosts had left the house to go on a trip to Vanuatu (they left on the 22nd).  I had told mum we wanted some time to ourselves, so we just spent the next couple of days cleaning and arranging down stairs. I was grateful that family wasn’t around, since they probably would have made it harder for us not to go to hospital.

By Friday night, I started having some mild contractions, very spaced apart. I called Julie and she said just to sleep and relax, because I would need my strength for the rest of the labour. Saturday was spent with a visit from family – cooking and cleaning together.  The contractions continued, but once again, they were very spaced apart and I was able to behave as normal, I just rested and leant forward during contractions. I had a nap in the afternoon as well. By 11:30pm the contractions had become stronger and closer together so we started timing them and they seemed to be between 1 and 5 minutes apart, lasting around a minute each. I was pretty sure that this meant I was fairly advanced in the process, so I called Julie expecting she would come soon. However, she said it sounded like it was still pre-labour and I should rest as much as I could through the night and we would talk about it in the morning. I was a little disappointed to hear that, but I did my best to rest though I couldn’t really sleep through the contractions any more. Lessan went downstairs and pumped up the birth pool, then we moved to sleep in the lounge downstairs, beside the fire (because it was getting cold upstairs). We dragged an armchair close to the mattress so that I could kneel on the bed and lay my head on the chair. I spent most of my time there, from then on. We put the electric heater next to the toilet as I frequented it often. I managed to get through the night by resting between contractions and trying to use my hypnosis techniques during contractions. Unfortunately the self-hypnosis didn’t seem to be eliminating pain, but it did help me to stay calm and relaxed, which made them easier to bear. Lessan suggested I listen to the Birthing Time track from the hypnosis course, but I flatly refused as I had tried listening to it earlier in the evening and it annoyed me by suggesting that my “warm and loving pressure waves” were comfortable like a big strong hug, which simply wasn’t true. I did, however, enjoy listening to the playlist that we had selected for this time, and appreciated the low light and the oil burner burning clary sage oil. 

In the morning it was apparent that I still wasn’t in active labour as my contractions were irregular. Julie sent us a link to an article about a pattern of labour whereby a woman can have a very long latent labour followed by a very short and effective active labour. The latent phase is characterized by irregular contractions (though sometimes close and intense), and can last many days.  Changes do occur to the cervix, but dilation goes up to about 3cm.  However, throughout, the body is doing necessary work to change the body and position the baby, so dilation can increase dramatically within minutes when the time is right.  So, it’s important to trust the body, be patient and think of it like an endurance test.  Sometimes, mothers are told to keep active to try to get things going, but by doing this, they end up exhausting themselves and end up in hospital as a result.  She reassured me that I wouldn’t be slowing the labour down by resting, I was doing what my body needed.  If I did want to be active, I should only do so in the day – keep day day and night night as much as possible.  This was crucial advice and I think I may just have had more problems if I hadn’t followed it.

I spent the rest of the day much as I had the previous night, mostly leaning forward over the couch but occasionally walking around a little or sitting on the birthing ball. Anything else just made contractions unbearable.  We kept the lighting low by having the curtain closed, which I found to help foster a calm environment. Lessan supported me by bringing me food and drinks and saying prayers aloud, and reading to me a little.

In the evening Julie came to visit. My contractions had gotten stronger and I couldn’t talk through them anymore. She checked the baby’s heart rate and informed us that I was still in pre-labour and needed to continue to rest.

By midnight I was finding it harder to relax through contractions. Lessan timed some of my contractions and it seemed like they were a bit more regular, around 5 minutes apart. I was also feeling pain in my cervix and near the coccyx bone so I thought I might be in active labour. I called Julie and she said it was most likely the beginning of active labour. Once again I was quite disappointed that it was only the “beginning”. She encouraged me to continue to rest and she would come to see me in the morning. She said that she would come to check my dilation at that point (she hadn’t up until that point). If it still hadn’t progressed much then I had the option of going to hospital if I wanted an epidural so I could get some sleep. These options started to become more appealing but I still hoped it wouldn’t come to that. I just worried what transition would be like, if this was just “early active labour”.  A little later I noticed that I had a strong urge to urinate but nothing would come out. Julie later told me that this meant the head was descending.

A few of hours later, Lessan had fallen asleep and I was having a lot of trouble managing, so I decided to have a quick shower, even though we were trying to conserve the limited hot water supply. By 4am I called Julie and asked if should go in the birthing pool. She said I could if I wanted to, but suggested I could also have a bath.  I reluctantly decided to have a bath – I had been longing to get into the birthing pool from the first contraction on Saturday night.  I soon started to feel a little ‘pushy’ at the end of contractions, and this got much stronger by the time I got into the bath, around 5am. In fact, my body was pushing without me doing anything at the end of each contraction. This really scared me as I was pretty sure my cervix couldn’t have been fully dilated yet, and I had heard stories of women pushing without being dilated which caused injury to the baby. So I frantically called Julie and she tried to reassure me that it was okay to push, and that she was coming. She asked me to put my finger up my vagina and I did feel something soft there, which she said was probably the head but I wasn’t so sure because it was so soft. I still didn’t believe it was okay to push, even though I couldn’t stop the pushing when I tried. I was making loud noises in my attempts not to push and counting the minutes until our midwife would arrive.  Meanwhile, Lessan went out to fill the birth pool.

When Julie arrived, she checked me and saw that I was more than fully dilated, the head was about to come out!  She helped me walk to the birth pool, which felt strange because the head was so low.  I was going as fast as I could so that I wouldn’t have a contraction on the way, but I didn’t, since they had become quite spaced apart.

Lessan got in the pool with me to support me.  We saw that it was 6:15am.  We were happy and smiling, marveling that the time to push had come so unexpectedly.  Lessan held me as I lay back, and then I decided to squat, so he sat in front of me and held my hands.  I pushed only when I felt a contraction.  As I said, they were now quite spaced apart and also their intensity seemed a lot less, more of just an opportunity to push, which was a huge relief.  Soon the head emerged and I could feel it with my hands.  It was so soft and I could also feel the hair swaying in the water.  Each time I pushed, the head came out, but then at the end of the contraction, it came back in.  This was happening for some time and I was starting to become impatient, but I still didn’t want to push too hard and risk tearing.  Julie was just sitting by and reassuring me that I was going well and that everything was as it should be.  She also busied herself boiling the kettle to keep the pool warm (unfortunately the hot water system wasn’t cooperating too well).  At some point, she checked the baby’s heartbeat and said that he was “enjoying his birthday”.  She also took a number of photos for us.  Lessan got out at some point, since I was managing without needing to lean on him and he was uncomfortable in the water.  Actually, I was too, but I liked the water for the pushing. Eventually, the head came out to a certain amount and didn’t retract again.  At the next contraction, it emerged fully as I was kneeling forward.  Then, with the next contraction, Julie told me to give a big push.  This took a lot of strength and I felt more uncomfortable stretching than ever before at that point, but it didn’t matter so much because that was the moment that the rest of Thomas’s body emerged.  Julie caught him from behind and passed him to me under the water so that I could lift him up!

I pulled him into my arms and held him for a while. He was quiet and not breathing at first, but Julie assured me he was okay, since he was still being fed by the placenta.  I blew on his face and he eventually let out a bit of a cry, which was a relief.  From then on, he was rather calm and content. I then tried to lead him to the breast, but he didn’t want to take it.  We called the family and had a chat.  After a while, I became a bit uncomfortable, as the water wasn’t warm enough and also I had a bit of discomfort down below.  I was also worried Thomas was getting cold.  Once the cord stopped pulsing, Julie clamped it and Lessan cut it.  I then handed Thomas to Lessan so that he could hold him while I pushed out the placenta.  The idea was to wait for contractions to come naturally from the nipple stimulation of the breastfeeding, but that wasn’t working, so I just pushed really hard and it came out, mostly.  I had to push and also pull it a little to get the rest out.  Big globules of blood also came out, which made it seem like the placenta was broken, but fortunately it wasn’t.  The pool went all red, like there’d been a shark attack (so I guess I hemorrhaged a bit)!  After that, I was pretty eager to get out.  Julie helped me climb out. It felt very strange because my belly was like jelly, it was as if I didn’t have any abdominal muscles at all!

She led me to the bed and I lay down and tried to breastfeed again.  It wasn’t working, so Julie intervened to help things along.  He finally latched on.  It was so strong, it felt like he was biting, but I remained calm as our midwife saw that he was latching on correctly. While he fed, I ate some food Lessan brought to me.  Julie then had a look to see if I had torn as I looked at Thomas next to me.  Unfortunately I had.  This had been something I really wanted to avoid.  But, now that it had happened, I wasn’t particularly concerned.  It hadn’t hurt me a lot and it seemed rather minor in the scheme of things.  I hadn’t torn when the head was coming out, as I had felt myself that whole time, but it must have happened when the shoulders were coming out, as he had probably twisted himself a bit.  In fact, I remember feeling him trying to wiggle his way out.  (Even when only part of his head was out, I felt him turn from side to side – a very weird experience!)  She saw that it was a shallow cut, but it went all the way to my anus, so it required stitches.  Apparently, I have an unusually short perineum.  At first, she thought it would be best to have the obstetrician to do it, so we prepared ourselves to go to the hospital.  But, after realizing this obstetrician wasn’t there, she called him at home to ask some questions and decided to do it herself. The local anaesthetic didn’t really hurt after the previous exertions, and then the stiches not at all.  Thankfully, I had a midwife who was a good suturer, who carried local anesthetic! I then got up and had a shower.  I still couldn’t wee, and it felt like I had no muscles left down there, but I weed later in the day and by the next day, I was basically back to normal in terms of elimination needs.

It felt so strange to suddenly have a baby.  It took me a little while to get my head around the idea.   I had used all my mental power to get through the labour and birth, I wasn’t quite ready for this next stage.  It also took a little while (that day I guess) to bond and really fall in love with Thomas.  I didn’t exactly feel a sudden rush of emotion for him; it grew slowly but surely over the day.  However, I was incredibly happy and excited about the birth.  I felt so relieved that it had gone so well in the end and that the baby was safe and healthy. I was so relieved that I hadn’t ended up in hospital. I had avoided being induced because of the leaking amniotic fluid and I had avoided going because of exhaustion from a long labour.  I was also incredibly surprised that I had handled the pain so well.  I had hardly even made a sound the whole time (except for the pushing, which had left me with a sore throat, not because it was painful, but due to the nature of the sensation).  I reflected that, although definitely uncomfortable, I found the labour manageable and not deserving of the fear that people create.  I felt much empowered for having gone through this experience almost entirely on my own – for many hours Lessan was asleep and our midwife wasn't there for most of the time.

Thomas asleep after his first feed

I should add, though, that it seemed like the hardest part of our midwife's job started after the birth.  She was responsible for making sure Thomas was healthy, was feeding okay and was gaining weight.  She visited me every day in the week after the birth to make sure this was the case and then a couple of times a week in the weeks before we left Adelaide.  Thomas and I had a little bit of trouble getting the hang of breastfeeding in the first few days, so it was such a relief to have that constant support and guidance.  I had many questions and concerns and Julie was always on available by phone, between visits, to help which was great.  This was a great, though brief, experience in continuity of care!

I think a lot of my good experience can be attributed to having a very experienced midwife who trusted in the natural order of things, yet knew when intervention would be needed, and encouraged me to rest and also take charge of my own experience by showing her confidence in my ability to birth this baby!  I also did benefit a lot from the hypnobirthing preparation.  It helped me learn to relax, even when I felt fearful.  Though it didn't eliminate pain, as it said it could, I don't think this is a problem.  I'm now not sure if it is realistic to do so.  It's part of the order of things, a part of transforming into a mother, but maybe that should be another post!