Ella's Birth Story

My birthing space

As a bit of background, we were planning a homebirth, as we had had with Thomas.  This time; however, we were on a government programme called the "Midwifery Group Practice" through Bunbury hospital.  This programme is for hospital and homebirths with a known midwife, but homebirths are only allowed for very low-risk pregnancies.  I was really grateful that throughout the pregnancy I had been well and there were no risk factors whatsoever.

My plan for getting through the labour naturally included preparing physically through yoga and exercises like squats, preparing mentally through mindful meditation and setting up my birthing space with positive affirmations and inspiring quotations on the wall, mood lighting, a playlist of calming music as well as shelves full of everything we might need for the birth.  I had comfort measures on hand like a ball to rock and lean on, a bean bag, a portable camping toilet (so I wouldn't have to walk too far to go to the loo),  a "birthing blend" to diffuse and also to use for massage, plenty of hot packs and of course, the birth pool. I also worked with my husband and doula to see if they could help me with massage, acupressure points and many other things. In summary, everything was ready to go.  All that was needed was for my body to go into labour!

In my previous post, I talked about the weeks and days leading up to the birth.  In it, I explain how we had a feeling that baby would come on 5 September (that's six days past the due date). The night before (Friday 4th September) we had been acting like it would happen the next day, but with no real reason to believe it would.

Nevertheless, that Friday night, just after falling asleep at say, 10pm, I started having contractions! They were definitely contractions because they were a kind of sharp cramp in my lower uterus. I was comfortable enough to lie down during them, but it helped to focus on my breathing a bit and wait for it to pass.  I got up a bit more than usual that night to go to the toilet, walk around and also do fast hip circles on the exercise ball (spinning babies suggests that helps babies to engage).  I still managed to sleep a fair bit between contractions, but I think that most of them were too strong to sleep through. I was excited that things were starting to happen.  Of course, there was always the possibility this was a false alarm, but I had a feeling it wasn't.  There was also a bit of wondering how long the labour would last and how much worse the pain would get, but I tried not to worry about that.

In the morning, I got up and made myself a good breakfast of eggs on toast and helped Thomas get his breakfast. I was having to concentrate a bit through contractions, but could still move and talk through them if someone spoke to me.  I casually reported the contractions to Lessan and he just said, "Oh, OK!".  Soon after, mum got up and jokingly proclaimed "So, this is the big day!' (because we had all been expecting it to happen that day, despite there being no real proof as to why) and I was happy to reply, "Well, I think it is actually, I've been having contractions throughout the night."  She excitedly gave me a hug.

Lessan looking happy that today is the day!

After breakfast, I decided to lie down in bed and get a bit more rest between contractions, since I hadn't gotten enough sleep over night.  Meanwhile, Mum took Thomas and Olivia out to a park for the morning.  After resting for a while, I decided to time my contractions. They were consistently 8 minutes apart and lasting 40 seconds.  I thought that their being regular was a good sign, so I decided to call the midwife to let her know I was in early labour.  I called my primary midwife's number, but it diverted to a different one who was on call - the one I'd hoped would attend the birth! I asked her if there was any way of knowing how long the labour would last given how regular the contractions were and she didn't know, but said that often, for mums who have other children, things really kick off at night, when the kids have gone to bed.  

At about 10am, I got up and had a shower.  I then just walked around and did some yoga exercises on the rug in the living room and rested a bit.  Even though I didn't feel a huge need for it, I prepared a hot pack for myself (it needed to be boiled in the pan and I wasn't sure others would know how to prepare it if it was needed later).  I then decided to watch a documentary on Netflix about the fashion industry.  I was surprised that I wanted to do that, since the idea of watching a screen during labour was repulsive to me last time.  I assumed that the fact that I could handle it meant that I was earlier in the process, despite the fact that by the end of the film, I was having to really concentrate for contractions.

At about 11am, Lessan takes a photo of my belly between contractions

At about 1pm,  Mum brought Thomas home and Lessan went to take him to sleep.  When he was finished putting Thomas to sleep, I had gone outside to labour in the sunshine and he met me there. I had been timing my contractions again and they were between 6 and 3 minutes apart, lasting as long as a minute, but usually only 40 seconds.  The fact that they were kind of irregular puzzled me.  They were generally closer and stronger, but I was still coping well, so I assumed it was still pre-labour.  We spent a bit of time there together chatting, hugging and kissing.  During contractions I would lean on him and we'd sound/tone together.  'Sounding' is a technique I had heard of in the mindful birthing book - it's basically making a sound like 'ah' or 'oh' or 'om', kind of like chanting, and the partner joins in for support. 

When we got inside, I had a chat with mum and then I decided to labour a bit in the bedroom (where I planned to birth).  I put on my peaceful birthing playlist and tried different positions on the bed.  I tried becoming more meditative, closing my eyes and relaxing, even between contractions.  I was still able to talk between contractions, but doing this seemed to help.  At some point during that time, I started to think it would be a good idea to inflate the pool and asked Lessan to do it.  Mum and Lessan laid out the plastic sheeting and taped it to the floor and then Lessan inflated the pool.  The sound of the pump was rather jarring and I had to work harder to stay relaxed (at this point I was kneeling and leaning forward on pillows on the bed in the same room).  During that time, I was finding it a bit harder to get through the contractions and was experimenting with different mental strategies. I also noticed I was starting to feel hotter.  Soon, I told Lessan I wanted him to actually fill the pool, not just inflate it.  As time went by, I became more insistent that he fill it asap!  I didn't consciously think that I would give birth in the pool, just that I needed the warm water for pain relief.  You see, I had this whole debate in my mind during the whole pregnancy about the theoretical benefits of land versus water births for the microbial transfer and so had considered labouring in the pool, but birthing on dry land.  But, at that moment, I only knew that I was having difficulty coping and the pool was my only option of making things a bit easier.

I think that it was at this time, or perhaps a little earlier, that I first started feeling my cervix expanding.  I had forgotten that feeling, but now that I was having it again, the memory of the sensation seemed ever so familiar from my first labour, and that happened towards the end, though  since it wasn't so clear in my mind exactly when that happened, I was still thinking I may have a long way to go.

Starting to fill the pool

As he began to fill it, I got out of bed and walked around and timed the contractions.  This kind of helped as a distraction.  I had a good app on my phone for that. They were coming every 4-5 minutes and lasting a minute or so.  They were also really strong and I was finding it harder to stay relaxed.  I was breathing faster, moaning a bit and moving in weird ways just to cope. I decided to text the midwife and she called back immediately.  I let her hear in my voice that it was getting more intense and when I told her I wanted to get into the pool, she said she was coming.  A few contractions later, I was desperate to get in for some relief from the intensity of the contractions and so, though the pool wasn't full yet, I got Lessan to help me in.  That feeling of the cervix expanding was stronger and I was starting to feel the urge to bear down, so I suddenly felt like I might give birth before I got in.  I realized I didn't want to do that because the contractions were forcefully pushing on my rather closed vaginal area and it hurt!  I hadn't experienced that to such an extent with Thomas because things had progressed much slower.

Not long before getting in the pool.

Once I got in, I felt a little more relaxed, though I wished the water was warmer.  (It was the right temperature, but the recommended 37.5 degrees was just not warm enough to ease the tightening sensations).  It was now 3:25pm. Lessan was busy running in and out to adjust the water and also help mum out the door, who had just decided it might be time to take Thomas and Olivia out.  I don't think they realized how close the birth was. All of his coming and going made me a bit frustrated, but I tried to focus on the task at hand! Getting through each contraction!

Birthing affirmations and quotations on the wall

One of the first contractions after getting in, I gave in a bit to the urge to push and felt a 'pop'.  I knew that was my waters breaking, as I saw little bits of vernix appear in the birth pool water.  I then put in my finger to see if I could feel the head. Sure enough it was there, about 3cm inside.  I knew from last time that this meant there was no point worrying about if I was fully dilated.  The head was there ready to come!

I had a few more contractions that were a bit 'expulsive' and I asked Lessan to see where the midwife was because I was pushing.  He called her and she said she was 7 minutes away.

I tried lying on my side to slow the birth a bit, but one or two contractions later, the head emerged, but then receded back in.  The midwife still wasn't there.  The realization that I would probably give birth unassisted didn't really worry me.  I was confident that I knew what to do, as the sensations seemed familiar.

I probably could have pushed out the head in one contraction, but I wanted to give my perineum more time to stretch, so I held back and so after emerging once, it retreated back in.  I tried using a bit of clitoral stimulation between this contraction and the next to hopefully bring some more blood to the area and allow it to stretch (tip from midwife, Ina May Gaskin).  It did help and eased the sensations a bit.  In the next contraction the head fully emerged.  It just stayed there and started to rotate (which was a bit of painful sensation).  Then, with the next contraction, I pushed and most of the body came out.  I leant forward and pulled the rest of the baby's body out and up to the surface. She immediately started crying, but she also seemed to have some trouble getting the sounds out, so I was a bit concerned. Thankfully, the midwife arrived just moments later. I yelled at her to hurry in and she quickly reassured us that the baby was fine. She had just probably had some fluid in her lungs because of the fast nature of the birth, but it wasn't too much.

Right after birth

She asked about what had happened and together we tried to figure out what time the birth had occurred.  We guessed 3:55pm, although we later figured out it would have been exactly 3:53pm.  She also asked if we had checked if it was a boy or girl yet.  We hadn't even thought to check! We did, and realized it was a girl! It was a lovely surprise, but at the time it was still a bit surreal to process.  I had planned to cut the umbilical cord after birthing the placenta, but the cord was rather short and it would have been hard to get out of the pool with it being so short (and the MGP programme's guidelines state that it should be done out of water to measure blood loss).  So, in the end, we just stayed in the pool until the cord stopped pulsing.  During this time a second midwife came to help. They clamped the cord and Lessan cut it.

I then had the rather unsavoury task of birthing the placenta.  I tried sitting on our little camping toilet for a while, hoping it would come out, but it just didn't seem ready (from my giving the cord a gentle, little tug).  I was cold and uncomfortable (plus still having strong contractions), so the midwives suggested I could lie on the bed and give Ella a feed while waiting for the placenta.

That was much more pleasant.  Even though the contractions were still strong (and became stronger with breastfeeding and the weight of the baby on my belly). it was much more comfortable lying in my warm, comfy bed, holding my sweet baby.  Eventually, I felt a bigger contraction and announced that I thought the placenta was ready. The midwife helped me get it out with gentle cord traction as I pushed a bit.  It came out in one piece and looking fine! (I didn't see it, actually, but that's what they said).  I felt a lot better with it out!

I think it was when I had gotten in bed that Larissa, our doula arrived.  We hadn't called her until I was in the pool, as I hadn't felt the need for extra help until it was too late for me to be in a state to do anything about it!  She got me a cup of tea, some snacks and drinks and helped the midwives with a few tasks.

From then on, I got to continue lying there, feeding Ella, while the midwives checked how much blood I was losing and tried to make sure that it slowed down.  There was a bit of concern on that front, so they were vigorously massaging my belly as well as some accupressure points on my hand and ankle, whilst getting me to smell clary sage and visualize the 'flower closing'.  It was a bit amusing for me, as I felt fine and didn't really feel like I would bleed to death, but I was nevertheless grateful that they were taking care of it!

When it was clear that my bleeding had slowed, they checked for perineal damage.  There was just a graze going up (towards the urethra) and a small tear going down into the perineum which they thought didn't need stitching.  I was very grateful and surprised that with such a quick birth there wasn't more damage!

The midwives also checked Ella over, checked for tongue and lip tie (she has a small lip tie that's probably not a problem). They weighed her and measured her and also gave her the Vitamin K injection, as we had requested.

Once everything was done, they left us to relax and cuddle in bed! Larissa left soon after, as my parents said they were on their way home and they would be able to help with the clean-up.

We felt amazed and awed at the experience. For most of the labour, I had been coping well and so I thought it was still the early stages.  Only in the last hour or so had it gotten quite intense.  And though the sensations were powerful, I hadn't been traumatized by them. It was simply a matter of working with them as much as possible.  I also hadn't been afraid at all when I realized that I would likely give birth without the midwife.  Though they were stronger than I remembered, the sensations were familiar and I knew what was happening and I was confident I knew what to do once the baby was born (though I wasn't actively thinking about that at the time).  Though I hadn't planned it, I was happy that I got to birth on my own, because having to interact with people, feeling observed and having to have observations taken would have definitely made it harder for me to relax and birth instinctively.  In the end, I felt the midwife arrived at the perfect time - in time to make sure the baby was okay and to help me birth the placenta and bring bleeding under control. 

As I write this, it is days later and I have already started to forget what the labour felt like.  I feel only positivity about how I got through it all so well, how it was so much faster than expected and grateful that Ella and I are both recovering so well.  Of course, I'm loving these first days of discovering who this new little person is and getting plenty of cuddles! The confidence I felt in the birth is also continuing into early mothering and so I'm incredibly grateful that God allowed me to have this experience.

Happy that the hard part was over and getting to cuddle my baby!

Now for Lessan's perspective:

Leading up to the birth, I had felt like we had planned well and we had everything we needed in place (towels, pool equipment, food, the birth plan, the doula, etc). Once the due date past, I felt like there was no need to do any more active thinking about the birth but we could just enjoy the time we had together, as the birth would surely come. I thought as we approached the end of the second week we could start thinking of options, but there was no need to do so before then. It turned out somewhat like that in practice, although Melissa did have lengthy conversations with our support team (midwives and doula) as well as the last-minute viewing of the spinning babies video. None of this was particularly troubling, but I mention it just to picture the mindset I was in at the time.

On the day of the labour I was tired as I hadn't had enough sleep the night before, but when I realized it was actually happening I must have had a burst of adrenaline because as you can see from the photo above, I was very happy. I just wanted to do what needed to be done and help Melissa in any way I could.

As the labour was progressing in the early afternoon, I asked her about our support team and she said she had been in contact with the midwife, and she didn't really feel the need to call the doula yet. I understood where she was coming from, as I could see that she was labouring in peace, just focused on being relaxed through the contractions and there was really nothing anyone could do to help her in any way. No offering of heat packs, no touching of her, no suggestions about positions, no conversations really - none of those would have helped. She knew what she was doing and she needed her space to do it. I also knew what she was doing, having been actively involved in her learning about birth during both labours, so there was nothing mysterious or unknown about what was going on. And anyway, I had my hands full with errands that needed to be done.

Like Melissa, I was also under the impression that the labour would take longer than it did. After setting up the pool I anticipated there would be at least a few hours more before the birth. I didn't actively think about it; I just felt like there's more to go. When Thomas woke up I helped take care of him a little, at least enough to ensure he wasn't coming into the bedroom where Melissa was labouring. When I returned to the bedroom I realized Melissa was quite far along and she made it clearly known she wanted to be in the pool asap.

We hadn't practiced filling in the pool before (we had inflated it so at least we knew it would hold its shape), so I was a little anxious that nothing would go wrong. I also expected the midwife to be there shortly and didn't want it to go over the mandated 37.5 degrees, so I went back and forth a few times to the tap to ensure it was filling up at the right temperature. Then Melissa got in, I called the midwife to check where she was and the doula to ask her to come, and then I realized the hot water was running out - even though it was fully on the hot setting the water coming out of the hose was lukewarm. So I rushed off again to turn off the water, and I filled a pot and put it on the stove on high heat just in case it would be needed later.

By this time Melissa's contractions were very intense, and she was yelling at their peak. It seemed to help her, and it didn't really bother me, but it made me feel more urgently the need to help her in any way, so for one of them I tried 'sounding' with her.

Another errand was to rush to the front door and unlock it, as we don't have a doorbell and wouldn't hear knocking especially with the sound machine on, and I expected the midwife would try opening the door when she arrived.

Another few minutes in the bedroom, and Melissa announced the head was out. Sure enough, I could see it, and it wasn't moving in any way. I walked to the side of the pool infront of her in case I needed to help lift the baby out of the water, but with the next contraction the body came out and Melissa pulled it out herself. I then rushed to get the camera, and we have some video and photos of Ella's first minute or two (see the "right after birth" picture above). Melissa was getting anxious about the baby's breathing, as although it was crying the cry came in fits and starts. I heard a sound outside the bedroom and saw that the midwife had arrived. That was a relief, as just that moment was when we really needed her help.  Up until that point, I don't think there's anything she could have done that would have changed the outcome of the birth.

Lessan holding Ella

In hindsight, I realize it would really have been helpful if I could have been present with Melissa for the last hour or so, just to be there so she would feel accompanied and reassured. We could have called the doula much earlier, just to take care of the errands I had been taking care of. And we could have had the other children taken away earlier, which would have helped reduce the errands I had to run.

But otherwise, I don't think we could have improved much on what happened, it all went so smoothly.

Just one little thing was that we should have bought a new birth pool (or hired one) as the one we got was second-hand and later that night it started leaking (we had decided to empty it the next day). We had to hurriedly empty it and drag its remains out. But that's not so important, in the grand scheme of things.

I'm very happy to be a two-time primary birth support person and to have seen both our children raised out of the water into this world. Sometimes I felt overwhelmed by all the details Melissa was sharing with me, but for the most part it has been very interesting to learn more about birthing and also some of the social issues surrounding birthing rights. While my focus is not to change that - I let Melissa take the lead on that one - I do feel that more husbands need to accompany their wives on this journey and kick off their fathering career by being engaged and present. I really admire and respect mothers. I am especially proud of those who have taken charge of their own birthing and put the effort in to educate themselves about it.

I'm also very happy to have a daughter. I don't know what it means, but I'm looking forward to finding out. And I'm looking forward to expanding the circle of love from three to four, increasing my capacity to love and my understanding of what it means in practice. During the first few years of our marriage, I would feel like I loved Melissa so much it wasn't possible for it to be more, but then it would take a turn and somehow expand. Then with Thomas, after a confusing initial period, I started to fall in love with him, and that has followed a similar path. I anticipate Ella to also open new vistas of affection and dedicated familial service.

Leading up to birth

8 August, 8 months pregnant

For approximately a month leading up to my due date (30 August), I had been sick with what seemed like a never ending flu - I had cold symptoms, then a sinus infection, then a bad cough... it just never seemed to stop. It was hard to manage the normal pregnancy tiredness along with this cold, plus the task of taking care of Thomas.  To make matters worse, everyone in the house also got sick. Days before my due date, both Mum and Lessan were in bed with fevers.  All of this left me feeling very anxious about the impending birth.  I was worried that I would still be sick when I went into labour, or worse, that my body would refuse to go into labour because it was sick and I would have to be induced! I was also very disturbed that my family, who were the ones that were going to help during the homebirth, and afterwards, may be out of action.  All my carefully laid plans that had been in the making for well nigh nine months were crumbling before my eyes.  I had a good cry about all of that with Lessan a few days before my due date and started to come to accept that whatever happened would be the best for me, even if it didn't turn out as I had hoped.  "Nothing save that which profiteth them can befall my loved ones."

29 August, the day before my due date

 The next day (Saturday 28 August) I had a visit from one of the midwives from the programme.  My primary midwife wasn't available, so another one (who happened to me my favourite) came by.  That was 2 days before my due date and there had been no sign of impending labour.  Baby was only 2/5th engaged.  That didn't surprise me since Thomas had come a week past his due date.  But, I was still in a bit of an emotional state, and didn't like the thought of having to be induced, so when she started talking about the options regarding "prolonged pregnancy", I started to cry.  I was still coughing uncontrollably and feeling pretty fluey, so I felt like it was likely I would go overdue, but at the same time, didn't want to have to deal with all the implications of that.  She was very understanding and helped me go through my fears.  After I'd had a bit of a cry, she encouraged me to just relax and enjoy the remaining time I had with my husband and son as a family of three, to get out in the sunshine (the weather had only just begun to improve after days of rain) and try to feel happier.  She also casually mentioned that she had a feeling I would give birth over the following weekend and that she would be at my birth because she was on call that weekend.  That was a nice thought, so I tried to believe that and to follow her advice.

Lessan and Thomas with a mobile crane at Dardanup Heritage Park

During a tractor ride

The next day, we were feeling a little better, so Lessan and I took Thomas out to Dardanup Heritage Park, which was basically a museum of antique tractors, trucks, trains and many other machines. I had thought it was a national park, so it was a complete accident that we ended up there, but Thomas LOVED it.  We couldn't have planned anything better.  It was really nice to do something special with Thomas.  In the next few days, since Lessan had taken time off work to help me (and also because he was still a bit sick) we continued to go out almost every day as a family.  That was really nice and now I look back, I am very grateful for that extra time we had together just the three of us.

I tried to savour this extra time with only one child

On Tuesday 1 September, I went to see an osteopath, Annette Richardson, whom I'd been seeing for a number of weeks to prepare my body for the birth. At previous visits, she had claimed to be able to predict the sex of the baby. She hadn't told me what she thought, but when we said we thought it might be a girl, her face gave the impression that she didn't agree.  She then got out a pendulum to see what 'it thought'... it seemed to think it was a boy and she said "it's just a fun exercise, but you'd be surprised how often the pendulum is right."  We left thinking we were going to have a boy! We got more serious about choosing a boy's name after that.  Anyway, on this particular day, I was hoping that the 'balance' would might kick labour off, as that was something it could do if birth was "imminent", whatever that means.  During the session, Annette said she was 'playing with numbers' and that the number five came out strong.  She thought this meant that the baby would come on the 5th of September, which was the coming Saturday.  This echoed the midwife's prediction, so that gave me more reason to believe it. In a way, though I always knew there was every possibility that the baby would be born before or much later, I wanted to believe that the bub would come that weekend and so I stuck to it.  This belief made me so much more relaxed, since I felt like I didn't need to worry about going too far overdue anymore. I could just enjoy the next few days.

The next day, on Wednesday, I had a visit with my primary midwife.  She saw that the baby was now 3/5th engaged, so I guess it was at least moving down.  It was also in a really good position - left/centre anterior.  There were no other signs of labour, except a few more braxton hicks contractions every now and then and the feeling that baby was moving down. She talked about how if I got to 41 weeks, I should start going to the hospital to have monitoring every few days and asked if I wanted to arrange that.  I said if I hadn't gone into labour by Sunday, I would call, but that I somehow felt it would come by Friday or Saturday.

The website that talks about fetal positioning

The next day was fairly uneventful.  I took Thomas to playgroup in the morning and in the afternoon, Lessan, Thomas and I walked around the neighbourhood a fair bit, partly in the hope that it might move the baby further down (since getting it to engage could kickstart labour).  I also looked up some spinning babies exercises to do that might help.

By the next day, I still hadn't had any signs of labour, such as waters breaking, a "bloody show" (though there had been some mucousy discharge) or any real contractions.  That morning, Lessan and I took Thomas for a long walk to the local shopping centre and back. While Thomas slept later, Lessan and I began watching a spinning babies parents course and did most of the exercises as they were being demonstrated in the video.  Then later, we had a visit from the doula.  We told her that, though there were no real signs of impending labour, we thought it might happen the next day.  She lent me a document about acupressure points and how they could be used as pain relief or to help induce labour.  After she left, I got Lessan to practice using the pain relief acupressure ones on me and then I watched the rest of the spinning babies video, all the while being careful to sit in positions that promoted optimal fetal positioning and also move a lot.  That video kind of scared me, as it talked a lot about possible 'stalls' and difficulties in labour.  At the end, it also showed a little video of some ladies in labour and their screams didn't make me feel too relaxed.  I started to realise that if I thought I might have the baby the next day, perhaps now wasn't the best time to be watching such videos.  Anyway, I tried to relax and go to sleep.

Well... what do you know? Things started to happen soon after that. But that's the subject of the next post.

Almost at the end of pregnancy no.2

So, my last post was about my early weeks of pregnancy and I'm now almost at the end.  Just over a week to go until my estimated due date! So, before this baby is born, I'd like to try to quickly record how the pregnancy has been!

I'm not sure, but I think before my last post, I wrote to the Midwifery Group Practice in Bunbury to try to get a spot for this baby, even before we moved down south (which was shortly after my last post).  I got a response a few weeks later and was eventually accepted onto their program, which is a government funded homebirth (and also hospital) program that allows low-risk women to birth with a known midwife.  My first visit was with a midwife, as well as a student, who assessed whether I met their criteria and also explained how the program worked. The midwife explained that the program was in a state of change and as such, I probably wouldn't meet my primary midwife until the end of my pregnancy and in the meantime would be cared for by a few different ones.  She also noted that, since I had birthed with an independent midwife last time, I might find some aspects of the program challenging, since the guidelines of the program are stricter than how an independent midwife might practice.  I thought about all this and decided that, unless something very challenging came up, or I was starting to feel very strongly about knowing who the midwife would be on the day, I would give the program a go since I felt fairly confident as a second-time mum.

Well, so far, the first midwife's prediction has been accurate.  I had the same midwife for two or three monthly visits, then a string of different ones, then finally in the last month or so I've met my primary midwife, who is new to the team.  Still, she may not be the one who will attend my homebirth. It could be any one four (including her), just depending on who happens to be on call that day.  A second one will also come towards the end.  I have found this aspect a bit challenging - I felt like I had to re-explain my thoughts on things every time I met a new midwife and it was sometimes a struggle to build rapport.  I also wondered for a while what a homebirth with the MGP would practically look like - what are their standard practices during and after the birth?  I was a bit concerned there I might come across something strange, but it was difficult to get a clear picture of that.  That was until I wrote a birth plan. Once I did that, the midwives explained how their standard practices did or didn't fit into how I imagined the birth to happen (and what would happen if complications arose).  They definitely do more checks and have stricter guidelines from what I am accustomed to, but I think I can deal with it.  I'm just hoping that my birth will unfold 'by the book' and so I won't have to worry about it all the other guidelines.  I would have liked a bit more openness on their part to dialogue and learning, but I understand that they are restricted by their guidelines and can't be as much "with women" as they may like to because the system forces them to be "with guideline".

As part of the MGP, I also needed to see a doctor registered with the program a few times.  It turns out that this person would be a member of my care team, would be in touch with the midwives about me, would be the one they go to if there are concerns during the birth and if I transfer to hospital, would be the doctor I'd see, even the one performing a C-section if neccessary (unless they weren't on call at the time).  I saw one doctor a couple of times and then decided to change because the first seemed rather on the conservative side and hard to dialogue with.  I'm pretty happy with the one I changed to, as I feel he isn't offended by me questioning him or putting forward alternative points of view.  Though he doesn't offer the exact perspective I espouse about birth, I think he's probably the best OB-GYN around here and I'm glad to have him on my team!

Anyway, overall, for a government funded program, I have to say it's been a pretty positive experience so far.  I'm grateful for the fact that every visit with the midwives (and even my doctor) has been unhurried, offering ample time for questions and discussion.  They always do their little checks as well, of course, and send me to various tests, like for iron levels, gestational diabetes and more recently, group B strep.  Thankfully, I have been very well during my pregnancy, all tests have come back clear.  Just a bit of low iron, which has lately gone up a bit (but was never dangerously low).  I was especially glad about being GBS negative! Yay! No need for antibiotics or any of that drama!

Now my only concern is going more than 2 weeks past my due date.  Home birth would no longer be supported by the program and I think there would be a fair bit of pressure to induce.  I'm fairly confident that I will go into labour before that time, anyway :)

I've been glad to meet quite a few other pregnant mamas through activities around the region.  Every Tuesday evening I try to go to a pregnancy yoga classs. I really enjoy that as a way to stretch and relax, plus meet some like-minded mamas.  I've also been going to a monthly meeting organized by a couple of doulas held in Eaton called "Bunbury Birth Circle".  Every time, an aspect of childbirth is discussed, with people sharing their experiences with the issue, as well as a few birth stories each time too.

Overall, it's been a fairly smooth and enjoyable pregnancy.  It has sometimes been hard keeping up with my son (now 2) as well as managing colds and flus when they come up for him (as he's prone to asthma), but overall, he is not to hard to take care of.  He is still taking a nap and sleeping through the night most of the time, so I guess I can't ask for more.


So now, we wait.  I have just over a week until my due date and it still feels unreal that it's this close.  I guess now is the time to make sure I do a few of those things I want to do to prepare for a good birth - praying for a good experience, practicing meditation techniques, doing optimal positioning exercises, stretching, squats, drinking red raspberry leaf tea and that sort of thing!  I just wish this cold would go away now so I'd have more energy for all of that!

Pregnant Again

So, it's happening again! I'm on my second journey through pregnancy.  It's still very early days - I'm only 7 weeks, so I know that it might not work out, so I'm not announcing it widely just yet (hardly anyone reads this blog, so no worries on that front).  It certainly feels quite different the second time around, but first let's talk a bit about the pre-conception period.

From the time our first child, Thomas, was about 3 months old, we started wishing for another child.  He was so sweet and we thought, why wait too long to have another!  We looked into age gaps, pros and cons and decided that 18 months or less as an age gap would be quite nice because the first child would be less likely to experience too much jealousy because he would be too young to remember being an only child. This was one idea we liked, anyway, but by the same token, we were engaged in a project that would make having another child right away a bit challenging and we weren't sure how we'd cope.  So, in the end, nature made it easy for us.  Basically, I couldn't have fallen pregnant much earlier than I did because until recently, I wasn't even fertile.

 I was breastfeeding Thomas full time until he was 8 months. We introduced solids at that time and even at that time, he was still subsisting primarily on breast milk, having just a few spoonfuls of food every other day at first. He wasn't eating three solid meals a day until 12 or 13 months.  This, and the fact that until a few days ago, he was also still feeding often at night, is probably why I didn't get my period back until Thomas was 14 months old (a part from an initial one at 6 weeks, which I've heard can be anovulatory).

 I'd read that it could take three cycles or more after menstruation returns to actually become fertile - that is, for you to ovulate and also have a few other things that would support pregnancy.  So, once we were in a place in our lives (and in the world, i.e., back in Australia!) where we thought it would be okay to start trying, I was curious to see if I was actually ovulating.  We bought an ovulation predictor test kit and that helped me reassure myself that I was fertile.  We used that for one month without trying, actually, partly because I wanted more time to prepare my body for pregnancy - get those pelvic floor muscles in shape and eat better food that would support a healthier microbiome! I did a fair bit of research about preconception diets, because I realized that that can have quite an impact on health.  I had been trying to eat well for a while, but in reality, no major dietary changes took place and then we started trying the next cycle.  The plan was also to use the ovulation predictor test to help use the "Shettles Method" of sex selection to try for a girl.

According to Dr. Shettles, insemination on different days of the menstrual cycle results in different gender ratios.  He proposed that you were more likely to conceive a girl if you have sex often leading up to ovulation, but stop two days or so before ovulation.  This is so that the slower swimming, but longer living 'female' sperm will still be there by the time the egg descends, whereas the faster swimming, but shorter lived 'male' sperm will have died out by the time ovulation occurs.  If you want to try for a boy, than it is theorized that you should have sex only at ovulation.  This theory was popular in the 1970's, but is now considered to be untrue.  But, hey, we thought we'd give it a go.  That was, until we had a couple of days where we were busy and couldn't do it, and wondered whether we may have stopped too soon and missed our opportunity for pregnancy completely (for that cycle), so we decided to do it again on ovulation day.  I told my mum about all this and, being an avid believer in the Shettles method, she's decided we're having a boy!  Oh well.  We're perfectly fine with that possibility.  We love boys too!  Anyway, we'll have to wait and see when he/she's born!  That's right, born!  I'm hoping to wait this time as I hear it can be a wonderful experience to discover the sex of the baby at birth! Hopefully an ultrasound technician won't spoil the surprise at some point!

So, after the infamous 'two-week wait' (which I handled a lot better this time round), I did a test and saw a second very faint, but still visible, line, indicating pregnancy! We were very excited that our efforts had had the desired result.  For the next two weeks, I was feeling pretty good health-wise.  Still energetic and no nausea yet.  This didn't worry me, as it did last time, because I know now that nausea doesn't usually turn up until 6 weeks.  And, anyway, it doesn't have to turn up either!  But, sure enough, morning sickness did start to appear at 6 weeks.  Not too severely.  I have only vomited two or three times and I still feel quite well for large chunks of the day as long as I eat regularly, rest enough and get some exercise and fresh air.  The exercise part seems surprising, because that's not what you feel like doing when nauseous, but apparently it really helps your body process the extra estrogen floating around the system, which is probably to blame for the nausea.  I've also noticed that taking my prenatal supplements makes me much more nauseous, so I've stopped taking them for the last few days. My mum says she has a condition whereby she doesn't absorb many vitamins from supplements and this may be the case for me too?  I'm not really sure what to do about this because I'm not sure my diet is rich enough to go without supplementation.

I also mentioned rest.  It's a bit harder to rest whenever I want when I have a toddler to chase!  He wants me to pick him up, play games with him and take him out to the park and this can get challenging if I'm really feeling sick. All in all, though, I think those things are good for me because it forces me to be active.  I'm also quite lucky that he usually has a long 3 hour nap in the day and I can usually sleep at that time.  At night, up until recently, Thomas would be breastfed to sleep and then when he woke up, anywhere from midnight to 3am, I would take him to bed with me and breastfeed him any time he woke up.  This was working quite well for us until one night.  The nausea was particularly bad, I was tired and it was hot and at that moment, breastfeeding just made the nausea came on stronger such that I had to leave a crying Thomas in his cot and go and vomit.  My husband, Lessan, took over for the rest of the night.  Thomas cried a lot since I think he was distressed wondering what happened to his mummy, but since that night, we continued the regime of Daddy taking over night-time duty and Thomas has adapted very well to this (being night-weaned).  He drinks some water from a bottle every now and then and is starting to sleep better.  We hope that we can encourage him to sleep through the night, at least by the time his sibling arrives!

Thomas is still breastfeeding in the day, but far less than before (maybe three or four times) and I have noticed that in the last week my supply has plummeted - probably a combination of pregnancy hormones and the sudden night-weaning.  I had hoped that I'd be able to breastfeed him until he's 2, maybe more, but we've gotten at least this far (20 months), which is not bad, and I think we'll make it further.

In terms of how I feel emotionally about this pregnancy, I feel a lot more relaxed than last time.  I'm not rushing to the Doctor's office to confirm that I'm pregnant.  I'm pretty sure that's the case because I still haven't had a period and certainly have all the symptoms. I'll see one eventually, but I'm taking my time for now.  Last time, I rushed to find a caregiver and, given the situation in Bosnia, I ended up with an OB-GYN who convinced me I needed an ultrasound at 6 weeks to confirm that the baby was in the uterus and not elsewhere (ectopic pregnancy) and then had another reason to do an ultrasound every few weeks after that!  This time I am having minimal ultrasounds!

I'm also looking forward to having the baby more this time.  Last time, everything was novel and I was savouring the experience of pregnancy (mostly once the nausea had subsided).  I was also pretty scared of the birth and also of becoming a mother and not knowing what to expect, so I was happy for the baby to take its time gestating.  This time, though I still have some fears perhaps, I'm much more relaxed about those things and therefore feel a bit more impatient about how long the pregnancy is going to take (that is if it is a viable pregnancy after all!).

I would definitely like to have more of a spiritual aspect for this newly created being to draw from too!  In fact, I need that in general.  It's being harder to keep up with prayers and reading since Thomas has been around, but I really should find more creative ways to make that happen since he is certainly more independent and I have more help around me now, too!

I guess that's about it for now.  We'll see when/if I get to give another update!

My guide to a positive birth experience

Here are some tips for preparing for a positive (natural) birth experience. However, they still apply in situations where medical intervention becomes necessary.


It can basically be broken down to two main aspects:

1. Preparing oneself for the birth; physical preparation (nutrition, exercise, body work), spiritual (prayer and meditation) and psychological (mental pain management techniques), as well as becoming informed of the birthing process and about common medical interventions (including making a birth plan).
2. Choosing appropriate caregivers and supportive birth partners, who will help maintain physical and psychological health during pregnancy and create a calm, supportive birthing environment

A third aspect, I suppose, is implementing this advice when you actually go into labour. 

There is a lot of good information about these topics, so I won't put everything down.  Below are just a few things that may not be commonly known.

1. Preparation

Health and well-being

• Pre-conception health is important - one reason is infections existing at the time of conception can reach the placenta and be more likely to cause premature labour.
  More: http://mobile.nytimes.com/2014/05/22/health/study-sees-bigger-role-for-placenta-in-newborns-health.html?smid=fb-share&_r=1&referrer
• More on pre-conception diet: http://www.bbc.com/news/magazine-34222452
• Nutrition during pregnancy - the Brewer diet is often recommended in the USA, but there has been some criticism of it as not being evidence-based.  The more I learn about a vegan diet, the more I realize that it is most likely the healthiest way for us to live, even (maybe especially?) during pregnancy. There are some people who claim a plant-based diet helped them conceive after years of TTC. However, it is very important to make sure all vitamin requirements are met, such as protein, iron, calcium and especially vitamin B12. Here are some resources to consider in regards to a vegan diet in pregnancy or in general:
• Vegan Pregnancy: Preventing Birth Defects
• nutritionfacts.org
• Forks over Knives (film)
• Thriving on a Plant-based diet http://doctorklaper.com/webinars/thriving-on-a-plant-based-diet/
• Dr. Klapper's take on dairy - http://doctorklaper.com/answers/answers11/
• On a similar topic, American midwife Nancy Wainer reccommends to her clients to avoid dairy and also sugar, as she believes these tend to contribute to larger than optimal babies which are a bit harder to birth. http://www.birthful.com/podcastvbac/ The reason for the dairy being problematic could be to do with Dr. Klapper's proposal that dairy is growth inducing.  The presence of these growth factors are actually quite harmful to our health, he proposes.
• Exercise - there was a study about how much exercise a mother did during pregnancy: babies whose mothers exercised had better health at birth. It also helps you maintain a healthy weight, as being overweight increases your risk of health complications. http://fitness.org.au/articles/health-lifestyle/more-activity-during-pregnancy-better-mood-and-less-worries/2/812/184
• Exercises to help you have enough strength to care for the baby are also helpful - your arms will get a lot more work than they are used to when you have to lift and rock the baby!  It's good to be ready for that!

Exercises and treatments for positioning in pregnancy and birth

• Fetal positioning exercises are helpful in positioning the baby for an easier birth. For example, to avoid a breech presentation. You can start early in the pregnancy. Part of it is just how you use your body every day, such as avoiding standing or sitting for too long, walking and stretching regularly etc.  Another part of it is specific exercises that release muscular tension in muscles supporting the uterus that may be unevenly tense leading to the baby not having enough room to move into an optimal position for birth.
  See http://spinningbabies.com/ and http://spinningbabies.com/product/spinning-babies-parent-class/
• This is also a great video explanation: https://www.youtube.com/watch?v=qsV70xXivH8
• Exercises for core strength are important to improve the baby's position to avoid a difficult labour, avoid diastisis recti and gynecological problems like prolapsed uterus in the future. Wearing a support belt can also help.
  See http://midwifeatyourdoorstep.com/articles/optimalfetalpositioning.html
• Another perspective on the pelvic floor and why squats might be better - http://breakingmuscle.com/womens-fitness/stop-doing-kegels-real-pelvic-floor-advice-for-women-and-men
• There are numerous exercises and positions that can be helpful in labour that not only aid in the baby's positioning and descent, but also in the release of painkilling hormones.  For example, learning forward, swaying the hips and using a birthing ball, plus the spinning babies labour exercises, especially "The Fantastic Four". http://spinningbabies.com/learn-more/techniques/the-fantastic-four/
• Chiropractic care (especially the Webster technique), osteopathic care or other forms of bodywork can be options - if your pelvis is misaligned or the muscles that support the uterus are unevenly tense, birth can be more difficult because it's harder for the baby to get into an optimal position. Spinning babies explains very well why this is the case.

Emotional readiness for birth

• Previous trauma, perhaps because of sexual abuse or traumatic sexual experiences can affect birth by making the mother less able to release and relax in labour, other emotional issues and stress can be barriers to a good birth experience, so it's worth working through these.

Psychological preparation for birth

• Many women like the idea of going drug free, but when the time comes, they are unprepared for how to handle the sensations.  In addition to things like rocking the hips, using a birthing ball, being upright and especially leaning forward, mental and breathing exercises can really help. 
• Hypnobirthing/natal hypnotherapy, "Calmbirth", as well as mindful meditation are all mental preparation tools that help manage stress in pregnancy as well as providing wonderful mental coping strategies.  During my first pregnancy, I ordered myself a Hypnobabies self-study course. Here is another good video about hypnobirthing. Some women achieve pain-free labour using these techniques. I personally didn't have that experience, but I still found the preparation helpful in getting through my 36 hour labour. There were some aspects to that philosophy which I now find lacking.  For my second birth, I prefered to use mindful meditation.  The book "Mindful Birthing" by Nancy Bardacke was quite helpful.  You can listen to it here.
• I also really like the Bradley method, especially the deep breathing. Oxygen helps reduce lactic acid build-up, which is part of what causes pain - https://www.youtube.com/watch?v=I5HJ83xXQvM
• Lamaze breathing is another option
• Read POSITIVE birth stories that help create a positive mental picture of what birth can be! For example, http://birthwithoutfearblog.com/

Spiritual Preparation

• Connected to psychological and emotional of course, but spiritually preparing oneself through prayer and meditation is very important in helping to prepare ourselves for whatever happens, and also in overcoming fear.  Some people talk about birth as being a spiritual experience.  I think it is! Part of that can be learning to accept whatever happens and surrender to the power of the experience.  This is a bit different to the hypnobirthing perspective which states that birth shouldn't be painful.  Perhaps it can involve pain, but if we surrender and relax and use it as an occasion for spiritual growth, it is bearable and a very positive experience.

Become informed about birth physiology

It's really helpful to understand the beauty of how our bodies were designed to function and how to support the body in reaching its biological potential, thus reaping the benefits of a physiological labour, birth and post-partum.

• Phsyiology of birth, hormones: http://sarahbuckley.com/pain-in-labour-your-hormones-are-your-helpers
• The human biome, birth and the health of the baby: http://midwifethinking.com/2014/01/15/the-human-microbiome-considerations-for-pregnancy-birth-and-early-mothering/
• Other forms of natural pain relief - water birth, music, movement etc.
• Active birth - http://www.bellybelly.com.au/birth/active-birth#.U5tTr_mSwRc
• Environment for birth by Michel Odent - https://www.youtube.com/watch?v=xk0QMq_agOo
• Anything by Ina May Gaskin!
• Here are some other general sites that could be helpful:
  Science and Sensibility
  Positive birth movement
  improvingbirth.org
  bellybelly.com.au
  http://homebirthersandhopefuls.com
• evidence based birth
• birthful podcast

Become informed about birth and newborn interventions

• Why we shouldn't just go with the flow - http://birthtraumatruths.wordpress.com/2012/03/26/the-pitfalls-of-going-with-the-flow-in-birth/
• Medicalization of birth in hospitals- https://www.birthinternational.com/articles/birth/18-fish-cant-see-water
• The Business of Being Born (film) discusses medicalization of birth and explores homebirth as an alternative.
• Learn about common interventions, such as induction, augmentation, episiotomy, forceps, ventouse as well as pain medications, such as epidural, and their effects.  In a normal labour, these are rarely needed.  For alternative perspectives on birth practices, see - 
• AIMS website
• Neighbourhood midwife: https://www.youtube.com/channel/UCraC14Kv89T9POXdkj8NMrw
• Midwife thinking (love this one!!): midwifethinking.com
• Once again, remember that when it comes to interventions, you have a right to informed consent.  Opinions vary about what interventions are needed and new information is coming up all the time about what is best.  One intervention to avoid is induction.  Here is another good article by Sarah Wickam. Stay strong in those last days! And remember that in the past, a 10 month pregnancy was not so unusual!
• Investigate newborn practices: http://blindedbythelightt.blogspot.com/2012/10/newborn-procedures-to-reconsider.html

2. Choice of Caregivers and Birth Setting

Caregivers

If at all possible, my personal preference for a caregiver for pregnancy, birth and the postpartum period is midwifery care.  Midwives are trained to support normal birth and do a lot to make that possible, including providing information about nutrition and health, providing support in labour and parenting and breastfeeding support afterwards. Research shows that midwifery care, especially when it is continued from the duration of pregnancy results in a much reduced level of intervention compared to obstetric care, even when looking at women of the same risk factor levels. Why is this the case? Well, obstetricians are experts in managing all the complications that can arise. In their training, they rarely see a normal, uncomplicated and unmedicated delivery.  They see all the risky cases where medication, monitoring and/or surgery is needed.  When they see a healthy women having a normal labour, they can tend to see signs of complications, when in fact there is nothing wrong.  They are just so used to intervening that they are uncomfortable sitting back at letting nature sit in the driver's seat.

This article explains quite well what the differences are between an obstetrician-gynecologist and a midwife.  This youtube talk is also very interesting.

Having said that, it does matter what kind of experience the midwife has had.  An independent midwife who has a lot of experience in homebirth is more likely to have skills and knowledge that will help avoid unnecessary interventions than one who has mainly worked in a high-risk hospital setting, for example. It's important to talk to your midwife about how she feels about things like prolonged pregnancy (going past your due date), meconium staining, waterbirth, delayed cord clamping, nuchal cord and so forth (midwifethinking.com explains how many of these things are not as scary as they are made out to be).

Where you have the birth also matters - this article explains the options quite well.

If you're planning a hospital birth, it's especially important to be informed about medical interventions in birth, and when they are needed as well as when they are not necessary.  A birth plan can be helpful in this regard.  A birth plan is not just a list of what procedures and medicines you want and don't want.  It recognises that sometimes there are deviations from the norm, and so a birth plan has a plan B and maybe a C and D.  It answers the question "How can I keep things as optimal for my baby's health and my birth experience if I this or that happens...".

In any setting, but especially in hospital, a doula can be helpful in advising you about medical interventions, advocating for your wishes and providing physical and emotional support.

Birth environment and setting

It should be noted that birth outcomes are not just about the health of the mother when she walks into the hospital.  And it's not just the interventions she endures, either (though this is very significant).  It is significantly linked to how the mother is feeling.  Her emotions (such as feeling in control and safe in her environment versus scared and powerless) can help or hinder the release of birthing hormones and it is these that ensure safety! Not many obstetricians acknowledge this.  They think they can manage things when they go wrong, but what about preventing things from going wrong in the first place?! Allowing the hormones to function properly, through meeting the physiological needs of a labouring women can do a lot to doing this. This includes the things I've mentioned, plus a darkly lit, warm, quiet and private space.  These things also make the 'pain' of childbirth less 'painful'.

The home environment provides all of these conditions - a sense of familiarity, control over the physical space and how others interact with you in your own home, privacy and freedom of movement, freedom to access natural comfort measures, and a much reduced likelihood of unnecessary intervention. Plus, when intervention is needed, most western countries have the facilities to make a quick hospital transfer smooth and successful. I feel that choosing home birth is about giving yourself the best chance of a successful physiological birth.  So, given a situation where there are no pressing medical concerns, I would never ever choose a hospital birth, if I had the choice. I know that not many women don't have that choice, so then it is about optimising the hospital experience so that it supports normal physiology.

This talk explains the advantages of homebirth and you can read more about homebirth here.

Rallying Support

Finally, it's important who you invite into your birthing space and their attitudes towards natural labour.  Not just the care provider and possibly a doula, but also family members! Rhea Dempsey in her book "Birth with Confidence" emphasizes that a birth support person should be strong for the mother and not overly sympathetic.  She tells the story of an athlete preparing to do a solo swim across a sea. She carefully selected a small group of people who would be in the small boat that would pull along the shark cage she would be swimming in.  Their role was to watch out for hazards, cheer her on and possibly pull her out if she had an accident.  She would have to swim throughout the night and day for a long period and she knew that she needed to keep up her morale, because there would be times when the loneliness, the cold, the fatigue and painful muscles would get too much and she would beg to be pulled out.  She knew that if her own mother was on that support boat, she would not have the strength to watch her daughter begging to be taken out and refuse to do that.  The swimmer didn't need people on the boat like that.  She didn't need rescuing when all that was wrong was a lack of confidence, but rather she needed people who could be strong for her, to rally her on and show that she believed in her strength. In every labour, there are times when the sensations get very intense.  We don't need the siren call of the epidural.  We need someone to tell us "you're doing a great job, even though you don't feel like it, you are so strong and you are going to birth this baby so well!".

Conclusion

To conclude, both of these aspects of personal preparation and supportive care are important. In stories I hear about birth, it sadly happens too often that a woman is well-prepared for birth but her experience is made so much harder by caregivers who are uninformed about best-practice and are too keen on intervening.  Sometimes it's not possible to avoid this, but in some cases, women pay extra to go to a private hospital and end up receiving unnecessary interventions because their caregivers are just more comfortable with medicalized birth.  On the other hand, a woman could have awesome caregivers, but still have a less than ideal experience if she has preventable health conditions or makes decisions based on unnecessary fear or lack of preparation.  However, I tend to think that the choice of caregivers could perhaps be more important than preparation.  If a women is minimally prepared, but has a great midwife whom she trusts, her midwife can really help her navigate the common pitfalls she could encounter.  And, of course, in the end, birth is not in our control and we shouldn't feel guilty if things don't go to plan or if we were unaware of something we later realized was important.  We do the best we can under the circumstances and in every case, we learn and grow!

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.