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.

My journey towards natural childbirth

When I try to recall my first impressions of birth, and where they came from, I can think of a few things.  One is an American movie that my Dad used to like and let me watch a number of times, called "Look Who's Talking".  It's about a married couple who have a baby and all the struggles the couple go through in the process.  Oh, and, when the baby is born, it's really cute and you can hear it's thoughts.  I remember the pregnancy was shown to be a big pain.  The mother was uncomfortable, she was moody and emotional and she was really thirsty all the time.  In one scene she drank a whole carton of orange juice.  When it came time for her labour, the contractions came on suddenly and it was all panic and agony as she rushed outside to hail a taxi, sped to the hospital (yelling at the driver to speed up) and cursed her husband for putting her in this mess as she pushed the baby out.  From watching another movie more recently, it was pretty much the same thing.  Panic, pain, fear.  Who'd want to go through that?

This negative impression was sadly reinforced by my mum's accounts of giving birth to me and my sister. She went a 10 days past her due date, I think, and was told she needed to be induced.  The doctor she had been seeing was busy playing golf when she had the procedure, and so she had to be with an unfamiliar staff, as well as student doctors who frequently came in and observed her.  My mum is a rather modest woman and so I don't think this would have been relaxing for her, to say the least.  Since she was having a chemical induction with the syntocin drip, she really found the pain unbearable, she even said she felt like she was being ripped in half!  Not encouraging stuff to hear as a girl contemplating becoming a mother.

As a teenager, I saw my step-mother give birth to my two half-brothers.  The first birth, my Dad took my sister and I to the hospital just as she was pushing the baby out.  This was a fairly positive experience.  She didn't seem to be suffering.  She was lying on her back, legs in stirrups.  She had had an epidural and when the baby came out, we got to cut the cord.  I was in rapture when I saw the sweet baby, looking around at his new environment, kicking his legs like a little frog.  The second birth, though, I must say, was a bit disturbing.  My step-mother had an induction and the whole process went very fast - she gave birth within two hours!  She decided to try without an epidural this time and only used gas and air towards the end. It was hard to watch, as she didn't seem to be coping too well and became loud.  This from a woman who frequently bears the pain of severe migraines with quiet resignation.  She was in good spirits afterwards, though, and said that the pain didn't matter because it only lasted a short time.

My sister then became a mother before me, at a young age, and she too had a difficult pregnancy with nine months of nausea as well as a long labour that she found traumatic.

All of this left me quite fearful of pregnancy and birth.  When I looked at pregnant women, I thought they must feel like they were sitting on a ticking time bomb as they counted the months and weeks towards the day of agony.  It didn't comfort me to think it would only last a day, or at worst, a few days.  It didn't comfort me that you would forget the pain.  I knew what it felt like to be in pain or discomfort (like when I burnt my hand or cut myself) and even a few minutes feels like an eternity. And, getting a baby at the end is a good reward, but I wasn't convinced it was compensation enough for what people seemed to go through on TV etc.

So, as you can imagine, I was somewhat anxious about the birth of my own baby when I fell pregnant and kind of assumed I would probably have an epidural, and maybe other things too.  However, I had already heard a little about the benefits of labouring without drugs from the time when my mum was pregnant with my youngest sister and I had already heard about the downsides of elective Cesarean section.  So, I hesitatingly began researching more about what natural birth was and it's benefits. As I read more, I realized that it may actually be something I wanted to pursue.

It seemed that every form of chemical pain relief had risks for me and/or the baby.  Just look at the cons listed on this Mayo clinic page.  I also learnt that they can interfere with the birthing process, thereby leading to a more complicated delivery, complicated afterbirth, and can possibly affect the health of the newborn and its ability to breastfeed.  It was really important to me to have a straightforward birth and for my baby to get a good start on breastfeeding.

Still, it took me a while to get my head around the idea of forsaking all chemical pain relief. I never, in fact completely ruled it out, but my hope of having a natural birth increased somewhat when I discovered the concept of hypnobirthing.  It's basically a way of achieving a comfortable, and even painless, childbirth through self-hypnosis.  I had already heard of people using self-hypnosis to undergo normally painful operations if they were allergic to anesthetic, and so I believed it was possible, but I wasn't sure I could achieve that kind of mind control.  I would have liked to have been coached in person and have that person actually attend the birth, but settled for a home-study course produced by "Hypnobabies". This course explained that self-hypnosis consists of two aspects - one is reprogramming the sub-conscious mind and the other is learning relaxation techniques. I'll briefly address each of these.

For the first aspect, the course explains that we all have preconceived ideas about childbirth and that "what the mind expects, it will create".  That is, if we have been trained to believe that birth is painful, we will expect that and then our bodies will experience pain.  Between our conscious mind and our sub-conscious mind, there is a kind of filter whereby we decide what to accept into our deepest beliefs.  In order to disable this filter, we have to go into a hypnotic state (which is basically a relaxed, passive state).  Once in that state, we can listen to positive birth affirmations and learn to believe and accept those statements or "hypnotic suggestions".  This part includes learning a new vocabulary to describe terms associated with birth that are free of the normal negative associations, and which describe birth positively, like "birthing time" instead of labour, "birthing wave" instead of contraction, and never mentioning pain.  Only "birthing sensations" or maybe "discomfort" if necessary.

The second aspect is entering a relaxed, hypnotic state, whereby you don't feel pain, but only "pressure".  Various techniques are used, including visualizations of "hypnoanethesia" spreading around the body, going loose and limp and focusing on deep, slow breathing.  By the way, the breathing that they teach is similar to that taught by the Bradley method.  Both methods also encourage the mother to move freely throughout the labour, which assists the descent of the baby.

Both of these methods work, it seems, because they fit into the physiology of birth.  Firstly, the hormone that initiates contractions is oxytocin.  Adrenaline, the hormone of fear and anxiety, undermines the effectiveness of oxytocin and, according to Hynobabies, fear can cause the lower abdominal muscles to work in opposition to the upper abdominal muscles, causing pain.  However, in a relaxed state, they argue, contractions are not really painful, but just powerful sensations.  Furthermore, deep breathing can reduce pain because it oxygenates the blood and one reason for pain is the accumulation of lactic acid from muscular contractions.  Oxygen allows the lactic acid to be broken down.  Finally, there is this thing called the fear-tension-pain cycle.  When you are in pain and fearful, you tense up because you are fearful, which increases your pain levels, causing more fear and so forth. The more your fear pain, the more pain you are in. So, purposefully relaxing, even if you are fearful or in pain, can reduce your overall pain and also release natural painkillers, endorphins.  Other things, like being able to move into natural positions in response to the descent of the child, swaying the hips, being in a darkened room, surrounded by familiar, reassuring people, can reduce fear, increase relaxation, and increase the release of natural pain killers whilst allowing labour to proceed without 'stalling'.  

The reasons for all of these are well documented in lots of places around the web, so I won't go any further into it, but it's a very interesting area.  Basically, when women are not conditioned to fear birth, are with supportive care givers who can minimize fear and the woman is free to labour and birth as she instinctively wants to, her natural ability to birth shines through and medical intervention is needed far less than it is administered in hospitals.  Giving birth in this natural way, where the natural hormones are not interfered with, can be a very empowering experience, as there is a rush of joy and a sense of accomplishment at the end.

Many of these ideas came across in a number of films, articles and stories I read and these gave me confidence that I could have a positive birth experience.  But, I came to realize that my best chances for achieving this involved finding a place to birth where I could control the circumstances to some degree and fully relax.  I would also need to be somewhere where they wouldn't interrupt my concentration during hypnosis. I imagined getting to hospital and having to fill in forms (in a foreign language) and having all sorts of exams and tests... not to mention if I didn't feel comfortable with the way the staff treated me...this would definitely break my concentration and maybe set off the fear-tension-pain cycle in a major way!  And, if this article about the situation in Serbia is true and if Bosnia is anything like this, I had good reason to run away as fast as my pregnant belly would allow.

Another part of the Hynobabies course involved staying healthy during pregnancy to reduce the likelihood of complications.  And, it presented a lot of information about routine hospital practices which can increase the likelihood of complications and make it harder to have a comfortable birth.  Through this, I realized that having a natural birth was not just about avoiding pain medication, it was also about not interfering unnecessarily in the physiological processes.  I say unnecessarily, because there is certainly a place for interventions, but it seems that hospitals apply them far too broadly based on their own convenience or on population data that doesn't adequately consider the individual case of each mother and baby. Furthermore, once you have upset that balance, the body often needs further medical help because you have taken away what the body needs to do what it's meant to do. Once you get on the bandwagon of interventions, you basically can't get off.  For example, if you have had interventions and pain medications in your labour, it is safer to have a 'managed' delivery of the placenta.  However, if you have managed to stay drug free, a natural 'third stage' is quite safe. See here.

Another big example of one procedure leading to another is induction.  That is, starting labour artificially. The worst kind is with a syntoccin/pitoccin (artificial oxytocin) drip, although other methods can also be quite nasty.  Syntocin (which is also used in 'augmenting labour') really interferes with the body's ability to produce it's own oxytocin, thereby majorly disrupting the body's own management of the system.  Syntocin contractions are said to feel much more painful because the drug doesn't affect the brain in the same way as oxytocin.  Since it's more likely that the baby goes into distress with an induction (because of the intensity of the contractions), the baby's heart rate needs to be continuously monitored, which means the mother becomes basically strapped to the bed, and this itself increases the sensation of pain.  There are also risks for the mother in overstimulating the uterus and uterine rupture is possible.  Also, once you have had this kind of labour, you are more likely to want an epidural to manage the pain, which can lead to difficulties pushing, which can lead to tearing or instrumental delivery.  First time mothers who are induced are also more likely to need an emergency Caesarian section. There are many articles talking about these risks (e.g. this).

Although there are some valid and neccessary reasons for inducing, the most common is for "prolonged pregnancy".  Take a look at this article from Midwifethinking and this article from the perspective of famous midwife Ina May Gaskin for more information about inductions for being 'overdue' and how it's not always neccessary.  I was hopeful to avoid an induction, and that is one of the reasons that I felt the need to have a private midwife who would be more responsive to my individual situation and health and not feel the need to arbitrarily send me for an induction if I went too far over my due date.

There are many other hospital procedures like that, many of which can interfere with the birth process, but which can be hard to fight if the hospital insists that these are it's policies.  For example, the routine use of glucose drips that restrict movement and potentially cause hypoglycemia in the baby, prohibitions from eating during labour, continuous fetal monitoring, restrictive ideas about how long labour or pushing can safely last, not allowing waterbirth, insistence on performing episiotomies, coached "purple" pushing, restricting movement during the pushing phase and insisting on an actively managed third-stage (birth of the placenta).   Also, it is important to consider a hospital's policies for dealing with complications, such as waters breaking hours before labour, the presence of meconium, breech presentation, or having a vaginal birth after previous Cesarean section.  These situations are not necessarily emergencies, but many hospitals have extreme stances on them.  Not to mention the way the hospital treats the baby when it's born, such as early cord clamping, taking the baby away from the mother for tests and examinations immediately after birth, bathing the baby (washing away beneficial bacteria and healthy vernix coating), giving formula instead of allowing the mother to exclusively breastfeed, observing it in the nursery away from the mother, routine injections that may not always be necessary, and so on.  I know that not all hospitals have all of these policies, but most have at least a few of them, which is why I became wary of hospitals.

The more I thought about it, I also just didn't like the idea of being in a hospital.  I felt that simply being in the place for sick people would make me expect pain.  Staff looking at me, expecting me to have pain, would also make it more likely for me to play that role, and this would also increase the sensation of pain.

Isn't that a bit risky, you may ask?  Well, generally speaking, physiological birth is safer.  Even hospitals will tell you to avoid coming in too early because that way, you will be less likely to be given medical procedures, which even they acknowledge, do tend to increase risk. Only when the risks of interventions outweigh the risks of complications that have arisen are they beneficial.  Furthermore, examples from the animal world can be very enlightening. I once read a story of how a breeder of valuable racehorses knew never to intrude on the labouring mare, as interfering risked the saftey of both mother and child. The veterinarian would simply hide and secretly observe the mare and only intervene if there was some major deviation from normal.

Through much investigation, I realized that a good midwife does very much the same thing as the veterinarian I described. She is an expert in normal birth.  She is is not trained to address major complications, but does have the experience to spot them before they become critical and can refer the expectant mother to specialist care.  As I was quite healthy and having an uncomplicated pregnancy, I felt I would be safe birthing in the comfort of a home environment with an experienced midwife.

I must admit that the leap to deciding to have a homebirth (and not just at a birth centre) was a bit scary.  It was partly precipitated by not having access to a birth centre (by the time I arrived in Australia, the only one in the city was fully booked), but it was also that I felt I would have more choice in regards to how I could respond to various potential (minor) complications.  Even birth centres have policies that can be overly restrictive when it comes to things like waters breaking early or going overdue. And, when deciding to stay at home, I was reassured by being very close to a hospital in case something went wrong. Finally, I had a very supportive husband who was, at times, even more enthusiastic about homebirth than I was!

Towards the end of my pregnancy, I started to think about having an empowering birth, not just a safe and comfortable one.  I started to move a little away from the hypnobirthing philosophy.  Maybe it was due to the influence of other mums I spoke to, maybe it was because I couldn't keep up with practising hypnosis five times a day!  I still believed that it could be possible to control your mind such as to eliminate pain but I also considered that maybe, learning to accept some pain and surrender to it with courage was part of God's way of preparing the woman to become a mother, a rite of passage in a beautiful, transformative process.

In the end, I did experience discomfort, maybe you could say pain, but I found it really manageable, and it was very healing to see that the negative image of birth I had received didn't have to be true for me. I wasn't excessively anxious or fearful.  I was patiently awaiting the arrival of my baby. The hypnosis techniques, as well as breathing deeply, really helped me to stay calm. There were times when I felt like it might be getting too much, where I thought it might help to yell out in pain. I tried this, but I could feel it instantly increased my heartrate, increasing fear and making me feel out of control and in more pain.  So, I stuck to being quite, breathing through it and visualizing positive things, like being with my baby in a "special place".  When I felt huge pressure opening up my cervix, I tried to imagine a romantic encounter with my husband on the beach. I think this helped!  In addition, using comfortable positions, being in the dark, listening to soft, gentle music and immersion in warm water all helped me to stay calm and manage the sensations.

For most of my pregancy, I found it hard to get my head around the idea that I was becoming a mother. In the first trimester, I didn't even allow myself to think too much about being pregnant, as I knew the risks of miscarriage were higher.  By the third trimester, I was enjoying being pregnant and I liked the look and feel of my big belly.  I looked with hope to the birth of my baby, but also with much trepidation, wondering if I was ready for this huge responsibility.  Even around my due date, when people asked me if I was sick of being pregnant, I said "No, I like being pregnant", maybe because I still felt a little unprepared.  So, I think I needed the long, quiet, contemplative labor I got.  Even the pain served a purpose of making me feel grateful for the gift I was about to receive, and when I got through it, the sense of accomplishment made me feel really strong and happy. I certainly needed that strength in the early days to get through the rigors of early parenthood, what with post-partum soreness, sleep deprivation, the steep learning curve of settling a baby and breastfeeding through painful nipples.

All in all, I got the birth experience I wanted.  It was a beautiful, empowering journey into motherhood.  I'm truly grateful for this because I realize that many women are not entirely satisfied with their birth experiences. I have read articles which say that the pain of labor doesn't matter because you forget it afterwards and you are rewarded with a beautiful baby.  I think this is not entirely true.  There is evidence that women who suffer traumatic births are at a higher risk of post-partum depression and even post-traumatic stress disorder. This kind of trauma can result from fear that hasn't been addressed, from environments that promote fear, from unnecessary interventions that cause complications and from inhumane protocols.  For many women, their birth experience reverberates not only into their early parenting, but also into the narrative of birth they share with their children, and so the negative image of birth persists.  It can also affect their desire to have more children.  This is such a shame because birth has the potential to be a beautiful experience.  That is why I feel motivated to share what I have learnt about birth in the hope that together, we can help create a system that respects physiological birth.

Birth in Bosnia - Some pros for natural birth

My previous post looked at birth in Bosnia from the perspective of episiotomy.  I think this example demonstrates how the system is bogged down with bureaucracy which is perpetuating outdated and non-evidence based care.  Nevertheless, I realize that there are probably many caregivers who long for change but are too overworked and underpaid to be able to do so.  It's also not surprising that women are put "on the clock" and subjected to restrictive policies due to financial and time constraints.

Nevertheless, I think there are some positive aspects to the current situation that deserve a mention, especially if you're looking to have a natural birth.  Here are some things I have gathered about the system, which seem quite positive for someone hoping for a natural birth, and there are probably more I've missed.  I hope to learn more about the situation in the coming months.  By the way, most of them apply to the Bosnian national hospital, Abdulah Nakas.

Baby Friendly Initiative
Abdulah Nakas hospital is a "baby friendly" hospital. It is an initiative of UNICEF and the WHO designed to promote breastfeeding.  It includes allowing the mother to have skin to skin contact with the baby immediately after birth and to keep the baby with her afterwards, "rooming-in", rather than have the baby kept in a nursury.  Also, the baby is not fed anything a part from breast milk and is not offered a pacifier.  I'm not sure how it works at the other hospital in terms of promoting and actively supporting breastfeeding.

Episiotomy
My previous post looked at this issue. I mentionned there, but perhaps it's worth emphasizing that it is only routinely done for first time mothers.  I've read a couple of birth stories where the midwife massaged the perineum during a subsequent birth to prevent the need for an episiotomy.  Still, the post gave the impression that episiotomy is the norm and it's something special if it is not used, and that is rather disturbing...

More flexible timelines
According to a second-hand account, Abdulah Nakas is a bit more generous in how long they will allow a woman to labour before trying to speed things along somehow.  Perhaps this is because it is a bit less busy than the other one in Jazero?  Just a guess.

No epidural
When I first heard this hospital didn't even offer epidural, I thought that must be a sign that they were more supportive of natural birth than other hospitals in Bosnia and maybe than others around the world.  That may be the case, but it's also possible that they simply haven't evolved since the time when epidural wasn't invented or they don't have the financial resources to pay an anesthesiologist.  I guess that would have implications for how many c-sections are done, and if they are done, how they are performed.  The other hospital in Sarajevo does offer epidural.

No continuous monitoring
According to the Dr. I spoke to, they don't usually do continuous fetal heart rate monitoring, which is a good thing, because continuous monitoring is known to falsely show signs of distress, increasing the likelihood of unnecessary interventions.  Instead, they take the heart rate intermittently.

Water Birth
Abdulah Nakas is the only hospital in Sarajevo that offers water birth.  This does seem like a great way to have a comfortable, natural birth.  However, my impression is that the staff are not in general comfortable with this kind of birth, as evidenced by the fact that they only allow you to use the pool for two hours and also that they still think an episiotomy should be performed in the water.  That is very strange, as the water itself helps soften and stretch the perineum.  So, I'm not convinced this is really as good as it sounds.  I'm happy to be proven wrong, though!

Skills for handling complicated cases more naturally
A friend of mine had a vaginal breech birth at this hospital about 10 years ago, so it was possible then and may still be.  This seems to show that the Drs there have skills that valuable.  In many places around the world, Drs are not taught how to handle vaginal breech birth; they are simply instructed to recommend a C-section when a breech presentation is discovered.  If it is taught, they are still afraid to do it, as the safety of vaginal breech birth is under debate.  However, it is very important to have care givers who are skilled in this area, as a baby can turn breech during labor and this can go undetected until it's too late.  Furthermore, breech birth doesn't have to be an emergency if the care giver is calm and experienced.

It does appear that vaginal birth after C-section is allowed, though perhaps there are restrictions I'm not aware of, such as perhaps how close the previous birth was.

Also, it seems that many Drs will support vaginal birth of twins, something that is also not always supported in other parts of the world, such as some hospitals in USA.

Birth in Bosnia - Episiotomy

Episiotomy... that's a word I had never heard before becoming pregnant.  In fact, I may not have even come across it were it not for one fateful evening at my Bosnian language class.

I was attending a small language school in the neighbourhood and, although my teacher was quite dedicated, the few number of other students were not, and so for not the first time, I was alone with Sandra, our teacher.  The conversation turned towards my pregnancy.  I was starting to show, so I was talking more about it with people.  At this point, I was planning to stay in the country for the birth.  I had already researched a lot about natural birth and knew that I wanted this.  My impression was that it would be possible in Bosnia, as one friend mentioned that the hospital where she gave birth didn't even have epidurals, so that seemed promising.  Nevertheless, we had done little firsthand research into the situation, so I was quite pleased when Sandra started talking about her sister's birth experience.  After a little while, she paused and said, "Now, I don't want to scare you, but I think there's something you should know.  When my sister called us from the hospital to announce that she had had the baby, my grandmother asked to know whether my sister 'had been cut'.  She said 'yes'. My grandmother said, 'oh yes, they always do that in Bosnia'."

As I walked home alone, along the cold, dark streets after class, I became filled with a kind of terror.  I felt unsafe and violated as I imagined the Dr. cutting my vagina.  When I got home, I googled "cut vagina birth" since I didn't understand what this cutting business was. I eventually figured out that what Sandra meant was an episiotomy - a practice whereby the skin between the vagina and the anus (the perineum) is cut as the baby's head is born.  I saw that it was routinely practiced in the 1950's, as they believed it made for an easier delivery, as it widens the birth canal. It was also thought to prevent severe perineal damage during birth and heal better, since it easier to stitch up than a natural tear.  Since then; however, it has not been practiced routinely in places like the UK and Australia because it was shown that it does not prevent severe tearing, and in fact, it could even lead to more severe tears.  It does not heal faster, is more painful than a natural tear and may even cause bladder and bowel control problems in future. More enlightened care givers view episiotomy as excusable only during an instrumental delivery (forceps or ventouse), which I think should also be a rare occurrence, or when a more speedy delivery is needed because the baby is in distress.  If Sandra was right, and they were still practicing episiotomy on all women, regardless of whether it was truly needed or not, this reflected very badly on the state of birth in Bosnia.

This was when I started to question whether I would be prepared to birth in a Bosnian hospital.  Sandra's revelation had really scared me and so it set me off on a quest to know if it was true and to see what else was routinely done in Bosnian hospitals.  I managed to talk to a few more women about their experiences and I was not very comforted.  I finally was able to see a Dr. at Abdulah Nakas hospital and asked him a number of questions.

Episiotomy scissors

He was very surprised that I didn't want him to examine me or give me an ultra-sound.  I guess it was very unusual for him to have patients who wanted to ask questions or go through a birth plan with him.  I calmly went through my list, as he sat there bewildered and amused at the strange foreigner.  For example, "Can I eat during labour?", "No, you might get nauseous and vomit and choke on your vomit", "Can my husband be there for the entire labour and birth?" "Not the labour, but part of the birth" (or the other way round, it wasn't clear), "Can someone else be with me who can translate in case it's needed?", "No. Everyone speaks English".  He said that despite the fact that he already misunderstood several of my questions and sitting next to him was a non-English speaking nurse.  "Can I have a water birth?", "Yes, but you can only stay in the water for two hours"... By this point, my opinion of the hospital wasn't too good.  I felt that many of the hospital rules were outdated and unnecessarily restrictive.  The fact that waterbirth was possible was definitely a plus, but combined with the rest, and the hospital's approach in general, I wasn't too hopeful about my chances of having the kind of experience I wanted.  This was confirmed when I asked about episiotomy. "Yes, all first time mothers need an episiotomy." "Why?" "Because you don't want to risk tearing and it heals better than a tear." "What about if you have a water birth?" "Oh, we can still do it in water." "Really, you can do it in the water?" "Yes, of course.  Trust me, I'm a surgeon."

Exactly, you're a surgeon, I thought.  That's why you shouldn't be handling normal pregnancies and births!  Your very useful skills should be reserved for when normal has turned pathological and the woman's body can no longer do what it normally can.  But that's the thing, I don't think he, and many other obstetricians (obstetrics is a branch of surgery), do trust a woman's body to do what it was designed to do.  That was essentially why I decided I needed to find another place to birth.

"Trust me, I'm a surgeon." At the end of the interview, he acted like he had done me a huge service by answering my questions.

In the end, Lessan and I decided to return to Australia and have a homebirth there, attended by a midwife.  A midwife is not a surgeon, she is someone who has been trained to assist normal births. It seems that, although there are midwives in Bosnia, they only practice in hospitals under the control of obstetricians.

And, as I side note, I now realize that it is difficult for hospitals to offer truly respectful care, as they are often affected by business models of functioning and so, even in places like the UK where midwives are basically in charge in hospitals, the situation is still not ideal.

Upon returning to Bosnia, a friend of ours, Maja, told me about her birth.  She noted that the hospital did everything according to a "need for speed". She had a very painful (unwanted) episiotomy that left her in severe pain for weeks and then discomfort until six months post partum! Of course, everyone's experience is not as bad as hers, but still! It now seems to me that performing episiotomies, like many other interventions, is based on hospital convenience.  The pushing phase, in a first time mother, can sometimes take three hours (and this is normal), but if an episiotomy is done, the baby can come out much faster. This is not only painful, traumatic and unnecessary for the mother, it could even be dangerous for the baby if they try to pull it out in the process.  I don't know if they do this, just theorizing here, but if they did pull it out, it could force the baby to come out at angle that causes it to 'get stuck', i.e. shoulder dystocia, which is a major problem!  Furthermore, Maja said she had asked not to have the episiotomy.  They said, of course, we only do it when it's needed.  They let her push for a while and then said that it was best to do the episiotomy to make more room.  This strikes me as the hospital not having faith in a woman's ability to birth her baby, in what was, as far as I can tell, a normal birth situation.

During the pregnancy, I sometimes felt guilty about going to the effort we did to have a good birth experience, but now I don't.  It was very worth it, as it was such an empowering experience that gave me so much confidence to proceed down the path of motherhood.  And, by the way, I ended up having a natural tear during my birth.  I didn't even notice it happening and I healed quickly, even with needing a couple of stitches.The sad thing is that I shouldn't have had to make such an effort to have a natural, undisturbed birth.  Every woman should have access to respectful, empowering care for her birth.  Interventions, like episiotomy, are wonderful if truly needed, but we should be wary of any 'routine' intervention in birth because birth is not a medical event needing to be managed, it is the body performing a function it was designed to do.

Birth in Australia: Vaginal Breech Delivery Story

Here is a rather unique birth story from a friend in Australia.  We were in the same class in primary school and though we haven't been in touch very much since, I feel like we are kindred spirits in a way since we are both now very passionate about issues surrounding natural birth and have a desire to change things for the better somehow, perhaps by becoming midwives!  She has much more experience than me though, this story being about her fifth baby!

She found out that her baby was breech towards the end of her pregnancy.  In Australia, and most places it seems, a baby presenting breech (i.e., bottom or feet down) automatically puts you in a high risk category, regardless of other considerations.  Obstetricians become concerned about vaginal birth and often seem to suggest Cesarean section, because the risks of infant mortality are slightly higher with vaginal birth.  However, the risks are still very low in both cases and C-sections have their own, fairly significant risks. Many are talking about the fact that fewer and fewer doctors are being trained to assist with vaginal breech deliveries. This article discusses some of the issues (http://www.theglobeandmail.com/life/parenting/c-section-not-best-option-for-breech-birth/article597103/).

It seems that my friend was lucky to have been well-informed of her options and also benefited from a supportive head Dr. from the UK.

This story is also interesting for another reason, but I'll let you discover that for yourselves.  Thanks for sharing!

"I was due for a checkup on Thursday morning at 11.30am at the birthing centre. The previous appointment I had just had at our regular GP and she wasn't entirely sure if she was breech or not; so the birthing centre double checked and then sent me up for a scan to confirm. It was a complete coincidence that in that same morning I started having a few contractions. Not very painful but regular enough to think, hmm it maybe starting!

I called Daniel as he had just flown out to work the day before. He said to call his boss so he could organize a flight home again. I then called mum who was already going to come to my appointment with me anyway. So I got the kids ready for the school bus, dropped them off, made the other kids' lunches and packed a few things to keep them occupied. Changed our sheets put a load of washing on and quickly packed a few things in a bag for hospital just in case I wasn't coming home (which I didn't!). So I drove to the appointment whilst having mild contractions. Baby was still breech so they said obviously I can't birth in the birthing centre. I had a student midwife who was great and kept me company almost the entire day. She had never seen a breech birth and I told her she was welcome to stay and watch. She was also a great help in confirming to me that I was right in my mind to insist on a vaginal delivery providing there was nothing else wrong. So they laid out all the options and thankfully the head Dr on that day was very supportive of vaginal breech births; otherwise I may have had a harder time getting what I wanted!

One of the options was to try and turn baby with an ECV. They give you a muscle relaxant to stop contractions and help shift baby's bottom out of the pelvis so they can manually turn it. They literally push down on your belly under the head and bottom and try to make it do a somersault. The twisting on my skin kind of felt like a chinese burn on my belly! It didn't work though unfortunately so there was no chance in going back to the birthing centre for my water birth, which I was a bit disappointed about. Funny though, I had quite an audience with the ECV as a lot of the student midwives hadn't seen one performed before. After trying, the nurse assumed that contractions would stop after the muscle relaxant and was talking to me about coming in again next week to try turn her again. The student midwife and I looked at each other in confusion and in my head I was thinking, um, contractions haven't even stopped at all! And they were still about 5-6 mins apart. I don't think she believed me when I told her! (I believe I am hard to read as I don't show I'm in pain). Anyway, the midwife came back and they did a vaginal examination which then confirmed I was already 6cms dilated (I was quite surprised I was that far along as it really wasn't that painful!) So they took me to the labour ward.

I was very fortunate to have midwives that backed me in my decision to have a vaginal delivery and did all they could to help. Since I had to have the fetal monitor on I wasn't allowed to labour in a bath but they managed to let me have a long shower (even though they were supposed to have the monitor on me). I seriously thought it was going to be a longer labour because although contractions were regular they weren't as painful as I remember them with my other labours. I could still talk and laugh and hold a conversation! Mentally I think I was also hoping it would take a bit longer as Daniel wouldn't be arriving until around 7pm from the airport. After the shower I put on my labouring clothes and got into a comfortable position on my side on the bed and just grimaced through the contractions as they came. I think it was after 5pm by this point. Finally Daniel arrived at 6.45pm. Contractions kind of stayed the same but they were getting a bit more intense. Then all of a sudden I started to feel like I needed to push and bear down.

The midwife looked down and said, I can see toes! I reached down and felt 5 curly toes sticking out. All of a sudden someone mentioned that baby didn't like something and the emergency button was hit. Drs came rushing in and started talking about a cesarean but I was already pushing baby out and literally she slipped out in about 2-3 pushes in under a minute! Poor Daniel was a bit overwhelmed and sitting on the floor when they mentioned a cesarean. They put her onto me and then after a bit, took her to clean her up and check everything. Something wasn't quite right I could tell by the vague chattering amongst the midwives. I had another shower to clean myself up and then when I came out and had a proper look at her I could see what they were talking about. She seemed to have a few features that look like down syndrome. It was all a bit of a shock and completely unexpected. Daniel was still lying on the floor and (I didn't realize at the time) was in even more shock with being told the rough diagnosis and likelihood of our baby having down syndrome before he had even seen her properly or recovered from thinking I might need a c-section.

My mum asked me if i was okay with her having down syndrome and all I could think of was how could I not be? She is my baby girl and i don't have a choice about it. I would love her like all of my other children. So from then it was a bit of a whirlwind of emotions and anxiety for both of us, trying to change our vision and expectations of how we imagined the next stage of our lives and trying to comprehend how we were going to manage with a special needs child. The day after the birth was definitely the hardest, talking to the neonatal specialist and various other drs explaining everything that comes along with having DS. Thankfully so far, a lot of the medical conditions that are often associated with DS have been ruled out, as she is healthy, feeding well and her bowels are functioning normally. They still had to make sure at that point that there weren't any small holes in her heart but due to her good colouring and no heart murmurs detected, we were told she should be safe - and thankfully the scan showed no irregularities at all. We are very fortunate in that respect as up to 60% of people with DS have some form of a heart condition. We also had to wait on test results to check her thyroid and of course to confirm whether she had the extra chromosome abnormality or not.

Initially the diagnosis was purely from examining her physical features - the slightly slanted eyes, flat bridge of the nose and extra fold of skin (nuchal fold) at the back of her neck. There are other features which are common but she doesn't display them. There is such a wide spectrum with DS so it's really hard to tell until she grows and develops.

Just as we were ready to leave the hospital, results came back that confirmed she has the full extra chromosome. But thankfully her thyroid is functioning as normal. Another tick in the box.

Since being home it has been wonderful to see her develop. She continuously amazes me with her strength. She is practically commando crawling when she is on her tummy! And I've lost count of the amount of times she's rolled - all before she is a month old! We had a little bit of trouble with her gaining weight for a couple of weeks but as I was adamant in not supplementing her with formula (I have read far too much about the damaging effects of formula produced these days), I made a conscious effort to increase the good fats and protein in my diet, along with monitoring the time I feed a lot more closely (I increased feeds to every 2 hours instead of 3-4).  It paid off as we weighed her again after a week and she had put on 330g and grown another 1.5cms! The nurse was very happy and said we can continue along just exclusively breastfeeding. I could not be happier :)"

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!